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1、2008国际严重脓毒症和脓毒性休国际严重脓毒症和脓毒性休克治疗指南克治疗指南International guidelines for management of severe sepsis and septic shock: 2008 1脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDV
2、T防治防治&应激性溃疡防治应激性溃疡防治2脓毒症指南基基 本本 概概 念念( (BasicDefinition)感染性休克画在哪里感染性休克画在哪里? ?3脓毒症指南基基 本本 概概 念念( (BasicDefinition)感染感染=无病原微生物的无病原微生物的无病原微生物的无病原微生物的地方出现病原微生物地方出现病原微生物地方出现病原微生物地方出现病原微生物菌血症菌血症=血液中出现血液中出现细菌细菌全身炎症反应综合全身炎症反应综合症症=符合符合4项中的两项中的两项项-浓毒症浓毒症=感染感染+全身炎全身炎全身炎全身炎症反应综合症症反应综合症症反应综合症症反应综合症4脓毒症指南基基 本本 概概
3、 念念( (BasicDefinition)严重严重严重严重浓毒症浓毒症浓毒症浓毒症= =浓毒症浓毒症浓毒症浓毒症+ +器器器器官功能不全官功能不全官功能不全官功能不全( (或低灌注或低灌注或低灌注或低灌注) )感染性休克感染性休克感染性休克感染性休克= =严重感染严重感染严重感染严重感染导致循环功能不全导致循环功能不全导致循环功能不全导致循环功能不全, ,需需需需要血管活性药要血管活性药要血管活性药要血管活性药浓毒症相关低血压浓毒症相关低血压浓毒症相关低血压浓毒症相关低血压= =- -MODS=MODS=两个以上器官两个以上器官两个以上器官两个以上器官功能障碍功能障碍功能障碍功能障碍5脓毒症
4、指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治6脓毒症指南早期复苏早期复苏 *Werecommendtheprotocolizedresuscitationofapatientwithsepsis-inducedshock,definedastiss
5、uehypoperfusion(hypotensionpersistingafterinitialfluidchallengeorbloodlactateconcentrationequaltoorgreaterthan4mmol/L).ThisprotocolshouldbeinitiatedassoonashypoperfusionisrecognizedandshouldnotbedelayedpendingICUadmission.Duringthefirst6hrsofresuscitation,thegoalsofinitialresuscitationofsepsis-induc
6、edhypoperfusionshouldincludeallofthefollowingasonepartofatreatmentprotocol:4针对确定存在血流灌针对确定存在血流灌注不足注不足( (经早期冲击经早期冲击液体疗法仍持续低血液体疗法仍持续低血压或血乳酸超过压或血乳酸超过4 4 mmol/L)mmol/L)的脓毒症患的脓毒症患者推荐使用常规复苏者推荐使用常规复苏方案方案. .此方案应该在此方案应该在确定存在血流灌注不确定存在血流灌注不足时立即实施足时立即实施, ,而不而不应该延迟到进入应该延迟到进入ICUICU后再进行后再进行7脓毒症指南早期复苏早期复苏 *During th
7、e first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as one part of atreatment protocol: !Central venous pressure (CVP): 812 mm Hg !Mean arterial pressure (MAP) 65 mm Hg !Urine output 0.5 mL.kg1.hr 1 !Central venous (s
8、uperior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (Grade 1C)4复苏开始的第一个复苏开始的第一个6 6小时小时应达到目标性复苏标准：应达到目标性复苏标准：4CVP: 812 mm Hg4MAP 65 mm Hg 4尿量 0.5 mL/kg/hr4中心静脉血氧饱和度或混合静脉血氧饱和度 70% or 65%, 4(Grade 1C)8脓毒症指南早期复苏早期复苏Aduringthefirst6hrsofresuscitationofseveresepsisorsepticshock,i
9、fSCVO2orSvO2of70%or65%respectivelyisnotachievedwithfluidresuscitationtotheCVPtarget,thentransfusionofpackedredbloodcellstoachieveahematocritof30%and/oradministrationofadobutamineinfusion(uptoamaximumof20g.kg1.min1)beutilizedtoachievethisgoal(Grade2C). n在脓毒症或脓毒性休克第一在脓毒症或脓毒性休克第一个个6 6小时复苏阶段小时复苏阶段, ,如果液
10、体如果液体复苏仍未使能复苏仍未使能SCVOSCVO2 2 or SvO or SvO2 2 达到达到 70% or 65% , 70% or 65% ,则应输血则应输血使使HCT 30% HCT 30% 和和/ /或滴注多或滴注多巴酚丁胺巴酚丁胺( (最大剂量最大剂量20 20 g/kg/min)g/kg/min)9脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松
