|
脓毒症筛查和早期诊治 For hospitals and health systems, we recommend using a performance improvement programme for sepsis, including sepsis screening for acutely ill, high‑risk patients and standard operating procedures for treatment. 对于医疗机构，推荐制定流程，以便能够快速识别、标准化救治脓毒症患者。 We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock. 不推荐单独使用qSOFA评分来筛查脓毒症、脓毒症休克。临床医生应当依据患者情况，综合评定、诊治脓毒症，诸如联合SIRS、NEWS、MEWS等评分来综合评定。 For adults suspected of having sepsis, we suggest measuring blood lactate. 怀疑脓毒症，推荐监测血乳酸。 Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. 脓毒症和脓毒症休克情况紧急，需要立即救治。 For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fuid should be given within the frst 3 h of resuscitation. 如果脓毒症伴有低血压或脓毒症休克，推荐3小时内给予至少30ml/kg的晶体液。 For adults with sepsis or septic shock, we suggest using dynamic measures to guide fuid resuscitation, over physical examination or static parameters alone. 对于脓毒症和脓毒症休克的患者，推荐动态监测患者相关指标来评估液体复苏情况，不能单独依赖一个静态指标或体格检查。【编者：前负荷指标分两类，一个为静态前负荷指标诸如GEDV、ITBV、CVP，一个为动态前负荷指标，诸如SVV、PPV、容量负荷试验。显然，动态前负荷指标更加有意义】 For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level,over not using serum lactate. 对于脓毒症或脓毒症休克患者来说，如果乳酸升高，推荐动态监测乳酸，进行休克复苏来降低乳酸水平，而不是不看血清乳酸水平。【编者：乳酸受到诸多因素影响，在临床工作中要综合看待，诸如乳酸的产生、代谢、在外周组织堆积等，动态监测乳酸更为重要】【点我点我，了解乳酸代谢】 For adults with septic shock, we suggest using capillary refll time to guide resuscitation as an adjunct to other measures of perfusion. 推荐使用毛细血管充盈时间作为复苏指标。【编者：毛细血管充盈时间是重要的组织灌注参数，可用于灌注评估】【点我点我，了解毛细血管充盈使用】 For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. 对于脓毒症休克患者来说，推荐初始MAP目标为65mmHg，而不是更高的平均动脉压目标。【编者：对于大多数患者来说，MAP维持65mmHg即可，而不是更高的血压，更高的血压目标可导致左心-动脉偶联失衡，或需要更多的血管活性药物，从而需要更高的代价】 For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patients to the ICU within 6 h. 推荐脓毒症或脓毒症休克患者，如需ICU救治，在6小时内转入ICU。
诊治感染 For adults with suspected sepsis or septic shock but unconfrmed infection, we recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected. 怀疑脓毒症或脓毒症休克，但没有明确感染，推荐持续评估、寻找其他诊断，如果不存在感染，撤除需广谱抗生素。
抗生素时间 For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials mmediately, ideally within 1 h of recognition. 如果患者是感染引起的脓毒症或脓毒症休克（或高度怀疑），需要尽快给予抗生素，理想状态下，应当1小时内使用抗生素。 For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infectious versus non‑infectious causes of acute illness. 怀疑脓毒症但没有休克的患者，推荐评估感染、非感染疾病。【编者：有诸多非感染疾病科导致脓毒症症状，在临床工作中需要仔细斟酌】 For adults with possible sepsis without shock, we suggest a time‑limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 h from the time when sepsis was first recognised. 怀疑脓毒症但没有休克的患者，应当快速展开诊治。如果考虑存在持续的感染，应当在考虑脓毒症诊治之后的3小时内给予抗生素。 For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient. 如果患者脓毒症概率很小且没有感染，建议无需使用抗生素，同时严密监测患者状态。
抗生素使用生物标志物 For adults with suspected sepsis or septic shock, we suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. 对于怀疑脓毒症、脓毒症休克的患者，不要依据降钙素原和临床评估来决定启用抗生素，也不能单独依赖临床评估。【编者：任何生物标志物都存在一定的局限性，降钙素原也一样，它也有开始分泌、峰值、降落的特点，不能单独依赖降钙素原来指导临床治疗】【点我点我，了解降钙素原】
抗生素选择 For adults with sepsis or septic shock at high risk of methicillin resistant staph aureus (MRSA), we recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage. 对于MRSA高危的脓毒症、脓毒症休克患者，推荐初始抗生素覆盖MRSA。 For adults with sepsis or septic shock at low risk of methicillin resistant staph aureus (MRSA), we suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage. 对于无MRSA高危的脓毒症、脓毒症休克患者，不推荐初始抗生素覆盖MRSA。 For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, we suggest using two antimicrobials with gram‑negative coverage for empiric treatment over one gram‑negative agent. 对于MDR高危患者，推荐使用两种可覆盖G-菌的抗生素，而不是单独用药。【编者：MDR的治疗，鉴于其多重耐药，一般都是联合用药】 For adults with sepsis or septic shock and low risk for MDR organisms,we suggest against using two Gram‑negative agents for empiric treatment, as compared to one Gram‑negative agen. 对于无MDR高危的患者，不推荐联合用药。【编者：常规的社群获得性感染，一般单独用药即可】 For adults with sepsis or septic shock, we suggest against using double gram‑negative coverage once the causative pathogen and the susceptibilities are known. 当病原菌明确、药敏明确，不推荐联合用药。【编者：如果存在明确的病原菌、药敏结果，需要及时降阶梯处理】
