也应及时使用血管活性药物GradeE2去甲肾上腺素和多巴胺是治疗

严重感染和感染性休克治疗进展邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所Annualincidenceofseveresepsis:3cases/1,000Kill:1,400peopleworldwide/d25people/hMoreover,No.ofsepsispatsisprojectedtoincreaseby1.5%perannum严重感染的病死人数超过乳腺癌、直肠癌、结肠癌、胰腺癌和前列腺癌的总和严重感染vsAMI:发病率相同，病死率明显高SepsisinworldwideSurvivingSepsisCompaign拯救Sepsis运动巴塞罗那宣言ESICMSCCMISF2002年10月2日,西班牙Committoagoalofa25%relativereductionofmortalityfromsepsisin5YSurvivingSepsisCampaignPhaseⅠ:BarcelonaDeclarationPhaseⅡ:GuidelinescreationPhaseⅢ:ClinicaloutcomeevaluationGUIDELINESFORMANAGEMENGTOFSEVERESEPSISANDSEPTICSHOCKAACCN;AmericanAssociationofCritical-CareNursesACCP:AmericanCollegeofChestPhysiciansACEP:AmericanCollegeofEmergencyPhysiciansATS:AmericanThoracicSocietyANZICS:AustralianandNewZealandIntensiveCareSocietyESCMID:EuropeanSocietyofClinicalMicrobiologyandInfectiousDisERS:EuropeanRespiratorySocietySIF:SurgicalInfectionSocietyESICM:EuropeanSocietyofIntensiveCareMedicineISF:InternationalSepsisForumSCCM:SocietyofCriticalCareMedicineGuidelinesforsepsis.IntensiveCareMed2004,30:536-555循证医学----推荐级别A：至少2个Ⅰ级研究证实B：1个Ⅰ级研究证实C：Ⅱ级研究证实D：至少1个Ⅲ级研究证实E：Ⅳ或Ⅴ级研究证实研究级别I.Large,randomizedtrialswithclearcutresultsII.Small,randomizedtrialswithuncertainresultsIII.Nonrandomized,contemporaneouscontrolsIV.Nonrandomized,historicalcontrolsandexpertopinionV.Caseseries,uncontrolledstudies,andexpertopinionA.早期复苏1.早期目标性复苏治疗(EGDT)最初6小时应达到的目标CVP:8-12mmHg（MV12-15mmHg）MAP≥65mmHgUrineoutput≥0.5mL·kg-1·h-1SvO2≥70%GradeBA.早期复苏2.若最初6h治疗，CVP达到8-12mmHg，而SvO270%Transfusepackedredbloodcells：HCT≥30%and/orDobuiv(uptomax20μg·kg-1·min-1)GradeBB.病源学诊断1.抗生素治疗前要进行细菌学培养AppropriateculturesbeforeantimicrobialtherapyisinitiatedInordertooptimizeidentificationofcausativeorganisms,atleasttwobloodculturesshouldbeobtainedwithatleastonedrawnpercutaneouslyandonedrawnthrougheachvascularaccessdevice,unlessthedevicewas48hinsertedGradeD0%20%40%60%80%100%血培养阳性率3ml9ml*p0.001VolumeofbloodmaybeimportantMermelLA.AnnInternMed1993,119:270-272B.病源学诊断2.尽快确定感染灶和致病菌TOdeterminethesourceofinfectionandthecausativeorganismImagingstudiesSamplingoflikelysourcesofinfUltrasoundGradeEC.抗生素治疗1.抗生素治疗在病人诊断为重症感染并已取标本后1h内开始2.Initialempiricanti-infectivetherapyBroad-spectrumPenetrateintothepresumedsourceGuidedbythesusceptibilitypatternsofmicroorganismsinthecommunityandinthehospGrade1E/2D/3E/4EHighmortalityofsepsis,severesepsisandsepticshock9%29%38%61%63%81%0%30%60%90%Mortality/%sepsissspesissshockAEATIEAT•Prospectivecohortstudy•ICUofatertiaryhosp•406patsincluded•AtICUadmission:Sepsis25.9%Ssepsis28.6%Sshock45.6%CCM,2003,31:2742严重感染的病死率降低23％C.