?????????????? (Severe Sepsis and Septic Shock)

1
??????????????(Severe Sepsis and Septic Shock)
2
????

• ????????????????????????????????????,?????????????
  ??????1000????3?????????????,????????????????,???1
  0??,???????????91.3,???1.5--8.0??????

3
????

• ???,??????????????????????,????????????30-70?
• ???,??????10??????,????25?????????????,???????????
  ????????????????????????
• ???????????????,???????????????????????????,????,?
  ????????,????????????????,????????????????????????
  ?

4
Sepsis Statistics------www.SCCM.org--- Putting
severe sepsis in perspective --

• Every year, severe sepsis strikes an estimated
  750,000 people in the United States.
• The annual incidence of severe sepsis is expected
  to rise to 1 million by the end of the decade as
  the population ages.
• The incidence rate of sepsis has increased 91.3
  percent over the last ten years.
• This year, severe sepsis will likely take 215,000
  lives in the United States.
• Sepsis is the leading cause of death in the
  non-coronary ICU.

5
Sepsis Statistics-----www.SCCM.org-- Putting
severe sepsis in perspective --

• Severe sepsis takes more lives than breast,
  colon/rectal, pancreatic, and prostate cancer
  combined.
• The CDC recently reported that septicemia, a form
  of sepsis, has become the tenth leading killer in
  the United States. And more people die from
  sepsis each year than from septicemia.
• Every hour, 25 people in the United States die
  from severe sepsis.
• One of every three patients who develop severe
  sepsis will die within a month.

6
??

• SIRS (????????????????????)
• Sepsis (???????????????)
• Severe Sepsis (?????????????
• ?????????????)
• Septic Shock (?????????????????
• ??)
• ----1991?ACCP/SCCM???????????

7
GENERAL SIGNS AND SYMPTOMS IN SEPSIS
8
2001???Sepsis ??????Sepsis??????
------Crit Care Med. 2003 Apr31(4)1250-6.
-----?????????200416(6)321-324
----???????????20043(3)131-133

•  
• ?????????,?????????
• (1)  ????
• ??(????gt38.3?)
• ??(????lt36.0?)
• ??gt90?/min??????????????2????
• ??gt30?/min
• ????
• ??????????(gt20ml/kg??24h)
• ????(??gt7.7mmol/L?110mg/dl)??????

9
2001???Sepsis ??????Sepsis??????(2)  ??????

• ??????(?????gt12109/L)
• ??????(?????lt4109/L)
• ???????,???????gt0.10
• ??C????gt???2????
• ????(????)gt???2????

10
2001???Sepsis ??????Sepsis??????(3)???????

• ???????lt90mmHg(1mmHg0.133kPa),?????lt70mmHg,??????
  ??gt40mmHg, ??????gt2?????
• ?????????gt0.70
• ????gt3.5Lmin-1m-2

11
2001???Sepsis ??????Sepsis??????(4)????????

• ????(PaO2/FiO2lt300mmHg)
• ????(??lt0.5mlkg-1h-1?45mmol/L???????2h)????5mg/
  L
• ????(???????gt1.5???????????gt60s)
• ??(?????)
• ??????(?????lt100109/L)
• ??????(????gt40mg/L?70mmol/L)?

12
2001???Sepsis ??????Sepsis??????(5)??????

• ?????(gt3mmol/L)
• ??????????????????

13
Sepsis???PIRO??

• ?????(predisposition)????????(infection/insult)???
  ??(response)???????(organdysfunction)???
• ?????PIRO?????????????(stagingsystem),??????????
  ????????,????????????
• PIRO?????????1???????????????????????????????????
  ??????????????(??????????)?2?????????????????????
  ????????????????????3?????????(?)????????????????
  ?????,????????????????????????????????4??????????
  ????????????(TNM)????,??????????????????

14
Sepsis???PIRO???? ?? ????
??????

• ??? ???????????? ????????????(TNF?IL 1?CD
• 
  
  14)
• ??????????? ?????????????????
• ???? ?????????? ???????????(LPS)?
• ??????
  ???????DNA??????
• ??????????
• ???? SIRS??????? ????????????(?????IL 6)
• ??C ???? ????????????????
  DR(HLA DR)
• 
  ?????????C?TNF????????(PAF)
• ?????? ???????? ????????????
• ??????MODS? (????,???????,?????
  ?)
• ???????????(SOFA)?

15
SSC-Phase 2

• Surviving Sepsis Campaign guidelines for
  management of severe sepsis and septic shock
• ---- Crit Care Med 2004 ,32(3)
  858-873
• ----Intensive Care Med
  2004305365.

16
?????(SSC-Phase 2)

• 11??????????????? (SCCM)????????? (ESICM)???????(
  ISF)??????????????(ANZICS)??????????(AACCN)???????
  ??(ACCP)?????????(ACEP)???????(ATS)???????(ERS)???
  ???????????????(SIS)???????????????????????,??????
  ?????????,???????????????????????????

