急诊成人脓毒症防治的新认识——美国急诊医师协会“急诊科与院前成人疑似脓毒症患者早期诊疗共识”解析

New understanding of prevention and treatment of adult sepsis in emergency department——Interpretation of "Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment:A Consensus-Based Task" issued by American Co

美国急诊医师协会(ACEP)2021年4月发布《急诊科与院前成人疑似脓毒症患者早期诊疗共识》。ACEP共识中的部分观点对拯救脓毒症运动(SSC)2016指南提出了质疑,其补充说明了院前急救与急诊科在脓毒症患者处置的原则,调整了SSC 2016指南的一些细节,更富有急诊特色。本文综合ACEP共识、SSC 2016指南以及中国预防脓毒症(PSCC)共识,对其中相关内容进行了对比分析。目前各个共识均以Sepsis-3脓毒症定义与诊断为标准,但ACEP共识与PSCC共识均将脓毒症的关注点前移,提出了"疑似脓毒症"的概念,这是由于急诊医师经常面对各种诊断尚不明确的患者,可能会对非脓毒症患者造成误诊及不恰当的早期治疗。在脓毒症早期筛查工具中,ACEP共识与PSCC共识均认为qSOFA评分在急诊脓毒症患者早期筛查的作用有限。对于脓毒症的治疗,ACEP共识仍需围绕评估感染部位、抗感染、液体复苏及使用血管活性药物进行,动态评估脏器损伤程度、患者状态及循环情况亦至关重要。抗感染治疗应结合当地常见病原体及耐药情况优先针对G^(-)菌和G^(+)菌应用广谱抗生素。ACEP共识仍然沿用了"液体复苏"的概念,并推荐使用平衡晶体液治疗,30 mL/kg是初始复苏补液量的可参照指标,但并不适用于全部患者;而PSCC共识则提出更早期的"液体支持治疗"。两个共识都提出"需结合患者病情变化及容量反应性进行综合评估"。去甲肾上腺素是一线的血管活性药,ACEP共识未对液体复苏与血管活动药物应用的先后顺序进行要求。推荐将SOFA评分作为急诊脓毒症患者病情严重程度评估的标准,可在一定条件下使用SpO_(2)/FiO_(2)替代PaO_(2)/FiO_(2)来简化SOFA评分标准。我们需要有脓毒症预防的理念,需关注尚未发展为脓毒症的感染患者,提早进行干预以预防和阻断脓毒症的发生。急诊工作中,依据实际情况,综合参照指南与共识,为急诊疑似脓毒症及脓毒症患者提供精准、及时、高效的治疗。

The American College of Emergency Physicians(ACEP) issued " Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task" in April 2021. ACEP consensus raises doubts about some viewpoints of the SSC 2016 guidelines. The new consensus has more emergency characteristics for adding the principles of early sepsis management in the emergency department and the out-of-hospital environment and adjusting some details of the SSC 2016 guidelines. In present paper, we made a comparative analysis based on the ACEP consensus, the SSC 2016 guidelines and the consensus of Preventing Sepsis Campaign in China(PSCC). All of them were based on the Sepsis-3 consensus. Since emergency physicians often face patients with an uncertain diagnosis, misdiagnosis and inappropriate early treatment may do harm to non-sepsis patients, the ACEP consensus and PSCC consensus coming up with "Suspected Sepsis" concept advocated early prevention and treatment of sepsis. Both of the ACEP consensus and PSCC consensus suggested that qSOFA scoring system plays a limited role in early screening of sepsis. Evaluation for source of infection, using antimicrobials, intravenous fluid administration and using vasopressors are key steps of sepsis intervention in emergency department. Dynamic assessment of the severity of organs damage, patient status and hemodynamic conditions are also critical. Screening of the infected sites is priority to focus on the respiratory system and urinary system, both of them are the most two common sites of infection. For the diagnosed or deemed likely sepsis patients without an identified pathogen, broad-spectrum antibiotics with activity against gram-negative and gram-positive bacteria according to local susceptibility patterns and antibiotics resistance status. The concentration of antibiotics at the site of infection is also an important factor to be considered. Balanced crystalloid solutions is recommended to be used as the primary resuscitation fiuid in ACEP consensus. 30 mL/kg is a reference volume, but is not suitable for all patients. PSCC consensus suggested giving fluid support therapy in theearlier stage. The viewpoint that patient response and volume responsiveness may serve as the best indicators of the appropriateness of fiuid resuscitation volume were accepted by both consensuses. Norepinephrine is the first-line vasopressor. ACEP consensus does not recognize a specific minimum fiuid amount before starting vasopressor support. SOFA scores is recommended to be used to assess severity of emergency sepsis patients. Meanwhile, SpO_(2)/FiO_(2) could be used to replace PaO_(2)/FiO_(2) to simplify SOFA scores under certain conditions. We need to construct the concept of sepsis prevention and blocking. It is necessary to pay attention to infected patients who have not yet developed sepsis, and give intervention early to prevent and block sepsis. Comprehensively considering of different guidelines/consensus and rational use them based on the clinical practice are the key methods to provide timely and efficient treatment to suspected sepsis and sepsis patients in emergency.