CONTENT

sepsis septic shock

.

septic shock




(intensive life
support)

(1-3)
septic shock
(systemic inflammatory response)
distributive shock Consensus
conference American College of Chest Physician Society of Critical Care
Medicine .. 1992(1)
Infection
Bacteremia

Sepsis Systemic
inflammatory response syndrome (SIRS) SIRS
2 1. 38 C 36 C, 2.
90 /, 3. 20 / PaCO2
32 . 4. 12,000 /.. 4,000 /

CONTENT
Sepsis Septic Shock

.. band form 10% SIRS

sepsis burn

organ perfusion severe
sepsis septic shock


Surviving Sepsis Campaign 2012(2) sepsis
1 severe sepsis sepsis

2
sepsis
(host response) (proinflammatory
response) " (anti-inflammatory response)

immune cell receptors
(pathogen-associated molecular patterns)
inflammatory genes inflammatory mediators
humoral response proinflammatory 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) tissue
factor anticoagulation system fibrinolysis
disseminated coagulation
thrombus consumptive coagulopathy (coagulation
platelet )
584

CONTENT

(anti-inflammatory response anergy)

phagocyte
regulatory T cell myeloid suppressor cell
apoptosis dendritic cells, T cell B cell
cytokine (anti-inflammatory cytokines)
neuroendocrine vagus nerve
proinflammatory cytokines
anergy immunosuppressive
state infection

(3,4)

generalized vasodilatation capillary leakage
pulse
pressure systemic inflammation
(cardiac contractility) cytokines coronary
blood flow acidosis
(disseminated
intravascular coagulation, DIC) (pericapillary edema)
(red cell deformability) mitochondrial damage
cytokines (5) (cytopathic hypoxia) sepsis

septic shock distributive shock
systemic vascular resistance maldistribution blood
flow generalized vasodilatation vascular leakage
hypovolemia hemodynamic profile
systemic vascular resistance cardiac output

585

CONTENT
Sepsis Septic Shock

1. sepsis(2)

586

CONTENT

2. severe sepsis(2)

(3,4)

systemic
inflammation

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

587

CONTENT
Sepsis Septic Shock

sepsis septic shock

1. 2. organ dysfunction 3.
4.

2
1 1
body fluid

organ dysfunction
CBC
lactate

lactate
(CBC)
(coagulation) DIC

lactate

588

CONTENT

shock

septic

A, B, C D
A airway
airway obstruction

B breathing oxygen
delivery respiratory failure

C circulation

D
septic shock
3 1)
2) intensive life support 3) neutralize toxin host inflammatory
response

body fluid exudate

septic shock hemoculture
2
septic shock
sepsis
septic shock

( Grams stain, AFB )


febrile neutropenia

589

CONTENT
Sepsis Septic Shock

Intensive life support

inflammatory response

(Goal of therapy)2 tissue perfusion

tissue oxygenation tissue perfusion
organ blood flow tissue oxygenation indexes

Mean arterial pressure 65 .

0.5 ././
Central venous (superior vena cava) 70% lactate
10%

(fluid therapy)

isotonic
crystalloid 0.9% NaCl solution, Lactated Ringers solution balanced salt solution
synthetic colloid starches
renal injury (6,7) albumin

SAFE study albumin (8) (ALBIOS
study)(9)
(fluid loading)
500-1,000 . crystalloid colloid 300-500 . 15
1 (2)

590

CONTENT

( 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
fluid 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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CONTENT
Sepsis Septic Shock

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 ././) b
adrenergic receptor cardiac output (> 10 ././)
-adrenergic receptor systemic vascular resistance
dopamine dopamine

epinephrine (2)

Optimization of tissue oxygenation(2)

microcirculation central venous oxygen saturation (ScvO2)
CVP oxygen saturation ScvO2 70%
tissue hypoxia CVP
serum lactate macrocirculation
lactate 10
tissue hypoxia(14)
tissue hypoxia goal

maintenance fluid intravascular volume capillary
leakage, vasodilatation activation coagulation pathway

592

CONTENT

tissue hypoxia oxygen

delivery hypovolemia vasopressors
hematocrit 30% packed
red cell transfusion hematocrit hematocrit
30% dobutamine cardiac output tissue oxygenation

hemodynamic support 2
tissue perfusion
continuing leakage 24 (
) maintenance fluid
prolonged tissue hypoxia
multiorgan dysfunction

anti-inflammatory substance

20-30 steroid septic
shock(15)
septic shock
stress cortisol
Annane (16) hydrocortisone 50 . 6
fludocortisone 50 ./ 7

multicenter trial CORTICUS(17)
hydrocortisone ACTH stimulation
hydrocortisone

593

CONTENT
Sepsis Septic Shock

-
-

2. septic shock

(goal)

Acceptable
BP
tissue perfusion MAP

65 .

MAP - 40 .

Organ
perfusion urine output 0.5 ././.,
Arterial Blood

pH , Blood lactate mixed venous saturation 70%

goal
persistent
leakage

intravascular

fluid

24

maintenance

volume

fluid

intravascular
(
JVP,
CVP

PCWP ) persistent hypotension

594

CONTENT

adrenal insufficiency, anaphylactic shock

obstructive shock
hydrocortisone relative adrenal insufficiency

(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 . PaO2, compliance PaO2
(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-hour
bundle 6-hour bundle
3-hour bundle
1. lactate
2. hemoculture
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CONTENT
Sepsis Septic Shock

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 (ScvO2)*
. Lactate
* Surviving sepsis (18,19)

septic shock
sepsis septic shock Surviving Sepsis
Campaign 2004 2012

CVP volume responsive tests
tissue oxygenation central venous oxygen saturation (ScvO2)
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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