PDF《Sepsis》

Sepsis 台中荣总 儿童医学部 ?明志 医师 Systemic Inflammatory Response Syndrome (SIRS) Infection Non-infection disease (e.

g., acute illness or trauma) Tissue injury Adequate support Inadequate resuscitation Excessive Inflammation Systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS) Recovery Recovery 定义 ? SIRS: >=2 criteria C 发烧 Core Temp > 38.5 or <

36 ℃ C 心跳加速Unexplained tachycardia or bradycardia <

1 y C 喘Tachypnea or mechanical ventilation for an acute process C 白血球?低或上升band form ? Leukopenia or 10% immature neutrophiles ? Sepsis: 感染相关的SIRS ? Severe sepsis: C Cardiac vascular dysfunction C ARDS C >=

2 organs dysfunctions ? Septic shock: C sepsis and cardiovascular organ dysfunction ??病学 ? SIRS/sepsis 750,000 American adults, mortality 28~60% ? Children 0.56 cases/1000 person-year ? In-hospital mortality 10% ? Death rate increased with the numbers of organ failure C 7% single organ, 53.1% four organ ? Mean length of stay

31 days ? Cost US$ 40,600, annually $1,970,000,000 Organ dysfunction 系统 表现 心血管系统 在fluid bolus >=

40 mL/kg in

1 hr仍 低血压 需使用强心剂 或以下?个以上: 1. 代谢性酸中毒 2. 乳酸升高?倍以上 3. 寡? 4. 微血管回填>=5 sec 5. 中心与周边体温差大於3? 呼吸 1. PaO2/FiO2 <

300 2. PaCO2 >

65 mmHg or

20 mmHg above baseline >50% FiO2 to maintain O2Sat > 92% 神经系统 GCS =3 血液 Plt <

80000 mm3 or decline > 50%, or INR >

2 肾脏 Cr >= 上限?倍,或?倍上升 肝脏 Bil. Total >

4 mg/dL (NB?外)or ALT ?倍上升 JAMA 1995;

273:

117 2008战胜败血症,黄??小时 N engl J Med 2001: 345:

1368 第一小时 1. Monitor ECG, SpO2, NIBP 2. Consider intubation and mechanical ventilation if respiratory failure 3. Artery-line placement & ABP monitor 4. Placement of a CVP catheter (PreSep CVP with ScvO2 is preferred) 5. Obtain smear and related cultures Obtain

2 or more blood culture (Previous colonized fungus → fungus culture) 6. Check CBC+DC, INR/PTT, AST, ALT, Bil T/D, Glu, electrolytes, BUN/Cr,CRP or Procalcitonin as needed 7. Check chest x-ray or other image study as needed 8. Check ABG, electrolytes, and lactate 9. Initiate empiric broad spectrum and adequate dose antibiotics therapy 10. Start early goal-directed treatment for shock Goals: MAP >

65 mmHg, ScvO2>70% Urine output >

1 ml/kg/h 11. Fluid supplement to target CVP as needed CVP→ 8-12 mmHg (12-15 mmHg if intubated) Push NS or colloid

20 ml/kg first, repeated over 60cc/kg as needed 12. If MAP still <

65 mmHg after adequate fluid supplement: 1st line Dopamine 5-20 mcg/kg/min Dobutamine 2-20 mcg/kg/min (if low cardiac output and elevated systemic vascular resistance states) 2nd line Levophed 0.5-2 mcg/kg/min, or Epinephrine 0.04-0.2 mcg/kg/min 1-6 hour 1. Ongoing early goal-directed treatment for shock 2. If shock is refractory to vasopressor and inotropic, may use Solu-Cortef

50 mg/m2/24hr if at risk for absolute adrenal insufficiency, remember to taper down steroid once the shock is resolved 3. If MAP >

65 mmHg, but ScvO2 < 70% Consider further fluid supplement as tolerated PRBC supplement for Hct < 30% 4. If shock persisted, evaluate heart function Check cardiac echo, PiCCO, PAC, or CCO as needed 5. Control blood sugar <

150 mg/dL 5. Check ABG, electrolytes, and lactate as needed 6-24 hour 1. Ongoing goal-directed treatment for shock 2. Recheck ABG, electrolytes, and lactate as needed 3. Remove source of infection if possible Site: Intervention: 4. Protective ventilation strategy If PaO2/FiO2