重症胰腺炎和SIRS.ppt

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Company Logo,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Company Logo,Department of Pancreatic Surgery,Union Hospital,wuhan,P.R.China,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Company Logo,Department of Pancreatic Surgery,Union Hospital,wuhan,P.R.China,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Company Logo,古老的困惑与永恒的思考,感染预防与和治疗,1,SAP,是特殊类型,SIRS,2,SIRS,SIRS,判断标准,体温,38,或,90,bpm,呼吸,20,bpm,或,PaCO2 12,000/mm,10%band forms.,S-SIRS,导致,MOF,与感染,4,MODS,与感染是,SAP,死亡的主要原因,1st week 2nd week,Hours,3rd-4th week,EARLY MIDDLE,INITIAL,LATE,Inappropriate,activation of,proteases,Necrosis,Microcirculatory,disorders,Progression of,necrosis,Gut and biliary,bacteria,Infection,of necrosis,Altered intra-acinar protein traffic,Accumulation of trypsinogen in the interstitial space,Macrophage,activation,PHASE,TIMING,MAJOR,EVENTS,?,19%37%,32%,12%,DEATHS,?,?,0 0,12%28%,26%,0%,0%,5%,M.O.F.,Infection,Causes,SAP,合并感染的防治,6,SIRS,导致毛细血管渗漏（,CLS,）,组织细胞,组织间隙,毛细血管,细胞内液,组织间液,血浆,5%,15%,40%,SAP,血管活性和炎性介质大量释放毛细血管通透性增加,白蛋白漏出,液体分布异常,加重组织水肿,正常的微循环,毛细血管渗漏时微循环改变,复苏液体的选择,SAP,胰酶活化,低血容量,微循环灌注障碍,组织缺氧,MODS,炎性介质大量释放,毛细血管渗漏,血管内白蛋白进入组织间隙,血浆胶体渗透压降低,血管内外液体重新分布,白蛋白丢失,液体渗出,晶体,人工胶体,12,容量控制,休克症状,CVP6cmH2O,PAWP,和,CO,乳酸,ScvO2100ml/h),CVP12cmH2O,PAWP,和,CO,或,乳酸,Hct,组织细胞氧供和氧需失调,心肺功能,病情,病程,微循环状况,第三间隙,全身炎症情况,容量再分布,个体化策略,容量过载,容量不足,容量平衡,13,早期目标指导液体治疗,EGDT,14,EGDT,实施策略,早期液体复苏,2448 h,重建循环,调控容量平衡 限制性液体复苏,复苏液体选择,晶胶比例,2:1 1:1,稳定循环功能 血流动力学监测,重建氧供平衡 微循环灌注监测,早期 适量 成份 个体,肠道损伤加重,SIRS,16,17,EN or TPN,18,EN,刺激肠道蠕动避免细菌过度繁殖,19,EN,更好维护免疫功能,20,EN,缓解,SIRS,反应,21,EN,改善肠粘膜免疫功能,22,EN,缓解,SIRS,23,EN,改善重症病人预后,24,EN,减少,SAP,合并感染,25,Meta,分析,EN/PN,Six studies with 263 participants were analysed.,26,Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis,本中心临床研究,营养支持,27,赵刚,王春友,.,中华肝胆外科杂志,2004,Zhao Gang,Wang Chun-You,.Word J Gastroenterol 