中国严重脓毒症指南的新旧对比

. .《中国严重脓毒症/脓毒性休克治疗指南《中国严重脓毒症/脓毒性休克治疗指南（2014》的产生与新旧指南比较瑞金严静于凯江中华危重病急救医学,2015,27(09):705-708.DOI:0.3760/cma.j.issn.2095-4352.2015.09.001脓毒症（sepsis）是当今对临床医生最严峻的挑战，迎接这个挑战并战胜它的任务不医学分会组织相关专家经过不懈努力，制定了《中国严重脓毒症/脓毒性休克治疗指南（2014）》（以下简称新指南）（SCC）的3个版本指南虽然SCC2004200820123虽然我国的重症医学事业起步较晚，但是在各位专家学者的不懈努力下，国在对脓毒症的认识和防治方面取得了一些可喜进步。中华医学会重症医学分会曾经在2007年就组织/脓毒性休克治疗指南》的颁布。新指南比SSC20123442Meta785712条，也首次增加了中医药的相关条目，进一步丰富了临床治疗的手段。以下就新指南的特点与SSC2012早期液体复预后判断：[,]新指南增加了液体复过程中乳酸与乳酸清除率可作为判断预后的指标12（1SSC2012[,][,,]降至正常水平345。[,,]液体选择与液体反应性：[,,,,新指南在进行液体复时的液体选择以与评估患者对液体反应性方面也有新增部分，例如液体复时可考虑使用限氯晶体液复678910；对无自主呼吸、心律失常和非小潮气量通气的患者，可选用脉压变异度、每搏量变异度[,,,,1/9. .[,,指标111213[,,[]者的液体反应性14。[]血管活性药物：[,引起严重心律失常；②持续的高心排血量和低血压；③当正性肌力药/缩血管药物与小剂量血管加压素联合应用未能达到目标平均动脉压1516[,[,,而在应用正性肌力药物治疗脓毒症和脓毒性休克患者时首次提出，如果经充足的液体复和维持足够的MAP治疗后COCO较快，可考虑使用短效β171819[,,早期目标导向治疗（EGDT）：[,,对于脓毒性休克的疗效并不优于常规治疗。其理由是，EGDT的治疗强度更高，如输入更多的液体、血管活性药物、红细胞，由此带来的后果则是器官衰竭评分增加、心血管支持时间更长、重症加强治疗病房住院时间更长，住院花费增加142021[,,[,,,,,]32022232425mmHg＝0.133MAP≥65mmHg、[,,,,,]尿量≥0.5mL·k-1·-1上腔静脉血氧饱和Scv≥0.70或混合静脉血氧饱和（ ）≥0.65作为初始复的目标，且提高了证据质量（由C升到B）。抗感染治疗：[]新指南在抗感染治疗方面较为明显的改变就是建议应用降钙素原（PCT）对可疑感染的重症患者进行脓毒症的早期诊断26，且一旦有明确的病原学依据，应考虑降阶梯治疗策略[][,[,,,,,] [2728。在感染的筛查方面，新指南推荐对所有重症患者进行早期感染的评价，对可疑的感染患1h药物进行治疗[,[,,,,,] [中医药部分成为新指南的一大亮点：3恩等在脓毒症的理论和实践方面进行了很多工作，为今后的工作打下了良好的基础。20062/9. .. .PAGEPAGE3/9资料的支持，但是只要沿着正确的方向走下去，脓毒症的治疗突破或许能率先在我国实现。营养支持方面新指南更为精细：[][,,-1 -1 -1 -1 [,,新指南在营养支持方面增加了3个条目，可见营养支持在脓毒症和脓毒性休克患者治喂养，以83.68～104.60kJ•kg•d（20～25kcal•kg•d）为目标313536；对脓毒性休克患者不推荐使用谷氨酰胺37征（ARDS）患者机械通气时间和ICU[][,,-1 -1 -1 -1 [,,其他方面的变动：[,,,,,]新指南在机械通气方面指出ARDS414243444546；[,,,,,][,,474849[,,[]面不建议使用高容量血液滤过治疗脓毒症合并急性肾损伤50。[]（19931201412SSC2012MEDLINE、EMBASECochraneLibrary[,,〔Cochrane系统评价数据库Jadad≥3Jadad≥2515253[,,脓毒性休克治疗指南[1]NguyenHB,RiversEP,KnoblichBP,etal.Earlylactateclearanceisassociatedwithimprovedoutcomeinseveresepsisandsepticshock[J].CritCareMed,2004,32(8):1637-1642.[2]MarecauxG,PinskyMR,DupontE,etal.BloodlactatelevelsareprognosticindicatorsthanTNFandIL-6levelsinpatientswithsepticshock[J].IntensiveCareMed,1996,22(5):404-408.[3]RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock[J].NEnglMed,2001,345(19):1368-1377.[4]JansenTC,vanBommelJ,BakkerJ.Bloodlactatemonitoringincriticallyillpatients：asystematichealthtechnologyassessment[J].CritMed,2009,37(10):2827-2839.[5]BakkerJ,NijstenMW,JansenTC.Clinicaluseoflactatemonitoringincriticallyillpatients[J].AnnIntensiveCare,2013,3(1):12.[6]BrunkhorstFM,EngelC,BloosF,

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