GB 15996-1995 Diagnostic criteria and treatment principles for epidemic hemorrhagic fever
Some standard content:
GB15996—1995
Internationally, epidemic hemorrhagic fever (EHF) and Nephropathia epidemica (NE) are collectively referred to as hemorrhagic fever with renal syndrome (HFRS). HFRS is a type of natural epidemic disease caused by certain viruses in the genus Hantavirus of the family Bunyaviridae and carried and spread by certain rodents. EHF is prevalent in my country, with black-striped field mice and brown rats as their main host animals and sources of infection. Its transmission is mainly through contact with host animals or their excreta (urine, feces)/secretions (saliva). EHF has an acute onset, rapid progression, and a high mortality rate. Early diagnosis is of special importance in reducing the mortality rate. Appendix A, Appendix B, and Appendix C of this standard are all standard appendices; Appendix D is a suggested appendix.
This standard is proposed by the Ministry of Health of the People's Republic of China. This standard was drafted by: Institute of Virology, Chinese Academy of Preventive Medicine, Institute of Epidemiology and Microbiology, Chinese Academy of Preventive Medicine, and the First Affiliated Hospital of Xi'an Medical University. The main drafters of this standard are: Song Gan, Hang Changshou, Chen Huaxin, and Zhang Chengwen. This standard is interpreted by the Office of Communicable Disease Supervision and Management of the Ministry of Health, which is the technical unit entrusted by the Ministry of Health. 376
1 Scope
National Standard of the People's Republic of China
Diagnostic criteria and principles of managementof epidemic hemorrhagic fever (EHF) This standard specifies the diagnostic criteria and principles of managementof epidemic hemorrhagic fever (EHF). GB15996--1995
This standard is applicable to the diagnosis, prevention and treatment of EHF patients by medical, health and health care institutions at all levels and of all types. 2 Diagnostic principles
Diagnosis is made based on the comprehensive judgment of the patient's epidemiological history, clinical manifestations and laboratory test results. Serological or etiological test results are required for confirmation.
3 Diagnostic criteria
3.1 Epidemiological history
The disease occurs in EHF epidemic areas and epidemic seasons, or there is a history of travel to epidemic areas within two months before the onset of the disease, or there is a history of direct or indirect contact with rodents or their excreta (urine, feces)/secretions (saliva) within two months before the onset of the disease. 3.2 Clinical manifestations
3.2.1 Early symptoms and signs: acute onset, chills, fever (above 38℃); body aches, fatigue, and exhaustion; headache, orbital pain, and back pain (three pains); congestion and flushing of the face, neck, and upper chest (three reds), with a drunken look; edema of the eyelids, conjunctival congestion, edema, and punctate or sheet-like bleeding; reticular congestion and punctate bleeding of the upper tibia mucosa; linear or clustered bleeding spots on the skin of the armpit; positive arm tie test. 3.2.2 Course of disease: Typical cases have five stages: fever, hypotension, oliguria, polyuria and recovery. The first three stages may overlap, and there are a large number of atypical or mild atypical cases with incomplete five stages. 3.3 Laboratory examination
3.3.1 Blood examination: The white blood cell count is low or normal in the early stage, and increases significantly after 3 to 4 days of illness. The number of band nuclei increases, and more atypical lymphocytes appear: platelets are significantly reduced.
3.3.2 Urine examination: Urine protein is positive and rapidly worsens, accompanied by microhematuria and tubular urine. 3.3.3 Serum specific IgM antibody is positive, see Appendix A. 3.3.4 Serum specific IgG antibody in the recovery period is more than 4 times higher than that in the acute period, see Appendix A. 3.3.5 EHF virus antigen or EHF virus RNA is detected from the patient's blood white blood cells or urine sediment cells, see Appendix D. 3.4 Case classification
3.4.1 Suspected case: meet 3.1 and 3.2.1. 3.4.2 Clinically diagnosed case: Suspected case plus 3.2.2.3.3.1, 3.3.2. 3.4.3 Confirmed case: Suspected case or clinically diagnosed case plus any one of 3.3.3, 3.3.4, 3.3.5. Approved by the State Administration of Technical Supervision on December 15, 1995 and implemented on July 1, 1996
4 Principle of prevention
GB15996—1995
Take comprehensive measures mainly based on rodent control and vaccination, do a good job in monitoring the epidemic situation between humans and rodents, and report the epidemic situation in a timely manner, see Appendix B.
4.1 Rodent control
Rodent control should be closely combined with rodent prevention. Improve environmental hygiene and sanitation, remove hidden places where rodents live and move, carry out rodent control measures mainly with drugs, mainly in residential areas and surrounding areas, and carry out a surprise rodent control activity half a month before the peak of the epidemic. Determine the focus of rodent control according to the different types of epidemic areas (house mouse type, field mouse type, mixed type). Generally, the focus is on rodent control in residential areas in spring, and in the autumn, the focus is on rodent control around residential areas and in the wild.
4.2 Preventive measures for field work sites and living areas Before entering, conduct epidemiological monitoring of construction areas and camping areas, especially epidemic sources, and do a good job of rodent control during the construction period, and strengthen personal protection measures.
4.3 Personal protection
Avoid contact with rodents and their excrement/secretions to reduce the risk of infection; vaccinate people in high-incidence areas and high-risk people in other epidemic areas.
5 Treatment principles
Efforts should be made to implement the "three early and one immediate" measures (early detection, early rest, early treatment, and nearby treatment) and treatment during the fever period, including antiviral treatment and preventive treatment (preventing the occurrence of hypotension and oliguria). Comprehensive rescue and treatment measures should be used to prevent/control hypotension shock, renal failure, and massive bleeding (three barriers), and nursing work should be done well during rescue and treatment. See Appendix C. 378
GB15996-1995
Appendix A
(Standard Appendix)
Serological diagnosis of epidemic hemorrhagic fever
A1 Detection of EHF IgM antibody by IgM capture ELISA A1.1 Principle
According to the principle of antigen-antibody specific binding, anti-human u chain polyclonal or monoclonal antibodies are used to capture IgM in the serum to be tested, and then specific antigens and enzyme-labeled specific antibodies (monoclonal antibodies or polyclonal antibodies) are added, and substrates are added for color development. The degree of color development is positively correlated with the IgM antibody content in the specific antibody. The ratio of the OD value of the test serum to the specific antigen and the negative (control) antigen reaction is used as the standard for determining the IgM antibody reaction.
A7.2 Materials
a) Polystyrene plastic plate: 40-well or 96-well plate, U-shaped. b) Variable micropipette: 20μL and 100μL each. c) Anti-human IgM (μ chain): mouse anti-human IgM (μ chain) monoclonal antibody or sheep anti-human IgM (u chain) polyclonal antibody. d) Antigen: Positive antigen: cell culture EHFV inactivated antigen or genetically engineered expression antigen: Negative antigen: cell culture antigen without virus inoculation or corresponding expression system antigen without exogenous genes. e) Anti-lgM negative or positive control serum. f) Horseradish peroxidase-EHF monoclonal antibody marker (HRP-McAb). g) Coating solution: 0.1 mol pH 9.6 carbonate buffer (NazCO3) 3.18 g, NaHCO: 5.88 g, add distilled water to 1 000 ml..
h) Washing solution (X10): 0. 2 mol pH 7. 4 PBS-T (Na2HP), 12H,0 51. 6 g, NaH2PO4 + 2H,0 8. 7 g, NaCl76 g, Tween-205 mL, dissolve to 1000 mL) Use after high pressure, dilute 10 times before use. i) Dilution solution: the above 10-fold diluted PBS-T solution, containing 5% bovine serum. j) Substrate solution: Take citrate phosphate buffer (pH 5.0) (citric acid 10.2 g, NazHPO,·12H03 6.8 g, add water to 1000 ml) before use.
k) Stop solution: 2 mol/L H2SO.
