脓毒血症文献报道新进展文献汇报.ppt
文献汇报,一、High versus Low Blood-Pressure Target in Patients with Septic Shock-March 18,2014,at NEJM.org,Background,The Surviving Sepsis Campaign 推荐 目标平均动脉压 65 mm Hg during initial resuscitation of patients with septic shock比较：该血压目标与更高的血压目标,Methods,2010.3 2011.12，29个中心，776例分组：MAP:80 to 85 mm Hg(high-target)-388例 65 to 70 mm Hg(low-target)-388例观察28天死亡率,Results,1、At 28 days,组间无显著区别Death 142 of 388 high-target group(36.6%)132 of 388 in the low-target group(34.0%)(P=0.57).,Results,2、90 days也无显著区别,170 deaths(43.8%)VS164 deaths（42.3%)P=0.743、严重并发症发生率组间无显著区别 74 events 19.1%VS69 events 17.8%P=0.64,Results,4、However,新诊断的房颤发病率，高压组低压组,Results,5、慢性高血压人群中(占研究人群40%),需要进行肾脏替代治疗的患者，高压组比低压组更少，但没有导致死亡率的差别。,Results,CONCLUSIONS,脓毒症休克的复苏，目标MAP of 80 to 85 mm Hg,与 65 to 70 mm Hg比较，28天或90天死亡率没有显著差异,Is There a Good MAP for Septic Shock?James A.Russell,M.D.March 18,EDITORIAL,与其他研究的差别进行了比较提示1：没有提示说常规目标定位在高的MAP，因为病死率无明显差别，且高压组房颤发生率增加,EDITORIAL,提示2：对高血压病人，高目标MAP可能减少肾脏损伤风险和肾脏替代治疗需要I make this point because of the well-known risks and costs of renal-replacement therapy,EDITORIAL,提示3：若干目标MAPs,取决于病人的情况，.In some randomized,controlled trials(and in clinical practice),practitioners use more fluid(increasing the risk of acute lung injury),whereas others use more vasopressors(increasing the risk of renal injury).,EDITORIAL,Indeed，methods for targeting a MAP among patients in septic shock are probably critical to the success of the strategy and deserving of greater investigation.,EDITORIAL,二、A Randomized Trial of Protocol-Based Care for Early Septic Shock（ProCESS）-March 18,2014,NEJM,Background,针对：6-hour protocol of early goal-directed therapy(EGDT)in which intravenous fluids,vasopressors,inotropes,and blood transfusions were adjusted to reach central hemodynamic targetsconducted a trial whether these findings were generalizable whether all aspects of the protocol were necessary,Methods,US,31个急诊室、1341例3组：6 hours of resuscitation 1、protocol-based EGDT（439例）;2、protocol-based standard therapy that did not require the placement of a central venous catheter（除非外周不可用）,administration of inotropes,or blood transfusions（7.5g再输rbc）;（446例）3、usual care（456例）在床旁由临床医师决定所需治疗）,Methods,观察：60天病死率在90天病死率1年病死率器官支持需要,Results,Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids,vasopressors,inotropes,and blood transfusions.,Results,By 60 days 92 deaths in the protocol-based EGDT group(21.0%)81 in the protocol-based standard-therapy group(18.2%)86 in the usual-care group(18.9%)There were no significant differences in 90-day mortality,1-year mortality,or the need for organ support.,Conclusions,In a multicenter trial conducted in the tertiary care setting,protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.,EDITORIAL,The ProCESS Trial A New Era of Sepsis Management Craig M.Lilly,M.D March 18,2014 NEJM,临床医师在脓毒症早期识别中的关键作用，至今仍然是努力提高生存率的基础。脓毒症的早期识别纳入试验设计：早期识别SSC要求的 早期抗生素 conservative transfusion thresholds 小潮气量通气和适度的血糖控制,EDITORIAL,在ProCESS试验中,其生存率高于预期，并高于以APACHEII为基础的预测,与感染性休克的早期识别、静脉应用抗生素、以及其他最佳临床方法应用有关。ProCESS重要贡献：提供的改善脓毒症生存率的证据：早期识别、抗生素治疗,EDITORIAL,与靠临床评估来判断adequacy of circulation循环充分性 相比，使用中心血流动力学和氧饱和度监测的EGDT组，并不能带来更好的结果。该研究发现，靠侵入性导管监测的生理目标，用该目标来调整治疗以减少死亡率是不需要的。这与一项研究结果相符，研究连续测量血乳酸水平不比靠导管监测的结果差，并且分析也未发现使用肺动脉导管有益处。国家立法和临床指南,包括国家质量论坛的支持的组织，应该更新观念，去除中心血流动力学监测的需求，关注低成本,低风险,同样有效的替代品。,EDITORIAL,EDITORIAL,在一个早期的研究中，EGDT多方面的干预实施与显著降低的死亡率，开启了EGDT的时代。Rivers E,Nguyen B,Havstad S,et al.Early goal-directed therapy in the treatment of severe sepsis and septic shock.N Engl J Med 2001;345:1368-77.这个里程碑似的研究，开始了脓毒症早期的识别 以及 早期接受大剂量的液体复苏，以改善结果。The ProCESS trial 改进了EGDT方法，通过定义液体使用的下限以达到同样的结果，设置限制，以避双重问题：液体太少所致的肾衰竭，液体过多所致的肺功能不全。,Craig M.Lilly,M.D.认为the prompting、血清乳酸筛查和SIRS标准的评估，以及各种活动的报告都是Rivers等人研究的一部分，ProCESS trial可以应用于临床实践，确保所有感染性休克患者早期诊断和治疗。,EDITORIAL,EDITORIAL,The ProCESS trial关注元素 脓毒症的早期识别 抗生素的早期使用 早期足够容量复苏 临床评估循环的充分性 ProCESS trial 的发表开始了脓毒症早期识别和治疗的新时代。,谢谢,
