Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
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DOI：
10.1097/ccm.0b013e31827e83af
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发表时间：
2013-02-01
影响因子：
8.8
通讯作者：
Zimmerman, Janice L.
中科院分区：
文献类型：
--
作者：
Dellinger, R. Phillip;Levy, Mitchell M.;Zimmerman, Janice L.
目的：为了提供对2008年最后出版的“严重脓毒症和脓毒性休克管理的生存脓毒症运动指南”的更新。设计：召集了代表30个国际组织的68名国际专家的共识委员会。名义上的团体在重要的国际会议上聚集（对于那些参加会议的委员会成员）。在这一进程开始时就制定了一项正式的利益冲突政策，并在整个过程中得到执行。整个指导方针过程独立于任何行业资金。为所有分组负责人、共同主席和副主席以及选定的个人举行了一次单独会议。小组之间和整个委员会之间的电子会议和讨论是开发的一个组成部分。方法：建议作者遵循建议分级评估、开发和评价（GRADE）系统的原则，指导证据质量从高（A）到极低（D）的评估，并将建议的强度确定为强（1）或弱（2）。强调了在证据质量不高的情况下提出强有力建议的潜在缺点。有些建议未评级（普遍定期审议）。建议分为三组：1）直接针对严重脓毒症; 2）针对危重病人的一般护理，并认为在严重脓毒症的高优先级;和3）儿科considerations.Results：关键的建议和意见，按类别列出，包括：早期定量复苏的脓毒症患者在第一个6小时后承认（1C）;抗生素治疗前进行血培养（1C）;及时进行影像学检查以确认潜在感染源（UG）;在确认脓毒性休克（1B）和无脓毒性休克的严重脓毒症（1C）后1小时内给予广谱抗菌药物治疗作为治疗目标;适当时，每日重新评估抗菌治疗以降低剂量（1B）;感染源控制，注意在诊断后12小时内所选方法的风险和获益平衡（1C）;初始液体复苏时使用晶体液（1B），并考虑在继续需要大量晶体液以维持适当平均动脉压的患者中添加白蛋白（2C），避免使用羟乙基淀粉制剂（1C）;脓毒症诱导的组织灌注不足和疑似血容量不足患者的初始液体挑战，以达到至少30 mL/kg的晶体液（某些患者可能需要更快速的给药和更大量的液体）（1C）;根据动态或静态变量（UG），只要血流动力学改善，液体挑战技术就继续进行;去甲肾上腺素作为维持平均动脉压≥ 65 mm Hg的首选血管加压药（1B）;当需要额外药物维持适当血压时使用肾上腺素（2B）;加压素（0.03 U/min）可以加到去甲肾上腺素中，以将平均动脉压升高到目标水平或减少去甲肾上腺素剂量，但不应用作初始血管加压剂（UG）;不推荐使用多巴胺，除非在高度选择的情况下（2C）;在存在a）心肌功能障碍，表现为心脏充盈压升高和心输出量降低，或B）尽管达到足够的血管内容量和足够的平均动脉压（1C），但仍存在灌注不足体征的情况下，输注多巴酚丁胺或将其添加到血管加压剂中（1C）;如果适当的液体复苏和血管加压剂治疗能够恢复血流动力学稳定，则避免在成人感染性休克患者中使用静脉内氢化可的松（2C）;在没有组织灌注不足、缺血性冠状动脉疾病或急性出血的情况下，血红蛋白目标为7-9 g/dL（1B）;低潮气量（1A）和限制吸气平台压（1B）治疗急性呼吸窘迫综合征（ARDS）;至少应用最小量的呼气末正压（PEEP）治疗ARDS（1B）;脓毒症诱导的中度或重度ARDS患者的PEEP水平较高而非较低（2C）;脓毒症诱导的ARDS患者的严重难治性低氧血症的复张策略（2C）;脓毒症诱导的ARDS患者的Pao（2）/Fio（2）比值为
Objective: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.Design: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.Methods: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.Results: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure >= 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao(2) /Fio(2) ratio of