What Is the Treatment for Gram-Negative Sepsis?

The pathogenesis of septic shock has not been fully elucidated. Bacterial toxins produced by infected bacteria can trigger complex immune responses, with the exception of endotoxin (the lipid component of lipopolysaccharide released from the cell wall of Gram-negative Enterobacteriaceae), There are also a large number of mediators, including tumor necrosis factor, leukotriene, lipoxygenase, histamine, bradykinin, serotonin, and interleukin-2.

Septic shock

Septic shock refers to shock caused by sepsis. In the past, it was called septic shock. It was defined as insufficient tissue perfusion of patients, that is, continuous hypotension or blood lactic acid concentration 4mmol / L after volume test. It is usually caused by Gram-negative bacilli and is mainly seen in acute purulent obstructive cholangitis, gangrene cholecystitis, pyelonephritis, acute pancreatitis, and some nosocomial infections.

Pathogenesis and Physiology of Septic Shock

The initial changes were dilation of arteries and arterioles, decreased peripheral arterial resistance, and normal or increased cardiac output. As the heart rate increases, the ejection fraction may decrease. Later cardiac output can decrease and peripheral resistance can increase. Despite increased cardiac output, the function of blood flowing into capillaries for exchange is impaired, and the supply of oxygen and the removal of carbon dioxide and waste are reduced. This decline in perfusion has particularly affected the kidneys and brain, which in turn has caused one or more organs Exhaustion. The result is a decrease in cardiac output and typical shock characteristics.

Susceptible populations and susceptible factors

Septic shock occurs in immunocompromised populations such as diabetes, liver cirrhosis, and leukopenia, especially in patients with tumors or cytotoxic drugs, patients with antibiotics, corticosteroids, or artificial respiratory devices, urinary tract, History of biliary or gastrointestinal infections. Invasive implants include catheters, drainage tubes, and other foreign bodies. Septic shock is more common in neonates, patients over 35 years of age, pregnant women, or patients with severe immunocompromised due to primary disease or patients with iatrogenic treatment complications.

Clinical manifestations and diagnosis of septic shock

Mainly proceed from the following three aspects: the manifestation of shock, sepsis, infection, and confirmation of infection.

Septic shock is distributed shock. The hemodynamic characteristics of the initial high-dynamic state are unique to sepsis: normal or increased cardiac output and reduced resistance of peripheral arteries, and warm and dry skin. A decrease in cardiac output with an increase in peripheral arterial resistance indicates a low dynamic state, which is usually seen in the later stages of septic shock. Hemodynamic measurement with a pulmonary artery catheter is helpful to rule out septic shock. Unlike hypovolemic shock, cardiac output is usually normal or increased while peripheral resistance is reduced during septic shock. Central venous pressure and pulmonary artery occlusion pressure are not the same. Will decrease. ECG can show non-specific ST-T wave abnormalities and supraventricular and ventricular arrhythmias. Part of the cause of this abnormality may be related to hypotension.

In the early stage of septic shock, the white blood cell count can be significantly reduced, among which polymorphonuclear leukocytes can be reduced to 20%, and the platelet count can be sharply reduced to 50,000 / l or less. But usually it can be quickly reversed within 1 to 4 hours, the total number of white blood cells and polymorphonuclear leukocytes increased significantly (polymorphonuclear leukocytes can rise to 80%, and the predominance of naive white blood cells).

Respiratory alkalosis with low PCO2 and increased arterial blood pH may occur early, which is also a compensation for lactaemia. Serum sodium bicarbonate usually decreases, and lactic acid in serum and blood increases. With the progress of shock, Metabolic acidosis follows, early respiratory failure can lead to hypoxemia, partial oxygen pressure (PO2) <70mmHg, ST segment depression, T wave inversion can be seen on ECG, occasionally atrial or ventricular arrhythmia, due to renal Functional failure and creatinine clearance decreased, and blood urea nitrogen and creatinine concentrations gradually increased.

