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1、陈攸涛2012 版儿童严重脓毒症与脓毒性休克治疗国际指南解读v2012版指南采用GRADE分级系统 vGRADE分级系统由推荐等级与证据强度两部分构成 推荐等级v1级推荐(recomment)：指该措施有着良好的预期效果和经济效益。 v2级建议(suggest)：指该措施可能有不可预知的不良反应和较低的经济效益证据强度分级A级(强)高质量随机对照研究B级(中等)中等质量随机对照或高质量观察性及队列研究C级(弱)完成良好、设对照的观察性及队列研究D级(极弱)病例总结或专家意见Part G Protein C and activated protein concentrate vG. Protei
2、n C and activated protein concentrate. 蛋白C和活化蛋白浓缩物 指南中在儿童及成人均不推荐使用（已退市）vSee “History of recommendations regarding use of recombinant activated protein C” . 参照“关于重组活化蛋白C（rhAPC）使用的旧版推荐”vRecombinant human activated protein C (rhAPC) was approved for use in adult patients in a number of countries in 200
3、1 following the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, which enrolled 1,690 severe sepsis patients and showed a significant reduction in mortality (24.7 %) with rhAPC compared with placebo (30.8 %, P = 0.005) . Part G Protein C and activated prot
4、ein concentrate v2001年一些国家根据PROWESS研究结果开始批准重组活化蛋白（rhAPC）应用于成人。vPROWESS研究一共收集了1690例严重脓毒症病例，证实rhAPC相对安慰剂可以明显降低严重脓毒症患者死亡率（24.7 %vs. 30.8 %, P = 0.005）。Part G Protein C and activated protein concentrate vThe 2004 SSC guidelines recommended use of rhAPC in line with the product labeling instructions requ
5、ired by the US and European regulatory authorities with a grade B quality of evidence 7, 8. v2004版SSC指南将rhAPC使用等级定为1B。Part G Protein C and activated protein concentrate vBy the time of publication of the 2008 SSC guidelines, additional studies of rhAPC in severe sepsis (as required by regulatory age
6、ncies) had shown it ineffective in less severely ill patients with severe sepsis as well as in children 229, 230. v到了2008年，又有一些新的研究表明rhAPC对一些疾病引起的严重脓毒症中是无效的（包括儿童）。Part G Protein C and activated protein concentrate vThe 2008 SSC recommendations reflected these findings, and the strength of the rhAPC
7、recommendation was downgraded to a suggestion for use in adult patients with a clinical assessment of high risk of death, most of whom will have Acute Physiology and Chronic Health Evaluation (APACHE) II scores C25 or multiple organ failure (grade 2C; quality of evidence was also downgraded from 200
8、4, from B to C) . Part G Protein C and activated protein concentrate v2008版SSC指南将rhAPC使用等级下调至2C，仅建议在具有死亡高风险（APACHE II评分C25）或合并多器官衰竭成人患者中使用。Part G Protein C and activated protein concentrate vThe 2008 guidelines also recommended against use of rhAPC in low-risk adult patients, most of whom will have
9、APACHE II scores B20 or single organ failures (grade 1A), and against use in all pediatric patients (grade 1B). v同时2008版指南提出反对rhAPC在低风险（APACHE II 评分B20）及单器官衰竭（1A）和儿童中使用（1B）。Part G Protein C and activated protein concentrate vThe results of the PROWESS SHOCK trial (1,696 patients) were released in la
10、te 2011, showing no benefit of rhAPC in patients with septic shock (mortality 26.4 % for rhAPC, 24.2 % placebo) with a relative risk of 1.09 and a P value of 0.31。v2011年PROWESS SHOCK研究显示严重脓毒症患者并没有从 rhAPC中受益，rhAPC组死亡率26.4 %，安慰剂组死亡率24.2 %（RR1.09，P0.31）Part G Protein C and activated protein concentrate
11、 vThe drug was withdrawn from the market and is no longer available, negating any need for an SSC recommendation regarding its use 。v这个药物从此退出市场Part G Protein C and activated protein concentrate Part H Blood products and plasma therapies v1. We suggest similar hemoglobin targets in children as in adu
12、lts. vDuring resuscitation of low superior vena cava oxygen saturation shock（70 %）, hemoglobin levels of 10 g/dL are targeted. vAfter stabilization and recovery from shock and hypoxemia, then a lower target 7.0 g/dL can be considered reasonable (grade 1B) Part H Blood products and plasma therapies v
13、建议儿童维持血红蛋白量与成人相似（7.09.0g/dL）。v在低上腔静脉血氧饱和度（70 %）的脓毒症休克复苏时，目标血红蛋白量为10 g/dL。v待病情稳定，休克和低氧血症纠正后，目标血红蛋白量可以考虑为7.0g/dL( 1B)。Part H Blood products and plasma therapies vThe optimal hemoglobin for a critically ill child with severe sepsis is not known.v儿童脓毒症最佳血红蛋白值尚无定论。v A recent multi-center trial reported n
14、o difference in mortality in hemodynamically stable critically ill children managed with a transfusion threshold of 7 g/dL compared with those managed with a transfusion threshold of 9.5 g/dLv一项多中心研究报道在血液动力血稳定的重症患儿HB 7 g/dL（输血阈值）组与 9.5 g/dL在死亡率上无明显差异。Part H Blood products and plasma therapies vhowev
15、er, the severe sepsis subgroup had an increase in nosocomial sepsis and lacked clear evidence of equivalence in outcomes with the restrictive strategyPart H Blood products and plasma therapies vBlood transfusion is recommended by the World Health Organization for severe anemia, hemoglobin value 5g/
16、dL, and acidosis. vWHO建议严重贫血（HB5g/ dL）及酸中毒时需要输血。Part H Blood products and plasma therapies vA RCT of early goal-directed therapy for pediatric septic shock using the threshold hemoglobin of 10 g/dL for patients with a SvcO2 saturation less than 70 % in the first 72h of pediatric ICU admission showed improved survival in the multimodal intervention arm . v一项RCT研究显示，早期目标导向治疗Svc O2 70%的患儿，最初72小时内HB低于10 g/dL时输血可提高生存率。Part H Blood products and plasma therapies v2. We suggest similar platelet transfus
