脓毒症指南.ppt

2019国际严重脓毒症和脓毒性休克治疗指南,Internationalguidelinesformanagementofseveresepsisandsepticshock:2019,内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,基本概念(BasicDefinition),感染性休克画在哪里?,基本概念(BasicDefinition),感染=无病原微生物的地方出现病原微生物菌血症=血液中出现细菌全身炎症反应综合症=符合4项中的两项-浓毒症=感染+全身炎症反应综合症,基本概念(BasicDefinition),严重浓毒症=浓毒症+器官功能不全(或低灌注)感染性休克=严重感染导致循环功能不全,需要血管活性药浓毒症相关低血压=-MODS=两个以上器官功能障碍,内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,早期复苏,Werecommendtheprotocolizedresuscitationofapatientwithsepsis-inducedshock,definedastissuehypoperfusion(hypotensionpersistingafterinitialfluidchallengeorbloodlactateconcentrationequaltoorgreaterthan4mmol/L).ThisprotocolshouldbeinitiatedassoonashypoperfusionisrecognizedandshouldnotbedelayedpendingICUadmission.Duringthefirst6hrsofresuscitation,thegoalsofinitialresuscitationofsepsis-inducedhypoperfusionshouldincludeallofthefollowingasonepartofatreatmentprotocol:,针对确定存在血流灌注不足(经早期冲击液体疗法仍持续低血压或血乳酸超过4mmol/L)的脓毒症患者推荐使用常规复苏方案.此方案应该在确定存在血流灌注不足时立即实施,而不应该延迟到进入ICU后再进行,早期复苏,Duringthefirst6hrsofresuscitation,thegoalsofinitialresuscitationofsepsis-inducedhypoperfusionshouldincludeallofthefollowingasonepartofatreatmentprotocol:Centralvenouspressure(CVP):812mmHgMeanarterialpressure(MAP)65mmHgUrineoutput0.5mL.kg1.hr1Centralvenous(superiorvenacava)ormixedvenousoxygensaturation70%or65%,respectively(Grade1C),复苏开始的第一个6小时应达到目标性复苏标准：CVP:812mmHgMAP65mmHg尿量0.5mL/kg/hr中心静脉血氧饱和度或混合静脉血氧饱和度70%or65%,(Grade1C),早期复苏,duringthefirst6hrsofresuscitationofseveresepsisorsepticshock,ifSCVO2orSvO2of70%or65%respectivelyisnotachievedwithfluidresuscitationtotheCVPtarget,thentransfusionofpackedredbloodcellstoachieveahematocritof30%and/oradministrationofadobutamineinfusion(uptoamaximumof20g.kg1.min1)beutilizedtoachievethisgoal(Grade2C).,在脓毒症或脓毒性休克第一个6小时复苏阶段,如果液体复苏仍未使能SCVO2orSvO2达到70%or65%,则应输血使HCT30%和/或滴注多巴酚丁胺(最大剂量20g/kg/min),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,诊断,Werecommendobtainingappropriateculturesbeforeantimicrobialtherapyisinitiatedifsuchculturesdonotcausesignificantdelayinantibioticadministration.Tooptimizeidentificationofcausativeorganisms,werecommendatleasttwobloodculturesbeobtainedpriortoantibioticswithatleastonedrawnpercutaneouslyandonedrawnthrougheachvascularaccessdevice,unlessthedevicewasrecently(300mghydrocortisonedailynotbeusedinseveresepsisorsepticshockforthepurposeoftreatingsepticshock(Grade1A).,对于严重脓毒症或脓毒性休克，皮质激素用量不应大于对应氢化可的松300mg每天(Grade1A).,皮质激素,Werecommendcorticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock.Thereis,however,nocontraindicationtocontinuingmaintenancesteroidtherapyortousingstressdoessteroidsifthepatientsendocrineorcorticosteroidadministrationhistorywarrants(Grade1D).,对于不伴休克的脓毒症患者不常规应用皮质激素，除非患者有相关内分泌或皮质激素治疗史(Grade1D).,内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,重组人活化蛋白C(rhAPC),Wesuggestthatadultpatientswithsepsisinducedorgandysfunctionassociatedwithaclinicalassessmentofhighriskofdeath,mostofwhomwillhaveAPACHEII25ormultipleorganfailure,receiverhAPCiftherearenocontraindications(Grade2