1、ESICM循環(huán)休克與血流動(dòng)力學(xué)監(jiān)測(cè)最新共識(shí)CSCCM 2014年12月10 2014年年12月的月的Intensive Care Medicine雜雜志發(fā)表了歐洲危重病醫(yī)學(xué)會(huì)有關(guān)休克及血志發(fā)表了歐洲危重病醫(yī)學(xué)會(huì)有關(guān)休克及血流動(dòng)力學(xué)監(jiān)測(cè)的新共識(shí)。流動(dòng)力學(xué)監(jiān)測(cè)的新共識(shí)。 第一部分介紹了共識(shí)中重要的推薦意見第一部分介紹了共識(shí)中重要的推薦意見No.說明說明/推薦意見推薦意見GRADE推薦級(jí)別推薦級(jí)別a; 證據(jù)質(zhì)量證據(jù)質(zhì)量說明的種說明的種類類1循環(huán)休克定義為危及生命的急性循環(huán)功能衰竭，伴有細(xì)胞的氧利用障礙。We define circulatory as a life-threatening, gene

2、ralized form of acute circulatory failure associated with inadequate oxygen utilization by the cells未分級(jí)定義2休克可以導(dǎo)致細(xì)胞缺氧，并伴有血乳酸升高。As a result, there is cellular dysoxia, associated with increased blood lactate levels未分級(jí)事實(shí)陳述3.休克可以表現(xiàn)為四種類型：其中三種為低血流狀態(tài)（低血容量性，心源性，梗阻性），另一種為高動(dòng)力狀態(tài)（分布性）.Shock can be associated wi

3、th four underlying patterns: three associated with a low flow state (hypovolemic, cardiogenic, obstructive) and one associated with a hyperkinetic state (distributive)未分級(jí)事實(shí)陳述4.休克可以由多種過程共同導(dǎo)致。Shock can be due to a combination of processes未分級(jí)事實(shí)陳述5.體格檢查時(shí)，休克通常伴隨組織灌注不足的表現(xiàn)。常常對(duì)三個(gè)器官進(jìn)行評(píng)估判斷組織灌注情況皮膚（表皮灌注情況）；腎臟（

4、尿量）；以及腦（意識(shí)狀態(tài)）。Shock is typically associated with evidence of inadequate tissue perfusion on physical examination. The three organs readily accessible to clinical assessment of tissue perfusion are the: -skin (degree of cutaneous perfusion); kidneys (urine output); and brain (mental status)未分級(jí)事實(shí)陳述6.對(duì)

5、于病史以及臨床表現(xiàn)提示存在休克的患者，我們推薦經(jīng)常評(píng)估心率、血壓、體溫和體格檢查指標(biāo)（包括低灌注的體征，尿量和意識(shí)狀態(tài)）。We recommend frequent measurement of heart rate, blood pressure, body temperature and physical examination variables (including signs of hypoperfusion, urine output and mental status) in patients with a history and clinical findings sugges

6、tive of shock未分級(jí)最佳臨床實(shí)踐7.我們推薦不要根據(jù)單一的指標(biāo)（診斷和/或治療休克）。We recommend not to use a single variable (for the diagnosis and/or management of shock未分級(jí)最佳臨床實(shí)踐8.我們推薦應(yīng)當(dāng)努力確定休克類型，以便更好地進(jìn)行病因和支持治療。We recommend efforts to identify the type of shock to better target causal and supportive therapies未分級(jí)最佳臨床實(shí)踐9.盡管休克時(shí)常常合并低血壓（

7、定義為收縮壓 90 mmHg，或MAP 65 mmHg，或較基礎(chǔ)值下降 40 mmHg），但我們推薦不要將低血壓作為診斷休克的標(biāo)準(zhǔn)。We recommend that the presence of arterial hypotension (defined as systolic blood pressure of 90 mmHg, or MAP of 2 mEq/L (mmol/L)。Lactate levels are typically 2 mEq/L (or mmol/L) in shock states未分級(jí)事實(shí)陳述13.如果臨床檢查不能明確診斷時(shí)，我們推薦進(jìn)行進(jìn)一步的血流動(dòng)力學(xué)評(píng)

8、估（如心功能評(píng)價(jià)）以確定休克類型。We recommend further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis未分級(jí)最佳臨床實(shí)踐14.當(dāng)需要進(jìn)一步血流動(dòng)力學(xué)評(píng)估時(shí)，與其他有創(chuàng)技術(shù)相比，我們建議采用心臟超聲作為初始評(píng)估休克類型的優(yōu)先選擇。We suggest that, when further hemodynamic asse

