ОПУБЛИКОВАНА ОБНОВЛЕННАЯ ВЕРСИЯ КЛИНИЧЕСКИХ РЕКОМЕНДАЦИЙ СЕПСИС (У ВЗРОСЛЫХ) - ВЕРСИЯ ОТ 20 ДЕКАБРЯ 2023
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( [height] => 200 ) [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Диагноз [~DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) ) [ANAMNESIS] => Array ( [ID] => 192 [TIMESTAMP_X] => 2018-03-06 15:04:16 [IBLOCK_ID] => 18 [NAME] => Анамнез [ACTIVE] => Y [SORT] => 500 [CODE] => ANAMNESIS [DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => HTML [USER_TYPE_SETTINGS] => Array ( [height] => 200 ) [HINT] => [PROPERTY_VALUE_ID] => 8093 [VALUE] => Array ( [TEXT] => <p> Течение последствий ожоговой травмы (ожог пламенем туловища, верхних и нижних конечностей I-II-III ст. 30% п.т. (III ст. 20% п.т.)) у пациента В. 67 лет ( с тяжелой сопутствующей патологией: состояние после ОНМК в 2016 году) осложнилось развитием инвазивной раневой инфекции, ассоциированной с полирезистентной нозокомиальной микрофлорой (при микробилогическом исследовании тканевого биоптата из зон раневого инфекционного процесса были выделены A.baumanii 10<sup>8</sup> КОЕ; K.pneumoniae 10<sup>4</sup>КОЕ, чувствительные к карбапенемам, аминогликозидам, защищённым цефалоспоринам). У больного в ходе наблюдения сохранялась фебрильная лихорадка, в клиническом анализе крови – лейкоцитоз со сдвигом формулы до юных форм, гнойное раневое отделяемое. </p> [TYPE] => HTML ) [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => Array ( [TEXT] =>

Течение последствий ожоговой травмы (ожог пламенем туловища, верхних и нижних конечностей I-II-III ст. 30% п.т. (III ст. 20% п.т.)) у пациента В. 67 лет ( с тяжелой сопутствующей патологией: состояние после ОНМК в 2016 году) осложнилось развитием инвазивной раневой инфекции, ассоциированной с полирезистентной нозокомиальной микрофлорой (при микробилогическом исследовании тканевого биоптата из зон раневого инфекционного процесса были выделены A.baumanii 108 КОЕ; K.pneumoniae 104КОЕ, чувствительные к карбапенемам, аминогликозидам, защищённым цефалоспоринам). У больного в ходе наблюдения сохранялась фебрильная лихорадка, в клиническом анализе крови – лейкоцитоз со сдвигом формулы до юных форм, гнойное раневое отделяемое.

[TYPE] => HTML ) [~DESCRIPTION] => [~NAME] => Анамнез [~DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) ) [THERAPY] => Array ( [ID] => 193 [TIMESTAMP_X] => 2018-03-06 15:04:57 [IBLOCK_ID] => 18 [NAME] => Терапия [ACTIVE] => Y [SORT] => 500 [CODE] => THERAPY [DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => HTML [USER_TYPE_SETTINGS] => Array ( [height] => 200 ) [HINT] => [PROPERTY_VALUE_ID] => 8094 [VALUE] => Array ( [TEXT] => <p> К 12 суткам наблюдения и лечения, у пациента было отмечено развитие гипотензии (84/45 мм.рт.ст) и прогрессирование энцефалопатии со снижением уровня сознания до сопора (10 баллов по шкале ком Глазго); оценка по qSOFA-2 балла. Пациент был переведён в отделение реанимации с диагнозом «сепсис, септический шок». В ходе дополнительного обследования были получены данные клинического анализа крови с увеличением уровня лейкоцитоза до 47×10<sup>9</sup>л ( п/я до 23%); прокальцитонин 3, 78 нг/мл, пресепсин 3200 пг/мл, С-реактивный белок 320 мг/л. На момент подключения к монитору зафиксирована гипотермия, до 34,6 ℃. Была проведена смена антибактериальной терапии – с целью преодоления возможной резистентности выделенных возбудителей к проводимому антимикробному лечению. Были назначены – меропенем 1 г/3 раза в сутки, внутривенная инфузия, тигацил -100 мг в сутки, внутривенно (с нагрузочной дозой в 100 мг). Была начата инфузионная терапия кристаллоидными растворами, однако, после введения 500 мл р-ра Рингера- у больного было отмечено появление тахипное до 32 в минуту, развитие одышки с преобладанием экспираторного компонента и удлинением выдоха, появление свистящих хрипов при аускультации лёгких, снижение индекса оксигенации до 240%. При этом центральное венозное давление достигало 12 мм.рт.ст. , сохранялась гипотензия ( 84/47 мм.рт.ст.), уровень лактата 4,9 ммоль/л. </p> [TYPE] => HTML ) [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => Array ( [TEXT] =>

