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1、感染性休克的延革指南的延革Organizations involvedNumber of participantsProcessPublicationFirst1(ISF)9EBM A to EIntensive Care Med,2001,27(Suppl 1):S1-134Second3(ISF,ESICM,SCCM)24EBM A to EIntensive Care Med,2004,30:536555Third1655GRADEIntensive Care Med,2008,34:1760Fourth3068GRADEIntensive Care Med,2013,39(2):165
2、-228.DefinitionsSepsis：infection+SIRSSevere sepsis：sepsis+sepsis-induced organ dysfunction or tissue hypoperfusionSeptic shock：sepsis-induced hypotension persisting despite adequate fluid resuscitationSepsis-induced tissue hypoperfusion：infection-induced hypotension,elevated lactate,or oliguria.Seps
3、is-induced hypotension：SBP 90 mm Hg or MAP 40 mm Hg or less than two standard deviations below normal for age in the absence of other causes of hypotension.Crit Care Med,2013,41(2):580-637Diagnostic Criteria for SepsisInfection,documented or suspected,and some of the following:General variablesFever
4、(38.3C)Hypothermia(core temperature 90/min1 or more than two SD above the normal value for ageTachypneaAltered mental statusSignificant edema or positive fluid balance(20 mL/kg over 24 hr)Hyperglycemia(plasma glucose 140 mg/dL or 7.7 mmol/L)in the absence of diabetesDiagnostic Criteria for SepsisInf
5、lammatory variablesLeukocytosis(WBC count 12,000 L1)Leukopenia(WBC count 4000 L1)Normal WBC count with greater than 10%immature formsPlasma C-reactive protein more than two sd above the normal valuePlasma procalcitonin more than two sd above the normal valueHemodynamic variablesArterial hypotension(
6、SBP 90 mm Hg,MAP 40 mm Hg in adults or less than SD below normal for age)Diagnostic Criteria for SepsisOrgan dysfunction variablesArterial hypoxemia(Pao2/Fio2 300)Acute oliguria(urine output 0.5 mg/dL or 44.2 mol/LCoagulation abnormalities(INR 1.5 or aPTT 60 s)Ileus(absent bowel sounds)Thrombocytope
7、nia(platelet count 4 mg/dL or 70 mol/L)Tissue perfusion variablesHyperlactatemia(1 mmol/L)Decreased capillary refill or mottlingDiagnostic Criteria for Sepsispediatric population signs and symptoms of inflammation infection hyper-or hypothermia(rectal temperature 38.5 or 35C),tachycardia(may be abse
8、nt in hypothermic patients),and at least one of the following indications of altered organ function:altered mental status hypoxemiaincreased serum lactate levelbounding pulsesSevere SepsisSevere sepsis definition=sepsis-induced tissue hypoperfusion or organ dysfunction(any of the following thought t
9、o be due to the infection)Sepsis-induced hypotensionLactate above upper limits laboratory normalUrine output 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitationAcute lung injury with Pao2/Fio2 250 in the absence of pneumonia as infection sourceAcute lung injury with Pao2/Fio2 2.0 m
10、g/dL(176.8 mol/L)Bilirubin 2 mg/dL(34.2 mol/L)Platelet count 1.5)感染性休克2008到 2012的延革2008指南指南2012指南指南初始复苏和感染问题初始复苏和感染问题血流动力学支持和辅助治疗血流动力学支持和辅助治疗其他辅助治疗其他辅助治疗初始复苏（2008和2012）复苏时机低血压高乳酸血症4mmol/L复苏目标CVP 812 mm HgMAP 65 mm Hg尿量 0.5 mL/kg/hrSCVO270%or SVO2 65%2012版指南：血乳酸正常（2C）血流动力学支持及辅助治疗的沿革2012液体治疗首选晶体液，反对羟乙
