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[NEJM临床病例决策]:感染性休克的治疗(问题)
2017年08月13日 临床话题, 模拟诊室 暂无评论

CASE VIGNETTE

A Woman with Septic Shock

Rebecca E. Berger, M.D.

http://www.nejm.org/doi/full/10.1056/NEJMclde1705277#discussion

Ms. Jones is a 65-year-old woman with a history of hypertension who presents to the emergency department with a 3-day history of chills and dysuria. The only medication she is taking is amlodipine, at a dose of 10 mg daily; she had had normal electrolyte levels and renal function at a routine visit 6 weeks earlier. On arrival at the emergency department, she reports feeling dizzy.

She is 165 cm (65 in.) tall and weighs 70 kg (154 lb). Her temperature is 38.6°C (101.5°F), heart rate 125 beats per minute, blood pressure 85/55 mm Hg (mean arterial pressure, 65 mm Hg), respiratory rate 28 breaths per minute, and oxygen saturation as measured by pulse oximetry 94% while she is breathing ambient air. A physical examination reveals dry mucous membranes; undetectable jugular venous pulsation; tachycardia without gallops, rubs, or murmurs; clear lungs; and warm extremities. She has tenderness on palpation of her suprapubic region. You begin intravenous administration of a bolus of crystalloid solution.

Laboratory testing shows a creatinine level of 1.8 mg per deciliter (159 μmol per liter) (normal range, 0.5 to 1.1 mg per deciliter [44 to 97 μmol per liter]), blood urea nitrogen 76 mg per deciliter (27 mmol per liter) (normal range, 7 to 20 mg per deciliter [2 to 7 mmol per liter]), lactate 5.0 mmol per liter (normal value, <2.0), anion gap 25 mmol per liter (normal range, 8 to 15), white-cell count 20,000 per cubic millimeter (normal range, 4500 to 11,000), and hemoglobin 9.0 g per deciliter (normal range, 12.0 to 15.5). Urinalysis shows 3+ leukocyte esterase, more than 100 white cells per high-power field, and abundant bacteria.

You make a presumptive diagnosis of sepsis from a urinary source and begin treatment with intravenous antibiotics to target likely urinary pathogens. Ultrasonography of the kidneys and bladder reveals no hydronephrosis or evidence of obstruction.

After administration of 2100 ml of crystalloid fluid (30 ml per kilogram of body weight), the patient’s jugular venous pressure is 8 cm of water, but her systemic arterial pressure has decreased to 80/50 mm Hg (mean arterial pressure, 60 mm Hg). During the 3 hours that she has been in the emergency department, she has produced 20 ml of urine, as measured through a Foley catheter that was placed on her arrival.

You place a central venous catheter and initiate a norepinephrine infusion, which you adjust with a goal of raising her mean arterial pressure to 65 to 70 mm Hg. She is transferred to the intensive care unit (ICU); on arrival in the ICU, her mean arterial pressure is 65 mm Hg while she is receiving 40 μg of norepinephrine per minute, and her heart rate is 100 beats per minute. A chest radiograph shows early evidence of acute lung injury and good central catheter placement. Her arterial oxygen saturation is 100% while she is receiving 4 liters of oxygen through a nasal cannula.

You are aware that there are two main approaches to the management of septic shock in a patient such as Ms. Jones. One approach involves serial measurement of central venous pressure, central venous oxygen saturation (Scvo2), and hemoglobin, and following the early, goal-directed therapy (EGDT) protocol, in which specified targets are used for the initiation of inotropic agents or transfusion of red cells.1 For example, if the central venous pressure is less than 8 mm Hg, additional fluid resuscitation is administered; if the Scvo2 is less than 70%, the patient receives a transfusion of red cells until a hematocrit goal of at least 30% is reached, and if the Scvo2 remains less than 70%, inotropic support is initiated.

The second approach involves continuing intravenous administration of antibiotics and vasopressors, guided by clinical signs including blood pressure and urine output, without serial central venous pressure monitoring, serial Scvo2 monitoring, transfusion of red cells, or administration of inotropic agents. You are undecided about which of these approaches would maximize the chance of survival for your patient with septic shock.

TREATMENT OPTIONS

Which of the following treatment strategies should you pursue for this patient?

  • 1. Follow the EGDT protocol.

  • 2. Monitor the patient and administer treatment on the basis of clinical signs.

To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose? Make your choice, vote, and offer your comments at NEJM.org.

  • Option 1: Follow the EGDT Protocol
  • Option 2: Monitor the Patient and Administer Treatment on the Basis of Clinical Signs

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