AncientEgyptianpapyrus:?DangerousPrinciple(?u-khed-u“),Whensomethingcomesoutoftheintestine,andspreadsintheheartthentothebody,endingindeath.“膿毒癥的最早記載內(nèi)容摘要定義流行病學(xué)臨床管理早期識別高危患者

Earlyrecognition感染源控制及早期恰當(dāng)抗生素

Appropriateandtimelyadministrationofantimicrobialdrugs液體復(fù)蘇及血管活性藥物

ResuscitationwithintravenousfluidsandvasoactivedrugsSIRS:符合以下2項(xiàng)或以上

體溫>38°C或<36°C

心率>90bpm

呼吸頻率>20/min或PaCO2<32mmHg

白細(xì)胞>12,000/ul,or<4,000/ul,

或白細(xì)胞計數(shù)正常但桿狀核分類>10%SepsisSeveresepsisSepticshock

Severesepsiswithpersistenthypotension(refractorytofluidbolus)

DefinitionTypesofShock95casesper100,0002weeksurveillance

206FrenchICUs95casesper100,0003monthsurvey

23Australian/NewZealandICUs143/100,000in2000to343/100,000in2007

USA135/100,000in1997to217/100,000in2006Taiwan,ChinaEpidemiologyofsepsis老年患者Sepsis發(fā)生率上升明顯內(nèi)容摘要定義流行病學(xué)臨床管理早期識別高?；颊?/p>

Earlyrecognition感染源控制及早期恰當(dāng)抗生素

Appropriateandtimelyadministrationofantimicrobialdrugs液體復(fù)蘇及血管活性藥物

ResuscitationwithintravenousfluidsandvasoactivedrugsPredictingtheevolutionofseveresepsis/septicshockBiomarkers

NumbersofSIRScriteriaPIROmodel

Predisposition:

premorbidfactors,geneticpolymorphisms

Infection:

site,type,andextentoftheinfection

Response:

putativebiomarkersofresponseseverity,e.gIL-6,PCT

Organdysfunction:

SOFAscore,etcSeverityscoringsystemGroup1:D0-2有感染，治療有效，D3-7感染緩解Group2:D0-2有感染，治療無效，D3-7感染持續(xù)Group3:D0-2無感染，D3-7出現(xiàn)新發(fā)感染Group4:D0-2及D3-7均無感染Amongchanges,thoseinCRP,ratherthanPCT,differedbetweengroupsaccordingtoinfectiousstatus,withalargedecreaseinGroup1andpersistentlyhighvaluesinGroup2and3,whereasabsolutevaluesofbothCRPandPCTdifferedamonggroups.CRP可預(yù)測感染狀態(tài)的改變，而PCT更擅長于預(yù)測是否繼發(fā)血行感染、繼發(fā)膿毒性休克或繼發(fā)臟器功能衰竭ProportionofSIRSprogressedtosepsisorseveresepsisandmortalityaccordingtonumberofSIRScriteriaTheprogressionofSIRStosepsisormoreseverestages:

Forthosewhomet2criteria

32%developedsepsisbyday14

Forthosewhomet3criteria(1821,72%)

36%developedsepsisbyday14

Forthosewhomet4criteria(975,39%)

45%developedsepsisbyday14

Mortalityvs.SIRScriteriaonday1

Thosewith2criteria(1206):6%died(69)Thosewith3criteria(924):9%died(84)Thosewith4criteria(397):18%(71)JAMA.1995Jan11;273(2):117-23.SOFA-T1(24h)wassignificantlyhigherinpatientswhoneededanICUadmissionDeterminantsofprogressiontosepsis,severesepsis,orsepticshockduringthefirstweekofhospitalstay

Thesourceofinfectionincreasetheriskofprogressiontomoreseverestagesofsepsis.

Intraabdominalandrespiratorysourcesofinfection,independentlyofSOFAandAPACHEIIscores,increasetheriskofclinicalprogressiontomoreseverestagesofsepsis.Canwepredictsepsisprecedingovertclinicalpresentation?

