การรักษาภาวะ sepsis และ septic shock

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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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Sepsis Septic Shock

.. 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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Sepsis Septic Shock

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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Sepsis Septic Shock

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.

2. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al., SurvivingSepsis Campaign: International Guidelines for Management of Severe Sepsis and

Septic Shock: 2012. Crit Care Med. 2013;41:580-637.

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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การรักษาภาวะ sepsis และ septic shock

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