К 12 суткам наблюдения и лечения, у пациента было отмечено развитие гипотензии (84/45 мм.рт.ст) и прогрессирование энцефалопатии со снижением уровня сознания до сопора (10 баллов по шкале ком Глазго); оценка по qSOFA-2 балла. Пациент был переведён в отделение реанимации с диагнозом «сепсис, септический шок». В ходе дополнительного обследования были получены данные клинического анализа крови с увеличением уровня лейкоцитоза до 47×109л ( п/я до 23%); прокальцитонин 3, 78 нг/мл, пресепсин 3200 пг/мл, С-реактивный белок 320 мг/л. На момент подключения к монитору зафиксирована гипотермия, до 34,6 ℃. Была проведена смена антибактериальной терапии – с целью преодоления возможной резистентности выделенных возбудителей к проводимому антимикробному лечению. Были назначены – меропенем 1 г/3 раза в сутки, внутривенная инфузия, тигацил -100 мг в сутки, внутривенно (с нагрузочной дозой в 100 мг). Была начата инфузионная терапия кристаллоидными растворами, однако, после введения 500 мл р-ра Рингера- у больного было отмечено появление тахипное до 32 в минуту, развитие одышки с преобладанием экспираторного компонента и удлинением выдоха, появление свистящих хрипов при аускультации лёгких, снижение индекса оксигенации до 240%. При этом центральное венозное давление достигало 12 мм.рт.ст. , сохранялась гипотензия ( 84/47 мм.рт.ст.), уровень лактата 4,9 ммоль/л.

[TYPE] => HTML ) [~DESCRIPTION] => [~NAME] => Терапия [~DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) ) [PATIENTS_SEX] => Array ( [ID] => 194 [TIMESTAMP_X] => 2018-03-06 15:05:22 [IBLOCK_ID] => 18 [NAME] => Пол пациента [ACTIVE] => Y [SORT] => 500 [CODE] => PATIENTS_SEX [DEFAULT_VALUE] => [PROPERTY_TYPE] => L [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => 827879 [VALUE] => Не знаю [DESCRIPTION] => [VALUE_ENUM] => Не знаю [VALUE_XML_ID] => UNKNOWN [VALUE_SORT] => 500 [VALUE_ENUM_ID] => 25 [~VALUE] => Не знаю [~DESCRIPTION] => [~NAME] => Пол пациента [~DEFAULT_VALUE] => ) [PATIENTS_AGE] => Array ( [ID] => 195 [TIMESTAMP_X] => 2018-03-07 12:37:41 [IBLOCK_ID] => 18 [NAME] => Возраст пациента [ACTIVE] => Y [SORT] => 500 [CODE] => PATIENTS_AGE [DEFAULT_VALUE] => [PROPERTY_TYPE] => N [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => Y [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => 8096 [VALUE] => 67 [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => 67 [~DESCRIPTION] => [~NAME] => Возраст пациента [~DEFAULT_VALUE] => ) [RESULT_DETAIL] => Array ( [ID] => 196 [TIMESTAMP_X] => 2018-03-06 14:59:44 [IBLOCK_ID] => 18 [NAME] => Результат [ACTIVE] => Y [SORT] => 500 [CODE] => RESULT_DETAIL [DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => HTML [USER_TYPE_SETTINGS] => Array ( [height] => 200 ) [HINT] => [PROPERTY_VALUE_ID] => 8097 [VALUE] => Array ( [TEXT] => <p> Проведение инфузионной терапии было приостановлено, с целью стабилизации гемодинамики начато введение норадреналина (0,17 мкг/кг/мин). Больной был переведён на ИВЛ. В ходе ЭКГ мониторинга у пациента отмечали наличие атрио-вентрикулярной блокады I ст (рисунок 1). </p> [TYPE] => HTML ) [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => Array ( [TEXT] =>

Проведение инфузионной терапии было приостановлено, с целью стабилизации гемодинамики начато введение норадреналина (0,17 мкг/кг/мин). Больной был переведён на ИВЛ. В ходе ЭКГ мониторинга у пациента отмечали наличие атрио-вентрикулярной блокады I ст (рисунок 1).

