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?????????????? (Severe Sepsis and Septic Shock)

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Title: ?????????????? (Severe Sepsis and Septic Shock)


1
??????????????(Severe Sepsis and Septic Shock)
2
????
  • ????????????????????????????????????,?????????????
    ??????1000????3?????????????,????????????????,???1
    0??,???????????91.3,???1.5--8.0??????

3
????
  • ???,??????????????????????,????????????30-70?
  • ???,??????10??????,????25?????????????,???????????
    ????????????????????????
  • ???????????????,???????????????????????????,????,?
    ????????,????????????????,????????????????????????
    ?

4
Sepsis Statistics------www.SCCM.org--- Putting
severe sepsis in perspective --
  • Every year, severe sepsis strikes an estimated
    750,000 people in the United States.
  • The annual incidence of severe sepsis is expected
    to rise to 1 million by the end of the decade as
    the population ages.
  • The incidence rate of sepsis has increased 91.3
    percent over the last ten years.
  • This year, severe sepsis will likely take 215,000
    lives in the United States.
  • Sepsis is the leading cause of death in the
    non-coronary ICU.

5
Sepsis Statistics-----www.SCCM.org-- Putting
severe sepsis in perspective --
  • Severe sepsis takes more lives than breast,
    colon/rectal, pancreatic, and prostate cancer
    combined.
  • The CDC recently reported that septicemia, a form
    of sepsis, has become the tenth leading killer in
    the United States. And more people die from
    sepsis each year than from septicemia.
  • Every hour, 25 people in the United States die
    from severe sepsis.
  • One of every three patients who develop severe
    sepsis will die within a month.

6
??
  • SIRS (????????????????????)
  • Sepsis (???????????????)
  • Severe Sepsis (?????????????
  • ?????????????)
  • Septic Shock (?????????????????
  • ??)
  • ----1991?ACCP/SCCM???????????

7
GENERAL SIGNS AND SYMPTOMS IN SEPSIS
8
2001???Sepsis ??????Sepsis??????
------Crit Care Med. 2003 Apr31(4)1250-6.
-----?????????200416(6)321-324
----???????????20043(3)131-133
  •  
  • ?????????,?????????
  • (1)  ????
  • ??(????gt38.3?)
  • ??(????lt36.0?)
  • ??gt90?/min??????????????2????
  • ??gt30?/min
  • ????
  • ??????????(gt20ml/kg??24h)
  • ????(??gt7.7mmol/L?110mg/dl)??????

9
2001???Sepsis ??????Sepsis??????(2)  ??????
  • ??????(?????gt12109/L)
  • ??????(?????lt4109/L)
  • ???????,???????gt0.10
  • ??C????gt???2????
  • ????(????)gt???2????

10
2001???Sepsis ??????Sepsis??????(3)???????
  • ???????lt90mmHg(1mmHg0.133kPa),?????lt70mmHg,??????
    ??gt40mmHg, ??????gt2?????
  • ?????????gt0.70
  • ????gt3.5Lmin-1m-2

11
2001???Sepsis ??????Sepsis??????(4)????????
  • ????(PaO2/FiO2lt300mmHg)
  • ????(??lt0.5mlkg-1h-1?45mmol/L???????2h)????5mg/
    L
  • ????(???????gt1.5???????????gt60s)
  • ??(?????)
  • ??????(?????lt100109/L)
  • ??????(????gt40mg/L?70mmol/L)?

12
2001???Sepsis ??????Sepsis??????(5)??????
  • ?????(gt3mmol/L)
  • ??????????????????

13
Sepsis???PIRO??
  • ?????(predisposition)????????(infection/insult)???
    ??(response)???????(organdysfunction)???
  • ?????PIRO?????????????(stagingsystem),??????????
    ????????,????????????
  • PIRO?????????1???????????????????????????????????
    ??????????????(??????????)?2?????????????????????
    ????????????????????3?????????(?)????????????????
    ?????,????????????????????????????????4??????????
    ????????????(TNM)????,??????????????????

