急诊医学-脓毒症及脓毒性休克.ppt

2015 .04更新 “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review. DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:EITHER: ? Repeat focused exam (after initial fluid resuscitation)?including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.OR TWO OF THE FOLLOWING: ? Measure CVP? Measure ScvO2? Bedside cardiovascular ultrasound? Dynamic assessment of fluid responsiveness with passive leg raise or fluid challengeOf note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected. For patients with?ARDS?due to severe sepsis, the authors made several suggestions based on consensus opinion/weak evidence: Using higher levels of?PEEP?(Grade 2C); Recruitment?maneuvers for patients with severe hypoxemia while receiving high PEEP and FiO2 (Grade 2C), Prone?positioning?for patients with PaO2/FiO2 ratios < 100 despite such maneuvers (Grade 2C). 血浆可溶性髓系细胞触发受体．1(soluble trig-gering receptor expressed on myeloid cells，sTREM-1) TREM-1 是一个相对分子质量为 30000 的糖蛋白，其跨膜信号转导通路在炎症反应级联放大和脓毒症的发生中起着关键作用，感染时在中性粒细胞和单核一巨噬细胞表面表达显著增加，sTREM-1 是 TREM-I 的可溶形式 sTREM-I 是诊断细菌感染的可靠指标。研究表明，sTREM-I 以 135ng/L 为最佳临界值，诊断脓毒症的敏感度为 93.8%，特异度为 84.7%，对脓毒症的早期诊断具有一定价值。 一项关于脓毒症患者 28d 生存组和死亡组早期血清蛋白表达差异的研究显示，采用双向凝胶电泳、质谱分析检测脓毒症和脓毒性休克患者确诊后 12h 内的血液标本发现，生存组补体因子 B、触珠蛋白等血清水平上调，死亡组α一 1 -B- 糖蛋白血清含量更高。 Presepsin（可溶性 CD14 亚型，sCD14-ST）是 CD14 的 N 端片段，往往在细菌感染时产生，是 2004 年发现的一种新的生物标志物。 ?Serge Masson? 通过从下肢向右心回流300毫升静脉血，PLR相当于一次的液体复苏(Critical Care 2015,19:18)。PLR阳性指标：双腿被动太高45 ° 10分钟后，根据医院条件进行下列任何一项检查。达下列指标者为阳性，即病人处于低容量状态，会对输液有效。1）每博输出量增加9%2）脉搏压增加10%3）平均动脉压增加10%4）ETCO2增加5% Intensive insulin therapy in medical patients on ICU for > 3 days ICU mortality In hospital mortality ARR (%) OR (95% CI) P value 38.1--- 31.3 Δ 6.8% 52.5 --- 43.0 Δ 9.5% 0.69 (0.50-0.95)