妊娠和产褥期脓毒症早期识别和处理

Early recognition and management of sepsis during pregnancy and puerperium

脓毒症和脓毒性休克是产科急症,其早期识别、进入重症医学科前的紧急干预和产科处理是产科医生需要重视及关注的临床问题。妊娠和产褥期生理性变化使得脓毒症临床特征不易被识别。对于可能的脓毒症,可使用简单的床边筛查工具进行早期识别。如果脓毒症筛查呈阳性,怀疑或存在感染证据时,无论是否发热,需进一步评估器官损伤的证据进行脓毒症诊断。识别脓毒症后的1 h内启动集束化治疗:疑似或确诊脓毒症的孕产妇,应尽早进行细菌培养(血液、尿液、呼吸道及其他部位体液)和血清乳酸水平测定;最好在1 h内给予经验性广谱抗生素治疗;建议在脓毒症并发低血压或器官灌注不足时尽早给予1~2 L晶体溶液进行液体复苏;尽管进行了液体复苏,但仍伴有持续低血压和/或灌注不足,建议使用血管升压药物以维持平均动脉压≥65 mmHg(1 mmHg=0.133 kPa),去甲肾上腺素作为一线药物。当怀疑或确诊脓毒症时,应积极寻找感染病灶,有效控制感染源。不建议仅以脓毒症为唯一指征而立即终止妊娠,终止妊娠应依据产科指征,根据孕周、母体及胎儿情况进行个体化综合考虑。若明确存在宫内感染,应立即终止妊娠。剖宫产通常需要全身麻醉;施行椎管内麻醉是相对禁忌。妊娠和产褥期脓毒症的诊疗应在遵循指南基础上实施个体化治疗。

Sepsis and septic shock are obstetric emergencies,which bring clinical issues for obstetricians to pay attention to,such as early identification and emergency intervention before transferring the patients to intensive care.Physiological changes during pregnancy and puerperium result in difficulty in identifying the clinical features of sepsis.Simple bedside screening tools can be used for early identification and screening for possible sepsis.If initial sepsis screening is positive with suspected or evidence of infection,regardless of the presence of fever,further evaluation of organ damage is required for the diagnosis of sepsis.Bundle therapy should be initiated within 1 h after the identification of sepsis:For pregnant women or puerpera with suspected or confirmed sepsis,bacterial culture(blood,urine,respiratory tract,and other body fluids)and serum lactate level detection should be conducted promptly,moreover,empirical broad-spectrum antibiotics given within 1 h are recommended;For patients with sepsis complicated by hypotension or organ hypoperfusion,it is recommended to administer 1-2 L crystal solution as soon as possible for liquid resuscitation;For those with persistent hypotension and/or organ hypoperfusion despite fluid resuscitation,vasopressors are recommended to maintain mean arterial pressure≥65 mmHg(1 mmHg=0.133 kPa),with norepinephrine as the first-line vasopressor.When sepsis is suspected or confirmed,the focus of infection should be actively sought to effectively control the source.Termination of pregnancy should be considered individually and comprehensively on the basis of obstetric indications,gestational age,and maternal and fetal conditions,but not depend on sepsis alone.If intrauterine infection is confirmed,pregnancy should be terminated immediately.Cesarean delivery usually requires general anesthesia for pregnant women with sepsis and intraspinal anesthesia is relatively contraindicated.The diagnosis and treatment of sepsis in pregnancy and puerperium should be individualized in accordance with the corresponding guidelines.