PDF《Sepsis》

50 sec, (2) compressing stocking, or (3) intermittent pneumatic compression device High risk - combine heparin and mechanical device 8. Discuss advance care plan with patient & family 9. IVIG may be considered in children with severe sepsis 10. ECMO be limited to refractory pediatric septic shock and/or respiratory failure that cannot be supported by conventional therapies 血??学之支持治? ? 输液治?: C Colloid v.s. crystalloid C CVP level ? 心肺肾?好:8 mmHg ? 单一器官:10 mmHg ? 器官正常:12 mmHg ? 呼吸器:12-15 mmHg 血??学之支持治? ? 升压剂 C MAP >

65 mmHg C dopamine, norepinephrine C Epinephrine C Vasopression (0.03 units/min), not for 1st line ? 避免低剂?dopamine保护肾脏 ? 尽快放置arterial line ? Dobutamine提高cardiac output ? ?建议以预设高於正常值的cardiac index治? 病人 N Engl J Med 2001;

344:699 N Engl J Med 2001;

344:699 N Engl J Med 2001;

344:699 呼吸照护 ? Low tidal volume, limited peak and plateau pressure C Tidal volume

6 mL/kg C Peak pressure <

35 mmH2O C Plateau pressure <

30 mmHg ? Permissive CO2 retention ? PEEP ? Prone position ? Head up 30-45 degress ? Pul. Artery catheterization not recommended ? Limited fluid therapy Ventilator Strategy for ARDS Ventilator Strategy for ARDS ?

6 mL/kg with PIP <

30 cmH2O compared with

12 mL/kg PIP <

50 cmH2O C 22% reduction in mortality C Increased ventilator free day during the first

28 hospital days C Adult patients (ARDS Network, NEJM 2000, 342: 1307-8) ? Permissive hypercapnia C CO2 allowed to rise C Maintain pH > 7.2 with buffered solution Parameter protocol Mode Volume assist-control Tidal Volume ≤6 mL/kg predicted body weight Plateau pressure ≤30 cm H2O Frequency 6C35 breaths/min, titrated for pH 7.30C7.45 IE ratio 1:1 to 1:3 Oxygenation Goal PaO2 55C80 mm Hg, or SaO2 88C95% FiO2/PEEP (cmH2O) combination allowed 0.3/5, 0.4/5, 0.4/8, 0.5/8, 0.5/10, 0.6/10, 0.7/10, 0.7/12, 0.7/14, 0.8/14, 0.9/14, 0.9/16, 0.9/18, 1.0/18, 1.0/20, 1.0/22, 1.0/24 Weaning By pressure support, required when FIO2/PEEP ≤ 0.4/8 (ARDS Network, NEJM 2000, 342: 1307-8) ARDS Net 输血的原则 ? 无心肌缺氧,组织血液灌??足,严重低 血氧,急性出血,缺氧性心脏病,乳酸血 症,PRBC keep 7-9 g/dL ? FFP?该被常规使用,10-15 mL/kg ? Plt < 5000/mm3, 5000-30000 ?有出血风 险,手术前 > 50,000 感染的Issue Crit Care Med 2006;

34:

1589 Crit Care Med 2006;

34:

1589 Circulation 1970;

41:

989 ?固醇使用的时机 ? Children with catecholamine resistance and suspected or proven adrenal insufficiency Special consideration in children