重癥醫(yī)學(xué)科

正常胰腺CT急性胰腺炎CT balthazar分級(jí)A級(jí)：胰腺及胰周脂肪顯示正常 0分B級(jí)：胰腺局部或普遍增大，胰腺輪廓不規(guī)則，胰周脂肪層尚正常，未見胰周滲液 1分C級(jí)：胰腺腫大，炎癥累積胰周，表現(xiàn)為胰周脂肪層模糊呈網(wǎng)狀或條索狀水腫或脂肪層消失 2分D級(jí)：除上述表現(xiàn)外，胰周有單個(gè)胰液儲(chǔ)留或有蜂窩織炎 3分E級(jí)：胰周兩個(gè)或兩個(gè)以上區(qū)域胰液儲(chǔ)留，或胰內(nèi)或以外氣體出現(xiàn)，或膿腫形成 4分

10月9日，70歲的潘爹爹因腹脹1周住進(jìn)漢川市人民醫(yī)院消化內(nèi)科，隨后出現(xiàn)血壓低、白細(xì)胞高，生命體征極不穩(wěn)定，經(jīng)會(huì)診后以“感染性休克”轉(zhuǎn)入重癥醫(yī)學(xué)科緊急救治。潘爹爹有高血壓病史多年，2021年因冠心病植入了6枚支架，同時(shí)還存在腎功能不全和嚴(yán)重貧血，情況十分危險(xiǎn)。在武漢大學(xué)人民醫(yī)院重癥醫(yī)學(xué)科王常永教授的指導(dǎo)下，科室醫(yī)護(hù)給予建立中心靜脈通路、補(bǔ)液、抗感染、輸血、利尿、營(yíng)養(yǎng)支持、臟器保護(hù)等治療，患者轉(zhuǎn)危為安，轉(zhuǎn)入腎病內(nèi)科繼續(xù)治療。然而，重癥患者的救治并非一帆風(fēng)順。轉(zhuǎn)入腎病內(nèi)科后，潘爹爹再次出現(xiàn)了發(fā)熱和休克，同時(shí)還出現(xiàn)了腎功能惡化和急性呼吸窘迫綜合征（ARDS）。經(jīng)過仔細(xì)檢查和認(rèn)真分析，王常永教授考慮患者再次出現(xiàn)休克的原因可能是肺部感染，而非之前的血流感染。經(jīng)胸部CT檢查后，王常永教授分析患者肺部感染很有可能由病毒引起，檢驗(yàn)結(jié)果再次證實(shí)了王常永教授的論斷。醫(yī)護(hù)人員給予對(duì)癥的血液凈化、抗感染、精準(zhǔn)補(bǔ)液、輸血、營(yíng)養(yǎng)支持、臟器保護(hù)等治療后，患者的病情逐漸好轉(zhuǎn)。重癥的治療環(huán)境相對(duì)封閉，隨著治療時(shí)間的延長(zhǎng)，積極樂觀的潘爹爹開始變得有些沮喪，極不配合治療。重癥醫(yī)學(xué)科醫(yī)護(hù)團(tuán)隊(duì)在積極救治潘爹爹的同時(shí)，經(jīng)常在床邊給予鼓勵(lì)，患者的情緒狀態(tài)有所好轉(zhuǎn)。病原菌的檢查和治療是重癥患者治療的重要一環(huán)。在潘爹爹的治療過程中，培養(yǎng)出了許多病原菌，有細(xì)菌、真菌，還有不少是耐藥病菌，如何精準(zhǔn)施治是十分棘手的問題。王常永教授結(jié)合最新的指南和豐富的臨床經(jīng)驗(yàn)，揭開層層迷霧，揪出“真兇”，為患者制定了精準(zhǔn)的治療方案，使感染迅速得到了控制。潘爹爹在重癥醫(yī)學(xué)科治療過程中經(jīng)歷感染性休克、腎功能衰竭、ARDS、多重耐藥菌感染等，在醫(yī)護(hù)人員的共同努力下，經(jīng)過一個(gè)月的拼搏，重獲新生，于11月2日轉(zhuǎn)出ICU，在普通病房繼續(xù)治療。漢川市人民醫(yī)院是武漢大學(xué)人民醫(yī)院的托管醫(yī)院，也是重癥醫(yī)學(xué)科?？坡?lián)盟單位，在武漢大學(xué)人民醫(yī)院重癥醫(yī)學(xué)科詹麗英主任團(tuán)隊(duì)的支持和幫助下，漢川醫(yī)院重癥患者的救治更為科學(xué)、精準(zhǔn)，重癥患者的救治成功率也有了明顯提高，遇到救治難度大的患者，及時(shí)轉(zhuǎn)到武漢大學(xué)人民醫(yī)院重癥醫(yī)學(xué)科救治，實(shí)現(xiàn)救治無縫對(duì)接，大大提高了危重患者的救治成功率。轉(zhuǎn)載：http://hanchuan.cjyun.org/p/94482.htmlhttps://news.hubeidaily.net/pc/c_1953424.html

膿毒癥篩查和早期診治Forhospitalsandhealthsystems,werecommendusingaperformanceimprovementprogrammeforsepsis,includingsepsisscreeningforacutelyill,high?riskpatientsandstandardoperatingproceduresfortreatment.對(duì)于醫(yī)療機(jī)構(gòu)，推薦制定流程，以便能夠快速識(shí)別、標(biāo)準(zhǔn)化救治膿毒癥患者。WerecommendagainstusingqSOFAcomparedtoSIRS,NEWS,orMEWSasasinglescreeningtoolforsepsisorsepticshock.不推薦單獨(dú)使用qSOFA評(píng)分來篩查膿毒癥、膿毒癥休克。Foradultssuspectedofhavingsepsis,wesuggestmeasuringbloodlactate.懷疑膿毒癥，推薦監(jiān)測(cè)血乳酸。