Long Brit, Koyfman Alex, Modisett Katharine L, Woods Christian J
Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas.
J Emerg Med. 2017 Apr;52(4):472-483. doi: 10.1016/j.jemermed.2016.10.008. Epub 2016 Nov 4.
Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment.
This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment.
Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario.
The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
脓毒症是急诊科常见的病症，大多数患者对复苏措施有反应，包括使用抗生素和静脉输液。然而，有一部分患者对标准治疗无反应。
本综述阐明了对标准治疗无反应的脓毒症患者管理的实际注意事项。
早期目标导向治疗彻底改变了脓毒症的管理。然而，缺乏为治疗后病情未改善的患者提供明确治疗算法的文献。难治性休克可定义为在充分补液（至少30ml/kg静脉输注）、使用两种血管升压药（其中一种为去甲肾上腺素）并给予抗生素后，患者仍存在血流动力学不稳定（平均动脉压≤65mmHg，乳酸≥4mmol/L，精神状态改变）。当在复苏早期明显缺乏改善时，系统地考虑源头控制、适当的容量复苏、充分的抗菌覆盖、血管升压药的选择、代谢病理情况以及复苏的并发症，如腹腔间隔室综合征和呼吸衰竭，能让急诊医生应对整个临床情况。
近年来，脓毒症的治疗发生了许多变化。对于初始复苏无适当反应的脓毒症患者的治疗，对急诊医生来说很棘手。本综述为感染性休克患者的复苏提供了实际注意事项。当脓毒症患者对标准治疗难治时，系统地评估患者及其临床过程可能会改善预后。