14
Sepsis???PIRO???? ?? ????
??????
  • ??? ???????????? ????????????(TNF?IL 1?CD


  • 14)
  • ??????????? ?????????????????
  • ???? ?????????? ???????????(LPS)?
  • ??????
    ???????DNA??????
  • ??????????
  • ???? SIRS??????? ????????????(?????IL 6)
  • ??C ???? ????????????????
    DR(HLA DR)

  • ?????????C?TNF????????(PAF)
  • ?????? ???????? ????????????
  • ??????MODS? (????,???????,?????
    ?)
  • ???????????(SOFA)?

15
SSC-Phase 2
  • Surviving Sepsis Campaign guidelines for
    management of severe sepsis and septic shock
  • ---- Crit Care Med 2004 ,32(3)
    858-873
  • ----Intensive Care Med
    2004305365.

16
?????(SSC-Phase 2)
  • 11??????????????? (SCCM)????????? (ESICM)???????(
    ISF)??????????????(ANZICS)??????????(AACCN)???????
    ??(ACCP)?????????(ACEP)???????(ATS)???????(ERS)???
    ???????????????(SIS)???????????????????????,??????
    ?????????,???????????????????????????

17
?????(SSC-Phase 2)
  • ??????????????????
  • ???Medline????10?????????
  • ????????(infection)???????????????????????????????
    ?????????????,?????????????????,??????????????????
    ,???23?????,?2830d?????????,????????????????,???
    ?????????????,???????????,??????????????,?????????
    ???,????,??????????????SSC?????????2003?10????????
    ?2???,??2003?12??????????11????44??????????????,??
    ??????????,??????????46??????

18
?????
  • ??????????2001?ISF???Delphi????
  • ???? ?? ??????
    ??
  • A ???2?I??????? I ?????????


  • ????,????


  • ????????
  • B ??1?I??????? II
    ????????,

  • ?????,????

  • (?)
    ????????
  • C ??II??????? III
    ??????????
  • D ???1?III??????? IV ????????


  • ?????
  • E ??IV??V??????? V ????,?????


  • ?????
  •  

19
??????
  • 1 ????(??????Early goal-directed therapy EGDT
    ---N Engl J Med. 2001 Nov 8345(19)1368-77. )
  • 1.1 ??????????,????????????6h???????
  • ?????(CVP)8-12mmHg(l cmH2O7.5mmHg)
  • ???????????????????,??????????????????????,CV
    Pl2-15mmHg???????
  • ?????65mm Hg(MAP???1/3???)
  • ?? 0.5ml kg-1h-1
  • ??????????????(ScvO2?Sv02) 0.70
  • (????B?)?

20
??????
  • 1 ????(?????? EGDT)
  • 1.2 ??????CVP?8-12mmHg,?ScvO2?SvO2????0.70,???????
    ?????????0.30??,?(?)???????(?????20µgkg-1min-1)?
    ?????????
  • (????B?)

21
??????
  • ?????
  • 2.1 ?????????????????????(????D?)?
  • ????????,????2???????????????,?????????????
    ?,?????????????,??????????????????????????????????
    ??????,???????????????????????????????????????????
    ???2h,??????????????????
  • ?????????????????

22
2 ?????
  • 2.2 ?????????????,??????????,??????????????(????E
    ?)?
  • ?????????????????????X????CT???B????????????
    ,???????????,??????????????,????????????????,?????
    ???ICU???????????????????????????????,??????????(?
    ?????????????????)????????,????????????CT???????,?
    ?????

23
??????
  • ?????
  • 3.1 ???????l h??,???????????(?
  • ???E?)?
  • 3.2 ???????????????????????????,???????????(?????)
    ??????,????????????????????(????D?)?
  • 3.3 ???????,??????,????,?????48-72h?,?????????????
    ?????,?????????????????????7-1Od(????E?)?a.??????
    ??,????????(????E?)?
  • b.??????????????????,????????,???????????????
    ?????(????E?)?
  • 3.4 ???????????????,????????(????E?)?