Sepsisandsepticshockaremedicalemergencies,andwerecommendthattreatmentandresuscitationbeginimmediately.膿毒癥和膿毒癥休克情況緊急，需要立即救治。Forpatientswithsepsisinducedhypoperfusionorsepticshockwesuggestthatatleast30mL/kgofintravenous(IV)crystalloidfuidshouldbegivenwithinthefrst3hofresuscitation.伴有低血壓、膿毒癥休克的膿毒癥患者，推薦3小時(shí)內(nèi)給予至少30ml/kg的晶體液。Foradultswithsepsisorsepticshock,wesuggestusingdynamicmeasurestoguidefuidresuscitation,overphysicalexaminationorstaticparametersalone.對(duì)于膿毒癥和膿毒癥休克的患者，推薦動(dòng)態(tài)監(jiān)測(cè)患者相關(guān)指標(biāo)來評(píng)估液體復(fù)蘇情況，不能單獨(dú)依賴一個(gè)靜態(tài)指標(biāo)或體格檢查。Foradultswithsepsisorsepticshock,wesuggestguidingresuscitationtodecreaseserumlactateinpatientswithelevatedlactatelevel,overnotusingserumlactate.對(duì)于膿毒癥或膿毒癥休克患者來說，如果乳酸升高，推薦動(dòng)態(tài)監(jiān)測(cè)乳酸，進(jìn)行休克復(fù)蘇來降低乳酸水平，而不是不看血清乳酸水平。Foradultswithsepticshock,wesuggestusingcapillaryreflltimetoguideresuscitationasanadjuncttoothermeasuresofperfusion.推薦使用毛細(xì)血管充盈時(shí)間作為復(fù)蘇指標(biāo)。Foradultswithsepticshockonvasopressors,werecommendaninitialtargetmeanarterialpressure(MAP)of65mmHgoverhigherMAPtargets.對(duì)于膿毒癥休克患者來說，推薦初始MAP目標(biāo)為≥65mmHg。ForadultswithsepsisorsepticshockwhorequireICUadmission,wesuggestadmittingthepatientstotheICUwithin6h.推薦膿毒癥或膿毒癥休克患者，如需ICU救治，在6小時(shí)內(nèi)轉(zhuǎn)入ICU。診治感染Foradultswithsuspectedsepsisorsepticshockbutunconfrmedinfection,werecommendcontinuouslyre-evaluatingandsearchingforalternativediagnosesanddiscontinuingempiricantimicrobialsifanalternativecauseofillnessisdemonstratedorstronglysuspected.懷疑膿毒癥或膿毒癥休克，但沒有明確感染，推薦持續(xù)評(píng)估、尋找其他診斷，如果不存在感染，撤除需廣譜抗生素?？股貢r(shí)間Foradultswithpossiblesepticshockorahighlikelihoodforsepsis,werecommendadministeringantimicrobialsmmediately,ideallywithin1hofrecognition.如果患者是感染引起的膿毒癥或膿毒癥休克（或高度懷疑），需要盡快給予抗生素，理想狀態(tài)下，應(yīng)當(dāng)1小時(shí)內(nèi)使用抗生素。Foradultswithpossiblesepsiswithoutshock,werecommendrapidassessmentofthelikelihoodofinfectiousversusnon?infectiouscausesofacuteillness.懷疑膿毒癥但沒有休克的患者，推薦評(píng)估感染、非感染疾病。Foradultswithpossiblesepsiswithoutshock,wesuggestatime?limitedcourseofrapidinvestigationandifconcernforinfectionpersists,theadministrationofantimicrobialswithin3hfromthetimewhensepsiswasfirstrecognised.懷疑膿毒癥但沒有休克的患者，應(yīng)當(dāng)快速展開診治。如果考慮存在持續(xù)的感染，應(yīng)當(dāng)在考慮膿毒癥診治之后的3小時(shí)內(nèi)給予抗生素。Foradultswithalowlikelihoodofinfectionandwithoutshock,wesuggestdeferringantimicrobialswhilecontinuingtocloselymonitorthepatient.