严重感染和感染性休克 治疗指南概要.docx
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严重感染和感染性休克 治疗指南概要.docx
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严重感染和感染性休克治疗指南概要
Internationalguidelinesformanagementofseveresepsisandsepticshock:
2008
2008严重感染和感染性休克治疗指南概要
MAJORRECOMMENDATIONS
Thegradesofrecommendations(A-E)andgradesofevidence(I-V)aredefinedattheendofthe"MajorRecommendations"field.
A.InitialResuscitation
1.Theresuscitationofapatientinseveresepsisorsepsis-inducedtissuehypoperfusion(hypotensionorlacticacidosis)shouldbeginassoonasthesyndromeisrecognizedandshouldnotbedelayedpendingintensivecareunit(ICU)admission.Anelevatedserumlactateconcentrationidentifiestissuehypoperfusioninpatientsatriskwhoarenothypotensive.Duringthefirst6hrsofresuscitation,thegoalsofinitialresuscitationofsepsis-inducedhypoperfusionshouldincludeallofthefollowingasonepartofatreatmentprotocol:
∙Centralvenouspressure:
8–12mmHg
∙Meanarterialpressure>65mmHg
∙Urineoutput>0.5mL/kg/hr
∙Centralvenous(superiorvenacava)ormixedvenousoxygensaturation>70%
GradeofRecommendationB
2.Duringthefirst6hrsofresuscitationofseveresepsisorsepticshock,ifcentralvenousoxygensaturationormixedvenousoxygensaturationof70%isnotachievedwithfluidresuscitationtoacentralvenouspressureof8–12mmHg,thentransfusepackedredbloodcellstoachieveahematocritof>30%and/oradministeradobutamineinfusion(uptoamaximumof20micrograms/kg/min)toachievethisgoal.
GradeofRecommendation:
B
早期复苏-1(推荐级别:
B级)
一旦临床诊断严重感染,应尽快进行积极的液体复苏,6h内达到复苏目标:
中心静脉压(CVP)8-12cmH2O
平均动脉压≥65mmHg
尿量≥0.5ml/kg/h
中心静脉或混合静脉血氧饱和度(ScvO2或SvO2)≥0.70
早期复苏-2(推荐级别:
B级)
若开始6h内液体复苏后CVP达8~12cmH2O,而ScvO2或SvO2仍未达到0.70,需输注浓缩红细胞使血细胞比容达到0.30以上和(或)输注多巴胺(最大剂量至20μg/kg/min)以达到上述复苏目标
B.Diagnosis
1.Appropriateculturesshouldalwaysbeobtainedbeforeantimicrobialtherapyisinitiated.Tooptimizeidentificationofcausativeorganisms,atleasttwobloodculturesshouldbeobtainedwithatleastonedrawnpercutaneouslyandonedrawnthrougheachvascularaccessdevice,unlessthedevicewasrecently(<48hrs)inserted.Culturesofothersitessuchasurine,cerebrospinalfluid,wounds,respiratorysecretions,orotherbodyfluidsshouldbeobtainedbeforeantibiotictherapyisinitiatedastheclinicalsituationdictates.
GradeofRecommendation:
D
2.Diagnosticstudiesshouldbeperformedpromptlytodeterminethesourceoftheinfectionandthecausativeorganism.Imagingstudiesandsamplingoflikelysourcesofinfectionshouldbeperformed;however,somepatientsmaybetoounstabletowarrantcertaininvasiveproceduresortransportoutsideoftheICU.Bedsidestudies,suchasultrasound,maybeusefulinthesecircumstances.
GradeofRecommendation:
E
病源学诊断
抗生素治疗前应首先进行及时正确的微生物培养(推荐级别:
D级)。
为了确定感染源和致病病原体,应迅速采用诊断性检查,如影像学检查和可疑感染源取样(推荐级别:
E级)。
C.AntibioticTherapy
1.Intravenousantibiotictherapyshouldbestartedwithinthefirsthourofrecognitionofseveresepsis,afterappropriatecultureshavebeenobtained.
GradeofRecommendation:
E
2.Initialempiricalanti-infectivetherapyshouldincludeoneormoredrugsthathaveactivityagainstthelikelypathogens(bacterialorfungal)andthatpenetrateintothepresumedsourceofsepsis.Thechoiceofdrugsshouldbeguidedbythesusceptibilitypatternsofmicroorganismsinthecommunityandinthehospital.