Septic shock should be distinguished from hypovolemic shock, cardiogenic shock, and obstructive shock. Measuring urine specific gravity and osmotic pressure is helpful.

A PCT greater than 10 ng / ml is evidence of strong infection.

Septic shock treatment

Focus on infection, shock and maintenance of vital signs should be supported by nasal oxygen to support breathing, tracheal intubation or tracheotomy and mechanical artificial respiration can be used if necessary.

Anti-shock treatments such as fluid replacement and acidosis correction are needed.

Early and timely antibiotic treatment may play a life-saving role. For septic shock with unknown pathogens, gentamicin or tobramycin plus 3rd-generation cephalosporins (cefotaxime or ceftriaxone, or ceftazid if you suspect a Pseudomonas If it is caused by gram-positive bacteria, vancomycin should be added; the source of infection should be anti-anaerobic drugs (such as metronidazole) in the abdomen. Large-dose single-dose medications such as ceftazidime 2 g intravenously every 8 hours or imipenem 500 mg intravenously every 6 hours may be effective, but not recommended. If drug-resistant staphylococci or enterococci are suspected, vancomycin must be used. Once the results of the culture and susceptibility tests are obtained, the antibiotic treatment plan should be adjusted accordingly. Antibiotics should be used for several days after the shock has disappeared and the primary infection has been cleared.

Hemofiltration is a reliable method that has emerged in recent years and can play a role in removing inflammatory mediators and the like.

1 Septic shock 1 early resuscitation

1.1 Recommendations Once the clinical diagnosis is insufficient perfusion, it is recommended that active fluid resuscitation should be performed as soon as possible, and the resuscitation target should be reached within 6 hours of the initial resuscitation: Central venous pressure (CVP) 8 to 12 mm Hg; Mean arterial pressure (MAP ) 65mm Hg; urine output 0.5 ml · kg · h; central venous blood oxygen saturation (ScvO2) or mixed venous blood oxygen saturation (SvO2) is 70% or 65% (recommended level) : 1C).

1.2 Recommendations For patients with severe infections and septic shock, if the CVP has reached 8-12 mm Hg within 6 hours of early fluid resuscitation, and ScvO2 or SvO2 still does not reach 70% or 65%, it is recommended to infuse concentrated red blood cells. Make Hct 30%, and / or infuse dobutamine (maximum dose to 20 g · kg · min) to achieve recovery goals (recommended level: 2C).

2 fluid therapy

2.1 Recommendations It is recommended to use natural (artificial) colloid or crystal fluid for liquid resuscitation, but there is no evidence to support which type of liquid is better (recommended level: 1B).

2.2 Recommendations It is recommended that the early goal of fluid resuscitation is a CVP of at least 8 mm Hg (12 mm Hg for mechanically ventilated patients), and further fluid therapy is often required (recommended level: 1C).

2.3 Recommendations It is recommended to use fluid loading test, as long as the hemodynamics continue to improve (ie, arterial pressure, heart rate, urine volume), continue to rehydration (recommended level: 1D).

2. 4 Recommendations For patients with suspected hypovolemia, it is recommended to start at least 1 000 ml of crystal fluid or 300 to 500 ml of colloidal fluid for more than 30 minutes at the beginning. Patients with hypoperfusion induced by sepsis may need more and faster Rehydration

(Recommended level: 1D).

2.5 Recommendations When the heart filling pressure (CVP or pulmonary artery balloon occlusion pressure) increases and hemodynamics do not improve at the same time, it is recommended to slow down the fluid replacement rate (recommended level: 1D).

3 Vasopressors

3.1 Recommendations It is recommended to maintain a MAP 65mm Hg (recommended level: 1C). 3.2 Recommendations Norepinephrine or dopamine is recommended as the first booster in septic shock to correct hypotension (as far as possible through a central venous catheter) (push

Recommendation level: 1C).

