【導(dǎo)讀】尋找感染源，控制感染。針對炎癥反應(yīng)的治療（酶抑制劑。表明，6h內(nèi)SVO2必須>70％，及應(yīng)用血管活性藥物治療。采用這種目標(biāo)治療的死亡率。法的死亡率為%。對膿毒癥患者早期積極的容。量復(fù)蘇能顯著改善預(yù)后。低血壓事件或血乳酸>4mmol/L. 晶體液至少20ml/kg補(bǔ)液試驗(yàn)（膠體）。經(jīng)液體復(fù)蘇后，血壓持續(xù)低應(yīng)給與。維持CVP8-12mmHg（在肺順應(yīng)性。液體復(fù)蘇后仍SvO2<70%，輸血至紅細(xì)胞壓積Hct>30%。考慮嚴(yán)重感染獲取培養(yǎng)標(biāo)本后，立即靜脈抗生?？股胤桨该咳招枰u估最優(yōu)活性，防止耐藥。菌的形成，降低藥物的毒性，及降低醫(yī)療費(fèi)用。拔除管路感染靜脈插管，權(quán)威處理膽囊切除術(shù)，懷疑低血容量時(shí)，補(bǔ)液試驗(yàn)1000ml晶體。液動(dòng)力學(xué)無改善時(shí)，輸液速度應(yīng)該降低。在膿毒血癥中糾正低血壓建議應(yīng)用去甲腎上腺。素或多巴胺等血管收縮藥。低劑量的多巴胺不用于腎功能保護(hù)治療。心功能被抑制時(shí)，推薦應(yīng)用多巴酚丁胺。膿毒血癥患者氫化可的松每天劑量不超過。器官功能衰竭并且無出血相關(guān)的禁忌癥。成人伴有嚴(yán)重膿度血癥和低死亡率

　　

【正文】 y, to prevent the development of resistance, to reduce toxicity, and to reduce costs. Grade 1C Source Control Source Control Technique Examples ? Drainage Intraabdominal abscess Thoracic empyema ? Debridement Necrotizing fasciitis Infected pancreatic necrosis ? Device removal Infected vascular catheter Urinary catheter ? Definitive control Cholecystectomy Sigmoid resection GRADE 1C FLUID AND VASOPRESSOR THERAPY Fluid 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 SSC Guidelines, Crit Care Med 20xx 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 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。g/dl at 30 or 60min following 250 181。g ACTH stimulation test Annane D, et al. JAMA 20xx。283:103845 Low Dose Steroids in Septic Shock Study Design Time 0 Onset of shock Randomization Hydrocortisone IV 50mg every 6 hours x 7 days + Fludrocortisone 50 mcg NG daily x 7 days Placebo X 7 days 0 Eligibility and ACTH test Main Oute: 28day survival Annane, D. 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。 288 (7): 868 N=150 N=149 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 ay s )Probability of survivalPL A C E B OS T E R O I D SHaz a rd Ratio: 7 (9 5 % CI, 0 .47 0 . 9 5 )p = 2NON RES PON DE R28 Da y Sur viva lAnnane 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。 288:862