Sepsis is a systemic inflammatory response syndrome caused by infection, which is common in patients with severe trauma or infectious diseases.Causes includeBacteria、fungus、VirusesandparasiteThe infection caused by, etc. will lead to the imbalance of inflammatory reaction and immune regulation of the body.Disease types are divided intoSepsis、Severe Sepsis andSeptic shockMore than 19 million people worldwide suffer from sepsis every year, of which about 6 million die, and about 3 million suffer from cognitive impairment.
The main symptoms of sepsis include chills, fever, panic, shortness of breath, and changes in mental status.Sepsis can develop into severe sepsis and septic shock, which can lead toOrgan dysfunctionAnd circulation disorder, which is life threatening.Although sepsis is not an infectious disease, its risk factors include age (young or old), impaired immune systemdiabetesOr cirrhosis history, long-termICUTreatment, trauma, invasive treatment, etc.
The treatment of sepsis includes etiological treatment, supportive treatment and immunomodulation treatment.Etiological treatment mainly includes early clearance of infected lesions and use of effective antibiotics;Support treatment aims to maintain the physiological function of the body, including early circulatory resuscitation, mechanical ventilation, kidney replacement, etc;Immunomodulation therapy is aimed at the treatment methods that affect the immune inflammatory reaction.Prevention mainly depends on timely treatment of various infectious sources that may cause sepsis, such as respiratory system infection, digestive system infectionurinary tract infection Etc.
Young or old people, people with impaired immune system, patients with diabetes or cirrhosis history, people who have been treated in intensive care unit for a long time, and patients with trauma
Sepsis refers to the systemic inflammatory response syndrome caused by definite or suspected infection.
Severe sepsis refers to sepsis, accompanied by organ dysfunction and insufficient tissue perfusion caused by it.
Septic shock refers to sepsis accompanied by hypotension, which cannot be reversed after liquid treatment.
pathogeny
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Bacteria, fungi, viruses and parasites can all cause infection, resulting inSepsis, commonly seen in patients with severe trauma or infectious diseases.The infection will cause the whole bodyinflammatory reaction Its pathogenesis is related to inflammatory reaction and immune regulation imbalance.
After infection, bacteria and toxins enter the body, activate inflammatory reaction cells, produce and release a large number of inflammatory mediators (such as TNF - α, IL-1 β, IL-6, etc.), and cause local or systemic inflammatory reactions.
If the inflammatory reaction intensifies and causes deep suppression of immune function, it will lead to sepsis, which is a sign that the immune inflammatory reaction of the body falls into decompensation.
In sepsis, severe infection caused by immunosuppression will further aggravate systemic inflammatory reaction, and various pathological changes driven by inflammatory reaction will also further deteriorate, leading to or aggravatingOrgan failure, even the patient died.
Predisposing factors
The risk factors of sepsis include the following aspects: age (young or old), immune system damagediabetesorcirrhosisMedical history, long-term treatment in intensive care unittrauma, invasive treatment (such as intravenous catheter or tracheal intubation), long-term useGlucocorticoidEtc.
symptom
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The main symptoms are chills, fever (or hypothermia), panic, shortness of breath, mental state changes, etc.Sepsis can develop into severe sepsis and septic shock, which can lead to organ function and circulatory disorders and endanger life.
Sepsis
The patient often has definite or suspicious infection, and has the following symptoms: shivering, fever (body temperature>38.3 ℃), or hypothermia (body temperature<36 ℃);Heart rate>90 times/min, or greater than two standard deviations of normal values of different ages;Shortness of breath, breathing>20 times/minute or hyperventilation, arterial blood partial pressure of carbon dioxide (PaCO2)<32mmHg;Change of mental state;Obvious edema or positive fluid balance (more than 20ml/kg in 24 hours).
Severe Sepsis
Symptoms of sepsis accompanied by organ dysfunction (such as cardiovascular, lung, brain and kidney)dysfunction）And insufficient tissue perfusion.Often accompanied byhypotension、Lactic acidosis、Oliguria, acute state of consciousness change, etc.
Septic shock
Sepsis symptoms accompanied by hypotension can not be reversed after liquid treatment.The main manifestations are disturbance of consciousness (such as anxiety, slow reaction or confusion), fine pulse, cold and wet limbs, oliguria or anuria.
