膿毒癥的診治指南

1、nSurviving Sepsis Campaign:International guidelines for managementof severe sepsis and septic shock: 2008 Intensive Care Med (2008) 34:1760DOI 10.1007/s00134-007-0934-2嚴(yán)重感染與感染性嚴(yán)重感染與感染性休克血流動(dòng)力學(xué)監(jiān)休克血流動(dòng)力學(xué)監(jiān)測(cè)與支持指南測(cè)與支持指南 中華醫(yī)學(xué)會(huì)重癥醫(yī)中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì)（草案）學(xué)分會(huì)（草案）感染感染Sepsis全身炎癥反應(yīng)綜全身炎癥反應(yīng)綜合征合征創(chuàng)傷創(chuàng)傷燒傷燒傷胰腺炎胰腺炎其他其他菌血癥菌血癥真菌血癥真

2、菌血癥病毒血癥病毒血癥其他其他 組織細(xì)胞損傷組織細(xì)胞損傷多器官功能障礙綜合癥（多器官功能障礙綜合癥（MODS）感染因素感染因素非感染因素非感染因素內(nèi)毒素內(nèi)毒素單核單核/巨噬細(xì)胞巨噬細(xì)胞炎癥介質(zhì)炎癥介質(zhì)激活中性粒細(xì)胞，損傷內(nèi)皮細(xì)胞激活中性粒細(xì)胞，損傷內(nèi)皮細(xì)胞釋放氧自由基、脂質(zhì)代釋放氧自由基、脂質(zhì)代 謝產(chǎn)物、溶酶體酶等謝產(chǎn)物、溶酶體酶等Sepsis微循環(huán)障礙微循環(huán)障礙凝血機(jī)制紊亂凝血機(jī)制紊亂細(xì)胞凋亡細(xì)胞凋亡血管活性和炎性介質(zhì)釋放血管活性和炎性介質(zhì)釋放 局部血管擴(kuò)張，毛細(xì)血管局部血管擴(kuò)張，毛細(xì)血管通透性增加通透性增加 水腫水腫，影響傷口愈合，影響傷口愈合組織細(xì)胞組織間隙毛細(xì)血管細(xì)胞內(nèi)液組織間液血漿毛

3、細(xì)血管滲漏毛細(xì)血管滲漏5%15%40%白蛋白漏出，膠體滲透壓降低，加重組織水腫?Rivers E et al. N Engl J Med. 2001; 345: 1368-77. Sepsis Resuscitation Bundle (to be accomplished as soon as possible and scored over first 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration Broad-spectrum antibiotics ad

4、ministered within 1 hr. of diagnosis (ICU admit) or 3 hours from presentation (ED admit )20 ml/kg of crystalloid (or colloid equivalent) delivered For hypotension not responding to volume resuscitation, vasopressors employed to maintain mean arterial pressure (MAP) 65 mmHgCentral venous pressure (CV

5、P) 8 mmHg achievedCentral venous oxygen saturation (ScvO2) of 70% achievedachieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative Low-dose steroids administered for septic shock in accordance with local guidelines Drotrecogin alfa (activated) administered in accordance with local guidelinesGlucose control maintaine lower limit of normal, but 150 mg/dl (8.3 mmol/L) For mechanically ventilated patients inspiratory plateau pressures maintained 30 cm H2O.Sepsis