感染性休克co存在低正常和高3种情况.ppt

严重感染和感染性休克治疗进展 邱海波 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所 Sepsis in worldwide Annual incidence of severe sepsis: 3 cases/ 1,000 Kill: 1,400 people worldwide /d 25 people /h Moreover, No. of sepsis pats is projected to increase by 1.5% per annum 严重感染的病死人数超过乳腺癌、直肠癌、结肠癌、胰腺癌和前列腺癌的总和 严重感染 vs AMI:发病率相同，病死率明显高 Surviving Sepsis Compaign拯救Sepsis运动 Surviving Sepsis Campaign Phase Ⅰ: Barcelona Declaration Phase Ⅱ: Guidelines creation Phase Ⅲ: Clinical outcome evaluation GUIDELINES FOR MANAGEMENGT OF SEVERE SEPSIS AND SEPTIC SHOCK 循证医学----推荐级别 A：至少2个Ⅰ级研究证实 B： 1个Ⅰ级研究证实 C： Ⅱ级研究证实 D：至少1个Ⅲ级研究证实 E：Ⅳ或Ⅴ级研究证实 A-Initial resuscitation: early goal-directed therapy B-Diagnosis: appropriate culture C-Antibiotic therapy: Early broad-spectrum, reassessed 2-3d D-Source control: E-Fluid therapy: colloids=crystalloids,VLT F-Vasopressors: After VLS, NE vs Dopa, Low-dose dopa is not , cath for vaso G-Inotropic therapy: low CO-dobu, high CO is not H-Steroid: low dose I-rhAPC: APACHE II 25, sepsis-induced ARDS/MOF and no bleeding risk J-Blood product administration: target Hb 7-9g/dl, EPO only in renal failure K-Mechanical ventilation: Ppla30, Hypercapnia, optimal PEEP, Prone position L-Sedation, analgesia and NBMs: Protocol M-Glucose control: 150mg% N-Renal replacement: O-Bicarbonate: pH 7.15 P-DVT: UH/LMWH Q-Stress ulcer prophylaxis: H2blocker R-Consideration of limitation of support A. 早期复苏 1. 早期目标性复苏治疗(EGDT) 最初6小时应达到的目标 CVP: 8-12 mmHg（MV 12-15mmHg） MAP≥65 mmHg Urine output≥0.5mL·kg-1·h-1 SvO2≥70% A. 早期复苏 2.若最初6h治疗，CVP达到8-12mmHg，而SvO270% Transfuse packed red blood cells： HCT ≥30% and/or Dobu iv ( up to max 20 μg·kg-1·min-1) B. 病源学诊断 1.抗生素治疗前要进行细菌学培养 Appropriate cultures before antimicrobial therapy is initiated In order to optimize identification of causative organisms, at least two blood cultures should be obtained with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was 48h inserted B. 病源学诊