3.3 Recommendations Adrenaline, phenylephrine, or vasopressin are not recommended as an initial booster for septic shock (recommended level: 2C). The combination of norepinephrine with 0.03 U / min vasopressin is equivalent to the application of norepinephrine alone.

3.5 Recommendations Do not recommend low-dose dopamine for renal protection (recommended level: 1A).

3.6 Recommendations If conditions permit, all patients who require booster drugs are recommended for arterial placement (recommended level: 1D).

4 Positive inotropic treatment

4.1 Recommendations Dobutamine infusion is recommended when elevated cardiac filling pressure and low CO suggest myocardial dysfunction (recommended level: 1C).

4.2 Recommendations do not advocate strategies to increase the cardiac index above normal expectations (recommended level: 1B).

Important recommendations for septic shock include

Early target resuscitation within the first 6 hours after the patient is diagnosed with septic shock; blood culture should be performed before antibiotics are used; rapid imaging is performed to identify potential infectious lesions; application within 1 hour after diagnosis of septic shock Broad-spectrum antibiotics for treatment. Within 1 hour after diagnosis of severe sepsis without septic shock, broad-spectrum antibiotics should be used for treatment; at the appropriate time, re-selection of narrow-spectrum coverage under clinical and microbiological guidance Antibiotics for pathogenic bacteria; clinical efficacy judgment after 7 to 10 days of antibiotic use; infection source control needs to consider the pros and cons of the chosen method; choose to use crystals or colloidal fluid for resuscitation; fluid load treatment in order to restore the circulating average perfusion pressure; Increased perfusion pressure while improving tissue perfusion should reduce fluid input; use of vasopressin is preferred over noradrenaline and dopamine (1C) in maintaining mean arterial blood pressure target 65 mmHg; Under the premise of fluid resuscitation and the application of vasoconstriction drugs, Fruit heart output is still low and dobutamine (1C) is applied; if septic shock is followed by aggressive fluid resuscitation and vasopressin treatment, blood pressure is still difficult to reach the desired level, and glucocorticoids are used; severe Patients with sepsis have a higher risk of death after clinical evaluation. Recombinant activated protein C is used; if there is no tissue hypoperfusion, coronary artery disease, and acute bleeding, hemoglobin is maintained at 7-9 g / dL (; Patients with ALI and ARDS use a small tidal volume and a ventilation strategy that limits the inspiratory plateau pressure. For patients with acute lung injury, at least a minimum positive end-expiratory pressure level should be applied; unless a contraindication exists, the patient bed is mechanically ventilated. The head needs to be raised. For patients with ALI / ARDS, routine use of pulmonary artery floating catheters should be avoided. For patients with ALI / ARDS who have been diagnosed without shock, in order to reduce mechanical ventilation and the number of days in the ICU, restrictions should be adopted. Fluid conservative strategy; sedative / analgesic treatment recommended; intermittent use of sedation Both bolus and continuous intravenous infusion; if possible, the application of neuromuscular blocking drugs should be completely avoided; the patient's blood glucose management should be strengthened; once the patient's condition is stable, the patient's target blood glucose should be controlled to <150 mg / dL; continuous intravenous -Venous hemofiltration or hemodialysis are equally effective; prevention of deep vein thrombosis; stress ulcers can be treated with H2 blockers to prevent upper gastrointestinal bleeding, or proton pump inhibitors can be used.

Septic shock supportive treatment for severe sepsis

A mechanical ventilation

1. For patients with acute lung injury (ALI) / acute respiratory distress syndrome (ARDS) caused by sepsis, it is recommended to set the mechanical ventilation tidal volume to 6 ml / kg (1B) as the predicted weight.

2. It is recommended to monitor the end-inspiratory plateau pressure of ALI / ARDS patients and set the initial plateau high limit to 30 cmH2O. The patient's thoracic compliance should be considered when assessing plateau pressure (1C).

