严重脓毒症与脓毒性休克的若干治疗进展

严重脓毒症（severe sepsis）与脓毒性休克（septic shock）是内外科危重患者常见的并发症,全球每年有数百万人发病,且呈不断增长趋势,死亡率超过25％。面对严重脓毒症与脓毒性休克的挑战,2002年10月欧洲危重病医学会（ESICM）、美国危重病医学会（SC—CM）和国际脓毒症论坛（ISF）在西班牙巴塞罗那共同发起了拯救脓毒症的全球性行动倡议一拯救脓毒症战役（surviving sepsis campaign,SSC）,     

脓毒症的诊断与治疗

脓毒症（Sepsis）是危重患者最主要的死因之一。虽然近年来对于脓毒症及其并发症的认识和治疗研究有了很大进展，但脓毒症的病死率仍没有改善。2002年10月，欧洲危重病协会和国际脓毒症论坛提出了《巴塞罗那宣言》，共同呼吁采取措施减少脓毒症，争取在今后5年内将脓毒症的病死率降低25％。2004年美国胸科年会和欧洲呼吸病年会上，脓毒症再一次成为关注的热点问题。     

不同血流动力学参数联合指导脓毒性休克合并急性呼吸窘迫综合征目标导向性补液治疗对临床预后的影响

目的：探讨胸腔内血容量指数（ITBVI）、血管外肺水指数（EVLWI）、心指数（CI）等血流参数联合监测对老年脓毒性休克伴急性呼吸窘迫综合征（ARDS）患者进行目标导向性补液治疗的应用价值。方法：回顾性收集2017年4月-2018年7月柳州市人民医院收治的62例老年脓毒性休克伴ARDS患者临床资料,其中31例以中心静脉压（CVP）监测为指导行目标导向性补液治疗,为对照组;另31例行持续心输出量（PICCO）监测,以ITBVI、EVLWI、CI为指导进行补液治疗,为研究组,分析比较2组患者相关指标变化及疗效。结果：研究组患者补液治疗6、24h达标率显著高于对照组（77.42% vs 45.16%;93.55% vs 70.95%,P均＜0.05）,平均动脉压（MAP）、CVP、复苏液体量、每小时尿量显著高于对照组（P均＜0.05）;治疗72h,研究组序贯器官衰竭评分（SOFA）、急性生理与慢性健康状况评估（APACHEⅡ）评分及去甲肾上腺素剂量、血清乳酸、呼吸参数（呼气末正压、呼吸频率、顺应性、氧合指数）显著优于治疗24h,且显著优于对照组（P均＜0.05）;研究组治疗72h血肌酐显著低于对照组（P<0.05）;研究组机械通气率及28d病死率显著低于对照组（48.39% vs 74.19%; 12.90% vs 35.48%,P均＜0.05）,患者平均机械通气、住ICU时间显著短于对照组（P均＜0.05）。结论：ITBVI、EVLWI、CI联合监测指导老年脓毒性休克伴ARDS患者目标导向性补液治疗,有助于改善预后,降低患者病死率。     