如果患者膿毒癥概率很小且沒有感染，建議無需使用抗生素，同時(shí)嚴(yán)密監(jiān)測(cè)患者狀態(tài)?？股厥褂蒙飿?biāo)志物Foradultswithsuspectedsepsisorsepticshock,wesuggestagainstusingprocalcitoninplusclinicalevaluationtodecidewhentostartantimicrobials,ascomparedtoclinicalevaluationalone.對(duì)于懷疑膿毒癥、膿毒癥休克的患者，不要依據(jù)降鈣素原和臨床評(píng)估來決定啟用抗生素，也不能單獨(dú)依賴臨床評(píng)估?？股剡x擇Foradultswithsepsisorsepticshockathighriskofmethicillinresistantstaphaureus(MRSA),werecommendusingempiricantimicrobialswithMRSAcoverageoverusingantimicrobialswithoutMRSAcoverage.對(duì)于MRSA高危的膿毒癥、膿毒癥休克患者，推薦初始抗生素覆蓋MRSA。Foradultswithsepsisorsepticshockatlowriskofmethicillinresistantstaphaureus(MRSA),wesuggestagainstusingempiricantimicrobialswithMRSAcoverage,ascomparedwithusingantimicrobialswithoutMRSAcoverage.對(duì)于無MRSA高危的膿毒癥、膿毒癥休克患者，不推薦初始抗生素覆蓋MRSA。Foradultswithsepsisorsepticshockandhighriskformultidrugresistant(MDR)organisms,wesuggestusingtwoantimicrobialswithgram?negativecoverageforempirictreatmentoveronegram?negativeagent.對(duì)于MDR高?；颊?，推薦使用兩種可覆蓋G-菌的抗生素，而不是單獨(dú)用藥。ForadultswithsepsisorsepticshockandlowriskforMDRorganisms,wesuggestagainstusingtwoGram?negativeagentsforempirictreatment,ascomparedtooneGram?negativeagen.對(duì)于無MDR高危的患者，不推薦聯(lián)合用藥。Foradultswithsepsisorsepticshock,wesuggestagainstusingdoublegram?negativecoverageoncethecausativepathogenandthesusceptibilitiesareknown.當(dāng)病原菌明確、藥敏明確，不推薦聯(lián)合用藥?？拐婢委烣oradultswithsepsisorsepticshockathighriskoffungalinfection,wesuggestusingempiricantifungaltherapyovernoantifungaltherapy.如果患者真菌感染高危，推薦初始廣譜抗真菌治療。Foradultswithsepsisorsepticshockatlowriskoffungalinfection,wesuggestagainstempiricuseofantifungaltherapy.如果不存在真菌感染高危，不推薦初始抗真菌治療?？共《舅幬颳emakenorecommendationontheuseofantiviralagents.關(guān)于抗病毒藥物，無法形成推薦。抗生素使用Foradultswithsepsisorsepticshock,wesuggestusingprolongedinfusionofbeta?lactamsformaintenance(afteraninitialbolus)overconventionalbolusinfusion.對(duì)于膿毒癥、膿毒癥休克患者，使用β內(nèi)酰胺抗生素建議延長(zhǎng)輸注時(shí)間（初始快速使用后）。藥效學(xué)和藥代動(dòng)力學(xué)Foradultswithsepsisorsepticshock,werecommendoptimisingdosingstrategiesofantimicrobialsbasedonacceptedpharmacoki?netic/pharmacodynamic(PK/PD)principlesandspecifcdrugproperties.推薦使用PK/PD原理、依據(jù)抗生素特性，優(yōu)化抗生素治療。感染源控制Foradultswithsepsisorsepticshock,werecommendrapidlyidentifingorexcludingaspecifcanatomicaldiagnosisofinfectionthatrequiresemergentsourcecontrolandimplementinganyrequiredsourcecontrol?interventionassoonasmedicallyandlogisticallypractical.