全身炎症反应综合症与脓毒血症（中）.pptVIP

Sepsis Resuscitation Bundle If persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate 4 mmol/L: Recommend insertion of central venous catheter Achieve CVP of 8-12 mmHg Higher with altered ventricular compliance or increased intrathoracic pressure Achieve ScvO2 of 70% or SvO2 65% SSC Guidelines-IHI Grade 1C Sepsis Resuscitation Bundle If ScvO2 remains 70% after fluid resuscitation goals are met Dobutamine up to 20 μg/kg/min Transfusion to maintain Hct 30% Grade 2C SSC Guidelines, Crit Care Med 2008 DIAGNOSIS OF SEVERE SEPSIS Diagnosis of Severe Sepsis Appropriate cultures should always be obtained before antimicrobial therapy is initiated. At least 2 blood cultures with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (48 h) inserted. GRADE 1C Antimicrobial Therapy IV antibiotics should be started within the first hour of recognition of severe sepsis after appropriate cultures have been obtained. Grade 1B Initial empirical antimicrobial therapy should include one or more drugs that have activity against the likely pathogens (bacterial or fungal) and that penetrate into the presumed source of sepsis. Grade 1B ???????????????????????????????? Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival Kumar A, et al. Crit Care Med 2006;34:1589 Antimicrobial Therapy Antimicrobial regimen should be reassessed daily to optimize activity, to prevent the development of resistance, to reduce toxicity, and to reduce costs. Grade 1C Source Control Source Control Technique Examples Drainage Intra-abdominal 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