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AIDS

.

9 2011, 14.00 16.00



(.., )

=

(MODS)

(SIRS)

2 SIRS

Shock

ACCP/SCCM:

Bone RC et al. Chest 1992;101:1644-55.


  • S.I.R.S: , ..: , ,

    • > 38C <36C

    • .> 90/min

    • > 20/min PaCO2< 32mmHg

    • WBC> 12.000 < 4.000/mm3 10%


  • : + + 2 SIRS

  • : +

    • : < 90 mmHg, < 70 mmHg, 40 mmHg

  • : 4 mmol/L


SIRS

SIRS

SEPSIS

/


SIRS

Sepsis

Severe Sepsis

Septic Shock

  • Severe Sepsis

  • (30 cc/kg bolus)

Bone et al. Chest 1992;101:1644



;

PaO2 <70 mm Hg

SaO2 <90%

0,5ml/Kg/h

PT

aPTT

C

D-dimer


1,800,000

600,000

1,600,000

500,000

>750,000 / *

1,400,000

1,200,000

400,000

1,000,000

x1,000

300,000

800,000

200,000

600,000

400,000

100,000

200,000

2001

2025

2050

/: !

83-240

/100.000

()

*Angus DC. Crit Care Med. 2001


:

/100,000

AIDS*

.

AIDS*

AMI

CHF

National Center for Health Statistics, 2001.American Cancer Society, 2001. *American Heart Association. 2000.Angus DC et al. Crit Care Med. 2001.


Shock ( !)

  • VIP

  • Very

  • Important

  • Person

    • (Weil & Shubin 1969)

  • Ventilation,

  • Infusion,

  • Pump,


  • .

    • ;

    • rhAPC ;;;;;;

    Intensive Care Med 2008;34(1):17-60


    .

    • (TV)

    • stress


    • :

      • : (, )

      • :

    • ()

    • (, , , , )

    • : : /, ,

    • : APC, IgG-IgM,

    • ()


    --


    E

    • - P = Hospital Acquired Pneumonia

    • No

      - HCAP = Healthcare Associated Pneumonia

    • - VAP = Ventilator Associated Pneumonia


    • HAP (Hospital Acquired Pneumonia)

      >48

    • CAP (Healthcare Associated Pneumonia)

      90

      .

      - ,

      , , ...


    E

    Rello J et al, Crit Care Med 2003, 31(10):2544-2551


    - large inoculum

    - virulent organism


    VAP

    2

    > 25%

    50%

    4

    -

    O = 30-70%

    - crude mortality

    A = 33-50%

    - ttributable mortality

    P. aeruginosa

    E. coli

    K. pneumoniae

    Acinetobacter spp.

    MRSA

    - . .

    -

    -


    • ambu

    • 30-45

    • , Levin

    • 8-12 ( )


    • Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation


    Frequency of Equipment Changes

    No Routine

    Changes

    Ventilator

    Tubing

    Not Enough

    Data

    Inner

    Cannulas

    of Trachs

    Between

    Patients

    Ambu

    Bags

    AACN VAP Practice Alert

    CDC Guideline for

    Prevention of Healthcare Associated Pneumonias 2003


    Handwashing

    What role does handwashing play in nosocomial pneumonias?

    AACN VAP Practice Alert

    Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994


    (VAP)

    • A. -

    • ,

    • 45

    • cuff

      • cuff 20-30 cmH2O

    • .

    • .

    • 0.12%, oralsolution 15 ml 2 , 24

    • , 2 PPIs

    • . -

    • ,

    • 1.


    - -


      • -

    Dimopoulos G. Clin Intens Care 2002;13(1):1-12


    : !!

    • : !!

      • ,


    • !