對(duì)于膿毒癥、膿毒癥休克的患者，應(yīng)當(dāng)快速尋找感染源，并控制感染病灶。Foradultswithsepsisorsepticshock,werecommendpromptremovalofintravascularaccessdevicesthatareapossiblesourceofsepsisorsepticshockafterothervascularaccesshasbeenestablished.膿毒癥、膿毒癥休克患者如果考慮有導(dǎo)管相關(guān)的感染，應(yīng)當(dāng)建立新的導(dǎo)管，并移除感染導(dǎo)管。Foradultswithsepsisorsepticshock,wesuggestdailyassessmentforde?escalationofantimicrobialsoverusingfxeddurationsoftherapywithoutdailyreassessmentforde?escalation.推薦每日評(píng)估抗生素降階梯策略。抗生素療程Foradultswithaninitialdiagnosisofsepsisorsepticshockandadequatesourcecontrol,wesuggestusingshorteroverlongerdurationofantimicrobialtherapy.膿毒癥休克、膿毒癥患者，在充分感染灶控制情況下，推薦短程抗生素療程。終止抗生素的標(biāo)志物Foradultswithaninitialdiagnosisofsepsisorsepticshockandadequatesourcecontrolwhereoptimaldurationoftherapyisunclear,wesuggestusingprocalcitoninANDclinicalevaluationtodecidewhentodiscontinueantimicrobialsoverclinicalevaluationalone.膿毒癥、膿毒癥休克患者感染控制足夠的情況下，但無法明確最佳抗生素療程，推薦參考降鈣素原和臨床情況來決定抗生素使用，而不是單獨(dú)依賴臨床情況。血流動(dòng)力學(xué)監(jiān)測(cè)Foradultswithsepsisorsepticshock,werecommendusingcrystaloidsasfrst-linefuidforresuscitation.推薦晶體液為復(fù)蘇首選液體。Foradultswithsepsisorsepticshock,wesuggestusingbalancedcrystalloidsinsteadofnormalsalineforresuscitation推薦使用平衡液來液體復(fù)蘇，而不是生理鹽水。Foradultswithsepsisorsepticshock,wesuggestusingalbumininpatientswhoreceivedlargevolumesofcrystalloidsoverusingcrystaloidsalone需要大量晶體液的時(shí)候，推薦聯(lián)合白蛋白。Foradultswithsepsisorsepticshock,werecommendagainstusingstarchesforresuscitation不推薦使用羥乙基淀粉復(fù)蘇。Foradultswithsepsisandsepticshock,wesuggestagainstusinggelatinforresuscitation不推薦使用明膠復(fù)蘇。血管活性藥物Foradultswithsepticshock,werecommendusingnorepinephrineasthefrst?lineagentoverothervasopressors.推薦一線藥物為去甲腎上腺素。ForadultswithsepticshockonnorepinephrinewithinadequateMAPlevels,wesuggestaddingvasopressininsteadofescalatingthedoseofnorepinephrine.當(dāng)單獨(dú)使用去甲腎上腺素血壓無法維持的時(shí)候，推薦加用血管加壓素，而不是一味的加用去甲腎上腺素?！救ゼ啄I上腺素范圍0.25–0.5μg/kg/min，可加用血管加壓素】ForadultswithsepticshockandinadequateMAPlevelsdespitenorepinephrineandvasopressin,wesuggestaddingepinephrine去甲腎上腺素聯(lián)合血管加壓素仍無法維持血壓，推薦加用腎上腺素。Foradultswithsepticshock,wesuggestagainstusingterlipressin不推薦使用特立加壓素。