氢化可的松联合维生素C、维生素B1治疗脓毒症疗效的Meta分析

背景维生素C与维生素B₁具有抗氧化作用,推测其与氢化可的松联合使用能产生协同效应,从而起到改善脓毒症或脓毒性休克患者免疫功能和减轻氧化应激的作用。有研究者基于此假设通过回顾性对照研究发现,此三联疗法能明显降低脓毒症患者病死率,但其后多篇随机对照研究对此治疗方案提出质疑。目的采用Meta分析评价氢化可的松联合维生素C、维生素B₁(HAT)治疗脓毒症的疗效。方法检索PubMed、Embase、Cochrane Library、Web of Science、中国知网、万方数据知识服务平台、中国生物医学文献服务系统及维普网自建库至2021-08-01发表的HAT治疗脓毒症的随机对照试验。对照组采用脓毒症集束化基础治疗,试验组在对照组基础上采用HAT治疗。主要观察指标为院内病死率,次要观察指标为72 h序贯器官衰竭估计评分变化值(72 hΔSOFA)、血管活性药物使用时间、急性肾损伤(AKI)发生率。由2名研究者独立进行文献筛选、资料提取,并采用Cochrane偏倚风险评估工具对纳入文献进行方法学质量评价。应用RevMan 5.3软件评估纳入文献的偏倚风险,应用R 3.6.2软件Meta包进行Meta分析。根据疾病类型将患者分为脓毒症、脓毒症和脓毒性休克、脓毒性休克3类,进行亚组分析。应用漏斗图和Egger检验评估纳入文献的发表偏倚。结果最终纳入文献10篇,共包含1611例患者,其中试验组805例、对照组806例。在随机序列产生、分配隐藏方面,7篇文献为低偏倚风险,2篇文献为高偏倚风险,1篇文献的偏倚风险不清楚;在对受试者、试验人员施盲及对结局评估员施盲、结果数据不完整、选择性报告研究结果、其他偏倚来源方面,10篇文献均为低偏倚风险。Meta分析结果显示:试验组与对照组院内病死率〔相对危险度(RR)=1.03,95%可信区间(CI)(0.92,1.15),P=0.65〕、AKI发生率〔RR=1.04,95%CI(0.89,1.21),P=0.70〕比较,差异无统计学意义;试验组72 hΔSOFA高于对照组〔标准均数差(SMD)=0.58,95%CI(0.09,1.07),P=0.02〕;试验组血管活性药物使用时间短于对照组〔SMD=-0.66,95%CI(-0.84,-0.47),P<0.0001〕。亚组分析结果显示:在脓毒症患者中,试验组院内病死率〔RR=0.27,95%CI(0.12,0.63),P=0.01〕、72 hΔSOFA〔SMD=0.95,95%CI(0.64,1.27),P=0.04〕、AKI发生率〔RR=0.32,95%CI(0.15,0.66),P<0.01〕低于对照组。在脓毒症和脓毒性休克患者中,试验组与对照组院内病死率〔RR=1.02,95%CI(0.89,1.18),P=0.09〕、72 hΔSOFA〔SMD=0.22,95%CI(-0.09,0.53),P=0.05〕、AKI发生率〔RR=1.05,95%CI(0.88,1.26),P=0.73〕比较,差异无统计学意义。在脓毒性休克患者中,试验组与对照组院内病死率〔RR=1.12,95%CI(0.91,1.38),P=0.31〕、72 hΔSOFA〔SMD=0.66,95%CI(-0.58,1.90),P=0.30〕、AKI发生率〔RR=1.25,95%CI(0.91,1.71),P=0.16〕比较,差异无统计学意义。漏斗图分析结果显示,HAT治疗脓毒症患者的院内病死率文献的漏斗图分布不对称。Egger检验结果显示,HAT治疗脓毒症患者的院内病死率文献存在发表偏倚(P=0.02),进一步利用剪补法进行矫正后结果显示,试验组与对照组院内病死率比较,差异无统计学意义〔RR=1.07,95%CI(0.84,1.38),P=0.57〕,提示文献原结果具有真实性。结论HAT可降低早期脓毒症患者的院内病死率及AKI发生率,缩短血管活性药物使用时间,改善其预后,但对于脓毒性休克患者的治疗效果有限。     

血浆人源性激肽释放酶结合蛋白水平对严重脓毒症患者预后评估的意义

目的:探讨血浆人源性激肽释放酶结合蛋白(Kal)水平对严重脓毒症患者预后评估的意义。方法:选择严重脓毒症和脓毒性休克患者88例。根据60 d后患者临床结局分为存活组(58例)和死亡组(30例)。比较2组患者在临床特征方面的差异,探讨Kal水平与各临床参数之间相关性及影响严重脓毒症和脓毒性休克患者预后的因素。结果:2组患者在年龄、急性呼吸窘迫综合征例数、脓毒性休克例数、APACHEⅡ评分、SOFA评分、ICU时间、机械通气时间、Kal水平、CRP水平方面差异显著(均P 0. 05)。Kal水平与年龄、急性呼吸窘迫综合征、有创机械通气、脓毒性休克、APACHEⅡ评分、SOFA评分、ICU时间、机械通气时间、CRP水平呈负相关(均P 0. 05)。APACHEⅡ评分高、SOFA评分高、Kal水平偏低、CRP水平偏高是影响严重脓毒症和脓毒性休克患者预后的危险性因素(均P 0. 05)。其中,入住ICU时血浆Kal水平4μg/mL提示患者预后差。结论:入住ICU时血浆Kal水平4μg/m L提示严重脓毒症和脓毒性休克患者预后不良,血浆Kal水平可作为严重脓毒症和脓毒性休克患者预后评估的重要指标。     

