SSC_脓毒症管理 2005 .ppt
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Surviving Sepsis
A global program to:
Reduce mortality rates in severe sepsis
Surviving Sepsis
Phase 1Barcelona declaration
Phase 2Evidence based guidelines
Phase 3Implementation and education
Surviving Sepsis
Phase 1Barcelona declaration
Phase 2Evidence based guidelines
Phase 3Implementation and education
Sponsoring Organizations
> American Association of Critical Care Nurses
> American College of Chest Physicians
> American College of Emergency Physicians
> American Thoracic Society
> Australian and New Zealand Intensive Care Society
> European Society of Clinical Microbiology and Infectious Diseases
> European Society of Intensive Care Medicine
> European Respiratory Society
> International Sepsis Forum
> Society of Critical Care Medicine
> Surgical Infection Society
Guidelines Committee*
Dellinger (RP)
Carlet
Masur
Gerlach
Levy
Vincent
Calandra
Cohen
Gea-Banacloche
Keh
Marshall
Parker
Harvey
Hazelzet
Hollenberg
Jorgensen
Maier
Maki
Marini
Opal
Osborn
Parrillo
Rhodes
Sevransky
Surviving Sepsis Campaign (SSC) Guidelines for Management of Severe Sepsis and Septic Shock
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM and the
SSC Management Guidelines Committee
Crit Care Med 2004;32:858-873
Intensive Care Med 2004;30:536-555
available online at
www.springerlink.com
www.sccm.org
www.sepsisforum.com
Clarifications
> Recommendations grouped by category and not by hierarchy
> Grading of recommendation implies literature support and not priority of importance
Initial Resuscitation
Initial Resuscitation
> In the presence of sepsis-induced hypoperfusion
* Hypotension
* Lactic acidosis
Initial Resuscitation
Goals during first 6 hours:
> Central venous pressure: 8-12 mm Hg
> Mean arterial pressure ? 65 mm Hg
> Urine output ?? 0.5 mL kg-1/hr-1
> Central venous (superior vena cava) or mixed venous oxygen [SvO2] saturation ? 70%
Grade B
Initial Resuscitation
Goals during first 6 hours:
> Central venous or mixed venous O2 sat < 70% after CVP of 8-12 mm Hg
? Packed RBCs to Hct 30%
? Dobutamine to max 20 ?g/kg/min
Grade B
Diagnosis
> Appropriate cultures
> Minimum 2 blood cultures
? 1 percutaneous
? 1 from each vascular access ? 48 hrs
Grade D
Antibiotic Therapy
> Begin intravenous antibiotics within first hour of recognition of severe sepsis.
Grade E
Antibiotic Therapy
> One or more drugs active against likely bacterial or fungal pathogens.
> Consider microorganism susceptibility patterns in the community and hospital.
Grade D
Antibiotic Therapy
Reassess antimicrobial regimen at 48-72 hrs
? Microbiologic and clinical data
? Narrow-spectrum antibiotics
? Non-infectious cause identified
? Prevent resistance, reduce toxicity, reduce costs
Grade E
Source Control
> Evaluate patient for a focused infection amendable to source control measures including abscess drainage or tissue debridement.
? Move rapidly
? Consider physiologic upset of measure
? Intravascular access devices
Grade E
Fluid Therapy
> Fluid resuscitation may consist of natural or artificial colloids or crystalloids.
Grade C
Fluid Therapy
> Fluid challenge over 30 min
? 500-1000 ml crystalloid
? 300-500 ml colloid
> Repeat based on response and tolerance
Grade E
Vasopressors
> Either norepinephrine or dopamine administered through a central catheter is the initial vasopressor of choice.
? Failure of fluid resuscitation
? During fluid resuscitation
Grade D
Vasopressors
> Do not use low-dose dopamine for renal protection.
Grade B
Vasopressors
> In patients requiring vasopressors, place an arterial catheter as soon as possible.
Grade E
Inotropic Therapy
> Consider dobutamine in patients with measured low cardiac output despite fluid resuscitation.
> Continue to titrate vasopressor to mean arterial pressure of 65 mm Hg or greater.
Grade E
Inotropic Therapy
> Do not increase cardiac index to achieve an arbitrarily predefined elevated level of oxygen delivery.
Grade A
Yu, et al.CCM 1993; 21:830-838
Hayes, et al.NEJM 1994; 330-1717-1722
Gattinoni, et al.NEJM 1995; 333:1025-1032
> Annane, Bollaert and Briegel
* Different doses, routes of administration and stopping/tapering rules
> Annane
* Required hypotension despite therapeutic intervention
> Bollaert and Briegel
* Required vasopressor support only
Steroids
Optional:
> Adrenocorticotropic hormone (ACTH) stimulation test (250-?g)
Dexamethasone and
Cortisol Assay
Steroids
Optional:
> Taper corticosteroid dose at end of therapy.
Grade E
ADRENALS AND SURVIVAL
FROMENDOTOXEMIA
Recombinant Human Activated Protein C (rhAPC)
> High risk of death
* APACHE II ? 25
* Sepsis-induced multiple organ failure
* Septic shock
* Sepsis induced ARDS
> No absolute contraindications
> Weigh relative contraindications
Grade B
Blood Product Administration
Red Blood Cells
Tissue hypoperfusion resolved
No extenuating circumstances
* Coronary artery disease
* Acute hemorrhage
* Lactic acidosis
Transfuse < 7.0 g/dl to maintain 7.0-9.0 g/dL
Grade B
Blood Product Administration
> Do not use erythropoietin to treat sepsis-related anemia.Erythropoietin may be used for other accepted reasons.......（后略) ......