9、ssment is needed, echocardiography is the preferred modality to initially evaluate the type of shock as opposed to more invasive technologies推薦級(jí)別2; 證據(jù)級(jí)別中等 (B)推薦意見15.對(duì)于病情復(fù)雜的病例，我們建議應(yīng)用肺動(dòng)脈導(dǎo)管或經(jīng)肺熱稀釋法確定休克類型。In complex patients, we suggest to additionally use pulmonary artery catheterization or transpulmona

10、ry thermodilution to determine the type of shock推薦級(jí)別2; 證據(jù)級(jí)別低 (C)推薦意見16.我們推薦進(jìn)行早期治療，包括（通過輸液及必要時(shí)使用升壓藥物）維持血流動(dòng)力學(xué)穩(wěn)定，并治療休克病因，同時(shí)頻繁評(píng)估治療反應(yīng)。We recommend early treatment, including hemodynamic stabilization (with fluids and vasopressors if needed) and treatment of the shock etiology, with frequent reassessment

11、of response未分級(jí)最佳臨床實(shí)踐17.對(duì)于初始治療無反應(yīng)和（或）需要輸注升壓藥物的休克患者，我們推薦留置動(dòng)脈和中心靜脈導(dǎo)管。We recommend arterial and central venous catheter insertion in shock not responsive to initial therapy and/or requiring vasopressor infusion未分級(jí)最佳臨床實(shí)踐18.如果患者留置中心靜脈導(dǎo)管，我們建議測(cè)定中心靜脈血氧飽和度(ScvO2)和靜脈動(dòng)脈PCO2差值(V-ApCO2)，以幫助評(píng)估休克類型和心輸出量是否足夠，并指導(dǎo)治療。I

12、n patients with a central venous catheter, we suggest measurements of ScvO2) and V-ApCO2to help assess the underlying pattern and the adequacy of cardiac output as well as to guide therapy推薦級(jí)別2; 證據(jù)級(jí)別中等 (B)推薦意見19.我們推薦連續(xù)測(cè)定血乳酸水平以進(jìn)行指導(dǎo)、監(jiān)測(cè)和評(píng)估。We recommend serial measurements of blood lactate to guide, mon

13、itor, and assess推薦級(jí)別1; 證據(jù)級(jí)別低(C)推薦意見20.我們建議評(píng)估局部循環(huán)或微循環(huán)的技術(shù)僅用于研究目的。We suggest the techniques to assess regional circulation or microcirculation for research purposes only推薦級(jí)別2; 證據(jù)級(jí)別低 (C)推薦意見21.我們推薦休克復(fù)蘇時(shí)對(duì)目標(biāo)血壓進(jìn)行個(gè)體化。We recommend individualizing the target blood pressure during shock resuscitation推薦級(jí)別1; 證據(jù)級(jí)

14、別中等 (B)推薦意見22.我們推薦初始血壓目標(biāo)為MAP 65 mmHg。We recommend to initially target a MAP of 65 mmHg推薦級(jí)別1; 證據(jù)級(jí)別低 (C)推薦意見23.對(duì)于未能控制的出血患者，如沒有重度顱腦損傷（即創(chuàng)傷患者），我們建議采用較低的目標(biāo)血壓。We suggest to tolerate a lower level of blood pressure in patients with uncontrolled bleeding (i.e. in patients with trauma) without severe head inj

15、ury推薦級(jí)別2; 證據(jù)級(jí)別 (C)推薦意見24.對(duì)于有高血壓病史的感染患者，以及升高血壓后病情改善的患者，我們建議采用較高的MAP。We suggest a higher MAP in septic patients with history of hypertension and in patients that show clinical improvement with higher blood pressure推薦級(jí)別2; 證據(jù)級(jí)別中等 (B)推薦意見25.適當(dāng)?shù)囊后w管理能夠改善患者預(yù)后；低血容量和血容量過多都是有害的。Optimal fluid management does im

16、prove patient outcome; hypovolemia and hypervolemia are harmful未分級(jí)事實(shí)陳述26.我們推薦評(píng)估容量狀態(tài)及容量反應(yīng)性。We recommend to assess volume status and volume responsiveness未分級(jí)最佳臨床實(shí)踐27如果休克患者通常使用的前負(fù)荷指標(biāo)處于非常低的狀態(tài)，我們推薦立即進(jìn)行液體復(fù)蘇。We recommend that immediate fluid resuscitation should be started in shock states associated with v