Medical treatment
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When the patient has a definite or suspected infection and has symptoms such as chills, fever (or hypothermia), panic, shortness of breath, sepsis should be considered and medical treatment should be taken as soon as possible.If the patient has shock symptoms such as continuous hypotension, oliguria, fine pulse, change of consciousness, etc., he/she should call 120 to seek medical treatment immediately, and some patients need emergency rescue treatment.The doctor may ask the following questions:
What's the main discomfort?How long has it been?
Is there any infection (wound/focus) on the body?
Do you have fever/hypothermia, chills, panic, shortness of breath and other symptoms?
Is there any examination/treatment?How effective?
diagnostic criteria
Diagnostic criteria for sepsis
There is a definite or suspected infection and some of the following clinical characteristics.
Physical signs and clinical symptoms
Body temperature: body temperature>38.3 ℃ or body temperature<36 ℃;
Heart rate>90 times/min, or the difference between two standard vertebrae greater than the normal value of different ages;
Shortness of breath: breathing>20 times/minute or hyperventilation, PaCO2<32mmHg;
Change of mental state;
Obvious edema or positive flush of liquid: more than 20ml/kg in 24 hours;
Hyperglycemia and no history of diabetes.
Hemodynamics
Hypotension: systolic blood pressure<90mmHg, mean arterial pressure (MAP)<70mmHg, or adult systolic blood pressure drops more than 40mmHg or below the normal value of the age group.
laboratory examination
Inflammatory reaction indicators:
Leukocytosis: WBC>12000/μ l;
Leukopenia: WBC<4000/μ l;
WBC is normal but the total number of immature leukocytes exceeds 10%;
Plasma C-reactive protein>normal two standard deviations;
Plasma procalcitonin>two standard deviations of normal.
Organ dysfunction indicators:
Hypoxemia: PaO2/FiO2<300mmHg;
Acute oliguria: even if given enough fluid resuscitation, the urine volume is still small;
Blood creatinine>44.2 μ mol/L (0.5mg/dl);
Abnormal coagulation function;
Intestinal obstruction: bowel sounds disappear;
Thrombocytopenia: platelet (PLT)<10000/μ l;
Hyperbilirubinemia.
Tissue perfusion index:
Hyperlactaemia (lactic acid>1mmol/L);
Capillary reperfusion capacity decreased or ecchymosis formed.
SOFA score
For patients with infection or suspected infection, sepsis can be diagnosed when the score of sequential (Sepsis related) Organ Failure Assessmengt (SDFA) increases by ≥ 2 points from the baseline.
Due to the complexity of SOFA scoring operation, bedside rapid SOFA (qSOFA) standard is often used to identify critical patients in clinical practice. If at least two of the qSOFA standards are met, then combined with the assessment results of organ dysfunction, sepsis can be preliminarily judged.The qSOFA standard is as follows:
Respiratory rate ≥ 22 times/minute
Change of consciousness
Systolic pressure ≤ 100mmHg
Diagnostic criteria for severe sepsis and septic shock
Sepsis accompanied by organ dysfunction and/or insufficient tissue perfusion caused by it, any of the following.
Physical signs and clinical symptoms
Hypotension due to sepsis;
Even if adequate fluid resuscitation is given, the urine volume is still<0.5ml/kg/h for at least 2 hours;
Acute lung injury caused by non pneumonia and PaO2/FiO2<250mmHg;
Acute lung injury caused by pneumonia and PaO2/FiO2<200mmHg;
laboratory examination
Lactic acid is greater than the normal value;
Blood creatinine>176.8 μ mol/L (2.0 mg/dl);
Bilirubin>34.2 μ mol/L (2mg/dl);
PLT<100000μl；
Coagulation disorders (International normalized ratio>1.5).
Visiting department
Emergency Department, Intensive Medicine Department, Infection Department
Relevant inspection
Blood related examination
Such as routine blood test, liver and kidney function, electrolytes, procalcitonin (evidence analysis of infection), blood gas analysis (metabolic supply and demand of the body), coagulation function, DIC (coagulation function may be seriously damaged), etc.
Etiological examination
Blood (or other body fluids, exudates) and pus cultures are routinely conducted before the treatment of antibacterial drugs, and drug sensitivity tests are conducted after the pathogenic bacteria are isolated for accurate drug use.
ECG, X-ray, ultrasound, CT
The doctor will carry out relevant imaging examination or ECG examination according to the patient's condition to find the infection focus. Some examinations may be repeated to determine the cause or monitor the treatment effect.
differential diagnosis
Sepsis can be similar to shock caused by other reasons, such asHypovolemic shock、Cardiogenic shockandAnaphylactic shockEtc.Sepsis often has infection symptoms, which can be differentiated from other diseases according to signs, clinical symptoms, inflammatory indicators, and bacterial culture results.
treatment
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The treatment of sepsis can be divided into three parts:Etiological treatmentSupport treatment and immunomodulation treatment.