強(qiáng)心藥Foradultswithsepticshockandcardiacdysfunctionwithpersistenthypoperfusiondespiteadequatevolumestatusandarterialbloodpressure,wesuggesteitheraddingdobutaminetonorepinephrineorusingepinephrinealone存在膿毒癥休克和心功能不全的時(shí)候，可使用去甲腎上腺素聯(lián)合多巴酚丁胺或單獨(dú)使用腎上腺素。Foradultswithsepticshockandcardiacdysfunctionwithpersistenthypoperfusiondespiteadequatevolumestatusandarterialbloodpresure,wesuggestagainstusinglevosimendan存在膿毒癥休克和心功能不全的時(shí)候，充足液體復(fù)蘇后，仍無法維持血壓，不推薦使用左西孟旦。監(jiān)測(cè)Foradultswithsepticshock,wesuggestusinginvasivemonitoringofarterialbloodpressureovernon?invasivemonitoring,assoonaspracticalandifresourcesareavailable推薦侵襲性監(jiān)測(cè)手段（有創(chuàng)動(dòng)脈壓監(jiān)測(cè)）Foradultswithsepticshock,wesuggeststartingvasopressorsperipherallytorestoreMAPratherthandelayinginitiationuntilacentralvenousaccessissecured推薦在中心靜脈未建立的時(shí)候，外周使用血管活性藥物，而不是等待建立中心靜脈。液體平衡Thereisinsufcientevidencetomakearecommendationontheuseofrestrictiveversusliberalfuidstrategiesinthefrst24hofresus?citationinpatientswithsepsisandsepticshockwhostillhavesignsofhypoperfusionandvolumedepletionafterinitialresuscitation關(guān)于液體復(fù)蘇方面，24小時(shí)內(nèi)的時(shí)候，無法推薦是采用限制性液體復(fù)蘇還是開放式液體復(fù)蘇。氧合目標(biāo)Thereisinsufcientevidencetomakearecommendationontheuseofconservativeoxygentargetsinadultswithsepsis?inducedhypoxemicrespiratoryfailure對(duì)于膿毒癥誘發(fā)的呼吸衰竭，關(guān)于氧目標(biāo)，無法形成推薦。高流量氧療Foradultswithsepsis?inducedhypoxemicrespiratoryfailure,wesuggesttheuseofhighfownasaloxygenovernon?invasiveventilation針對(duì)膿毒癥誘發(fā)的低氧血癥，推薦高流量吸氧。無創(chuàng)通氣Thereisinsufcientevidencetomakearecommendationontheuseofnon?invasiveventilationincomparisontoinvasiveventilationforadultswithsepsis?inducedhypoxemicrespiratoryfailure無創(chuàng)通氣和有創(chuàng)通氣相比，治療膿毒癥誘發(fā)的低氧血癥方面，無法形成推薦。ARDS的保護(hù)性肺通氣Foradultswithsepsis?inducedARDS,werecommendusingalowtidalvolumeventilationstrategy(6mL/kg),overahightidalvolumestrategy(>10mL/kg)推薦膿毒癥誘發(fā)的ARDS使用保護(hù)性肺通氣策略，使用小潮氣量（6ml/kg）。Foradultswithsepsis?inducedsevereARDS,werecommendusinganupperlimitgoalforplateaupressuresof30cmH2O,overhigherplateaupressures推薦膿毒癥誘發(fā)的ARDS，控制平臺(tái)壓≤30cmH2O。Foradultswithmoderatetoseveresepsis?inducedARDS,wesuggestusinghigherPEEPoverlowerPEEP對(duì)于膿毒癥誘發(fā)的ARDS，如果中重度的，推薦高PEEP。非ARDS患者小潮氣量Foradultswithsepsis?inducedrespiratoryfailure(withoutARDS),wesuggestusinglowtidalvolumeascomparedtohightidalvolumeventilation膿毒癥誘發(fā)的低氧血癥但無法診斷ARDS，推薦低潮氣量。肺復(fù)張F(tuán)oradultswithsepsis?inducedmoderate?severeARDS,wesuggestusingtraditionalrecruitmentmaneuvers對(duì)于膿毒癥誘發(fā)的ARDS，推薦肺復(fù)張。