[TYPE] => HTML ) [~DESCRIPTION] => [~NAME] => Результат [~DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) ) [SPECIALIST] => Array ( [ID] => 197 [TIMESTAMP_X] => 2018-03-06 14:59:44 [IBLOCK_ID] => 18 [NAME] => Специалист [ACTIVE] => Y [SORT] => 500 [CODE] => SPECIALIST [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => UserID [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Специалист [~DEFAULT_VALUE] => ) [SPECIALIST_COMMENT] => Array ( [ID] => 198 [TIMESTAMP_X] => 2018-03-06 14:59:44 [IBLOCK_ID] => 18 [NAME] => Комментарий [ACTIVE] => Y [SORT] => 500 [CODE] => SPECIALIST_COMMENT [DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => HTML [USER_TYPE_SETTINGS] => Array ( [height] => 200 ) [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Комментарий [~DEFAULT_VALUE] => Array ( [TEXT] => [TYPE] => HTML ) ) [SUBTITLE] => Array ( [ID] => 136 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Подзаголовок [ACTIVE] => Y [SORT] => 501 [CODE] => SUBTITLE [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Подзаголовок [~DEFAULT_VALUE] => ) [AUTHOR] => Array ( [ID] => 137 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Автор [ACTIVE] => Y [SORT] => 502 [CODE] => AUTHOR [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => Y [VERSION] => 1 [USER_TYPE] => UserID [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => Array ( [0] => 8091 ) [VALUE] => Array ( [0] => 8 ) [DESCRIPTION] => Array ( [0] => ) [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => Array ( [0] => 8 ) [~DESCRIPTION] => Array ( [0] => ) [~NAME] => Автор [~DEFAULT_VALUE] => ) [QUOTE] => Array ( [ID] => 138 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Цитата [ACTIVE] => Y [SORT] => 503 [CODE] => QUOTE [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Цитата [~DEFAULT_VALUE] => ) [SLIDER] => Array ( [ID] => 139 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Слайдер [ACTIVE] => Y [SORT] => 503 [CODE] => SLIDER [DEFAULT_VALUE] => [PROPERTY_TYPE] => F [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => jpg, gif, bmp, png, jpeg [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Слайдер [~DEFAULT_VALUE] => ) [SLIDER_DESC] => Array ( [ID] => 140 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Слайдер описание [ACTIVE] => Y [SORT] => 504 [CODE] => SLIDER_DESC [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Слайдер описание [~DEFAULT_VALUE] => ) [INFO_SOURCES] => Array ( [ID] => 141 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Информация и источники [ACTIVE] => Y [SORT] => 505 [CODE] => INFO_SOURCES [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Информация и источники [~DEFAULT_VALUE] => ) [SUBJECTS] => Array ( [ID] => 143 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Тематика [ACTIVE] => Y [SORT] => 5000 [CODE] => SUBJECTS [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => Y [VERSION] => 1 [USER_TYPE] => directory [USER_TYPE_SETTINGS] => Array ( [size] => 1 [width] => 0 [group] => N [multiple] => N [TABLE_NAME] => b_hlbd_subjects ) [HINT] => [PROPERTY_VALUE_ID] => Array ( [0] => 8092 ) [VALUE] => Array ( [0] => sluchayizpraktiki ) [DESCRIPTION] => Array ( [0] => ) [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => Array ( [0] => sluchayizpraktiki ) [~DESCRIPTION] => Array ( [0] => ) [~NAME] => Тематика [~DEFAULT_VALUE] => ) [COMMENTS_COUNT] => Array ( [ID] => 144 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Количество комментариев [ACTIVE] => Y [SORT] => 5010 [CODE] => COMMENTS_COUNT [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Количество комментариев [~DEFAULT_VALUE] => ) [FB2] => Array ( [ID] => 174 [TIMESTAMP_X] => 2017-10-12 14:43:54 [IBLOCK_ID] => 18 [NAME] => FB2 [ACTIVE] => Y [SORT] => 5020 [CODE] => FB2 [DEFAULT_VALUE] => [PROPERTY_TYPE] => F [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => fb2 [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => FB2 [~DEFAULT_VALUE] => ) [ADD_DATES] => Array ( [ID] => 208 [TIMESTAMP_X] => 2018-05-11 11:01:55 [IBLOCK_ID] => 18 [NAME] => Даты добавления материалов [ACTIVE] => Y [SORT] => 5030 [CODE] => ADD_DATES [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => Date [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => [VALUE] => [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => [~DESCRIPTION] => [~NAME] => Даты добавления материалов [~DEFAULT_VALUE] => ) [LENGHT] => [VIDEO_PREVIEW] => [VIDEO_FULL] => ) [DISPLAY_PROPERTIES] => Array ( [rating] => Array ( [ID] => 135 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Рейтинг [ACTIVE] => Y [SORT] => 500 [CODE] => rating [DEFAULT_VALUE] => [PROPERTY_TYPE] => N [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => N [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => N [VERSION] => 1 [USER_TYPE] => [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => 821970 [VALUE] => 2.5 [DESCRIPTION] => [VALUE_ENUM] => [VALUE_XML_ID] => [VALUE_SORT] => [~VALUE] => 2.5 [~DESCRIPTION] => [~NAME] => Рейтинг [~DEFAULT_VALUE] => [DISPLAY_VALUE] => 2.5 ) [AUTHOR] => Array ( [ID] => 137 [TIMESTAMP_X] => 2017-09-08 11:11:31 [IBLOCK_ID] => 18 [NAME] => Автор [ACTIVE] => Y [SORT] => 502 [CODE] => AUTHOR [DEFAULT_VALUE] => [PROPERTY_TYPE] => S [ROW_COUNT] => 1 [COL_COUNT] => 30 [LIST_TYPE] => L [MULTIPLE] => Y [XML_ID] => [FILE_TYPE] => [MULTIPLE_CNT] => 5 [TMP_ID] => [LINK_IBLOCK_ID] => 0 [WITH_DESCRIPTION] => N [SEARCHABLE] => N [FILTRABLE] => N [IS_REQUIRED] => Y [VERSION] => 1 [USER_TYPE] => UserID [USER_TYPE_SETTINGS] => [HINT] => [PROPERTY_VALUE_ID] => Array ( [0] => 8091 ) [VALUE] => Array ( [0] => 8 ) [DESCRIPTION] => 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4 июля 2018