Etiological treatment includes early clearance of infected lesions and use of effective antibiotics.
Support treatment includes early circulatory resuscitation, mechanical ventilation, renal replacement, metabolic support, anticoagulation and other measures for different organ and system damage.
Immunomodulation therapy mainly refers to the treatment that can affect the immune inflammatory reaction of the body.
Acute treatment
The mortality rate of sepsis is extremely high, and standardized treatment in the acute phase is crucial to the prognosis of patients. Therefore, the survival sepsis campaign proposed the concept of 1-hour cluster treatment.1 hour must complete the project:
Monitor the lactic acid level, and measure again when the initial lactic acid content is>2mmol/L;
Blood was taken for culture before the application of antibiotics;
Application of broad-spectrum antibiotics;
For patients with low blood pressure or lactic acid level ≥ 4 mmol/L, early full fluid resuscitation and rapid administration of 30 ml/kg crystal liquid;
If the patient continues to have hypotension during or after the initial fluid resuscitation, vasopressors should be used to maintain the mean arterial pressure ≥ 65mmHg.
The guiding principle is that these complex patients need a detailed preliminary assessment of their condition before assessing their treatment response.
General treatment
Fluid resuscitation
Early fluid resuscitation is essential for septic shock,Septic shockThe fluid resuscitation of patients should be started as soon as possible. For the hypoperfusion caused by sepsis, it is recommended to infuse at least 30ml/kg of crystal solution within 3 hours after the suspected septic shock for initial resuscitation. At the same time of initial fluid resuscitation, pathogen control should be carried out to obtain further laboratory examination results and more accurate hemodynamic state measurement data.
Nutrition support treatment
After resuscitation of severe sepsis/septic shockHemodynamicsStabilizers should start as soon as possiblenutritional support (within 48 hours), enteral nutrition is the first choice.Low dose vasoactive drugs are not contraindications to early enteral nutrition. Early enteral nutrition can maintain the integrity of intestinal mucosa and prevent bacterial translocation and organ dysfunction.
Prevention of stress ulcer
For patients with sepsis and septic shock, if there are risk factors for gastrointestinal bleeding, it is necessary to prevent stress ulcer.It is recommended to use H2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) to prevent stress ulcer in severe sepsis patients with bleeding risk factors.
medication
Anti infection treatment
AntibacterialsIt should be used as soon as possible after admission or judgment of sepsis, and the early use of antibacterial drugs can prevent sepsis orSeptic shockThe prognosis of patients is crucial.For patients with sepsis or septic shock, one or more intravenous empirically administered broad-spectrum antibiotics are needed to cover all possible pathogens.
Once the pathogen and sensitivity are determined, empirical antimicrobial treatment should be downgraded, or antimicrobial treatment should be stopped when it is determined that the patient is not infected.On the premise of not affecting the treatment of antibiotics, routine microbial culture is required.
Vasoactive drug
Norepinephrine is recommended as the first choice of vasopressor. For patients with low risk of tachyarrhythmia or bradycardia, dopamine can be used as an alternative.
Prevention of deep vein thrombosis
The risk of septic venous thrombosis is very high, especially for ICU patients. If pulmonary embolism occurs, it may be fatal.Therefore, it is suggested that heparin should be used to prevent deep vein thrombosis in patients with severe sepsis without contraindication.
Glucocorticoid
For septic shock patients, ifHemodynamicsStill unstable, intravenous use recommendedHydrocortisoneAnd the dosage is 200mg per day.
surgical treatment
For some patients with definite surgical infection focus, the control of infection requires surgical removal of necrotic tissue or drainage of infection focus.However, it is difficult to completely remove the necrotic tissue of some diseases in the early stage, such as extensive burns and soft tissue lacerations;Early surgical intervention is not recommended for acute pancreatitis. Even if surgery is needed, it should be delayed to one week after the course of disease.
TCM treatment
Sepsis belongs to the category of "exogenous fever", "syndrome withdrawal", "blood syndrome", "violent asthma", "mental stupor", "visceral exhaustion", etc. in traditional Chinese medicine.Its occurrence is mainly due to the deficiency of vital qi in the body, the invasion of external evils, the heat in the body, the consumption of qi and the injury of yin;The vital qi is weak, the poison and evil are trapped inside, and the blood circulation of the collaterals is not smooth, which leads to toxic heat, blood stasis, turbid phlegm and internal obstruction of the veins, and then the organs are damaged by evil, causing this disease.