    • HIV


    The Extended Prevalence ofInfection in the ICU Study:EPIC II. Submitted JAMA

    • Gram-positive2399 (47)

    • Gram-negative3165 (62)

    • Anaerobes225 (4.4)

    • Fungi 945 (19.2%)

      • Candidaspp859 (16.8%)

      • Aspergillus71 (1.4%)

      • Others50 (1%)

    • Viral/parasitic135 (2.6)

    • Others110 (2.2)


    Candida albicans vs.non-albicans Candida species: 50-50

    Almirante B, et al. J Clin Microbiol2005;43:182935


    ;


    • , & :

    • (stents, assist devices, ) 8%

    • , ,

    • : <500/l > 10

    • , > 7

    • > 2 , (>100,000 )

    • 2 pH



    vs

    Roehrborn A, et al. CID 2001;33:1513


    ........

    Gram (+)

    - Coagulase-negative staphylococci (CoNS)

    - Staphylococcus aureus

    - Enterococci

    Gram (-)

    - Pseudomonas spp

    - Acinetobacter spp

    - ESBL-producing bacteria

    Fungi


    MRSA

    • ,


    MRSA

    • > 2



    ,CDC

      • > 15 CFU (Colony Forming Units)

      • 2 cm

      • , , > 2 cm

    • (pocket, )

    • :

    • :

      • 1 / , (, , )

      • 1 :

      • (> 15 CFU/) (> 30 CFU/) /

      • / 5:1

      • > 2


      • ( ),

      • gram, acridine orange,

    • /

      • (roll plate): 15 cfu , < 1

      • : (flushing, vortex, sonication) 102cfu ,

      • :

        • roll plate: 60%,

        • flushing: 40-50%,

        • sonication: 80%

      • : /


    • /

      • 2 , 1

      • 63-73% 99% -

    • /

      • 5-10 100 cfu/ml

    • / /

      • 2 /

      • /


    19861989 19921999

    Pathogen (%) (%)

    Coagulase-negative staphylococci 2737

    S. Epidermitis

    Staphylococcus aureus1613

    Enterococcus813

    Gram-negative rods1914

    Escherichia coli62

    Enterobacter55

    Pseudomonasaeruginosa44

    Klebsiella pneumoniae43

    Candida spp.88


      • 3 way, stopcocks

      • : PVC, Polyethylene ( ) vs. Teflon, silicon, polyurethane

      • : (gram -)

      • : S. aureus fibronectin , Candida spp


    • /

      • swan ganz,

      • Acridine ornage leukocyte cytospin

    • /

      • 2 , 1

      • /


      • , /

      • .

      • .

      • , , , 3

      • 3 (2.6 /1000 ), 5 ,

      • 2.9 /1000 , > 4 10 ,


      • MRSA

      • 3 4 ( )

      • : , ,


      • (, , , )

      • Coagulase-negative staphylococci: S. Epidermitis: 5 7

      • , : 10 14

      • , : 4 6

      • : 6 8


      • !

      • ?

      • (<50 , 3 6 )

      • > > ( , )

      • 4.5 vs. 1.2 1000 -

      • >

      • PVC, Polyethylene ( ) vs. Teflon, silicon, polyurethane

      • , , ,

      • $ 167


      • 2% 10% 70%

      • ,

      • !

      • Claves: , ,

    • /

      • , : 7.6 1.6/1000 (RR: 0.21), $ 196

      • : ?

      • > 2% ( )


    • ?

      • : , VRE

    • / ?

      • povodine-iodine ( , )

      • Mupirocin (S. aureus , )

      • 10 IU/ml , ,

    • : 3 , 5 7 3-5%, 7 5-10%

      • 10 IU/ml , 5000 U 6-12 , 2500 U


    (CLABSI)

    CLABSI 5 :

    • . , , , , .

    • , , , , .

    • 0,5%, 10% ( >0,5%). 0,5% 30 sec, 10% 2 min.

    • . . .

    • .


    -

    • .

    • , , , ,

    • (70%) 2%. ( 2 min)

    • .

    • ( )

    • 7 .

    • .

    • / ( , )



    • 69% ..

    • > 80% ..

    • 3.3 10.1 1000

    • 31% . 2

    • 1 3

    • 3-10%

    • 25%

    • 3%

    • $ 676

    • $ 2.836


    • :

      • 5%

    • : 1-4% , 13-30%

    • : 12.7%


      • , , , ,

    • /

    • /


      • 80% , 5-10%

      • :

      • : , ()

      • ..

