2008年拯救严重脓毒症与感染性休克治疗指南

发布时间：2018-06-09 23:11

本文选题：严重脓毒症 + 感染性休克　；参考：《继续医学教育》2008年01期

【摘要】：目的:对2004年发表的第一版《拯救严重脓毒症与感染性休克治疗指南》进行修订。设计:55位国际专家通过分组、远程电话、电子邮件以及全体大会等方式进行讨论,最后统一意见对Delphi方法进行了修改。这个过程是在没有任何企业资助的前提下进行的。方法:应用等级分级系统对证据进行评价,分从高级别的A级到低级别的D级共四个等级,并且以此决定建议的力度。给出的强烈建议表示该项治疗干预措施产生的作用效果显著的超过其可能产生的副作用(比如风险,负担,费用),或者就根本没有这些副作用。给出的次强建议表示该项治疗干预措施产生的作用效果与可能产生的副作用二者比较尚不明确。强级或者次强级的等级划分更重要的是考虑临床的重要性而不是简单的不同等级字母代表的证据质量。在没有达成一致意见方面,有一个正式解决该问题的途径。建议分为三个部分,包括:直接针对严重脓毒症患者建议;适用高度怀疑为严重脓毒症的危重病患者建议;小儿脓毒症患者建议。结果:重要的建议包括:患者确诊感染性休克后第一个6小时内的早期目标复苏(1C);应用抗生素之前应该进行血培养(1C);快速进行影像学检查以明确潜在的感染病灶(1C);在诊断为感染性休克后的1小时之内应用广谱抗生素进行治疗(1B),在诊断为严重脓毒症而没有发生感染性休克后的1小时之内应用广谱抗生素进行治疗(1D);在适当时机,在临床以及微生物学的指导下重新选择应用窄谱覆盖致病菌的抗生素(1C);抗生素应用7～10天后进行临床疗效判断(1D);感染源控制需要综合考虑所选择方法的利弊(1C);选择使用晶体或者胶体液进行复苏(1B);为了恢复循环的平均灌注压进行液体负荷治疗(1C);在增加了灌注压的同时而不能改善组织灌注的情况下应当减少液体的输入(1D);在维持平均动脉血压目标≥65mmHg使用血管加压素要优先于去甲肾上腺素与多巴胺(1C);在已经予以液体复苏以及应用了血管收缩药物的前提下,如果心输出量仍然偏低,应用多巴酚丁胺(1C);感染性休克如果经过积极的液体复苏以及应用了血管加压素治疗后,血压仍然难以达到理想水平,应用糖皮质激素(2C);严重脓毒症患者经过临床评价后有较高的死亡风险,应用重组活化蛋白C(2B,但是对于手术后患者为2C);如果没有组织的低灌注,冠状动脉疾病以及急性出血的情况,血红蛋白维持在7～9g/dL(1B);对ALI以及ARDS患者采取小潮气量(1B)以及限制吸气平台压(1C)的通气策略;对于急性肺损伤的患者,至少需要应用一个最小量的呼气末正压水平(1C);除非有禁忌证存在,进行机械通气的患者床头端需要抬高(1B);对于ALI/ARDS的患者应当避免常规应用肺动脉漂浮导管(1A);对已经诊断明确的ALI/ARDS患者在没有发生休克的情况下,为了降低机械通气以及入住ICU的天数,应当采取限制液体的保守策略(1C);建议应用镇静/镇痛治疗(1B);镇静治疗可以选择使用间断的弹丸式以及持续的静脉输入两种方式(1B);如果可能,应当完全避免应用神经肌肉阻滞药物(1B);应当强化患者血糖管理(1B),患者病情一旦稳定以后应当将患者目标血糖控制在150mg/dL(2C);持续静脉-静脉血液滤过或者血液透析效果相等(2B);预防深静脉血栓的形成(1A);应激性溃疡可以应用H2阻滞剂来预防上消化道出血(1A),也可以应用质子泵抑制剂(1B)。关于小儿脓毒症建议等级(略)。摘要
[Abstract]:Objective: a revision of the first edition of the first edition of the 2004 guidelines for the treatment of severe sepsis and septic shock. Design: 55 international experts were discussed through groups, telephones, e-mail, and the general assembly, and the final unification of the Delphi method was revised. This process is not funded by any enterprise. Under the precondition. Method: the application grade classification system evaluates the evidence from a high grade A to a low level D level in a total of four levels and determines the strength of the proposal. A strong suggestion is given that the effect of the treatment intervention is significantly more than the possible side effects (such as risk, burden, and the burden,) It is not clear that the effect of the treatment intervention and the possible side effects are not clear. The strong or sub grade classification is more important to consider the importance of the clinical and not the evidence of a simple representative of different grade letters. Amount. There is a formal solution to the problem in the absence of agreement. It is proposed to be divided into three parts: recommendations directly for patients with severe sepsis; recommendations for critically ill patients with severe sepsis; recommendations for children with sepsis. Results: important recommendations include: Patients after the diagnosis of septic shock. The first 6 hours of early target resuscitation (1C); blood culture (1C) should be performed before the application of antibiotics; a rapid imaging examination is performed to identify the potential infection (1C); the use of broad-spectrum antibiotics for treatment (1B) within the diagnosis of septic