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sepsis septic shock
.
septic shock
(intensive lifesupport)
(1-3)
septic shock (systemic inammatory response) distributive shock Consensusconference American College of Chest Physician Society of Critical Care
Medicine .. 1992(1)
Infection Bacteremia
Sepsis Systemic
inammatory response syndrome (SIRS) SIRS 2 1. 38 C 36 C, 2.
90 /, 3. 20 / PaCO232 . 4. 12,000 /.. 4,000 /
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.. band form 10% SIRS sepsis burn
organ perfusion severesepsis septic shock
Surviving Sepsis Campaign 2012(2) sepsis 1 severe sepsis sepsis
2 sepsis
(host response) (proinammatoryresponse) " (anti-inammatory response)
immune cell receptors (pathogen-associated molecular patterns)
inammatory genes inammatory mediators humoral response proinammatory mediators tumor necrotic factor (TNF), interleukin 1 interleukin 6 active oxygen free radicals, nitric oxide complement lymphocyte phagocytic cells
endothelial cell sepsis endothelium (adhesion) activated phagocytes proteolytic enzymes (permeability) (edema) tissuefactor anticoagulation system brinolysis disseminated coagulation
thrombus consumptive coagulopathy (coagulation platelet )
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(anti-inammatory response anergy) phagocyte regulatory T cell myeloid suppressor cell apoptosis dendritic cells, T cell B cell cytokine (anti-inammatory cytokines) neuroendocrine vagus nerve proinammatory cytokines anergy immunosuppressivestate infection
(3,4)
generalized vasodilatation capillary leakage pulsepressure systemic inammation (cardiac contractility) cytokines coronaryblood ow acidosis
(disseminatedintravascular coagulation, DIC) (pericapillary edema) (red cell deformability) mitochondrial damage cytokines (5) (cytopathic hypoxia) sepsis
septic shock distributive shock systemic vascular resistance maldistribution blood
ow generalized vasodilatation vascular leakage hypovolemia hemodynamic prole systemic vascular resistance cardiac output
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Sepsis Septic Shock
1. sepsis(2)
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2. severe sepsis(2)
(3,4)
systemic inammation
warm shock cold shock 24-96 progressive organ dysfunction multiple organ failure
lymphoma, leukemia, neutropenia malnutrition corticosteroid hyperventilation
septic shock shock SIRS sepsis severe
sepsis sepsis 1 2
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septic
shock
A, B, C D A airway
airway obstruction
B breathing oxygendelivery respiratory failure
C circulation
D septic shock 3 1)
2) intensive life support 3) neutralize toxin host inammatory
response body uid exudate
septic shock hemoculture 2
septic shock sepsis
septic shock ( Grams stain, AFB ) febrile neutropenia
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Intensive life support
inammatory response
(Goal of therapy)2 tissue perfusion
tissue oxygenation tissue perfusion organ blood ow tissue oxygenation indexes
Mean arterial pressure 65 . 0.5 ././ Central venous (superior vena cava) 70% lactate
10%
(fuid therapy)
isotoniccrystalloid 0.9% NaCl solution, Lactated Ringers solution balanced salt solution
synthetic colloid starches renal injury (6,7)albumin SAFE study albumin (8) (ALBIOSstudy)(9)
(uid loading) 500-1,000 . crystalloid colloid 300-500 . 15 1 (2)
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( 2000 .) jugular venous pressure, central venous pressure (CVP) volume responsive test (cardiopulmonary interaction during positive pressure ventilation) pulse pressure variation (PPV) passive leg raising test cardiac output
CVP CVP
CVP 1015. ( 8-12 .)(2) COPD, pulmonary hypertension ascites abdominal hypertension CVP
uid challenge(10)CVP CVP 100-200 . 15 ( CVP) CVP 5 . preload
CVP 2 . preload CVP (volume excess) 12. 15 . ( )
CVP CVP
(safety limit) (target of therapy)
multiorgan failure 800 .(11)
inotropic drugs vasopressors(2)
norepinephrine (NE)
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NE stroke volume (limb ischemia) NE (central vein) NE 0.1 - 2.0 ././(12)
Dopamine NE(13) NE dopamine (1-2
././) dopamine 1 receptor (5-10 ././) badrenergic receptor cardiac output (> 10 ././)-adrenergic receptor systemic vascular resistance dopamine dopamine
epinephrine
(2)
Optimization of tissue oxygenation(2)
microcirculation central venous oxygen saturation (ScvO
2)
CVP oxygen saturation ScvO2 70%
tissue hypoxia CVP
serum lactate macrocirculation lactate 10 tissue hypoxia(14)
tissue hypoxia goal maintenance fuid intravascular volume capillaryleakage, vasodilatation activation coagulation pathway
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tissue hypoxia oxygendelivery hypovolemia vasopressors hematocrit 30% packedred cell transfusion hematocrit hematocrit 30% dobutamine cardiac output tissue oxygenation
hemodynamic support 2 tissue perfusion continuing leakage 24 () maintenance uid
prolonged tissue hypoxia multiorgan dysfunction
anti-infammatory substance
20-30 steroid septicshock(15)
septic shock stress cortisol Annane (16) hydrocortisone 50 . 6 udocortisone 50 ./ 7 multicenter trial CORTICUS(17) hydrocortisone ACTH stimulation
hydrocortisone
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2. septic shock
(goal) Acceptable BP tissue perfusion MAP
65 . MAP - 40 .
