1、According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline20122012年严重脓毒症和脓毒性休克治疗指南年严重脓毒症和脓毒性休克治疗指南According to the assessment requirements of party conduct
2、 and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline概 念p 感染：Infectionp 全身炎症反应综合症:SIRSp 脓毒症:Sepsisp 严重脓毒症:Severe SepsisAccording to the assessment requirements of party conduct and clean government,combined
3、with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineSepsis:Defining A Disease ContinuumAdult CriteriaA clinical response arising from aNonspecific insult,including 2 of theFolowing:Temperature:38 or 90 beat/minRespirations:20/minWBC coun
4、t:12*109 or 10%immature neutrophilSIRS with a presumed or confirmed infetious processSepsis with 1 sign of organ dysfunction According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders i
5、ntegrity and self-discipline促炎介质促炎介质过度产生过度产生原始病因原始病因感染因子感染因子非感染因子非感染因子抗炎介质抗炎介质过度产生过度产生 全身反应全身炎症反应综合征 （SIRS）代偿性炎症反应综合征（CARS）混合性抗炎反应综合征（MARS）SIRS和和CARS 稳态稳态SIRS占优占优细胞调亡细胞调亡CARS占优占优免疫功能障碍免疫功能障碍SIRS占优占优 MODSSIRS占优占优 休克休克According to the assessment requirements of party conduct and clean government,combi
6、ned with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineAccording to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integri
7、ty and self-disciplineAccording to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineAccording to the assessment requirements of party conduct and clean governm
8、ent,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline脓毒症流行病学：Angus DC,et a1.Crit Care Med,2001,29;1303-10 美国每年发生严重脓毒症人数750,000病死率高达30%50%每小时有25名患者死于严重感染或感染性休克是ICU的首要致死原因是第10位致死原因死亡率与急性心梗相近！According to the assessment requirem
9、ents of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline巴塞罗那宣言Phase 1Phase 2Phase 3呼吁全球的医务人员、卫生机构和政府乃至公众应高度认识和重视严重脓毒症和脓毒症休克,力争5 年内将全身性感染患者的病死率降低25%作为行动目标。制定严重脓毒症和脓毒症休克管理指南,旨在提高对严重感染的认识并努力改善
10、预后。将致力于治疗指南的临床应用和疗效评估,以期最终降低严重脓毒症患者的病死率。在评估指南中临床疗效的同时,将根据临床研究的进展和新的依据,每年对指南进行修订。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline20042004年，年，1111个
11、国际医学组织的感染个国际医学组织的感染和脓毒症诊治方面的专家，出版了和脓毒症诊治方面的专家，出版了第一个改进重症脓毒症和脓毒症休第一个改进重症脓毒症和脓毒症休克预后的指南。这些指南代表了拯克预后的指南。这些指南代表了拯救脓毒症运动（救脓毒症运动（SSCSSC）的第）的第阶段，阶段，一个国际性努力来提高对重症脓毒一个国际性努力来提高对重症脓毒症的认识和改善它的预后。联合另症的认识和改善它的预后。联合另外的一些组织，这个工作组在外的一些组织，这个工作组在20062006年和年和20072007年再次举行会议，用新的年再次举行会议，用新的循证方法论系统来评估证据的质量循证方法论系统来评估证据的质量和
12、推荐力度，以更新该指南文件。和推荐力度，以更新该指南文件。这些建议的目的是用来指导临床医这些建议的目的是用来指导临床医生治疗重症脓毒症和脓毒症性休克生治疗重症脓毒症和脓毒症性休克的病人。的病人。需要指出的是，当医生面需要指出的是，当医生面对具体病人独特的临床指标时，这对具体病人独特的临床指标时，这些指南中的建议不能取代临床医生些指南中的建议不能取代临床医生的决策。的决策。According to the assessment requirements of party conduct and clean government,combined with the five regulations
13、 and five new requirements of state-owned Enterprise leaders integrity and self-discipline内 容：p液体复苏液体复苏p诊断诊断p抗生素治疗抗生素治疗p病因治疗病因治疗p血管收缩药血管收缩药p正性肌力药正性肌力药p皮质类固醇皮质类固醇p活化蛋白活化蛋白Cp血制品的使用血制品的使用p机械通气p镇静、镇痛和肌松剂p血糖控制p肾脏替代治疗p预防深静脉血栓形成预防深静脉血栓形成p预防应激性溃疡预防应激性溃疡p选择性肠道净化治疗选择性肠道净化治疗According to the assessment requirem
14、ents of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineA 初期复苏EGDTp 1.复苏的最初6小时目标 1)CVP 8-12 mmHgMechanical Ventilation 12-15mmHg 2)MAP 65mmHg 3)Urine Output 0.5ml/kg/h 4)ScvO270%或 SvO265%（1
