新光医院感染科败血症标准作业流程

新光醫院感染科敗血症標準作業 流程 快递问题件怎么处理流程河南自建厂房流程下载关于规范招聘需求审批流程制作流程表下载邮件下载流程设计 severesepsisandsepticshock新光醫院感染科黃建賢SEPSISDEFINITIONSmicrobesinvolvesarapidlyamplifyingpolyphonyofsignalsandresponsesthatmayspreadbeyondtheinvadedtissue.1.敗血症的定義敗血症的定義1.1宿主因微生物感染大量繁殖並造而造成全身性症狀，臨床上可 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 現出發燒，低體溫，寒顫，呼吸加速，心搏加速，宿主因為微生物的侵犯而表現出”系統性發炎反應症候群”(systemicinflammatoryresponsesyndrome，SIRS)1.2”系統性發炎反應症候群”定義為包函下列或兩者以上1.2.1體溫38度C以上或36度C以下1.2.2心跳速度超越每分鐘90下1.2.3呼吸速率超越每分鐘20下1.2.4血液中白血球大於每毫升12000或小於每毫升4000或含百分之10以上之不成熟白血球(bands)ETIOLOGYgram-negativeandgram-positivebacteriafungi,mycobacteria,rickettsiae,viruses,orprotozoans…Positivebloodcultures:30to60%ofpatientswithsepsis60to80%ofpatientswithsepticshockSepsisDefinitionsUsedtoDescribetheConditionofSepticPatientsBacteremiaSystemicinflammatoryresponsesyndrome(SIRS)SepsisSeveresepsisSepticshockMultiple-organdysfunctionsyndrome(MODS)PresenceofbacteriainbloodFever,tachypnea,tachycardia,leukocytosis/leukopeniaSIRShasaprovenorsuspectedmicrobialetiologySepsiswith≥1signsoforgandysfunctionSepsiswithhypotensionorneedforvasopressorDysfunctionof≥1organEpidemiologyofSepsisintheUnitedStatesfrom1979-2000NEnglJMed2003;348:1546-54.EPIDEMIOLOGY2/3:inhospitalizedpatients.RiskFactorstoGNBbacteremiadiabetesmellituslymphoproliferativediseasescirrhosisoftheliverburnsinvasiveproceduresordevicesdrugsthatcauseneutropeniaEPIDEMIOLOGYRiskfactorsforGPCbacteremiavascularcatheters,indwellingmechanicaldevices,burns,intravenousdruginjection.Fungemia:immunosuppressedpatientsneutropeniabroad-spectrumantimicrobialtherapyTPNIntestinalperforationPATHOPHYSIOLOGYEndotoxinGramnegativebacilliLipopolysaccharide(LPS,alsocalledendotoxin)PATHOPHYSIOLOGYMicrobialsignalsGrampositivecoccipeptidoglycanandlipoteichoicacidsextracellularenzymes敗血症的症狀Feverorhypothermia(lowbodytemperature)HyperventilationChillsShakingWarmskinSkinrashRapidheartbeatConfusionordeliriumDecreasedurineoutputCLINICALMANIFESTATIONSS/S:fever,chills,tachycardia,tachypnea,alteredmentalstatus,andhypotension.afebrilecommoninneonates,inelderlypatientsandinpersonswithuremiaoralcoholism.CLINICALMANIFESTATIONSLlaboratoryfinding:C-reactiveproteinfibrinogencomplementcomponentstransferrininhibitsalbuminsynthesisLeukocytosis,leftshiftLABORATORYFINDINGSEarlysepsisleukocytosiswithaleftshiftRespiratoryalkalosisThrombocytopeniaHyperbilirubinemiaproteinuria.neutrophilsmaycontaintoxicgranulations,Dohlebodies,orcytoplasmicvacuolesLABORATORYFINDINGSProgressingofsepsis:thrombocytopeniaworsensprolongationofthethrombintimedecreasedfibrinogenpresenceofD-dimers,suggestingDIC)Azotemia,hyperbilirubinemiabecomeprominentElevatedGOTGPTLABORATORYFINDINGSProgressingsepsis:hyperventilationinducesrespiratoryalkalosis.accumulationoflactate,metabolicacidosis(withincreasedaniongap)hyperglycemia,severeinfectionmayprecipitatediabeticketoacidosis(DKA)MultipleorgandysfunctionsyndromeMOF:Dysfunctionorfailureofmultipleorgansreflectingwidespreadvascularendothelialinjuryassociatedwithhighfatalityrates.Mortalityandmorbiditycorrelatewiththenumberoforgansaffected.DIAGNOSISS/S--Progressingsepsistachypnea,tachycardia,alteredmentalstatus,ThesepticresponsecanbequitevariablesystemicinflammatoryresponsesyndromeSIRSDIAGNOSISDefinitivediagnosisisolationofthemicroorganismfrombloodoralocalinfectedsiteGram'sstaincultureoftheprimarysiteofinfection.TREATMENTSepsismaybefatalquickly.Successfulmanagementurgentmeasurestotreatthelocalsiteofinfection,hemodynamicandrespiratorysupporteliminatetheoffendingmicroorganismTherapyofacidosisandDIC,othercomplicationsTREATMENTOutcomeinfluencedbythepatient'sunderlyingdiseaseaggressivelytreated.AntimicrobialagentsPROGNOSISMortality:Morethan25%1/3withinthefirst48hmortalitycanoccur14ormoredayslater.Latedeathspoorlycontrolledinfectioncomplicationsofintensivecaremultipleorgansfailure2.敗血症初期之緊急處理2.1敗血症最初七小時之緊急處理措施著眼於恢復因敗血症所引起的低血流灌注，恢復組織功能，應包含以下所有之緊急處理2.1.1中心靜脈壓維持8-12mmHg2.1.2平均動脈壓維持大於等於65mmHg2.1.3小便量維持大於等於每小時每公斤體重0.5毫升2.1.4中心靜脈氧飽含量維持大於等於70﹪2.敗血症初期之緊急處理2.2臨床檢驗2.2.1由周邊靜脈至少抽取2至3套血液培養後盡快給予抗生素治療2.2.2盡快找尋可能之感染部位並取得檢體，如導管相關之感染，呼吸器相關之肺炎等2.2.3在抗生素使用前須取得可能感染部位之培養檢體，如尿液，腦脊髓液，傷口，呼吸道檢體或其他部位之組織液2.2.4必要時可作血清學檢查、檢測抗體及抗原或檢測尿液中退伍軍人菌抗體2.敗血症初期之緊急處理2.2臨床檢驗2.2.5如有液狀檢體，可作染色鏡檢如葛蘭氏染色，抗酸菌染色等2.2.6軟組織感染時，除了做血液培養外，盡可能取得檢體做染色鏡檢2.2.7必要時可在主治醫師同意下對病灶施行超音波檢查，電腦斷層或核磁共振檢查以確立病灶及嚴重程度2.2.8必要時可對病灶做抽吸或切片檢查以取得檢體2.2.9如病灶有明顯積液、必要時可施以抽吸引流或外科治療3.抗生素療法3.1抗生素治療必須在取得適當檢體後盡快給予3.2當病患有嚴重敗血症或敗血性休克時，要盡速給予體液補充，除非有相當禁忌症(如急性肺水腫等)3.3抗生素經驗療法必須依社區或院內感染，感染部位、菌種、抗生素穿透能力及疾病人實際狀況來給予(參考本院每半年出版之菌種及抗生素敏感試驗表)3.3.1抗生素治療以一種抗生素為原則3.3.2必要時可以合併抗生素使用以治療混合型感染或加強抗生素療效3.3.3抗生素之選擇依病人過去病史，過敏史，合併疾病，合併症及臨床抗生素敏感性做選擇3.