shock (1B), in the diagnosis of severe sepsis without septic shock The use of broad-spectrum antibiotics for treatment (1D) within 1 hours; at the appropriate time, under the guidance of clinical and microbiological guidance, the application of antibiotics (1C) with narrow spectrum covering pathogenic bacteria (1C); antibiotic application for clinical efficacy judgment (1D); infection source control system needs to consider the advantages and disadvantages of the selected method (1C); choose the use of crystal. Body or colloid fluid resuscitation (1B); liquid load therapy (1C) is performed to restore the mean perfusion pressure of the circulation; liquid input (1D) should be reduced when the perfusion pressure is increased and the tissue perfusion cannot be improved (1D); the use of vasopressin to maintain the average arterial blood pressure target > 65mmHg should be preceded by norepinephrine and the norepinephrine. Dopamine (1C); on the premise of the fluid resuscitation and the application of vasoconstrictor drugs, if the cardiac output is still low, dobutamine (1C) is applied; after active fluid resuscitation and the application of vasopressin therapy, the blood pressure is still difficult to reach the ideal level, with Glucocorticoid (2C) and strict application of Glucocorticoid (2C); Patients with severe sepsis have a high risk of death after clinical evaluation, using recombinant activation protein C (2B, but for 2C after surgery); if there is no tissue low perfusion, coronary artery disease and acute bleeding, hemoglobin is maintained at 7 to 9g/dL (1B); ALI and ARDS patients take small tidal volume (1B) and restricted suction. Air platform pressure (1C) ventilation strategy; for patients with acute lung injury, at least one minimum level of positive end expiratory pressure (1C) should be applied; unless there is a taboo, the head end of the patient with mechanical ventilation needs to be raised (1B); for patients with ALI/ARDS, the routine use of the pulmonary artery floating catheter (1A) should be avoided; and the diagnosis is clear. In the absence of shock, in order to reduce mechanical ventilation and the number of days in ICU, a conservative strategy for limiting liquids (1C) should be taken to reduce the number of days of mechanical ventilation (1C); it is recommended to use sedation / analgesia (1B); sedation can choose two methods (1B) using intermittent projectile and continued intravenous infusion (1B); if possible, it should be complete. Avoid the use of neuromuscular block drugs (1B); should strengthen the patient's blood glucose management (1B). Once the patient's condition is stable, the patient's target blood sugar should be controlled at 150mg/dL (2C); the continuous veno venous hemofiltration or the hemodialysis effect is equal (2B); the prevention of the formation of deep venous thrombosis (1A); the stress ulcer can be used as a H2 blocker. To prevent upper gastrointestinal bleeding (1A), proton pump inhibitors (1B) can also be used.
【作者单位】：首都医科大学急诊医学系附属北京朝阳医院急诊科首都医科大学急诊医学系附属北京朝阳医院急诊科首都医科大学急诊医学系附属北京朝阳医院急诊科首都医科大学急诊医学系附属北京朝阳医院急诊科首都医科大学急诊医学系附属北京朝阳医院急诊科首都医科大学急诊医学系附属北京朝阳医院急诊科
【分类号】：R459.7

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