Title: Hemodynamic Pearls from the Surviving Sepsis Guideline
题目:2013年休克急救指南的血液动力学要素
Author作者: Haney Mallemat
The updated Surviving Sepsis Guidelines have been released and here are some recommendations as they pertain to hemodynamic management (grades of recommendations in parenthesis).
新一版的休克急救指南已出炉,这里是有关血液动力学方面的几个建议。
Fluid therapy
液体治疗
• An initial fluid bolus of at least 30 mL/kg is recommended; crystalloids should be the initial fluids (1B).
• 建议最初的液体复苏的量为每公斤体重30毫升,首先的液体应该是晶体液(1B)。
• Consider albumin when “substantial” amounts of crystalloid have been given (2C).
• 在输入相当量的晶体液后,要考虑给白蛋白(2C)。
• Use of hydroxyethyl starch is not recommended (1B)
• 不建议使用羟乙基淀粉液
Vasopressors (targeting MAP of at least 65 mmHg)
血管加压素(目标MAP最低要达到65mmHg)
• Norepinephrine (NE) is the vasopressor of choice (1B)
• 首选去甲基肾上腺素(NE)(1B)
• Epinephrine (EPI) if an additional agent is required; can be added to or substituted for NE (2B)
• 如再需要血管加压素,可加用肾上腺素(EPI)或取代NE(2B)
• Vasopressin (0.03 units/minute) can be added to NE; it should not be titrated or used as a single agent (ungraded).
• 脑垂体后叶素(0.03单位/分钟)可于NE同用,不要静脉滴注或单独使用。
• In selected patients (e.g., bradycardia or low-risk of tachyarrhythmia), dopamine may be considered (2C). Low-dose dopamine (for renal protection) should not be used (1A).
• 在某些特定病人(如心动过缓或心动过速可能性不大)中,可考虑用多巴胺(2C)。不要用低剂量(肾保护剂量)的多巴胺(1A)。
• Phenylephrine (PE) is not recommended, except if (1C):
• 去氧肾上腺素(新福林,PE)不建议用,除非(1C):
◦ Serious NE associated arrhythmias
◦ NE导致的严重心律失常
◦ Cardiac output can be measured and is increased with low MAP (PE can reduce cardiac output)
◦ 可监测心输出量,心输出量高但血压低(PE可以降低心输出量)
◦ Other therapies cannot achieve the target MAP
◦ 其它任何方法无法维持理想MAP
Corticosteroids
皮质激素
• Use if fluids and vasopressors cannot restore adequate perfusion
• 如液体和血管加压剂不能恢复正常循环时,可考虑用
• Total daily dose of 200 mg (2C) administered by continuous infusion (2D)
• 总剂量为200毫克(2C),静脉持续滴注(2D)
• ACTH stimulation test is not recommended (2B)
• 没有必要做ACTH刺激试验(2B)
• Tapering hydrocortisone when vasopressors have been discontinued (2D)
• 在停止血管加压素后,逐渐减激素的量
Inotropic Therapy
强心治疗
• Administer dobutamine if it is believed that cardiac filling pressures are elevated, cardiac output is low, or persistent signs of hypoperfusion despite other therapies (1C)
• 在如下的情况下可考虑使用多巴酚丁胺:心脏充盈压高,心输出量低,或对其它治疗效果无效的持续性低灌注症状
References参考文献