A1.3 Detection steps
a) Dilute anti-human IgM (μ chain) monoclonal antibody (or goat anti-human IgM (μ chain) with 0.1 mol pH 9.6 carbonate buffer, coat polystyrene plastic plate, 100 μl per well, 4°C overnight (or 37°C 2h). b) Discard the coating solution, wash with washing solution 3 times, and spin dry. c) Add serum to be tested: dilute the serum 100 times with PBS-T solution, add to 2 reaction wells, 100 μL per well (if positive and negative serum controls are required, the same method should be used).37℃1h. d) Discard serum, wash 5 times with washing solution, and spin dry. e) Add positive antigen and negative antigen: dilute the positive antigen with diluent to an appropriate working concentration, add 100μL to one of the reaction wells; dilute the negative antigen in the same way, add to another reaction well, incubate in a 37℃ water bath for 2h or place at 4℃ overnight (better effect). f) Discard antigen, wash 5 times with washing solution, and spin dry. g) Add HRP-McAb: dilute HRP-McAb with diluent to a working concentration, add 100μL to each well at 37'C1h. h) Discard marker, wash 5 times with washing solution, and spin dry. i) Color development: add 100μL of freshly prepared substrate solution to each well. Place in the dark at room temperature for color development. i) When the positive antigen (or serum) control is observed to be yellow and the negative antigen (or serum) control is colorless, add 50μL 2 mol/L H,SO to each well to terminate the reaction.
A1.4 Result judgment
GB15996-1995
a) OD value is measured by enzyme label detector (blank control is adjusted to zero), P/N=2.1 is judged as positive (P: OD value of positive antigen well; N: OD value of negative antigen well).
b) Visual inspection: Compared with the control well, the positive antigen well is obviously light yellow, orange or dark yellow, and the negative antigen well is basically colorless. A1.5 Significance
Positive IgM antibody indicates that the patient has recently been infected with EHF virus. This method has high sensitivity and specificity, and is particularly suitable for early specific diagnosis of EHF.
A2 Detection of EHF IgG Antibodies by Indirect Enzyme Immunosorbent Assay (ELISA) A2.1 Principle
Based on the principle of specific binding of antigen and antibody, plastic plates are coated with purified virus antigens and combined with specific antibodies in the serum to be tested that is continuously diluted at 1:100. The serum IgG part is then combined with the enzyme-labeled anti-human IgG added later, and a visible color reaction is produced through the action of the enzyme and the substrate. The antibody is quantitatively determined based on the amount of the reaction product, that is, the color depth. A2.2 Materials
a) Polystyrene plastic plates and variable micropipette: Same as A1.2. b) Coated positive antigens and normal control antigens: Cell culture EHFV antigens (inactivated) or preliminarily purified genetically engineered expression antigens are positive antigens; cell culture normal antigens that are not inoculated with EHFV or antigens of the corresponding expression system without exogenous genes are control antigens. The positive antigen and control antigen are diluted 2 times, coated on polystyrene plastic plates, and incubated overnight at 4°C. Use appropriately diluted EHF convalescent serum to measure antigens, and select the antigen dilution with the highest OD value in the specific antigen well and the OD value of the control antigen well lower than 0.05 as the working concentration. c) Horseradish peroxidase labeled anti-human IgG (HRP-IgG), determine its working concentration according to the above method. d) Positive control serum (EHF patient convalescent serum); serum of patients to be tested (serum of patients in the acute and convalescent phases). e) Antigen coating solution, washing solution, serum and conjugate diluent, substrate solution and stop solution are the same as A1.2. A2.3 Detection steps
A2.3.1 Dilute the antigen with 0.1mol/L pH9.6 carbonate buffer, coat the polystyrene plastic plate, 100μL per well at 4℃ overnight (or 37C2 h), and set up 2 wells for positive and negative antigens, respectively, to react with positive serum and serum to be tested. A2.3.2 Discard the coating solution, wash repeatedly with washing solution 3 to 5 times, and spin dry. A2.3.3 Dilute the serum to be tested 4 times from 1:100, add 100μL to each antigen well, incubate at 37℃ for 1h. A2.3.4 Discard the serum, wash repeatedly with detergent 5 times, and spin dry. A2.3.5 Add enzyme conjugate, 100μL to each well, incubate at 37℃ for 1.5h, wash 6 times in the same way as A2.3.4, and spin dry. A2.3.6 Add 100μL of freshly prepared substrate solution to each well, and place in the dark at room temperature for color development. A2.3.7 When the positive antigen and positive serum control wells show yellow color, while the negative antigen wells are colorless (10-20min), add 50μl2mol/LH,SO to each well to terminate the reaction.
A2.4 Result judgment
a) Visual inspection: Compared with the negative antigen wells, the positive antigen wells obviously show light yellow, orange or dark yellow color development reaction, and are judged as positive. b) OD value is measured by enzyme label detector (blank control is adjusted to zero). If P/N value is greater than 2.1, it is judged as positive (P: OD/492 value of positive antigen well; N: OD/492 value of negative antigen well). The reciprocal of the highest dilution of positive serum is the IgG antibody titer of the patient's serum. A2.5 Significance
The IgG antibody titer of the serum of patients in the recovery period is higher than that of the serum in the acute period, with an increase of more than 4 times, which can confirm the infection. The single serum test generally indicates that the patient has been infected with hemorrhagic fever virus. However, when the antibody titer is greater than or equal to 1:320, combined with clinical manifestations and epidemiological history, it can also be determined as a recent virus infection.
A3 Detection of EHF total antibody by reverse passive hemagglutination inhibition test (RPHI) A3.1 Principle
GB15996-1995
First, fix sheep red blood cells with glutaraldehyde to make their surface anionized, and then treat with acid or chromium chloride (cross-linking agent) to make the purified specific antibodies adsorbed to the surface of the aldehyded red blood cells for sensitization. When the sensitized blood cells meet the corresponding specific antigens, a specific antigen-antibody reaction occurs, causing the blood cells to agglutinate, which is called reverse passive agglutination (RPHA). . The serum to be tested containing specific antibodies is first mixed with the known antigen to cause a specific antigen-antibody reaction and occupy the binding sites on the antigen. At this time, the sensitized blood cells with antibodies can no longer react with the known antigen, so no hemagglutination occurs. This method is called reverse passive hemagglutination inhibition (RPHI). The reverse passive hemagglutination test is used to check antigens, while the reverse passive hemagglutination inhibition test is used to detect antibodies. A3.2 Materials
a) Microplate: 96 wells, U-shaped.
b) Adjustable micropipette.
c) High titer rabbit anti-EHF IgG sensitized sheep red blood cells, each tube contains 1ml of 3% freeze-dried red blood cells, and before use, it is restored to 1ml with distilled water. Then dilute 10 times with diluent to 0.3%. d) EHFV antigen (liquid or freeze-dried): before use, the hemagglutinin titer must be determined and diluted to 4 hemagglutination units. e) Diluent: pH7.2, 0.01mol/LPBS, containing 1% rabbit serum, used to dilute all reagents and the serum to be tested. A3.3 Detection steps
A3.3.1 Antigen hemagglutination unit determination: Use a 96-well U-shaped plate, add 25uL of diluent to each well, take 25μl of antigen and make dilutions in 1:2, 1:4, 1:8, .·, 1:256 times, then add 25μL of 0.3% sensitized red blood cell solution on a micro-oscillator and mix well, put in a 37C water bath for 1h, observe the results, and the antigen dilution that appears ++ (such as 1:64) is 1 hemagglutination unit, and the first two antigen dilutions (1:16) are 4 hemagglutination units.