11、镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治10脓毒症指南诊断诊断 pWerecommendobtainingappropriateculturesbeforeantimicrobialtherapyisinitiatedifsuchculturesdonotcausesignificantdelayinantibioticadministration.Tooptimizeidentificationofcausativeorganisms,werecommendatleasttwobloodculturesbeobt
12、ainedpriortoantibioticswithatleastonedrawnpercutaneouslyandonedrawnthrougheachvascularaccessdevice,unlessthedevicewasrecently(48h)inserted.Culturesofothersites(preferablyquantitativewhereappropriate)suchasurine,cerebrospinalfluid,wounds,respiratorysecretions,orotherbodyfluidsthatmaybethesourceofinfe
13、ctionshouldalsobeobtainedbeforeantibiotictherapyifnotassociatedwithsignificantdelayinantibioticadministration(Grade1C). n在不延误抗生素治疗前提下在不延误抗生素治疗前提下, ,给给抗生素前尽量获得可靠的病原微抗生素前尽量获得可靠的病原微生物培养结果生物培养结果, ,使用抗生素前至使用抗生素前至少获得两份血培养标本少获得两份血培养标本, , 一份直一份直接经皮穿刺获得接经皮穿刺获得, ,另一份可由任另一份可由任一血管通路获得一血管通路获得( (除非除非48H48H内新建内新建通
14、路通路).).其他部位包括尿液、脑脊其他部位包括尿液、脑脊液、创口、呼吸道分泌物或其他液、创口、呼吸道分泌物或其他可确定感染来源的体液，也最好可确定感染来源的体液，也最好进行定量培养（进行定量培养（1C1C）11脓毒症指南诊断诊断 nimaging studies be performed promptly in attempts to confirm apotential source of infection. Sampling of potential sources of infection should occur as they are identified; however, s
15、ome patients may be too unstable to warrant certain invasive procedures or transport outside of the ICU. Bedside studies, such as ultrasound, are useful in these circumstances (Grade 1C). n尽快完成影象学检查以确定尽快完成影象学检查以确定感染源，一旦发现疑似感染感染源，一旦发现疑似感染灶应立即在该部位进行取样。灶应立即在该部位进行取样。当然，有些患者因病情不稳当然，有些患者因病情不稳定而不容许进行某些具有侵定
16、而不容许进行某些具有侵袭性的特殊操作检查，或因袭性的特殊操作检查，或因尚在转运过程中而不具备检尚在转运过程中而不具备检查条件。一些床边检查，如查条件。一些床边检查，如超声检查也极具诊断价值超声检查也极具诊断价值（1C1C）12脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&
17、应激性溃疡防治应激性溃疡防治13脓毒症指南抗生素治疗抗生素治疗 rintravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1D). rAppropriate cultures should be obtained before initiating antibiotic therapy, but should not pre
18、vent prompt administration of antimicrobial therapy (Grade 1D). n脓毒性休克尽早脓毒性休克尽早( (确诊后确诊后1 1小时内小时内) )静脉使用抗生静脉使用抗生素素(1B)(1B) n不伴不伴休克的严重脓毒亦休克的严重脓毒亦尽早尽早( (确诊后确诊后1 1小时内小时内) )静静脉使用抗生素脉使用抗生素(1D)(1D)n使用抗生素前获取病原使用抗生素前获取病原微生物标本微生物标本, ,但不因为而但不因为而防碍给予抗生素防碍给予抗生素(1D)(1D)14脓毒症指南抗生素治疗抗生素治疗 Binitial empirical anti-i
19、nfective therapy include one or more drugs that have activity against all likely pathogens (bacterial and/or fungal) and that penetrate in adequate concentrations into the presumed source of sepsis (Grade 1B). n经验性使用一种或多种经验性使用一种或多种能覆盖可能的病原微生能覆盖可能的病原微生物物( (包括真菌包括真菌) )广谱抗生广谱抗生素素, ,并有良好组织穿透力并有良好组织穿透力(1
20、B)(1B)15脓毒症指南抗生素治疗抗生素治疗the antimicrobial regimen be reassessed daily to optimize activity, to prevent the development of resistance, to reduce toxicity, and to reduce costs (Grade 1C). n每日对抗生素治疗效果每日对抗生素治疗效果进行评估进行评估, ,保证疗效保证疗效, ,预预防耐药、减少不良反应、防耐药、减少不良反应、降低费用（降低费用（1C1C）16脓毒症指南抗生素治疗抗生素治疗(We suggest comb
