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膿毒癥指南更新,，搶先看一下 膿毒癥篩查和早期診治 For hospitals and health systems, we recommend using a performance improvement programme for sepsis, including sepsis screening for acutely ill, high?risk patients and standard operating procedures for treatment.
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。 We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock. 不推薦單獨(dú)使用qSOFA評(píng)分來(lái)篩查膿毒癥,、膿毒癥休克,。 For adults suspected of having sepsis, we suggest measuring blood lactate. 懷疑膿毒癥，推薦監(jiān)測(cè)血乳酸,。 Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. 膿毒癥和膿毒癥休克情況緊急,，需要立即救治,。 For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fuid should be given within the frst 3 h of resuscitation. 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,。 For adults with sepsis or septic shock, we suggest using dynamic measures to guide fuid resuscitation, over physical examination or static parameters alone. 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(lái)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,。 For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level,over not using serum lactate. 對(duì)于膿毒癥或膿毒癥休克患者來(lái)說(shuō)，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(lái)降低乳酸水平，而不是只看血清乳酸水平,。 For adults with septic shock, we suggest using capillary refll time to guide resuscitation as an adjunct to other measures of perfusion. 推薦使用毛細(xì)血管充盈時(shí)間作為復(fù)蘇指標(biāo),。 For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. 對(duì)于膿毒癥休克患者來(lái)說(shuō)，推薦初始MAP目標(biāo)為≥65mmHg,。 For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patients to the ICU within 6 h. 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 For adults with suspected sepsis or septic shock but unconfrmed infection, we recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected. 懷疑膿毒癥或膿毒癥休克,，但沒(méi)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,。
抗生素時(shí)間 For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials mmediately, ideally within 1 h of recognition. 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,。 For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infectious versus non?infectious causes of acute illness. 懷疑膿毒癥但沒(méi)有休克的患者，推薦評(píng)估感染,、非感染疾病,。 For adults with possible sepsis without shock, we suggest a time?limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 h from the time when sepsis was first recognised. 懷疑膿毒癥但沒(méi)有休克的患者，應(yīng)當(dāng)快速展開(kāi)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。 For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient. 如果患者膿毒癥概率很小且沒(méi)有感染,，建議無(wú)需使用抗生素,，同時(shí)嚴(yán)密監(jiān)測(cè)患者狀態(tài)。
抗生素使用生物標(biāo)志物 For adults with suspected sepsis or septic shock, we suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. 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(lái)決定啟用抗生素,，也不能單獨(dú)依賴臨床評(píng)估。
抗生素選擇 For adults with sepsis or septic shock at high risk of methicillin resistant staph aureus (MRSA), we recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage. 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。 For adults with sepsis or septic shock at low risk of methicillin resistant staph aureus (MRSA), we suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage. 對(duì)于無(wú)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。 For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, we suggest using two antimicrobials with gram?negative coverage for empiric treatment over one gram?negative agent. 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,。 For adults with sepsis or septic shock and low risk for MDR organisms,we suggest against using two Gram?negative agents for empiric treatment, as compared to one Gram?negative agen. 對(duì)于無(wú)MDR高危的患者,，不推薦聯(lián)合用藥。 For adults with sepsis or septic shock, we suggest against using double gram?negative coverage once the causative pathogen and the susceptibilities are known. 當(dāng)病原菌明確,、藥敏明確,，不推薦聯(lián)合用藥。
抗真菌治療 For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy over no antifungal therapy. 如果患者真菌感染高危,，推薦初始廣譜抗真菌治療,。 For adults with sepsis or septic shock at low risk of fungal infection,we suggest against empiric use of antifungal therapy. 如果不存在真菌感染高危，不推薦初始抗真菌治療,。
抗病毒藥物 抗生素使用 For adults with sepsis or septic shock, we suggest using prolonged infusion of beta?lactams for maintenance (after an initial bolus) over conventional bolus infusion. 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) For adults with sepsis or septic shock, we recommend optimising dosing strategies of antimicrobials based on accepted pharmacoki?netic/pharmacodynamic (PK/PD) principles and specifc drug properties. 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 For adults with sepsis or septic shock, we recommend rapidly identifing or excluding a specifc anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical. 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,。 For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established. 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。 For adults with sepsis or septic shock, we suggest daily assessment for de?escalation of antimicrobials over using fxed durations of therapy without daily reassessment for de?escalation. 推薦每日評(píng)估抗生素降階梯策略,。