Surviving Sepsis
A global program to:
Reduce mortality rates in severe sepsis
Surviving Sepsis
Phase 1Barcelona declaration
Phase 2Evidence based guidelines
Phase 3Implementation and education
Surviving Sepsis
Phase 1Barcelona declaration
Phase 2Evidence based guidelines
Phase 3Implementation and education
Sponsoring Organizations
> American Association of Critical Care Nurses
> American College of Chest Physicians
> American College of Emergency Physicians
> American Thoracic Society
> Australian and New Zealand Intensive Care Society
> European Society of Clinical Microbiology and Infectious Diseases
> European Society of Intensive Care Medicine
> European Respiratory Society
> International Sepsis Forum
> Society of Critical Care Medicine
> Surgical Infection Society
Guidelines Committee*
Dellinger (RP)
Carlet
Masur
Gerlach
Levy
Vincent
Calandra
Cohen
Gea-Banacloche
Keh
Marshall
Parker
Harvey
Hazelzet
Hollenberg
Jorgensen
Maier
Maki
Marini
Opal
Osborn
Parrillo
Rhodes
Sevransky
Surviving Sepsis Campaign (SSC) Guidelines for Management of Severe Sepsis and Septic Shock
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM and the
SSC Management Guidelines Committee
Crit Care Med 2004;32:858-873
Intensive Care Med 2004;30:536-555
available online at
www.springerlink.com
www.sccm.org
www.sepsisforum.com
Clarifications
> Recommendations grouped by category and not by hierarchy
> Grading of recommendation implies literature support and not priority of importance
Initial Resuscitation
Initial Resuscitation
> In the presence of sepsis-induced hypoperfusion
* Hypotension
* Lactic acidosis
Initial Resuscitation
Goals during first 6 hours:
> Central venous pressure: 8-12 mm Hg
> Mean arterial pressure ? 65 mm Hg
> Urine output ?? 0.5 mL kg-1/hr-1
> Central venous (superior vena cava) or mixed venous oxygen [SvO2] saturation ? 70%
Grade B
Initial Resuscitation
Goals during first 6 hours:
> Central venous or mixed venous O2 sat < 70% after CVP of 8-12 mm Hg
? Packed RBCs to Hct 30%
? Dobutamine to max 20 ?g/kg/min
Grade B
Diagnosis
> Appropriate cultures
> Minimum 2 blood cultures
? 1 percutaneous
? 1 from each vascular access ? 48 hrs
Grade D
Antibiotic Therapy
> Begin intravenous antibiotics within first hour of recognition of severe sepsis.
Grade E
Antibiotic Therapy
> One or more drugs active against likely bacterial or fungal pathogens.
> Consider microorganism susceptibility patterns in the community and hospital.
Grade D
Antibiotic Therapy
Reassess antimicrobial regimen at 48-72 hrs
? Microbiologic and clinical data
? Narrow-spectrum antibiotics
? Non-infectious cause identified
? Prevent resistance, reduce toxicity, reduce costs
Grade E
Source Control
> Evaluate patient for a focused infection amendable to source control measures including abscess drainage or tissue debridement.
? Move rapidly
? Consider physiologic upset of measure
? Intravascular access devices
Grade E
Fluid Therapy
> Fluid resuscitation may consist of natural or artificial colloids or crystalloids.
Grade C
Fluid Therapy
> Fluid challenge over 30 min
? 500-1000 ml crystalloid
? 300-500 ml colloid
> Repeat based on response and tolerance
Grade E
Vasopressors
> Either norepinephrine or dopamine administered through a central catheter is the initial vasopressor of choice.
? Failure of fluid resuscitation
? During fluid resuscitation
Grade D
Vasopressors
> Do not use low-dose dopamine for renal protection.
Grade B
Vasopressors
> In patients requiring vasopressors, place an arterial catheter as soon as possible.
Grade E
Inotropic Therapy
> Consider dobutamine in patients with measured low cardiac output despite fluid resuscitation.
> Continue to titrate vasopressor to mean arterial pressure of 65 mm Hg or greater.
Grade E
Inotropic Therapy
> Do not increase cardiac index to achieve an arbitrarily predefined elevated level of oxygen delivery.
Grade A
Yu, et al.CCM 1993; 21:830-838
Hayes, et al.NEJM 1994; 330-1717-1722
Gattinoni, et al.NEJM 1995; 333:1025-1032
> Annane, Bollaert and Briegel
* Different doses, routes of administration and stopping/tapering rules
> Annane
* Required hypotension despite therapeutic intervention
> Bollaert and Briegel
* Required vasopressor support only
Steroids
Optional:
> Adrenocorticotropic hormone (ACTH) stimulation test (250-?g)
Dexamethasone and
Cortisol Assay
Steroids
Optional:
> Taper corticosteroid dose at end of therapy.
Grade E
ADRENALS AND SURVIVAL
FROMENDOTOXEMIA
Recombinant Human Activated Protein C (rhAPC)
> High risk of death
* APACHE II ? 25
* Sepsis-induced multiple organ failure
* Septic shock
* Sepsis induced ARDS
> No absolute contraindications
> Weigh relative contraindications
Grade B
Blood Product Administration
Red Blood Cells
Tissue hypoperfusion resolved
No extenuating circumstances
* Coronary artery disease
* Acute hemorrhage
* Lactic acidosis
Transfuse < 7.0 g/dl to maintain 7.0-9.0 g/dL
Grade B
Blood Product Administration
> Do not use erythropoietin to treat sepsis-related anemia.Erythropoietin may be used for other accepted reasons.......（后略) ......
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