21、ination therapy for patients with known or suspected Pseudomonas infections as acause of severe sepsis (Grade 2D). n对已知或疑似假单胞菌感染实施抗生素联合治疗（2D）17脓毒症指南抗生素治疗抗生素治疗nWe suggest combination empiric therapy for neutropenic patients with severe sepsis (Grade 2D). n对伴中性粒细胞减少的严重脓毒症患者联合经验使用抗生素（2D）18脓毒症指南抗生素治疗抗生素
22、治疗When used empirically in patients with severe sepsis, we suggest that combination therapy should not be administered for more than 3 to 5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility pro known. (Grade 2D). n经验治疗不应超过35天，然后根据药敏结果降阶梯治疗，尽
23、快单一抗生素治疗（2D）19脓毒症指南抗生素治疗抗生素治疗!We recommend that the duration of therapy typically be 710 days; longer courses may be appropriate in patients who have aslow clinical response, undrainable foci of infection, or who have immunologic deficiencies including neutropenia (Grade 1D). !常规治疗常规治疗7 71010天，对天，对治
24、疗反应差、未确定感治疗反应差、未确定感染源或有粒细胞减少、染源或有粒细胞减少、免疫缺陷者，可适当延免疫缺陷者，可适当延长抗生素使用时间长抗生素使用时间 (Grade 1D).(Grade 1D). 20脓毒症指南抗生素治疗抗生素治疗 nIf the presenting clinical syndrome is determined to be due to anoninfectious cause, we recommend antimicrobial therapy be stopped promptly to minimize the likelihood that the patien
25、t will become infected with an antibiotic resistant pathogen or will develop adrug related adverse effect (Grade 1D). n如果认为非感染因素如果认为非感染因素引起，立即停用抗生引起，立即停用抗生素，以最大限度减少素，以最大限度减少细菌耐药、二重感染细菌耐药、二重感染及不良反应及不良反应(Grade (Grade 1D). 1D). 21脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强
26、心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治22脓毒症指南控制感染源控制感染源 nWe recommend that aspecific anatomic diagnosis of infection requiring consideration for emergent source control- for example necrotizing fasciitis, diffu
27、se peritonitis, cholangitis, intestinal infarction be sought and diagnosed or excluded as rapidly as possible (Grade 1C) and within the first 6 hours following presentation (Grade 1D). n对感染源进行准确对感染源进行准确的解剖学诊断和排的解剖学诊断和排除诊断除诊断(Grade 1C) (Grade 1C) n应在应在6 6小时内完成小时内完成(Grade 1D)(Grade 1D)23脓毒症指南控制感染源控制感染
28、源nWefurtherrecommendthatallpatientspresentingwithseveresepsisbeevaluatedforthepresenceofafocusofinfectionamenabletosourcecontrolmeasures,specificallythedrainageofanabscessorlocalfocusofinfection,thedebridementofinfectednecrotictissue,theremovalofapotentiallyinfecteddevice,orthedefinitivecontrolofaso
29、urceofongoingmicrobialcontamination(Grade1C)n感染灶的病原学感染灶的病原学检察、引流、坏检察、引流、坏死组织清除，拔死组织清除，拔除可能引起感染除可能引起感染的置管或消除微的置管或消除微生物污染生物污染(Grade (Grade 1C) 1C) 24脓毒症指南控制感染源控制感染源nWe suggest that when infected peripancreatic necrosis is identified as apotential source of infection, definitive intervention is best de
30、layed until adequate demarcation of viable and non-viable tissues has occurred (Grade 2B). n如果发现感染源为已感染的坏死胰腺组织时,在未确切区分有活力组织和坏死组织前建议先不要进行手术治疗(2B)25脓毒症指南严重脓毒症的治疗严重脓毒症的治疗 nWe recommend that when source control is required, the effective intervention associated with the least physiologic insult be emplo
