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1、感染性休克的液体复苏,感染性休克的液体复苏,补什么? 补多少? 补多快?,Fluid resuscitation of septic shock,2001 EGDT 2004 initial guidelines 2008 updated version guidelines 2010 severe sepsis bundles,Fluid resuscitation of septic shock,2001 EGDT 2004 initial guidelines 2008 updated version guidelines 2010 severe sepsis bundles 2012
2、updated Guidelines,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P=0.009).,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,Ema
3、nuel Rivers et al.N Engl J Med 2001;345:1368-77,Emanuel Rivers et al.N Engl J Med 2001;345:1368-77,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.,Fluid therapy,Fluid-resuscitate using crystalloids or colloids. （1B ） Targe
4、t a CVP of 8mmHg （ 12mmHg if mechanically ventilated ）. （ 1C ） Use a fluid challenge technique while associated with a haemodynamic improvement. （ 1D ）,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.,Fluid therapy,Give fluid challenges of 1000 ml of crystalloids or 300500 ml of colloi
5、ds over 30min. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion. （ 1D ） Rate of fluid administration should be reduced if cardiac filling pressures increase without concurrent hemodynamic improvement. （ 1D ）,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):29
6、6-327.,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Sepsis Resuscitation Bundle（first 6hrs）,1. Serum lactate measured. 2. Blood cultures obtained prior to antibiotic administration. 3. From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions an
7、d 1 hour for non-ED ICU admissions.,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Sepsis Resuscitation Bundle（first 6hrs）,4. In the event of hypotension and/or lactate 4 mmol/L (36 mg/dl): a) Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). b) Apply vasopressors
8、 for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) 65 mm Hg.,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Sepsis Resuscitation Bundle（first 6hrs）,5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or
9、lactate 4 mmol/L (36 mg/dl): a) Achieve central venous pressure (CVP) of 8 mm Hg. b) Achieve central venous oxygen saturation (ScvO2) of 70%.*,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,1. Low-dose steroids administered for septic shock in accordance with a standardized hospital policy. 2
10、. Drotrecogin alfa (activated) administered in accordance with a standardized hospital policy.,Sepsis Management Bundle（first 24hrs）,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,3. Glucose control maintained lower limit of normal, but 150 mg/dl (8.3 mmol/L). 4. Inspiratory plateau pressures
11、 maintained 30 cm H2O for mechanically ventilated patients.,Sepsis Management Bundle（first 24hrs）,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Main results,Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mort
12、ality.,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Main results,Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 years (P 0.0001). Compliance with the entire management bundle started at 18.4% in the first quar
13、ter and increased to 36.1% by the end of 2 years (P = 0.008).,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,Main results,Unadjusted hospital mortality decreased from 37 to 30.8% over 2 years (P = 0.001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, re
14、sulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 years (95% CI, 2.58.4%).,Levy MM et al. Intensive Care Med. 2010;36(2):222-31.,补什么：晶体 or 胶体？,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.,We recommend fluid resuscitation with either natural/artificial colloid
15、s or crystalloids. There is no evidence-based support for one type of fluid over another (Grade 1B).,R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.,液体复苏-2004年SAFE研究,随机对照多中心研究 共6997例需要液体复苏的ICU病人 观察28天的结果 组别： 干预组：3497 4%人血白蛋白 对照组：3500 生理盐水,N Engl J Med 2004;350:2247-56.,结论 在液体复苏时，应用4%白
16、蛋白与生理盐水在28天内效果相当；,N Engl J Med 2004;350:2247-56.,亚组分析 脓毒性休克：死亡率有减少趋势 （30.7% vs 35.3%，P=0.09） 创伤病人，特别是脑外伤病人：死亡率有增加趋势 （13.6% vs 10.0%，P=0.06）,N Engl J Med 2004;350:2247-56.,Surviving Sepsis Campaign Previews Updated Guidelines for 2012,Additions to Fluid Therapy Recommendations（2012）,With regard to fluid therapy, the use of crystalloids in the initial fluid resuscitation in severe sepsis is recommended (strong recommendation; Grade 1A).,Additions to Fluid Therapy Recommendations（2012）,