抗生素療程 For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy. 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 For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear,we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. 膿毒癥,、膿毒癥休克患者感染控制足夠的情況下，但無(wú)法明確最佳抗生素療程,，推薦參考降鈣素原和臨床情況來(lái)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) For adults with sepsis or septic shock, we recommend using crystaloids as frst-line fuid for resuscitation. 推薦晶體液為復(fù)蘇首選液體,。 For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation 推薦使用平衡液來(lái)液體復(fù)蘇,，而不是生理鹽水。 For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids over using crystaloids alone 需要大量晶體液的時(shí)候,，推薦聯(lián)合白蛋白,。 For adults with sepsis or septic shock, we recommend against using starches for resuscitation 不推薦使用羥乙基淀粉復(fù)蘇。 For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation 不推薦使用明膠復(fù)蘇,。
血管活性藥物 For adults with septic shock, we recommend using norepinephrine as the frst?line agent over other vasopressors. 推薦一線藥物為去甲腎上腺素,。 For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine. 當(dāng)單獨(dú)使用去甲腎上腺素血壓無(wú)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,。【去甲腎上腺素范圍0.25–0.5 μg/kg/min,，可加用血管加壓素】 For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine 去甲腎上腺素聯(lián)合血管加壓素仍無(wú)法維持血壓,，推薦加用腎上腺素。 For adults with septic shock, we suggest against using terlipressin 不推薦使用特利加壓素,。
強(qiáng)心藥 For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest either adding dobutamine to norepinephrine or using epinephrine alone 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。 For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood presure, we suggest against using levosimendan 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(wú)法維持血壓，不推薦使用左西孟旦,。
監(jiān)測(cè) For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over non?invasive monitoring, as soon as practical and if resources are available 推薦侵襲性監(jiān)測(cè)手段（有創(chuàng)動(dòng)脈壓監(jiān)測(cè)） For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured 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 There is insufcient evidence to make a recommendation on the use of restrictive versus liberal fuid strategies in the frst 24 h of resus?citation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after initial resuscitation 關(guān)于液體復(fù)蘇方面,，24小時(shí)內(nèi)的時(shí)候，無(wú)法推薦是采用限制性液體復(fù)蘇還是開(kāi)放式液體復(fù)蘇,。
氧合目標(biāo) There is insufcient evidence to make a recommendation on the use of conservative oxygen targets in adults with sepsis?induced hypoxemic respiratory failure 對(duì)于膿毒癥誘發(fā)的呼吸衰竭,，關(guān)于氧目標(biāo)，無(wú)法形成推薦,。
高流量氧療 For adults with sepsis?induced hypoxemic respiratory failure, we suggest the use of high fow nasal oxygen over non?invasive ventilation 針對(duì)膿毒癥誘發(fā)的低氧血癥,，推薦高流量吸氧,。
無(wú)創(chuàng)通氣 There is insufcient evidence to make a recommendation on the use of non?invasive ventilation in comparison to invasive ventilation for adults with sepsis?induced hypoxemic respiratory failure 無(wú)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(wú)法形成推薦,。
ARDS的保護(hù)性肺通氣 For adults with sepsis?induced ARDS, we recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/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）,。 For adults with sepsis?induced severe ARDS, we recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures 推薦膿毒癥誘發(fā)的ARDS,，控制平臺(tái)壓≤30cmH2O。 For adults with moderate to severe sepsis?induced ARDS, we suggest using higher PEEP over lower PEEP 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 For adults with sepsis?induced respiratory failure (without ARDS), we suggest using low tidal volume as compared to high tidal volume ventilation 膿毒癥誘發(fā)的低氧血癥但無(wú)法診斷ARDS,，推薦低潮氣量,。
肺復(fù)張 For adults with sepsis?induced moderate?severe ARDS, we suggest using traditional recruitment maneuvers 對(duì)于膿毒癥誘發(fā)的ARDS，推薦肺復(fù)張,。 When using recruitment maneuvers, we recommend against using incremental PEEP titration/strategy 如果進(jìn)行肺復(fù)張,，不推薦使用PEEP遞增法。
俯臥位 For adults with sepsis?induced moderate?severe ARDS, we recommend using prone ventilation for more than 12 h daily 中重度ARDS,，每日俯臥位大于12小時(shí),。
肌肉松弛藥物 For adults with sepsis induced moderate?severe ARDS, we suggest using intermittent NMBA boluses, over NMBA continuous infusion 中重度ARDS，推薦間歇NMBA應(yīng)用,，而不是持續(xù)輸注,。
ECMO For adults with sepsis?induced severe ARDS, we suggest using veno?venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use 如果常規(guī)支持治療無(wú)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 For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids 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≥ 0.2ug/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 For adults with sepsis or septic shock, we suggest against using polymyxin B haemoperfusion 不推薦血液灌流,； There is insufcient evidence to make a recommendation on the use of other blood purifcation techniques 其他血液凈化技術(shù)無(wú)法形成推薦,。
紅細(xì)胞 For adults with sepsis or septic shock, we recommend using a restric?tive (over liberal) transfusion strategy 推薦限制性紅細(xì)胞輸注（70 g/L足夠，但仍需要綜合評(píng)估心功能等指標(biāo)）,。
免疫球蛋白 應(yīng)激性潰瘍 深靜脈血栓 For adults with sepsis or septic shock, we recommend using pharmacologic VTE prophylaxis unless a contraindication to such therapy exists 推薦藥物預(yù)防VTE,，除非有禁忌癥,。 For adults with sepsis or septic shock, we recommend using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for VTE prophylaxis 推薦使用低分子肝素，而不是普通肝素，來(lái)預(yù)防深靜脈血栓,。 For adults with sepsis or septic shock, we suggest against using mechanical VTE prophylaxis in addition to pharmacological prophy?laxis, over pharmacologic prophylaxis alone 不推薦使用機(jī)械性聯(lián)合低分子肝素來(lái)防治VTE,。