A3.3.2 Dilution and reaction of the tested serum: Add 25μL of diluent to each well of the U-shaped microplate, dilute the serum to be tested 1:10, take 25μL and add it to the first well for multiple dilution, then add 25μL of 4 hemagglutination units antigen to each well, mix well, place in a 37℃ water bath (humid box) for 30min, add 25ul of 0.3% sensitized red blood cell solution to each well, mix well as above, place in a 37℃ wet box for 2h, and observe the results. A3.3.3 Set up blank controls of EHF virus antigen (4 hemagglutination units) and diluent, and set up positive serum of EHF patients and negative (normal) serum controls if necessary.
A3.4 Result judgment
On the premise that all controls are established, the reciprocal of the highest dilution of serum that completely inhibits red blood cell agglutination is the serum inhibitory antibody titer.
A3.5 SignificancebzxZ.net
This method can be used for serum epidemiological surveys and vaccine immunization serum antibody detection. A single serum test for reverse passive hemagglutination inhibition antibody indicates that the individual has been infected with EHF virus. Generally, the antibody level in the recovery period is more than 4 times higher than that in the acute period, and the diagnosis can be confirmed.
A4 Detection of EHF hemagglutination inhibition antibody by hemagglutination inhibition test (HI) A4.1 Principle
Many viruses have hemagglutination antigens (hemagglutinins), which can selectively interact with the receptors of red blood cells of various animals, attach to their surfaces, and cause agglutination of red blood cells, which is called hemagglutination phenomenon, referred to as hemagglutination (HA). Adding specific antibodies to hemagglutinins can inhibit this hemagglutination reaction, which is called hemagglutination inhibition (HI), and can be used for the determination of hemagglutination inhibition antibodies. The hemagglutination requirements of EHF virus are relatively strict, such as the animal species that provides red blood cells (geese or pigeons) and the pH value of the reaction. Different types of viruses have different hemagglutinins and corresponding hemagglutination inhibition antibodies. Based on this, the patient's serum can be typed to infer which type of virus the patient is infected with.
A4.2 Materials
a) Microplate: 96-well, U-shaped.
b) Adjustable micropipette: 20μL and 100ul. One each. c) Hemagglutination antigen (hemagglutinin):
GB15996--1995
Wild rat hemagglutination antigen is prepared with Hantan virus, and the hemagglutination titer is ≥1:64; house mouse hemagglutination antigen is prepared with Seoul virus, and the hemagglutination titer is ≥1:32. d) Diluent:
pH6.0 phosphate buffer, used to prepare fresh goose red blood cells (60mL); pH9.0 boric acid-sodium hydroxide solution (containing 0.5% bovine serum albumin), used to dilute hemagglutination antigen and serum to be tested. e) Reference serum:
Hantan immune serum, Seoul immune serum. f) Preparation of goose erythrocytes:
Blood was drawn from the subwing vein of the goose, injected into the Alfred solution and mixed, washed with saline for 3 times, centrifuged at 2000r/min for 10min for the last time, discarded the supernatant, diluted with pH6.0 phosphate buffer to -0.3% of goose erythrocytes, and stored in a refrigerator at 4℃ for later use. g) Treatment of serum to be tested:
Take the serum to be tested and make it 1:10 with saline, treat it with 10 times the amount of 4℃ cold acetone twice, centrifuge and discard the supernatant (acetone), dry the precipitate in vacuum or at room temperature, add pH9.0 boric acid-sodium hydroxide solution, restore it to a concentration of 1:10, and store it in a refrigerator at 4℃ overnight. Add 0.05mL of packed red blood cells to each tube of serum mentioned above, mix well, adsorb in a 37℃ water bath for 60min (shake several times in between), centrifuge and take the supernatant, which is the 1:10 treated serum.
A4.3 Detection steps
a) Determination of hemagglutination antigen units:
On a 96-well U-shaped microplate, add 25μL of pH9.0 boric acid-sodium hydroxide diluent to each well, take 25μL of the hemagglutination antigen to be tested and add it to the first well, and make multiple dilutions from the first well. After mixing the last well, discard 25μL, then add 25μL of diluent to each well, add 50μL of 0.3% fresh goose red blood cells, mix well, and place in a 37℃ water bath for 60-90 minutes to observe the results. The highest antigen dilution with ++ is a hemagglutination unit (such as 1:64). When detecting antibodies (typing), use 4 hemagglutination units (i.e. 1:16). b) Hemagglutination inhibition test:
In a U-shaped microplate, add 25μL of pH9.0 boric acid-sodium hydroxide diluent to each well, then add 25uL of the treated serum to be tested to the first and second wells and the eighth well respectively, and then make multiple dilutions from the second well to the seventh well. No antigen is added to the eighth well as a non-specific agglutination control of serum. Except for the eighth well, add 25μL of 4 units of hemagglutination antigen to each well and mix well. Place in a 37℃ water bath to react for 1~2h, then add 50μL of 0.3% goose red blood cells to each well, mix well, place in a 37℃ water bath, react for 1~2h, and observe the results. A4.4 Result judgment
The reciprocal of the highest dilution of serum that completely inhibits goose red blood cell agglutination is the hemagglutination inhibition antibody titer. A4.5 Significance
Hemagglutinin is mainly located on the envelope glycoprotein. The presence of hemagglutination inhibition antibodies partially reflects the characteristics of the viral envelope glycoprotein. The determination of serum types is based on the different titers of the same serum with the two hemagglutination antigens. If the titer of a single serum with the Hantan type hemagglutination antigen is 4 times or more higher than that with the Seoul type hemagglutination antigen, it is judged as the wild mouse type, and vice versa. A5 Immunofluorescence test (IFAT) to detect IgG antibodies in two sera A5.1 Principle
After chemical coupling, fluorescein (such as the commonly used fluorescein isothiocyanate, FITC) and antibodies (IgG, IgM) do not affect the fluorescence display of fluorescein and the specific immune reaction between antibodies and antigens. When the specific fluorescent antibody (i.e., the conjugate) binds to the corresponding antigen in the host cell, it displays fluorescence under a fluorescence microscope, indicating the presence of specific antigens. Direct immunofluorescence can be used to detect specific viral antigens in infected cells, and indirect methods can be used to detect specific antibodies in the serum to be tested. This method is highly sensitive and specific and is currently the most widely used serological method.
A5.2 Materials
a) Porous EHF virus antigen sheet, prepared by infecting Vero-E6 cells with domestic and foreign standard virus strains, and stored dry below -20°C. b) Goat anti-human or rabbit anti-human IgG fluorescein conjugate. 382
c) Serum of patients to be tested (acute and recovery phase). d) Fluorescence microscope.
