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(欵……一般民眾看不懂沒關係 :P )
敗血症(Sepsis)的新定義是:
「宿主對感染的反應失調,導致威脅性命的器官功能失常。」
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我是這樣理解(搭配SOFA的重要器官):
「感染之後的宿主反應失調,導致重要維生器官功能失常。」
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此次的共識,摒棄了自1991年使用至今的SIRS criteria(其命運就如其項目縮寫一樣被THRoW「丟」了!^_^)
「重要維生器官」就是SOFA score裡的六項,從頭到腳點名的話就是:腦、心、肺、肝、腎、血(歡迎提供更好記的口訣)
每個器官最多4分(總分24分),若在感染時,總分比baseline上升2分,就算有Sepsis。
.
腦是 Coma scale
心是 MAP與升壓劑
肺是 PF ratio
肝是 Bilirubin
腎是 Creatinine與Urine output
血是 Platelet
.
Septic Shock: 經足夠輸液後,仍須使用升壓劑維持MAP>=65及Lactate>2.
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另外,對於非ICU病人,有個簡易版的SOFA叫qSOFA(Quick SOFA),只有三個項目:
我把它縮寫成「CRP」口訣(因為感染時,我們一般會測CRP嘛~ 不是說一定要測CRP喔~只是方便記憶)
.
Conscious alteration(只要不是滿分就算)
RR >= 22/min
Pressure (systolic) <= 100
.
感染症病人,若有兩項,就要懷疑有Sepsis(這是不必抽血就可以計算,算是快速方便的篩檢。)不是說有兩項就是Sepsis,而是要提高警覺,病人可能有sepsis,要抽血測SOFA score。
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喜歡的話,請自由分享取用~
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JAMA 全文:http://jama.jamanetwork.com/article.aspx?articleid=2492881
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最近有同學在問sepsis,那我們就來複習一下吧。這個課程會分個幾天上喔。
首先,Sepsis是一種因感染而導致的發炎反應。比較常見的菌種是Gram positive bacteria。可能是某個器官的感染或是菌血症,甚至導致多重器官衰竭和死亡。
2016年the Society of Critical Care Medicine and European Society of Intensive Care Medicine (SCCM/EISCM)有對sepsis and septic shock有新的定義:
1. 敗血症(Sepsis)定義為因感染造成的宿主反應,導致致死性的器官衰竭。現在器官衰竭則由sequential (sepsis-related) organ failure assessment (SOFA) score超過兩分以上定義。原本的The systemic inflammatory response syndrome (SIRS) criteria 已經不再使用。SOFA score的算法可以看此網址: http://clincalc.com/IcuMortality/SOFA.aspx
2. 敗血性休克(Septic shock)定義為有敗血症,且有循環,細胞和代謝性不正常,經過適當的fluid resuscitation後,還需要血管升壓劑才能達到平均動脈壓(a mean arterial pressure (MAP)) ≥65 mmHg和 a lactate >2 mmol/L (>18 mg/dL).而且此情況會比單獨有敗血症的死亡率來的高。
3. 敗血症的危險因子包括: 住在ICU,院內感染,菌血症,老年人,免疫抑制,之前曾經住院,尤其是因為感染住院,社區型肺炎。
4. 懷疑或確定敗血症的病人,通常會有低血壓,心跳變快,發燒和白血球增生的情況。在嚴重一點,可能有休克的徵兆,如皮膚冷汗發酣,器官失能,如: 寡尿,急性腎衰竭,心志受到影響。
5. 死亡率很高,但這幾年因為醫療的進步有下降的趨勢,約10-52 %,越嚴重死亡率越高,若病人燒不起來,嗜中性球低下,年齡大於40歲,有AIDS,肝衰竭等共病症,不適當的抗生素都有可能預後較差。
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新定義 敗血性休克 :敗血症病患中,
因循環 /細胞/代謝太過異常,以致增加死亡率
臨床上敗血性休克定義 : 經過足夠輸液急救後 ,仍需要昇壓劑來維持 MAP >65 mmHg 以及血中乳酸濃度 > 2 mmol/L 的病患。
Sepsis 新一代定義 將於 2016/02/22 於 JAMA 刊出
Singer M, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). (JAMA, Feb 22, 2016).
在刊出前,ESICM (歐洲醫學會 )寫了一篇 short review
http://www.esicm.org/…/Sepsis-3-International-Consensus-def…
簡單翻譯一下 KEY DEFINITIONS
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1. Sepsis is now defined as a ‘life-threatening organ dysfunction due to a dysregulated host response to infection’.
SIRS criteria have less of a role to play, as they are considered overly non-specific and of poor clinical utility:
sepsis 新定義為 : 宿主對感染反應失調,導致器官失能而危及生命。
過去的 SIRS : 較 non specific , 較難臨床應用,新定義將較少強調
---------------------------------------------------------------------------------------------
2. The key element of sepsis-induced organ dysfunction is defined by ‘an acute change in total SOFA score ≥ 2 points consequent to infection, reflecting an overall mortality rate of approximately 10%’
對 sepsis induced organ dysfunction 新定義 :
感染後 SOFA分數改變 ≥ 2 分
因為整體死亡率約(增加) 10 %
相對來說,過去說的 Severe sepsis 可能被捨棄
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3. A simple bedside score (‘qSOFA’, for quick SOFA) has been proposed, which incorporates hypotension (systolic blood pressure ≤100mmHg), altered mental status and tachypnea (respiratory rate > 22/min):the presence of at least two of these criteria strongly predicts the likelihood of poor outcome in out-of-ICU patients with clinical suspicion of sepsis.
如果不是在 ICU, 可以用 qSOFA 來篩選病患
三項 :低血壓 ( SBP < 100 mmHg) , 意識改變 ,喘 ( rate > 22)
三者有二 ,便可預測 poor outcome
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4. Septic shock is now defined as a ‘subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality’. Clinical criteria identifying such condition include the need for vasopressors to obtain a MAP≥ 65mmHg and an increase in lactate concentration > 2 mmol/L, despite adequate fluid resuscitation.
新定義 sepsis shock : sepsis 病患中,
因循環 /細胞/代謝太過異常,以致增加死亡率
臨床上sepsis shock 定義 : 經過足夠 fluid resuscitation 後 ,仍需要昇壓劑來維持 MAP >65 mmHg 以及血中乳酸濃度 > 2 mmol/L 的病患。
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sofa score 在 Sepsis: Sequential Organ Failure Assessment (SOFA) Score 的八卦
The Sequential Organ Failure Assessment score involves the evaluation of the neurologic, respiratory, cardiac, coagulation, hepatic, ... ... <看更多>