抗真菌治疗 For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy over no antifungal therapy. 如果患者真菌感染高危，推荐初始广谱抗真菌治疗。 For adults with sepsis or septic shock at low risk of fungal infection,we suggest against empiric use of antifungal therapy. 如果不存在真菌感染高危，不推荐初始抗真菌治疗。
抗病毒药物 抗生素使用 For adults with sepsis or septic shock, we suggest using prolonged infusion of beta‑lactams for maintenance (after an initial bolus) over conventional bolus infusion. 对于脓毒症、脓毒症休克患者，使用β内酰胺抗生素建议延长输注时间（初始快速使用后）。【编者：β内酰胺类抗生素为时间依赖性，超过MIC的时间越长，作用效果越好，因此，需要延长给药时间】
药效学和药代动力学 For adults with sepsis or septic shock, we recommend optimising dosing strategies of antimicrobials based on accepted pharmacoki‑netic/pharmacodynamic (PK/PD) principles and specifc drug properties. 推荐使用PK/PD原理、依据抗生素特性，优化抗生素治疗。【编者：对于抗生素，要将其分为时间依赖性、浓度依赖性和其他，针对不同特点，进行特定给药】
感染源控制 For adults with sepsis or septic shock, we recommend rapidly identifing or excluding a specifc anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical. 对于脓毒症、脓毒症休克的患者，应当快速寻找感染源，并控制感染病灶。 For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established. 脓毒症、脓毒症休克患者如果考虑有导管相关的感染，应当建立新的导管，并移除感染导管。 For adults with sepsis or septic shock, we suggest daily assessment for de‑escalation of antimicrobials over using fxed durations of therapy without daily reassessment for de‑escalation. 推荐每日评估抗生素降阶梯策略。【编者：脓毒症的治疗时间可能很长，在长时间的救治过程中，一定要每天评估是否需要急性使用抗生素、是否要降阶梯】
抗生素疗程 For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy. 脓毒症休克、脓毒症患者，在充分感染灶控制情况下，推荐短程抗生素疗程。
终止抗生素的标志物 For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear,we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. 脓毒症、脓毒症休克患者感染控制足够的情况下，但无法明确最佳抗生素疗程，推荐参考降钙素原和临床情况来决定抗生素使用，而不是单独依赖临床情况。
血流动力学监测 For adults with sepsis or septic shock, we recommend using crystaloids as frst-line fuid for resuscitation. 推荐晶体液为复苏首选液体。 For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation 推荐使用平衡液来液体复苏，而不是生理盐水。【编者：生理盐水可引起高氯血症、高钠血症，而平衡液更接近血浆成分，更为合适】 For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids over using crystaloids alone 需要大量晶体液的时候，推荐联合白蛋白。 For adults with sepsis or septic shock, we recommend against using starches for resuscitation 不推荐使用羟乙基淀粉复苏。 For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation 不推荐使用明胶复苏。
血管活性药物 For adults with septic shock, we recommend using norepinephrine as the frst‑line agent over other vasopressors. 推荐一线药物为去甲肾上腺素。【其他可替代的药物为：多巴胺、肾上腺素，当使用这两者的时候，一定要注意心率】 For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine. 当单独使用去甲肾上腺素血压无法维持的时候，推荐加用血管加压素，而不是一味的加用去甲肾上腺素。【去甲肾上腺素范围0.25–0.5 μg/kg/min，可加用血管加压素】 For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine 去甲肾上腺素联合血管加压素仍无法维持血压，推荐加用肾上腺素。 For adults with septic shock, we suggest against using terlipressin 不推荐使用特立加压素。
强心药 For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest either adding dobutamine to norepinephrine or using epinephrine alone 存在脓毒症休克和心功能不全的时候，可使用去甲肾上腺素联合多巴酚丁胺或单独使用肾上腺素。 For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood presure, we suggest against using levosimendan 存在脓毒症休克和心功能不全的时候，充足液体复苏后，仍无法维持血压，不推荐使用左西孟旦。
监测 For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over non‑invasive monitoring, as soon as practical and if resources are available 推荐侵袭性监测手段（有创动脉压监测） For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured 推荐在中心静脉未建立的时候，外周使用血管活性药物，而不是等待建立中心静脉。
液体平衡 There is insufcient evidence to make a recommendation on the use of restrictive versus liberal fuid strategies in the frst 24 h of resus‑citation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after initial resuscitation 关于液体复苏方面，24小时内的时候，无法推荐是采用限制性液体复苏还是开放式液体复苏。