Whenusingrecruitmentmaneuvers,werecommendagainstusingincrementalPEEPtitration/strategy如果進(jìn)行肺復(fù)張，不推薦使用PEEP遞增法。俯臥位Foradultswithsepsis?inducedmoderate?severeARDS,werecommendusingproneventilationformorethan12hdaily中重度ARDS，每日俯臥位大于12小時(shí)。肌肉松弛藥物Foradultswithsepsisinducedmoderate?severeARDS,wesuggestusingintermittentNMBAboluses,overNMBAcontinuousinfusion中重度ARDS，推薦間歇NMBA應(yīng)用，而不是持續(xù)輸注。ECMOForadultswithsepsis?inducedsevereARDS,wesuggestusingveno?venous(VV)ECMOwhenconventionalmechanicalventilationfailsinexperiencedcenterswiththeinfrastructureinplacetosupportitsuse如果常規(guī)支持治療無效，推薦ARDS患者使用VV-ECMO，但需要在有經(jīng)驗(yàn)的中心進(jìn)行，有配套設(shè)施。激素ForadultswithsepticshockandanongoingrequirementforvasopressortherapywesuggestusingIVcorticosteroids膿毒癥休克和持續(xù)使用血管活性藥物的患者，推薦靜脈使用皮質(zhì)醇。【去甲腎上腺素≥0.25mcg/kg/min且維持4小時(shí)的時(shí)候，可使用氫化可的松200mg持續(xù)泵入或50mgQ6H】血液凈化Foradultswithsepsisorsepticshock,wesuggestagainstusingpolymyxinBhaemoperfusion不推薦血液灌流；Thereisinsufcientevidencetomakearecommendationontheuseofotherbloodpurifcationtechniques其他血液凈化技術(shù)無法形成推薦。紅細(xì)胞Foradultswithsepsisorsepticshock,werecommendusingarestric?tive(overliberal)transfusionstrategy推薦限制性紅細(xì)胞輸注（70g/L足夠，但仍需要綜合評(píng)估心功能等指標(biāo)）。免疫球蛋白Foradultswithsepsisorsepticshock,wesuggestagainstusingintravenousimmunoglobulins不推薦使用免疫球蛋白。應(yīng)激性潰瘍Foradultswithsepsisorsepticshock,andwhohaveriskfactorsforgastrointestinal(GI)bleeding,wesuggestusingstressulcerprophylaxis推薦預(yù)防應(yīng)激性潰瘍。深靜脈血栓Foradultswithsepsisorsepticshock,werecommendusingpharmacologicVTEprophylaxisunlessacontraindicationtosuchtherapyexists推薦藥物預(yù)防VTE，除非有禁忌癥。Foradultswithsepsisorsepticshock,werecommendusinglowmolecularweightheparin(LMWH)overunfractionatedheparin(UFH)forVTEprophylaxis推薦使用低分子肝素，而不是普通肝素，來預(yù)防深靜脈血栓。Foradultswithsepsisorsepticshock,wesuggestagainstusingmechanicalVTEprophylaxisinadditiontopharmacologicalprophy?laxis,overpharmacologicprophylaxisalone不推薦使用機(jī)械性聯(lián)合低分子肝素來防治VTE。腎臟替代InadultswithsepsisorsepticshockandAKIwhorequirerenalreplacementtherapy,wesuggestusingeithercontinuousorintermitentrenalreplacementtherapy對(duì)于膿毒癥、膿毒癥休克合并AKI的，推薦持續(xù)腎臟替代或間歇腎臟替代。InadultswithsepsisorsepticshockandAKI,withnodefnitiveindicationsforrenalreplacementtherapy,wesuggestagainstusingrenalreplacementtherapy對(duì)于膿毒癥、膿毒癥休克合并AKI的，沒有明確腎臟替代指征的，不推薦腎臟替代治療。