17
?????(SSC-Phase 2)

• ??????????????????
• ???Medline????10?????????
• ????????(infection)???????????????????????????????
  ?????????????,?????????????????,??????????????????
  ,???23?????,?2830d?????????,????????????????,???
  ?????????????,???????????,??????????????,?????????
  ???,????,??????????????SSC?????????2003?10????????
  ?2???,??2003?12??????????11????44??????????????,??
  ??????????,??????????46??????

18
?????

• ??????????2001?ISF???Delphi????
• ???? ?? ??????
  ??
• A ???2?I??????? I ?????????
• 
  
  ????,????
• 
  
  ????????
• B ??1?I??????? II
  ????????,
• 
  ?????,????
• 
  (?)
  ????????
• C ??II??????? III
  ??????????
• D ???1?III??????? IV ????????
• 
  
  ?????
• E ??IV??V??????? V ????,?????
• 
  
  ?????
•  

19
??????

• 1 ????(??????Early goal-directed therapy EGDT
  ---N Engl J Med. 2001 Nov 8345(19)1368-77. )
• 1.1 ??????????,????????????6h???????
• ?????(CVP)8-12mmHg(l cmH2O7.5mmHg)
• ???????????????????,??????????????????????,CV
  Pl2-15mmHg???????
• ?????65mm Hg(MAP???1/3???)
• ?? 0.5ml kg-1h-1
• ??????????????(ScvO2?Sv02) 0.70
• (????B?)?

20
??????

• 1 ????(?????? EGDT)
• 1.2 ??????CVP?8-12mmHg,?ScvO2?SvO2????0.70,???????
  ?????????0.30??,?(?)???????(?????20µgkg-1min-1)?
  ?????????
• (????B?)

21
??????

• ?????
• 2.1 ?????????????????????(????D?)?
• ????????,????2???????????????,?????????????
  ?,?????????????,??????????????????????????????????
  ??????,???????????????????????????????????????????
  ???2h,??????????????????
• ?????????????????

22
2 ?????

• 2.2 ?????????????,??????????,??????????????(????E
  ?)?
• ?????????????????????X????CT???B????????????
  ,???????????,??????????????,????????????????,?????
  ???ICU???????????????????????????????,??????????(?
  ?????????????????)????????,????????????CT???????,?
  ?????

23
??????

• ?????
• 3.1 ???????l h??,???????????(?
• ???E?)?
• 3.2 ???????????????????????????,???????????(?????)
  ??????,????????????????????(????D?)?
• 3.3 ???????,??????,????,?????48-72h?,?????????????
  ?????,?????????????????????7-1Od(????E?)?a.??????
  ??,????????(????E?)?
• b.??????????????????,????????,???????????????
  ?????(????E?)?
• 3.4 ???????????????,????????(????E?)?

24
??????

• 4 ?????
• 4.1 ????????(????E?)?
• 4.2 ?????????,??????,???????????(????E?)?
• 4.3??????(????????????????????),?????????,????????
  (????E?)?
• 4.4???????????????????????????????????,???????????
  ,?????(????E?)?

25
??????

• ????
• 5.1?????????????????????,?????????????????????(???
  ?C?)?
• 5.2????????????????,????????,??30min???500-1000ml?
  ???300-500ml???,?????????(?????????)????(?????????
  )???????????????(????E?)?

26
??????

• 6 ??????
• 6.1???????????????????????,
• ?????????????????????,???
• ?????????,??????????????????????????lt????E?gt?
• 6.2 ???????????????????????????lt????D?gt?
• 6.3 ????????????????????(????B?)?
• 6.4 ????????,????????????????,??????(????E?)?
• 6.5 ?????????,???????????,???????????????,????????
  ,???????????????????????????????0.01-0.04U/min(???
  ?E?)?

27
??????

• 7 ???????
• 7.1???????????????,???????????????????????,???????
  ?(????E?)?
• 7.2???????????????????(????A?)?

28
??????

• 8 ????????
• 8.1 ????????????????????????????,???????????,????
  ?200-300mg/d,?3-4??????,??7d(????C?)?
• 8.2 ????????????300mg(????A?)?
• 8.3 ???????????,????????????????????????????,????
  ??????????(????E?)?

29
??????

• ??????C (rh-APC)
• ??????????????ltAPACHEgtII25????????????????(MODS)?
  ????????????????????(ARDS)??????????,??????????,??
  ????rh-APC(????B?)?

30
rhAPC???????

• ????????????????????,???????????????????????
  ???
• ???????????????????????????????,????????????????
  ,????????????????????????????????????????????????
  ???????rhAPC??????????,???????????????????????????
  ???,??rhAPC??????????????????????,????????????????
  ????????????,Gordon????1690???????,????,?24µgkg-1
  h-1??96h????rhAPC??????????????????????(28d????24
  .7?30.8)?

31
??????

• ??rhAPC????
• lt????????????agt
• rhAPC???????,??????????,??rhAPC?????????????????
• ???????
• ???????(3???)
• ???????????,???????(2???)
• ?????????????????
• ???????
• ??????????????
• ?a????????rh APC?????????????30x109/L

32
??????