2003,早期空肠营养（,EN,）调控,SIRS,28,营养管置入,营养管置入,如何进行,EN,31,SAP,发病,(10.8,1.8)d,(7.6,1.7)d,发病,34d,SIRS,下调,液体复苏,晶体为主,多,45d,PN,1/2,量到,2/3 or 3/4,胃肠,功能,部分,恢复,PN+EN,特殊者,TPN,恢复,耐受,适应,发病,3W,(17.6,2.1)d,TEN,EN,进食,预防性抗生素使用,10 randomized clinical trials,Primary outcomes,Infected necrosis,Mortality,Secondary outcomes,Need for surgery,Incidence of sepsis,Meta-analysis of prophylactic parenteral antibiotic Use in acute necrotizing pancreatitis,Medicina(Kaunas)2007;43(4),32,胰腺坏死继发感染,33,脓毒症,34,手术干预,35,死亡率,36,预防性抗生素选择,37,三代头孢类,甲硝唑,喹诺酮,哌拉西林,氨苄青霉素,氨基糖苷类,一代头孢菌素,感染治疗策略,38,SIRS,再次出现提示严重感染,39,感染的定性诊断,治疗时间窗,40,强化抗感染治疗的指征,41,感染的定位诊断,胰外,/,胰腺,影像学检查,胰腺,CT,气泡症、坏死范围加重,肺部,X,线感染征象,胆道,B,超，,MRCP,实验室检查,深部痰培养，胸穿引流液培养,FNA,穿刺，腹腔引流物培养,中段尿培养,血培养,导管尖培养,42,胰腺感染征象,气泡征,43,胰腺感染征象,坏死短期增大,44,经验性抗生素使用原则,45,SAP,继发感染的细菌谱,细菌种类 百分比,大肠杆菌,35%,克雷伯杆菌,25%,肠球菌,24%,葡萄球菌,4%,铜绿假单孢菌,11%,变形杆菌,8%,链球菌,7%,肠杆菌,7%,类杆菌,6%,厌氧菌,6%,Buchler P,Reber HA.Gastroenterol Clin North Am,1999,28:661,671,46,47,本中心,SAP,继发感染细菌谱,病菌种类 百分比,G-,菌,61.9%,大肠埃希菌,16.5%,铜绿假单孢菌,14.3%,鲍曼不动杆菌,12.1%,阴沟肠杆菌,5.6%,肺炎克雷伯菌,3.8%,G+,菌,20.8%,金黄色葡萄球菌,9.5%,粪肠球菌,3.8%,真菌,17.3%,白色念珠菌,8.7%,似酵母样菌,3.8%,Bchler M,Malfertheiner P,Friess H,et al.Gastroenterology.1992;103(6):1902-8.,胰腺组织浓度,低,不能达到大多数细菌的,MIC,胰腺组织浓度足以抑制一些细菌，但,不能覆盖所有,病原菌,胰腺组织浓度,高,，且,对大多数胰腺感染的病原菌有效,奈替米星,妥布霉素,氧哌嗪青霉素,头孢噻肟,亚胺培南,环丙沙星,氧氟沙星,不同抗生素在正常胰腺组织的渗透性及其对常见胰腺感染细菌的疗效,对碳青霉烯类耐药率,2,对头孢哌酮,/,舒巴坦、阿米卡星、头孢吡肟和哌拉西林,/,他唑巴坦的耐药率次之（,20%,）,2008,年,CHINET,监测网,1416,株肠杆菌属细菌耐药率（,%,）,SAP,合并严重感染经验用药,50,严重感染治疗需要标本兼顾,TRAUMA,BURNS,PANCREATITIS,SEPSIS,SIRS,INFECTION,SEPSIS,BACTEREMIA,预防性与治疗性抗真菌药物,52,深部侵袭性细菌感染,治疗时间窗,53,SAP,合并真菌感染经验用药,54,治疗方式抉择,手术干预,明确感染灶，腹腔,/,胆道,强化抗感染治疗无效,55,动脉破裂出血 腐蚀性,/,感染性动脉瘤,动脉破裂出血及栓塞,门静脉病变 脾静脉栓塞区域性门脉高压,肠系膜上血管栓塞,SAP,感染相关并发症,腹腔出血,SAP,出血并发症救治措施,TAE,腐蚀性成功率高,感染性急救措施,手术止血 缝扎出血动脉（不确切）,清除坏死组织（关键）,再出血问题 感染是否控制（真菌）,引流是否充分,非感染性囊内腐蚀性动脉瘤出血,TAE,治疗为主,感染性胃十二指肠动脉动脉瘤破裂出血,TAE,手术引流,假性脾动脉瘤栓塞（,TAE,）,胃十二指肠动脉瘤微导管栓塞,胰源性门脉高压、门静脉系统血栓,结语,1,SAP,为特殊类型,SIRS,2,3,抗感染治疗需要标本兼顾,63,SIRS,为重症感染始动因素,时间静止，思绪流逝,65,66,67,68,69,70,