31、yed e. g., percutaneous rather than surgical drainage of an abscess (Grade 1D). 300 mg hydrocortisone daily not be used in severe sepsis or septic shock for the purpose of treating septic shock (Grade 1A). D对于严重脓毒症或对于严重脓毒症或脓毒性休克，皮质脓毒性休克，皮质激素用量不应大于激素用量不应大于对应氢化可的松对应氢化可的松300 mg 每天(Grade 1A). 50脓毒症指南皮质激
32、素皮质激素We recommend corticosteroids not be administered for the treatment of sepsis in the absence of shock. There is, however, no contraindication to continuing maintenance steroid therapy or to using stress does steroids if the patients endocrine or corticosteroid administration history warrants (Gr
33、ade 1D). D对于不伴休克的脓对于不伴休克的脓毒症患者不常规应毒症患者不常规应用皮质激素，除非用皮质激素，除非患者有相关内分泌患者有相关内分泌或皮质激素治疗史或皮质激素治疗史(Grade 1D). 51脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激
34、性溃疡防治52脓毒症指南重组人活化蛋白重组人活化蛋白C(rhAPC)BWe suggest that adult patients with sepsis induced organ dysfunction associated with aclinical assessment of high risk of death, most of whom will have APACHEII 25 or multiple organ failure, receive rhAPC if there are no contraindications (Grade 2B except for patie
35、nts within 30 days of surgery where it is Grade 2C). Relative contraindications should also be considered in decision making B对于伴有脓毒症所致器对于伴有脓毒症所致器官衰竭成人患者官衰竭成人患者, ,且存且存在临床死亡高危风险在临床死亡高危风险(APACHE(APACHEII 25 or II 25 or multiple organ multiple organ failure)failure)时时, ,如果无禁如果无禁忌忌, ,建议应用建议应用rhAPC(2B,rh
36、APC(2B,术后患者术后患者2C)2C)53脓毒症指南重组人活化蛋白重组人活化蛋白C(rhAPC)We recommend that adult patients with severe sepsis and low risk of death, most of whom will have APACHE II 20 or one organ failure, do not receive rhAPC (Grade 1A). B对临床死亡危险度对临床死亡危险度较低较低(APACHE II (APACHE II 20 or one organ 20 or one organ failure)f
37、ailure)的成人脓的成人脓毒症患者不推荐使毒症患者不推荐使用用rhAPC(1ArhAPC(1A) )54脓毒症指南血液制品血液制品Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis (see recommendations for initial resu
38、scitation), we recommend that red blood cell transfusion occur when hemoglobin decreases to 7.0 g/dL ( 70 g/L) to target ahemoglobin of 7.09.0 g/dL (7090 g/L) in adults (Grade 1B). B一旦组织低灌注得一旦组织低灌注得以改善以改善, ,且不存在某且不存在某些特殊情况些特殊情况, ,推荐只推荐只在血红蛋白降至在血红蛋白降至 70 g/L70 g/L时给予红细时给予红细胞胞, ,使血红蛋白达到使血红蛋白达到707090 g
39、/L(1B)90 g/L(1B)55脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治56脓毒症指南血液制品血液制品BWe recommend that erythropoietin not be used as aspecific treatme
40、nt of anemia associated with severe sepsis, but may be used when septic patients have other accepted reasons for administration of erythropoietin such as renal failure-induced compromise of red blood cell production (Grade 1B). B不推荐应用促红细胞生不推荐应用促红细胞生成素治疗脓毒症相关的成素治疗脓毒症相关的贫血贫血, ,但由其他原因引但由其他原因引起的贫血可考虑适当使