氧合目标 高流量氧疗 无创通气 There is insufcient evidence to make a recommendation on the use of non‑invasive ventilation in comparison to invasive ventilation for adults with sepsis‑induced hypoxemic respiratory failure 无创通气和有创通气相比，治疗脓毒症诱发的低氧血症方面，无法形成推荐。
ARDS的保护性肺通气 For adults with sepsis‑induced ARDS, we recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg) 推荐脓毒症诱发的ARDS使用保护性肺通气策略，使用小潮气量（6ml/kg）。 For adults with sepsis‑induced severe ARDS, we recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures 推荐脓毒症诱发的ARDS，控制平台压≤30cmH2O。 For adults with moderate to severe sepsis‑induced ARDS, we suggest using higher PEEP over lower PEEP 对于脓毒症诱发的ARDS，如果中重度的，推荐高PEEP。【编者：脓毒症诱发呼吸衰竭，可使用高PEEP，但一定要注意高PEEP对循环的影响】【点我点我，了解ARDSpeep的选择】
非ARDS患者小潮气量 For adults with sepsis‑induced respiratory failure (without ARDS), we suggest using low tidal volume as compared to high tidal volume ventilation 脓毒症诱发的低氧血症但无法诊断ARDS，推荐低潮气量。
肺复张 For adults with sepsis‑induced moderate‑severe ARDS, we suggest using traditional recruitment maneuvers 对于脓毒症诱发的ARDS，推荐肺复张。 When using recruitment maneuvers, we recommend against using incremental PEEP titration/strategy 如果进行肺复张，不推荐使用PEEP递增法。
俯卧位 肌肉松弛药物 For adults with sepsis induced moderate‑severe ARDS, we suggest using intermittent NMBA boluses, over NMBA continuous infusion 中重度ARDS，推荐间歇NMBA应用，而不是持续输注。
ECMO For adults with sepsis‑induced severe ARDS, we suggest using veno‑venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use 如果常规支持治疗无效，推荐ARDS患者使用VV-ECMO，但需要在有经验的中心进行，有配套设施。
激素 For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids 脓毒症休克和持续使用血管活性药物的患者，推荐静脉使用皮质醇。【去甲肾上腺素≥ 0.25 mcg/kg/min且维持4小时的时候，可使用氢化可的松200mg持续泵入或50mgQ6H】【编者：脓毒症存在炎症反应，激素可抑制炎症反应，从而起到保护作用。如果脓毒症存在休克、且休克持续无法纠正（超过4小时），就有使用激素的指征】
血液净化 For adults with sepsis or septic shock, we suggest against using polymyxin B haemoperfusion 不推荐血液灌流； There is insufcient evidence to make a recommendation on the use of other blood purifcation techniques 其他血液净化技术无法形成推荐。
红细胞 For adults with sepsis or septic shock, we recommend using a restric‑tive (over liberal) transfusion strategy 推荐限制性红细胞输注（70 g/L足够，但仍需要综合评估心功能等指标）。
免疫球蛋白 应激性溃疡 深静脉血栓 For adults with sepsis or septic shock, we recommend using pharmacologic VTE prophylaxis unless a contraindication to such therapy exists 推荐药物预防VTE，除非有禁忌症。 For adults with sepsis or septic shock, we recommend using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for VTE prophylaxis 推荐使用低分子肝素，而不是普通肝素，来预防深静脉血栓。 For adults with sepsis or septic shock, we suggest against using mechanical VTE prophylaxis in addition to pharmacological prophy‑laxis, over pharmacologic prophylaxis alone 不推荐使用机械性联合低分子肝素来防治VTE。
肾脏替代 In adults with sepsis or septic shock and AKI who require renal replacement therapy, we suggest using either continuous or intermitent renal replacement therapy 对于脓毒症、脓毒症休克合并AKI的，推荐持续肾脏替代或间歇肾脏替代。 In adults with sepsis or septic shock and AKI, with no defnitive indications for renal replacement therapy, we suggest against using renal replacement therapy 对于脓毒症、脓毒症休克合并AKI的，没有明确肾脏替代指征的，不推荐肾脏替代治疗。
血糖控制 For adults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of≥ 180 mg/dL (10mmol/L) 推荐控制血糖，在血糖大于10mmol/l的时候，使用胰岛素【维持8–10 mmol/L】。
维生素C For adults with sepsis or septic shock, we suggest against using IV
vitamin C 对于脓毒症、脓毒症休克的患者，不推荐静脉使用VC。
碳酸氢钠 For adults with septic shock and hypoperfusion‑induced lactic acidemia, we suggest against using sodium bicarbonate therapy to improve haemodynamics or to reduce vasopressor requirements 对于脓毒症诱导的或低血压诱导的乳酸酸中毒，不推荐使用碳酸氢钠来提高血流动力学或减少血管活性药物的使用剂量。 For adults with septic shock, severe metabolic acidemia (pH≤ 7.2) and AKI (AKIN score 2 or 3), we suggest using sodium bicarbonate therapy 当患者因为休克或AKI出现代谢性酸中毒的时候，如果ph≤7.2，体检使用碳酸氢钠。
