脓毒症3.0

严重脓毒症及脓毒性休克流行病学严重脓毒症患者死亡风险为34%，脓毒性休克患者死亡风险为50%。新近流调显示脓毒性休克死亡率下降结果发现，重症感染患者的绝对死亡率从35.0%下降到了18.4%，总死亡率下降了16.6%，年绝对死亡率下降了1.3%，相对风险下降了47.5%。JAMA.2014Apr2;311(13):1308-16.脓毒症定义变迁（1.0）Sepsis1.0=感染＋SIRSChest1992Jun;101(6):1644-55创伤烧伤胰腺炎缺血SIRSsepsisSEVERESEPSIS细菌其他病毒原虫真菌其他INFECTION脓毒症定义变迁（2.0）IntensiveCareMed.2003Apr;29(4):530-8.Epub2003Mar28.Sepsis2.0=感染＋SIRS会议提出了包括20余条临床症状和体征评估指标构成的诊断标准，即Sepsis2.0。然而该标准过于复杂，且缺乏充分的研究基础和科学研究证据支持，并未得到临床认可和应用。创伤烧伤胰腺炎缺血SIRSsepsisSEVERESEPSIS细菌其他病毒原虫真菌其他INFECTIONDiagnosticcriteriaforsepsisThePIROsystemforstagingsepsis2012SSC指南发展Criticalcaremedicine2004Mar;32(3):858-73.Criticalcaremedicine2008Jan;36(1):296-327.CritCareMed.2013Feb;41(2):580-637.20082004脓毒症诊断标准的“争议”方法：通过对2000年至2013年澳大利亚和新西兰172个重症加强治疗病房(ICU)近120万例患者的数据分析，根据是否满足≥2条全身炎症反应综合征(SIRS)的诊断标准将感染伴器官功能障碍的患者分为SIRS阳性和SIRS阴性两组。结果：在近11万例感染伴器官功能障碍的患者中，87.9%为SIRS阳性，12.1%为SIRS阴性，在14年内两组患者的临床特征和病死率变化相似。校正分析显示，患者病死率随着满足SIRS标准项目的增加呈线性增高。结论：该研究说明现有脓毒症标准有可能遗漏约1/8的感染伴器官功能障碍患者，且该标准不能确定病死率增加的临界点，这提示当前脓毒症的筛查标准的特异性不佳。NEnglJMed,2015,372(17):1629-1638.Doweneedanewdefinitionofsepsis?……thedefinitionofsepticshockcurrentlyrevolvesaroundvariablebloodpressureand/orlactatelevels,withlooselytermedorundefined‘adequacyoffluidresuscitation’and‘persistent’hypotension.Definingsepsismust,however,beanongoingiterativeprocessrequiringminorormajorrevisionsasnewfindingscometolight.Inmuchthesamewaythatsoftwareenhancementsmovefromversion1.0to1.1orto2.0dependingonthemagnitudeofchange,soanewsepsis3.0definitionmustberefinedintoversions3.1,3.2,andsoonuntilaneventualcompleteoverhaulgeneratesthedevelopmentofsepsis4.0.IntensiveCareMed,2015,41(5):909-911.脓毒症的诊断标准于1991年发布（脓毒症1.0）,但过于敏感，可能导致脓毒症的过度诊断和治疗；2001年更新版（脓毒症2.0）又过于复杂，未被广泛应用。脓毒症3.0…..2016年……Sepsis3.0“应运而生”JAMA.2016Feb23;315(8):801-10｀Sepsis3.0定义JAMA.2016Feb23;315(8):801-10｀Mortality10%Sepsis3.0＝Infection＋SOFA≥2Sepsis3.0诊断标准JAMA.2016Feb23;315(8):801-10Septicshock定义及诊断标准JAMA.2016Feb23;315(8):801-10Mortality40%Septicshock=Sepsis+输液无反应低血压+使用缩血管药物维持MAP≥65mmHg）+乳酸则＞2mmol/L。Septicshockisasubsetofsepsisinwhichunderlyingcirculatoryandcellular/metabolicabnormalitiesareprofoundenoughtosubstantiallyincreasemortality.