血糖控制Foradultswithsepsisorsepticshock,werecommendinitiatinginsulintherapyataglucoselevelof≥180mg/dL(10mmol/L)推薦控制血糖，在血糖大于10mmol/l的時(shí)候，使用胰島素【維持8–10mmol/L】。維生素CForadultswithsepsisorsepticshock,wesuggestagainstusingIVvitaminC對(duì)于膿毒癥、膿毒癥休克的患者，不推薦靜脈使用VC。碳酸氫鈉Foradultswithsepticshockandhypoperfusion?inducedlacticacidemia,wesuggestagainstusingsodiumbicarbonatetherapytoimprovehaemodynamicsortoreducevasopressorrequirements對(duì)于膿毒癥誘導(dǎo)的或低血壓誘導(dǎo)的乳酸酸中毒，不推薦使用碳酸氫鈉來提高血流動(dòng)力學(xué)或減少血管活性藥物的使用劑量。Foradultswithsepticshock,severemetabolicacidemia(pH≤7.2)andAKI(AKINscore2or3),wesuggestusingsodiumbicarbonatetherapy當(dāng)患者因?yàn)樾菘嘶駻KI出現(xiàn)代謝性酸中毒的時(shí)候，如果ph≤7.2，體檢使用碳酸氫鈉。營(yíng)養(yǎng)Foradultpatientswithsepsisorsepticshockwhocanbefedenterally,wesuggestearly(within72h)initiationofenteralnutrition對(duì)于膿毒癥、膿毒癥休克的患者來說，如果能夠進(jìn)行腸內(nèi)營(yíng)養(yǎng)，推薦早期腸內(nèi)支持（72小時(shí)內(nèi)）。治療目標(biāo)Foradultswithsepsisorsepticshock,werecommenddiscussinggoalsofcareandprognosiswithpatientsandfamiliesovernosuchdiscussion推薦同患者及家屬討論治療目標(biāo)和預(yù)后。Foradultswithsepsisorsepticshock,wesuggestaddressinggoalsofcareearly(within72h)overlate推薦早期制定治療目標(biāo)（72小時(shí)內(nèi)）Thereisinsufcientevidencetomakearecommendationforanyspecifcstandardisedcriteriontotriggergoalsofcarediscussion對(duì)特異性標(biāo)準(zhǔn)來啟動(dòng)救治目標(biāo)，無法形成推薦。姑息療法Foradultswithsepsisorsepticshock,werecommendintegratingprinciplesofpalliativecare(whichmayincludepalliativecareconsulta?tionbasedonclinicianjudgement)intothetreatmentplan,whenappropriate,toaddresspatientandfamilysymptomsandsufering推薦在救治膿毒癥和膿毒癥休克的時(shí)候，依據(jù)患者情況，將姑息療法考慮在內(nèi)。?Foradultswithsepsisorsepticshock,wesuggestagainstroutineformalpalliativecareconsultationforallpatientsoverpalliativecareconsultationbasedonclinicianjudgement對(duì)于膿毒癥和膿毒癥休克，不推薦所有患者常規(guī)考慮姑息療法，應(yīng)當(dāng)依據(jù)患者病情綜合評(píng)定。后續(xù)支持治療Foradultsurvivorsofsepsisorsepticshockandtheirfamilies,wesuggestreferraltopeersupportgroupsovernosuchreferral膿毒癥休克患者救治之后，推薦轉(zhuǎn)移至專有機(jī)構(gòu)進(jìn)行康復(fù)。Foradultswithsepsisorsepticshock,wesuggestusingahandofprocessofcriticallyimportantinformationattransitionsofcare,overno?suchhandofprocessThereisinsufcientevidencetomakearecommendationfortheuseofanyspecifcstructuredhandoftooloverusualhandofprocesses推薦膿毒癥、膿毒癥休克患者接力性治療，從而保持治療的完整性，但具體無法形成推薦。