GradeofRecommendation:
D
3.Theantimicrobialregimenshouldalwaysbereassessedafter48–72hrsonthebasisofmicrobiologicalandclinicaldatawiththeaimofusinganarrow-spectrumantibiotictopreventthedevelopmentofresistance,toreducetoxicity,andtoreducecosts.Onceacausativepathogenisidentified,thereisnoevidencethatcombinationtherapyismoreeffectivethanmonotherapy.Thedurationoftherapyshouldtypicallybe7–10daysandguidedbyclinicalresponse.
GradeofRecommendation:
E
a.SomeexpertsprefercombinationtherapyforpatientswithPseudomonasinfections.
GradeofRecommendation:
E
b.Mostexpertswouldusecombinationtherapyforneutropenicpatientswithseveresepsisorsepticshock.Forneutropenicpatients,broad-spectrumtherapyusuallymustbecontinuedforthedurationoftheneutropenia.
GradeofRecommendation:
E
4.Ifthepresentingclinicalsyndromeisdeterminedtobeduetoanoninfectiouscause,antimicrobialtherapyshouldbestoppedpromptlytominimizethedevelopmentofresistantpathogensandsuperinfectionwithotherpathogenicorganisms.
GradeofRecommendation:
E
抗生素治疗
诊断严重感染后1h以内,立即给予静脉抗生素治疗(推荐级别:
E级)。
早期经验性抗感染治疗应根据社区或医院微生物流行病学资料,采用覆盖可能致病微生物(细菌或真菌)的广谱抗生素,而且抗生素在感染组织具有良好的组织穿透力(推荐级别:
D级)。
为阻止细菌耐药,降低药物毒性,减少花费,应用抗生素48~72h后,根据微生物培养结果和临床反应评估疗效,选择目标性的窄谱抗生素治疗。
抗生素疗程一般7~10d(推荐级别:
E级)
若临床判断症状由非感染因素所致,应立即停用抗生素(推荐级别:
E级)。
D.SourceControl
1.Everypatientpresentingwithseveresepsisshouldbeevaluatedforthepresenceofafocusoninfectionamenabletosourcecontrolmeasures,specificallythedrainageofanabscessorlocalfocusoninfection,thedebridementofinfectednecrotictissue,theremovalofapotentiallyinfecteddevice,orthedefinitivecontrolofasourceofongoingmicrobialcontamination.(SeeAppendixAintheoriginalguidelinedocumentforexamplesofpotentialsitesneedingsourcecontrol.)
GradeofRecommendation:
E
2.Theselectionofoptimalsourcecontrolmethodsmustweighbenefitsandrisksofthespecificintervention.Sourcecontrolinterventionsmaycausefurthercomplicationssuchasbleeding,fistulas,orinadvertentorganinjury;ingeneral,theinterventionthataccomplishesthesourcecontrolobjectivewiththeleastphysiologicupsetshouldbeemployed,forexample,considerationofpercutaneousratherthansurgicaldrainageofanabscess.
GradeofRecommendation:
E
3.Whenafocusofinfectionamenabletosourcecontrolmeasures,suchasanintra-abdominalabscess,agastrointestinalperforation,cholangitis,orintestinalischemia,hasbeenidentifiedasthecauseofseveresepsisorsepticshock,sourcecontrolmeasuresshouldbeinstitutedassoonaspossiblefollowinginitialresuscitation.
GradeofRecommendation:
E
4.Ifintravascularaccessdevicesarepotentiallythesourceofseveresepsisorsepticshock,theyshouldbepromptlyremovedafterestablishingothervascularaccess.
GradeofRecommendation:
E
控制感染源
评估和控制感染灶(推荐级别:
E级)
根据患者的具体情况,通过权衡利弊,选择适当的感染控制手段(推荐级别:
E级)
若感染灶明确(如腹腔内脓肿、胃肠穿孔、胆囊炎或小肠缺血),应在复苏开始的同时,尽可能控制感染源(推荐级别:
E级)。
控制感染源
若深静脉导管等血管内有创装置被认为是导致严重感染或感染性休克的感染源时,在建立其他的血管通路后,应立即去除(推荐级别:
E级)。
E.FluidTherapy
Seeinitialresuscitationrecommendations(A1–2)fortimingofresuscitation.
1.Fluidresuscitationmayconsistofnaturalorartificialcolloidsorcrystalloids.Thereisnoevidence-basedsupportforonetypeoffluidoveranother.