抗生素療法3.4抗生素治療必須在使用48小時至72小時後重新評估3.4.1依細菌培養及抗生素敏感性試驗之結果做調整3.4.2以窄效性抗生素為原則3.4.3為避免抗藥性產生，抗生素之選擇以低毒性及同類藥中價廉為原則3.4.4治療以7-10天為原則，必要時可延長之3.4.5抗生素之使用及停用以培養結果及臨床醫師判定為原則4控制病源4.1臨床上所有敗血症病患均盡量查出並除去感染源4.1.1必要時以引流、清創或外科手術行之4.1.2病患有外科手術需求時，必須在完成初步急救並解釋病情之後、在家屬同意下、盡速施行之5輸液治療5.1輸液治療包括自然血漿，人工血漿及一般輸液5.1.1人工輸液較血漿易出現水份積蓄及水腫5.1.2輸液速度以每30分鐘輸人工輸液300至1000毫升、或血漿以每30分鐘300至500毫升為主5.1.3輸液速度及輸液量以臨床反應、血壓及尿液量做調整5.1.4密切監視病患以避免出現肺水腫及其他併發症5.2個人體液需求量依個體及疾病狀況不同依臨床狀況做調整6血管收縮劑6.1當病患經輸液治療後仍無法維持適當的血壓及組織灌流時得使用血管收縮劑治療6.2當低血壓足以危及生命時，血管收縮劑得以和輸液治療同時給予6.3Nor-epinephrine或dopamine須以中心靜脈方式給予6.4使用血管收縮劑病患得施行動脈血壓監測6.5Nor-epinephrine起始劑量以0.01至0.04units/分為原則6.6Cardiacindex在2.5L.min-1.m2以下者不宜使用血管收縮劑7升壓劑(Dobutamine)7.1病患在經適當輸液治療後仍無法維持正常之輸出量時得以使用升壓劑，必要時得合併血管收縮劑使用8類固醇8.1休克病患在適當補充輸液，使用血管升壓劑後，仍無法維持正常血壓時得以使用類固醇8.2劑量以每天hydrocortisone200至300毫克，分3至4次給予，使用7天為原則、必要時得延長之8.3病患在檢測ATCH前得以使用dexamethasone取代hydrocortisone以免影響血中cortisol濃度檢測值8.4敗血症病患未合併休克時，不建議使用類固醇9人類活性C蛋白使用9.1高死亡率之多重器官衰竭、敗血性休克、成人呼吸窘迫症病患，無出血傾向時、APACHEIIscore>=25、在主治醫師同意下得以使用人類活性C蛋白(rhAPC)10血類製劑10.1無特殊禁忌症之敗血症病患在血色素7.0g/dl以下時得以輸血10.2輸血目標值為血色素7.0至9.0g/dl10.3病患無明顯出血時、不建議以冷凍新鮮血漿來改善血液中之凝血值10.4不論有無出血現象，嚴重敗血症病患得以輸用血小板以維持血小板值在5000/mm3以上(5×10-9/L)11呼吸器使用11.1呼吸器使用依本院呼吸器使用原則，及成人呼吸窘迫症呼吸器使用原則行之12鎮靜劑麻醉藥品及肌肉鬆弛劑使用12.1嚴重敗血症病患合併呼吸衰竭及呼吸器使用時、得依本院藥物使用規範使用鎮靜劑麻醉藥物及肌肉鬆弛劑12.2必要時得以會診麻醉科、以進行藥物調整及避免藥物副作用13血中葡萄糖控制13.1敗血症病患須嚴密監測並控制血糖13.2血中葡萄糖控制以200mg/dl以下為原則(有嚴格監測時得控制在140mg/dl以下)13.3必要時得以使用胰島素取代口服降血糖藥控制血糖14碳酸鹽治療14.1碳酸鹽治療得以使用於敗血症合併血流灌注所引起之酸中毒14.2碳酸鹽治療酸中毒以pH值7.3以下為原則14.3嚴重敗血症病患得使用低劑量肝素或低分子量肝素預防深部靜脈血栓形成14.4病患有出血傾向或其他禁忌症時應避免使用肝素15預防壓力性腸胃道潰瘍15.1所有敗血症病患均應預防壓力性潰瘍之產生15.2以使用H2receptor抑制劑為原則，有禁忌症或不適用者除外16褥瘡之預防16.1敗血症合併活動能力降低之病患、應預防褥瘡之產生16.2臨床上依預防褥瘡形成臨床技術手冊行之16.3褥瘡之治療、必要時可給予抗生素及施行清創手術EpidemiologyofSepsisintheUnitedStatesfrom1979-2000NEnglJMed2003;348:1546-54.CausativeOrganismsGram-positivebacteria52.1%Gram-negativebacteria37.6%polymicrobialinfections4.7%anaerobes1.0%fungi4.6%Specificorganismscausingsepsiswererecordedin51%ofalldischargerecordsoverthe22-yearperiod.AntimicrobialAgentsintheManagementofSepsisCritCareMed2004;32:858-73.Twobloodcultureonepercutaneousonefromeachvascularaccess>48hrsmicrobialandclinicaldatanarrow-spectrumantibioticsnon-infectiouscauseidentifiedpreventresistance,reducetoxicityandreducecostoneormoredrugsactiveagainstlikelybacterialorfungalpathogensconsidermicrobialsusceptibilitypatternsEvaluatepatientforafocusedinfectionReassessantimicrobialregimenat48-72hrsBeginIVantibioticswithinthefirsthrofrecognitionofseveresepsisNorepinephrine4mg/4ml/amp(dilutedbyD5W)-0.03~3.3μg/kg/min(2~200μg/kg/hr)Epinephrine1mg/1ml/amp-0.06~0.47μg/kg/min(3.6~30μg/kg/hr)Dopamine200mg/5ml/amp2~55μg/kg/min