多器官功能障碍综合征／严重脓毒症的中西医结合治疗方案

Protocals for treatment of multiple organ dysfunction syndrome/severe sepsis combined of traditional Chinese medicine and Western medicine

目的2003年，欧洲“拯救脓毒症运动”（SSC）会议提出了《脓毒症治疗指南》，该指南虽在临床广为使用，但是并没有显著降低脓毒症患者的病死率。北京市多器官功能障碍综合征（MODS）课题组依据自己的临床研究结果，提出中西医结合的《MODS／严重脓毒症治疗指南》作为对SSC指南的补充。方法依据循征医学，在MODS免疫调理、早期抗凝、胃肠促动、急性呼吸窘迫综合征（ARDS）患者的小潮气量机械通气加肺复张法等方面，进行了多中心、大样本、临床对照研究，并提出4项推荐意见。推荐级别参见Delphi分级。结果草案包括4项推荐意见：①对MODS／严重脓毒症患者，建议进行免疫调理治疗（B级）；②MODS／严重脓毒症患者易发生凝血功能障碍，建议早期抗凝治疗（B级）；③MODS／严重脓毒症易发生肠道功能障碍，建议应用中药通腑治疗（B级）；④ARDS患者推荐应用小潮气量机械通气加肺复张法（B级）。结论本推荐意见涉及到脓毒症治疗中SSC指南回避的一些问题，希望能有助改善MODS患者的转归；本指南只是初步的草案，有待进一步完善。

Objective In 2003, European critical care experts have drafted surviving sepsis campaign （SSC） guidelines for therapy of sepsis, and it would be of practical use for the clinician, but case mortality of severe sepsis was expected to lower obviously. Our effort is to draft our guidelines of combining traditional Chinese medicine and western medicine as a supplement to SSC guidelines. Methods On evidence- based medicine, We undertook some large - sample randomized clinical trials in immunity regulation, anticoagulant therapy, promoting motility of intestinal tract in patients with severe sepsis and mechanical ventilation for acute respiratory distress syndrome （ARDS）. The modified Delphi methodology was used for grading recommendations. Results It was essential to control the primary disease in multiple organ dysfunction syndrome （MODS）. Our four recommendations were graded B according to the modified Delphi methodology. First, modulation of immunity benefitted MODS/severe sepsis; second, early anticoagulant therapy was essential to MODS/severe sepsis, because disseminated intravascular coagulopathy occurred in 44. 1% of MODS; third, Chinese herb medicines could promote and protect gastrointestinal function in MODS/severe sepsis; fourth, institution of mechanical ventilation with low tidal volume （VT） was effective and safe in ARDS. Conclusion The present guidelines supplements some pertinent problems which were neglected in SSC guidelines for the management of MODS/severe sepsis,and they may hopefully improve the outcome of the critically ill patient. The guidelines will be updated when some important new knowledge becomes available.