41、起的贫血可考虑适当使用用(1B)(1B)57脓毒症指南血液制品血液制品BWe suggest that fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (Grade 2D). B除非有出血或即将进行除非有出血或即将进行侵袭性手术操作侵袭性手术操作, ,否则否则不应使用新鲜冰冻血浆不应使用新鲜冰冻血浆来纠正实验室凝血指标来纠正实验室凝血指标的异常的异常(2D)(2D)58脓毒症
42、指南血液制品血液制品Bagainst antithrombin administration for the treatment of severe sepsis and septic shock (Grade 1B). B反对使用抗凝血酶治疗反对使用抗凝血酶治疗严重脓毒症和脓毒性休严重脓毒症和脓毒性休克克(1B)59脓毒症指南血液制品血液制品BIn patients with severe sepsis, we suggest that platelets should be administered when counts are 5000/mm3 (5 109/L) regardless
43、 of apparent bleeding. Platelet transfusion may be considered when counts are 5,00030,000/mm3 (530 109/L) and there is asignificant risk of bleeding. Higher platelet counts ( 50,000/mm3 (50 109/L) are typically required for surgery or invasive procedures (Grade 2D). B当存在下列情况时当存在下列情况时,输输血小板血小板:B无论是否出
44、血无论是否出血, ,血小板血小板 5000/mm3 B血小板血小板5,00030,000/mm3且存在明显出血风险且存在明显出血风险B需进行外科手术或相关需进行外科手术或相关侵袭性操作侵袭性操作, ,且血小板且血小板 50,000/mm3 B(Grade 2D)60脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT
45、治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治61脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗BWerecommendthatclinicianstargetatidalvolumeof6ml/kg(predicted)bodyweightinpatientswithALI/ARDS(Grade1B). B将患者潮气量维将患者潮气量维持在持在6 ml/kg 6 ml/kg (1B)(1B)62脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗BWe recommend that plat
46、eau pressures be measured in patients with ALI/ARDS and that the initial upper limit goal for plateau pressures in apassively inflated patient be 30 cm H2O. Chest wall compliance should be considered in the assessment of plateau pressure (Grade 1C). B初期平台压维初期平台压维持持 30 cm H2O(1C)63脓毒症指南脓毒症相关脓毒症相关ALI/
47、ARDSALI/ARDS的机械通气治疗的机械通气治疗Werecommendthathypercapnia(allowingPaCO2toincreaseaboveitspre-morbidbaseline,so-calledpermissivehypercapnia)beallowedinpatientswithALI/ARDSifneededtominimizeplateaupressuresandtidalvolumes(Grade1C).B为将平台压和潮为将平台压和潮气量降至低水平气量降至低水平,容许出现高碳酸容许出现高碳酸血症血症(1C)64脓毒症指南脓毒症相关脓毒症相关ALI/ARD
48、SALI/ARDS的机械通气治疗的机械通气治疗AWe recommend that positive end-expiratory pressure (PEEP) be set so as to avoid extensive lung collapse at end-expiration (Grade 1C). n使用呼气末正压,防止呼气末出现广泛肺萎陷(1C)65脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AWe suggest prone positioning in ARDS patients requiring potentially i
49、njurious levels of FIO2 or plateau pressure who are not at high risk for adverse consequences of positional changes in those facilities who have experience with such practices (Grade 2C). n对于需要有潜在风险的吸氧浓度或平台压患者,建议采用俯卧位通气,只要变换体位不会造成不良后果(Grade 2C). 66脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AA) Unl