24
??????
  • 4 ?????
  • 4.1 ????????(????E?)?
  • 4.2 ?????????,??????,???????????(????E?)?
  • 4.3??????(????????????????????),?????????,????????
    (????E?)?
  • 4.4???????????????????????????????????,???????????
    ,?????(????E?)?

25
??????
  • ????
  • 5.1?????????????????????,?????????????????????(???
    ?C?)?
  • 5.2????????????????,????????,??30min???500-1000ml?
    ???300-500ml???,?????????(?????????)????(?????????
    )???????????????(????E?)?

26
??????
  • 6 ??????
  • 6.1???????????????????????,
  • ?????????????????????,???
  • ?????????,??????????????????????????lt????E?gt?
  • 6.2 ???????????????????????????lt????D?gt?
  • 6.3 ????????????????????(????B?)?
  • 6.4 ????????,????????????????,??????(????E?)?
  • 6.5 ?????????,???????????,???????????????,????????
    ,???????????????????????????????0.01-0.04U/min(???
    ?E?)?

27
??????
  • 7 ???????
  • 7.1???????????????,???????????????????????,???????
    ?(????E?)?
  • 7.2???????????????????(????A?)?

28
??????
  • 8 ????????
  • 8.1 ????????????????????????????,???????????,????
    ?200-300mg/d,?3-4??????,??7d(????C?)?
  • 8.2 ????????????300mg(????A?)?
  • 8.3 ???????????,????????????????????????????,????
    ??????????(????E?)?

29
??????
  • ??????C (rh-APC)
  • ??????????????ltAPACHEgtII25????????????????(MODS)?
    ????????????????????(ARDS)??????????,??????????,??
    ????rh-APC(????B?)?

30
rhAPC???????
  • ????????????????????,???????????????????????
    ???
  • ???????????????????????????????,????????????????
    ,????????????????????????????????????????????????
    ???????rhAPC??????????,???????????????????????????
    ???,??rhAPC??????????????????????,????????????????
    ????????????,Gordon????1690???????,????,?24µgkg-1
    h-1??96h????rhAPC??????????????????????(28d????24
    .7?30.8)?

31
??????
  • ??rhAPC????
  • lt????????????agt
  • rhAPC???????,??????????,??rhAPC?????????????????
  • ???????
  • ???????(3???)
  • ???????????,???????(2???)
  • ?????????????????
  • ???????
  • ??????????????
  • ?a????????rh APC?????????????30x109/L

32
??????
  • 10 ???????
  • 10.1 ?????????,????????????????????,?????lt7Og/L?,
    ????????,?????????70-9Og/L(????B?)?
  • 10.2 ?????????????????????,??????????(????B?)?
  • 10.3 ????????????,??????????????(FFP)???????(????
    E?)?
  • 10.4 ?????????????????????(????B?)?
  • 10.5 ?????lt5109/L,????????,?????????????(5-30)
    109/L,?????????,????????????????????????????gt5O10
    9/L(????E?)?

33
??????
  • 11 ?????????(ALI)?(?)ARDS?????
  • 11.1 ALI?(?)ARDS????????????????,???????????(????
    ???6ml/kg),??????????3Ocm H20(????B?)
  • ?
  • 11.2 ?????????????????,???????????(PaCO2)????,???
    ????????(????C?)?
  • 11.3 ????????????????????(PEEP)(????E?)?
  • 11.4 ???????(FiO2)??????????ARDS??,???????????,??
    ??????(????E?)?
  • 11.5 ??????????45????,?????????????(????C?)?
  • 11.6 ??????????,?????????(SBT),??????????????????
    ????????(??????)????????????????????PEEP??????
    ?????????FiO2???SBT??,??????SBT????5cm
    H2O?????????T?(????A?gt?

