重症领域哪些干预是有害的？.doc

重症领域哪些干预是有害的？028vancom发表于昨天11:19|只看大图|阅读模式|复制链接 意大利人2013年组织专家对2013年7月以前发表的重症领域多中心临床干预试验（mRCT）进行了系统分析。纳入与排除标准纳入：研究发表在同行评阅杂志的文章；mRCT设计；运用在成人患者上的非外科干预；死亡率增加或降低在统计学上有意义。排除：半随机或非随机设计；外科干预；儿童人群；仅涉及围术期；院外；死亡率差异的统计学意义仅限于亚组分析或校正后；认可度低于问卷调查者的50%。结果共计24项mRCT研究探寻15项临床干预。七项治疗降低危重患者的死亡率。伴有急性呼吸衰竭的特殊人群（如COPD急性加重，呼吸性酸中毒，低氧性呼吸衰竭，有创机械通气撤机）进行无创通气（共计8项mRCT）；心脏骤停后给予亚低温治疗；ARDS患者给予俯卧位和低潮气量通气；存在或有创伤失血性休克风险人群给予氨甲环酸治疗（盲）；机械通气患者实施每日唤醒计划；肝硬化伴原发性细菌性腹膜炎患者给予白蛋白治疗（盲）。这其中仅有两项研究为盲法。八项治疗增加危重患者的死亡率。创伤失血性休克给予琥珀酰水杨酸交联血红蛋白（非盲）；脓毒性休克给予羟乙基淀粉；高频振荡通气（非盲）；ARDS给予沙丁胺醇（iv）；超正常范围给予全身性氧输送；强化胰岛素治疗（非盲，血糖控制在81-108mg/dL）。这其中有五项研究为盲法。这些研究结果认同度如何？为了探索这个问题，意大利人随后开展了一项问卷调查，结果并不乐观。61个国家的555位临床医师参与了问卷调查，大多数为美国、澳大利亚及意大利人，80%的为ICU工作者。总的来说，这些人对上述研究的认可度达到81%，但只有71%的参与者将研究结果运用在临床。其中，保护性通气有85%的受访者进行了临床应用，氨甲环酸只有56%，俯卧位只有55%。应用及认可度不高主要受制于部分研究的样本量、研究质量、中心数量不多的原因。附1：24项mRCT1. Sort P, Navasa M, Arroyo V, et al: Effect of intravenousalbumin on renal impairment and mortality in patients with cirrhosis andspontaneous bacterial peritonitis.N Engl J Med1999; 341:4034092. Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermiato improve the neurologic outcome after cardiac arrest.N Engl J Med2002; 346:5495563. Brochard L, Mancebo J, Wysocki M, et al: Noninvasive ventilation for acuteexacerbations of chronic obstructive pulmonary disease.N Engl J Med1995; 333:8178224. Gurin C, Reignier J, Richard JC, et al; PROSEVA Study Group: Pronepositioning in severe acute respiratory distress syndrome.N Engl J Med2013;368:215921685. Amato MB, Barbas CS, Medeiros DM, et al: Effect of a protectiveventilationstrategy on mortality in the acute respiratory distress syndrome.N Engl J Med1998; 338:3473546. The Acute Respiratory Distress Syndrome Network: Ventilation with lowertidal volumes as compared with traditional tidal volumes for acute lung injuryand the acute respiratory distress syndrome.NEnglJ Med2000;342:130113087. Hayes MA, Timmins AC, Yau EH, et al: Elevation of systemic oxygen deliveryin the treatment of critically ill patients.NEngl J Med1994; 330:171717228. Takala J, Ruokonen E, Webster NR, et al: Increased mortality associated withgrowth hormone treatment in critically ill adults.NEngl JMed1999; 341:7857929. Finfer S, Chittock DR, Su SY, et al; NICE-SUGAR Study Investigators: Intensiveversus conventional glucose control in critically ill patients.N Engl J Med2009; 360:1283129710. Perner A, Haase N, Guttormsen AB, et al; 6S Trial Group;Scandinavian Critical Care Trials Group: Hydroxyethyl starch 130/0.42 versus Ringersacetate in severe sepsis.N Engl J Med2012; 367:12413411. Ferguson ND, Cook DJ, Guyatt GH, et al; OSCILLATE Trial Investigators;Canadian Critical Care Trials Group: High-frequency oscillation in early acuterespiratory distress syndrome.N Engl J Med2013; 368:79580512. Heyland D, Muscedere J, Wischmeyer PE, et al; Canadian Critical Care TrialsGroup: A randomized trial of glutamine and antioxidants in critically illpatients.N Engl J Med2013;368:1489149713. Sloan EP, Koenigsberg M, Gens D, et al: Diaspirin cross-linked hemoglobin(DCLHb) in the treatment of severe traumatic hemorrhagic shock: A randomizedcontrolled efficacy trial.JAMA1999; 282:1857186414. Gao Smith F, Perkins GD, Gates S, et al; BALTI-2 study investigators: Effectof intravenous -2 agonist treatment onclinical outcomes in acute respiratory distress syndrome (BALTI-2): Amulticentre, randomised controlled trial.Lancet2012; 379:22923515. Girard TD, Kress JP, Fuchs BD, et al: Efficacy and safety of a paired sedationand ventilator weaning protocol for mechanically ventilated patients inintensive care (Awakening and Breathing Controlled trial): A randomisedcontrolled trial.Lancet2008; 371:12613416. Nava S, Ambrosino N, Clini E, et al: Noninvasive mechanical ventilation inthe weaning of patients with respiratory failure due to chronic obstructivepulmonary disease. A randomized, controlled trial.AnnIntern Med1998;128:72172817. Plant PK, Owen JL, Elliott MW: Early use of non-invasive ventilation foracute exacerbations of chronic obstructive pulmonary disease on generalrespiratory wards: A multicentre randomised controlled trial.Lancet2000;355:1931193518. Ferrer M, Esquinas A, Leon M, et al: Noninvasive ventilation in severe hypoxemicrespiratory failure: A randomized clinical trial.AmJ RespirCrit Care Med2003;168:1438144419. Ferrer M, Valencia M, Nicolas JM, et al: Early noninvasive ventilation avertsextubation failure in patients at risk: A randomized trial.Am JRespir Crit CareMed2006; 173:16417020. Collaborating Research Group for Noninvasive Mechanical Ventilation ofChinese Respiratory Society: Pulmonary infection control window in treatment ofsevere respiratory failure of chronic obstructive pulmonary diseases: Aprospective, randomized controlled, multi-centred study.Chin Med J (Engl)2005;118:1589159421. Ferrer M, Sellars J, Valencia M, et al: Non-invasive ventilation after extubationin hypercapnic patients with chronic respiratory disorders: Randomisedcontrolled trial.Lancet2009; 374:1082108822. Nava S, Grassi M, Fanfulla F, et al: Non-invasiveventilation in elderly patients with acute hypercapnic respiratory failure: A randomizedcontrolled trial.Age Ageing2011; 40:44445023. Villar J, Kacmarek RM, Prez-Mndez L, et al: A high positive endexpiratorypressure, low tidal volume ventilatory strategy improves outcome in persistentacute respiratory distress syndrome: A randomized, controlled trial.Crit Care Med2006; 34:1311131824. Shakur H, Roberts I, Bautista R, et al; CRASH-2 trial collaborators: Effectsof tranexamic acid on death, vascular occlusive events, and blood transfusionin trauma patients with significant haemorrhage (CRASH-2): A ra