(0.12~3.3mg/kg/hr)Dobutamine250mg/20ml/amp2~28μg/kg/min(0.12~1.68mg/kg/hr)Vasopressin20U/1ml/amp0.01~0.04U/min(0.6~2.4U/hr)CritCareMed2004;32:1928-48.VasopressorandInotropicsRoleofCorticosteroidintheManagementofSepticShockCritCareMed2004;32:858-73.Treatpatientswhostillrequirevasopressorsdespitefluidreplacementwithhydrocortisone200-300mg/dayfor7daysdividedin3-4dosesorbycontinuousinfusion(GradeC)Highdoseofcorticosteroids(>300mg/day)shouldNOTbeusedinseveresepsisorsepticshock.(GradeA)CritCareMed2004;32:858-73.RoleofCorticosteroidintheManagementofSepticShockIntheabsenceofshock,corticosteroidsshouldNOTbeadministratedforthetreatmentofsepsis(GradeE)TheuseofACTHstimulationtesttoidentifyresponders(>9μg/mlincreaseincortisol30-60minspost-ACTHadministration)andtocontinuetherapyisoptional.ShouldNOTwaitforACTHstimulationresultstoadministercorticosteroids(GradeE)MechanicalVentilationofSepsis-inducedALI/ARDSCritCareMed2004;32:858-73.HightidalvolumethatarecoupledwithhighplateaupressuresshouldbeavoidedinALI/ARDS.reducetidalvolumeover1-2hrsto6ml/kgpredictedbodyweightmaintaininspiratoryplateaupressure<30cmH2OmaintainSaO2/SpO288-95%anticipatedPEEPsettingsatvariousFiO2requirementsFiO20.30.40.40.50.50.60.70.70.70.80.90.90.91.0PEEP55888101012141414161820-24(GradeB)IntensiveInsulininCriticalIllPatientsCritCareMed2004;32:858-73.Afterinitialstabilizationofpatientswithseveresepsismaintainglucose<150mg/dlbycontinuousinfusionofinsulinmonitorbloodglucoseevery30-60minsandthenq4h(GradeD)Inpatientswithseveresepsis,astrategyofglycemiccontrolshouldincludeanutritionprotocolwiththepreferentialuseoftheenteralroute.(GradeE)IntensiveInsulininCriticalIllPatientsNEnglJMed2006;354:449-61.prospective,randomized,controlledtrialadultsadmittedtoSICU(N=1,548)whowerereceivingMVadultsadmittedtoMICU(N=1,200)whowereconsideredtoneedICUcareforatleast3days50IUactrapidHM/50mlNSinfusedbypump(max.dose50IU/hr)intensiveinsulin(bloodglucose~80-110mg/dl)conventionaltreatment(bloodsugar~180-200mg/dl)primaryendpoint:ICUmortality/in-hospitalmortalityIntensiveInsulininCriticalIllPatientsNEnglJMed2001;345:1359-67.NEnglJMed2006;354:449-61.ICUdeathIn-hospitaldeathICUdeathIn-hospitaldeathMortality8.0%vs4.6%10.9%vs7.2%26.8%vs24.2%38.1%vs31.3%*40.0%vs37.3%52.5%vs43.0%*ARR3.4%3.7%2.6%6.8%2.7%9.5%NNT2927-14-10RRR42.5%33.9%9.7%17.8%6.8%18.1%Pvalue<0.040.010.310.050.330.009*patientswhostayedintheICU≥3daysSurgicalICUMedicalICU