11、基淀粉（1B）白蛋白（2C）30ml/kg晶体液或等量白蛋白（1C）血管活性药物首选去甲肾上腺素（1B）肾上腺素可加用（或替代）使MAP 65mmHg（2B）血管加压素0.03U/min多巴胺仅限于：心律失常风险极低、绝对或相对心率缓慢的患者（2C）去氧肾上腺素：去甲肾上腺素出现严重心律失常高心输出量，而血压持续低作为联合正性肌力药、升压药和血管加压素仍未达到目标MBP的补救治疗（1C）2008液体治疗晶体液或胶体液（1B）1000ml晶体液或300-500ml胶体液（30min）（1D）血管活性药物首选去甲肾上腺素或多巴胺（1C）肾上腺素可加用（或替代）使MAP 65mmHg（2B）血管加压
12、素0.03U/min血流动力学支持及辅助治疗的沿革2012正性肌力药心肌功能障碍,心脏充盈压高,低心输出量(1C)充足的血容量和MBP,依然低灌注时(1C)不建议心脏指数超正常化策略(1B)糖皮质激素液体复苏和血管活性药物仍未能达到血流动力学稳定,氢化可的松200mg/d(2C)2008正性肌力药心肌功能障碍,心脏充盈压高,低心输出量(1C)不建议心脏指数超正常化策略(1B)糖皮质激素液体复苏和血管活性药物仍未能达到血流动力学稳定(2C)氢化可的松300mg/d(1A)感染问题的延革（2012）诊断1,3 beta-D-glucan assay(grade 2B)mannan and anti
13、-mannan antibody assays(2C)抗感染药物尽可能覆盖所有可疑病原菌（细菌/真菌/病毒）（1B）病毒感染所致的严重感染或感染性休克，迟早抗病毒治疗。（2C）对缺乏明确感染证据的患者，可使用PCT或类似生物标志物停用抗生素。（2C）感染的预防SOD和SDD预防VAP（2B）其他辅助治疗的延革2012指南指南2008指南指南不建议使用丙种球蛋白（2B）不建议使用硒（2C）APACHE II 25或MOF时，建议使用活化蛋白C（2B/2C）BS10mmol/L（1A）BS 8.3 mmol/L（2C）营养支持感染性休克延革带来了困惑该如何看待指南？指南指南Guidelines a
14、re the product of an explicit,systematic approach to the evaluation and synthesis of available information on a particular clinical topic.Guidelines also represent the best available synthesis of contemporary knowledge in this area,and for this reason we believe they must be promoted.Implementation
15、of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care.指南Guidelines are not a compilation of truths.Guidelines are not rules.Guidelines do not establish legal standards of practice.A strong rating for any particular recommenda
16、tion does not preclude further research.Critical Care 2008,12:162Guidelines are the product of an explicit,systematic approach to the evaluation and synthesis of available information on a particular clinical topic.Their reliability depends on three factorsthe extent to which all relevant evidence i
17、s sought for evaluationthe quality of the available evidencethe rigour of the evaluation process usedGRADEGrading of Recommendations,Assessment,Development,and Evaluation methodology which assigns a measure of the strength of the recommendation based not only on the evidence,but also on factors such
18、 as cost,plausibility,toxicity,and clinician acceptance.This method provides a more nuanced synthesis of data and,in the current guidelines,the strength of recommendation was established through a formal voting process,in recognition of the fact that in many areas participants had divergent interpre
19、tations of the evidence.a strong Grading of Recommendations,Assessment,Development,and Evaluation recommendation had to receive the support of at least 80%of the participants.常用血管活性药物药物物配置配置用法用法注意点注意点多巴胺NS 50ml+多巴胺200mg初始剂量3-5ug/kg/min，每次调整1-2ug/kg/min，极量20ug/kg/min。如与去甲肾上腺素联用升压，一般维持在7-10ug/kg/min心动过速、心律失常慎用多巴酚丁胺NS 50ml+多巴酚丁胺200mg初始剂量3-5ug/kg/min，每次调整1-2ug/kg/min，极量20ug/kg/min。心动过速、心律失常慎用去甲肾上腺素NS 50ml+去甲肾上腺素20mg初始剂量0.1-0.2ug/kg/min，每次调整0.1ug/kg/min，极量2-3ug/kg/min。避免漏出血管外，如有漏出，NS10-15ml+酚托拉明5-10mg,局部封闭，防止坏死肾上腺素NS 50ml+肾上腺素20mg初始剂量0.1ug/kg/min，每次调整0.05-0.1ug/kg/min谢谢大家谢谢大家