脓毒症集束化治疗的演变

1、脓毒症集束化治疗张 舸浙江大学医学院从属邵逸夫医院 中国首家经过国际医院 （JCI）评审公立医院中国医疗机构最正确雇主邵逸夫医院下沙院区第1页脓毒症与多发性创伤、急性心肌梗塞以及卒中一样，在严重脓毒症发生最初几个小时内及时采取有效治疗办法，很有可能改进预后脓毒症患者需要紧急评定与治疗第2页Surviving Sepsis Campaign制订了严重脓毒症和脓毒症休克诊疗指南。年更新20再次更新20又一次更新第3页指南提出了6小时治疗目标 a）中心静脉压（CVP） 812 mm Hg b）平均动脉压（MAP） 65 mm Hg c）尿量 0.5 mLkg时 d）上腔静脉或混合静脉血氧饱和度（Sc

2、vo2） 70%。第4页Early goal-directed therapy in the treatment of severe sepsis and septic shock Engl J Med. Nov 8;345(19):1368-77.Rivers E第5页第6页第7页 第8页将指南中含有明确降低病死率几项关键内容和治疗办法组合形成“脓毒症集束化治疗(surviving sepsis campaign bundle，SSCB)”，包含6 h和24 h集束治疗。第9页6 h集束治疗包含： (1)动脉血乳酸测定 (2)使用抗生素前留取病原学标本 (3)早期广谱抗生素治疗 (4)早期目

3、标性复苏(EGDT)第10页24 h集束治疗包含： (1)小剂量糖皮质激素使用 (2)血糖控制 (3)重组人活化蛋白C (4)肺保护机械通气第11页最新SSCB删除了原有24 h集束治疗，并将过去6 h集束治疗更改为3 h和6 h集束治疗第12页3h集束治疗包含： (1)动脉血乳酸测定 (2)应用抗生素前留取血培养 (3)使用广谱抗生素 (4)在低血压和(或)乳酸4 mmolL时，开启晶体液30 mlkg进行复苏第13页6 h集束治疗包含： (1)经初始液体复苏低血压无法纠正时，应用升压药品维持平均动脉压(MAP)65 mm Hg (2)经初始液体复苏血压仍低或初始乳酸水平4 mmolL时，测

4、定CVP及ScvO2（SvO2），6 h复苏治疗定量目标为CVP8 mm Hg，ScvO70（SvO65%） (3)假如初始乳酸水平升高，应重复测定乳酸，复苏治疗定量目标为乳酸恢复正常第14页ProCESSProMISeARISE第15页第16页第17页Protocol-based standard therapy required adequate peripheral venous access (with placement of a central venous catheter only if peripheral access was insufficient) and admin

5、istration of fluids and vasoactive agents to reach goals for systolic blood pressure and shock index (the ratio of heart rate to systolic blood pressure) and to address fluid status and hypoperfusion, which were assessed clinically at least once an hour.第18页During the first 6 hours, the volume of in

6、travenous fluids 2.8 liters in the protocol-based EGDT group,3.3 liters in the protocol-based standard-therapy group, and2.3 liters in the usual care group第19页More patients in the protocol-based EGDT group than in the protocol-based standard-therapy group or the usual-care group received dobutamine

7、and packed red-cell transfusions (dobutamine use, 8.0% vs. 1.1% and 0.9%, respectively; P 70%（ProCESS研究中为71%）。ScvO2反应是氧供和氧耗平衡，怎样判断患者容量状态和心输出量有更可靠地方法。第33页EGDT推广意义引发广大医护人员对脓毒症重视早期识别，早期处理脓毒症液体复苏与容量判断第34页SSC指南取消了EGDT提议，本身并未对3/6小时集束化内容进行详述SSC官网专门设置了一个Bundles网页，以供最新集束化指南更新，基于EDGT临床试验结果，SSC在其官网上公布了对版集束化治疗修

8、改，但只是对6小时集束化治疗中第二点做了更新第35页集束化目标修订TO BE COMPLETED WITHIN 3 HOURS:1) Measure lactate level2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L第36页集束化目标修订TO BE COMPLETED WITHIN 6 HOUR

9、S:5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg6) In the event of persistent hypotension after initial fluid administration (MAP 2mmol/L), it should be remeasured within 24 h to guide resuscitation to

10、normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion第45页抗生素使用前获取血培养Sterilization of cultures can occur within minutes of the first dose of an appropriate antimicrobial , so cultures must be obtained before antibiotic administration to optimize the identifica

11、tion of pathogens and improve outcomes第46页Appropriate blood cultures include at least two sets(aerobic and anaerobic). Administration of appropriate antibiotic therapy should not be delayed in order to obtain blood cultures.第47页广谱抗生素使用Empiric broad-spectrum therapy with one or more intravenous antim

12、icrobials to cover all likely pathogens should be started immediately for patients presenting with sepsis or septic shock.第48页液体复苏脓毒症患者伴或不伴休克、乳酸升高，均需要立马开始液体复苏最少30ml/kg晶体液3小时内完成第49页第50页We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml o

13、f 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania。第51页第52页Fluid boluses significantly increased 48-hour mortality in critically ill chil

14、dren with impaired perfusion in these resource-limited settings in Africa.第53页There are only limited data to support the use offluidbolustherapy in hospitalized children.FluidBolusTherapy-Based Resuscitation for SevereSepsisin Hospitalized Children: A Systematic Review.Pediatr Crit Care Med. Oct;16(8):e297-307.第54页缩血管药品使用Urgent restoration of an adequate perfusion pressure to the vital organs is a key part of resuscitation.