Sepsis课件.ppt

* Since patients with septic shock typically have a lactic acidosis, and since lactic acidosis is associated with a “oxygen debt”, the the possibility of improving outcome by reversing oxygen debt by producing supranormal oxygen delivery has led to multiple clinical trials in this area. Unfortunately, none of these trials have shown clinical outcome benefit, and one study (Hayes) suggested harm when very high level inotropes were used to drive oxygen delivery to supranormal levels. Therapy should therefore be targeted toward reversing clinical signs of tissue hypoperfusion and not toward an arbitrarily pre-defined level of oxygen delivery. * This chest radiograph shows a patient with ARDS characterized by diffuse bilateral infiltrates. * Sepsis is the most frequent cause of acute lung injury and acute respiratory distress syndrome (ARDS). Acute lung injury is the most common system dysfunction in sepsis and is associated with significant morbidity and mortality. Patients with severe lung injury, i.e., sepsis induced ARDS almost always require mechanical ventilation, and many patients with acute lung injury are also mechanically ventilated. * The ARDSnet trial compared 6 ml/kg ideal body weight vs. 12 ml/kg ideal body weight (low tidal volume/high tidal volume comparison). The low tidal volume group demonstrated a significant decrease in mortality. * Measurement of inspiratory plateau pressure allows estimation of the end inspiratory alveolar pressure as a marker of lung inflation. A .5 second end inspiratory typically allows this measurement. * The recommendation for mechanical ventilation of sepsis induced ALI/ARDS is to reduce tidal volume (TV) over 1 to 2 hours to 6ml/kg predicted body weight (PBW—formula available on the ARDSnet and SSC websites) starting at 8ml/kg. In addition, inspiratory plateau pressure should be measured and maintained 30 cm H2O. This may require further reduction of TV to as low as 4.0 ml/kg/PBW. * In addition to avoiding lung