- 期刊
嚴重敗血症患者的血糖控制、腎臟替代治療及輸血治療
Glucose Control, Renal Replacement Therapy and Blood Product Administration in Severe Sepsis Patients
摘要
嚴重敗血症患者的血糖控制，在加護病房最好以靜脈注射方式給予胰島素，依循一個有效的血糖控制流程表，來調整胰島素的量，血糖控制目標在150mg/dl以下，每1-2小時追蹤血糖一次，若血糖值穩定可4小時追蹤一次。若敗血症合併腎衰竭需洗腎，可使用間斷式血液透析或連續性血液透析兩種方式，兩種方法各有優缺點，對患者的死亡率沒有顯著性的差別，但對於血液動力學不穩的患者，連續性血液透析較好操作。患者若沒有合併心臟缺氧、嚴重的低血氧、急性出血、發紺性心臟病或乳酸中毒，血色素可以維持到7-9g/dl之間，血色素低於7g/dl時，再予以輸血治療，不要使用紅血球生成素來治療敗血症引起的貧血，除非敗血症患者合併腎衰竭導致造血功能下降。不要使用新鮮冷凍血漿來治療凝血異常患者，除非患者有出血的現象，或要做侵入性的檢查或治療。不要使用抗凝血酵素。血小板低於5000/立方公厘，不管有無出血現象予以輸血小板；血小板在5000到30000/立方公厘之間，若有出血之風險，可以補充血小板；若要開刀或做侵入性檢查，血小板可以輸到50000/立方公厘以上再做。
並列摘要
Patients with severe sepsis and hyperglycemia who are admitted to the ICU receive intravenous insulin therapy to reduce blood glucose level. We suggest use of a validated protocol for insulin dose adjustments and targeting glucose levels to the ＜ 150mg/ dl and blood glucose values be monitored every 1-2 hours until glucose values and insulin infusion rates are stable and then every 4 hours thereafter. Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure. There are no significant differences of hospital mortality rate between patients who receive continuous and intermittent renal replacement therapies. Continuous renal replacement therapies are suggested to facilitate management of fluid balance in hemodynamically unstable septic patients. We recommend that red blood cell transfusion occur when hemoglobin decrease to 7.0 g/ dl to target a hemoglobin 7-9 g/dl in adults if tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease or lactic acidosis. Erythropoietin should not be used a specific treatment of anemia associated with severe sepsis except septic patients with renal failure-induced compromise if red blood cell production. Fresh frozen plasma do not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedure. Antithrombin should not be administered for the treatment of severe sepsis and septic shock. We suggested that platelets be administered when counts are ＜5000/mm^3 regardless of apparent bleeding. Platelet may be considered when counts are 5000-30000/mm^3 and there is a significant risk of bleeding. Higher platelet counts (≧50000/mm^3) are typically required for surgery or invasive procedure.