The main purpose of sepsis treatment is to cut off the disease in the early stage of sepsis and prevent it from developing towards severe sepsis《Inner Canon of Huangdi》The theory of "prevention of disease" proposed coincides.At present, the clinical practice is mostly divided into "four syndromes and four methods": toxic heat syndrome and heat clearing and detoxification method, fu qi blockage syndrome and internal circulation and attack method, blood stasis syndrome and blood activating and stasis removing method, acute deficiency syndrome and strengthening the body.
Other treatments
Blood glucose management
Programmed blood glucose management scheme is recommended for ICU sepsis patients, and monitoring is recommended every 1-2 hoursblood sugarWhen the blood glucose measured twice in a row is more than 10mmol/L, insulin treatment is started. The target blood glucose is ≤ 10mmol/L. The blood glucose level and insulin dosage are monitored every 4 hours after they are stable.Arterial blood was collected from patients with arterial catheterization to measure blood glucose.
Renal replacement therapy
For sepsis patients with acute renal injury (AKI), renal replacement therapy (RRT) was performed,Continuous renal replacement therapy(CRRT) and intermittent RRT.aboutHemodynamicsCRRT is recommended for patients with unstable sepsis.However, for patients with sepsis and AKI, RRT is not recommended if there is only creatinine increase or oliguria without other dialysis indications.
mechanical ventilation
at presentAcute respiratory distress syndromeIt is widely accepted to use low tidal volume lung protection strategy for patients with ARDS.When mechanical ventilation is carried out for patients with acute respiratory distress syndrome (ARDS) induced by sepsis, it is recommended to set the tidal volume as 6ml/kg and the upper limit of platform pressure as 30cmH2O.Higher positive end expiratory pressure (PEEP) is recommended for patients with moderate to severe ARDS caused by sepsis.
Frontier treatment
Immunomodulation therapy
The pathophysiological mechanism of sepsis patients is complex, in which inflammatory imbalance and abnormal immune function are important causes of death, including a series of cytokinescomplementActivation and release of the immune systemimmune responseAnd so on.
Immunomodulatory therapy is a therapeutic program aimed at the pathogenesis of sepsis, which theoretically can play a major role in the treatment of sepsis.However, over the years, the research on immunomodulatory treatment of furuncles has progressed slowly. So far, no treatment has been unanimously recognized by the industry, which needs to be carefully selected.
prognosis
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Sepsis is a systemic inflammatory response syndrome caused by infection, with high morbidity and mortality.The number of sepsis patients worldwide each year exceeds 19 million, of which 6 million patients die, with a mortality rate of more than 1/4. The patients who survive at the same time may have cognitive dysfunction.Early identification and timely standardized treatment can improve the prognosis of sepsis patients.
Patients with uremic shock will have renal function damage, and water, electrolyte and acid-base balance disorders in the body. If the disease progresses, it can develop into acute renal failure.
Patients with uremic shock may develop respiratory distress syndrome.Keep the respiratory tract unobstructed and continue to breathe oxygen.If necessary, use respiratory stimulants or ventilators to assist the patient in breathing.
During septic shock, important organs of the human body such as kidney, heart, lung, brain and liver will be damaged. If not treated in time and effectively, irreversible damage or even death may result.
The most effective way to treat and prevent sepsis is toPathogenesisIt is a pity that the pathogenesis of sepsis has not yet been fully clarified. In this case, we should do a good job in all aspects of clinical prevention according to the causes of sepsis and try to reduce the incidence of infectionRisk factorsIt plays an important role in the treatment and prevention of sepsis.With the progress of medical research, large samplesMulticenterThe clinical randomized controlled study will bring more evidence to the treatment of sepsisMedical evidenceThe clarification of the mechanism of sepsis in the future will certainly bring new hope for the treatment and prevention of sepsis.
In 2020, the team of Li Yiming, a doctor in the Department of Critical Care Medicine of Central South Hospital of Wuhan University, aimed at sepsis, a "hard bone" with a mortality rate of 35.5% in domestic ICUs, and spent two years to invent a new material for blood purification and adsorption, "toxin scavenger", which will treat both the symptoms and the symptoms of sepsis at the same time, and reduce the cost of blood purification for sepsis by more than 60%.
