脓毒血症文献报道新进展文献汇报

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、