全身炎癥反應(yīng)綜合癥與膿毒血癥（中）(文件)
【正文】 patients at risk who are not hypotensive. Resuscitation Goals Goals in the first 6 hours: ? CVP: 812 mm Hg ? MAP 65 mm Hg ? Urine output ml/kg/hr ? Central venous (SVC) or mixed venous oxygen (SvO2) saturation 70% GRADE 1C EARLY GOAL DIRECTED THERAPY EGDT for Severe Sepsis and Septic Shock Rivers, E et al. NEJM 20xx。g/kg/min ? Transfusion to maintain Hct 30% Grade 2C SSC Guidelines, Crit Care Med 20xx DIAGNOSIS OF SEVERE SEPSIS Diagnosis of Severe Sepsis ? Appropriate cultures should always be obtained before antimicrobial therapy is initiated. ? At least 2 blood cultures with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (48 h) inserted. GRADE 1C Antimicrobial Therapy ? IV antibiotics should be started within the first hour of recognition of severe sepsis after appropriate cultures have been obtained. Grade 1B ? Initial empirical antimicrobial therapy should include one or more drugs that have activity against the likely pathogens (bacterial or fungal) and that perate into the presumed source of sepsis. Grade 1B Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival Kumar A, et al. Crit Care Med 20xx。g ACTH stimulation test Annane D, et al. JAMA 20xx。288:862 3 0 %4 0 %5 0 %6 0 %7 0 %8 0 %9 0 %1 0 0 %0 4 8 12 16 20 24 28T I M E ( d a y s )Probability of survivalP L AC E B OS T E R O I D SRES PONDE RSLog R a nk Te s t , ?2= 0 .5 6p = 0 .8 128 Da y Sur vivalAnnane et al. JAMA 20xx。 288 (7): 863 Low Dose Steroids in Septic Shock: 28 Day Mortality All Patients 55%61%0%20%40%60%80%100%Lowdose Steroids Placebo P= 28day Mortality Annane, D. JAMA, 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 STEROIDS 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。345:1368 EGDT in the Treatment of Severe Sepsis and Septic Shock Rivers et al, NEJM 20xx。36:296327 Surviving Sepsis Campaign ? Partial funding by unrestricted educational industry grants from: ? Edwards LifeSciences ? Eli Lilly and Company ? Philips Medical Systems ? Coalition for Critical Care Excellence of SCCM ? No industry funding was used in the guidelines revision process Crit Care Med 20xx。 American Cancer Society 050100150200250300A I D S Br e as tC an c e r1s t M I S e v e r eS e p s i sIncidence Cases/100,000 05000010000015000020xx00250000A I D S Br
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