番禺的各位同行
Download
1 / 65

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


  • 255 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' 番禺的各位同行 : 早 上 好!' - garren


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

番禺的各位同行 : 早 上 好!


Sirs sepsis mods shock mods

SIRS , SepsisMODS & Shock 全身炎症反应综合征 脓毒症 , MODS 和休克

曾 其 毅



What is SIRS three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. ?

全身炎症反应综合征


SIRS three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 的诊断标准:

1、呼吸加快

 2、心率加快

 3、体温升高: 36‘C> T >38’C

 4、白细胞升高或降低

        >WBC>12×10


What is sepsis three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. ?

脓 毒 血 症


什么脓毒血症 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. ?

机体 对免疫原性物质的应答性反应,表现为大量的针对抗原的免疫物质产生,在清除抗原的同时损伤组织细胞导致器官功能障碍的病理生理过程 .


现代医学证实: three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

危重病的主要病理生理是

内 环 境 和 免 疫失 衡 导 致

自身免疫损伤!!


人体内稳态与内环境平衡 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 血液内稳态:循环、携氧能力

  • 内环境平衡;

    晶体环境--电生理稳态

    胶体环境--白蛋白-水稳态

    酸硷环境--生化稳态-生物代谢


历史回顾 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 一战:休克

  • 二战:肾衰

  • 朝战:急性肺损伤

  • 越战:序惯性损伤


历史回顾 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

1991年前

  • 抗生素越来越多,sepsis发病率增加,

    死亡率未降(>30% )。

  • 抗休克:

    • 扩容:胶体?晶体?

    • 血管活性药物:收缩剂?扩张剂?


历史回顾 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

1991年后

  • SIRS Sepsis Sever Sepsis

  • Septic Shock MODS MOF

  • 死亡率:>30% <10%


流行病学 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • Sepsis发病率:

    • 2004年:75万

    • 2010年:100万

  • Septic Shock 发病率:5%~30%

    • 占ICU感染病人63%

  • 致死率:25%~30%

    • 占ICU感染病人第一位

      —— 美国


流行病学 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

致死率:

  • Sepsis-associated:

    • 1966年:97%

    • 1990s年:9%

  • Severe sepsis:

    • 1995年:10.3%

    • 近年:7% —— Watson et al

      —— 美国


Accp sccm
ACCP–SCCM three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 联席会议

  • 时间:1991年(1992年公布)

  • 专题:

    • SIRS,Sepsis,MODS

  • 定义:

    • SIRS:机体对炎性损伤的反应

    • Sepsis:SIRS+感染

    • Severe Sepsis:Sepsis+MODS

    • Septic Shock:Sepsis+顽固性低灌注

    • MODS


Sccm esicm accp ats sis
SCCM ESICM ACCP ATS SIS three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 时间:2001年(2002年公布)

  • 专题:

    • 重新审定 SIRS,Sepsis,MODS

  • 定义:

    • SIRS,Sepsis,Severe Sepsis,

    • Septic Shock,MODS


Surviving sepsis campaign guidelines 2008
Surviving Sepsis Campaign: guidelines 2008 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 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 20081
Surviving Sepsis Campaign: guidelines 2008 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 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
Sepsis three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 的本质之一——宿主自身免疫损伤

  • 细胞因子风暴

  • 炎症介质瀑布

  • 呼吸爆发

  • 级联反应

  • 肠道细菌移位和肠源性毒素血症

  • 肠道中心说

  • 凝血系统和炎症系统交互作用


SIRS / Sepsis three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

其他

菌血症

SIRS

创伤

感染

全身性感染

真菌

烧伤

寄生虫

病毒

其他

应激


Sepsis1

细胞因子 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

如TNF、IL、INF等

补体

内毒素

溶酶体酶

氧自由基

组织胺

如5-羟色胺

血小板激活因子

凝血酶原

花生四烯酸代谢物

包括白三烯、前列腺素

生物活性物质

如整合素、选择素、粘附分子等

参与sepsis的炎症介质


细胞因子风暴和炎症介质瀑布 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.


内毒素 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

“炎症介质瀑布”

感染

应激

TNF

血小板激活因子

溶酶体酶

SIRS

炎症介质失控释放

单核巨噬细胞系统

粘附因子

CARS

组织灌注不足

微循环障碍和再灌注损伤

损伤组织细胞

MODS

MOF


Sirs cars
SIRS three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 与CARS


病理生理: three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 促炎因子和抗炎因子的平衡

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
凝血 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. -炎症系统CROSS-TALK

  • 血小板降低

  • 凝血功能障碍

  • 出血


炎症反应扩大 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

抗生素

炎症反应

抗生素——杀手!

杀死病原菌会引起更强烈的

自身免疫损伤!


呼吸爆发 three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction.

  • 细胞内线粒体代谢呈现超高水平状态称为“呼吸爆发”

  • 中性粒细胞—内皮细胞相互作用导致组织损伤是SIRS引起MODS的共同途径


Sepsis2
Sepsis three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. 的本质之二—— 微循环障碍


缺血时微循环出现氧合不均衡,表现为富氧区与低氧区相邻。低氧的微循环区域称之为微循环衰弱单元。缺血时微循环出现氧合不均衡,表现为富氧区与低氧区相邻。低氧的微循环区域称之为微循环衰弱单元。


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.


Sepsis3
Sepsis 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的本质之三——亚细胞结构损伤与内呼吸障碍

MMDS--对sepsis的新认识

  • Microcirculatory and Mitochondrial

    Distress Syndrome

  • 微循环和线粒体窘迫综合征

  • 内呼吸窘迫综合征???


