留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

老年脓毒症患者围术期管理专家共识(2021年)

于吉人 王锷 王迪芬 仓静 冯艺 张西京 杨毅 杨云梅 吴水晶 汪炜健 杜斌 尚游 林茹 程宝莉 谢郭豪 方向明

于吉人, 王锷, 王迪芬, 仓静, 冯艺, 张西京, 杨毅, 杨云梅, 吴水晶, 汪炜健, 杜斌, 尚游, 林茹, 程宝莉, 谢郭豪, 方向明. 老年脓毒症患者围术期管理专家共识(2021年)[J]. 协和医学杂志, 2021, 12(4): 481-489. doi: 10.12290/xhyxzz.2021-0312
引用本文: 于吉人, 王锷, 王迪芬, 仓静, 冯艺, 张西京, 杨毅, 杨云梅, 吴水晶, 汪炜健, 杜斌, 尚游, 林茹, 程宝莉, 谢郭豪, 方向明. 老年脓毒症患者围术期管理专家共识(2021年)[J]. 协和医学杂志, 2021, 12(4): 481-489. doi: 10.12290/xhyxzz.2021-0312
YU Jiren, WANG E, WANG Difen, CANG Jing, FENG Yi, ZHANG Xijing, YANG Yi, YANG Yunmei, WU Shuijing, WANG Weijian, DU Bin, SHANG You, LIN Ru, CHENG Baoli, XIE Guohao, FANG Xiangming. Expert Consensus on Perioperative Management of Elderly Septic Patients (2021)[J]. Medical Journal of Peking Union Medical College Hospital, 2021, 12(4): 481-489. doi: 10.12290/xhyxzz.2021-0312
Citation: YU Jiren, WANG E, WANG Difen, CANG Jing, FENG Yi, ZHANG Xijing, YANG Yi, YANG Yunmei, WU Shuijing, WANG Weijian, DU Bin, SHANG You, LIN Ru, CHENG Baoli, XIE Guohao, FANG Xiangming. Expert Consensus on Perioperative Management of Elderly Septic Patients (2021)[J]. Medical Journal of Peking Union Medical College Hospital, 2021, 12(4): 481-489. doi: 10.12290/xhyxzz.2021-0312

老年脓毒症患者围术期管理专家共识(2021年)

doi: 10.12290/xhyxzz.2021-0312
基金项目: 

国家重点研发计划 2018YFC2001904

详细信息
    通讯作者:

    方向明  电话: 0571-88208006, E-mail: xmfang@zju.edu.cn

  • 中图分类号: R631;R782.05+3

Expert Consensus on Perioperative Management of Elderly Septic Patients (2021)

Funds: 

National Key Research and Development Program of China 2018YFC2001904

More Information
    Corresponding author: FANG Xiangming  Tel: 86-571-88208006, E-mail: xmfang@zju.edu.cn
  • 摘要: 随着人口老龄化加剧,老年患者手术量呈指数上升。一些危险因素如共病、用药前状态、营养不良、虚弱和免疫系统功能受损等与老年患者脓毒症的高易感性相关,这些因素不仅增加了脓毒症的发生风险,还可导致更严重的感染,并可能与更高的死亡率相关。与非老年患者相比,老年脓毒症患者的预后更差,但其治疗并无显著差异。此外,老年脓毒症幸存者的生活质量也较差。因此,为优化老年脓毒症患者围术期管理,相关学科临床专家就该问题进行讨论并制订了此共识。
    作者贡献:方向明教授牵头组织了专家共识撰写小组,建立了编辑委员会(编委会),并任命吴水晶、谢郭豪负责编委会对共识的撰写工作;吴水晶、谢郭豪共同起草了专家共识初稿,并在方向明教授的组织下联合编委会其他成员对共识进行修订、凝练推荐意见;于吉人、王锷、王迪芬、仓静、冯艺、张西京、杨毅、杨云梅、吴水晶、汪炜健、杜斌、尚游、林茹、程宝莉、谢郭豪、方向明共同参与了共识的三轮修订工作;在方向明教授的指导下,吴水晶、谢郭豪对专家共识终稿全文进行审校,所有作者均通过了共识终稿,并形成共识定稿。
    利益冲突:
  • 表  1  SOFA评分标准[1]

