ESICM循环休克与血流动力学监测最新共识

1、ESICM循环休克与血流动力学监测最新共识CSCCM 2014年12月10 2014年年12月的月的Intensive Care Medicine杂杂志发表了欧洲危重病医学会有关休克及血志发表了欧洲危重病医学会有关休克及血流动力学监测的新共识。流动力学监测的新共识。 第一部分介绍了共识中重要的推荐意见第一部分介绍了共识中重要的推荐意见No.说明说明/推荐意见推荐意见GRADE推荐级别推荐级别a; 证据质量证据质量说明的种说明的种类类1循环休克定义为危及生命的急性循环功能衰竭，伴有细胞的氧利用障碍。We define circulatory as a life-threatening, gene

2、ralized form of acute circulatory failure associated with inadequate oxygen utilization by the cells未分级定义2休克可以导致细胞缺氧，并伴有血乳酸升高。As a result, there is cellular dysoxia, associated with increased blood lactate levels未分级事实陈述3.休克可以表现为四种类型：其中三种为低血流状态（低血容量性，心源性，梗阻性），另一种为高动力状态（分布性）.Shock can be associated wi

3、th four underlying patterns: three associated with a low flow state (hypovolemic, cardiogenic, obstructive) and one associated with a hyperkinetic state (distributive)未分级事实陈述4.休克可以由多种过程共同导致。Shock can be due to a combination of processes未分级事实陈述5.体格检查时，休克通常伴随组织灌注不足的表现。常常对三个器官进行评估判断组织灌注情况皮肤（表皮灌注情况）；肾脏（

4、尿量）；以及脑（意识状态）。Shock is typically associated with evidence of inadequate tissue perfusion on physical examination. The three organs readily accessible to clinical assessment of tissue perfusion are the: -skin (degree of cutaneous perfusion); kidneys (urine output); and brain (mental status)未分级事实陈述6.对

5、于病史以及临床表现提示存在休克的患者，我们推荐经常评估心率、血压、体温和体格检查指标（包括低灌注的体征，尿量和意识状态）。We recommend frequent measurement of heart rate, blood pressure, body temperature and physical examination variables (including signs of hypoperfusion, urine output and mental status) in patients with a history and clinical findings sugges

6、tive of shock未分级最佳临床实践7.我们推荐不要根据单一的指标（诊断和/或治疗休克）。We recommend not to use a single variable (for the diagnosis and/or management of shock未分级最佳临床实践8.我们推荐应当努力确定休克类型，以便更好地进行病因和支持治疗。We recommend efforts to identify the type of shock to better target causal and supportive therapies未分级最佳临床实践9.尽管休克时常常合并低血压（

7、定义为收缩压 90 mmHg，或MAP 65 mmHg，或较基础值下降 40 mmHg），但我们推荐不要将低血压作为诊断休克的标准。We recommend that the presence of arterial hypotension (defined as systolic blood pressure of 90 mmHg, or MAP of 2 mEq/L (mmol/L)。Lactate levels are typically 2 mEq/L (or mmol/L) in shock states未分级事实陈述13.如果临床检查不能明确诊断时，我们推荐进行进一步的血流动力学评

8、估（如心功能评价）以确定休克类型。We recommend further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis未分级最佳临床实践14.当需要进一步血流动力学评估时，与其他有创技术相比，我们建议采用心脏超声作为初始评估休克类型的优先选择。We suggest that, when further hemodynamic asse

9、ssment is needed, echocardiography is the preferred modality to initially evaluate the type of shock as opposed to more invasive technologies推荐级别2; 证据级别中等 (B)推荐意见15.对于病情复杂的病例，我们建议应用肺动脉导管或经肺热稀释法确定休克类型。In complex patients, we suggest to additionally use pulmonary artery catheterization or transpulmona

10、ry thermodilution to determine the type of shock推荐级别2; 证据级别低 (C)推荐意见16.我们推荐进行早期治疗，包括（通过输液及必要时使用升压药物）维持血流动力学稳定，并治疗休克病因，同时频繁评估治疗反应。We recommend early treatment, including hemodynamic stabilization (with fluids and vasopressors if needed) and treatment of the shock etiology, with frequent reassessment

