Surviving Sepsis Guidelines 2016 改版摘要

初步復甦
3小時內給予 Crystalloid fluid ≥ 30 ml/kg
復甦目標 MAP > 65 mmHg, lactate 降至正常
EGDT, CVP, ScvO2 不再被建議用來評估復甦成效！
改以非侵入性動態指標監測

Initial Resuscitation
☑ Crystalloid fluid ≥ 30 ml/kg within the first 3 hrs
☐ Target MAP ≥ 65 mmHg
☐ Normalize lactate
☒ EGDT, CVP, ScvO2

Antimicrobial Therapy
☐ Empiric broad-spectrum antibiotics within 1 hr
☐ Procalcitonin to support the discontinuation of antibiotics

Fluid Therapy
☑ Crystalloids ± albumin
☒ HESs

Vasopressors
☑ Norepinephrine ± vasopressin or epinephrine

Corticosteroids
☐ Hydrocortisone 200 mg per day for refractory shock

Blood Products
☐ pRBC: Hb < 7
☐ platelet: 10K, 20K, 50K

Glucose Control
☐ Target blood glucose ≤ 180 mg/dl

Bicarbonate Therapy
☐ pH < 7 .15

Shock 的治療目標 Early goal-directed therapy

Early goal-directed therapy: do we have a definitive answer?
by Daniel De Backer| Jean-Louis Vincent

Early goal-directed therapy (EGDT) for the treatment of septic shock was first proposed in 2001 by Rivers et al. [1]. These authors reported that patients with hypotension refractory to a fluid challenge of 20–30 ml/kg of crystalloids over 30 min or with plasma lactate levels of at least 4 mEq/l and who were treated to restore and maintain a central venous oxygen saturation (ScvO2) of greater than 70 % had lower 28-day mortality rates than control patients (33 vs 49 %). That publication generated considerable enthusiasm but also much debate. The resuscitation protocol was incorporated into the Surviving Sepsis Campaign (SSC) guidelines [2] and several uncontrolled studies reported similar improvements in outcome [3–5]. However, concerns were raised about the single-center nature of the trial, the limited sample size (263 patients), the multiple interventions proposed in the EGDT package making it difficult to differentiate which was most effective, and the potential influence of confounding factors including the increased presence of doctors at the bedside of patients randomized to the intervention.
Three large-scale multicenter studies published in 2014 and 2015 [6–8] were unable to replicate the results of the Rivers study, but is there a plausible explanation for this? Among the important differences between the trials, the mortality rate in the control groups in the recent trials was markedly lower than that in the Rivers study (Table 1). In addition, ScvO2 values in the study groups were markedly reduced (to an average of 49 %) in the Rivers trial but were already within the greater than 70 % target zone in the three other trials. One explanation may be that Rivers et al. treated a special patient population with severe comorbidities and/or who presented quite late to the emergency department. Another possible explanation is that there has been a marked improvement in prehospital and initial care of patients with septic shock, maybe as a direct result of the Rivers trial and the SSC guidelines. However, adequacy of antibiotic treatment and amounts of fluid administered prior to randomization do not seem to account for these differences (Table 1).
...
This patient selection issue does not challenge the internal validity of these recent trials, but clearly raises questions about their external validity. These trials have indicated that patients with low severity septic shock who rapidly respond to therapy do not benefit from routine EGDT. However, the results of the Rivers trial have not been invalidated as patients with high disease severity and low ScvO2 were not included in these recent trials. EGDT may still be beneficial in the most severely ill patients, especially when less experienced staff who may appreciate using simple protocols are in charge.

http://bit.ly/22uWfBQ

加護病房查房日誌20141119
今天早上和一個學長聊到小小公主的事情，老師說: 我很開心，很期待，老實說: 沒有想到太多會很累等等的問題。就連現在要買小小公主的東西，雖然花很多錢，不過一想到她的笑容，很多事情都是值得的。有沒有同學推薦去L.A.可以去那裏買阿，老師12月去開會，想順便去逛逛。
我們回到敗血性休克的治療，之前講完給水，給升壓劑，今天來談談其他額外的治療: 強心劑(inotropic therapy)和red blood cell transfusion(輸紅血球)。
這類治療主要是要增加心臟輸出以改善組織灌流和提高中央靜脈氧飽和度，使ScvO2 >= 70%。UpToDate上是建議用於經過給水和升壓劑後，難治型的敗血性休克和ScvO2 < 70%。
來強心劑常用的是那一種?
Dobutamine，沒錯，不過要注意一點，他在低劑量的時候會降血壓，原因是他在周邊的效果會使得血管擴張。然而當劑量增加時，增加心收縮力的效果就會大過於周邊血管擴張的效果了。
基本上輸血的部分，會希望Hb >= 7 g/dL，主要是根據一些研究和準則而建議的。研究發現Hb < 7 vs. <9輸血，在28天的死亡率是沒有差別的。嚴格限制輸血，當然可減少輸血的量，而且也沒有增加缺血事件的發生。
下次我們來講early goal-directed therapy的目標，知道的同學也可以先講喔。