儿童严重脓毒症与脓毒性休克

2012年儿童严重脓毒症与脓毒性休克

国际指南I.Mechanicalventilation1.Wesuggestprovidinglung-protectivestrategiesduring

mechanicalventilation(grade2C).1、建议在机械通气时使用肺保护性通气策略（2C）。I.MechanicalventilationRationale.SomepatientswithARDSwillrequire

increasedPEEPtoattainfunctionalresidualcapacityand

maintainoxygenation,andpeakpressuresabove

30–35cmH2Otoattaineffectivetidalvolumesof6–8mL/kg

withadequateCO2

removal.理论：ARDS患儿需要高PEEP来维持功能残气量和氧合，30-50cmH2O的高气道锋压来维持潮气量在6-8ml/kg和清除CO2。I.Mechanicalventilation

Inthesepatients,physicians

generallytransitionfromconventionalpressurecontrolventilationtopressurereleaseventilation(airwaypressurerelease

ventilation)ortohigh-frequencyoscillatoryventilation.

在这些病人中，医生通常将压力控制通气转换为压力释放通气（气道压释放通气）或高频振荡通气。I.MechanicalventilationThesemodesmaintainoxygenationwithhighermeanairway

pressuresusingan‘‘open’’lungventilationstrategy.Tobe

effective,thesemodescanrequireameanairwaypressure

5cmH2Ohigherthanthatusedwithconventionalventilation.

Thiscanreducevenousreturnleadingtogreaterneedforfluid

resuscitationandvasopressorrequirements[612–616].这些模式通过利用一种“开放”肺通气策略保持较高平均气道压来维持氧合。为达效果，这些模式需要比常频通气模式高5cmH2O的平均气道压。这会引起静脉回流减少，导致需要更积极的液体复苏及升压药物的使用。J.Sedation/analgesia/drugtoxicities1.Werecommenduseofsedationwithasedationgoalin

criticallyillmechanicallyventilatedpatientswithsepsis

(grade1D).推荐机械通气的脓毒症患者使用镇静治疗以达到镇静的目的（1D）。J.Sedation/analgesia/drugtoxicitiesRationale.Althoughtherearenodatasupporting

any

particulardrugsorregimens,propofolshouldnotbeused

forlong-termsedationinchildrenyoungerthan3years

becauseofthereportedassociationwithfatalmetabolic

acidosis.理论虽然尚无任何数据支持应用某种特定药物或方案，但是丙泊酚不应长时间用于＜3岁的婴幼儿，因其可能发生致死的代谢性酸中毒。J.Sedation/analgesia/drugtoxicitiesTheuseofetomidateand/ordexmedetomidine

duringsepticshockshouldbediscouraged,oratleast

consideredcarefully,becausethesedrugsinhibitthe

adrenalaxisandthesympatheticnervoussystem,

respectively,bothofwhichareneededforhemodynamic

stability[617–620].脓毒性休克的患儿需避免或谨慎使用依托咪酯或右美托咪啶，因其分别影响肾上腺轴及交感神经系统，不利于血流动力学的稳定。J.Sedation/analgesia/drugtoxicities2.Werecommendmonitoringdrugtoxicitylabsbecause

drugmetabolismisreducedduringseveresepsis,puttingchildrenatgreaterriskofadversedrug-related

events(grade1C).

Rationale.Childrenwithseveresepsishavereduced

drugmetabolism[621].推