5—1995
GB 15996
e) Common diluents, reagents and equipment (oscillator, etc.). A5.3 Detection steps
A5.3.1 Dilute the serum to be tested with pH7.4~7.6 PBS, and dilute it 2-fold or 4-fold continuously from 1:20 to the required dilution. A5.3.2 Take out the antigen sheet, rinse it once with distilled water, and blow it dry with cold air. A5.3.3 Use a pipette to add the diluted serum to be tested one by one from high dilution to low dilution. The required amount is based on the complete coverage of the cell antigen surface. Incubate in a 37C water bath wet box for 30 to 45 minutes. A5.3.4 Wash with 0.01mol/L pH7.47.6 PBS for 3 times with oscillation, 5 minutes each time, then wash once with distilled water, desalt, and blow with cold air.
A5.3.5 According to the instructions for use, dilute the fluorescent conjugate with PBS (containing 1:3×10 Evans blue). The amount added to each well is based on the complete coverage of the cell surface. Place in a 37C water bath wet box for 30 minutes. Then wash, rinse and blow dry in the same way as A5.3.4. A5.3.6 Observe the results using a fluorescence microscope
A5.4 Result judgment
The virus-specific fluorescence in the cells is yellow-green particles. According to the fluorescence brightness and the proportion of positive cells in the total number of cells, the immunofluorescence reaction can be roughly divided into 1 to 4 *+". Those without specific fluorescence are "". When detecting antibody titers, the reciprocal of the highest serum dilution that emits obvious specific fluorescence reaction (+) is used to express it. A5.5 Significance
Positive serum fluorescent antibodies indicate that the individual providing the serum has been infected with EHF virus. Generally, a single serum sample cannot confirm the diagnosis of current patients. Retrospective diagnosis requires double serum samples, that is, the antibody titer of the recovery serum is more than 4 times higher than that of the acute phase. This method is mostly used for retrospective diagnosis and Seroepidemiological survey. Appendix B
(Standard Appendix)
Prevention methods for epidemic hemorrhagic fever
B1 Prevention methods
EHF epidemic prevention and control: Take comprehensive measures with rodent control and rodent prevention as the main focus, and vaccinate the high-incidence populations in high-incidence areas and high-risk populations in other epidemic areas.
B1.1 Rodent control and rodent prevention: Take comprehensive prevention and control measures with rodent control and rodent prevention as the main focus. It is necessary to strengthen organizational leadership, give full play to the role of the Health Promotion Committee and the three-level health network, and strive for the support and active cooperation of relevant departments such as agriculture, forestry, water conservancy, transportation, and urban and rural construction. Seriously carry out environmental sanitation improvement and eliminate conditions for rodent habitats and activities. Adhere to the combination of rodent control and rodent prevention, and carry out Rodent control measures mainly using drugs. Raid deratization should be carried out in high-incidence areas at least once a year in spring and autumn. Rodent control should be carried out in both domestic rat and wild rat epidemic areas one month before the peak of the epidemic. Domestic rats can be the focus of deratization in domestic rat epidemic areas. Wild rats and domestic rats must be killed in wild rat epidemic areas. In mixed epidemic areas, domestic rats should be eliminated in spring, and wild rats in autumn and winter. B1.2 Combine deratization with drug deratization.
B1.3 Preventive measures for field construction sites: For large-scale field construction sites such as water conservancy, agricultural reclamation, mining, national defense, bridges, and railways, epidemiological reconnaissance and epidemic source monitoring should be carried out before entering. If it is an EHF epidemic area or epidemic source, organization and publicity must be strengthened to do a good job in deratization and rodent prevention in construction and camping areas.
B1.4 Vaccination ：EHF inactivated vaccine should be given to young and middle-aged people in high-incidence areas (regardless of age in rat-infected areas) and other occupations or types of work in epidemic areas that have many opportunities to contact rodents and wild epidemic sources, including relevant medical, nursing, inspection and epidemic prevention personnel (high-risk groups). The corresponding type of vaccine should be selected according to the type of epidemic. Vaccination should be completed within one month before the start of the peak season of the epidemic. After the initial immunization, it is advisable to boost the vaccination once a year. Vaccination should be carried out strictly in accordance with the instructions for use of the vaccine. Vaccination is strictly prohibited for those with contraindications, and expired vaccines cannot be used. B1.5 Strengthen personal protection and try to avoid contact with rodents and their excreta (urine, feces) or secretions (sleeping fluid). Pay special attention to personal protection during the process of rodent control. When entering the wild epidemic source for work and staying overnight, personal protection must be strengthened to prevent contact infection. B2 Monitoring methods
EHF epidemic monitoring includes human epidemic monitoring (human infection and morbidity) and rodent infection monitoring. Through monitoring, provide a basis for determining EHF prevention and control strategies and measures. B2.1 Human epidemic monitoring
B2.1.1 Monitoring content
a) Appoint a dedicated person to be responsible for epidemic monitoring and epidemic management in each county, and keep track of the epidemic figures in the jurisdiction in a timely manner. Draw a distribution map of the epidemic situation every year, count the number of cases and deaths on a monthly basis, count the incidence, mortality and case fatality rate on an annual basis, and analyze the dynamics and development trends of the epidemic situation. b) For clinically suspected cases, blood should be drawn for antibody testing to confirm the diagnosis and verify the epidemic situation, and the epidemic report figures should be revised in a timely manner based on the confirmed misdiagnosed and missed cases.
c) Case investigations should be conducted on suspected cases that need to be verified, as well as cases in newly discovered epidemic areas, sporadic or sporadic epidemic areas. d) Sampling and hemagglutination inhibition test (HI) should be used to type the serum antibodies of the infected virus type of the patient, and the IFAT method should be used to monitor the serum antibody level (latent infection) and HI method typing of the normal population every 2 to 3 years to determine the type of EHF virus in the local area and the immune level of the population.
B2.1.2 Monitoring methods
First, the population, time and spatial distribution of the epidemic in the area (township or town) where the fixed monitoring point is located and the administrative area (province, prefecture and county) to which it belongs should be systematically analyzed and described. The method for analyzing the distribution of the epidemic is to count the reported epidemic data (name, gender, age, occupation, address, time of onset and death, etc.) by population, region and time, and calculate the number of cases, incidence, number of deaths, mortality and case fatality rate. When describing the distribution of the epidemic, the whole population and all cases in the whole population should be observed. The reliability of the reported epidemic should be considered, and if necessary, an investigation on the underreporting of the epidemic and a case investigation should be conducted. It is required to verify the epidemic with serological methods. B2.1.3 Serological verification of the epidemic
Depending on the actual conditions of the monitoring point, one of the following methods can be selected: indirect immunofluorescence method, reverse passive hemagglutination inhibition test or enzyme-linked immunosorbent assay. Antibody typing test can be carried out in mixed epidemic areas. For details, please refer to the laboratory diagnosis section of the Manual for the Prevention and Control of Epidemic Hemorrhagic Fever. B2.2 Monitoring of infection among rats
B2.2.1 Monitoring content
a) Taking counties as units, gradually clarify the composition, distribution, density, virus-carrying rate and serum antibody positive rate of rats in residential areas and the wild. b) Select areas where it is expected that the epidemic may break out, and conduct fixed-point monitoring of the density and virus-carrying rate of the main host rat species in the area. Conduct irregular monitoring of other areas where the epidemic may break out as needed. Monitoring should be carried out within one month before the peak of the two types of EHF. c) Serological monitoring of EHF virus infection should be carried out regularly (at least once a year) for rats, mice and rabbits in experimental animal breeding farms in the epidemic area. Once EHF virus infection is found, all rats should be destroyed under supervision, and the breeding houses should be thoroughly disinfected and deratized.