GradeofRecommendation:
C
2.Fluidchallengeinpatientswithsuspectedhypovolemia(suspectedinadequatearterialcirculation)maybegivenatarateof500–1,000mLofcrystalloidsor300–500mLofcolloidsover30minsandrepeatedbasedonresponse(increaseinbloodpressureandurineoutput)andtolerance(evidenceofintravascularvolumeoverload).
GradeofRecommendation:
E
液体治疗
复苏液体包括天然的或人工合成的晶体或胶体液,尚无证据表明某种液体的复苏效果优于其他液体(推荐级别:
C级)。
对于疑有低容量状态的严重感染患者,应行快速补液试验,即在30min内输入500~1000ml晶体液或300~500ml胶体液,同时根据患者反应性(血压升高和尿量增加)和耐受性(血管内容量负荷过多)来决定是否再次给予快速补液试验(推荐级别:
E级)。
F.Vasopressors
1.Whenanappropriatefluidchallengefailstorestoreadequatebloodpressureandorganperfusion,therapywithvasopressoragentsshouldbestarted.Vasopressortherapymayalsoberequiredtransientlytosustainlifeandmaintainperfusioninthefaceoflife-threateninghypotension,evenwhenafluidchallengeisinprogressandhypovolemiahasnotyetbeencorrected.
GradeofRecommendation:
E
2.Eithernorepinephrineordopamine(throughacentralcatheterassoonasavailable)isthefirst-choicevasopressoragenttocorrecthypotensioninsepticshock
GradeofRecommendation:
D
3.Low-dosedopamineshouldnotbeusedforrenalprotectionaspartofthetreatmentofseveresepsis.
GradeofRecommendation:
B
4.Allpatientsrequiringvasopressorsshouldhaveanarterialcatheterplacedassoonaspracticalifresourcesareavailable.
GradeofRecommendation:
E
5.Vasopressinusemaybeconsideredinpatientswithrefractoryshockdespiteadequatefluidresuscitationandhigh-doseconventionalvasopressors.Pendingtheoutcomeofongoingtrials,itisnotrecommendedasareplacementfornorepinephrineordopamineasafirst-lineagent.Ifusedinadults,itshouldbeadministeredatinfusionratesof0.01–0.04units/min.Itmaydecreasestrokevolume.
GradeofRecommendation:
E
升压药的应用
如果充分的液体复苏仍不能恢复动脉血压和组织灌注,有指征时应用升压药。
存在威胁生命的低血压时,即使低血容量状态尚未纠正,液体复苏的同时可以暂时使用升压药以维持生命和器官灌注(推荐级别:
E级)
去甲肾上腺素和多巴胺是纠正感染性休克低血压的首选升压药(推荐级别:
D级)。
小剂量多巴胺对严重感染患者无肾脏保护作用(推荐级别:
B级)。
升压药的应用
条件许可的情况下,应用升压药的患者均应留置动脉导管,监测有创血压(推荐级别:
E级)。
对经过充分液体复苏,并应用大剂量常规升压药,血压仍不能纠正的难治性休克患者,可应用血管加压素,但不推荐将其代替去甲肾上腺素和多巴胺等一线药物。
成人使用剂量为0.01~0.04U/min(推荐级别:
E级)。
G.InotropicTherapy
1.Inpatientswithlowcardiacoutputdespiteadequatefluidresuscitation,dobutaminemaybeusedtoincreasecardiacoutput.Ifusedinthepresenceoflowbloodpressure,itshouldbecombinedwithvasopressortherapy.
GradeofRecommendation:
E
2.Astrategyofincreasingcardiacindextoachieveanarbitrarilypredefinedelevatedlevelisnotrecommended.
GradeofRecommendation:
A
强心药物的应用
充分液体复苏后仍然存在低心排量,应使用多巴酚丁胺增加心排血量。
若同时存在低血压,应联合使用升压药(推荐级别:
E级)
不推荐提高心排指数达到目标性的高氧输送(推荐级别:
A级)。
H.Steroids
1.Intravenouscorticosteroids(hydrocortisone200–300mg/day,for7daysinthreeorfourdivideddosesorbycontinuousinfusion)arerecommendedinpatientswithsepticshockwho,despiteadequatefluidreplacement,requirevasopressortherapytomaintainadequatebloodpressure.
GradeofRecommendation:
C
a.Someexpertswouldusea250-microgramadrenocorticotropic
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