严重全身性感染与感染性休克.ppt

感染性休克的激素替代治疗 Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71. ACTH test 8 hours SEPTIC SHOCK placebo HC 50 mg/6 hours + FC 50 mcg/day p.o. N = 150 N = 149 28-day mortality 7 days 感染性休克的激素替代治疗 Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71. P = 0.04 P = 0.96 严重全身性感染 – 循证医学指南 干预措施 NNT 小潮气量通气策略 11 早期目标指导治疗 6 – 8 活化蛋白C 16 (whole trial) 8 (APACHE II 25) 强化胰岛素治疗 29 ACTH刺激试验无反应者小剂量激素治疗 7 Sepsis Resuscitation Bundle(应在最初6小时内达到) 测定血清乳酸水平 应用抗生素前留取血培养 入急诊室3小时或入ICU1小时内应用抗生素 低血压和(或)乳酸 4 mmol/L (36 mg/dl)时: 最初应用晶体液至少20 ml/kg(或等量的胶体液) 最初液体复苏无效时应用升压药物以维持MAP 65 mmHg 经过液体复苏后仍持续低血压(感染性休克)和(或)乳酸 4 mmol/L (36 mg/dl): 使CVP 8 mmHg 使ScvO2 70% Sepsis Management Bundle(应在最初24小时内达到) 对感染性休克患者根据ICU标准化规定应用小剂量激素 根据ICU标准化规定应用活化蛋白C 控制血糖水平?正常值下限, 且 150 mg/dl (8.3 mmol/L) 维持机械通气患者吸气平台压力 30 cmH2O Surviving Sepsis Campaign Initial ResultsReporting the Gap betweenPerception and Practice What We Think We Do vs. What We Actually Do ARDS保护性通气策略 – ARDSnet The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301-1308 P = 0.007 研究结果的发表对日常工作并无影响 Rubenfeld GD, et al. Am J Respir Crit Care Med 2001; 163: A295 P = 0.11 P = 0.02 Adhere to “Best Practice”? Do you use lung protective strategy in ventilating acute lung injury patients? Brunkhorst FM, et al, for the German Competence Network Sepsis [SepNet]. The gap between perception and practice of sepsis therapy. (submitted) 非特异性损伤引 起的临床反应, 满足? 2条标准: T 38?C or 36?C HR 90 bpm RR 20 bpm WCC 12,000/mm3 or 4,000/mm3 or 10%杆状核 SIRS = systemic inflammatory response syndrome SIRS及可疑或 明确的感染 Chest 1992;101:1644. 全身性感染