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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幸存的败血症运动：严重败血症和化粪池冲击管理的国际指南，2012年。
DOI：
10.1007/s00134-012-2769-8
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发表时间：
2013-03
影响因子：
38.9
通讯作者：
Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup
中科院分区：
文献类型：
--
作者：
Dellinger RP;Levy MM;Rhodes A;Annane D;Gerlach H;Opal SM;Sevransky JE;Sprung CL;Douglas IS;Jaeschke R;Osborn TM;Nunnally ME;Townsend SR;Reinhart K;Kleinpell RM;Angus DC;Deutschman CS;Machado FR;Rubenfeld GD;Webb S;Beale RJ;Vincent JL;Moreno R;Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup
为2008年出版的《脓毒症生存运动严重脓毒症和脓毒性休克管理指南》提供更新。召开了一个由代表30个国际组织的68名国际专家组成的协商一致委员会。在重要的国际会议上（为出席会议的委员会成员）召集名义上的小组。一项正式的利益冲突政策在这个过程开始时就被制定出来，并在整个过程中得到执行。整个指导方针的制定过程是独立于任何行业资助的。为所有小组负责人、联席主席和副主席以及选定的个人举行了一次独立会议。小组之间和整个委员会之间的电话会议和以电子为基础的讨论是发展的一个组成部分。建议作者遵循建议评估、发展和评价分级（GRADE）系统的原则，指导证据质量从高(A)到极低(D)的评估，并确定建议的强度为强(1)或弱(2)。强调了在低质量证据面前提出强烈建议的潜在弊端。建议分为三类：(1)直接针对严重脓毒症的建议；(2)针对危重病人的一般护理，在严重脓毒症中优先考虑的；(3)儿科注意事项。按类别列出的主要建议和建议包括：脓毒症患者在识别后的前6小时早期定量复苏（1C）；抗生素治疗前血培养（1C）；迅速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（1C）的严重脓毒症后1小时内给予广谱抗菌药物治疗；在适当的情况下，每天重新评估抗菌药物治疗以降低剂量（1B）；感染源控制，在诊断后12小时内注意所选方法的风险和收益的平衡（1C）；用crystalloid进行初始液体复苏（1B），考虑在继续需要大量crystalloid维持足够的平均动脉压（2C）的患者中添加白蛋白，并避免使用hetastarch制剂（1B）；败血症引起的组织灌注不足和怀疑低血容量患者的初始液体挑战，以达到至少30 mL/kg的晶体（某些患者可能需要更快速的给药和更大量的液体）；只要血流动力学改善是基于动态或静态变量（UG），流体挑战技术就会继续进行；首选去甲肾上腺素维持平均动脉压≥65 mmHg (1B)；当需要额外的药物来维持适当的血压时使用肾上腺素（2B）；加压素（0.03 U/min）可加入去甲肾上腺素以提高平均动脉压达到目标或降低去甲肾上腺素剂量，但不应作为初始加压素（UG）；除非在高度选定的情况下，不建议使用多巴胺（2C）；在存在(a)心肌功能障碍（如心脏充盈压升高和心输出量低）或(b)尽管达到足够的血管内容积和足够的平均动脉压（1C），但仍有灌注不足的迹象时，给予多巴酚丁胺输注或添加血管加压剂；如果充分的液体复苏和血管加压治疗能够恢复血流动力学稳定性，避免在成人感染性休克患者中静脉注射氢化可的松（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）和吸气平台压（1B）限制急性呼吸窘迫综合征（ARDS）；在ARDS中应用至少少量的呼气末正压（PEEP） （1B）；脓毒症引起的中、重度ARDS患者的PEEP高于而不是较低（2C）；ARDS合并严重难治性低氧血症脓毒症患者的招募策略（2C）在有此类做法经验的机构中，Pao 2/Fio 2比值≤100 mm Hg的败血症性ARDS患者的俯卧位（2C）；机械通气患者床头抬高，除非有禁忌症（1B）；对于没有组织灌注不足证据的ARDS患者，采用保守的液体治疗方案；脱机和镇静方案（1A）；尽量减少间歇大剂量镇静或针对特定滴定终点的连续输液镇静的使用（1B）；在没有ARDS的脓毒症患者中尽可能避免使用神经肌肉阻滞剂（1C）；对于早期急性呼吸窘迫综合征（ARDS）和Pao 2/Fi o 2 <150 mm Hg的患者，给予短疗程的神经肌肉阻滞剂（不超过48小时）；当连续两次血糖水平为bb0 ~ 180mg /dL时，针对上血糖≤180mg /dL开始胰岛素治疗的协议化血糖管理方法（1A）；连续性静脉-静脉血液滤过或间歇血液透析的等效性（2B）；预防深静脉血栓形成（1B）；有出血危险因素的患者应用应激性溃疡预防上消化道出血（1B）；口服或肠内（如有必要）喂养，在诊断为严重脓毒症/感染性休克后的头48小时内，而不是完全禁食或仅静脉注射葡萄糖（2C）；尽早解决护理目标，包括治疗计划和临终计划（酌情）（1B），但在重症监护病房入住后72小时内（2C）。针对儿童严重脓毒症的具体建议包括：在出现呼吸窘迫和低氧血症（2C）的情况下，使用面罩供氧、高流量鼻插管供氧或鼻咽连续PEEP进行治疗，使用体检治疗终点，如毛细血管充血（2C）；对于脓毒性休克合并低血容量，使用晶体物或白蛋白在5-10分钟内给药20ml /kg晶体物（或白蛋白当量）；在低心输出量感染性休克伴全身血管阻力升高的情况下更常使用收缩性药物和血管扩张剂（2C）；只有怀疑或证实“绝对”肾上腺功能不全的儿童才使用氢化可的松（2C）。大量国际专家就严重脓毒症患者最佳护理的许多一级建议达成了强烈的一致意见。尽管许多护理方面的支持相对较弱，但关于脓毒症和感染性休克的急性管理的循证建议是改善这一重要危重患者群体预后的基础。本文的在线版本（doi:10.1007/s00134-012-2769-8）包含补充材料，授权用户可使用。
To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. 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. 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. 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. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h 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 h of the 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 h 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 (1B); 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 is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (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 ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao 2/Fi o 2 <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients. The online version of this article (doi:10.1007/s00134-012-2769-8) contains supplementary material, which is available to authorized users.
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影响因子：
158.5
作者：
Abraham, E;Laterre, P;Macias, WL
通讯作者：
Macias, WL
影响因子：
158.5
作者：
Amato, MBP;Barbas, CSV;Carvalho, CRR
通讯作者：
Carvalho, CRR
影响因子：
168.9
作者：
Annane, Djillali;Vignon, Philippe;Bellissant, Eric
通讯作者：
Bellissant, Eric
影响因子：
8.8
作者：
Angus, D C;Linde-Zwirble, W T;Pinsky, M R
通讯作者：
Pinsky, M R
影响因子：
120.7
作者：
Annane, D;Sébille, V;Bellissant, E
通讯作者：
Bellissant, E