摘要脓毒症是目前医学界面临的重大难题与挑战,随着现代医学的快速发展进步,各个领域对脓毒症的研究探索越来越深入。尽管多年来国际上对脓毒症采取积极的"拯救"措施,但是脓毒症的发病率和病死率仍然居高不下。根据目前国际指南对脓毒症定义的更新,脓毒症被定义为感染引起的宿主反应失调,进而导致循环功能障碍及器官功能损害。感染是引发脓毒症的最初源头,而从感染发展到脓毒症是一个复杂的病理生理过程,其中包括病原体的侵入、细胞因子的释放、毛细血管渗漏和微循环功能障碍等,最终导致器官代谢紊乱和功能衰竭。在目前国际采用的Sepsis-3指南推荐中,以感染+序贯器官衰竭评分(SOFA)≥2分为脓毒症诊断标准,应对脓毒症的策略更多侧重在器官功能的"拯救"治疗上。经过近20年的努力,"拯救脓毒症运动"并未得到令人满意的效果。急诊医学作为急危重症的前沿学科,能够最早收治急性感染患者。如果能够在感染早期从人群特点、感染病原体和部位、病情严重程度等方面来预测脓毒症发生的可能性,通过细胞因子检测及时发现"炎症风暴",利用有效的临床评分系统对患者进行评估,对脓毒症高危患者采取更为积极有效的治疗手段以防止和阻断感染向脓毒症发展的进程,将有可能大大降低急性感染患者的脓毒症发病率和病死率。基于此,中国急诊医学专家提出"预防与阻断"脓毒症的概念,并在全国范围内开展了"中国预防脓毒症行动"(PSCC),提出在"脓毒症前期"及"围脓毒症期"开展针对性的诊断、检查和处理,实现"早预防、早发现、早干预,降低脓毒症的发病率和病死率"的"三早两降",为急性重症感染患者的诊治提出一个新的思路。本共识由急诊医学领域的4个学(协)会及5个相关杂志出版机构共同倡导、探讨、撰写,由来自急诊医学、重症医学、感染病学、药学及检验医学等专业学科的40余名专家多次讨论形成。共识内容包括急性感染患者的确定识别、抗感染治疗、脓毒症高危患者的排查筛查、"炎症风暴"的发现和应对、血管内皮细胞的保护和凝血功能的调控、液体支持方案及器官功能保护策略等,不仅总结归纳了临床常用的西医诊断治疗措施,也将祖国医学在脓毒症防治中的优势融入共识,期望能为临床医生提供一个全面的诊疗参考,为减少感染患者发展为脓毒症提供可靠的诊疗依据。
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abstractsSepsis is an ongoing conundrum and challenge in medical field. With the rapid development and progress of modern medicine, sepsis has been researched and explored in greater depth across different fields. Although "Surviving Sepsis Campaign" (SSC) has been taken to tackle sepsis in the world for years, its incidence and mortality stay high. According to the updated definition of sepsis stated in the current international guidelines, sepsis is defined as the infection-induced host response disorder, which further results in circulation and/or organ dysfunction. The original source of sepsis is infection, and it is a complicated pathophysiological process from infection to sepsis, which involves the invasion of pathogens, release of cytokines, capillary leakage, and microcirculation dysfunction, thus causing organ metabolism disorder and failure. As shown in Sepsis-3, the sepsis diagnosis standard is stipulated as infection plus sequential organ failure assessment (SOFA) score ≥ 2, and the tackling of sepsis mainly lies on the "life-saving" treatment regarding organ functions. After about 20 years' efforts, SSC has not achieved satisfactory results. As a frontier discipline of acute and critical diseases, emergency medical department is able to receive and cure the patients with acute infection at the earliest. The incidence and mortality of sepsis could be greatly reduced if the possibility of sepsis can be predicted from population characteristics, pathogens and locations of infection, and severity of illness at the early stage of infection. Besides, timely discovering "inflammation storm" by cytokine detection and accessing the patients with an effective clinical scoring system should also be helpful to take more active and effective treatment to the high-risk patients, and block the progression from infection to sepsis. On such a basis, Chinese emergency medicine specialists have put forward the concept of "prevention and blocking" of sepsis, and carried out "Preventing Sepsis Campaign in China" (PSCC) throughout China. They have also proposed the principles of performing targeted diagnosis, examination and treatment at the "early stage of sepsis" and "peri-sepsis period", so as to realize the early prevention, early discovery, and early intervention, and reduce the morbidity and mortality of sepsis, thus providing a new concept for diagnosis and treatment of patients with acute severe infection. This consensus is jointly advocated, discussed and written by four academic societies (associations) and five related publishing houses, and formed after several turns of discussions by more than 40 specialists and experts from emergency medicine, critical medicine, infectious medicine, pharmacy, laboratory medicine, and other professional disciplines. This consensus involves determination and recognition of patients with acute infection, anti-infective therapy, screening of high-risk sepsis patients, discovery of and response to "inflammation storm", protection of vascular endothelial cells and regulation of coagulation function, liquid support scheme and organ function protection strategy, etc. This consensus summarizes the commonly used Western medical diagnosis and treatment measures, and also integrates the advantages of traditional Chinese medicine in prevention and treatment of sepsis, so as to provide a comprehensive reference for the clinicians to perform diagnosis and treatment, and provide a reliable basis for reducing progression of infected patients to sepsis.
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