50、ess contraindicated, we recommend mechanically ventilated patients be maintained with the head of the bed elevated to limit aspiration risk and to prevent the development of ventilator-associated pneumonia (Grade 1B). B) We suggest that the head of bed is elevated approximately 3045 degrees (Grade 2
51、C).n除非有禁忌症,否则机械通气患者应保持半卧位,以降低误吸风险,预防呼吸机相关肺炎的发生(1B)n患者头部抬高3045 degrees (Grade 2C).67脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AWesuggestthatnoninvasivemaskventilation(NIV)onlybeconsideredinthatminorityofALI/ARDSpatientswithmild-moderatehypoxemicrespiratoryfailure(responsivetorelativelylowlevelsofp
52、ressuresupportandPEEP)withstablehemodynamicswhocanbemadecomfortableandeasilyarousable,whoareabletoprotecttheairway,spontaneouslycleartheairwayofsecretions,andareanticipatedtorecoverrapidlyfromtheprecipitatinginsult.Alowthresholdforairwayintubationshouldbemaintained(Grade2B).M少数ALI/ARDS伴有轻度血氧不足的呼吸衰竭患
53、者(对低水平的压力支持和PEEP敏感),可使用无创通气.其血流动力学稳定的,处于舒适易唤醒状态,具有主动保护气道及清洁分泌物的能力，且被预计能迅速恢复，同时应保证紧急情况时可方便快捷地对对患者进行气管插管(Grade 2B). 68脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AWerecommendthataweaningprotocolbeinplace,andmechanicallyventilatedpatientswithseveresepsisundergospontaneousbreathingtrialsonaregularbasis
54、toevaluatetheabilitytodiscontinuemechanicalventilationwhentheysatisfythefollowingcriteria:a)arousable;b)hemodynamicallystable(withoutvasopressoragents);c)nonewpotentiallyseriousconditions;d)lowventilatoryandend-expiratorypressurerequirements;ande)FIO2requirementsthatcouldbesafelydeliveredwithafacema
55、skornasalcannula.Ifthespontaneousbreathingtrialissuccessful,considerationshouldbegivenforextubation(seeAppendixE).Spontaneousbreathingtrialoptionsincludealowlevelofpressuresupport,continuouspositiveairwaypressure(5cmH2O)oraT-piece(Grade1A).J当患者满足以下条件,推荐进行自主呼吸试验(SBT)来评估严重脓毒症患者是否可以脱机:1.清醒状态;2.在不使用血管升压
56、药的前提下处于血流动力学稳定状态;3.排除新的潜在严重病变;4,需要低的通气支持条件及PEEP;5.面罩给氧或鼻导管吸氧时可确保吸入氧浓度处于正常水平.如果SBT成功,可考虑拔管;SBT时可采用5 cm H2O 连续气道正压通气,提供低水平通气支持(Grade 1A)69脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗Aagainst the routine use of the pulmonary artery catheter for patients with ALI/ARDS (Grade 1A). n不支持将肺动脉导管作为ALI/ARDS患者
57、的常规监测手段(1A)70脓毒症指南脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗ATo decrease days of mechanical ventilation and ICU length of stay we recommend aconservative fluid strategy for patients with established acute lung injury who do not have evidence of tissue hypoperfusion (Grade 1C). n为缩短机械通气及ICU住院时间,对ALI无组织
58、血流灌注不足的患者,采取保守的液体治疗(Grade 1C). 71脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治72脓毒症指南镇静、镇痛和肌松药的使用镇静、镇痛和肌松药的使用 AWe recommend sedation protocols w
59、ith asedation goal when sedation of critically ill mechanically ventilated patients with sepsis is required (Grade 1B). n机械通气而需要镇静时，使用有镇静目标的镇静治疗方案(Grade 1B). 73脓毒症指南镇静、镇痛和肌松药的使用镇静、镇痛和肌松药的使用AWe recommend intermittent bolus sedation or continuous infusion sedation to predetermined end points (e. g., s