    器官系统 评分
    0 1 2 3 4
    呼吸系统
      PaO2/FiO2(mm Hg) ≥400 <400 <300 <200 <100
      呼吸支持 - - - 需要 需要
    凝血系统
      血小板(×109/L) ≥150 <150 <100 <50 <20
    肝脏
      胆红素(μmol/L) <20 20~32 33~101 102~204 >204
    循环系统
      平均动脉压(mm Hg) ≥70 <70 - - -
      儿茶酚胺类药物a [μg/(kg·min)] - - 多巴胺<5或任何剂量的多巴酚丁胺 多巴胺5.1~15或肾上腺素≤0.1或去甲肾上腺素≤0.1 多巴胺>15或肾上腺素>0.1或去甲肾上腺素>0.1
    中枢神经系统
      GCS评分 15 13~14 10~12 6~9 <6
    肾脏b
      肌酐(μmol/L) <110 110~170 171~299 300~440 >440
      24 h尿量(mL) - - - <500 <200
    SOFA:序贯性器官衰竭评分;PaO2/FiO2:动脉血氧分压与吸入气氧浓度的比值,即氧合指数;GCS:格拉斯哥昏迷指数;a儿茶酚胺类药物的使用时间至少为1 h; b肌酐或24 h尿量一项达到标准即评为3分或4分;-:不需要或未给出标准
    下载: 导出CSV
  • [1] Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the third international consensus definitions for sepsis and septic shock (sepsis-3)[J]. JAMA, 2016, 315: 775-787. doi:  10.1001/jama.2016.0289
    [2] Fleischmann-Struzek C, Mellhammar L, Rose N, et al. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis[J]. Intensive Care Med, 2020, 46: 1552-1562. doi:  10.1007/s00134-020-06151-x
    [3] Shetty AK, Kodali M, Upadhya R, et al. Emerging anti-aging strategies-scientific basis and efficacy[J]. Aging Dis, 2018, 9: 1165-1184. doi:  10.14336/AD.2018.1026
    [4] Martin GS, Mannino DM, Eaton S, et al. The epidemio-logy of sepsis in the United States from 1979 through 2000[J]. N Engl J Med, 2003, 348: 1546-1554. doi:  10.1056/NEJMoa022139
    [5] American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea[J]. Anesthesiology, 2014, 120: 268-286. doi:  10.1097/ALN.0000000000000053
    [6] Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign bundle: 2018 update[J]. Crit Care Med, 2018, 46: 997-1000. doi:  10.1097/CCM.0000000000003119
    [7] Yuki K, Murakami N. Sepsis pathophysiology and anes-thetic consideration[J]. Cardiovasc Hematol Disord Drug Targets, 2015, 15: 57-69. doi:  10.2174/1871529X15666150108114810
    [8] Li Y, Chen D, Wang H, et al. Intravenous versus volatile anesthetic effects on postoperative cognition in elderly patients undergoing laparoscopic abdominal surgery[J]. Anesthesiology, 2021, 134: 381-394. doi:  10.1097/ALN.0000000000003680
    [9] Herling SF, Dreijer B, Wrist Lam G, et al. Total intravenous anaesthesia versus inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic surgery[J]. Cochrane Database Syst Rev, 2017(4): CD011387. http://europepmc.org/abstract/MED/28374886
    [10] 李佳静, 季方兵, 郑曼, 等. 全凭静脉麻醉与全程吸入麻醉对老年腹部手术患者心脏功能的影响[J]. 临床麻醉学杂志, 2019, 35: 137-140. doi:  10.12089/jca.2019.02.008

