【正文】 uration of CRRT, or mechanical ventilation ? ICU and Hospital LOS NEJM 20xx。 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 ? 膿毒血癥患者氫化可的松 每天劑量不超過300mg。1C 避免使用增加心指數以增加超出正常水平狀態(tài)。 1D ? 當心臟充盈壓（ CVP或 PAOP）增加或血液動力學無改善時，輸液速度應該降低。 ? 1C 抗生素治療 Antimicrobial Therapy ? 考慮嚴重感染獲取培養(yǎng)標本后，立即靜脈抗生素治療。多巴酚丁胺 20181。經液體復蘇后，血壓持續(xù)低應給與血管升壓藥，維持平均動脈血壓（ MAP）65mmHg： C1 膿毒血癥液體復蘇 Sepsis Resuscitation Bundle ? 經液體復蘇后持續(xù)低血壓（膿毒性休克）或血乳酸 4mmol/L ? 1。 ? 采用這種目標治療的死亡率為 %，而傳統(tǒng)的治療方法的死亡率為 %。器官功能支持 ? 4。 全身炎癥反應綜合癥 與膿毒血癥 （中） XXXX醫(yī)院 六膿毒血癥治療 ? 1。針對炎癥反應的治療（酶抑制劑。 ? 對膿毒癥患者早期積極的容量復蘇能顯著改善預后。建議放置 CVP （ 中心靜脈插管） ? 2。g/kg/min， ? 2。 1B ? 開始經驗治療應用抗生素至少 1種或幾種抗生素，具有廣譜抗病源菌的活力（覆蓋細菌和真菌）和具有穿透組織能力抗生素。1D 血管收縮藥物應用 ? 在膿毒血癥中糾正低血壓建議應用去甲腎上腺素或多巴胺等血管收縮藥。 1B SSC Guidelines, Crit Care Med 20xx 皮質醇激素治療 ? 靜脈注射氫化可的松應用于成人伴有膿毒性休克，雖經液體復蘇和 血管收縮劑治療無效者。 1A ? SSC Guidelines, Crit Care Med 20xx 重組人活化蛋白 C的應用 ? 推薦成人伴有膿度血癥誘導器官功能障礙伴高死亡率（ APACHEⅡ≥25 ）或多器官功能衰竭并且無出血相關的禁忌癥。 1C 血糖的控制 ? 推薦病人伴有膿毒血癥和高血糖者進入ICU應靜脈應用胰島素降低血糖 。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 cosyntropin) of 9 181。344:699709 0 7 14 21 28 70 80 90 100 Days from Start of Infusion to Death Percent Survivors P=.006 (stratified logrank test) 0 Placebo (n=840) Drotrecogin alfa (activated) (n=850) Drotrecogin Alfa (Activated) Significantly Reduced Mortality in PROWESS 6% Absolute mortality difference Stephen M. Pastores, MD, FCCM, FCCP, FACP Professor of Medicine in Anesthesiology Weill Cornell Medical College Director, Critical Care Medicine Fellowship Program Memorial Sloan Kettering Cancer Center New York, NY Diagnosis and Management of Severe Sepsis and Septic Shock Objectives ? Review the epidemiology and pathophysiology of severe sepsis ? Discuss history of existing medical therapies for sepsis ? Provide key evidencebased remendations from Surviving Sepsis Guidelines 20xx Update Severe Sepsis: Scope of the Problem ? 750,000 new cases per year in the . ? Mortality rates range from 28% to 50% ? Approximately 500 to 1,000 Americans die daily of severe sepsis Angus DC, et al. Crit Care Med 20xx。348:1546 Sepsis Battlefield: Cells and Mediators Hotchkiss RS, Karl IE, NEJM 20xx。129:17481 Severe Sepsis: nitial Resuscitation (1st 6 hours) ? Should begin as soon as the syndrome is recognized and should not be delayed pending ICU admission. ? Elevated serum lactate concentration identifies tissue hypoperfusion in