60、edation scales) with daily interruption/lightening of continuous infusion sedation with awakening and retitration if necessary for sedation administration to septic mechanically ventilated patients (Grade 1B). n通过间断冲击给药或连续输注药物的方式，达到预定目标使患者处于镇静状态。应每日中断给药以能唤醒患者，必要时可重新滴注给药（1B）74脓毒症指南镇静、镇痛和肌松药的使用镇静、镇痛和肌
61、松药的使用AWe recommend that NMBAs be avoided if possible in the septic patient due to the risk of prolonged neuromuscular blockade following discontinuation. If NMBAs must be maintained, either intermittent bolus as required or continuous infusion with monitoring the depth of blockade with train-of-four
62、 monitoring should be used (Grade 1B). n尽量避免使用肌松药。肌松药。若病情需要进行连续若病情需要进行连续滴注时应严密监测阻滴注时应严密监测阻滞深度（滞深度（1B)1B)75脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治
63、应激性溃疡防治76脓毒症指南控制血糖控制血糖DWe recommend that, following initial stabilization, patients with severe sepsis and hyperglycemia who are admitted to the ICU receive IV insulin therapy to reduce blood glucose levels (Grade 1B). D脓毒症合并高血糖患者,在病情初步稳定后推荐进行胰岛素治疗以控制血糖(Grade 1B)77脓毒症指南控制血糖控制血糖DWe suggest use of ava
64、lidated protocol for insulin dose adjustments and targeting glucose levels to the 150 mg/dl range (Grade 2C). D建议使用得到确认的方案调整胰岛素剂量,以控制血糖 150 mg/dl (8.3mmol/L) (Grade 2C)78脓毒症指南控制血糖控制血糖DWe recommend that all patients receiving intravenous insulin receive aglucose calorie source and that blood glucose
65、values be monitored every 12 hours until glucose values and insulin infusion rates are stable and then every 4 hours thereafter (Grade 1C). (所有静脉使用胰岛素并接受葡萄糖作为热量来源,应每12小时监测一次血糖,病情稳定后4小时一次(Grade 1C). 79脓毒症指南控制血糖控制血糖DWe recommend that low glucose levels obtained with point-of-care testing of capillary
66、blood be interpreted with caution, as such measurements may overestimate arterial blood or plasma glucose values (Grade 1B). D推荐谨慎分析通过毛细血管所监测的低血糖值,他可能会造成对动脉血或血浆葡萄糖水平的高估(Grade 1B) 80脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相
67、关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治81脓毒症指南肾脏替代治疗肾脏替代治疗DWe suggest that continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure (Grade 2B). D持续肾脏替代治持续肾脏替代治疗和间断血液透疗和间断血液透析对
68、于严重脓毒析对于严重脓毒症和急性肾功能症和急性肾功能衰竭患者具有相衰竭患者具有相同作用（同作用（2B）82脓毒症指南肾脏替代治疗肾脏替代治疗DWe suggest the use of continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients (Grade 2D). D对血流动力学不对血流动力学不稳定患者，持续稳定患者，持续血液滤过能更好血液滤过能更好控制液体平衡控制液体平衡（2D）83脓毒症指南碳酸氢盐治疗碳酸氢盐治疗Dagainst t
69、he use of sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH 7.15 (Grade 1B). D对于血流灌注不对于血流灌注不足所致高乳酸血足所致高乳酸血症症(pH 7.15 )时时,不推荐为了改善不推荐为了改善血流动力学状况血流动力学状况或减少血管升压或减少血管升压药用量而给予碳药用量而给予碳酸氢盐酸
70、氢盐(Grade 1B)84脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治85脓毒症指南预防深静脉血栓形成预防深静脉血栓形成DWe recommend that severe sepsis patients receive deep vein
