Sessler Curtis N, Perry John C, Varney Kimberly L
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.
Curr Opin Crit Care. 2004 Oct;10(5):354-63. doi: 10.1097/01.ccx.0000139363.76068.7b.
Severe sepsis and septic shock are common and deadly conditions for which the epidemiology, pathogenesis, and management continue to evolve. Recent publications (2003 and early 2004) have been systematically reviewed for important new original research and scholarly reviews, with an emphasis on clinical advances in adults.
Important new epidemiologic studies establish the increasing frequency (nearly 9% per year) and falling mortality rates associated with sepsis. Sepsis definitions were reviewed by a group of experts, and the principal features of the 1991 consensus conference definitions were supported, with a new framework for evaluation of sepsis proposed. New research and thoughtful reviews continue to elucidate the pathogenesis of sepsis, with emphasis on innate immunity and time-based changes in immune status, varying from hyperreactive immunity and inflammation to immune depression with enhanced risk for nosocomial infections. A comprehensive evidence-based approach to the management of severe sepsis is presented in an important document developed by representatives from many critical care and infectious disease societies. Management includes early targeted resuscitation, broad empiric antibiotic coverage and source control, effective shock evaluation and treatment, adjuvant therapy with recombinant human activated protein C and moderate-dose hydrocortisone in selected patients, and comprehensive supportive care. Recently published multicenter clinical trials for novel agents have been disappointing, particularly for a nitric oxide synthase inhibitor that effectively supported blood pressure but increased mortality.
The works reviewed reflect the advances in the care of patients with sepsis.
严重脓毒症和脓毒性休克是常见的致命病症，其流行病学、发病机制及治疗方法都在不断演变。对2003年及2004年初发表的近期文献进行了系统回顾，以获取重要的新原创研究和学术综述，重点关注成人患者的临床进展。
重要的新流行病学研究表明脓毒症的发病率呈上升趋势（每年近9%），死亡率则有所下降。一组专家对脓毒症的定义进行了回顾，支持1991年共识会议定义的主要特征，并提出了一个脓毒症评估的新框架。新的研究和深入的综述继续阐明脓毒症的发病机制，重点关注固有免疫以及免疫状态随时间的变化，从免疫反应亢进和炎症到免疫抑制，后者会增加医院感染的风险。许多重症监护和传染病学会的代表共同制定了一份重要文件，提出了一种基于循证医学的综合方法来治疗严重脓毒症。治疗措施包括早期目标导向性复苏、广泛的经验性抗生素覆盖和源头控制、有效的休克评估和治疗、在特定患者中使用重组人活化蛋白C和中等剂量氢化可的松进行辅助治疗以及全面的支持治疗。最近发表的针对新型药物的多中心临床试验结果令人失望，尤其是一种一氧化氮合酶抑制剂，它虽能有效维持血压，但却增加了死亡率。
所综述的文献反映了脓毒症患者治疗方面的进展。
