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[NEJM作者回复]:感染性休克的早期目标指导治疗—患者水平的meta分析
2017年09月23日 研究点评, 进展交流 暂无评论

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Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis

N Engl J Med 2017; 377:994-995

DOI: 10.1056/NEJMc1708979

The authors reply:

In response to Saleh: we do not have specific information on monitoring in the usual-care (control) groups. However, all three original trials1-3 were conducted at sites that did not systematically apply any protocolized approach to resuscitation of patients with sepsis as part of usual care and, by definition, did not use continuous monitoring of central venous oxygen saturation.

有关Saleh的回复:我们没有常规治疗(对照)组监测的信息。然而,所有3项临床试验的参研中心对全身性感染患者的复苏治疗中均没有系统使用任何治疗方案,即根据定义,并不持续监测中心静脉血氧饱和度。

Dhooria et al. contend that the ProCESS, ARISE, and ProMISe trials differed from that of Rivers et al.4 because the usual care in the trial reported by Rivers and colleagues lacked the prompt use of antibiotics, fluid resuscitation, and vasopressors. Contrary to this contention, however, the usual-care group in the trial by Rivers et al. did, in fact, require an intravenous fluid bolus (at a dose of 20 to 30 ml per kilogram of body weight over a 30-minute period) before the first 6 hours of treatment and included the prompt use of antibiotics and adjustment of amounts of both intravenous fluids and vasopressors according to blood pressure and central venous pressure targets. That said, we certainly concur that the trial by Rivers et al. was important in spurring research and quality improvement in the early care of patients with sepsis.

Dhooria等人认为,ProCESS,ARISE和ProMISe试验与Rivers的研究不同之处在于,Rivers研究的常规治疗组并不立即使用抗生素、液体复苏和升压药物。然而,与这种想法相反,Rivers研究中的常规治疗组事实上要求,在开始6个小时的治疗前应快速输注静脉液体(30分钟内剂量20-30 ml/kg),同时还包括及时使用抗生素,并根据血压和中心静脉压的目标调整静脉液体量和升压药物剂量。因此,我们赞同这一观点,即Rivers的研究促进了全身性感染患者早期治疗的研究及质量改进。

Derek C. Angus, M.D., M.P.H.

University of Pittsburgh School of Medicine, Pittsburgh, PA

Rinaldo Bellomo, M.D.

Monash University, Melbourne, VIC, Australia

Kathryn M. Rowan, Ph.D.

Intensive Care National Audit and Research Centre, London, United Kingdom

Since publication of their article, the authors report no further potential conflict of interest.

Reference

1. The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-1693 Free Full Text | Web of Science | Medline

2. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-1506 Free Full Text | Web of Science | Medline

3. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-1311 Free Full Text | Web of Science | Medline

4. 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;345:1368-1377 Free Full Text | Web of Science | Medline

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