Regarding the evaluation of the effect of reducing the inspiratory pressure by limiting the tidal volume, there have been several multi-center randomized trials in the past decade with different conclusions. Among the largest trials, comparing with a tidal volume of 12 ml / kg, the application of a low tidal volume (6 ml / kg) to limit the plateau pressure to below 30 cm / H2O can reduce the all-cause mortality of patients with ALI / ARDS by 9%. .

Lung protection strategies for ALI patients have been supported by the trial and widely recognized, but the accurate selection of initial tidal volume needs to consider factors such as plateau pressure, positive end expiratory pressure (PEEP) value, and compliance of the chest and abdomen.

The final recommendation is that patients with ALI / ARDS should avoid high plateau pressure and high tidal volume ventilation. The initial 1-2 hour tidal volume should be set to 6 ml / kg, so that the end-inspiratory platform pressure is controlled below 30 cmH2O. If the plateau pressure is still higher than 30 cmH2O at a tidal volume of 6 ml / kg, the tidal volume is reduced to 4 ml / kg.

Under the same principles of lung protection, it has not been proven that one ventilation method (pressure control, volume control, pressure release ventilation, high-frequency ventilation) is definitely better than another.

3. In order to reduce the platform pressure and tidal volume as much as possible, patients with ALL / ARDS are allowed to have hypercapnia (PaCO2 is higher than normal, called "permissive hypercapnia") (1C).

Some small, non-randomized trials have proven that it is safe to allow moderate hypercapnia, corresponding to reducing tidal volume and plateau pressure. Large trials have also shown that limiting tidal volume and airway pressure can improve patient outcomes, but these trials did not take "permissive hypercapnia" as the main treatment target. This hypercapnia should be restricted to those who already have metabolic acidosis, and its use should be prohibited in patients with high intracranial pressure.

4. PEEP is recommended to prevent end-expiratory alveolar collapse (1C).

Increasing PEEP can prevent end-expiratory alveolar collapse in patients with ALI / ARDS, which is beneficial to blood gas exchange. Regardless of tracheal intubation or non-invasive ventilation (NIV), PEEP is beneficial to increase the oxygen partial pressure. The setting of PEEP depends on two factors: the compliance of the thorax with the lungs, the degree of hypoxia, and the oxygen concentration when maintaining an adequate oxygen supply. PEEP> 5 cmH2O is the lower limit to prevent alveolar collapse.

5. In experienced units, ARDS patients who need to use high inspiratory oxygen content (FiO2) and plateau pressure that may cause lung injury should be considered to be in the prone position (2C) if there is no high risk of changing position.

Some trials have shown that prone position can improve blood oxygen exchange in patients, but a large multicenter study has not shown that maintaining the prone position for about 7 hours a day can reduce mortality in patients with ALI / ARDS. Prone ventilation may cause some fatal complications such as tracheal intubation or central venous tube prolapse, but appropriate measures can be prevented.

6A . If there is no contraindication, it is recommended that patients with mechanical ventilation remain in a semi-recumbent position to prevent aspiration and ventilator-associated pneumonia (VAP) (1B).

6B. It is recommended that the bed head be raised by 30 ~ 45 degrees (2C).

A semi-recumbent position reduces VAP. Studies have shown that enteral nutrition increases the incidence of VAP, and VAP occurs in 50% of supine patients with enteral nutrition. However, a recent study found no difference in the incidence of VAP between supine and semi-recumbent patients. When receiving certain treatments or hemodynamic tests and the presence of hypotension, the patient can lie supine, and the bedside cannot be lowered to 0 degrees during enteral feeding.

7. NIV is recommended only for a few patients with ALI / ARDS who meet the following conditions: mild respiratory failure (relatively low pressure support and effective PEEP), stable hemodynamics, more comfortable and easy to wake up, able to sputum And protect the airway, subjective expectation of an early recovery. It is recommended to maintain a low intubation threshold (2B).