      • HIV


      • Enterococcus spp,

      • Candida spp,

      • E coli,

      • Klebsiella spp, and

      • P. aeruginosa.

    • ..

      • Escherichia coli (39%),

      • Pseudomonas aeruginosa (22%),

      • Enterobacter aerogenes (15%),

      • Acinetobacter acinus (11%),

      • Klebsiella spp. (11%),

      • Proteus spp. (11%).


    • Latex vs. silicone

    • ( ) vs. silicone, hydrogel, Teflon latex

    • :

    • 10 ml:


      • :

      • :

    • : 97 8-15%

      • . !

      • :

        • - :


      • 13%

      • 41% -

      • !

    • ?

    • ?

    • ? $ 4

    • : , .


    . .

    • :

      • :

    • ,

      • ,

    • :

      • :



    , ,

    AST, ALT

    (ALP)

    - - (GT)

    5- (5-NU)

    (LDH)

    , , I, II, V,

    VII, IX, X PT)


    MRI

    R

    ERCP / MRCP

    SPECT / PET

    (+/- )

    CT


      • ECHO / CT)


    - 0-8 %

    - 3-47 %

    () 2-56 %

    5-18 %

    1-14 %

    19-44 %


    /

      • , , ,


    HIV / AIDS


    HIV 2005

    Eastern Europe and

    Central Asia

    1.4 million

    Western/

    Central Europe

    720,000

    North America

    1.3 million

    East Asia

    680,000

    North Africa and Middle East

    440,000

    Caribbean

    330,000

    Southern and Southest Asia

    7.6 million

    Sub-Saharan Africa

    24.5 million

    Latin America

    1.6 million

    Oceania

    78,000

    UNAIDS, 2006. Available at: http://www.unaids.org.


    HIV , 12/2005*

    HIV/AIDS 1984-2005= (5898 + 1433 )=7371

    * 2005 data 30-6-05, www.keel.org.gr access 30-11-05



    CD4+ HIV (+)


    HIV CD4

    Bacterial skin infection, Herpex simplex, zoster, Oral, skin fungal infections

    800

    600

    Thrombocytopenia Lymphadenopathy

    Kaposis sarcoma

    500

    300

    400

    400

    CD4 cell count /mm3

    200

    Hairy leukoplakia

    Tuberculosis

    Lymphoma

    PCP

    200

    Cryptococcosis

    Toxoplasmosis

    100

    CMV

    MAC

    0

    Years

    Months


    Highly Aggressive ART HAART

      • CD4


    . (RT) No . (PI)


    Nucleoside RTIs

    Zidovudine (ZDV,AZT,Retrovir)

    Didanosine (ddI, Videx)

    Zalcitabine (ddC, HIVID)

    Stavudine (d4T, Zerit)

    Lamivudine (3TC, Epivir)

    Abacavir (Ziagen)

    Combivir (ZDV + 3TC)

    Adefovir (Preveon)

    Non-nucleoside RTIs

    Nevirapine (Viramune)

    Delaviridine (Rescriptovir)

    Efavirenz (Sustiva)

    Protease Inhibitors

    Saquinovir (Fortovase)

    Indinavir (Crixivan)

    Ritonavir (Norvir)

    Nelfinavir (Viracept)

    Amprenavir (Agenerase)


    • - , , .

    • .

    • .

    • .

    • , , , .


    • .

    • , , , .

    • ( ), ""


    • .

    • : ,

    • ( ) , .

    • (TIG).


    • . , . , .. , . , , . , .

    • , .



    • , Clostridiumbotulinum, .

    • .

    • O .

    • , , , .


    • .

    • . .

    • (aerosol).

    • .

    • ( ).


    • 12 36 . .

    • , , (), .

    • , , .

    • , ( ) .

    • 10% .


    • , .

    • .

    • , . ( 24 ), .

    • 3 - 12 .

    • .


    • - - .

    • .

    • , .


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