脓毒血症的抗生素治疗培训课件

et al. Shock on admission 2005;127:598-603.
day
is
the
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Golden Hour and Silver Day
• Detection and Correction of Occult Hypoperfusion within 24 Hrs Improves Outcome from Major Trauma in EDs
-17%
47% 30%
Hydrocortisone
Annane et al. JAMA 2002;288:862-871
Early goal
Rivers E et al. NEJM 2001; 345:1368-73
Wit脓ho毒u血t症的抗生W素治ith疗
-32%
63%
31%
Adequate ATB therapy
脓毒血症的抗生素治疗
Severe sepsis and septic shock is common in Hosp
• 2.9% of hospital admissions • 10% of admissions into ICU • Mortality > 30%
脓毒血症的抗生素治疗
Crit Care Med 2001;29:1303-10. Curr Opin Crit Care 20022;8:600-6
Sepsis resuscitation bundle
1.测定血浆乳酸水平
2. 在使用抗生素之前先进行血培养
3. 在进入急诊室的3小时内和ICU的1小时内给予广谱抗生素
4. 患者存在低血压和/或乳酸水平>4 mmol/L(EGDT)
a, 给予一个首次20 ml/kg 的晶体(或胶体液) b. 对最初的液体复苏无效的低血压可给予血管收缩剂，使其平均动脉压维持在
Effective antimicrobial therapy at first 6h
• Outcome: 低血压发生后第1h(H1)内接受有效抗生素治疗者： 存活率 79.9% 低血压发生后接受有效抗生素每延误1h：存活率平均降低7.6%
Survival rate (%)
100% 80% 60% 40% 20% 0%
SSC脓毒症及感染性休克治疗指南(2008)
• A． 液体复苏 • B．细菌学诊断 • C．抗生素治疗 • D，感染源的控制 • E．液体治疗 • F．血管加压剂 • G．正性心肌力药物治疗 • H．激素 • I．重组人体活化蛋白C
（rhAPC）
• J．血液制品的使用 • K．机械通气 • L．镇静、麻醉及神经
Valles J et al. Chest 2003;123:1615-1624.
7
感染性休克常发生在 Sepsis后24h内
• When: Transition from sepsis to shock ?? • Most often during the first 24 hrs of hospitalization
脓毒血症的抗生素治疗
6
Sepsis病人的高死亡率
% Mortality
-6%
70
60
50
40
30 20
3311%% 2255%%
Leabharlann Baidu10
0 Activated C
protein
Bernard GR et al. N Engl J. Med 2001;344:699-709.
-10%
6633%% 5533%%
Morbidity and survival versus time to correct occult hypoperfusion.
Filled bars, survival Hatched bars, Respit complication Dotted bars, MSOF.
脓毒血症的抗生素治疗
Blow O, et al. Golden Hour and the9Silver Day:
Detection and Correction of Occult Hypoperfusion within 24 Hrs Improves Outcome from Major Trauma. J Trauma, 1999,47:964
肌肉阻滞剂 • M．血糖控制 • N．肾替代治疗 • O．碳酸氢盐治疗 • P．预防深静脉血栓 • Q．预防应激性溃疡
脓毒血症的抗生素治疗
3
Sepsis Bundle
• Sepsis resuscitation bundle
• 5 (7) tasks • Within 6h
• Sepsis management bundle
>=65mmHg
5. 尽管进行了液体复苏，但患者仍存在持续的低血压和/或乳酸> 4 mmol/L
a. 应维持 CVP >=8 mmHg b. 应使 ScvO2 >=70% (OR 65%)
脓毒血症的抗生素治疗
5
Sepsis management bundle
1. 对于感染性休克患者，给予小剂量的皮质醇 2. 给予重组活化蛋白C 3. 控制血糖水平，应低于150 mg/dl (8.3 mmol/L) 4. 机械通气时，送气平台压 <30 cmH2O
• 4 management goals • Within 24h
Institute for Healthcare Improvement: bundle up for safety. 脓毒血症W的W抗生W素.i治hi疗.org/IHI/Topics/Critical Care/Inte4nsiveCare
Early death (Died before hosp d21)
62%
PMV
33%
Non-PMV
62%
Shock at day 1 Shock at day 1
0%
50%
100%
0% 20% 40% 60% 80%
PMV: prolonged MV (MV>21d)
Estenssoro E, Gonzalez F, Laffaire E, Canales脓H,毒S血ae症nz的G抗, 生Re素in治a 疗R, predictor of prolonged mechanical ventilation in the ICU. Chest