B2.2.2 Monitoring methods
B2.2.2.1 Selection of monitoring areas: Areas with different geographical landscapes (plains, hills, mountains, etc.) should be selected. Residential areas should be selected in areas with poor living conditions, living conditions and sanitary conditions; the wild areas should be selected in rivers, canals, roadsides, fields, cemeteries and yards where rodents may live and move; warehouses at long-distance bus stations, railway stations, ship terminals, etc. should also be monitored. B2.2.2.2 Monitoring time: Monitoring should be carried out simultaneously in towns, rural residential areas and the wild in March and April and September and October each year. B2.2.2.3 Monitoring objects and quantity: Each monitoring point should capture more than 100 local dominant rodent species in residential areas and the wild; experimental rats, mice and rabbits, etc., should be sampled at 5% of the breeding quantity. B2.2.2.4 Monitoring and calculation methods
B2.2.2.4.1 Method of placing mousetraps in residential areas: Place mousetraps in every 15m2 room. The bait is peanuts, fried dough sticks or fried cakes (the same bait should be used in each region). At night, place the mousetrap in places where mice often appear and move, and draw arrows on the wall near the trap with chalk. Take the mousetrap back the next morning, put the captured mice in a plastic bag (or white cloth bag), number them, keep records, and tie the bag tightly. B2.2.2.4.2 Method of placing traps (or cages) in the field: Places with mouse activity should be selected, with a row spacing of more than 30m and a distance of 5m between traps (or cages). The bait should be uniform, and all traps (or cages) should be placed before dark and retrieved the next morning; if catching mice active during the day, place them in the same place for 24 hours before changing the trap (or cage) location. During this period, inspections should be conducted once in the morning and evening, and captured mice should be retrieved and bait should be replenished. B2.2.2.4.3 Classification and identification of captured mice: scientific names should be written, and the names of mice should be determined by referring to the "Classification and Identification of Medical Animals". B2.2.2.4.4 Dissect mouse lungs and take blood samples: Take the mouse for classification and identification, disinfect the fur on the mouse chest with alcohol cotton, cut open the chest cavity, extract the mouse lungs with tweezers and cut them off, put them into a numbered small plastic tube, cover the lid and seal it with tape, and store it in a liquid nitrogen tank. When cutting the mouse lungs, use filter paper strips (7cm×1cm) to soak up the mouse blood, dry them in the shade, tie them together, wrap them in a plastic bag, and store them in a liquid nitrogen tank. After the above specimens are brought to the laboratory, they should be stored in an ultra-low temperature or low-temperature refrigerator in time, or be packaged and tested as soon as possible. B2.2.2.4.5 Detect mouse lung antigens using direct immunofluorescence method: freeze the mouse lungs and cut them into 4~5μm slices, adhere them to a perforated slide, blow dry with a fan, fix them with cold acetone for 7 minutes, and blow dry them with distilled water once. Add direct fluorescent serum, combine in a porcelain plate in a 37C water bath for 30 minutes, vibrate and wash 3 times with 0.01mol/LpH7.2PBS, 1~2min each time, wash 3 times with distilled water, blow dry. After sealing with buffered glycerol, observe under a fluorescence microscope. Granular yellow-green fluorescence in the cytoplasm of mouse lung epithelial cells indicates specific antigen. B2.2.2.4.6 Detect mouse blood antibodies by indirect immunofluorescence method: take out the antigen piece and blow dry, number it, cut out a round blood piece, put it in the round hole of the antigen piece, add drops of PBS to wet the blood piece, put the slide into a porcelain plate in a 37C water bath, take it out after 30 minutes, vibrate 3 times with PBS, wash 3 times with distilled water, blow dry, add goat anti-mouse fluorescent serum, put it in a water bath for 30 minutes, vibrate 3 times with PBS, wash 3 times with distilled water. Blow dry, seal the slide, and examine under a microscope. Yellow-green particles in the cytoplasm indicate positive specific antibodies. B2.2.2.4.7 The composition of rat species shall be calculated according to formula (B1): Number of rats of each type
Composition of rat species (%) = Total number of rats captured
B2.2.2.4.8 The total rat density and the density of each type of rat shall be calculated according to formula (B2) and (B3) respectively: Total number of rats captured
Total rat density (%) -
Number of mousetraps
Density of each type of rat (%) -
Number of rats captured of each type
Number of mousetraps
B2 .2.2.4.9 The total virus-carrying rate of rats and the virus-carrying rate of each type of rat are calculated according to formula (B4) and (B5) respectively: Total virus-carrying rate of rats (%)
Total number of positive rats of various types
Total number of rats tested of various types
Number of positive rats of each type×100
Virus-carrying rate of each type of rat (%)
Number of each type of rat tested
B2.2.2.4.10 The virus-carrying rat index is calculated according to formula (B6): It can be calculated according to the total number of rats of various types and each type of rat. Index of virus-carrying mice = √ mouse density virus-carrying rate Appendix C
(Standard Appendix)
Treatment methods for epidemic hemorrhagic fever
Center Center of China
.....( B1 )
......( B2)
*·...+*.( B3 )
......( B4 )
.......(B5 )
.......( B6 )
At present, comprehensive treatment is still needed. First of all, we should do a good job in "three early and one immediate" (i.e. early detection, early rest, early treatment and nearby treatment). According to the pathological and physiological changes of each stage, preventive treatment and treatment for the prevention and treatment of complications should be taken before the arrival of each stage, especially antiviral treatment and fluid therapy. For severe patients, we should grasp the treatment of anti-shock, prevention of bleeding and renal failure. C1
Treatment during the fever period
The treatment principle is anti-virus, anti-exudation and anti-bleeding. 385
GB15996—1995
C1.1 Rest in bed as soon as possible and give high-calorie, multivitamin and easily digestible diet. For those who vomit and cannot eat, balanced salt solution and glucose solution should be supplemented intravenously.
C1.2 Maintain the balance of water, electrolytes, acid-base and plasma osmotic pressure: In the early stage of fever, the amount of fluid replacement for adults is generally about 1500mL per day. For those with vomiting and diarrhea, the amount should be increased as appropriate. Oral replacement is best, and the insufficient part should be supplemented intravenously. In the late stage of fever, there is often hemoconcentration, and intravenous rehydration should be given, and a comprehensive fluid therapy based on balanced salt solution should be adopted. At the same time, pay attention to calorie intake (hypertonic glucose solution can be used), and give large doses (5g) of vitamin C and vitamin E. Some patients have severe poisoning symptoms in the late stage of fever, with nausea and vomiting, and the acid-base balance should be adjusted and maintained according to the condition. For those with obvious exosmosis, low molecular weight dextran, plasma or human albumin should be supplemented intravenously. C1.3 Antiviral drug treatment: Generally, the effect is good within 5 days of illness. Adults generally take 1.0g of ribavirin per day, divided into two intravenous drips. The course of treatment is 5 to 7 days. In the early stage of the disease, severe patients can choose convalescent serum (20 to 30mL, one intramuscular injection) and interferon (1 million to 3 million u/day, intramuscular injection, for 3 to 5 consecutive days).
