脓毒症指南

2008国际严重脓毒症和脓毒性休克治疗指南,International guidelines for management of severe sepsis and septic shock: 2008,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(Basic Definition),感染性休克画在哪里?,基 本 概 念(Basic Definition),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(Basic Definition),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,We recommend the protocolized resuscitation of apatient with sepsis-induced shock, defined as tissue hypoperfusion (hypotension persisting after initial fluid challenge or blood lactate concentration equal to or greater than 4 mmol/L). This protocol should be initiated as soon as hypoperfusion is recognized and should not be delayed pending ICU admission. During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of atreatment protocol:,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4 mmol/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,During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of atreatment protocol: Central venous pressure (CVP): 812 mm Hg Mean arterial pressure (MAP) 65 mm Hg Urine output 0.5 mL.kg1.hr 1 Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (Grade 1C),复苏开始的第一个6小时应达到目标性复苏标准：CVP: 812 mm HgMAP 65 mm Hg 尿量 0.5 mL/kg/hr中心静脉血氧饱和度或混合静脉血氧饱和度 70% or 65%, (Grade 1C),早期复苏,during the first 6 hrs of resuscitation of severe sepsis or septic shock, if SCVO2 or SvO2 of 70% or 65% respectively is not achieved with fluid resuscitation to the CVP target, then transfusion of packed red blood cells to achieve ahematocrit of 30% and/or administration of adobutamine infusion (up to amaximum of 20 g.kg1.min1) be utilized to achieve this goal (Grade 2C).,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SCVO2 or SvO2 达到 70% or 65% ,则应输血使HCT 30% 和/或滴注多巴酚丁胺(最大剂量20 g/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,We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay in antibiotic administration. To optimize identification of causative organisms, we recommend at least two blood cultures be obtained prior to antibiotics with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently ( 300 mg hydrocortisone daily not be used in severe sepsis or septic shock for the purpose of treating septic shock (Grade 1A).,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300 mg 每天(Grade 1A).,皮质激素,We recommend corticosteroids not be administered for the treatment of sepsis in the absence of shock. There is, however, no contraindication to continuing maintenance steroid therapy or to using stress does steroids if the patients endocrine or corticosteroid administration history warrants (Grade 1D).,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(Grade 1D).,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),We suggest that adult patients with sepsis induced organ dysfunction associated with aclinical assessment of high risk of death, most of whom will have APACHEII 25 or multiple organ failure, receive rhAPC if there are no contraindications (Grade 2B except for patients within 30 days of surgery where it is Grade 2C). Relative contraindications should also be considered in decision making,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(APACHEII 25 or multiple organ failure)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),We recommend that adult patients with severe sepsis and low risk of death, most of whom will have APACHE II 20 or one organ failure, do not receive rhAPC (Grade 1A).,对临床死亡危险度较低(APACHE II 20 or one organ failure)的成人脓毒症患者不推荐使用rhAPC(1A),血液制品,Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis (see recommendations for initial resuscitation), we recommend that red blood cell transfusion occur when hemoglobin decreases to 7.0 g/dL ( 70 g/L) to target ahemoglobin of 7.09.0 g/dL (7090 g/L) in adults (Grade 1B).,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 70 g/L时给予红细胞,使血红蛋白达到7090 g/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,We recommend that erythropoietin not be used as aspecific treatment of anemia associated with severe sepsis, but may be used when septic patients have other accepted reasons for administration of erythropoietin such as renal failure-induced compromise of red blood cell production (Grade 1B).,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,We suggest that fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (Grade 2D).,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,against antithrombin administration for the treatment of severe sepsis and septic shock (Grade 1B).,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,In patients with severe sepsis, we suggest that platelets should be administered when counts are 5000/mm3 (5 109/L) regardless of apparent bleeding. Platelet transfusion may be considered when counts are 5,00030,000/mm3 (530 109/L) and there is asignificant risk of bleeding. Higher platelet counts ( 50,000/mm3 (50 109/L) are typically required for surgery or invasive procedures (Grade 2D).,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 (Grade 2D),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,We recommend that clinicians target atidal volume of 6 ml/kg (predicted) body weight in patients with ALI/ARDS (Grade 1B).,将患者潮气量维持在6 ml/kg (1B),脓毒症相关ALI/ARDS的机械通气治疗,We recommend that plateau pressures be measured in patients with ALI/ARDS and that the initial upper limit goal for plateau pressures in apassively inflated patient be 30 cm H2O. Chest wall compliance should be considered in the assessment of plateau pressure (Grade 1C).,初期平台压维持 30 cm H2O(1C),脓毒症相关ALI/ARDS的机械通气治疗,We recommend that hypercapnia (allowing PaCO2 to increase above its pre-morbid baseline, so-called permissive hypercapnia) be allowed in patients with ALI/ARDS if needed to minimize plateau pressures and tidal volumes (Grade 1C).,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,We recommend that positive end-expiratory pressure (PEEP) be set so as to avoid extensive lung collapse at end-expiration (Grade 1C).,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,We suggest prone positioning in ARDS patients requiring potentially injurious levels of FIO2 or plateau pressure who are not at high risk for adverse consequences of positional changes in those facilities who have experience with such practices (Grade 2C).,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(Grade 2C).,脓毒症相关ALI/ARDS的机械通气治疗,A) Unless contraindicated, we recommend mechanically ventilated patients be maintained with the head of the bed elevated to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (Grade 1B). B) We suggest that the head of bed is elevated approximately 3045 degrees (Grade 2C).,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3045 degrees (Grade 2C).,脓毒症相关ALI/ARDS的机械通气治疗,We suggest that noninvasive mask ventilation (NIV) only be considered in that minority of ALI/ARDS patients with mild-moderate hypoxemic respiratory failure (responsive to relatively low levels of pressure support and PEEP) with stable hemodynamics who can be made comfortable and easily arousable, who are able to protect the airway, spontaneously clear the airway of secretions, and are anticipated to recover rapidly from the precipitating insult. Alow threshold for airway intubation should be maintained (Grade 2B).,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(Grade 2B).,脓毒症相关ALI/ARDS的机械通气治疗,We recommend that aweaning protocol be in place, and mechanically ventilated patients with severe sepsis undergo spontaneous breathing trials on aregular basis 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) FIO2 requirements that could be safely delivered with aface mask or nasal cannula. If the spontaneous breathing trial is successful, consideration should be given for extubation (see Appendix E). Spontaneous breathing trial options include alow level of pressure support, continuous positive airway pressure ( 5 cm H2O) or aT-piece (Grade 1A).,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5 cm H2O 连续气道正压通气,提供低水平通气支持(Grade 1A),脓毒症相关ALI/ARDS的机械通气治疗,against the rout