- 期刊
呼吸照護－嚴重敗血症病患使用呼吸器的面面觀
Surviving Sepsis Campaign for Severe Sepsis and Septic Shock-Management Guideline for Respiratory Care
摘要
重度敗血症常會造成急性呼吸衰竭。其中又以急性肺傷害(ALI)、急性呼吸窘迫症(ARDS)最爲常見。這些病患多需要使用呼吸器以度過這段急性危險期。本文僅就重度敗血症、敗血性休克病患如何協助他們度過急性呼吸衰竭，陳述其指導方針。本文依據Delphi與55位全球專家經由視訊會議於2004及2008 年結論的方法，將指導方針的臨床證據強弱由高到低分爲A到D。而臨床建議的強弱分爲(Grade 1)-高度建議：使用價值明顯高過其危險性、費用及副作用及(Grade 2)-低度建議：使用價值與其危險性、副作用兩者差距不大。 用低潮氣容積(Grade 1B)以及限制進氣末正壓(Grade 1C)對急性肺損傷及急性呼吸窘迫症確有臨床價值。吐氣末正壓對急性肺損傷的應用(Grade 1C)有益。除非有特別禁忌，使用呼吸器病患頭部應上仰(Grade1B)。肺動脈導管應避免列爲急性肺損傷病患常規使用(Grade 1A)。當ALI/ARDS病患未處於休克時，宜保守給予輸液，以減少呼吸器及加護病房留滯日數(Grade 1C)。擬定呼吸器脫離計畫，依計畫給予鎮定劑、止痛劑且每日中斷給藥以評估呼吸器脫離可能性(Grade 1B)。如果可能的話，盡量避免使用肌肉鬆弛劑(Grade 1B)。
並列摘要
Acute respiratory failure is very common during severe sepsis (sepsis with organ failure) and septic shock. Mechanical ventilation is usually indicated for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). A low tidal volume (Grade 1B) and limitation of inspiratory plateau pressure strategy (Grade 1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) has been proved to reduce mortality. Application of positive end expiratory pressure (PEEP) in acute lung injury (Grade 1C), head of bed elevation in mechanically ventilated patients unless contraindicated (1B) are recommended. Avoiding routine use of pulmonary artery catheters in ALI/ARDS (Grade 1A), a conservative fluid strategy for patients with ALI/ARDS who are not in shock (Grade 1C), protocol for weaning and sedation/analgesia (Grade 1B) may reduce days of mechanical ventilation and ICU stay up. Using either intermittent bolus sedation or continuous infusion sedation with daily interruption or lightening and avoidance of neuromuscular blockers (Grade 1B), if possible are helpful to reduce days of mechanically ventilation and ICU stay up.