Foradultswithsepsisorsepticshockandtheirfamilies,werecommendscreeningforeconomicandsocialsupport(includinghousing,nutritional,fnancial,andspiritualsupport),andmakereferralswhereavailabletomeettheseneeds推薦評(píng)估、篩查、尋求膿毒癥患者救治的經(jīng)濟(jì)支持和社會(huì)支持。教育Foradultswithsepsisorsepticshockandtheirfamilies,wesuggestoferingwrittenandverbalsepsiseducation(diagnosis,treatment,andpost?ICU/post?sepsissyndrome)priortohospitaldischargeandinthefollow?upsetting推薦對(duì)膿毒癥患者及家屬進(jìn)行紙面上的、視頻上的科普教育。Foradultswithsepsisorsepticshockandtheirfamilies,werecommendtheclinicalteamprovidetheopportunitytoparticipateinshareddecisionmakinginpost?ICUandhospitaldischargeplanningtoensuredischargeplansareacceptableandfeasible推薦醫(yī)療團(tuán)隊(duì)同患者及家屬，溝通、設(shè)定住院后計(jì)劃且計(jì)劃可行，以確保順利康復(fù)。出院Foradultswithsepsisandsepticshockandtheirfamilies,wesuggestusingacriticalcaretransitionprogramme,comparedtousualcare,upontransfertothefoorForadultswithsepsisandsepticshock,werecommendreconcilingmedicationsatbothICUandhospitaldischargeForadultsurvivorsofsepsisandsepticshockandtheirfamilies,werecommendincludinginformationabouttheICUstay,sepsisandrelateddiagnoses,treatments,andcommonimpairmentsaftersepsisinthewrittenandverbalhospitaldischargesummaryForadultswithsepsisorsepticshockwhodevelopednewimpairments,werecommendhospitaldischargeplansincludefollow?upwithcliniciansabletosupportandmanagenewandlong?termsequelaeThereisinsufcientevidencetomakearecommendationonearlypost?hospitaldischargefollow?upcomparedtoroutinepost?hospitaldischargefollow?up對(duì)于膿毒癥患者，需要設(shè)定相應(yīng)轉(zhuǎn)運(yùn)、出院流程，在ICU和出院后，都需要制定藥物治療策略。出院時(shí)候，提供紙質(zhì)的、口頭的信息，以完整記錄疾病救治過程。出院后，需要及時(shí)隨訪患者，幫助那些存在功能受損的患者，建立后續(xù)治療流程，但關(guān)于隨訪時(shí)機(jī)，無法形成推薦。認(rèn)知療法Thereisinsufcientevidencetomakearecommendationonearlycognitivetherapyforadultsurvivorsofsepsisorsepticshock對(duì)于膿毒癥患者認(rèn)知情況，無法形成救治推薦。隨訪Foradultsurvivorsofsepsisorsepticshock,werecommendassessmentandfollow?upforphysical,cognitive,andemotionalproblemsafterhospitaldischargeForadultsurvivorsofsepsisorsepticshock,wesuggestreferraltoapost?criticalillnessfollow?upprogrammeifavailableForadultsurvivorsofsepsisorsepticshockreceivingmechanicalventilationfor>48horanICUstayof>72h,wesuggestreferraltoapost?hospitalrehabilitationprogramme如果有條件，應(yīng)當(dāng)對(duì)膿毒癥患者出院后制定隨訪流程，關(guān)注、評(píng)估患者身體、意識(shí)、情感情況。如果有條件（機(jī)械通氣＞48小時(shí)、ICU滯留時(shí)間＞72小時(shí)），推薦將其轉(zhuǎn)入后續(xù)治療程序中。