There are many benefits to avoiding tracheal intubation, such as facilitating communication, reducing the chance of infection, and anesthesia. Two randomized controlled clinical trials have shown that successful NIV can improve patient prognosis. Unfortunately, only a small proportion of life-threatening hypoxemia patients are suitable for this method.

8. It is recommended to develop an appropriate offline plan to perform an autonomous breathing test for mechanically ventilated patients to assess the ability to detach from mechanical ventilation. The patient must also meet the following conditions: wake-up, stable hemodynamics (without booster drugs) ), there is no new potentially serious disease, only low ventilation and low PEEP, mask or nasal catheter oxygen can meet the oxygen concentration requirements. Low level pressure support, continuous positive airway pressure (CPAP, 5 cmH2O) or T-tube should be selected for spontaneous breathing test (1A).

Recent studies have shown that daily spontaneous breathing tests can reduce mechanical ventilation for patients who may be offline. Successful spontaneous breathing tests can increase offline success rates.

9. For patients with ALI / ARDS, it is not recommended to use pulmonary artery catheters as a routine (1A).

Pulmonary artery catheterization may provide useful information such as the patient's circulatory capacity and cardiac function, but the benefits of this information are diminished by the following factors: differences in interpretation of results, lack of a link between pulmonary occlusion pressure and clinical response, and no proven catheterization Results Improve patient prognosis strategies. But for patients who need pulmonary artery catheterization monitoring data to guide treatment, they can choose to use.

10. For patients with ALI and no evidence of tissue hypoperfusion, a conservative fluid replacement strategy is recommended to reduce the number of days of mechanical ventilation and ICU stay (1C).

Reducing fluid replacement and weight gain through conservative fluid replacement strategies can reduce mechanical ventilation time and ICU days in patients with ALI, but not significantly reduce mortality and incidence of renal failure. It should be noted that these studies are aimed at patients with clear ALI, some of them with shock, and conservative fluid replacement strategies are only used in non-shock periods.

B sedation, anesthesia, neuromuscular blockade

1. When critically ill patients with mechanical ventilation need to be sedated, anesthesia records and anesthesia goals should be established (1B). There is growing evidence that this can reduce mechanical ventilation and ICU days.

2. If mechanical ventilation patients need anesthesia and sedation, intermittent injections or continuous drips are recommended to reach the predetermined sedation end point, and the sedation is interrupted / reduced daily to make the patient awake / re-drip (1B).

Although there are no trials specifically for patients with sepsis, but with a predetermined end point of anesthesia, the implementation of a strategy of intermittent anesthesia, daily interruptions and drips can reduce the mechanical ventilation time of patients.

Studies have shown that continuous sedation increases the duration of mechanical ventilation and ICU stay in patients.

3. In view of the long duration of neuromuscular blockade after drug withdrawal, it is recommended to avoid the application of neuromuscular blockers (NMBA) in patients with sepsis. If it must be applied, the bolus should be discontinued, or the block depth should be monitored using a 4-hour sequence during the continuous drip (1B).

The main indication for the use of NBMA in ICU is assisted mechanical ventilation. Proper application can improve thoracic compliance, reduce respiratory resistance and peak airway pressure. Muscle palsy can also reduce the work of breathing and blood flow to the respiratory muscles, thereby reducing oxygen consumption. However, a randomized controlled trial showed that the use of NBMA did not improve oxygen delivery and oxygen consumption in patients with severe sepsis.

Some studies have shown that the use of NBMA is related to myopathy and neuropathy, and it is more likely to cause it when combined with hormones, and the mechanism is unknown. Therefore, NBMA is not recommended when there is no obvious indication such as proper intubation or ventilation after proper sedation and analgesia.

C blood glucose control

1. For patients with severe sepsis and hyperglycemia that have been initially stable after entering the ICU, intravenous insulin therapy is recommended to control blood glucose (1B).

2. It is recommended to use an effective regimen to adjust the insulin dose to control blood glucose below 150 mg / dl (2C).