C1.4 In the late stage of fever, if the daily urine volume is less than 1000mL or the average urine volume per hour is less than 40mL, it is a tendency to oliguria. Preventive treatment should be adopted in time, and diuretics can be used as appropriate.
C1.5 For patients with high fever and severe poisoning symptoms, hydrocortisone (100-200mg each time) or dexamethasone (5-10mg each time) can be diluted and slowly dripped intravenously.
C2 Treatment of hypotension period
Mainly replenish blood volume actively, and carry out corresponding treatment for microcirculatory dysfunction, acidosis, heart failure, etc. Strive to raise blood pressure as soon as possible and achieve stability within 4 hours. Volume replenishment should be early, rapid and appropriate. C2.1 Replenish blood volume
C2.1.1 Fluid composition: mainly comprehensive fluids (such as balanced salt solution, low molecular weight dextran solution). For patients with severe exudation, the amount of colloid solution can be increased (about 150 mL is required for every 1 mL increase in hemoglobin), but the amount of low-molecular-weight dextran used in 24 hours should not exceed 100 mL. If conditions permit, colloidal solutions such as plasma or human albumin can be used. C2.1.2 Early volume expansion: If the systolic blood pressure is lower than 13kPa (100mmHg), or 2.7kPa (20mmHg) lower than the patient's baseline blood pressure, fluid expansion should be performed immediately.
C2.1.3 Rapid volume expansion: Rapid intravenous drip in case of hypotension, about 100 drops/min. In case of shock, the first 300mL of fluid is dripped intravenously within 30 minutes, followed by rapid intravenous drip of 200~300mL (130150 drops/min). In the future, adjust the fluid replacement speed and volume according to the recovery of blood pressure and the degree of improvement of hemoconcentration. Rapid fluid replacement should pay attention to the liquid temperature (appropriate heating), infusion reaction and cardiopulmonary condition. For the elderly and those with poor cardiopulmonary function, the rate of fluid replacement should be appropriately slowed down. C2.1.4 Appropriate volume expansion: Determine the amount of fluid replacement based on the following five indicators. a) Systolic blood pressure reaches 12-13 kPa (90-100 mmHg); b) Pulse pressure difference is greater than 3.4 kPa (26 mmHg); c) Heart rate is about 100 beats/min;
d) Microcirculatory disorders are relieved;
e) Red blood cells, hemoglobin and hematocrit are close to normal. C2.2 Adjustment of acid-base balance: When there is acidosis, 5% sodium bicarbonate solution or 3.64% trihydroxymethylamine (THAM) can be used. C2.3 Application of cardiotonic agents: When the blood volume is basically replenished and the heart rate is still above 140 beats/min, digoxin or schizonepeta can be used.
C2.4 Application of vasoactive drugs: After rapid rehydration, cardiotonic, acid correction and other treatments, if the blood pressure is still not recovered satisfactorily, vasoactive drugs such as alamin and dopamine may be used as appropriate. In some cases, atropine and sanguisorbazone (654-2) are used. C2.5 Application of corticosteroids: Generally, hydrocortisone 200-300 mg or dexamethasone 10 mg is used in the early stage, 1-2 times a day, and the course of treatment does not exceed 3 days. It should be used with caution during the hypotensive period, but it can be considered for use in case of heavy bleeding. C2.6 Anticoagulant therapy: In response to changes in coagulation images, dipyridamole, protamine or heparin can be used for treatment. There are no basic laboratory indicators, and it is difficult to grasp hypercoagulation and fibrinolysis, so anticoagulant therapy should be used with caution. 386
GB15996-1995
C2.7 Application of Chinese medicine: On the basis of comprehensive treatment, Shengmai San, Sini Tang, Shenfu Tang intravenous injection and other intravenous infusions can be used. C3 Treatment of oliguria
Urine volume of 500-1000mL/day is oliguria tendency, less than 500mL/day is oliguria, and less than 50mL/day is urine retention. For the convenience of early treatment, an average urine volume of less than 30mL per hour can be regarded as oliguria, and corresponding treatment measures should be taken in time. The treatment principle of this stage is to stabilize the internal environment, promote the recovery of renal function, and prevent complications. C3.1 Stabilize the internal environment
C3.1.1 Water and electrolyte balance: In the functional oliguria stage, 500-1000mL of electrolyte solution can be supplemented daily, and diuretics can be used at the same time to keep the urine volume above 50mL/h. Entering the organic oliguria stage, the amount of fluid should be limited, that is, the amount of fluid output is 1000mL, mainly hypertonic glucose solution. However, the occurrence of hypervolemia should be prevented to aggravate the condition. Unless there is indeed hypokalemia, potassium salt input should generally be limited. C3.1.2 The daily sugar intake should not be less than 200g, and the calorie intake should not be less than 5kJ. The daily protein intake is 0.5g/kg. C3.1.3 Maintain acid-base balance: For severe acidemia, CO2 binding capacity is lower than 13.47mmol/L, acid should be corrected as appropriate. C3.1.4 Maintain plasma osmotic pressure (280~320mmol/L) and blood pressure stability. C3.2 Promote diuresis
C3.2.1 High-efficiency diuretics: furosemide, sodium urate, buturonamine, etc. are often used. C3.2.2 Vasodilators: can use rutin, propranolol, captopril, etc. C3.2.3 Increase plasma colloid osmotic pressure: if the plasma colloid osmotic pressure is reduced, human albumin or plasma can be used. C3.3 Catharsis therapy
Commonly used are mannitol, magnesium sulfate, Chinese herbal medicine rhubarb, and mirabilite. C3.4 Dialysis therapy
C3.4.1 Dialysis indications
a) Oliguria for more than 5 days or urine retention for more than 2 days, which is ineffective after diuretic treatment; b) Slow increase in urine volume, increasingly severe symptoms of uremia, and blood urea nitrogen greater than 28.56~35.7mmol/L (80~100mg/dL); c) Hypervolemia syndrome is ineffective after conservative treatment, accompanied by pulmonary edema or cerebral edema, and massive intestinal bleeding, which can be treated with drugs at the same time; d) Combined with hyperkalemia (6.5mmol/L), hyperkalemia pattern appears on the electrocardiogram, and cannot be relieved by general methods; e) After entering the oliguria stage, the disease progresses rapidly, with severe impaired consciousness and persistent vomiting in the early stage; f) Massive bleeding, rapid increase in urea nitrogen, exceeding 9mmol/L per day (high catabolic type), can be treated with dialysis as soon as possible regardless of the number of days of oliguria and blood biochemical indicators.
C3.4.2 Dialysis method: hemodialysis or peritoneal dialysis. C4 Treatment of polyuria
After the oliguria period, if the daily urine volume increases to 500-2000ml, it is the transition stage from oliguria to polyuria. If it exceeds 2000mL, it enters the polyuria period. Urine volume exceeds 3000mL, which is polyuria. In the early stage of polyuria, the treatment principle of oliguria should still be followed. After a few days of polyuria, the water and electrolyte balance should be adjusted according to the treatment principle of this stage, and supportive therapy should be strengthened. C4.1 Supplement appropriate amount of fluid: In principle, there is no need to limit fluid replacement, but it should not be too much. Generally, after the onset of polyuria, the amount of fluid replacement can be two-thirds of the urine volume (under-replenishment) to avoid prolonging the polyuria period. It is necessary to maintain the balance of intake and output and electrolytes. Fluid replacement is mainly oral, and intravenous fluid replacement can be used for those with poor appetite.