17、ery low values of commonly used preload parameters未分級(jí)最佳臨床實(shí)踐28.我們推薦不應(yīng)單純根據(jù)常用的前負(fù)荷指標(biāo)（如CVP或PAOP或舒張末面積或全心舒張末容積）指導(dǎo)液體復(fù)蘇治療。We recommend that commonly used preload measures (such as CVP or PAOP or end diastolic area or global end diastolic volume) alone should not be used to guide fluid resuscitation推薦級(jí)別1; 證據(jù)

18、級(jí)別中等 (B)推薦意見29.我們推薦不應(yīng)當(dāng)以心室充盈壓或容積的任何絕對(duì)數(shù)值作為治療目標(biāo)。We recommend not to target any absolute value of ventricular filling pressure or volume推薦級(jí)別1; 證據(jù)級(jí)別中等 (B)推薦意見30.我們推薦根據(jù)超過一種血流動(dòng)力學(xué)指標(biāo)指導(dǎo)液體復(fù)蘇治療。We recommend that fluid resuscitation should be guided by more than one single hemodynamic variable未分級(jí)最佳臨床實(shí)踐31.有條件時(shí)，我們

19、推薦采用動(dòng)態(tài)而非靜態(tài)指標(biāo)預(yù)測(cè)輸液反應(yīng)性。We recommend using dynamic over static variables to predict fluid responsiveness, when applicable推薦級(jí)別1; 證據(jù)級(jí)別 (B)推薦意見32.當(dāng)決定進(jìn)行輸液治療時(shí)，我們推薦進(jìn)行快速補(bǔ)液試驗(yàn)，除非患者有明顯的低血容量（如動(dòng)脈瘤破裂導(dǎo)致出血）。When the decision for fluid administration is made we recommend to perform a fluid challenge, unless in cases of

20、 obvious hypovolemia (such as overt bleeding in a ruptured aneurysm)推薦級(jí)別1; 證據(jù)級(jí)別低 (C)推薦意見33.即使對(duì)于輸液有反應(yīng)的患者，我們也推薦謹(jǐn)慎地進(jìn)行輸液治療，尤其是血管內(nèi)充盈壓或血管外肺水已經(jīng)升高的患者。We recommend that even in the context of fluid-responsive patients, fluid management should be titrated carefully, especially in the presence of elevated intr

21、avascular filling pressures or extravascular lung water未分級(jí)推薦意見34.當(dāng)患者心功能發(fā)生改變，導(dǎo)致心輸出量降低或不足，且在優(yōu)化前負(fù)荷后仍有組織低灌注表現(xiàn)時(shí)，我們建議加用強(qiáng)心藥物。We suggest that inotropic agents should be added when the altered cardiac function is accompanied by a low or inadequate cardiac output, and signs of tissue hypoperfusion persist aft

22、er preload optimization推薦級(jí)別2; 證據(jù)級(jí)別低 (C)推薦意見35.對(duì)于單純的心功能不全患者，我們推薦不要使用強(qiáng)心藥物。We recommend not to give inotropes for isolated impaired cardiac function推薦級(jí)別1; 證據(jù)級(jí)別中等 (B)推薦意見36.對(duì)于休克患者，我們不推薦將氧輸送的絕對(duì)數(shù)值作為治療目標(biāo)。We do not recommend targeting absolute values of oxygen delivery in patients with shock推薦級(jí)別1; 證據(jù)級(jí)別高 (A)

23、推薦意見37.如果休克患者對(duì)初始治療有反應(yīng)，我們不推薦常規(guī)測(cè)定心輸出量。We do not recommend routine measurement of cardiac output for patients with shock responding to the initial therapy推薦級(jí)別1; 證據(jù)級(jí)別低 (C)推薦意見38.如果患者對(duì)初始治療沒有反應(yīng)，我們推薦測(cè)定心輸出量和每搏輸出量以評(píng)估患者對(duì)液體治療或強(qiáng)心藥物的反應(yīng)。We recommend measurements of cardiac output and stroke volume to evaluate the

