【正文】 目標潮氣量 6ml/kg 1B ? 維持平臺壓 30cmH2O 1C ? 允許性高碳酸血癥被接受維持最低的平臺壓和潮氣量 1C ? PEEP設(shè)置避免在呼氣時廣泛的肺塌陷 1C ? 在嚴重的 ARDS可以腹臥位 2C ? 降低 VAP需要頭抬高 3045 176。 2C ? 建議不常規(guī)行 PA檢測 1A ? 建議保守液體療法減少機械通氣時間和在 ICU的時間。 1C 血糖的控制 ? 推薦病人伴有膿毒血癥和高血糖者進入ICU應(yīng)靜脈應(yīng)用胰島素降低血糖 。 1B ? 應(yīng)用胰島素維持血糖 150mg/dl 2C ? 病人接受靜脈胰島素時，應(yīng)該給與葡萄糖提供熱卡時，應(yīng)該每 12小時監(jiān)測血糖水平，直到胰島素靜脈輸注速度穩(wěn)定時，每 4小時監(jiān)測血糖。 1C 其他 ? 鎮(zhèn)靜，止痛 和神經(jīng)肌肉阻滯劑（肯定要求鎮(zhèn)靜方案， 1B） ? 腎替代治療（ 2D） ? 碳酸氫鈉的治療（否定， 1B） ? DVT的預防（肯定， 1A） ? 應(yīng)激性潰瘍的預防（肯定， 1A用 H2RA； ? 1B用 PPI） ? 選擇性消化道去污治療 展望未來的治療 ? 脂多糖 A的拮抗劑 ? 補體的阻滯劑 ? 凋亡的抑制物 ? HMOB 的抑制物 ? MIF抑制物 總結(jié) ? 嚴重的膿毒血癥和膿度性休克最常見的死亡率 2550% ? 促炎反應(yīng)和抗凝反應(yīng)在膿毒血癥病生理中起關(guān)鍵作用 ? 尋癥醫(yī)學推薦是可以被應(yīng)用并且應(yīng)該參與改善病人預后的工作。 液體及血管活性藥物應(yīng)用 FLUID AND VASOPRESSOR THERAPY ? Fluid resuscitation with either natural or artificial colloids or crystalloids. Grade 1B ? Fluid challenge in patients with suspected hypovolemia may start with 1000 ml of crystalloids or 300500 ml of colloids over 30 mins. Grade 1D ? Rate of fluid administration should be reduced substantially when cardiac filling pressures (CVP or PAOP) increase without concurrent hemodynamic improvement Grade 1D 液體及血管活性藥物應(yīng)用 FLUID AND VASOPRESSOR THERAPY ? Fluid resuscitation with either natural or artificial colloids or crystalloids. Grade 1B ? Fluid challenge in patients with suspected hypovolemia may start with 1000 ml of crystalloids or 300500 ml of colloids over 30 mins. Grade 1D ? Rate of fluid administration should be reduced substantially when cardiac filling pressures (CVP or PAOP) increase without concurrent hemodynamic improvement Grade 1D Albumin and Saline for Fluid Resuscitation in the ICU (SAFE Trial) ? RCT ~ 7,000 pts in 16 Australian/NZ ICUs ? Excluded pts after cardiac surgery, liver transplant and burns ? 4% albumin or NS ? No significant difference: ? 28day mortality ? New an failure, duration of CRRT, or mechanical ventilation ? ICU and Hospital LOS NEJM 20xx。350:22472256 Vasopressor Therapy ? Either norepinephrine or dopamine is the first choice vasopressor agent to correct hypotension in septic shock. Grade 1C ? Lowdose dopamine should not be used for renal protection. Grade 1A ? Epinephrine (2B) or Vasopressin ( U/min) (2C) may be added in pts with refractory shock despite adequate fluids and highdose conventional vasopressors. ? SSC Guidelines, Crit Care Med 20xx Inotropic Therapy ? Dobutamine infusion is remended in the presence of myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output. Grade 1C ? Avoid use of strategy to increase cardiac index to predetermined supranormal levels. Grade 1B SSC Guidelines, Crit Care Med 20xx Corticosteroid Therapy ? IV hydrocortisone should be given only to adult septic shock patients after it has been confirmed that their BP is poorly responsive to fluid resuscitation and vasopressor therapy. Grade 2C ? Crit Care Med 20xx SSC Update Rapid ACTH Test Can Identify Septic Patients at High Risk of Death Relative adrenal insufficiency ? Failure to increase cortisol by 9 181。g/dl at 30 or 60min following 250 181。g ACTH stimulation test ? ? Annane D, et al. JAMA 20xx。283:103845 ? Clinical Practice Guidelines for the Diagnosis and Management of Corticosteroid Insufficiency in Critical Illness: Remendations from an International Task Force Marik PE, Pastores SM, Annane D, Meduri GU, Sprung C, et al. Crit Care Med (under review) Consensus Statement ? At this time, CIRCI is best diagnosed by a delta cortisol (following 250 181。g cosyntropin) of 9 181。g/dl or a random cortisol of 10 1