34
ARDSNET Ventilator Management
  • Assist control modevolume ventilation
  • Reduce tidal volume to 6 mL/kg predicted body
    weight
  • Keep Pplat lt 30 cm H2O
  • Reduce Tv as low as 4 mL/kg predicted body
    weight to limit Pplat
  • Maintain SaO2/SpO2 8895
  • Anticipated PEEP settings at various FIO2
    requirements
  • FIO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9
    0.9 0.9 1.0
  • PEEP 5 5 8 8 10 10 10 12 14 14
    14 16 18 2024
  • Predicted Body Weight Calculation
  • Male50 2.3 height (inches) _- 60 or 50
    0.91 height (cm) -152.4
  • Female45.5 2.3 height (inches) - 60 or 45.5
    0.91 height (cm) - 152.4
  • Tv, tidal volume SaO2, arterial oxygen
    saturation PEEP, positive end-expiratory
    pressure.
  • 872 Crit Care Med 2004 Vol. 32, No. 3

35
??????
  • Use of spontaneous breathing trial in weaning
    ARDS patients
  • Original illness resolving no
    new illness
  • Off vasopressors and continous
    sedatives
  • Cough during suctioning
  • PaO2/FiO2 gt200mmHg
  • PEEP?5cmH2O
  • Minute ventilation lt
    15L/min
  • F/Tv ratio ?105 during 2-min spontaneous
    breathing trial
  • Spontaneous breathing trial
    (30-120 mins)

36
  • Respiratory rate gt 35/min
    Oxygen saturation lt 90
    Pulse gt 140/min or change 20
  • SBP gt 180 mmHg or lt 90 mmHg
  • Agitation,diaphoresis,anxiety
  • F/Tv ratio gt 105
  • No
    Yes
  • Cough adequate to secretions
  • Able to protect airway
  • Yes No
  • Extubate Return to
    maintenance MV

37
ESICM/ATS/ERS/SCCM/SRLF CONSENSUS CONFERENCES
  • The 2005 Conference is scheduled in Budapest,
    Hungary, on 28-29 April 2005. The topic will be
    Weaning from mechanical ventilation. The ERS is
    the organisation body.  

38
??????
  • 12 ???????????
  • 12.1 ????????????,?????????????(????B?)?
  • 12.2 ??????????????????,??????????????????,???????
    ?,?????????(????B?)?
  • 12.3 ???????????????,?????(????E?)?

39
??????
  • ????
  • 13.1 ??????????????????????8.3mmol/L(150mg/dl)????
    ?,?????????????????????????????30-60min??????,????
    4h????(????D?)?
  • 13.2??????????????????????(????E?)?

40
??????
  • 14??????
  • ??????????,????-????????????????????????
    ???????????????,?????????????????(????B?)?

41
??????
  • 15 ??????
  • pH7.15????????????(????C?)?
  • ????,??????????????????????,?Cooper???????????
    ??????????pH?7.13?????,?????????????,?????????????
    ?????,??????CVP??????????????????????????????????,
    ????????????????????????????????????????????????

42
??????
  • 16 ?????(DVT)???
  • ??????????????????????DVT?????????(???
    ????????????????????)?,????????????lt??????????)???
    ?DVT????????,?????????????????(????A?)?

43
??????
  • DVT??????????????????????????????????????????????
    ??????,????????????,???????????????????????,?????,
    ????DVT?????,?????DVT???
  • ?????????????????,??????????????????????????(ICU)?
    ?(?????????)??DVT?????????????????,Samama??1102???
    ?????????,????,???????40mg/d???????????5.5,??????
    ??(14.9gt,?????????????????DVT??????,Cade?????????
    ??,DVT????29.0?????500OU????2?/d?????,DVT????13.0
    ,??????????(29.0gt?
  • ????????????????????DVT????????,??????????????????
    ???,???????????????DVT?

44
??????
  • 17 ????????
  • ??????????????????H2???????????????????P
    H???,??????????H2?????(????A?)?

45
??????
  • 18 ??????
  • ?????????????????????????????,?????????
    ??????????(????E?gt?

46
Treatments HOW IS SEPSIS TREATED?
47
Thank you !
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