Норадреналин при септическом шоке: всегда ли?

#Случай из практики

Пациент

Возраст: 67

Анамнез

Течение последствий ожоговой травмы (ожог пламенем туловища, верхних и нижних конечностей I-II-III ст. 30% п.т. (III ст. 20% п.т.)) у пациента В. 67 лет ( с тяжелой сопутствующей патологией: состояние после ОНМК в 2016 году) осложнилось развитием инвазивной раневой инфекции, ассоциированной с полирезистентной нозокомиальной микрофлорой (при микробилогическом исследовании тканевого биоптата из зон раневого инфекционного процесса были выделены A.baumanii 108 КОЕ; K.pneumoniae 104КОЕ, чувствительные к карбапенемам, аминогликозидам, защищённым цефалоспоринам). У больного в ходе наблюдения сохранялась фебрильная лихорадка, в клиническом анализе крови – лейкоцитоз со сдвигом формулы до юных форм, гнойное раневое отделяемое.

Терапия

К 12 суткам наблюдения и лечения, у пациента было отмечено развитие гипотензии (84/45 мм.рт.ст) и прогрессирование энцефалопатии со снижением уровня сознания до сопора (10 баллов по шкале ком Глазго); оценка по qSOFA-2 балла. Пациент был переведён в отделение реанимации с диагнозом «сепсис, септический шок». В ходе дополнительного обследования были получены данные клинического анализа крови с увеличением уровня лейкоцитоза до 47×109л ( п/я до 23%); прокальцитонин 3, 78 нг/мл, пресепсин 3200 пг/мл, С-реактивный белок 320 мг/л. На момент подключения к монитору зафиксирована гипотермия, до 34,6 ℃. Была проведена смена антибактериальной терапии – с целью преодоления возможной резистентности выделенных возбудителей к проводимому антимикробному лечению. Были назначены – меропенем 1 г/3 раза в сутки, внутривенная инфузия, тигацил -100 мг в сутки, внутривенно (с нагрузочной дозой в 100 мг). Была начата инфузионная терапия кристаллоидными растворами, однако, после введения 500 мл р-ра Рингера- у больного было отмечено появление тахипное до 32 в минуту, развитие одышки с преобладанием экспираторного компонента и удлинением выдоха, появление свистящих хрипов при аускультации лёгких, снижение индекса оксигенации до 240%. При этом центральное венозное давление достигало 12 мм.рт.ст. , сохранялась гипотензия ( 84/47 мм.рт.ст.), уровень лактата 4,9 ммоль/л.

Результат

Проведение инфузионной терапии было приостановлено, с целью стабилизации гемодинамики начато введение норадреналина (0,17 мкг/кг/мин). Больной был переведён на ИВЛ. В ходе ЭКГ мониторинга у пациента отмечали наличие атрио-вентрикулярной блокады I ст (рисунок 1).

Комментарий специалиста


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