Bench-to-bedside review: the initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines--does one size fit all?
Bench-to-bedside review: the initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines--does one size fit all?
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DOI：
10.1186/cc6979
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发表时间：
2008
期刊：
影响因子：
--
通讯作者：
Perel A
中科院分区：
文献类型：
--
作者：
Perel A
《脓毒症生存运动》对严重脓毒症和脓毒性休克的管理指南建议，根据Rivers及其同事在其著名的早期目标导向治疗（EGDT）研究中使用的方案，进行初始血流动力学复苏。然而，很可能他们的病人在入院时比许多其他脓毒症病人病情严重得多。与其他脓毒症患者相比，Rivers等患者严重合并症的发生率更高，入院时血流动力学状态更严重（中心静脉氧饱和度过低[ScvO2]、中心静脉压过低[CVP]、乳酸浓度高），死亡率更高。因此，这些患者很可能是在未经治疗的晚期低血容量性败血症中到达医院的，这可能至少部分是由于低社会经济地位和获得医疗保健的机会减少。EGDT方案使用CVP和ScvO2的目标值来指导血流动力学管理。然而，灌注压力并不能可靠地预测对液体给药的反应，而脓毒症患者的ScvO2由于吸氧减少而具有高的特征。由于所有这些原因，生存败血症运动指南的血流动力学部分似乎不能适用于所有败血症患者，特别是那些在住院期间发生败血症的患者。
The Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock recommend that the initial hemodynamic resuscitation be done according to the protocol used by Rivers and colleagues in their well-known early goal-directed therapy (EGDT) study. However, it may well be that their patients were much sicker on admission than many other septic patients. Compared with other populations of septic patients, the patients of Rivers and colleagues had a higher incidence of severe comorbidities, a more severe hemodynamic status on admission (excessively low central venous oxygen saturation [ScvO2], low central venous pressure [CVP], and high lactate), and higher mortality rates. Therefore, it may well be that these patients arrived to the hospital in late untreated hypovolemic sepsis, which may have been due, in part at least, to low socioeconomic status and reduced access to health care. The EGDT protocol uses target values for CVP and ScvO2 to guide hemodynamic management. However, filling pressures do not reliably predict the response to fluid administration, while the ScvO2 of septic patients is characteristically high due to decreased oxygen extraction. For all these reasons, it seems that the hemodynamic component of the Surviving Sepsis Campaign guidelines cannot be applied to all septic patients, particularly those who develop sepsis during their hospital stay.
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