严重脓毒症和脓毒性休克的治疗新进展

一、严重脓毒症的流行和研究状况 脓毒症是指感染合并全身炎症反应,严重脓毒症是指脓毒症合并脓毒症诱导的器官功能障碍或组织低灌注。组织低灌注是指收缩压（SBP）〈90mmHg（1mmHg=0．133kPa）或平均动脉压〈70mmHg或收缩压下降〉40mmHg,或在缺乏其他低灌注原因下按年龄下降〉2个标准差,脓毒性休克是指在充分液体复苏后仍表现低灌注。脓毒症引起的组织低灌注的临床表现包括脓毒性休克、乳酸增高或少尿。     

重症肺炎合并糖尿病的抢救与治疗

糖尿病诊断依据2010年ADA糖尿病诊断标准[1]。重症肺炎诊断标准按美国感染疾病学会/国胸科学会(IDSA/ATS)于2007年制定的重症肺炎诊断标准[2],主要标准:①需要有创机械通气;②感染性休克需要血管收缩剂治疗;次要标准:①呼吸频率≥30次/分;②氧合指数(PaO2/FiO2)≤250;③多肺叶浸润;④意识障碍/定向障碍;⑤氮质血症(BUN≥     

糖尿病痛性神经病变的诊断与治疗

糖尿病痛性神经病变（PDN）是一种临床常见的感觉性周围神经病变,其中最常见的原因为远端对称性的多发性神经病变（DSPN）,PDN在糖尿病患者中的患病率达16％,而其中39％的患者未得到治疗[1].PDN发病机制复杂,临床表现多样,以肢体远端对称性的疼痛和夜间加重为突出特点,严重影响患者生活质量.针对该病的治疗主要以控制疼痛为主,目前有较多的临床试验对此进行研究.认识该病的临床特点,给予有效的药物治疗,有助于缓解症状,提高生活质量.     

晕厥的诊断与治疗概述

晕厥是一种常见的临床症状,其病因较多,机制复杂,常涉及多个学科。现结合自己的临床体会和近年来晕厥诊断与治疗的相关问题作一概述。1晕厥的诊断晕厥是一种临床症状,表现为突然、短暂的意识丧失,并能迅速、完全且无需外界干预而恢复意识。导致晕厥的病因     

咪达唑仑与异丙酚目标镇静对ICU机械通气患者心率变异性的影响

将全身麻醉术后行机械通气患者随机分成咪达唑仑 芬太尼组(MF组)和异丙酚 芬太尼组(PF组).全麻清醒时分别给予负荷剂量的不同镇静剂后,改用微量泵持续泵入镇静镇痛药物,根据脑电双频指数(BIS)调整用量达到目标镇静.用药即刻开始记录动态心电图及用药前后的心率(HR)、血压、脉搏血氧饱和度.结果 血流动力学、频域分析指标中,两组均表现为血压、总功率、低频(LF)、高频(HF)下降(P＜0.05),但MF组HR增快,LF/HF升高,而PF组HR减慢,LF/HF下降,两者间差异均有统计学意义(P＜0.05).两组时域指标分析,RR间期标准差随时间延长均显著降低(P＜0.05),相邻RR之差的均方根值仍在正常范围内.认为心率变异性分析可动态反映咪达唑仑和异丙酚镇静时患者自主神经的不同变化;ICU术后机械通气患者可根据病情选择镇静药物,以提高镇静治疗的安全性.     

The diagnosis and treatment of acute respiratory failure in sepsis.

Early diagnosis is mandatory in the adult respiratory distress syndromes, particularly in sepsis, and therapy should begin as soon as there is a reasonable suspicion that this problem is developing. Blood-gas changes cannot usually be appreciated clinically until the respiratory problem is quite severe. Accordingly, serial blood-gas analyses should be performed in any septic patient who has an increased chance of developing ARDS. Any deterioration in the patient's condition, blood gases, or ventilatory effort should be considered as an indication for early ventilatory assistance. Control of the primary process, high tidal volumes, PEEP, and careful dehydration are the mainstays of therapy. Serial blood gases and careful observation of the patient's effective compliance are essential to determine the optimal ventilator settings and the optimal PEEP. Early administration of massive steroids should be considered if the patient fails to respond to correction of the underlying etiologic problem (particularly sepsis), careful progressive dehydration, and optimal expansion of the alveoli (using high tidal volumes and/or PEEP).     

