1、嚴重感染與感染性嚴重感染與感染性休克血流動力學監(jiān)休克血流動力學監(jiān)測與支持指南測與支持指南 中華醫(yī)學會重癥醫(yī)中華醫(yī)學會重癥醫(yī)學分會（草案）學分會（草案）感染感染Sepsis全身炎癥反應綜全身炎癥反應綜合征合征創(chuàng)傷創(chuàng)傷燒傷燒傷胰腺炎胰腺炎其他其他菌血癥菌血癥真菌血癥真菌血癥病毒血癥病毒血癥其他其他 組織細胞損傷組織細胞損傷多器官功能障礙綜合癥（多器官功能障礙綜合癥（MODS）感染因素感染因素非感染因素非感染因素內毒素內毒素單核單核/巨噬細胞巨噬細胞炎癥介質炎癥介質激活中性粒細胞，損傷內皮細胞激活中性粒細胞，損傷內皮細胞釋放氧自由基、脂質代釋放氧自由基、脂質代 謝產物、溶酶體酶等謝產物、溶酶體酶等S

2、epsis微循環(huán)障礙微循環(huán)障礙凝血機制紊亂凝血機制紊亂細胞凋亡細胞凋亡血管活性和炎性介質釋放血管活性和炎性介質釋放 局部血管擴張，毛細血管局部血管擴張，毛細血管通透性增加通透性增加 水腫，影響傷口愈合水腫，影響傷口愈合組織細胞組織間隙毛細血管細胞內液組織間液血漿毛細血管滲漏毛細血管滲漏5%15%40%白蛋白漏出，膠體滲透壓降低，加重組織水腫?Rivers E et al. N Engl J Med. 2001; 345: 1368-77. Sepsis Resuscitation Bundle (to be accomplished as soon as possible and scored

3、 over first 6 hours) Serum lactate measured Blood cultures obtained prior to antibiotic administration Broad-spectrum antibiotics administered within 1 hr. of diagnosis (ICU admit) or 3 hours from presentation (ED admit )20 ml/kg of crystalloid (or colloid equivalent) delivered For hypotension not r

4、esponding to volume resuscitation, vasopressors employed to maintain mean arterial pressure (MAP) 65 mmHgCentral venous pressure (CVP) 8 mmHg achievedCentral venous oxygen saturation (ScvO2) of 70% achievedachieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative Low-dose

5、 steroids administered for septic shock in accordance with local guidelines Drotrecogin alfa (activated) administered in accordance with local guidelinesGlucose control maintaine lower limit of normal, but 150 mg/dl (8.3 mmol/L) For mechanically ventilated patients inspiratory plateau pressures maintained 30 cm H2O.Sepsis Managem