腎臟替代 In adults with sepsis or septic shock and AKI who require renal replacement therapy, we suggest using either continuous or intermitent renal replacement therapy 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。 In adults with sepsis or septic shock and AKI, with no defnitive indications for renal replacement therapy, we suggest against using renal replacement therapy 對(duì)于膿毒癥,、膿毒癥休克合并AKI的,，沒(méi)有明確腎臟替代指征的，不推薦腎臟替代治療,。
血糖控制 For adults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of≥ 180 mg/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8–10 mmol/L】,。
維生素C For adults with sepsis or septic shock, we suggest against using IV
vitamin C 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 For adults with septic shock and hypoperfusion?induced lactic acidemia, we suggest against using sodium bicarbonate therapy to improve haemodynamics or to reduce vasopressor requirements 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(lái)提高血流動(dòng)力學(xué)或減少血管活性藥物的使用劑量。 For adults with septic shock, severe metabolic acidemia (pH≤ 7.2) and AKI (AKIN score 2 or 3), we suggest using sodium bicarbonate therapy 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,，使用碳酸氫鈉。
營(yíng)養(yǎng) For adult patients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 h) initiation of enteral nutrition 對(duì)于膿毒癥,、膿毒癥休克的患者來(lái)說(shuō),，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) For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis with patients and families over no such discussion 推薦同患者及家屬討論治療目標(biāo)和預(yù)后,。 For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 h) over late 推薦早期制定治療目標(biāo)（72小時(shí)內(nèi)） There is insufcient evidence to make a recommendation for any specifc standardised criterion to trigger goals of care discussion 對(duì)特異性標(biāo)準(zhǔn)來(lái)啟動(dòng)救治目標(biāo)，無(wú)法形成推薦,。
姑息療法 For adults with sepsis or septic shock, we recommend integrating principles of palliative care (which may include palliative care consulta?tion based on clinician judgement) into the treatment plan, when appropriate, to address patient and family symptoms and sufering 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),。 For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement 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 For adult survivors of sepsis or septic shock and their families, we suggest referral to peer support groups over no such referral 膿毒癥休克患者救治之后,，推薦轉(zhuǎn)移至專(zhuān)有機(jī)構(gòu)進(jìn)行康復(fù)。 For adults with sepsis or septic shock, we suggest using a handof process of critically important information at transitions of care, over no such handof process There is insufcient evidence to make a recommendation for the use of any specifc structured handof tool over usual handof processes 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(wú)法形成推薦。 For adults with sepsis or septic shock and their families, we recommend screening for economic and social support (including housing,nutritional, fnancial, and spiritual support), and make referrals where available to meet these needs 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 For adults with sepsis or septic shock and their families, we suggest ofering written and verbal sepsis education (diagnosis, treatment, and post?ICU/post?sepsis syndrome) prior to hospital discharge and in the follow?up setting 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,。 For adults with sepsis or septic shock and their families, we recommend the clinical team provide the opportunity to participate in shared decision making in post?ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible 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 For adults with sepsis and septic shock and their families, we suggest using a critical care transition programme, compared to usual care,upon transfer to the foor For adults with sepsis and septic shock, we recommend reconciling medications at both ICU and hospital discharge For adult survivors of sepsis and septic shock and their families, we recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary For adults with sepsis or septic shock who developed new impairments, we recommend hospital discharge plans include follow?up with clinicians able to support and manage new and long?term sequelae There is insufcient evidence to make a recommendation on early post?hospital discharge follow?up compared to routine post?hospital discharge follow?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,、視頻的信息,，以完整記錄疾病救治過(guò)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(wú)法形成推薦。
認(rèn)知療法 There is insufcient evidence to make a recommendation on early cognitive therapy for adult survivors of sepsis or septic shock 對(duì)于膿毒癥患者認(rèn)知情況,，無(wú)法形成救治推薦,。
隨訪 For adult survivors of sepsis or septic shock, we recommend assessment and follow?up for physical, cognitive, and emotional problems after hospital discharge For adult survivors of sepsis or septic shock, we suggest referral to a post?critical illness follow?up programme if available For adult survivors of sepsis or septic shock receiving mechanical ventilation for > 48 h or an ICU stay of > 72 h, we suggest referral to a post?hospital rehabilitation programme 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,。
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