C4.2 Supportive therapy: Patients should eat a nutritious, easy-to-digest, high-potassium diet. For patients with severe anemia and hypoproteinemia, fresh blood, plasma or human albumin can be transfused as appropriate. C4.3 Potassium should be supplemented if the urine volume exceeds 3000mL/day, mainly orally, and can be slowly intravenously dripped when necessary. At the same time, attention should be paid to the supplementation of electrolytes such as sodium and calcium.
C4.4 For patients with daily urine volume exceeding 5000mL, clofibrate or hydrochlorothiazide, posterior pituitary hormone, indomethacin, etc. can be tried. C4.5 Application of traditional Chinese medicine: Jinkui Shenqi Decoction or Maiwei Dihuang Decoction can be used. 3875 For patients with high fever and severe poisoning symptoms, hydrocortisone (100-200 mg each time) or dexamethasone (5-10 mg each time) can be diluted and slowly dripped intravenously.
C2 Treatment of hypotension
Mainly replenish blood volume actively, and carry out corresponding treatment for microcirculatory dysfunction, acidosis, heart failure, etc. Strive to restore blood pressure as soon as possible and achieve stability within 4 hours. Volume replenishment should be early, rapid, and appropriate. C2.1 Replenish blood volume
C2.1.1 Fluid composition: mainly comprehensive fluids (such as balanced salt solution, low molecular weight dextran solution). For patients with severe exudation, the amount of colloid fluid can be increased (about 150 mL is required for every 1 mL increase in hemoglobin), but the amount of low molecular weight dextran in 24 hours should not exceed 100 mL. If conditions permit, colloid solutions such as plasma or human albumin can be used. C2.1.2 Early volume expansion: If the systolic blood pressure is lower than 13kPa (100mmHg), or 2.7kPa (20mmHg) lower than the patient's baseline blood pressure, fluid should be immediately administered to expand the volume.
C2.1.3 Rapid volume expansion: Rapid intravenous drip in case of hypotension, about 100 drops/min. In case of shock, the first 300mL of fluid is intravenously dripped within 30 minutes, followed by 200~300mL of intravenous rapid drip (130150 drops/min). In the future, the rate and amount of fluid infusion will be adjusted according to the recovery of blood pressure and the degree of improvement of hemoconcentration. Rapid fluid infusion should pay attention to the temperature of the fluid (appropriate heating), infusion reaction and cardiopulmonary condition. For the elderly and those with poor cardiopulmonary function, the rate of fluid infusion should be appropriately slowed down. C2.1.4 Appropriate volume expansion: Determine the amount of fluid infusion based on the achievement of the following five indicators. a) Systolic blood pressure reaches 12-13 kPa (90-100 mmHg); b) Pulse pressure difference is greater than 3.4 kPa (26 mmHg); c) Heart rate is about 100 beats/min;
d) Microcirculatory disorders are relieved;
e) Red blood cells, hemoglobin and hematocrit are close to normal. C2.2 Adjustment of acid-base balance: When there is acidosis, 5% sodium bicarbonate solution or 3.64% tris(hydroxymethyl)aminomethane (THAM) can be used. C2.3 Application of cardiotonic agents: When the blood volume is basically replenished and the heart rate is still above 140 beats/min, digoxin or Convolvulus sphaerocephalus can be used.
C2.4 Application of vasoactive drugs: After rapid rehydration, cardiotonic, acid correction and other treatments, if the blood pressure recovery is still not satisfactory, vasoactive drugs such as alamin and dopamine can be used as appropriate. In some cases, atropine and sanguisorba officinalis (654-2) are used. C2.5 Application of corticosteroids: Generally, hydrocortisone 200-300 mg or dexamethasone 10 mg is used in the early stage, 1-2 times a day, and the course of treatment does not exceed 3 days. It should be used with caution during the hypotensive period, but it can be considered for use in case of severe bleeding. C2.6 Anticoagulant therapy: In view of the changes in coagulation images, dipyridamole, protamine or heparin can be used for treatment. There are no laboratory indicators at the basic level, and it is difficult to grasp hypercoagulation and fibrinolysis, so anticoagulant therapy should be used with caution. 386
GB15996-1995
C2.7 Application of traditional Chinese medicine: On the basis of comprehensive treatment, Shengmai San, Sini Tang, Shenfu Tang intravenous injection and other intravenous infusions can be used. C3 Treatment of oliguria
Urine volume of 500-1000 mL/day is oliguria tendency, less than 500 mL/day is oliguria, and less than 50 mL/day is urinary retention. In order to facilitate early treatment, an average urine volume of less than 30 mL per hour can be considered oliguria, and appropriate treatment measures should be taken in time. The treatment principle of this stage is to stabilize the internal environment, promote the recovery of renal function, and prevent complications. C3.1 Stabilize the internal environment
C3.1.1 Water and electrolyte balance: In the functional oliguria stage, 500~1000 mL of electrolyte solution can be supplemented daily, and diuretics can be used at the same time to keep the urine volume above 50 mL/h. Entering the organic oliguria stage, the amount of fluid should be limited, that is, the amount of fluid per person is 500 mL, mainly hypertonic glucose solution. However, the occurrence of hypervolemia should be prevented to aggravate the condition. Unless there is a definite hypokalemia, potassium salt input should generally be limited. C3.1.2 The daily sugar intake should not be less than 200 g, and the calorie intake should not be less than 5 kJ. The daily protein intake is 0.5 g/kg. C3.1.3 Maintain acid-base balance: For severe acidemia, those with CO2 binding capacity lower than 13.47 mmol/L should be corrected as appropriate. C3.1.4 Maintain plasma osmotic pressure (280~320mmol/L) and blood pressure stability. C3.2 Promote diuresis
C3.2.1 High-efficiency diuretics: Furosemide, sodium urate, buturonamine, etc. are often used. C3.2.2 Vasodilators: Conothioline, propranolol, captopril, etc. can be used. C3.2.3 Increase plasma colloid osmotic pressure: If the plasma colloid osmotic pressure is reduced, human serum albumin or plasma can be used. C3.3 Catharsis therapy
Commonly used are mannitol, magnesium sulfate, Chinese herbal medicine rhubarb, and mirabilite. C3.4 Dialysis therapy
C3.4.1 Dialysis indications
a) Oliguria for more than 5 days or urine retention for more than 2 days, which is ineffective after diuretic treatment; b) Slow increase in urine volume, increasingly severe symptoms of uremia, and blood urea nitrogen greater than 28.56~35.7mmol/L (80~100mg/dL); c) Hypervolemia syndrome is ineffective after conservative treatment, accompanied by pulmonary edema or cerebral edema, and massive intestinal bleeding, which can be treated with drugs at the same time; d) Combined with hyperkalemia (6.5mmol/L), hyperkalemia pattern appears on the electrocardiogram, and cannot be relieved by general methods; e) After entering the oliguria stage, the disease progresses rapidly, with severe impaired consciousness and persistent vomiting in the early stage; f) Massive bleeding, rapid increase in urea nitrogen, exceeding 9mmol/L per day (high catabolic type), can be treated with dialysis as soon as possible regardless of the number of days of oliguria and blood biochemical indicators.
