读书报告 2015 年 月 唐之韵

Transcription

1 读书报告 2015 年 月 唐之韵

2 Mar. Apr. NEJM VOL.372

3 Kaukonen KM1, Bailey M, Pilcher D, et al. N Engl J Med Apr 23;372(17): Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. 全身炎症反应综合征用于诊断严重脓毒症

4 ABSTRACT METHODS CONCLUSIONS RESULTS BACKGROUND We Of The Moreover, 1,171,797 studied need for this data two patients, pattern from or more patients remained a total SIRS from of similar criteria 109, after to had The consensus definition of severe sepsis intensive infection define adjustment severe care and for units organ sepsis baseline failure. excluded Australia characteristics Among and one New in these, (odds eight requires Zealand from suspected 2000 through or proven infection, 96,385 otherwise ratio in patients similar SIRS-positive (87.9%) patients group, had with SIRS-positive 0.96; infection, We 95% identified organ patients failure, with infection and signs and that organ meet failure two and or severe organ confidence failure, sepsis interval and 13,278 substantial [CI], 0.96 (12.1%) to mortality 0.97; had odds SIRSnegative and ratio more categorized criteria them for according the systemic to whether inflammatory in the failed SIRS severe negative to define sepsis. group, a transition Over 0.96; a period 95% point CI, they of in the to response had 0.98; signs P = 0.12 meeting syndrome for between-group two (SIRS). or more We SIRS aimed difference). criteria to test In years, risk of these death. groups had similar (SIRS-positive the adjusted sensitivity, analysis, severe face validity, sepsis) mortality and less increased construct than two characteristics and changes in mortality validity SIRS linearly criteria with of this (SIRS each approach. negative additional severe SIRS criterion sepsis). We (odds compared (SIRS-positive ratio for each their additional group: characteristics from criterion, 36.1% and 1.13; outcomes [829 95% of CI, and assessed to patients] 1.15; P<0.001) them to 18.3% for without the [2037 presence any of transitional 11,119], of a step P<0.001; increase in SIRS-negative risk the risk a of threshold death group: at of a two threshold from SIRS 27.7% of two [100 criteria. SIRS of 361] criteria. to 9.3% [122 of 1315], P<0.001).

5 Mouncey PR, Osborn TM, Power GS, et al. N Engl J Med Apr 2;372(14): Trial of Early, Goal-directed Resuscitation for Septic Shock. 早期目标导向液体复苏治疗脓毒症休克

6 Mar. Apr. JAMA

7 McLario DJ, Sivitz AB. JAMA Pediatr Apr 20. Point-of-care Ultrasound in Pediatric Clinical Care. Review 床旁超声技术在小儿 ICU 的临床应用

8 内容简介 床旁超声技术被很多非影像科的医生广泛使用, 该文旨在探讨截止到 2014 年 12 月 31 日前儿科医生使用床旁超声所应用的领域及使用方法 文章中总结了超声技术在血管评估, 软组织, 肌肉骨骼, 肺部疾病, 急性阑尾炎, 幽门狭窄等疾病中的作用并总结了小儿床旁超声技术在未来面临的机遇与挑战

9 Hart JL, Harhay MO, Gabler NB, et al. JAMA Intern Med Mar 30. Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-sustaining Therapies. 美国 ICU 患者生命支持治疗管理差异与入 ICU 时是否存在限 制抢救措施的相关性分析

10 ABSTRACT IMPORTANCE OBJECTIVE DESIGN, MAIN RESULTS CONCLUSIONS OUTCOMES SETTINGS, AND AND RELEVANCE MEASURES PARTICIPANTS Although To Retrospective Outcomes Of Among After among Intensive examine the risk ICU patients care adjustment, the included survivors, admissions the units end-of-life cohort proportions who vary the dramatically survived study ICUs evaluated, provision care proportion varied using of to patients in hospital the 4.8%(95%CI, of widely how who Project receive they in had admitted IMPACT 4.7%-4.9%) discharge, the new manage known (1) proportions treatment cardiopulmonary care database to more for had vary the patients limitations previously intensive of experienced across (from patients admitted nations, April resuscitation, care established admitted 1, reversals with unit 2001, regions, treatment (ICU) with to (11.2% of with and limitations. Among patients who survive, escalations centers, December established existing treatment [95%CI, (2) new 1.9%-57.3%]) treatment these limitations 31, forms life-sustaining 2008) differences of including (median, and limitations. support, are reversal treatments during best %; Patients of ICUs explored the range, in and ICU in the aggressiveness of care are more common within the 105 admitted stay <1.0%-20.9%), treatment during (3) proportions hospitals (17.8%[95%CI, the addition a group ICU with limitations stay in treatment the or of of than patients (4) proportions such 17.0%-18.7%]) United reversal are during patients de-escalations limitations with States or of of presumably following treatment who those and than were in receive 277 who ICU similar 693 limitations. more additions received admission aggressiveness. ICU likely care patient cardiopulmonary of (20.2%[95%CI, care to preferences. new This be across visits. older limits study We individual cannot with (11.7%[95% 1.8%-76.2%]). used resuscitation more directly logistic ICUs. functional CI, measure 11.1%- The regression limitations 12.4%]) (37.7%[95%CI, observed whether care (P variability < analysis and received.01). 3.8%-92.4%]), comorbidities. Among models was could consistent patients not adjusted the be with consistently proportions who for patients available died,15.7%(95%ci, of explained preferences new forms patient using but of suggests measurable life characteristics %) support that ICU center-level (30.0%[95%CI, culture had and and received clustered visits cardiopulmonary 6.0%-84.2%]), characteristics. physicians by individual practice and, styles resuscitation. ICU. contribute The full analysis to the was aggressiveness of care. last performed in October 2014.