71、thrombosis (DVT) prophylaxis with either (a) low-dose unfractionated heparin (UFH) administered b.i.d. or t.i.d. or (b) daily low-molecular weight heparin (LMWH) unless there are contraindications (i. e., thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) (Grade
72、1A). D除非存在禁忌症(包括血小板减少症、严重凝血紊乱、活动性出血、新近颅内出血等),对严重脓毒症患者推荐使用预防DVT治疗：普通肝素(23次/日)或低分子肝素(1次/日） Grade1A86脓毒症指南预防深静脉血栓形成预防深静脉血栓形成nWe recommend that septic patients who have acontraindication for heparin use receive mechanical prophylactic device such as graduated compression stockings (GCS) or intermittent
73、compression devices (ICD) unless contraindicated (Grade 1A). D有肝素使用禁忌症有肝素使用禁忌症者者,推荐使用机械推荐使用机械性预防促施性预防促施,如加如加压弹力袜或间歇加压弹力袜或间歇加压装置压装置(Grade 1A)87脓毒症指南预防深静脉血栓形成预防深静脉血栓形成nWe suggest that in very high-risk patients such as those who have severe sepsis and history of DVT, trauma, or orthopedic surgery, aco
74、mbination of pharmacologic and mechanical therapy be used unless contraindicated or not practical (Grade 2C). D对严重脓毒症和有对严重脓毒症和有DVT、创伤或骨科手、创伤或骨科手术病史的患者，建议术病史的患者，建议进行药物及机械联合进行药物及机械联合疗法，除非有禁忌症疗法，除非有禁忌症或无法使用或无法使用(Grade 2C)88脓毒症指南预防深静脉血栓形成预防深静脉血栓形成nWe suggest that in patients at very high risk, LMWH be u
75、sed rather than UFH as LMWH is proven superior in other high-risk patients (Grade 2C). D当患者存在极高当患者存在极高DVT、风险，建议首选低分风险，建议首选低分子肝素，而不使用普子肝素，而不使用普通肝素。因为低分子通肝素。因为低分子肝素被证实对其他高肝素被证实对其他高危患者更具疗效。危患者更具疗效。(Grade 2C)89脓毒症指南内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCA
76、PC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治90脓毒症指南预防应激性溃疡nWe recommend that stress ulcer prophylaxis using H2 blocker (Grade 1A) or proton pump inhibitor PPI (Grade 1B) be given to patients with severe sepsis to prevent upper GI bleed.
77、Benefit of prevention of upper GI bleed must be weighed against potential effect of an increased stomach pH on development of ventilator-associated pneumonia.1推荐使用H2受体阻滞剂（1A）或质子泵抑制剂（1B）来预防上消化道出血。必须谨慎评估预防上消化道出血和诱发呼吸机相关肺炎可能性的利弊关系91脓毒症指南选择性消化道去污染（SDD）nTheguidelinesgroupwasevenlysplitontheissueofSDD,wit
78、hequalnumbersweaklyinfavorandagainstrecommendingtheuseofSDD(seeappendixH).ThecommitteethereforechosenottomakearecommendationfortheuseofSDDspecificallyinseveresepsisatthistime.ThefinalconsensusonuseofSDDinseveresepsiswasachievedatthelastnominalcommitteemeetingandsubsequentlyapprovedbytheentirecommitt
79、ee(seeAppendixHforcommitteevote)k对是否进行SDD的观点尚不一致，持支持与反对意见的比例相似。因此暂不推荐SDD作为治疗脓毒症的常用方法92脓毒症指南支持疗法的局限性nWe recommend that advance care planning, including the communication of likely outcomes and realistic goals of treatment, be discussed with patients and families (Grade 1D). a推荐积极与患者及家属沟通商讨进一步的治疗护理方案，交代可能出现的后果及治疗达到的目标(Grade 1D)93脓毒症指南THANKYOUVERYMUCHINDEED!94脓毒症指南