C3.4.2 Dialysis method: hemodialysis or peritoneal dialysis. C4 Treatment of polyuria
After the oliguria period, if the daily urine volume increases to 500-2000ml, it is the transition stage from oliguria to polyuria. If it exceeds 2000mL, it enters the polyuria period. Urine volume exceeds 3000mL, which is polyuria. In the early stage of polyuria, the treatment principle of oliguria should still be followed. After a few days of polyuria, the water and electrolyte balance should be adjusted according to the treatment principle of this stage, and supportive therapy should be strengthened. C4.1 Supplement appropriate amount of fluid: In principle, there is no need to limit fluid replacement, but it should not be too much. Generally, after the onset of polyuria, the amount of fluid replacement can be two-thirds of the urine volume (under-replenishment) to avoid prolonging the polyuria period. It is necessary to maintain the balance of intake and output and electrolytes. Fluid replacement is mainly oral, and intravenous fluid replacement can be used for those with poor appetite.
C4.2 Supportive therapy: Patients should eat a nutritious, easy-to-digest, high-potassium diet. For patients with severe anemia and hypoproteinemia, fresh blood, plasma or human albumin can be transfused as appropriate. C4.3 Potassium should be supplemented if the urine volume exceeds 3000mL/day, mainly orally, and can be slowly intravenously dripped when necessary. At the same time, attention should be paid to the supplementation of electrolytes such as sodium and calcium.
C4.4 For patients with daily urine volume exceeding 5000mL, clofibrate or hydrochlorothiazide, posterior pituitary hormone, indomethacin, etc. can be tried. C4.5 Application of traditional Chinese medicine: Jinkui Shenqi Decoction or Maiwei Dihuang Decoction can be used. 3875 For patients with high fever and severe poisoning symptoms, hydrocortisone (100-200 mg each time) or dexamethasone (5-10 mg each time) can be diluted and slowly dripped intravenously.
C2 Treatment of hypotension
Mainly replenish blood volume actively, and carry out corresponding treatment for microcirculatory dysfunction, acidosis, heart failure, etc. Strive to restore blood pressure as soon as possible and achieve stability within 4 hours. Volume replenishment should be early, rapid, and appropriate. C2.1 Replenish blood volume
C2.1.1 Fluid composition: mainly comprehensive fluids (such as balanced salt solution, low molecular weight dextran solution). For patients with severe exudation, the amount of colloid fluid can be increased (about 150 mL is required for every 1 mL increase in hemoglobin), but the amount of low molecular weight dextran in 24 hours should not exceed 100 mL. If conditions permit, colloid solutions such as plasma or human albumin can be used. C2.1.2 Early volume expansion: If the systolic blood pressure is lower than 13kPa (100mmHg), or 2.7kPa (20mmHg) lower than the patient's baseline blood pressure, fluid should be immediately administered to expand the volume.
C2.1.3 Rapid volume expansion: Rapid intravenous drip in case of hypotension, about 100 drops/min. In case of shock, the first 300mL of fluid is intravenously dripped within 30 minutes, followed by 200~300mL of intravenous rapid drip (130150 drops/min). In the future, the rate and amount of fluid infusion will be adjusted according to the recovery of blood pressure and the degree of improvement of hemoconcentration. Rapid fluid infusion should pay attention to the temperature of the fluid (appropriate heating), infusion reaction and cardiopulmonary condition. For the elderly and those with poor cardiopulmonary function, the rate of fluid infusion should be appropriately slowed down. C2.1.4 Appropriate volume expansion: Determine the amount of fluid infusion based on the achievement of the following five indicators. a) Systolic blood pressure reaches 12-13 kPa (90-100 mmHg); b) Pulse pressure difference is greater than 3.4 kPa (26 mmHg); c) Heart rate is about 100 beats/min;
d) Microcirculatory disorders are relieved;
e) Red blood cells, hemoglobin and hematocrit are close to normal. C2.2 Adjustment of acid-base balance: When there is acidosis, 5% sodium bicarbonate solution or 3.64% tris(hydroxymethyl)aminomethane (THAM) can be used. C2.3 Application of cardiotonic agents: When the blood volume is basically replenished and the heart rate is still above 140 beats/min, digoxin or Convolvulus sphaerocephalus can be used.
C2.4 Application of vasoactive drugs: After rapid rehydration, cardiotonic, acid correction and other treatments, if the blood pressure recovery is still not satisfactory, vasoactive drugs such as alamin and dopamine can be used as appropriate. In some cases, atropine and sanguisorba officinalis (654-2) are used. C2.5 Application of corticosteroids: Generally, hydrocortisone 200-300 mg or dexamethasone 10 mg is used in the early stage, 1-2 times a day, and the course of treatment does not exceed 3 days. It should be used with caution during the hypotensive period, but it can be considered for use in case of severe bleeding. C2.6 Anticoagulant therapy: In view of the changes in coagulation images, dipyridamole, protamine or heparin can be used for treatment. There are no laboratory indicators at the basic level, and it is difficult to grasp hypercoagulation and fibrinolysis, so anticoagulant therapy should be used with caution. 386
GB15996-1995
C2.7 Application of traditional Chinese medicine: On the basis of comprehensive treatment, Shengmai San, Sini Tang, Shenfu Tang intravenous injection and other intravenous infusions can be used. C3 Treatment of oliguria
Urine volume of 500-1000 mL/day is oliguria tendency, less than 500 mL/day is oliguria, and less than 50 mL/day is urinary retention. In order to facilitate early treatment, an average urine volume of less than 30 mL per hour can be considered oliguria, and appropriate treatment measures should be taken in time. The treatment principle of this stage is to stabilize the internal environment, promote the recovery of renal function, and prevent complications. C3.1 Stabilize the internal environment
C3.1.1 Water and electrolyte balance: In the functional oliguria stage, 500~1000 mL of electrolyte solution can be supplemented daily, and diuretics can be used at the same time to keep the urine volume above 50 mL/h. Entering the organic oliguria stage, the amount of fluid should be limited, that is, the amount of fluid per person is 500 mL, mainly hypertonic glucose solution. However, the occurrence of hypervolemia should be prevented to aggravate the condition. Unless there is a definite hypokalemia, potassium salt input should generally be limited. C3.1.2 The daily sugar intake should not be less than 200 g, and the calorie intake should not be less than 5 kJ. The daily protein intake is 0.5 g/kg. C3.1.3 Maintain acid-base balance: For severe acidemia, those with CO2 binding capacity lower than 13.47 mmol/L should be corrected as appropriate. C3.1.4 Maintain plasma osmotic pressure (280~320mmol/L) and blood pressure stability. C3.2 Promote diuresis
C3.2.1 High-efficiency diuretics: Furosemide, sodium urate, buturonamine, etc. are often used. C3.2.2 Vasodilators: Conothioline, propranolol, captopril, etc. can be used. C3.2.3 Increase plasma colloid osmotic pressure: If the plasma colloid osmotic pressure is reduced, human serum albumin or plasma can be used. C3.3 Catharsis therapy
Commonly used are mannitol, magnesium sulfate, Chi
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