Alarmingplatformbasedearlierrecognitionofdeterioratingpatientsandearlierinterventionwithamedicalemergencyteam(MET)Severesepsisatthewardswasmainlydetectedbytherapidresponseteamandwasthemostcommonadmittingdiagnosisamongtherapidresponseteampatients.內(nèi)容摘要定義流行病學(xué)臨床管理早期識別高?；颊?/p>

Earlyrecognition感染源控制及早期恰當(dāng)抗生素

Appropriateandtimelyadministrationofantimicrobialdrugs液體復(fù)蘇及血管活性藥物

Resuscitationwithintravenousfluidsandvasoactivedrugs內(nèi)容摘要定義流行病學(xué)臨床管理早期識別高危患者

Earlyrecognition感染源控制及早期恰當(dāng)抗生素

Appropriateandtimelyadministrationofantimicrobialdrugs液體復(fù)蘇及血管活性藥物

Resuscitationwithintravenousfluidsandvasoactivedrugs嚴(yán)重膿毒癥/膿毒性休克患者早期目標(biāo)導(dǎo)向治療（EGDT）能明顯提高患者預(yù)后液體復(fù)蘇及血管活性藥物如何判斷患者對液體的反應(yīng)性液體選擇：晶體vs

膠體，白蛋白液體過量管理血管活性藥物：種類、使用時機(jī)及血壓目標(biāo)新的文獻(xiàn)進(jìn)展靜態(tài)壓力指標(biāo)CVPPAP靜態(tài)容量指標(biāo)PICCO中GEDV和ITBV二維心超中舒張末容積動態(tài)反應(yīng)指標(biāo)：PPV,SVV等如何判斷患者對液體的反應(yīng)性FluidchallengeVincent,JL.WeilMH.CritCareMed2006PLR（PassiveLegRaising）注意：動脈血壓監(jiān)測患者，非房顫，鎮(zhèn)靜；MV患者晶體vs

膠體，白蛋白液體過量管理水能載舟，也能覆舟！

病例患者，女性，61y/o，因肝內(nèi)外膽管結(jié)石，腹腔鏡下膽囊切除+膽總管切開取石+T管引流術(shù)后1天發(fā)熱，低血壓，氣急轉(zhuǎn)入ICU.入科診斷;重度膿毒血癥，感染性休克？膽漏，急性肺損傷，急性呼吸衰竭，入科后經(jīng)過積極液體復(fù)蘇，次日停多巴胺入科后24hI/O;12075/9465,其中膠體約4000~4500ml,系列胸片變化

血管活性藥物：種類及血壓目標(biāo)血管活性藥物：血壓目標(biāo)多中心，開放標(biāo)簽的隨機(jī)實(shí)驗(yàn)Highbloodpressuretarget:MAP:80-85mmHgLowbloodpressuretarget:MAP:65-70mmHg新的文獻(xiàn)進(jìn)展在美國的31個急診科，2008.3-2013.5月間我們將感染性休克患者隨機(jī)分為3組接受6小時復(fù)蘇治療：基于EGDT方案程序化治療；(protocol-basedEGDT)

基于標(biāo)準(zhǔn)的程序化治療（不要求留置中心靜脈插管、使用強(qiáng)心藥物或輸血）；(protocol-basedstandardtherapy,thatdidnotrequiretheplacementofacentralvenouscatheter,administrationofinotropes,orbloodtransfusions;orusualcare)

常規(guī)治療。(usualcare)主要預(yù)后終點(diǎn)為60天住院病死率。我們還檢驗(yàn)基于方案的治療（綜合EGDT組及標(biāo)準(zhǔn)治療組）是否優(yōu)于常規(guī)治療，以及基于EGDT的程序化方案是否優(yōu)于標(biāo)準(zhǔn)的程序化治療方案。次要預(yù)后指標(biāo)