11、of response未分级最佳临床实践17.对于初始治疗无反应和（或）需要输注升压药物的休克患者，我们推荐留置动脉和中心静脉导管。We recommend arterial and central venous catheter insertion in shock not responsive to initial therapy and/or requiring vasopressor infusion未分级最佳临床实践18.如果患者留置中心静脉导管，我们建议测定中心静脉血氧饱和度(ScvO2)和静脉动脉PCO2差值(V-ApCO2)，以帮助评估休克类型和心输出量是否足够，并指导治疗。I

12、n patients with a central venous catheter, we suggest measurements of ScvO2) and V-ApCO2to help assess the underlying pattern and the adequacy of cardiac output as well as to guide therapy推荐级别2; 证据级别中等 (B)推荐意见19.我们推荐连续测定血乳酸水平以进行指导、监测和评估。We recommend serial measurements of blood lactate to guide, mon

13、itor, and assess推荐级别1; 证据级别低(C)推荐意见20.我们建议评估局部循环或微循环的技术仅用于研究目的。We suggest the techniques to assess regional circulation or microcirculation for research purposes only推荐级别2; 证据级别低 (C)推荐意见21.我们推荐休克复苏时对目标血压进行个体化。We recommend individualizing the target blood pressure during shock resuscitation推荐级别1; 证据级

14、别中等 (B)推荐意见22.我们推荐初始血压目标为MAP 65 mmHg。We recommend to initially target a MAP of 65 mmHg推荐级别1; 证据级别低 (C)推荐意见23.对于未能控制的出血患者，如没有重度颅脑损伤（即创伤患者），我们建议采用较低的目标血压。We suggest to tolerate a lower level of blood pressure in patients with uncontrolled bleeding (i.e. in patients with trauma) without severe head inj

15、ury推荐级别2; 证据级别 (C)推荐意见24.对于有高血压病史的感染患者，以及升高血压后病情改善的患者，我们建议采用较高的MAP。We suggest a higher MAP in septic patients with history of hypertension and in patients that show clinical improvement with higher blood pressure推荐级别2; 证据级别中等 (B)推荐意见25.适当的液体管理能够改善患者预后；低血容量和血容量过多都是有害的。Optimal fluid management does im

16、prove patient outcome; hypovolemia and hypervolemia are harmful未分级事实陈述26.我们推荐评估容量状态及容量反应性。We recommend to assess volume status and volume responsiveness未分级最佳临床实践27如果休克患者通常使用的前负荷指标处于非常低的状态，我们推荐立即进行液体复苏。We recommend that immediate fluid resuscitation should be started in shock states associated with v

17、ery low values of commonly used preload parameters未分级最佳临床实践28.我们推荐不应单纯根据常用的前负荷指标（如CVP或PAOP或舒张末面积或全心舒张末容积）指导液体复苏治疗。We recommend that commonly used preload measures (such as CVP or PAOP or end diastolic area or global end diastolic volume) alone should not be used to guide fluid resuscitation推荐级别1; 证据

18、级别中等 (B)推荐意见29.我们推荐不应当以心室充盈压或容积的任何绝对数值作为治疗目标。We recommend not to target any absolute value of ventricular filling pressure or volume推荐级别1; 证据级别中等 (B)推荐意见30.我们推荐根据超过一种血流动力学指标指导液体复苏治疗。We recommend that fluid resuscitation should be guided by more than one single hemodynamic variable未分级最佳临床实践31.有条件时，我们

19、推荐采用动态而非静态指标预测输液反应性。We recommend using dynamic over static variables to predict fluid responsiveness, when applicable推荐级别1; 证据级别 (B)推荐意见32.当决定进行输液治疗时，我们推荐进行快速补液试验，除非患者有明显的低血容量（如动脉瘤破裂导致出血）。When the decision for fluid administration is made we recommend to perform a fluid challenge, unless in cases of

20、 obvious hypovolemia (such as overt bleeding in a ruptured aneurysm)推荐级别1; 证据级别低 (C)推荐意见33.即使对于输液有反应的患者，我们也推荐谨慎地进行输液治疗，尤其是血管内充盈压或血管外肺水已经升高的患者。We recommend that even in the context of fluid-responsive patients, fluid management should be titrated carefully, especially in the presence of elevated intr

21、avascular filling pressures or extravascular lung water未分级推荐意见34.当患者心功能发生改变，导致心输出量降低或不足，且在优化前负荷后仍有组织低灌注表现时，我们建议加用强心药物。We suggest that inotropic agents should be added when the altered cardiac function is accompanied by a low or inadequate cardiac output, and signs of tissue hypoperfusion persist aft