15、C）According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineA 初期复苏（2012）p 推荐对sepsis诱导的休克进行程序化复苏（即开始EGDT），Sepsis诱导的休克定义为组织低灌注（即经初始液体复苏后仍持续低血压，或乳酸浓度4mmol/L）。
16、一旦发现存在低灌注，应尽快启动初始复苏流程，不应延迟到入住ICU才启动。p 在没有能力取得中心静脉血氧饱和度的医院，建议将脓毒症患者的血乳酸尽快降至正常值。因为血乳酸增高是组织灌注不足的指标。即强调乳酸清除率的重要性（2C）.p 提议6h复苏时，若ScVO2 70%(或ScVO2 65%)，分别持续液体复苏达到CVP目标，并输注浓缩红细胞达到Hct30%，和/或输注多巴酚丁胺（最大剂量20ug/kg.min）（Grade 2C）According to the assessment requirements of party conduct and clean government,combi
17、ned with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline低容量表现心动过速低血压(严重者)高乳酸(严重者)肢端温度降低脱水表现皮肤充盈下降口渴口干腋窝干燥高血钠高蛋白血症高血红蛋白高血球压积体位性低血压动脉血压或每搏输出量的呼吸波动下肢被动抬高容量负荷试验结果阳性肾脏灌注减少浓缩尿(低尿钠,高尿渗)BUN升高(与肌酐升高不成比例)持续性代谢性酸中毒动态指标静态指标容量状态评价According to the ass
18、essment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineAccording to the assessment requirements of party conduct and clean government,combined with the five regulations and
19、 five new requirements of state-owned Enterprise leaders integrity and self-disciplineWeil MH,Henning RJ:New concepts in the diagnosis and fluid treatment of circulatory shock.Anesth Analg 1979;58:124132According to the assessment requirements of party conduct and clean government,combined with the
20、five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline感染相关建议 p1.感染预防p提议采用或探讨SDD或SOD以减少VAP；这些感染控制方法可随后在健康护理单位和区域继续进行，因已证明在这些场所仍有效（1B）。pSOD(选择性口咽去污)：Selective Oropharyngeal Decontamination.仅口咽部应用相同抗菌素。pSDD（选择性消化道去污）:Selective Digestive Decontaminatio
21、n.头孢噻肟静滴4天+口咽/胃局部应用妥布霉素、多粘菌素、两性霉素B。pDecontamination of the Digestive Tract and Oropharyngeal in icu Patients.N Engl J Med,2009,360(1):20-31.According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enter
22、prise leaders integrity and self-disciplineB 诊断（2008）p2.为明确可能的感染源，应尽快进行影像学检查。应该对可能的感染源进行取样，以便明确诊断。但是部分患者可能病情不稳定以至于不能接受某些有创操作或搬运至ICU以外。在这种情况下，一些床旁检查（如超声检查）比较有效(1C)。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requiremen
23、ts of state-owned Enterprise leaders integrity and self-disciplineC 抗生素治疗(2012)p 建议尽早开始静脉使用抗生素，感染性休克确诊后1h之内（1B），严重Sepsis无休克者确认后1h内（1C）。提议未发现感染证据时，PCT低水平可用于辅助停用经验性抗生素治疗（2C）。p 不建议将PCT作为诊断重症感染的指标p 降钙素原降低可以作为经验性抗生素治疗过程中的停药依据。（Grade 2C)p 对于那些可能感染真菌的高危患者，建议将1,3-D葡聚糖、甘露聚糖和抗甘露聚糖抗体作为侵袭性真菌感染诊断的参考指标According t
24、o the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineD控制感染源（2008）p 1a.由于某些特定解剖部位的感染（如坏死性筋膜炎、弥漫性腹膜炎、胆管炎、肠梗死）需要采取紧急的治疗措施，所以应该尽快寻找、做出诊断或排除诊断，并在发病后的最初6小时内完成。1b.在此基础上
25、，对所有表现为重症脓毒症的患者都应该寻找可以通过干预措施治疗的感染源，特别是脓肿和局部感染灶的引流，感染坏死组织的清创，潜在感染器械的去除，或即将发生感染的微生物污染源的去除。p 1b.在此基础上，对所有表现为重症脓毒症的患者都应该寻找可以通过干预措施治疗的感染源，特别是脓肿和局部感染灶的引流，感染坏死组织的清创，潜在感染器械的去除，或即将发生感染的微生物污染源的去除。According to the assessment requirements of party conduct and clean government,combined with the five regulations
26、and five new requirements of state-owned Enterprise leaders integrity and self-disciplineE 液体疗法（2012）p 在初期液体复苏中，推荐首先使用晶体液（1A）p 在初期液体复苏中，也可以考虑使用白蛋白（2B）p 不建议使用贺斯，对于万文和明胶，我们保持沉默（1B）According to the assessment requirements of party conduct and clean government,combined with the five regulations and five
27、 new requirements of state-owned Enterprise leaders integrity and self-disciplineE 液体治疗(2012)p 建议对Sepsis诱导组织低灌注怀疑低血容量患者，初始液体挑战时以输注晶体液1000ml开始（最初4-6小时至少30ml/kg）；部分患者可能需要更大更快的输液（Grade 1B）。p 建议只要血流动力学改善，就继续采用分次递增方法进行液体挑战。血流动力学改善的依据，动态（PP、SVV）、或静态（动脉血压、心率）指标（Grade 1C）。According to the assessment require
