脓毒症3.0

脓毒症定义变迁（1.0）
细菌 其他 缺血
真菌
sepsis
INFECTION SEVERE 原虫 SEPSIS 病毒 其他
SIRS
创伤 烧伤
胰腺炎
Sepsis 1.0=感染＋SIRS
Chest 1992 Jun; 101(6):1644-55
脓毒症定义变迁（2.0）
细菌 真菌
其他
缺血
sepsis
ACCP反对Sepsis 3.0
1.Given that use of the current definitions results in saving lives, it seems unwise to change course in midstream by shifting the definition. This is especially true because there is still no known precise pathophysiological feature that defines sepsis. 2.Abandoning the use of SIRS to focus on findings that are more highly predictive of death could encourage waiting, rather than early, aggressive intervention. This is a mistake that we cannot make. 3.To abandon one system of recognizing sepsis because it is imperfect and not yet in universal use for another system that is used even less seems unwise without prospective validation of the new system’s utility.
Intensive Care Med, 2015, 41 (5): 909-911.
脓毒症3.0…..
2016年……
Sepsis 3.0“应运而生”
JAMA. 2016 Feb 23;315(8):801-10｀
Sepsis 3.0定义
Mortality 10%
JAMA. 2016 Feb 23;315(8):801-10｀
(2) Don’t assume that the predominant abnormality in sepsis is immunological–that hypothesis has dominated both mechanistic and therapeutic investigation for over two decades, and has yet to bear fruit.
脓毒症诊断标准的“争议”
方法：通过对2000 年至2013 年澳大利亚 和新西兰172 个重症加强治疗病房(ICU)近 120 万例患者的数据分析，根据是否满足 ≥2条全身炎症反应综合征(SIRS)的诊断标 准将感染伴器官功能障碍的患者分为SIRS 阳性和SIRS 阴性两组。 结果：在近11万例感染伴器官功能障碍的 患者中，87.9%为SIRS阳性，12.1%为SIRS 阴性，在14年内两组患者的临床特征和病 死率变化相似。校正分析显示，患者病死 率随着满足SIRS标准项目的增加呈线性增 高。
Intensive Care Med. 2003 Apr;29(4):530-8. Epub 2003 Mar 28.
DiaΒιβλιοθήκη Baidunostic criteria for sepsis
The PIRO system for staging sepsis
SSC指南发展
2004
2008
2012
Critical care medicine 2004 Mar; 32(3):858-73. Critical care medicine 2008 Jan; 36(1):296-327. Crit Care Med. 2013 Feb;41(2):580-637.
intervention in this highly time-dependent condition, with additional risk to patients.
Chest 2016 Feb
精准医学下的Sepsis 3.0不足
“Definition” versus “Clinical Criteria”. (1)Sepsis researchers, both bench and clinical, should consider how their findings might validate or invalidate the new definition; (2)Clinicians should determine if the clinical criteria are useful in their own practices and consider what additional elements ought to be tested;
……the definition of septic shock currently revolves around variable blood pressure and/or lactate levels, with loosely termed or undefined ‘adequacy of fluid resuscitation’ and ‘persistent’ hypotension. Defining sepsis must, however, be an ongoing iterative process requiring minor or major revisions as new findings come to light. In much the same way that software enhancements move from version 1.0 to 1.1 or to 2.0 depending on the magnitude of change, so a new sepsis 3.0 definition must be refined into versions 3.1, 3.2, and so on until an eventual complete overhaul generates the development of sepsis 4.0. 脓毒症的诊断标准于1991年发布（脓毒症1.0）,但过于敏感，可能导致脓毒症的 过度诊断和治疗；2001年更新版（脓毒症2.0）又过于复杂，未被广泛应用。
Critical care medicine 2016 May; 44(5):857-8.
精准医学下的Sepsis 3.0不足
“Appropriate comparators”.
(1)We need to reconsider just what constitutes an appropriate control for sepsis research;
(3)sooner rather than later.
Critical care medicine 2016 May; 44(5):857-8.
精准医学下的Sepsis 3.0不足
“Dependent and Independent Variables”.
Sepsis = ƒ[(life-threatening)(organ dysfunction)(dysregulated host response)(infection)].
(1) Don’t assume that the sequence of events identified in the new definition reflects pathobiological reality, because no one really knows how things are ordered and connected;
Sepsis 3.0诊断标准
Sepsis 3.0＝Infection＋SOFA≥2
JAMA. 2016 Feb 23;315(8):801-10
Septic shock 定义及诊断标准
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
SIRS
INFECTION SEVERE 原虫 SEPSIS 病毒 其他
创伤 烧伤
胰腺炎
Sepsis 2.0=感染＋SIRS 会议提出了包括20余条临床症状和体 征评估指标构成的诊断标准，即 Sepsis 2.0。然而该标准过于复杂， 且缺乏充分的研究基础和科学研究证 据支持，并未得到临床认可和应用。
Mortality 40%
Septic shock=Sepsis+输液无反应低血压+使用缩血管药 物维持MAP≥65mmHg）+乳酸则＞2mmol/L。
JAMA. 2016 Feb 23;315(8):801-10
脓毒症3.0诊断流程
JAMA. 2016 Feb 23;315(8):801-10
Sepsis 3.0
(2) At the very least, we ought to make sure that studies characterizing sepsis in animal models and in patients use similar controls.
“What comes next? ”.
严重脓毒症及脓毒性休克流行病学
严重脓毒症患者死亡风险为34%，脓毒性休克患者死亡风险为50%。
新近流调显示脓毒性休克死亡率下降
结果发现，重症感染患者的绝对死亡率从 35.0% 下降到了 18.4%，总死亡率
下降了 16.6%，年绝对死亡率下降了 1.3%，相对风险下降了 47.5%。
JAMA. 2014 Apr 2;311(13):1308-16.
How−and how soon−do we initiate Sepsis-4.0? I don’t know−but let’s not wait a decade and a half this time.
结论：该研究说明现有脓毒症标准有可能 遗漏约 1/8 的感染伴器官功能障碍患者， 且该标准不能确定病死率增加的临界点， 这提示当前脓毒症的筛查标准的特异性不 佳。
N Engl J Med, 2015, 372 (17): 1629-1638.
Do we need a new definition of sepsis?
Chest 2016 Feb
ACCP反对Sepsis 3.0
4. What patients need is that we continue to build on the momentum of the last two decades and that we not disrupt it by conflating change with progress. 5. Our principal concern is that the new definition de-emphasizes intervention at earlier stages of sepsis when the syndrome is actually at its most treatable. We believe that adopting a more restrictive definition that requires further progression along the sepsis pathway may delay