3. It is recommended that all patients receiving intravenous insulin use glucose as a calorie source to monitor blood glucose every 1 to 2 hours. After the blood glucose and insulin dosage is stable, it can be monitored every 4 hours (1C).

4. When the peripheral blood glucose level is monitored by the bedside rapid test method, if the blood glucose value is low, it should be handled with caution, because the arterial blood or plasma glucose level may be lower than the test value (1B).

A large randomized single-center study in the ICU of cardiac surgery showed that using intensive intravenous insulin therapy (Leuven protocol) and controlling blood glucose at 80-110 mg / dl can reduce ICU mortality (relative and absolute mortality for all patients) (43% and 3.4% reductions, relative and absolute mortality reductions of 48% and 9.6% for patients living in the ICU for more than 5 days). Patients who lived in the ICU for more than 5 days also reduced organ dysfunction and shortened the ICU stay (median: 15 days to 12 days)

A randomized study of patients expected to be hospitalized for> 3 days in 3 medical ICUs showed that intensive insulin therapy did not reduce the total mortality of patients, but it was beneficial to shorten the ICU and hospital stay, early withdrawal and reduce acute kidney damage.

A large comparative observational study before and after the study showed that the relative and absolute mortality of patients decreased by 29% and 6.1%, respectively, and the number of days ICU stayed decreased by 10.8%. The relative and absolute mortality of 53 patients with septic shock decreased by 45% and 27%, respectively (P = 0.02).

Compared with traditional treatment, intensive insulin treatment with Leuven protocol in the medical ICU increased the risk of hypoglycemia by about three times (18% vs. 6.2%).

Two studies have observed the relationship between the average blood glucose level of patients and mortality, multiple neuropathy, acute renal failure, in-hospital acquired bacteremia, and infusion volume, and proposed that the blood glucose threshold to reduce patient mortality is between 145 and 180 mg / dl.

A large sample observational study (7049 cases) found that lowering average blood glucose levels was as important as reducing blood glucose fluctuations.

D kidney replacement therapy

1. For patients with severe sepsis and acute renal failure, continuous renal replacement therapy is equivalent to intermittent hemodialysis (2B).

2. For hemodynamically unstable patients, continuous renal replacement therapy is recommended to help maintain fluid balance (2D).

Two meta-analyses showed that continuous and intermittent renal replacement therapy had no significant difference in reducing in-hospital mortality.

There is no evidence to support better hemodynamic tolerance in continuous renal replacement therapy. Two prospective studies have shown that continuous therapy is better tolerated by hemodynamics, but has not improved local perfusion and patient survival. The other four prospective studies did not find significant differences in mean arterial pressure or systolic blood pressure reduction in patients using the two methods. Two studies have shown that continuous therapy is better for achieving the goal of maintaining fluid balance.

In short, the current evidence is insufficient to conclude which alternative treatment mode to choose for patients with sepsis complicated by acute renal failure.

Four randomized controlled trials (none of them specifically for sepsis) explored whether continuous renal replacement doses affect patient prognosis. Three of them suggested that higher doses could reduce patient mortality, but this conclusion cannot be easily generalized. Two large-sample, multicenter, randomized studies comparing renal replacement doses (ATN in the United States and RENAL in Australia and New Zealand) will draw conclusions and guide practice in 2008.

E bicarbonate treatment

For patients with hypoperfusion-induced hyperlactic acidemia and pH 7.15, it is not appropriate to use sodium bicarbonate to improve hemodynamics or reduce the use of booster drugs (1B).

There is no evidence to support the use of sodium bicarbonate for the treatment of hyperlactaemia due to hypoperfusion in sepsis. Two randomized, blinded crossover studies have shown that equimolar saline and bicarbonate have no significant difference in improving hemodynamic indexes or reducing the need for booster drugs in patients with hyperlactic acidemia, but studies have rarely included patients with pH <7.15 .