11 Niven DJ, Rubenfeld GD, Kramer AA, et al. JAMA Intern Med Mar 16. Effect of Published Scientific Evidence on Glycemic Control in Adult Intensive Care Units. 已发表的科学文章证据对于成人 ICU 患者血糖控制的影响

12 ABSTRACT IMPORTANCE OBJECTIVE MAIN DESIGN, RESULTS OUTCOMES SETTING, AND PARTICIPANTS MEASURES Little To The Interrupted After Following Before evaluate physiologically is the the known the publication glycemic time-series about most control of the of analysis extreme deadoption Leuven of NICE-SUGAR, in critically I, of I, there blood % of 464 were ill ineffective glucose patients significant there (95%CI, was level 16.2%-18.2%) before admitted no increases on change harmful and day to after in clinical of the ICU adult the relative proportion admissions publication practices. ICUs proportion from of A had of large clinical defined January of patients tight admissions glycemic clinical trials 1, with 2001, trial that tight with control, through (the initially glycemic tight Normoglycemia 3.0% glycemic as suggested December tight control (95%CI, control that 2.6%- 31, in 2012, tight Intensive glycemic (glucose in (1.7%per hyperglycemia. 3.5%) the had United level, control quarter; Care hypoglycemia, States mg/dL; Evaluation There reduced 95%CI, using was and mortality 1.2%-2.3%; data to immediate 40.2%(95%CI, Survival from convert (Leuven the P Using < to.001) I) Glucose but millimoles Acute and decrease 38.8%-41.5%) subsequently hypoglycemia Physiology Algorithm in per the had liter, relative and demonstrated (2.5%per hyperglycemia. Regulation multiply Chronic proportion quarter; by Health [NICE-SUGAR] ), that of 95%CI, it trial) increased hypoglycemia Evaluation 1.9%-3.2%; patients demonstrated with mortality database. P < hypoglycemia (glucose.001)(nice-sugar). that and level, strict decreases (22.4%; <70mg/dL), blood in 95%CI, glucose those and control with 13.2%-30.1%; hyperglycemia (tight glycemic P (glucose <.001) (0.6%per control) but level,180mg/dl). no quarter; subsequent in patients 95%CI, admitted Temporal 0.4%-0.9%; change over to changes P adult time. <.001). intensive each marker care units were (ICUs) should examined be using de-adopted; mixed-effects however, segmented it is unknown linear regression. whether deadoption occurred and how it compared with the initial adoption.

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16 ABSTRACT CONCLUSIONS AND RELEVANCE Among patients admitted to adult ICUs in the United States, there was a slow steady adoption of tight glycemic control following publication of a clinical trial that suggested benefit, with little to no deadoption following a subsequent trial that demonstrated harm. There is an urgent need to understand and promote the deadoption of ineffective clinical practices.

17 Prescott HC, Langa KM, Iwashyna TJ. JAMA Mar 10;313(10): Readmission Diagnoses After Hospitalization for Severe Sepsis and Other Acute Medical Conditions. letter 严重脓毒症和其他急症再入院分析

18 内容简介 严重脓毒症患者 90 天内的再入院率较高, 但是没有研究了解再入院的原因和是否能够降低他们的再入院率, 因此研究者对 年 50 岁及以上的人群进行了相关研究 他们的研究中发现 3494 个严重脓毒症患者中有 2843 (81.4%) 人出院, 这部分病人中有 2617 (92.1%) 人在院期间有其他急症与之匹配 他们中 1115(42.6%) 人在 90 天内再入院, 这其中主要是由于包括心衰 肺炎 COPD 加重和泌尿道感染等在内的流动性护理敏感的疾病 (ambulatory care sensitive conditions,acsc)

19 Trial of Early, Goal-directed Resuscitation for Septic Shock 文献精读

20 借鉴之处 如何根据已有的研究和临床工作找到一个新研究 使用成本效益进行分析 讨论本次研究中发现 EGDT 无益的方法

21 背景 Since 2002, the Surviving Sepsis Campaign (SSC) has promoted best practice 早期识别 early recognition 控制原发病 source control 合适及时的抗生素治疗 appropriate and timely antibiotic administration 静脉液体复苏 resuscitation with intravenous fluids 血管活性药物使用 vasoactive drugs

22 背景 2001 single center, proof-of-concept study: (early,goal-directed therapy,egdt) early septic shock continuous monitoring CVP, MAP, ScvO2 guide delivery of intravenous fluids, vasoactive drugs, and red-cell transfusions optimize tissue oxygen transport reduced hospital mortality and hospital stay

23 背景 EGDT 缺陷 a single center complexity of delivery potential risks of the components resources required for implementation 后续解决试验 ProCESS ARISE ProMISe The two published studies reported no benefit for EGDT Both reported lower-than-anticipated mortality clinical and cost-effectiveness measures

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25 结果

26 结果

27 结果

28 结果

29 讨论

30 讨论

31 讨论

32 结论

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