1、脓毒症及感染性休克的临床表现
2、脓毒症及感染性休克的诊断
2、脓毒症及感染性休克的治疗
1、脓毒症及感染性休克的临床表现
For patients with sepsis and septic shock, therapeutic priorities include securing the airway, correcting hypoxemia, and establishing vascular access for the early administration of fluids and antibiotics. Simultaneously obtaining the following is preferable (within 45 minutes) but should not delay the administration of fluids and antibiotics: routine laboratory studies, serum lactate, arterial blood gases, blood cultures (aerobic and anaerobic) from two distinct venipuncture sites and from all indwelling vascular access devices, cultures from easily accessible sites (eg, sputum, urine), and imaging of suspected sources.
2、脓毒症及感染性休克的诊断
3、脓毒症及感染性休克的治疗
For patients with sepsis and septic shock, we recommend the infusion of intravenous fluids (30mL/kg)within the first three hours of presentation, rather than vasopressors, inotropes, or red blood cell transfusions (Grade 1B). Fluid boluses are the preferred method of administration and should be repeated until blood pressure and tissue perfusion are acceptable, pulmonary edema ensues, or there is no further response. Crystalloid solutions (eg, normal saline or Ringer’s lactate) are our preferred resuscitation fluid. We recommend that a hyperoncotic starch solution NOT be administered (Grade 1A).
For patients with sepsis, we recommend that optimal doses of empiric broad spectrum intravenous therapy with one or more antimicrobials be administered, in a prompt fashion (eg, within one hour) of presentation (Grade 1B). Broad spectrum is defined as therapeutic agent(s) with sufficient activity to cover a broad range of gram negative and positive organisms and, if suspected, against fungi and viruses. For patients with septic shock, particularly that associated with likely gram negative sepsis, we suggest combination therapy, defined as multiple antibiotics (at least two) from different classes given with the intent of covering a known or suspected pathogen with more than one antibiotic. Agent selection depends upon patient’s history, comorbidities, immune defects, clinical context, suspected site of infection, presence of invasive devices, Gram stain data, and local prevalence and resistance patterns. The routine administration of antifungal therapy is not warranted in non-neutropenic patients.
For most patients with sepsis and septic shock, we recommend that fluid management be guided using clinical targets including mean arterial pressure 65 mmHg to 70 mmHg and urine output ≥0.5 mL/kg/hour (Grade 1B). In addition, while dynamic measures of fluid responsiveness (eg, respiratory changes in the radial artery pulse pressure) are preferred, static measures of determining adequacy of fluid administration (eg, central venous pressure 8 to 12 mmHg or central venous oxygen saturation ≥70 percent) may be more readily available. Serum lactate should be followed (eg, every six hours), until there is a definitive clinical response. It is prudent that other measures of the overall response to infection also be followed (eg, routine laboratory studies, arterial blood gases, microbiology studies).
For patients with sepsis who remain hypotensive despite adequate fluid resuscitation (eg, 3L in first three hours), we recommend vasopressors (Grade 1B); the preferred initial agent is norepinephrine . For patients who are refractory to intravenous fluid and vasopressor therapy, additional therapies, such as glucocorticoids, inotropic therapy, and blood transfusions, can be administered on an individual basis. We typically reserve red blood cell transfusion for patients with a hemoglobin level <7 g per deciliter.
Following initial investigations and empiric antimicrobial therapy, further efforts aimed at identifying and controlling the source(s) of infection (ideally within 6 to 12 hours) should be performed in all patients with sepsis . In addition, for those who fail despite therapy or those who fail having initially responded to therapy, further investigations aimed at removal of devices suspected to be infected, adequacy of the antimicrobial regimen, or nosocomial super infection should be considered.
For patients with sepsis who have demonstrated a response to therapy, we suggest that the rate of fluid administration should be reduced or stopped, vasopressor support weaned, and if necessary diuretics administered. We also recommend that antimicrobial therapy be narrowed once pathogen identification and susceptibility data return. Antimicrobial therapy should be pathogen- and susceptibility-directed for a total duration of 7 to 10 days, although shorter or longer courses are appropriate for select patients.
(更新时间:2018年11月03日)