Bexceptforpatientswithin30daysofsurgerywhereitisGrade2C).Relativecontraindicationsshouldalsobeconsideredindecisionmaking,对于伴有脓毒症所致器官衰竭成人患者,且存在临床死亡高危风险(APACHEII25ormultipleorganfailure)时,如果无禁忌,建议应用rhAPC(2B,术后患者2C),重组人活化蛋白C(rhAPC),Werecommendthatadultpatientswithseveresepsisandlowriskofdeath,mostofwhomwillhaveAPACHEII20oroneorganfailure,donotreceiverhAPC(Grade1A).,对临床死亡危险度较低(APACHEII20oroneorganfailure)的成人脓毒症患者不推荐使用rhAPC(1A),血液制品,Oncetissuehypoperfusionhasresolvedandintheabsenceofextenuatingcircumstances,suchasmyocardialischemia,severehypoxemia,acutehemorrhage,cyanoticheartdisease,orlacticacidosis(seerecommendationsforinitialresuscitation),werecommendthatredbloodcelltransfusionoccurwhenhemoglobindecreasesto7.0g/dL(70g/L)totargetahemoglobinof7.09.0g/dL(7090g/L)inadults(Grade1B).,一旦组织低灌注得以改善,且不存在某些特殊情况,推荐只在血红蛋白降至70g/L时给予红细胞,使血红蛋白达到7090g/L(1B),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,血液制品,Werecommendthaterythropoietinnotbeusedasaspecifictreatmentofanemiaassociatedwithseveresepsis,butmaybeusedwhensepticpatientshaveotheracceptedreasonsforadministrationoferythropoietinsuchasrenalfailure-inducedcompromiseofredbloodcellproduction(Grade1B).,不推荐应用促红细胞生成素治疗脓毒症相关的贫血,但由其他原因引起的贫血可考虑适当使用(1B),血液制品,Wesuggestthatfreshfrozenplasmanotbeusedtocorrectlaboratoryclottingabnormalitiesintheabsenceofbleedingorplannedinvasiveprocedures(Grade2D).,除非有出血或即将进行侵袭性手术操作,否则不应使用新鲜冰冻血浆来纠正实验室凝血指标的异常(2D),血液制品,againstantithrombinadministrationforthetreatmentofseveresepsisandsepticshock(Grade1B).,反对使用抗凝血酶治疗严重脓毒症和脓毒性休克(1B),血液制品,Inpatientswithseveresepsis,wesuggestthatplateletsshouldbeadministeredwhencountsare5000/mm3(5109/L)regardlessofapparentbleeding.Platelettransfusionmaybeconsideredwhencountsare5,00030,000/mm3(530109/L)andthereisasignificantriskofbleeding.Higherplateletcounts(50,000/mm3(50109/L)aretypicallyrequiredforsurgeryorinvasiveprocedures(Grade2D).,当存在下列情况时,输血小板:无论是否出血,血小板5000/mm3血小板5,00030,000/mm3且存在明显出血风险需进行外科手术或相关侵袭性操作,且血小板50,000/mm3(Grade2D),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,脓毒症相关ALI/ARDS的机械通气治疗,Werecommendthatclinicianstargetatidalvolumeof6ml/kg(predicted)bodyweightinpatientswithALI/ARDS(Grade1B).,将患者潮气量维持在6ml/kg(1B),脓毒症相关ALI/ARDS的机械通气治疗,WerecommendthatplateaupressuresbemeasuredinpatientswithALI/ARDSandthattheinitialupperlimitgoalforplateaupressuresinapassivelyinflatedpatientbe30cmH2O.Chestwallcomplianceshouldbeconsideredintheassessmentofplateaupressure(Grade1C).,初期平台压维持30cmH2O(1C),脓毒症相关ALI/ARDS的机械通气治疗,Werecommendthathypercapnia(allowingPaCO2toincreaseaboveitspre-morbidbaseline,so-calledpermissivehypercapnia)beallowedinpatientswithALI/ARDSifneededtominimizeplateaupressuresandtidalvolumes(Grade1C).,为将平台压和潮气量降至低水平,容许出现高碳酸血症(1C),脓毒症相关ALI/ARDS的机械通气治疗,Werecommendthatpositiveend-expiratorypressure(PEEP)besetsoastoavoidextensivelungcollapseatend-expiration(Grade1C).,使用呼气末正压,防止呼气末出现广泛肺萎陷(1C),脓毒症相关ALI/ARDS的机械通气治疗,WesuggestpronepositioninginARDSpatientsrequiringpotentiallyinjuriouslevelsofFIO2orplateaupressurewhoarenotathighriskforadverseconsequencesofpositionalchangesinthosefacilitieswhohaveexperiencewithsuchpractices(Grade2C).,对于需要有潜在风险的吸氧浓度或平台压患者,建议采用俯卧位通气,只要变换体位不会造成不良后果(Grade2C).,脓毒症相关ALI/ARDS的机械通气治疗,A)Unlesscontraindicated,werecommendmechanicallyventilatedpatientsbemaintainedwiththeheadofthebedelevatedtolimitaspirationriskandtopreventthedevelopmentofventilator-associatedpneumonia(Grade1B).B)Wesuggestthattheheadofbediselevatedapproximately3045degrees(Grade2C).,除非有禁忌症,否则机械通气患者应保持半卧位,以降低误吸风险,预防呼吸机相关肺炎的发生(1B)患者头部抬高3045degrees(Grade2C).,脓毒症相关ALI/ARDS的机械通气治疗,Wesuggestthatnoninvasivemaskventilation(NIV)onlybeconsideredinthatminorityofALI/ARDSpatientswithmild-moderatehypoxemicrespiratoryfailure(responsivetorelativelylowlevelsofpressuresupportandPEEP)withstablehemodynamicswhocanbemadecomfortableandeasilyarousable,whoareabletoprotecttheairway,spontaneouslycleartheairwayofsecretions,andareanticipatedtorecoverrapidlyfromtheprecipitatinginsult.Alowthresholdforairwayintubationshouldbemaintained(Grade2B).,少数ALI/ARDS伴有轻度血氧不足的呼吸衰竭患者(对低水平的压力支持和PEEP敏感),可使用无创通气.其血流动力学稳定的,处于舒适易唤醒状态,具有主动保护气道及清洁分泌物的能力，且被预计能迅速恢复，同时应保证紧急情况时可方便快捷地对对患者进行气管插管(Grade2B).,脓毒症相关ALI/ARDS的机械通气治疗,Werecommendthataweaningprotocolbeinplace,andmechanicallyventilatedpatientswithseveresepsisundergospontaneousbreathingtrialsonaregularbasistoevaluatetheabilitytodiscontinuemechanicalventilationwhentheysatisfythefollowingcriteria:a)arousable;b)hemodynamicallystable(withoutvasopressoragents);c)nonewpotentiallyseriousconditions;d)lowventilatoryandend-expiratorypressurerequirements;ande)FIO2requirementsthatcouldbesafelydeliveredwithafacemaskornasalcannula.Ifthespontaneousbreathingtrialissuccessful,considerationshouldbegivenforextubation(seeAppendixE).Spontaneousbreathingtrialoptionsincludealowlevelofpressuresupport,continuouspositiveairwaypressure(5cmH2O)oraT-piece(Grade1A).,当患者满足以下条件,推荐进行自主呼吸试验(SBT)来评估严重脓毒症患者是否可以脱机:1.清醒状态;2.在不使用血管升压药的前提下处于血流动力学稳定状态;3.排除新的潜在严重病变;4,需要低的通气支持条件及PEEP;5.面罩给氧或鼻导管吸氧时可确保吸入氧浓度处于正常水平.如果SBT成功,可考虑拔管;SBT时可采用5cmH2O连续气道正压通气,提供低水平通气支持(Grade1A),脓毒症相关ALI/ARDS的机械通气治疗,againsttheroutineuseofthepulmonaryarterycatheterforpatientswithALI/ARDS(Grade1A).,不支持将肺动脉导管作为ALI/ARDS患者的常规监测手段(1A),脓毒症相关ALI/ARDS的机械通气治疗,TodecreasedaysofmechanicalventilationandICUlengthofstaywerecommendaconservativefluidstrategyforpatientswithestablishedacutelunginjurywhodonothaveevidenceoftissuehypoperfusion(Grade1C).,为缩短机械通气及ICU住院时间,对ALI无组织血流灌注不足的患者,采取保守的液体治疗(Grade1C).,内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,镇静、镇痛和肌松药的使用,Werecommendsedationprotocolswithasedationgoalwhensedationofcriticallyillmechanicallyventilatedpatientswithsepsisisrequired(Grade1B).,机械通气而需要镇静时，使用有镇静目标的镇静治疗方案(Grade1B).,镇静、镇痛和肌松药的使用,Werecommendintermittentbolussedationorcontinuousinfusionsedationtopredeterminedendpoints(e.g.,sedationscales)withdailyinterruption/lighteningofcontinuousinfusionsedationwithawakeningandretitrationifnecessaryforsedationadministrationtosepticmechanicallyventilatedpatients(Grade1B).,通过间断冲击给药或连续输注药物的方式，达到预定目标使患者处于镇静状态。