【正文】 al pulses with no differential between peripheral and central pulses, warm extremities, urine output 1 mL ? kg1 ? hr1, and normal mental status[290] (grade 2C). 第六十八頁(yè)，共八十頁(yè)。 Pediatric Considerations in Severe Sepsis F. Approach to Pediatric Septic Shock〔略〕 G. Steroids — We suggest that hydrocortisone therapy be reserved for use in children with catecholamine resistance and suspected or proven adrenal insufficiency (grade 2C). — Patients at risk for adrenal insufficiency include children with severe septic shock and purpura,[318,319] children who have previously received steroid therapies for chronic illness, and children with pituitary or adrenal abnormalities. Children who have clear risk factors for adrenal insufficiency should be treated with stressdose steroids (hydrocortisone 50 mg/m2/24 hrs) 第六十九頁(yè)，共八十頁(yè)。 Pediatric Considerations in Severe Sepsis H. Protein C and Activated Protein C We remend against the use rhAPC in children (grade 1B) I. DVT Prophylaxis We suggest the use of DVT prophylaxis in postpubertal children with severe sepsis (grade 2C) J. Stress Ulcer Prophylaxis No graded remendations. 第七十頁(yè)，共八十頁(yè)。 Pediatric Considerations in Severe Sepsis K. Renal Replacement Therapy No graded remendations L. Glycemic Control No graded remendations M. Sedation/Analgesia We remend sedation protocols with a sedation goal when sedation of critically ill mechanically ventilated patients with sepsis is required (grade 1D) 第七十一頁(yè)，共八十頁(yè)。 Pediatric Considerations in Severe Sepsis N. Blood Products No graded remendations O. Intravenous Immunoglobulin We suggest that immunoglobulin be considered in children with severe sepsis (grade 2C) P. Extracorporeal Membrane Oxygenation (ECMO) We suggest that use of ECMO be limited to refractory pediatric septic shock and/or respiratory failure that cannot be supported by conventional therapies (grade 2C) 第七十二頁(yè)，共八十頁(yè)。 休克診治中應(yīng)注意的問(wèn)題 一、判斷失誤導(dǎo)致治療延遲或錯(cuò)誤： ? 休克誤診為心力衰竭：強(qiáng)心、利尿、限液 ? 休克誤診為顱內(nèi)感染：脫水、限液 ? 炎性水腫誤判為液體超負(fù)荷：利尿、限液 第七十三頁(yè)，共八十頁(yè)。 液體復(fù)蘇應(yīng)注意的問(wèn)題 二、液體復(fù)蘇實(shí)施過(guò)程中的一些問(wèn)題： 復(fù)蘇液量缺乏，速度不夠 血管活性藥物使用不當(dāng) 液體配置不當(dāng)：用糖稀釋高漲液，過(guò)多使用堿性液 血管通路 ：建立困難，通路本身不暢 第七十四頁(yè)，共八十頁(yè)。 休克診治中應(yīng)注意的問(wèn)題 三、復(fù)蘇時(shí)輸入含糖液的危害 ? 5％葡萄糖的含糖量 100ml含 5g 20ml含 1g 20ml/kg=1g/kg ? 高糖致高滲血癥 休克患兒多有應(yīng)激性高血糖 腦 滲透性利尿 第七十五頁(yè)，共八十頁(yè)。 液體復(fù)蘇應(yīng)注意的問(wèn)題 四、過(guò)多使用堿性液的危害 氧離曲線左移 增加 CO細(xì)胞內(nèi)酸中毒 高鈉、低鉀、高滲 代堿 兩項(xiàng)研究：比較 NS和等張?zhí)妓釟溻c治療代酸，碳酸氫鈉不能增加 CO，也不能減少血管活性藥物應(yīng)用 Cooper, et al. Ann Intern Med 1990 Mathieu, et al. Crit Care Med 1991 第七十六頁(yè)，共八十頁(yè)。 Final Thoughts ? Recognize pensated shock quickly have a high index of suspicion, remember tachycardia is first sign. Hypotension is late and ominous. ? Gain access quickly if necessary use an IO line. ? Administer adequate amounts of fluid rapidly. Remember ongoing losses. ? Correct electrloytes and glucose problems quickly. ? If the patient is not responding the way you think he should, broaden your differential, think about different types of shock. 第七十七頁(yè)，共八十頁(yè)。 第七十八頁(yè)，共八十頁(yè)。 第七十九頁(yè)，共八十頁(yè)。 內(nèi)容總結(jié) 兒科休克的診治。 →左房壓 ↑→肺毛細(xì)血管楔壓 ↑→肺淤血。由于血液重新分布和毛細(xì)血管滲漏液體喪失 , 持續(xù)低血容量可能持續(xù)數(shù)日。收縮壓 該年齡組第 5百分位或 該年齡組正常值 2個(gè)標(biāo)準(zhǔn)差。 1~10歲 70mmHg+[2年齡〔歲〕 ]。反復(fù)評(píng)估循環(huán)及灌注、肺部羅音及肝大小。繼續(xù)輸液和維持輸液。液體配置不當(dāng)：用糖稀釋高漲液，過(guò)多使用堿性液。謝謝 第八十頁(yè)，共八十頁(yè)。