24、 response to fluids or inotropes in patients that are not responding to initial therapy推薦級(jí)別1; 證據(jù)級(jí)別低 (C)推薦意見39.我們建議休克期間連續(xù)評(píng)價(jià)血?jiǎng)恿W(xué)狀態(tài)。We suggest sequential evaluation of hemodynamic status during shock推薦級(jí)別1; 證據(jù)級(jí)別低 (C)推薦意見40.心臟超聲可用于休克時(shí)心功能的連續(xù)評(píng)估。Echocardiography can be used for the sequential evaluation of

25、cardiac function in shock未分級(jí)事實(shí)陳述41.我們不推薦在休克患者常規(guī)使用肺動(dòng)脈導(dǎo)管。We do not recommend the routine use of the pulmonary artery catheter for patients in shock推薦級(jí)別1; 證據(jù)級(jí)別高 (A)推薦意見42.我們建議在頑固性休克及右心功能不全患者使用肺動(dòng)脈導(dǎo)管。We suggest pulmonary artery catheterization in patients with refractory shock and right ventricular dysfu

26、nction推薦級(jí)別2; 證據(jù)級(jí)別低 (C)推薦意見43.對(duì)于重度休克患者，尤其是伴有急性呼吸窘迫綜合征的患者，我們建議使用經(jīng)肺熱稀釋法或肺動(dòng)脈導(dǎo)管。We suggest the use of transpulmonary thermodilution or pulmonary artery catheterization in patients with severe shock especially in the case of associated acute respiratory distress syndrome推薦級(jí)別2; 證據(jù)級(jí)別低 (C)推薦意見44.我們推薦采用創(chuàng)傷較小的方

27、法（在休克患者經(jīng)過驗(yàn)證）代替創(chuàng)傷較大的方法。We recommend that less invasive devices are used, instead of more invasive devices, only when they have been validated in the context of patients with shock未分級(jí)最佳臨床實(shí)踐 第二部分對(duì)于2006年以及2014年共識(shí)內(nèi)容進(jìn)行了比較。 2006年與年與2014年共識(shí)有關(guān)休克定義、血壓和輸液反應(yīng)性說明的主要區(qū)別年共識(shí)有關(guān)休克定義、血壓和輸液反應(yīng)性說明的主要區(qū)別內(nèi)容內(nèi)容ICM Antonelli 200

28、7ICM Cecconi 2014定義我們推薦將休克定義為危及生命的血流分布異常，導(dǎo)致不能提供和（或）利用足夠的氧，從而造成組織缺氧。推薦級(jí)別1；證據(jù)級(jí)別中等(B)循環(huán)休克定義為危及生命的急性循環(huán)功能衰竭，伴有細(xì)胞的氧利用障礙。未分級(jí)有關(guān)血壓的說明我們推薦休克初始復(fù)蘇時(shí)的目標(biāo)血壓為：對(duì)于未能控制出血的創(chuàng)傷患者：MAP 40 mmHg直至通過手術(shù)控制出血。推薦級(jí)別1；證據(jù)級(jí)別中等(B)對(duì)于沒有全身出血的TBI患者：MAP 90 mmHg。推薦級(jí)別1；證據(jù)級(jí)別低(C)對(duì)于其他所有休克：MAP 65 mmHg。推薦級(jí)別1；證據(jù)級(jí)別中等(B)我們推薦休克復(fù)蘇時(shí)對(duì)目標(biāo)血壓進(jìn)行個(gè)體化。推薦級(jí)別1；證據(jù)級(jí)別

29、中等(B)我們推薦初始血壓目標(biāo)為MAP 65 mmHg。推薦級(jí)別1；證據(jù)級(jí)別低(C)對(duì)于未能控制的出血患者，如沒有重度顱腦損傷（即創(chuàng)傷患者），我們建議采用較低的目標(biāo)血壓。推薦級(jí)別2；證據(jù)級(jí)別低(C)對(duì)于有高血壓病史的感染患者，以及升高血壓后病情改善的患者，我們建議采用較高的MAP。推薦級(jí)別2；證據(jù)級(jí)別中等(B)2006年與年與2014年共識(shí)有關(guān)休克定義、血壓和輸液反應(yīng)性說明的主要區(qū)別年共識(shí)有關(guān)休克定義、血壓和輸液反應(yīng)性說明的主要區(qū)別有關(guān)輸液反應(yīng)性的說明我們不推薦常規(guī)使用評(píng)估輸液反應(yīng)性的動(dòng)態(tài)指標(biāo)（包括但不限于脈壓差變異，主動(dòng)脈血流改變，收縮壓變異，呼吸周期收縮壓變異試驗(yàn)，以及腔靜脈塌陷）。推薦級(jí)別