应每日中断给药以能唤醒患者，必要时可重新滴注给药（1B）,镇静、镇痛和肌松药的使用,WerecommendthatNMBAsbeavoidedifpossibleinthesepticpatientduetotheriskofprolongedneuromuscularblockadefollowingdiscontinuation.IfNMBAsmustbemaintained,eitherintermittentbolusasrequiredorcontinuousinfusionwithmonitoringthedepthofblockadewithtrain-of-fourmonitoringshouldbeused(Grade1B).,尽量避免使用肌松药。若病情需要进行连续滴注时应严密监测阻滞深度（1B),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,控制血糖,Werecommendthat,followinginitialstabilization,patientswithseveresepsisandhyperglycemiawhoareadmittedtotheICUreceiveIVinsulintherapytoreducebloodglucoselevels(Grade1B).,脓毒症合并高血糖患者,在病情初步稳定后推荐进行胰岛素治疗以控制血糖(Grade1B),控制血糖,Wesuggestuseofavalidatedprotocolforinsulindoseadjustmentsandtargetingglucoselevelstothe150mg/dlrange(Grade2C).,建议使用得到确认的方案调整胰岛素剂量,以控制血糖150mg/dl(8.3mmol/L)(Grade2C),控制血糖,Werecommendthatallpatientsreceivingintravenousinsulinreceiveaglucosecaloriesourceandthatbloodglucosevaluesbemonitoredevery12hoursuntilglucosevaluesandinsulininfusionratesarestableandthenevery4hoursthereafter(Grade1C).,所有静脉使用胰岛素并接受葡萄糖作为热量来源,应每12小时监测一次血糖,病情稳定后4小时一次(Grade1C).,控制血糖,Werecommendthatlowglucoselevelsobtainedwithpoint-of-caretestingofcapillarybloodbeinterpretedwithcaution,assuchmeasurementsmayoverestimatearterialbloodorplasmaglucosevalues(Grade1B).,推荐谨慎分析通过毛细血管所监测的低血糖值,他可能会造成对动脉血或血浆葡萄糖水平的高估(Grade1B),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,肾脏替代治疗,Wesuggestthatcontinuousrenalreplacementtherapiesandintermittenthemodialysisareequivalentinpatientswithseveresepsisandacuterenalfailure(Grade2B).,持续肾脏替代治疗和间断血液透析对于严重脓毒症和急性肾功能衰竭患者具有相同作用（2B）,肾脏替代治疗,Wesuggesttheuseofcontinuoustherapiestofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients(Grade2D).,对血流动力学不稳定患者，持续血液滤过能更好控制液体平衡（2D）,碳酸氢盐治疗,againsttheuseofsodiumbicarbonatetherapyforthepurposeofimprovinghemodynamicsorreducingvasopressorrequirementsinpatientswithhypoperfusion-inducedlacticacidemiawithpH7.15(Grade1B).,对于血流灌注不足所致高乳酸血症(pH7.15)时,不推荐为了改善血流动力学状况或减少血管升压药用量而给予碳酸氢盐(Grade1B),内容提要,基本概念复习早期复苏诊断抗生素治疗控制感染源升压药物强心治疗皮质激素APC与感染性休,血液制品相关ARDS治疗镇静、镇痛及肌松控制血糖CRRT治疗相关DVT防治应激性溃疡防治,预防深静脉血栓形成,Werecommendthatseveresepsispatientsreceivedeepveinthrombosis(DVT)prophylaxiswitheither(a)low-doseunfractionatedheparin(UFH)administeredb.i.d.ort.i.d.or(b)dailylow-molecularweightheparin(LMWH)unlesstherearecontraindications(i.e.,thrombocytopenia,severecoagulopathy,activebleeding,recentintracerebralhemorrhage)(Grade1A).,除非存在禁忌症(包括血小板减少症、严重凝血紊乱、活动性出血、新近颅内出血等),对严重脓毒症患者推荐使用预防DVT治疗：普通肝素(23次/日)或低分子肝素(1次/日）Grade1A,预防深静脉血栓形成,Werecommendthatsepticpatientswhohaveacontraindicationforheparinusereceivemechanicalprophylacticdevicesuchasgraduatedcompressionstockings(GCS)orintermittentcompressiondevices(ICD)unlesscontraindicated(Grade1A).,有肝素使用禁忌症者,推荐使用机械性预防促施,如加压弹力袜或间歇加压装置(Grade1A),预防深静脉血栓形成,Wesuggestthatinveryhigh-riskpatientssuchasthosewhohaveseveresepsisandhistoryofDVT,trauma,ororthopedicsurgery,acombinationofpharmacologicandmechanicaltherapybeusedunlesscontraindicatedornotpractical(Grade2C).,对严重脓毒症和有DVT、创伤或骨科手术病史的患者，建议进行药物及机械联合疗法，除非有禁