Organ perfusion urine output 0.5 ././., Arterial BloodpH , Blood lactate mixed venous saturation 70%
goal persistent leakage
intravascular uid 24 maintenance
uid intravascular volume (JVP, CVP PCWP ) persistent hypotension
-
-
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adrenal insufciency, anaphylactic shock obstructive shock
hydrocortisone relative adrenal insufciency
(2) ACTH stimulation test
Other organ support
Pulmonary support(2)
acute lung injury sepsis compliance pericapillary edema airway resistance hypercatabolic state respiratory failure respiratory load oxygenation
acute lung injury ARDS septic shock ARDS (6-8 ./.) PEEP lung compliance oxygenation end tidal collapse 5-8 . PaO
2, compliance PaO
2
(PaO2> 60 .) oxygen saturation 90%
(FiO2) < 0.6 plateau airway pressure 35 . PEEP
septic shock induced ARDS PEEP cardiac output
oxygen delivery pressure complication
Sepsis bundle(2)
3-hourbundle 6-hour bundle
3-hour bundle
1. lactate2. hemoculture
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3. hemoculture 4. crystalloids 30 ./. hypotension
lactate 4 /. 6 (6-hour bundle)5. vasopressors hypotension
mean arterial pressure (MAP) 65 .6. septic shock initial lactate 4 /.
. Central venous pressure (CVP)*. Central venous oxygen saturation (ScvO
2)*
. Lactate * Surviving sepsis (18,19)
septic shock
sepsis septic shock Surviving SepsisCampaign 2004 2012
CVP volume responsive tests tissue oxygenation central venous oxygen saturation (ScvO
2)
lactate
(. ) PROCESS(18) ARISE(19) study intravascular volume JVP early goal directed guidelines
www.criticalthai.com www.sepsiseasy.com
Septic shock
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1. ACCP/SCCM Consensus Conference: denition for sepsis and organ failure andguideline for the use of innovative therapies in sepsis: Chest. 1992;101:1644-55.
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3. Angus DC, van der Poll T. Severe Sepsis and Septic Shock. N Engl J Med.2013;369:840-51.
4. Hotclkiss RS, Karl IE. The pathophysiology and treatment of sepsis. N Eng J Med2003; 348:138-50.
5. Fink MP. Bench to bedside review: Cytopathic hypoxia. Critical care. 2002;6:491-9.6. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, neman A, et al.
Hydroxyethyl Starch 130/0.42 versus Ringers Acetate in Severe Sepsis. N Engl JMed. 2012;367:124-34.
7. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl Starch
or Saline for Fluid Resuscitation in Intensive Care. N Engl J Med. 2012;367:1901-11.
8. The SAFE Study Investigators. A compassion of albumin and saline for uidresuscitation in the intensive care unit. N Eng J Med. 2004;350:2247-56.
9. Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. AlbuminReplacement in Patients with Severe Sepsis or Septic Shock. N Engl J Med.2014;370:1412-21.
10. Vincent JL, MD, Weil MH. Fluid challenge revisited. Crit Care Med. 2006;34:13337.11. Permpikul C1, Tongyoo S, Ratanarat R, Wilachone W, Poompichet A. Impact ofSeptic Shock Hemodynamic Resuscitation Guidelines on Rapid Early Volume
Replacement. J Med Assoc Thai. 2006;89 Suppl 5:S55-61.
12. Finfer SR, Vincent JL Circulatory Shock. N Engl J Med. 2013;369:1726-34.
13. De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine versus norepinephrine in
the treatment of septic shock: A meta-analysis. Crit Care Med. 2012;40:725-30.
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14. Jones AE1, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate
clearance vs central venous oxygen saturation as goals of early sepsis therapy. A
Randomized Clinical Trial. JAMA. 2010;303(8):739-46.
15. Cronin L, Cook DJ, Carlet J, Heyland DK, King D, Lansang MA, et.al. Corticosteroid
treatment for sepsis: A critical appraisal and meta-analysis of the literature. Crit
Care Med. 1995;23:1430-9.
16. Annane D1, Sbille V, Charpentier C, Bollaert PE, Franois B, Korach JM, et al. Effect
of treatment with low dose of hydrocortisone and udocortisone on mortality in
patients with septic shock. JAMA. 2002;288:862-71.
17. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al. Hydrocortisone
Therapy for Patients with Septic Shock. N Engl J Med. 2008;358:111-24.
18. The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early
Septic Shock. N Engl J Med. 2014 DOI: 10.1056/NEJMoa1401602.
19. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-Directed
Resuscitation for Patients
with Early Septic Shock. N Engl J Med. 2014;371:1496-506.
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