严重脓毒症与脓毒性休克诊治策略PPT.ppt

SSC推荐的脓毒症集束化治疗意见 G. Fluid Therapy of Severe Sepsis 1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B). 2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B). 3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C). 4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C). 5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG). H. Vasopressors 对比去甲肾上腺素和多巴胺治疗严重脓毒症的证据总结 a 假定风险是各项研究中对照组的风险。对应风险（及其95% CI）建立在对照组假定风险和干预的相对效应（及其95% CI）的基础之上。CI = 置信区间 I. Inotropic Therapy J. Corticosteroids 5. When hydrocortisone is given, use continuous flow (grade 2D). 5. When low-dose hydrocortisone is given, we suggest using continuous infusion rather than repetitive bolus injections (grade 2D). 给予氢化可的松时，我们建议连续输注，而不采用重复静推注射（等级：2D）。 原理阐述。几项有关在脓毒性休克患者中使用低剂量氢化可的松的随机试验显示，其具有显著增加高血糖症和高钠血症的副作用。一项小规模前瞻性研究表明，重复静推氢化可的松将显著增加血糖，而连续输注期间检测不到此峰值效应。此外，在应用弹丸式氢化可的松后的血糖峰值中可以看到个体间存在明显的变异性。虽然患者预后测量中没有显示与高血糖症和高钠血症的联系，但是良好的做法是采用避免和/或察觉副作用的方法。 K. Blood Product Administration In patients with severe sepsis, administer platelets prophylactically when counts are 10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. L. ImmunoglobulinsM. SeleniumN.rhAPC A history of the evolution of SSC recommendations as to rhAPC (no longer available) is provided. 2011年发布的 PROWESS SHOCK 试验（1，696例患者）结果显示，rhAPC对脓毒性休克患者没有任何好处 大多数 IVIG 研究均是小规模研究，有些有方法上的缺陷，唯一的