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1、解读2008年脓毒血症与感染性休克管理国际指南（儿科部分） 深圳 2010-07-08,公明医院 张文辉,Surviving Sesis Camaign: International guidelines for management of severe sesis and setic shock: 2008,Surviving Sesis Camaign历史, Society of Critical Care Medicine 2007 The article will also be ublished in Critical Care Medicine Sonsor of 2004 gui
2、delines; Sonsor of 2008 guidelines but did not articiate formally in revision rocess; Members of the 2007 SSC Guidelines Committee are listed in Aendix I; lease see Aendix J for author disclosure information,跨洲、跨国的多中心联合,Sonsoring Organizations: American Association of Critical-Care Nurses*, American
3、 College of Chest hysicians*, American College of Emergency hysicians*, Canadian Critical Care Society, Euroean Society of Clinical Microbiology and Infectious Diseases*, Euroean Society of Intensive Care Medicine*, Euroean Resiratory Society*, International Sesis Forum*, Jaanese Association for Acu
4、te Medicine, Jaanese Society of Intensive Care Medicine, Society of Critical Care Medicine*, Society of Hosital Medicine*, Surgical Infection Society*, World Federation of Societies of Intensive and Critical Care,Table 1 Determination of the Quality of Evidence,Underlying methodology A RCT B Downgra
5、ded RCT or ugraded observational studies C Well-done observational studies D Case series or exert oinion Factors that may decrease the strength of evidence 1 oor quality of lanning and imlementation of available RCTs suggesting high likelihood of bias 2 Inconsistency of results (including roblems wi
6、th subgrou analyses) 3 Indirectness of evidence (differing oulation, intervention, control, outcomes, comarison) 4 Imrecision of results 5 High likelihood of reorting bias Main factors that may increase the strength of evidence 1 Large magnitude of effect (direct evidence, relative risk (RR) 2 with
7、no lausible confounders) 2 Very large magnitude of effect with RR 5 and no threats to validity (by two levels) 3 Dose resonse gradient RCT, randomized controlled trial; RR, relative risk,Table 2 Factors Determining Strong vs Weak Recommendation,What should be considered Recommended rocess Quality of
8、 evidence The lower the quality of evidence the less likely a strong recommendation Relative imortance of the outcomes If values and references vary widely, a strong recommendation becomes less likely Baseline risks of outcomes The higher the risk, the greater the magnitude of benefit Magnitude of r
9、elative risk including Larger relative risk reductions or larger benefits, harms, and burden increases in relative risk of harm make a strong recommendation more or less likely resectively Absolute magnitude of the effect The larger the absolute benefits and harms, the greater or lesser likelihood r
10、esectively of a strong recommendation recision of the estimates of the effects The greater the recision the more likely is a strong recommendation Costs The higher the cost of treatment, the less likely a strong recommendation,Table 3 Initial Resuscitation and Infection Issues,Initial resuscitation
11、(first 6 hours) Strength of recommendation and quality of evidence have been assessed using the GRADE criteria, resented in brackets after each guidelineFor added clarity: Indicates a strong recommendation or “we recommend”; indicates a weak recommendation or “we suggest” Begin resuscitation immedia
12、tely in atients with hyotension or elevated serum lactate 4mmol/l; do not delay ending ICU admission (1C) Resuscitation goals: (1C)-EGDT Central venous ressure (CV) 812 mm Hg Mean arterial ressure 65 mm Hg Urine outut 05 mLkg-1hr-1 Central venous (suerior vena cava) oxygen saturation 70%, or mixed v
13、enous 65% If venous O2 saturation target not achieved: (2C),Table 3 Initial Resuscitation and Infection Issues （续一）, If venous O2 saturation target not achieved: (2C) consider further fluid transfuse acked red blood cells if required to hematocrit of 30% and/or dobutamine infusion max 20 gkg1min1 A
14、higher target CV of 1215 mmHg is recommended in the resence of mechanical ventilation or re-esting decreased ventricular comliance Diagnosis Obtain aroriate cultures before starting antibiotics rovided this does not significantly delay antimicrobial administration (1C) Obtain two or more blood cultu
15、res (BCs) One or more BCs should be ercutaneous One BC from each vascular access device in lace 48 h Culture other sites as clinically indicated erform imaging studies romtly in order to confirm and samle any source of infection; if safe to do so (1C) ,Table 3 Initial Resuscitation and Infection Issues （续二）,Antibiotic theray Begin intravenous antibiotics as early as ossible, and always within the first hour of recognizing severe sesis (1D) and setic shock (1B) Br