• 10 ???????
• 10.1 ?????????,????????????????????,?????lt7Og/L?,
  ????????,?????????70-9Og/L(????B?)?
• 10.2 ?????????????????????,??????????(????B?)?
• 10.3 ????????????,??????????????(FFP)???????(????
  E?)?
• 10.4 ?????????????????????(????B?)?
• 10.5 ?????lt5109/L,????????,?????????????(5-30)
  109/L,?????????,????????????????????????????gt5O10
  9/L(????E?)?

33
??????

• 11 ?????????(ALI)?(?)ARDS?????
• 11.1 ALI?(?)ARDS????????????????,???????????(????
  ???6ml/kg),??????????3Ocm H20(????B?)
• ?
• 11.2 ?????????????????,???????????(PaCO2)????,???
  ????????(????C?)?
• 11.3 ????????????????????(PEEP)(????E?)?
• 11.4 ???????(FiO2)??????????ARDS??,???????????,??
  ??????(????E?)?
• 11.5 ??????????45????,?????????????(????C?)?
• 11.6 ??????????,?????????(SBT),??????????????????
  ????????(??????)????????????????????PEEP??????
  ?????????FiO2???SBT??,??????SBT????5cm
  H2O?????????T?(????A?gt?

34
ARDSNET Ventilator Management

• Assist control modevolume ventilation
• Reduce tidal volume to 6 mL/kg predicted body
  weight
• Keep Pplat lt 30 cm H2O
• Reduce Tv as low as 4 mL/kg predicted body
  weight to limit Pplat
• Maintain SaO2/SpO2 8895
• Anticipated PEEP settings at various FIO2
  requirements
• FIO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9
  0.9 0.9 1.0
• PEEP 5 5 8 8 10 10 10 12 14 14
  14 16 18 2024
• Predicted Body Weight Calculation
• Male50 2.3 height (inches) _- 60 or 50
  0.91 height (cm) -152.4
• Female45.5 2.3 height (inches) - 60 or 45.5
  0.91 height (cm) - 152.4
• Tv, tidal volume SaO2, arterial oxygen
  saturation PEEP, positive end-expiratory
  pressure.
• 872 Crit Care Med 2004 Vol. 32, No. 3

35
??????

• Use of spontaneous breathing trial in weaning
  ARDS patients
• Original illness resolving no
  new illness
• Off vasopressors and continous
  sedatives
• Cough during suctioning
• PaO2/FiO2 gt200mmHg
• PEEP?5cmH2O
• Minute ventilation lt
  15L/min
• F/Tv ratio ?105 during 2-min spontaneous
  breathing trial
• Spontaneous breathing trial
  (30-120 mins)

36

• Respiratory rate gt 35/min
  Oxygen saturation lt 90
  Pulse gt 140/min or change 20
• SBP gt 180 mmHg or lt 90 mmHg
• Agitation,diaphoresis,anxiety
• F/Tv ratio gt 105
• No
  Yes
• Cough adequate to secretions
• Able to protect airway
• Yes No
• Extubate Return to
  maintenance MV

37
ESICM/ATS/ERS/SCCM/SRLF CONSENSUS CONFERENCES

• The 2005 Conference is scheduled in Budapest,
  Hungary, on 28-29 April 2005. The topic will be
  Weaning from mechanical ventilation. The ERS is
  the organisation body.  

38
??????

• 12 ???????????
• 12.1 ????????????,?????????????(????B?)?
• 12.2 ??????????????????,??????????????????,???????
  ?,?????????(????B?)?
• 12.3 ???????????????,?????(????E?)?

39
??????

• ????
• 13.1 ??????????????????????8.3mmol/L(150mg/dl)????
  ?,?????????????????????????????30-60min??????,????
  4h????(????D?)?
• 13.2??????????????????????(????E?)?

40
??????

• 14??????
• ??????????,????-????????????????????????
  ???????????????,?????????????????(????B?)?

41
??????

• 15 ??????
• pH7.15????????????(????C?)?
• ????,??????????????????????,?Cooper???????????
  ??????????pH?7.13?????,?????????????,?????????????
  ?????,??????CVP??????????????????????????????????,
  ????????????????????????????????????????????????

42
??????

• 16 ?????(DVT)???
• ??????????????????????DVT?????????(???
  ????????????????????)?,????????????lt??????????)???
  ?DVT????????,?????????????????(????A?)?

43
??????

• DVT??????????????????????????????????????????????
  ??????,????????????,???????????????????????,?????,
  ????DVT?????,?????DVT???
• ?????????????????,??????????????????????????(ICU)?
  ?(?????????)??DVT?????????????????,Samama??1102???
  ?????????,????,???????40mg/d???????????5.5,??????
  ??(14.9gt,?????????????????DVT??????,Cade?????????
  ??,DVT????29.0?????500OU????2?/d?????,DVT????13.0
  ,??????????(29.0gt?
• ????????????????????DVT????????,??????????????????
  ???,???????????????DVT?

44
??????

• 17 ????????
• ??????????????????H2???????????????????P
  H???,??????????H2?????(????A?)?

45
??????

• 18 ??????
• ?????????????????????????????,?????????
  ??????????(????E?gt?

46
Treatments HOW IS SEPSIS TREATED?
47
Thank you !