脓毒症新定义新治疗.ppt

Sepsis, emergency myelopoiesis, myeloid-derived suppressor cell (MDSC) expansion, and the development of chronic critical illness (CCI) and persistentinflammation-immunosuppression and catabolism syndrome (PICS). Sepsis results in a self-stimulating cycle. Initially, sepsis leads to emergency myelopoiesis andMDSC expansion (52). Although MDSC expansion has proven to be of early benefit, prolonged MDSC expansion leads to immunosuppression, chronic inflammation, and features of CCI (61). These patients advance to PICS suffering from manageable organ failure, ongoing protein catabolism, poor nutrition, cachexia, andpoor wound healing in addition to persistent inflammation and immune suppression (28). Patients with CCI and PICS have increased susceptibility to secondary ornosocomial infections, which reestablish inflammation, and the cycle repeats. ADL = activities of daily living, Arg = arginine, EPO = erythropoietin, IL = interleukin,iNOS = nitric oxide synthase, MIP-I = macrophage inhibitory protein-1, NO = nitric oxide, RANTES = regulated on activation, normal T cell expressed and secreted,ROS = reactive oxygen species, TGF-β = transforming growth factor-β, TNF = tumor necrosis factor, VEGF = vascular endothelial growth factor. * 2、Septic Shock 3.0 定义为存在循环和细胞代谢紊乱，且严重到足以增加死亡率的一种脓毒症。 在临床上可以通过下情况被识别：在排除低血容量的情况下，需应用升压药以保持平均动脉压≥65mmHg，以及在没有低血容量情况下血乳酸＞2mmol/L(18mg/dL)。 * 3、SepticShock3.0优点 更高死亡风险的预测指标：血压、血乳酸水平和液体复苏量。 这一组合既包括细胞功能障碍还包括了心血管功能损害，且与风险校正后的死亡率显著升高直接相关。 这个联合标准诊断的感染性休克患者相关的住院死亡率＞40%。 * 4、关于定义中血乳酸的分歧 纵然乳酸水平受到多种因素的影响, 如组织供氧不足、有氧呼吸受损、糖酵解加速和肝脏清除减少等。高乳酸血症是疾病严重程度的一个恰当的标志物，其水平越高预测的死亡率也就越高。 而“充分的液体复苏”或“需要使用升压药”用作感染性休克的诊断指标并不是很明确，它们高度依赖使用该标准进行诊断的医生，不同的监测方式和治疗的血流动力学目标会产生不同的结果。 而其他方面的治疗，如镇静和容量状态评估，也是低血压与血管活性药物关系潜在的干扰因素。 * 三、脓毒症和脓毒性休克的识别流程 * *