Bicarbonate may increase the water and sodium load, increase blood lactic acid and PCO2, and reduce serum ionized calcium, but the relationship between these parameters and patient prognosis is uncertain. The effect of bicarbonate on hemodynamic parameters or booster drug demand in patients with low pH or any pH is unknown.

F to prevent deep vein thrombosis

1.For patients with severe sepsis, low-dose common heparin (UFH) is recommended 2 to 3 times daily or low molecular weight heparin (LMWH) to prevent deep vein thrombosis (DVT) unless there are contraindications such as thrombocytopenia, severe Coagulation dysfunction, active bleeding, recent cerebral hemorrhage, etc. (1A).

2. For those with contraindications to heparin, the use of device precautions such as gradual compression socks (GCS) or intermittent compression devices (ICD) is recommended, unless contraindications are available (1A).

3. For very high-risk patients, such as those with severe sepsis combined with a history of DVT, trauma, or orthopedic surgery, combined drug and mechanical prophylaxis are recommended, unless contraindicated or impossible (2C).

4. Given the advantages of LMWH in other high-risk patients, it is recommended to use LMWH instead of UFH (2C) for very high-risk patients.

Nine randomized placebo-controlled trials showed that preventive measures for acute patients can significantly reduce the incidence of lower extremity DVT or pulmonary embolism. The benefits of DVT prevention are also supported by a meta-analysis, so the level of evidence is high. This measure has low cost and relatively small risk. Failure to implement this measure may lead to serious consequences, so it is recommended at a higher level.

Evidence suggests that LMWH is equivalent to UFH in general patients. A recent meta-analysis showed that UFH was more effective 3 times a day and less bleeding twice a day. The choice should be weighed in practice.

For patients with moderate to severe renal insufficiency, UFH is recommended instead of LMWH. Device precautions (ICD and GCS) can be used in patients with anticoagulation contraindications, or as an adjunct to anticoagulation therapy in high-risk patients. LMWH is more recommended for high-risk patients. Patients receiving heparin therapy should be monitored for heparin-induced thrombocytopenia (HIT).

G prevention of stress ulcers

H2 receptor blockers (1A) or proton pump inhibitors (PPI) (1B) are recommended for patients with severe sepsis to prevent upper gastrointestinal bleeding caused by stress ulcers, but elevated gastric pH should also be considered May increase VAP risk.

Studies on general ICU patients have confirmed the benefits of preventing stress ulcers, and 20% to 25% of them have sepsis. In addition, several types of patients benefiting from the prevention of stress ulcers (coagulation dysfunction, mechanical ventilation, hypotension) are often associated with severe sepsis and septic shock.

Cook and other trials involving 1,200 patients and a meta-analysis showed that H2 receptor blockers have better acid suppression effects than sucralfate. Two studies support the equivalence of H2 receptor blockers with PPI.

H- selective intestinal purification

Experts are quite divided on the issue of selective intestinal decontamination (SDD), and the number of users in favor of and against is almost the same. Therefore, the use of SDD in patients with severe sepsis is not currently proposed.

Experience has shown that the prophylactic use of SDD (intestinal non-absorbable antibiotics and short-course intravenous antibiotics) can reduce infections (mainly pneumonia) and reduce the overall mortality of severe and trauma patients without increasing the risk of Gram-negative bacteria resistance.

Analysis of two prospective blinded studies shows that SDD can reduce nosocomial (secondary) infection in patients with ICU due to primary infection and reduce mortality. The main purpose of using SDD in patients with severe sepsis or septic shock may be to prevent secondary infections.

The main role of SDD is to prevent VAP, so it is necessary to compare SDD with non-antibacterial VAP interventions such as ventilator intervention systems. Although studies including intestinal vancomycin have shown its safety, there is still the possibility of drug-resistant Gram-positive infections.

Consideration of support limits

It is recommended to discuss further treatment plans with patients and their families, including possible outcomes and realistic treatment goals (1D). ^[1]