中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

再论脓毒症的集束化治疗策略

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   “拯救脓毒症运动(Surviving Sepsis Campaign,SSC)”是国际危重病医学界为提高脓毒症诊治水平、降低病死率而于2002年发起的全球性运动。随后,由多个国际学术组织暨国际专家组发起与组编的《严重脓毒症与脓毒症休克治疗指南》[1]及其修订版[2](以下统称为“SSC指南”)分别于2004年和2008年颁布。指南以循证医学为依据,总结了早期目标指导治疗(EGDT)、强化血糖控制(TGC)、小剂量激素替代治疗、活性蛋白C(APC)治疗等治疗方案,其核心就是将各自独立的疗法整合为整体化的“集束化治疗策略(Bundle Strategy)”,以期最大限度地发挥综合治疗效应[3]。按照SSC的建议,集束化治疗策略包括脓毒症复苏集束化策略(Sepsis Resuscitation Bundle)和脓毒症治疗集束化策略(Sepsis Management Bundle)。前者要求在诊断严重脓毒症后的6 h内完成血乳酸测定、血培养、早期广谱抗菌药物应用和EGDT等6项治疗策略;后者则要求在24 h内完成由小剂量激素、APC、TGC和限制气道平台压构成的4项治疗策略[4]。显然,上述策略借鉴了创伤救治的“黄金6小时”和“白银24小时”的理念。
  目前已有越来越多的研究证据支持集束化治疗策略在急诊和ICU的早期实施,并显示出病死率降低的趋势。但实际的情况是临床上对该策略的实施与执行严重不足,集束化治疗策略所代表的强化、优先、积极的治疗理念并未获得普遍的贯彻,进而影响到获得病死率显著降低的收益。另一方面,集束化治疗策略的各治疗要素也非完美,其所依据的相关临床试验存在着诸多不足甚至可疑之处,而单纯的疗法叠加是否真能发挥事半功倍的效果也值得考量。为此,本文就当前国际上的相关研究进展进行反思,以供同道参考。

关键词: 脓毒症; 治疗

引用本文: 黄伟,万献尧. 再论脓毒症的集束化治疗策略. 中国呼吸与危重监护杂志, 2009, 09(2): 106-109. doi: 复制

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