营养 For adult patients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 h) initiation of enteral nutrition 对于脓毒症、脓毒症休克的患者来说，如果能够进行肠内营养，推荐早期肠内支持（72小时内）。
治疗目标 For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis with patients and families over no such discussion 推荐同患者及家属讨论治疗目标和预后。 For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 h) over late 推荐早期制定治疗目标（72小时内） There is insufcient evidence to make a recommendation for any specifc standardised criterion to trigger goals of care discussion 对特异性标准来启动救治目标，无法形成推荐。
姑息疗法 For adults with sepsis or septic shock, we recommend integrating principles of palliative care (which may include palliative care consulta‑tion based on clinician judgement) into the treatment plan, when appropriate, to address patient and family symptoms and sufering 推荐在救治脓毒症和脓毒症休克的时候，依据患者情况，将姑息疗法考虑在内。 For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement 对于脓毒症和脓毒症休克，不推荐所有患者常规考虑姑息疗法，应当依据患者病情综合评定。
后续支持治疗 For adult survivors of sepsis or septic shock and their families, we suggest referral to peer support groups over no such referral 脓毒症休克患者救治之后，推荐转移至专有机构进行康复。 For adults with sepsis or septic shock, we suggest using a handof process of critically important information at transitions of care, over no such handof process There is insufcient evidence to make a recommendation for the use of any specifc structured handof tool over usual handof processes 推荐脓毒症、脓毒症休克患者接力性治疗，从而保持治疗的完整性，但具体无法形成推荐。 For adults with sepsis or septic shock and their families, we recommend screening for economic and social support (including housing,nutritional, fnancial, and spiritual support), and make referrals where available to meet these needs 推荐评估、筛查、寻求脓毒症患者救治的经济支持和社会支持。
教育 For adults with sepsis or septic shock and their families, we suggest ofering written and verbal sepsis education (diagnosis, treatment, and post‑ICU/post‑sepsis syndrome) prior to hospital discharge and in the follow‑up setting 推荐对脓毒症患者及家属进行纸面上的、视频上的科普教育。 For adults with sepsis or septic shock and their families, we recommend the clinical team provide the opportunity to participate in shared decision making in post‑ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible 推荐医疗团队同患者及家属，沟通、设定住院后计划且计划可行，以确保顺利康复。
出院 For adults with sepsis and septic shock and their families, we suggest using a critical care transition programme, compared to usual care,upon transfer to the foor For adults with sepsis and septic shock, we recommend reconciling medications at both ICU and hospital discharge For adult survivors of sepsis and septic shock and their families, we recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary For adults with sepsis or septic shock who developed new impairments, we recommend hospital discharge plans include follow‑up with clinicians able to support and manage new and long‑term sequelae There is insufcient evidence to make a recommendation on early post‑hospital discharge follow‑up compared to routine post‑hospital discharge follow‑up 对于脓毒症患者，需要设定相应转运、出院流程，在ICU和出院后，都需要制定药物治疗策略。出院时候，提供纸质的、口头的信息，以完整记录疾病救治过程。出院后，需要及时随访患者，帮助那些存在功能受损的患者，建立后续治疗流程，但关于随访时机，无法形成推荐。
认知疗法 随访 For adult survivors of sepsis or septic shock, we recommend assessment and follow‑up for physical, cognitive, and emotional problems after hospital discharge For adult survivors of sepsis or septic shock, we suggest referral to a post‑critical illness follow‑up programme if available For adult survivors of sepsis or septic shock receiving mechanical ventilation for > 48 h or an ICU stay of > 72 h, we suggest referral to a post‑hospital rehabilitation programme 如果有条件，应当对脓毒症患者出院后制定随访流程，关注、评估患者身体、意识、情感情况。如果有条件（机械通气＞48小时、ICU滞留时间＞72小时），推荐将其转入后续治疗程序中。
感谢支持
|