28、ments of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineF 血管加压类药物（2012年）p 推荐将去甲肾上腺素作为纠正脓毒性休克低血压时首选的血管加压药物(1B)。p 多巴胺不作为首先的血管活性药物，只有当患者心律失常发生风险比较低，而且低心输出量时，才考虑使用多巴胺(2C)According to the asses
29、sment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineG 正性肌力药物(2012年)p 建议对存在心肌功能障碍时，输注多巴酚丁胺，或已使用缩血管药物时加用多巴酚丁胺。提示存在心肌功能障碍：心脏充盈压身高并低心输出量，或已达到充分血容量和足够MAP时仍有低灌注征象（Grade 1C）。Acco
30、rding to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineH 糖皮质激素（2012年）p建议对感染性休克成人患者，若充分液体复苏和缩血管治疗可恢复血流动力学稳定，不用皮质醇激素；若不能恢复稳定，则建议给予氢化可的松（HC）200mg/天静滴持续输注（Grade
31、 2C）.p提议不采用ACTH刺激试验来确定哪些亚组患者应接受皮质醇激素（Grade 2B）。提议感染性休克患者用HC而不是用其他皮质醇激素，建议单独用HC，而不是用HC+氟氢松（Grade 1B）。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipl
32、ine重组活化蛋白C(2012)p 没有关于rhAPC的建议，因药品已不能获得According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineH 血液制品的输注(2012)p 一旦消除组织低灌注，且无削弱组织灌注的状况，如心肌缺血（或其他相关心脏病）、严重缺
33、氧、急性出血或严重乳酸酸中毒，建议有必要输注红细胞HB 7.0g/L（1B）。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineI Sepsis所致ARDS的机械通气(2012)p建议对ARDS患者的潮气量目标是6ml/kg，根据患者的呼吸驱动
34、和需求，兼顾平台压前提下，可有例外，（6ml/kg与12ml/kg时为1A）。p建议对ARDS患者测量平台压（1B）。被动充气患者平台压上限目标为30cmH2O(在正常肺外顺应性时)。p提议对更严重ARDS者，在给定FiO2下给于更高水平的PEEP（2C）；提议对更严重的顽固性低氧血症患者采用肺复张手法（2C）；提议对严重ARDS患者、实施肺复张后仍然PaO2/FiO2100,采用俯卧位通气（2C）。According to the assessment requirements of party conduct and clean government,combined with the f
35、ive regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineJ 镇静镇痛与肌松药（2012年）p 建议对Sepsi而无ARDS者，避免使用神经肌肉阻滞剂，因有停药后长期神经肌肉阻滞风险。若必须持续使用，或按需间断给药，或在四个成串监测阻滞深度下连续输注（1C）。提议对严重sepsis诱导ARDS的早期短疗程使用神经肌肉阻滞剂，不超过48小时（2C）。According to the assessment requirements of party
36、 conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineK 血糖控制（2012年）p 建议对严重sepsis的ICU患者进行程序化的血糖管理，当连续监测血糖水平180mg/L开始使用胰岛素。上限目标是血糖180mg/L，而非110mg/L(1A)。According to the assessment requirements of party
37、conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineO 肾脏替代治疗（2012年）p 提议对血流动力学不稳定，有AKI（表现为无尿或少尿）的sepsis患者，采用连续肾脏替代、而非间断血液透析，以便优化液体平衡的管理（2D）。（而对指征、剂量没有建议）According to the assessment requirements of par
38、ty conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineP 应急性溃疡的预防（2012年）p 建议对严重sepsis/感染性休克具有出血风险者，应用H2RA或PPI进行应激性溃疡预防（1B）。若行应激性溃疡预防，提议使用PPI而非H2RA(2C)。According to the assessment requirements of part
39、y conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineQ 其他内容（2012年）p 营养支持（有专门的指南）；处理目标和预后沟通；儿科考虑。According to the assessment requirements of party conduct and clean government,combined with the five
40、regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline SSC bundle的更新（2012年）p 原先的bundle，6小时复苏的Bundle(5条)，24小时复苏的Bundle(4条)。更新的SSCBundles，Sepsis初始复苏（Initial Resuscitation bundle）：确认严重的sepsis和感染性休克即启动，3h内完成：测量血乳酸，应用抗生素前获得血培养标本，尽量提前广谱抗生素给药时间，在低血压和/或乳酸4mmol/
41、L时，至少输注30ml/kg晶体溶液（或相当的胶体液）。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline SSC bundle的更新（2012年）p 感染性休克（Septic shock bundle）:对感染休克在6h内启动和完成。即低血压
42、对初始复苏无反应者，应用缩血管药物维持MAP 65mmHg,在容量复苏后仍然持续动脉低血压（感染性休克），和/或初始血乳酸4mmol/L：达到CVP8mmHg,SCVO270%。According to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-disciplineAccording to the assessment requirements of party conduct and clean government,combined with the five regulations and five new requirements of state-owned Enterprise leaders integrity and self-discipline