脓毒症合并肝损伤的诊断与治疗研究进展

脓毒症合并肝损伤是临床较常见的急危重症之一,是脓毒症导致多器官功能障碍的表现形式之一,尽早发现并给予干预和治疗,将可以有效减少住院时间和改善患者的预后。早期诊断、早期给予干预和治疗,在脓毒症合并肝损伤患者中显得尤为重要。然而如何早期诊断、早期治疗脓毒症合并肝损伤是临床医师经常面临的问题。该文就脓毒症合并肝损伤的诊断与治疗进展作一综述。     

New concepts in the pathogenesis, diagnosis and treatment of bacteremia and sepsis

Bacteremia and sepsis are major health concerns. Despite intensive research, there are only a limited number of successful treatment options, and it is difficult to see the forest for the trees when considering the pathogenesis of this condition. Studies in the last decade have shown that a major pathophysiologic event in sepsis is the progression from proinflammation to an immunosuppressive state. However, recent genome-based data indicate that sepsis-related inflammatory responses are highly variable, which calls in question the classic two-phase model of sepsis. Adequate and timely antimicrobial treatment is a cornerstone for survival in patients with bacteremia and sepsis. However, microbial resistance has emerged as an increasing challenge for clinicians and with an increasing number of resistant pathogens causing infections, selection of empiric antimicrobial treatment has become difficult. Treatment options currently under way are targeted to enhance immune responses, rebalance the regulation of the dysregulated immune system, remove endotoxin and block/inhibit apoptosis.     

The diagnosis and management of severe sepsis and septic shock.

Shock due to or associated with sepsis may present a clinical picture quite different from that usually seen in hypovolemic or cardiogenic shock. Any trend which suggests increasing sepsis should be treated aggressively as if shock were present. The earlier such therapy is begun, the better the results tend to be. Perhaps the greatest errors in the therapy of severe sepsis and septic shock are (1) delayed control of the primary septic process, (2) giving too little fluid in the early phases of therapy (and too much later), and (3) delaying ventilator assistance if the patient's ventilation or blood gases are deteriorating.     

脓毒症与高血糖及其治疗的研究进展

脓毒症及脓毒性休克是急危重症医学面临的重大难题,随着人口老龄化及医疗相关侵入性操作增加等,脓毒症的发病率逐渐增高。目前脓毒症的定义不仅局限于感染与全身炎症反应,更准确地强调机体对感染反应的失控及由此导致的器官功能障碍,其涉及的病理过程还包括神经内分泌、代谢障碍、凝血异常等非免疫方面。脓毒症及脓毒性休克的高血糖状态常见,高血糖得不到有效控制对患者预后不利。     

Rapid diagnosis of intravascular catheter-related sepsis

The use of Gram-stained "impression smears" of the external surface of intravascular catheters for rapid detection of catheter-associated infection was studied. Gram's stain results of 322 catheters were correlated with clinical episodes of systemic sepsis and semiquantitative cultures of the catheters. Organisms were seen on Gram's stain of 82 catheters, 37 of which were positive on semiquantitative cultures (greater than or equal to 15 colonies per plate). Catheter-related bacteremia occurred on three occasions. All three catheters showed numerous organisms on Gram's stain, although one was negative on semiquantitative culture. All five catheters, in place during bacteremic episodes that were unrelated to catheter infection, were negative on Gram's stain. If the presence of any organisms on Gram's stain was taken as a positive test result, the sensitivity of Gram's stain in predicting the result of semiquantitative culture was 83%, the specificity was 81%, and the predictive value of a positive and negative culture was 44% and 96%, respectively. Slides took two to five minutes to examine microscopically. Gram-stained impression smears of intravenous catheters can be made by a simple, inexpensive, and rapid technique that is accurate in diagnosing catheter-related infection. However, in this study in which a relatively low prevalence of catheter-related bacteremia occurred, the positive predictive value of the Gram's stain result in the diagnosis of catheter-related bacteremia, in contrast to catheter colonization, was low. Only in a patient group with a high prevalence of catheter-related bacteremia would the test be likely to have a high positive predictive value. Thus, selectivity should be exercised in the application of this method.     

Biomarkers: diagnosis and risk assessment in sepsis

Prompt diagnosis, intervention, and risk assessment are critical in caring for septic patient but remain difficult with currently available methods. Biomarkers may become useful adjuncts to clinicians and ultimately serve as targets for future therapeutic trials in sepsis. The most relevant markers are reviewed in this article, including interleukin-6, C-reactive protein, procalcitonin, triggering receptor expressed on myeloid cells-1, and biomarker panels.