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番禺的各位同行 : 早 上 好! PowerPoint PPT Presentation


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番禺的各位同行 : 早 上 好!. SIRS , Sepsis MODS & Shock 全身炎症反应综合征 脓毒症 , MODS 和休克. 曾 其 毅. A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2004; 320(Suppl):S595-S597.

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番禺的各位同行 : 早 上 好!

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SIRS , SepsisMODS & Shock , MODS


  • A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2004; 320(Suppl):S595-S597


What is SIRS


SIRS:

1

10


What is sepsis


?

,, .


!




1991

  • sepsis

    >30%

  • :

    • ??


1991

  • SIRS Sepsis Sever Sepsis

  • Septic Shock MODS MOF

  • >30% <10%


  • Sepsis

    • 2004:75

    • 2010:100

  • Septic Shock 5%30%

    • ICU63%

  • 25%30%

    • ICU


  • Sepsis-associated

    • 196697%

    • 1990s9%

  • Severe sepsis:

    • 199510.3%

    • 7% Watson et al


ACCPSCCM

  • 19911992

    • SIRSSepsisMODS

    • SIRS

    • SepsisSIRS+

    • Severe SepsisSepsis+MODS

    • Septic ShockSepsis+

    • MODS


SCCM ESICM ACCP ATS SIS

  • 20012002

    • SIRSSepsisMODS

    • SIRSSepsisSevere Sepsis

    • Septic ShockMODS


Surviving Sepsis Campaign: guidelines 2008

  • Sepsis

    • infection plus systemic manifestations of infection

  • Severe Sepsis

    • infection plus sepsis-induced organ dysfunction or tissue hypoperfusion

  • Septic Shock

    • sepsis induced hypotension persisting despite adequate fluid resuscitation


Surviving Sepsis Campaign: guidelines 2008

  • Sepsis induced hypoperfusion

    • either sepsis shock

    • an elevated lactate

    • or oliguria

  • Sepsis induced hypotension

    • a systolic blood pressure (SPB) of <90mmHg

    • or mean arterial pressure <70mm Hg

    • or a SBP decrease >40 mm Hg or <2 SD below normal for age

    • in the absence of other causes of hypotension


Sepsis


SIRS / Sepsis

SIRS


TNFILINF

5-

sepsis



TNF

SIRS

CARS

MODS

MOF


SIRSCARS


Balance between pro- and anti-inflammatory mediators

pro-inflammatory anti-inflammatoryTNF-, IL-1, IFN-, LT-, IL-1RA, sTNFR, sIL-1RIL-2, IL-8, IL-12,IL-18, C TGF-, IL-4, IL-6, IL-10LTB4, PAF, Kinine, NO IL-11, IL-13, PGE2, G-CSFGM-CSF, chemokine, MIF antioxidants, IFN-a


-CROSS-TALK



  • SIRSMODS


Sepsis



Examples of high and low capillary density. The capillary density was calculated similar to the technique of De Backer et al.1 A grid of equidistant vertical and horizontal lines was superimposed on the image. The vessel density was calculated as the number of small

vessels (20 m) intersecting the lines of the grid divided by the total length of the lines yielding the number of small vessels per millimeter. The image in A represents a high capillary density, and the image in B represents a low capillary density. Real-time video sequences of orthogonal polarization spectral imaging in severe sepsis and septic shock are available from the authors through a file download.


Sepsis

MMDS--sepsis

  • Microcirculatory and Mitochondrial

    Distress Syndrome

  • ???


---

DO2DO2VO2AO2

ARDSSHOCKMMDS


  • MMDS

  • MMDS


sepsis


Shock was commonly not recognizedFewer patients were referred for shock than had shock (335 vs 1803)

37%

7%


sepsis


THE PIRO CONCEPT

P ()

I () () XCT

R () , WBCCRPPCT

APTT

O () PaO2/FIO2

Glasgow


sepsis

  • Diamond minute!!!

  • Golden hour

    • First six hour

    • Silver day


How to treat sepsis


Cost / effect

Cost = !!


  • endpoint!()

  • No Target Therapy!

  • No Magic Bullet!

  • (Tailoring , Modualating Therapy)


PCWPCOSVR

PCWPCOSVR

PCWPCOSVR








    • 30min 1000mL 300500mL sepsis


  • :

    • (CVP)812mmHg*

    • 65mmHg

    • 0.5mL/(kg.hr)

    • ()70%

    • 65%




    • PHPO2PCO2



  • Sepsis


  • cross talk



    • CVVH

    • CVVH


  • cross talk


  • septic shock


  • 300 mg/day

  • sepsis



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