成人脓毒症

最后审阅: 26 八月 2022
最后更新: 22 七月 2022
22 七月 2022

英国新指南对脓毒症进行初步检查和给予抗菌治疗时机的建议予以更新

代表英国所有医学院的皇家医学院(Academy of Medical Royal Colleges, AOMRC)已发布指南,帮助对于病情危重、最有可能通过快速治疗获益的患者给予优先处理。该指南亦使得被认为病情不甚严重的脓毒症可能病例通过延长检查周期和接受更为精准的治疗达成获益,并减少抗微生物药物耐药负担。AOMRC 作出如下具体推荐:

  • 按最初发病时的疾病严重程度对患者进行分层

  • 使用国家早期预警评分 2(National Early Warning Score 2, NEWS2)作为评估严重程度的主要工具,同时结合您的临床判断。对于疑似脓毒症患者:

    • NEWS2 评分为 7 分或以上,应在 1 小时内进行检查和治疗

    • NEWS2 评分 5 分或 6 分,应在 3 小时内进行检查和治疗

  • 在临床评估背景下解读 NEWS2 初步评分,从而可在临床工作者或照护者对重症诊断、持续加重、中性粒细胞减少或器官功能障碍血气证据/实验室证据(包括血清乳酸升高)感到担忧时,将严重程度状态和相应行动至少提升至下一个 NEWS2 级别。

AOMRC 声明得到了英国多个组织认可,包括英国抗菌药物化疗学会、英格兰、威尔士和北爱尔兰重症诊疗网络、重症学会和英国脓毒症慈善基金,并得到了英国国家卫生研究院支持。

查看诊断:诊断建议

查看治疗:治疗路径

更新原始来源

小结

定义

病史和体格检查

关键诊断因素

  • 危险因素
  • 特定感染源的体征
  • 较高的早期预警得分(例如,NEWS2 ≥5 分)
  • 呼吸急促(NEWS2)
  • 体温偏高或偏低,偶有寒战(NEWS2)
  • 心动过速(NEWS2)
  • 急性意识状态改变(NEWS2)
  • 低血氧饱和度(NEWS2)
  • 低血压(NEWS2)
  • 少尿
  • 毛细血管再充盈不良、皮肤斑驳或面色苍白
  • 紫绀
完整详情

其他诊断因素

  • 周身不适/昏睡
  • 恶心/呕吐/腹泻
  • 暴发性紫癜
  • 肠梗阻
  • 黄疸
完整详情

危险因素

  • 年龄>65 岁
  • 免疫功能受损
  • 留置输液管或导管
  • 近期手术或其他侵入性操作
  • 血液透析
  • 糖尿病
  • 静脉注射药物滥用
  • 酒精依赖
  • 妊娠
  • 皮肤完整性破坏
  • 城市居民
  • 肺部疾病
  • 男性
  • 非白人血统
  • 冬季
完整详情

诊断性检查

首要检查

  • 血液培养
  • 血清乳酸
  • 每小时尿量
  • 全血细胞计数
  • 尿素和电解质(包括肌酐)
  • 血清葡萄糖
  • C 反应蛋白
  • 血清原降钙素
  • 凝血筛查
  • 肝功能检测
  • 血气
  • 心电图(ECG)
完整详情

需考虑的检查

  • 尿液分析
  • 胸部 X 线检查
  • 多来源样本培养
  • 腰椎穿刺:
  • 计算机断层扫描
  • 超声
  • 尿抗原检测
  • 病毒拭子
  • HIV 筛查
  • 超声心动图
完整详情

治疗流程

初步治疗

住院:高度怀疑脓毒症,细菌感染来源未知或不明

社区中:高度怀疑脓毒症,确诊或高度怀疑细菌感染

急症处理

住院:高度怀疑脓毒症,细菌感染源明确

撰稿人

专家顾问

Alexander Alexiou, MB, BS, BSc, DCH, FRCEM, Dip IMC RCSEd

Emergency Medicine Consultant

Physician Response Unit Consultant

Barts Health NHS Trust

London’s Air Ambulance

Royal London Hospital

London

UK

利益声明

AA declares that he has no competing interests.

Clovis Rau, MBBS, BSc, FRCEM, DipIMC

Specialty Registrar Emergency Medicine (ST6)

Barnet Hospital

Royal Free NHS Foundation Trust

London

UK

利益声明

CR declares that he has no competing interests.

Acknowledgements,

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Ron Daniels MBChB, FRCA

Chief Executive

United Kingdom Sepsis Trust

Chief Executive

Global Sepsis Alliance

Programme Director

Survive Sepsis

Consultant in Critical Care and Anaesthesia

Heart of England NHS Foundation Trust

Birmingham

UK

Matt Inada-Kim MBBS, FRCP

Consultant Acute Physician & Sepsis Lead

Department of Acute Medicine

Royal Hampshire County Hospital

Hampshire Hospitals NHS Foundation Trust

Winchester

UK

Aamir Saifuddin BMBCh, BA, MRCP, AFFMLM

Specialty Registrar in Gastroenterology and General Medicine

Maidstone and Tunbridge Wells NHS Trust

UK

Tim Nutbeam MSc, Dip IMC FRCEM

Consultant in Emergency Medicine

Clinical Academic

University of Plymouth

Lead Doctor

Devon Air Ambulance Trust

Derriford Hospital

Plymouth

UK

Edward Berry MBChB, MCEM

Specialty Registrar in Emergency Medicine

Derriford Hospital

Plymouth

UK

利益声明

RD has received payment for consultancy on sepsis from Kimal Plc, manufacturers of vascular access devices, from the Northumbria Partnership, a patient safety collaborative, and, where annual leave or other income was compromised in fulfilling his charity duties, from the UK Sepsis Trust. RD has received sponsorship to attend and speak at one meeting from Abbott Diagnostics. He is CEO of the UK Sepsis Trust and Global Sepsis Alliance, and advises HM Government, the World Health Organization, and NHS England on sepsis. Each of these positions demands that he express opinion on strategies around the recognition and management of sepsis. MIK is a national clinical advisor on sepsis to NHS England and a national clinical advisor on deterioration to NHS Improvement. He was reimbursed for a slide set by Relias Learning. AS is the clinical fellow to the National Medical Director at NHS Improvement. AS has been sponsored on two occasions by Dr Falk Pharma UK to attend specialist gastroenterology conferences abroad; there was no contractual obligation to disseminate product information. TN is a clinical adviser to the UK Sepsis Trust. EB declares that he has no competing interests.

同行评议者

Matt Inada-Kim, MBBS, FRCP

Consultant Acute Physician & Sepsis Lead

Department of Acute Medicine

Royal Hampshire County Hospital

Hampshire Hospitals NHS Foundation Trust

Winchester

UK

利益声明

MIK is a national clinical advisor on sepsis to NHS England and a national clinical advisor on deterioration to NHS Improvement. He was reimbursed for a slide set by Relias Learning.

编辑

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice

利益声明

TAO declares that she has no competing interests.

Jo Haynes,

Head of Editorial, BMJ Knowledge Centre

利益声明

JH declares that she has no competing interests.

Rachel Wheeler,

Lead Section Editor, BMJ Best Practice

利益声明

RW declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

利益声明

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

利益声明

AM declares that he has no competing interests.

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