1、感染性休克的延革,指南的延革,Definitions,Sepsis ：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 lac
2、tate, or oliguria.Sepsis-induced hypotension ：SBP 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):580-637,Diagnostic Criteria for Sepsis,Infection, documented or suspected, and some of the following:General va
3、riablesFever ( 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 diabetes,Diagnostic Cr
4、iteria for Sepsis,Inflammatory variablesLeukocytosis (WBC count 12,000 L1)Leukopenia (WBC count 40 mm Hg in adults or less than SD below normal for age),Diagnostic Criteria for Sepsis,Organ dysfunction variablesArterial hypoxemia (Pao2/Fio2 0.5 mg/dL or 44.2 mol/LCoagulation abnormalities (INR 1.5 o
5、r aPTT 60 s)Ileus (absent bowel sounds)Thrombocytopenia (platelet count 4 mg/dL or 70 mol/L)Tissue perfusion variablesHyperlactatemia ( 1 mmol/L)Decreased capillary refill or mottling,Diagnostic Criteria for Sepsis,pediatric population signs and symptoms of inflammation infection hyper- or hypotherm
6、ia (rectal temperature 38.5 or 2 mg/dL (34.2 mol/L)Platelet count 1.5),感染性休克2008到 2012的延革,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
7、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
8、(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-mannan antibody assays (2C)抗感染药物尽可能覆盖所有可疑病原菌（
9、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,感染性休克延革带来了困惑该如何看待指南？,指南,Guidelines are the product of an explicit, systematic approach to the evaluation and synthesis of available information on a particular clinical topic.Guidelines al
10、so represent the best available synthesis of contemporary knowledge in this area, and for this reason we believe they must be promoted.,Implementation 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 n
11、ot a compilation of truths.Guidelines are not rules.Guidelines do not establish legal standards of practice.A strong rating for any particular recommendation does not preclude further research.,Critical Care 2008, 12:162,Guidelines are the product of an explicit, systematic approach to the evaluatio
12、n and synthesis of available information on a particular clinical topic.Their reliability depends on three factorsthe extent to which all relevant evidence is sought for evaluationthe quality of the available evidencethe rigour of the evaluation process used,GRADE,Grading of Recommendations, Assessm
13、ent, 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 as cost, plausibility, toxicity, and clinician acceptance.This method provides a more nuanced synthesis of data and, in the current guid
14、elines, the strength of recommendation was established through a formal voting process, in recognition of the fact that in many areas participants had divergent interpretations 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,谢谢大家,