人体供氧过程 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

肺-肺循环体循环毛细血管--组织细胞

气体交换氧输送气体交换

DO2DO2VO2,AO2

外呼吸 内呼吸

ARDSSHOCKMMDS


  • MMDS 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的表现

  • MMDS包含了一系列微循环和线粒体功能障碍的症状和体征,并且在全身大血管复苏后会自我放大

  • 选择治疗方案时恢复微循环灌注和功能至关重要 


Sepsis4
决定 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 smallsepsis发展的因素——外因

  • 医生的认识水平


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

37%

7%


Sepsis5
决定 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 smallsepsis发展的因素——内因

  • 基因多态性

  • 同一基因的基因状态

  • 细胞内环境

  • 细胞内生理——内分泌、代谢


The piro concept
THE PIRO CONCEPT 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

临床 其他检查

P (诱因) 年龄,酗酒, 免疫监控,基因因素

激素或免疫抑制治疗

I (感染) 特定部位 (如,肺炎,腹膜炎) X线,CT扫描,细菌学

R (反应) 不适, 体温,心率, WBC,CRP,PCT,

呼吸频率 修正的APTT

O (器官功能障碍) 动脉血压,尿量, PaO2/FIO2,肌酐,

Glasgow 昏迷评分 胆红素,血小板


Sepsis6
决定 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 smallsepsis发展的因素——时间

  • Diamond minute!!!

  • 病情发展的时间

  • 采取治疗的时间

    • 治疗开始的时间

    • 治疗措施的及时

  • Golden hour

    • First six hour

    • Silver day


How to treat sepsis

How to treat sepsis 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?


用什么来衡量治疗水平? 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

死 亡 率!

性价比—Cost / effect

Cost = 时间 + 金钱!!


  • 强调 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 smallendpoint!(评判标准)

  • 没有靶疗法!No Target Therapy!

  • 没有魔术弹!No Magic Bullet!

  • 裁缝疗法和帡图疗法

  • (Tailoring , Modualating Therapy)


休克时 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

血流动力学改变

暖休克 PCWP/CO↑/SVR↓

PCWP↓/CO↑/SVR↓

冷休克

PCWP↓↓/CO↓/SVR↑


病理生理特征 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

  • 高代谢状态

  • 高动力循环状态

  • 炎症介质释放

  • 细胞结构损伤


治疗思路 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

  • 阻止损伤因素的损伤

    • 祛除诱因

    • 抗炎

    • 抗过敏

    • 抗感染


  • 精确控制内环境,保持动态平衡 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

    ——晶体、胶体、酸碱内环境分分钟平衡!

    • 白蛋白缓冲对

    • 红细胞缓冲对

    • 血浆

    • 碳酸氢钠——杀手!


  • 强调生命支持 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

    • 营养、液体

    • 减轻代谢,减低代偿机制

    • 呼吸循环的支持

    • 内在细胞代谢水平的支持

    • 维生素


  • 充分调动机体的复苏和康复本能 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

  • 充分考虑远期康复计划

    • 早期即想到恢复——早期干预、营养、理疗


治 疗 误 区 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


早期 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

  • 充分的液体复苏、及时评估。

  • 液体挑战疗法:

    • 在30min内 给予1000mL 的晶体液或300~500mL 胶体液。如果是sepsis导致的低灌注,可能需要更多、更快地给予容量。


  • 初期复苏目标 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:

    • 中心静脉压(CVP)8–12mmHg*

    • 平均动脉压≥65mmHg

    • 尿量 ≥0.5mL/(kg.hr)

    • 中心静脉(上腔静脉)氧饱和度≥70%,

    • 或混合静脉≥65%


中晚期 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

  • 不要任何不确定的治疗。

  • 任何不确定的治疗均会增加死亡率!

  • 只需要支持:呼吸、循环、透析。

    晚期

  • 积极康复!


具 体 问 题 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


颅高压与神经细胞水肿 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

  • 颅内压的形成:

    • 平均动脉压-胸内压

  • 脑血流的调节机制:

    • PH值,PO2,PCO2

  • 甘露醇——杀手!


心力衰竭与心律失常 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

  • 橡皮筋理论

  • 维持氧供、循环

  • 不用抗心律失常药物


消化功能失调与出血 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

  • 消化道——Sepsis的启动器官!

  • 肠源性内毒素血症

  • 肠道菌群移位


  • 微循环障碍 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

  • 炎症—凝血系统 cross talk

  • 禁食

  • 低钾


  • 改善微循环 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——容量,东莨菪碱

  • 补钾

  • 胃肠道喂养

  • 维生素

  • 肠道微生态制剂——杀手!

    • 内毒素血症、败血症


急性肾功能衰竭 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

  • 肾损伤的时间

  • 本质——炎性损伤

  • 抗炎、抗过敏

  • 血液透析

    • 间歇性血液透析和持续静脉静脉血液滤过(CVVH) 的作用是一样的。

    • 对于血流动力学不稳定的患者,CVVH更易于液体管理。


肺功能障碍与肺出血 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

  • 低氧

  • 炎症反应性损伤

  • 炎症-凝血系统cross talk

  • 保证通气、氧供

  • 改善微循环


激素的应用 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

  • 对于经充分液体复苏和血管升压药物后血压仍

    反应不佳的成人的septic shock,推荐静脉给予氢化的可松治疗。

  • 当不再需要血管加压药物时,应停止激素治疗。


  • 氢化可的松的剂量应≤ 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 small300 mg/day。

  • 如果缺乏休克的证据,不推荐用激素治疗sepsis,除非患者有内分泌疾病,或既往有接受皮质激素治疗的病史。


抗生素与抗病毒药物的应用 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

  • 能否不用抗生素?

  • 中药抗病毒


ad