抗生素治疗3.Theantimicrobialregimenshouldalwaysbereassessedafter48~72honthemicrobiologicalandclinicaldatawiththeaimofusinganarrow-spectrumantibiotic(Durationoftherapy:7-10d,guidedbyclinicalresponse)4.Iftheclinicalsyndromeisdeterminedtobeduetoanon-infectiouscauseStopantimicrobialtherapypromptlyMinimizetheresistantandsuperinfectionGrade1E/2D/3E/4EGuidelinesfortheManagementofAdultswithHospital-acquired,Ventilator-associated,andHealthcare-associatedPneumoniaThisofficialstatementAmericanThoracicSociety(ATS)AndInfectiousDiseasesSocietyofAmerica(ISDA)ApprovedbytheATSBoardofDirectors,December2004andtheIDSAGuidelineCommittee,October2004AmJRespirCritCareMed2005,171.388–416ModifiableRiskFactorsIntubation&mechanicalventilationNoninvasivepositive-pressureventilationshouldbepreferredReintubationshouldbeavoidedOralinsertionispreferredCuffpressure20mmHgContinousaspirationofsubglotticsecretionsContaminatedcondensateshouldbeemptiedATS.AmJRespirCritCareMed2005;171:388-416ModifiableRiskFactorsAspiration,bodyposition,andfeedingSemirecumbentposition(30-45)EnteralfeedingispreferredModulationofcolonizationRoutineprophylaxisisnotrecommendedStressbleedingprophylaxis,transfusion,andhyperglysemiaH2antogonistsorsucralfateisacceptableRestrictedtransfusiontriggerpolicyIntensiveinsulintherapyATS.AmJRespirCritCareMed2005;171:388-416E.液体治疗1.Fluidresuscitationmayconsistofartificialcolloidsorcrystalloids.Thereisnoevidence-basedsupportofonetypeoffluidoveranotherGradeCE.液体治疗2.Fluidchallengeinpatswithsuspectedhypovolemiamaybegivenatarateof500-1000mlofcrystalloidsor300-500mlcolloidsover30minandrepeatedbasedonresponse(increaseinBPandurineoutput)andtolerance(evidenceofintravascularvolumeoverload)GradeEF.血管活性药物1.充分液体复苏后血压和器官灌注仍不能维持，是应用血管活性药物的指征；对于威胁生命的低血压，即使低容量状态尚未纠正，也应及时使用血管活性药物GradeE2.去甲肾上腺素和多巴胺是治疗感染性休克的一线药物GradeD3.小剂量多巴胺对重症感染者无肾保护作用GradeBF.血管活性药物4.应用血管活性药物时，最好采用动脉置管监测有创血压GradeE5.充分容量复苏和大剂量传统血管活性药物无效的难治性休克，可应用血管加压素（0.01－0.04U／min）－（降低SV）GradeEG.正性肌力药物1.如果病人经充分容量复苏后,存在低CO，可应用Dobu；对低血压者，应联合应用血管活性药物合适的容量状态和MAP时，Dobu是低CI者首选无CO监测时，感染性休克CO存在低、正常和高3种情况，推荐NE＋Dopa能够监测血压和CO时，可目标性应用NE提升血压，应用Dobu提高COGradeEG.正性肌力药物2.应用Dobu以达到超常的氧输送水平对重症感染无效GradeAH.糖皮质激素1.经足够液体复苏，但仍需应用缩血管药物维持血压的感染性休克患者，推荐应用皮质类固醇激素。氢化可的松200-300mg/d，分3~4次静点，连用7dGradeCa.对于感染性休克，不需作ACTH应激试验就可应用激素GradeEb.休克改善后，激素应减量GradeE肾上腺功能低下的感染性休克低剂量的糖皮质激素可逆转休克、降低病死率Objective:evaluatedlowdoseGStosurvivalinsepticshockpatientsandAI(Post-ACTHcortisolrise9ug/dl)Design:placebo-controlled,randomized,double-blind,parallel-grouptrialSetti