脓毒症3.0诊断流程JAMA.2016Feb23;315(8):801-10Sepsis3.0ACCP反对Sepsis3.01.Giventhatuseofthecurrentdefinitionsresultsinsavinglives,itseemsunwisetochangecourseinmidstreambyshiftingthedefinition.Thisisespeciallytruebecausethereisstillnoknownprecisepathophysiologicalfeaturethatdefinessepsis.2.AbandoningtheuseofSIRStofocusonfindingsthataremorehighlypredictiveofdeathcouldencouragewaiting,ratherthanearly,aggressiveintervention.Thisisamistakethatwecannotmake.3.Toabandononesystemofrecognizingsepsisbecauseitisimperfectandnotyetinuniversaluseforanothersystemthatisusedevenlessseemsunwisewithoutprospectivevalidationofthenewsystem’sutility.Chest2016FebACCP反对Sepsis3.04.Whatpatientsneedisthatwecontinuetobuildonthemomentumofthelasttwodecadesandthatwenotdisruptitbyconflatingchangewithprogress.5.Ourprincipalconcernisthatthenewdefinitionde-emphasizesinterventionatearlierstagesofsepsiswhenthesyndromeisactuallyatitsmosttreatable.Webelievethatadoptingamorerestrictivedefinitionthatrequiresfurtherprogressionalongthesepsispathwaymaydelayinterventioninthishighlytime-dependentcondition,withadditionalrisktopatients.Chest2016Feb精准医学下的Sepsis3.0不足“Definition”versus“ClinicalCriteria”.(1)Sepsisresearchers,bothbenchandclinical,shouldconsiderhowtheirfindingsmightvalidateorinvalidatethenewdefinition;(2)Cliniciansshoulddetermineiftheclinicalcriteriaareusefulintheirownpracticesandconsiderwhatadditionalelementsoughttobetested;(3)soonerratherthanlater.Criticalcaremedicine2016May;44(5):857-8.“DependentandIndependentVariables”.Sepsis=ƒ[(life-threatening)(organdysfunction)(dysregulatedhostresponse)(infection)].(1)Don’tassumethatthesequenceofeventsidentifiedinthenewdefinitionreflectspathobiologicalreality,becausenoonereallyknowshowthingsareorderedandconnected;(2)Don’tassumethatthepredominantabnormalityinsepsisisimmunological–thathypothesishasdominatedbothmechanisticandtherapeuticinvestigationforovertwodecades,andhasyettobearfruit.Criticalcaremedicine2016May;44(5):857-8.精准医学下的Sepsis3.0不足精准医学下的Sepsis3.0不足“Appropriatecomparators”.(1)Weneedtoreconsiderjustwhatconstitutesanappropriatecontrolforsepsisresearch;(2)Attheveryleast,weoughttomakesurethatstudiescharacterizingsepsisinanimalmodelsandinpatientsusesimilarcontrols.“Whatcomesnext?”.How−andhowsoon−doweinitiateSepsis-4.0?Idon’tknow−butlet’snotwaitadecadeandahalfthistime.Criticalcaremedicine2016May;44(5):857-8.Problem#1:Sepsis-IIIremainssubjectiveSepsis3.0的10个疑问（一）所有定义都包含了“suspectedinfection”，但怎么去界定“suspectedinfection”却很难。Problem#2:qSOFA&SOFAaremortalitypredictors,nottestsforsepsisSepsis3.0的10个疑问（二）qSOFA&SOFA评分多用于死亡预测，而非用于检测sepsis。Problem#3:Sepsis-IIIislessspecificforinfectionthanSepsis-IISepsis3.0的10个疑问（三）Sepsis3.0对诊断感染特异性低于Sepsis2.0。Problem#4:qSOFAhassimilarperformancecomparedtoSIRSformortalitypredictionSepsis3.0的10个疑问（四）事实上，qSOFA与SIRS对死亡预测价值相当。Problem#5:qSOFAmaybelessspecificindiseasesthatdirectlycausehypotension,tachyp