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新光醫院感染科敗血症標準作業流程severesepsisandsepticshock新光醫院感染科黃建賢SEPSISDEFINITIONS–microbesinvolvesarapidlyamplifyingpolyphonyofsignalsandresponsesthatmayspreadbeyondtheinvadedtissue.1.敗血症的定義1.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-positivebacteria–fungi,–mycobacteria,–rickettsiae,–viruses,–orprotozoans…Positivebloodcultures:–30to60%ofpatientswithsepsis–60to80%ofpatientswithsepticshockSepsisDefinitionsUsedtoDescribetheConditionofSepticPatientsBacteremiaSystemicinflammatoryresponsesyndrome(SIRS)SepsisSeveresepsisSepticshockMultiple-organdysfunctionsyndrome(MODS)PresenceofbacteriainbloodFever,tachypnea,tachycardia,leukocytosis/leukopeniaSIRShasaprovenorsuspectedmicrobialetiologySepsiswith≥1signsoforgandysfunctionSepsiswithhypotensionorneedforvasopressorDysfunctionof≥1organEpidemiologyofSepsisintheUnitedStatesfrom1979-2000NEnglJMed2003;348:1546-54.EPIDEMIOLOGY2/3:inhospitalizedpatients.RiskFactorstoGNBbacteremia–diabetesmellitus–lymphoproliferativediseases–cirrhosisoftheliver–burns–invasiveproceduresordevices–drugsthatcauseneutropeniaEPIDEMIOLOGYRiskfactorsforGPCbacteremia–vascularcatheters,–indwellingmechanicaldevices,–burns,–intravenousdruginjection.Fungemia:–immunosuppressedpatients–neutropenia–broad-spectrumantimicrobialtherapy–TPN–IntestinalperforationPATHOPHYSIOLOGYEndotoxinGramnegativebacilliLipopolysaccharide(LPS,alsocalledendotoxin)PATHOPHYSIOLOGYMicrobialsignalsGrampositivecoccipeptidoglycanandlipoteichoicacidsextracellularenzymes敗血症的症狀Feverorhypothermia(lowbodytemperature)HyperventilationChillsShakingWarmskinSkinrashRapidheartbeatConfusionordeliriumDecreasedurineoutputCLINICALMANIFESTATIONSS/S:–fever,chills,tachycardia,tachypnea,alteredmentalstatus,andhypotension.afebrile–commoninneonates,inelderlypatients–andinpersonswithuremiaoralcoholism.CLINICALMANIFESTATIONSLlaboratoryfinding:–C-reactiveprotein–fibrinogen–complementcomponents–transferrin–inhibitsalbuminsynthesis–Leukocytosis,leftshiftLABORATORYFINDINGSEarlysepsis–leukocytosiswithaleftshift–Respiratoryalkalosis–Thrombocytopenia–Hyperbilirubinemia–proteinuria.–neutrophilsmaycontaintoxicgranulations,Dohlebodies,orcytoplasmicvacuolesLABORATORYFINDINGSProgressingofsepsis:–thrombocytopeniaworsens–prolongationofthethrombintime–decreasedfibrinogen–presenceofD-dimers,suggestingDIC)–Azotemia,hyperbilirubinemiabecomeprominent–ElevatedGOTGPTLABORATORYFINDINGSProgressingsepsis:–hyperventilationinducesrespiratoryalkalosis.–accumulationoflactate,–metabolicacidosis(withincreasedaniongap)–hyperglycemia,severeinfectionmayprecipitatediabeticketoacidosis(DKA)MultipleorgandysfunctionsyndromeMOF:–Dysfunctionorfailureofmultipleorgans–reflectingwidespreadvascularendothelialinjury–associatedwithhighfatalityrates.–Mortalityandmorbiditycorrelatewiththenumberoforgansaffected.DIAGNOSISS/S--Progressingsepsis–tachypnea,–tachycardia,–alteredmentalstatus,–Thesepticresponsecanbequitevariable–systemicinflammatoryresponsesyndromeSIRSDIAGNOSISDefinitivediagnosis–isolationofthemicroorganismfrombloodoralocalinfectedsite–Gram'sstain–cultureoftheprimarysiteofinfection.TREATMENTSepsismaybefatalquickly.Successfulmanagement–urgentmeasurestotreatthelocalsiteofinfection,–hemodynamicandrespiratorysupport–eliminatetheoffendingmicroorganism–TherapyofacidosisandDIC,othercomplicationsTREATMENTOutcome–influencedbythepatient'sunderlyingdisease–aggressivelytreated.–AntimicrobialagentsPROGNOSISMortality:–Morethan25%–1/3withinthefirst48h–mortalitycanoccur14ormoredayslater.–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