2013脓毒症（解毒2012脓毒症）

1,儿童脓毒症的治疗 2012指南解读,2,概述,儿童脓毒症是死亡的主要原因 严重脓毒症死亡率远低于成人,3,初步复苏,如果需要氧疗可以先予面罩或高流量鼻导管吸氧或鼻咽持续气道正压通气（NPCPAP）(2C) 尽快建立静脉（外周或中心）或骨髓通路，这些通路可用于液体复苏或应用血管活性物质(2C) 按照ACCM-PALS指南进行感染性休克的复苏 如果需要气管插管，插管前最好给予液体或血管活性药物(2C),4,初步复苏,最初的复苏终点(2C) 毛细血管再充盈时间 血压 脉搏 肢体末端 尿量 意识状态 ScvO2和CI,5,初步复苏,对于难治性休克要注意气胸、心包填塞、内分泌等问题，并予处理(1C),6,抗感染和感染灶的清除,严重脓毒症应尽早经验性抗感染治疗（1h内），给予抗感染药物前留取血培养（1D） 对于毒性休克综合征患儿低血压难以纠正时应使用林可霉素和抗毒素（2D） 早期、积极处理感染灶（1D） 艰难梭菌肠炎最好通过消化道给药，重症患儿首选万古霉素（1A）,9,体外膜氧合,对于难治性休克或脓毒症导致的急性呼吸窘迫综合征患儿使用体外膜氧合治疗（2C）,10,激素,对于液体复苏无效、儿茶酚胺抵抗的患儿以及怀疑（或证实）有绝对肾上腺皮质功能不全者使用氢化可的松（1A）,11,血液制品和血浆,对于复苏时上腔静脉血氧饱和度70%的患儿，保持Hb100g/L以上，稳定者Hb70g/ L以上即可（1B） 血小板计数10109/L，或20109/L但有出血风险时，预防性输血小板，活动性出血、手术或侵袭性操作血小板计数应50109/L （2C） 脓毒症诱发的血栓性紫癜性疾病（DIC、TMA、TTP）时输血浆（2C） 丙种球蛋白？ （1A）,12,机械通气,采取肺保护性通气策略（2C）,13,镇静/镇痛/药物毒性,脓毒症患儿机械通气时应用镇静剂以达到需要的镇静程度（1D） 监测药物毒性（1C）,14,控制血糖,血糖控制在10mmol/L以下，输入糖水时要同时加入胰岛素（2C）,15,利尿和肾替代治疗,如果休克已纠正，若容量负荷过度则使用利尿剂，如果效果不好可以持续血液滤过或间断血液透析（2C）,16,碳酸氢钠,动脉血pH 7.15时不推荐应用 (2B),17,深静脉血栓/应激性溃疡预防,对于深静脉血栓/应激性溃疡的预防，没有分级的建议,18,营养,消化道能耐受者给予胃肠内营养，不能耐受者给予胃肠外营养（2C）,19,毛细血管再充盈时间,hemodynamic abnormalities with mortality tachycardia/bradycardia (3%) hypotension with capillary refill 3 secs (5%) normotension with capillary refill greater than 3 secs (7%) hypotension with capillary refill greater than 3 secs (33%),Orr et al. Pediatrics. 2009V124N2:500-8,20,抗感染,Vascular access and blood drawing is more difficult in newborns and children. Antimicrobials can be given intramuscularly or orally (if tolerated) until intravenous line access is available.,Corey et al. Pediatr Oncol Nurs 2008; 25:208212 Amado et al. J Crit Care 2011; 26:103.e9103.12,21,毒性休克综合征,Pyrexia 39C Rash Diarrhoea +/- vomiting Irritability Lymphopaenia,22,毒性休克综合征,Clindamycin is affected less by the growth stage of an organism than penicillin, which acts only on organisms in the growth phase and not on those in the stationary phase. Clindamycin suppresses toxin production by the organism. Clindamycin suppresses cytokine production by monocytes. Clindamycin inhibits the synthesis of penicillin-binding proteins. Clindamycin has a longer postantibiotic effect than do beta-lactam antibiotics. The role of IVIG in toxic shock syndrome is unclear, but it may be considered in refractory toxic shock syndrome.,23,液体复苏,Result: The 48-hour mortality was 10.6% (111 of 1050 children), 10.5% (110 of 1047 children), and 7.3% (76 of 1044 children) in the albumin-bolus, saline-bolus, and control groups, respectively. Conclusion: Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.,Kathryn et al. NEJM 2011;364:2483-95,24,正性肌力/血管活性药物,dopamine Norepinephrine Epinephrine Vasopressin Type III phosphodiesterase inhibitors nitrosovasodilators levosimendan dobutamine,25,激素,Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C). Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).,26,激素,In treated patients hydrocortisone tapered when vasopressors are no longer required (grade 2D). Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D). When hydrocortisone is given, use continuous flow (grade 2D).,27,丙种球蛋白,We suggest not using intravenous immunoglobulins in adult patients with severe sepsis or septic shock (grade 2B),Werdan et al. Crit Care Med 2007; 35:26932701 Brocklehurst et al. NEJM 2011; 365:12011211,28,机械通气,Target a tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS (grade 1A). Plateau pressures be measured in patients with ARDS and initial upper limit goal for plateau pressures in a passively inflated lung be 30 cm H2O (grade 1B). Positive end-expiratory pressure (PEEP) be applied to avoid alveolar collapse at end expiration (atelectotrauma) (grade 1B). Strategies based on higher rather than lower levels of PEEP be used for patients with sepsis- induced moderate or severe ARDS (grade 2C).,29,机械通气,Recruitment maneuvers be used in sepsis patients with severe refractory hypoxemia (grade 2C). Prone positioning be used in sepsis-induced ARDS patients with a PaO2/FiO2 ratio 100 mm Hg in facilities that have experience with such practices (grade 2B). That mechanically ventilated sepsis patients be maintained with the head of the bed elevated to 30-45 degrees to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (grade 1B). That noninvasive mask ventilation (NIV) be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks (grade 2B).,30,机械通气,That a weaning protocol be in place and that mechanically ventilated patients with severe sepsis undergo spontaneous breathing trials regularly to evaluate the ability to discontinue mechanical ventilation when they satisfy the following criteria: a)arousable; b) hemodynamically stable (without vasopressor agents); c) no new potentially serious conditions; d) low ventilatory and end-expiratory pressure requirements; and e) low FiO2 requirements which can be met safely delivered with a face mask or nasal cannula. If the spontaneous breathing trial is successful, consideration should be given for extubation (grade 1A).,31,机械通气,Against the routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS (grade 1A). A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion (grade 1C). In the absence of specific indications such as bronchospasm, not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B).,32,镇静/镇痛/药物毒性,When intubation or invasive procedures are required, patients are at risk of worsening hypotension from the direct myocardial depressant and vasodilator effects of induction agents as well as indirect effects due to blunting of endogenous catecholamine release. Propofol, thiopental, benzodiazepines, and inhalational agents all carry these risks. Ketamine Etomidate Dexmedetomidine,33,控制血糖,A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are 180 mg/dL. This protocolized approach should target an upper blood glucose 180 mg/dL rather than an upper target blood glucose 110 mg/dL (grade 1A). Blood glucose values be monitored every 12 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter (grade 1C). Glucose levels obtained with point-of-care testi