22、er preload optimization推荐级别2; 证据级别低 (C)推荐意见35.对于单纯的心功能不全患者，我们推荐不要使用强心药物。We recommend not to give inotropes for isolated impaired cardiac function推荐级别1; 证据级别中等 (B)推荐意见36.对于休克患者，我们不推荐将氧输送的绝对数值作为治疗目标。We do not recommend targeting absolute values of oxygen delivery in patients with shock推荐级别1; 证据级别高 (A)

23、推荐意见37.如果休克患者对初始治疗有反应，我们不推荐常规测定心输出量。We do not recommend routine measurement of cardiac output for patients with shock responding to the initial therapy推荐级别1; 证据级别低 (C)推荐意见38.如果患者对初始治疗没有反应，我们推荐测定心输出量和每搏输出量以评估患者对液体治疗或强心药物的反应。We recommend measurements of cardiac output and stroke volume to evaluate the

24、 response to fluids or inotropes in patients that are not responding to initial therapy推荐级别1; 证据级别低 (C)推荐意见39.我们建议休克期间连续评价血动力学状态。We suggest sequential evaluation of hemodynamic status during shock推荐级别1; 证据级别低 (C)推荐意见40.心脏超声可用于休克时心功能的连续评估。Echocardiography can be used for the sequential evaluation of

25、cardiac function in shock未分级事实陈述41.我们不推荐在休克患者常规使用肺动脉导管。We do not recommend the routine use of the pulmonary artery catheter for patients in shock推荐级别1; 证据级别高 (A)推荐意见42.我们建议在顽固性休克及右心功能不全患者使用肺动脉导管。We suggest pulmonary artery catheterization in patients with refractory shock and right ventricular dysfu

26、nction推荐级别2; 证据级别低 (C)推荐意见43.对于重度休克患者，尤其是伴有急性呼吸窘迫综合征的患者，我们建议使用经肺热稀释法或肺动脉导管。We suggest the use of transpulmonary thermodilution or pulmonary artery catheterization in patients with severe shock especially in the case of associated acute respiratory distress syndrome推荐级别2; 证据级别低 (C)推荐意见44.我们推荐采用创伤较小的方

27、法（在休克患者经过验证）代替创伤较大的方法。We recommend that less invasive devices are used, instead of more invasive devices, only when they have been validated in the context of patients with shock未分级最佳临床实践 第二部分对于2006年以及2014年共识内容进行了比较。 2006年与年与2014年共识有关休克定义、血压和输液反应性说明的主要区别年共识有关休克定义、血压和输液反应性说明的主要区别内容内容ICM Antonelli 200

28、7ICM Cecconi 2014定义我们推荐将休克定义为危及生命的血流分布异常，导致不能提供和（或）利用足够的氧，从而造成组织缺氧。推荐级别1；证据级别中等(B)循环休克定义为危及生命的急性循环功能衰竭，伴有细胞的氧利用障碍。未分级有关血压的说明我们推荐休克初始复苏时的目标血压为：对于未能控制出血的创伤患者：MAP 40 mmHg直至通过手术控制出血。推荐级别1；证据级别中等(B)对于没有全身出血的TBI患者：MAP 90 mmHg。推荐级别1；证据级别低(C)对于其他所有休克：MAP 65 mmHg。推荐级别1；证据级别中等(B)我们推荐休克复苏时对目标血压进行个体化。推荐级别1；证据级别

29、中等(B)我们推荐初始血压目标为MAP 65 mmHg。推荐级别1；证据级别低(C)对于未能控制的出血患者，如没有重度颅脑损伤（即创伤患者），我们建议采用较低的目标血压。推荐级别2；证据级别低(C)对于有高血压病史的感染患者，以及升高血压后病情改善的患者，我们建议采用较高的MAP。推荐级别2；证据级别中等(B)2006年与年与2014年共识有关休克定义、血压和输液反应性说明的主要区别年共识有关休克定义、血压和输液反应性说明的主要区别有关输液反应性的说明我们不推荐常规使用评估输液反应性的动态指标（包括但不限于脉压差变异，主动脉血流改变，收缩压变异，呼吸周期收缩压变异试验，以及腔静脉塌陷）。推荐级别