以下內(nèi)容來(lái)自Surviving Sepsis Campaign網(wǎng)站

（本平臺(tái)email:zg_zzyx@163.com，微信號(hào)：blue533007）

根據(jù)新證據(jù)對(duì)集束化治療措施的更新

(Updated Bundles in Response to New Evidence)

自從成立以來(lái)，拯救全身性感染行動(dòng)(SSC)委員會(huì)就相信，隨著新證據(jù)不斷出現(xiàn)，我們對(duì)于如何為嚴(yán)重全身性感染和感染性休克患者提供最佳治療的認(rèn)識(shí)也更為深入，SSC指南以及行為改進(jìn)指標(biāo)(1)也應(yīng)當(dāng)相應(yīng)改變。

The leadership of the Surviving Sepsis Campaign (SSC) has believed since its inception that both the SSC Guidelines and the SSC performance improvement indicators (1) will evolve as new evidence that improves our understanding of how best to care for patients with severe sepsis and septic shock becomes available.

近期發(fā)表的三項(xiàng)臨床試驗(yàn)(2,3,4)發(fā)現(xiàn)，對(duì)于那些已經(jīng)接受及時(shí)抗生素治療和液體復(fù)蘇的感染性休克患者，或者對(duì)于所有乳酸水平> 4 mmol/L的患者，與對(duì)照組相比，使用中心靜脈導(dǎo)管(CVC)監(jiān)測(cè)中心靜脈壓(CVP)和中心靜脈血氧飽和度(ScvO2)未能顯示任何優(yōu)勢(shì)。因此，SSC執(zhí)行委員會(huì)對(duì)集束化治療進(jìn)行了如下改動(dòng)：

With publication of 3 trials (2,3,4) that do not demonstrate superiority of required use of a central venous catheter (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (ScvO2) in all patients with septic shock who have received timely antibiotics and fluid resuscitation compared with controls or in all patients with lactate >4 mmol/L, the SSC Executive Committee has revised the improvement bundles as follows:

就診3小時(shí)內(nèi)必須完成的項(xiàng)目*

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:

1. 測(cè)定乳酸水平(Measure lactate level)

2. 在應(yīng)用抗生素前留取血培養(yǎng)(Obtain blood cultures prior to administration of antibiotics)

3. 應(yīng)用廣譜抗生素(Administer broad spectrum antibiotics)

4. 對(duì)于低血壓或乳酸水平≥ 4 mmol/L的患者輸注晶體液30 ml/kg (Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L)

*“Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

*“就診時(shí)間”定義為急診分診的時(shí)間，或者，如果為其他就診途徑，則病歷中最早記錄符合嚴(yán)重全身性感染或感染性休克所有表現(xiàn)的時(shí)間。

就診6小時(shí)內(nèi)必須完成的項(xiàng)目

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:

5. 應(yīng)用升壓藥物（對(duì)初始液體復(fù)蘇治療無(wú)反應(yīng)的低血壓）以維持平均動(dòng)脈壓(MAP) ≥ 65 mmHg (Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg)

6. 如果初始液體復(fù)蘇治療后仍有持續(xù)低血壓(MAP < 65 mmHg)或初始乳酸≥ 4 mmol/L，應(yīng)重新評(píng)估容量狀態(tài)及組織灌注指標(biāo)，并根據(jù)表1記錄相應(yīng)發(fā)現(xiàn)(In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1).

7. 如果初始乳酸水平升高，應(yīng)重新評(píng)估(Re-measure lactate if initial lactate elevated).

表1 (TABLE 1)

對(duì)容量狀態(tài)及組織灌注進(jìn)行重新評(píng)估并記錄(DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH):

或(EITHER)

· 由有資質(zhì)的醫(yī)生重復(fù)進(jìn)行針對(duì)性體格檢查（在初始液體復(fù)蘇治療后），包括生命體征、心肺、毛細(xì)血管再充盈時(shí)間、脈搏及皮膚(Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings)

或以下2項(xiàng)指標(biāo)(OR TWO OF THE FOLLOWING):

· 測(cè)定CVP (Measure CVP)

· 測(cè)定ScvO2 (Measure ScvO2)

· 床旁心血管超聲檢查(Bedside cardiovascular ultrasound)

· 通過(guò)被動(dòng)抬腿試驗(yàn)或液體負(fù)荷試驗(yàn)動(dòng)態(tài)評(píng)估液體反應(yīng)性(Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge)

值得注意的是，我們對(duì)6小時(shí)的集束化治療措施進(jìn)行了更新；但3小時(shí)SSC集束化治療措施并未改變。

Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected.

盡管任何試驗(yàn)均未提示使用中心靜脈導(dǎo)管導(dǎo)致對(duì)患者的危害，已經(jīng)發(fā)表的證據(jù)顯示采用SSC集束化治療能夠顯著降低病死率(5)，但是委員會(huì)仍對(duì)現(xiàn)有資料采取了謹(jǐn)慎的態(tài)度，考慮到所有研究存在的局限性，委員會(huì)認(rèn)為上述集束化治療是目前最適宜的治療措施。

While no suggestion of harm was indicated with use of a central line in any trial, and published evidence shows significant mortality reduction using the original SSC bundles (5), the committee has taken a prudent look at all current data and, despite weaknesses as in all studies, determined the above bundles to be the appropriate approach at this time.

參考文獻(xiàn)(References):

1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637

2. ProCESS Investigators, Yealy DM, Kellum JA, Juang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370(18):1683-1693

3. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496-1506

4. Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015: DOI: 10.1056/NEJMoa1500896

5. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5 –year study. Intensive Care Med 2014; 40: 1623-1633