    Li JJ, Ji FB, Zheng M, et al. Effects of all intravenous anesthesia versus total inhalation anesthesia on the cardiac function in elderly patients during intestinal surgery[J]. Linchuang Mazuixue Zazhi, 2019, 35: 137-140. doi:  10.12089/jca.2019.02.008
    [11] Kim S, Brooks AK, Groban L. Preoperative assessment of the older surgical patient: honing in on geriatric syndromes[J]. Clin Interv Aging, 2015, 10: 13-27. http://europepmc.org/abstract/med/25565783
    [12] 中华医学会麻醉学分会老年人麻醉与围术期管理学组, 国家老年疾病临床医学研究中心, 国家老年麻醉联盟. 中国老年患者围术期麻醉管理指导意见(2020版)(二)[J]. 中华医学杂志, 2020, 100: 2565-2578. doi:  10.3760/cma.j.cn112137-20200503-01407
    [13] 吴本俨. 老年人消化系统的衰老改变[J]. 中华老年医学杂志, 2007, 26: 76-78. doi:  10.3760/j:issn:0254-9026.2007.01.025
    [14] Li H, Wang W, Lu YP, et al. Evaluation of endotracheal intubation with a flexible fiberoptic bronchoscope in lateral patient positioning: a prospective randomized controlled trial[J]. Chin Med J (Engl), 2016, 129: 2045-2049. doi:  10.4103/0366-6999.189069
    [15] Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis[J]. Br J Anaesth, 2010, 105: 734-743. doi:  10.1093/bja/aeq305
    [16] Naeije G, Pepersack T. Delirium in elderly people[J]. Lancet, 2014, 383: 2044-2045. doi:  10.1016/S0140-6736(14)60993-4
    [17] Heinrich S, Schmidt J, Ackermann A, et al. Comparison of clinical outcome variables in patients with and without etomidate-facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis[J]. Crit Care, 2014, 18: R150. doi:  10.1186/cc13988
    [18] McPhee LC, Badawi O, Fraser GL, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database[J]. Crit Care Med, 2013, 41: 774-783. doi:  10.1097/CCM.0b013e318274190d
    [19] Gu WJ, Wang F, Tang L, et al. Single-dose etomidate does not increase mortality in patients with sepsis: a systematic review and meta-analysis of randomized controlled trials and observational studies[J]. Chest, 2015, 147: 335-346. doi:  10.1378/chest.14-1012
    [20] Zausig YA, Busse H, Lunz D, et al. Cardiac effects of induction agents in the septic rat heart[J]. Crit Care, 2009, 13: R144. doi:  10.1186/cc8038
    [21] Kochiyama T, Li X, Nakayama H, et al. Effect of propofol on the production of inflammatory cytokines by human polarized macrophages[J]. Mediators Inflamm, 2019, 2019: 1919538. http://www.ncbi.nlm.nih.gov/pubmed/31007601
    [22] Marra EM, Mazer-Amirshahi M, Mullins P, et al. Opioid administration and prescribing in older adults in U.S. emergency departments (2005-2015)[J]. West J Emerg Med, 2018, 19: 678-688. doi:  10.5811/westjem.2018.5.37853
    [23] Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step Ⅲ opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone)[J]. Pain Pract, 2008, 8: 287-313. doi:  10.1111/j.1533-2500.2008.00204.x
    [24] Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock[J]. Eur Heart J, 2012, 33: 895-903. doi:  10.1093/eurheartj/ehr351
    [25] Mouncey PR, Osborn TM, Power GS, et al. Protocolised management in sepsis (ProMISe): a multicentre rando-mised controlled trial of the clinical effectiveness and cost-ef-fectiveness of early, goal-directed, protocolised resuscita-tion for emerging septic shock[J]. Health Technol Assess, 2015, 19: i-xxv, 1-150. http://www.ncbi.nlm.nih.gov/pubmed/26597979
    [26] Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock[J]. N Engl J Med, 2014, 371: 1496-1506. doi:  10.1056/NEJMoa1404380
    [27] Rowan KM, Angus DC, Bailey M, et al. Early, Goal-directed therapy for septic shock - A patient-level meta-analysis[J]. N Engl J Med, 2017, 376: 2223-2234. doi:  10.1056/NEJMoa1701380
    [28] Perner A, Haase N, Winkel P, et al. Long-term outcomes in patients with severe sepsis randomised to resuscitation with hydroxyethyl starch 130/0.42 or Ringer's acetate[J]. Intensive Care Med, 2014, 40: 927-934. doi:  10.1007/s00134-014-3311-y
    [29] Park CHL, de Almeida JP, de Oliveira GQ, et al. Lactated Ringer's Versus 4% Albumin on Lactated Ringer's in Early Sepsis Therapy in Cancer Patients: A Pilot Single-Center Randomized Trial[J]. Crit Care Med, 2019, 47: e798-e805. doi:  10.1097/CCM.0000000000003900
    [30] De Backer D, Aldecoa C, Njimi H, et al. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis[J]. Crit Care Med, 2012, 40: 725-730. doi:  10.1097/CCM.0b013e31823778ee
    [31] Jin Y, Ying J, Zhang K, et al. Endotracheal intubation under video laryngoscopic guidance during upper gastrointestinal endoscopic surgery in the left lateral position: A randomized controlled trial[J]. Medicine (Baltimore), 2017, 96: e9461. doi:  10.1097/MD.0000000000009461
    [32] Fan E, Brodie D, Slutsky AS. Acute respiratory distress syndrome: advances in diagnosis and treatment[J]. JAMA, 2018, 319: 698-710. doi:  10.1001/jama.2017.21907
    [33] Futier E, Marret E, Jaber S. Perioperative positive pressure ventilation: an integrated approach to improve pulmonary care[J]. Anesthesiology, 2014, 121: 400-408. doi:  10.1097/ALN.0000000000000335
    [34] Lescot T, Karvellas C, Beaussier M, et al. Acquired liver injury in the intensive care unit[J]. Anesthesiology, 2012, 117: 898-904. doi:  10.1097/ALN.0b013e318266c6df
    [35] Joannidis M, Druml W, Forni LG, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017: expert opinion of the working group on prevention, AKI section, European Society of Intensive Care Medicine[J]. Intensive Care Med, 2017, 43: 730-749. doi:  10.1007/s00134-017-4832-y
    [36] Gofton TE, Young GB. Sepsis-associated encephalopathy[J]. Nat Rev Neurol, 2012, 8: 557-566. doi:  10.1038/nrneurol.2012.183
    [37] Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016[J]. Intensive Care Med, 2017, 43: 304-377. doi:  10.1007/s00134-017-4683-6
    [38] Wang N, Liu X, Zheng X, et al. Ulinastatin is a novel candidate drug for sepsis and secondary acute lung injury, evidence from an optimized CLP rat model[J]. Int Immunopharmacol, 2013, 17: 799-807. doi:  10.1016/j.intimp.2013.09.004
    [39] He QL, Zhong F, Ye F, et al. Does intraoperative ulinastatin improve postoperative clinical outcomes in patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials[J]. Biomed Res Int, 2014, 2014: 630835. http://pubmedcentralcanada.ca/pmcc/articles/PMC3964764/
    [40] Karnad DR, Bhadade R, Verma PK, et al. Intravenous administration of ulinastatin (human urinary trypsin inhibitor) in severe sepsis: a multicenter randomized controlled study[J]. Intensive Care Med, 2014, 40: 830-838. doi:  10.1007/s00134-014-3278-8
    [41] Pei F, Guan X, Wu J. Thymosin alpha 1 treatment for patients with sepsis[J]. Expert Opin Biol Ther, 2018, 18: 71-76. doi:  10.1080/14712598.2018.1484104
    [42] Liu MW, Wang YH, Qian CY, et al. Xuebijing exerts protective effects on lung permeability leakage and lung injury by upregulating Toll-interacting protein expression in rats with sepsis[J]. Int J Mol Med, 2014, 34: 1492-1504. doi:  10.3892/ijmm.2014.1943
    [43] Yin Q, Li C. Treatment effects of xuebijing injection in severe septic patients with disseminated intravascular coagula-tion[J]. Evid Based Complement Alternat Med, 2014, 2014: 949254.
    [44] Zhang Y, Chen H, Li YM, et al. Thymosin alpha1- and ulinastatin-based immunomodulatory strategy for sepsis arising from intra-abdominal infection due to carbapenem-resistant bacteria[J]. J Infect Dis, 2008, 198: 723-730. doi:  10.1086/590500
    [45] Martín S, Pérez A, Aldecoa C. Sepsis and immunosenescence in the elderly patient: a review[J]. Front Med (Lausanne), 2017, 4: 20. http://www.ncbi.nlm.nih.gov/pubmed/28293557
  • 加载中
表(1)
计量
  • 文章访问数:  95
  • HTML全文浏览量:  18
  • PDF下载量:  47
  • 被引次数: 0
出版历程
  • 收稿日期:  2021-04-06
  • 录用日期:  2021-04-29
  • 刊出日期:  2021-07-30

目录

    /

    返回文章
    返回