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[MEDSCAPE]: 激素治疗加速感染性休克恢复,但无生存率获益
2018年02月10日 研究点评, 进展交流 暂无评论

Steroid Therapy Speeds Recovery From Septic Shock, but With No Survival Benefit

By Gene Emery

January 22, 2018

(Reuters Health) - A hydrocortisone infusion does not reduce mortality among septic shock patients undergoing mechanical ventilation, but it does speed recovery when the condition is not fatal, according to an international study of 3,658 patients treated over four years.

根据一项历时4年入选了3658名患者的国际研究结果,接受机械通气的感染性休克患者输注氢化可的松不能降低病死率,但能够加速病情恢复。

The findings, reported at the Critical Care Reviews 2018 meeting in Belfast and online January 19 in The New England Journal of Medicine, support a treatment that has been used for more than 40 years despite a dearth of convincing evidence that it works against a condition that kills 30% to 45% of affected hospitalized patients.

1月19日,这一发现在贝尔法斯特召开的Critical Care Reviews 2018会议上报告,新英格兰医学杂志同时在线发表。尽管临床使用激素治疗感染性休克已经超过40年,但缺乏令人信服的证据。研究结果支持在病死率高达30-45%的患者使用激素。

Mortality at 90 days was 27.9% with hydrocortisone and 28.8% with placebo, a nonsignificant difference. The steroid also did not reduce mortality at 28 days, cut the number of days alive and free from mechanical ventilation, reduce the rate of recurrent shock, or diminish the number of days alive and out of the intensive care unit (ICU).

氢化可的松组90天病死率27.9%,安慰剂组28.8%,没有显著差异。激素不能降低28天病死率,也不影响无机械通气时间,复发性休克,或非ICU住院日。

However, the international study, known as ADRENAL, did find that the therapy resolved the shock a day faster than placebo (median, 3 vs. 4 days; P<0.001). In addition, fewer hydrocortisone than placebo recipients received a blood transfusion (37.0% vs. 41.7%; P=0.004).

然而,ADRENAL研究发现,激素治疗较安慰剂能够提前1天逆转休克(中位数 3 vs. 4 天;P<0.001)。另外,氢化可的松组更少患者接受输血治疗(37.0% vs. 41.7%; P=0.004)。

The study was done in 69 ICUs in Australia, New Zealand, Saudi Arabia, the UK, and Denmark. The hydrocortisone dose was 200 mg per day. It was given for a maximum of 7 days or until ICU discharge. Patients, their doctors, and trial personnel did not know the assigned treatment of any individual patient.

研究在澳大利亚、新西兰、沙特阿拉伯、英国和丹麦的69个ICU进行。氢化可的松剂量为每日200 mg。最长疗程为7天,或直至转出ICU。患者、主管医生及试验人员并不了解每位患者的分组情况。

"Steroids are widely used in around half of all hospitals to treat septic shock, and we would expect that the results will mean there will be a change in practice and we would see more clinicians using steroids to treat septic shock," coauthor Dr. John Myburgh of the George Institute for Global Health in New South Wales, Australia, told Reuters Health by email.

共同作者,澳大利亚新南威尔士州乔治全球健康学院的John Myburgh医生在给路透社健康频道的邮件中写到:“约半数医院普遍使用激素治疗感染性休克,我们希望这一研究结果能够改变医疗行为,从而看到更多医生使用激素治疗感染性休克。”

"We have finally shown what part steroids play in the treatment of these patients," lead author Dr. Bala Venkatesh of the institute said in a news release. "If we can reduce the time spent in intensive care units, that not only frees up space for other patients, it saves health systems worldwide a huge amount of money,” perhaps hundreds of millions of dollars.

“我们最终发现激素在治疗这些患者中发挥何种作用,”研究首席作者,乔治全球健康学院的Bala Ventakesh在新闻发布会上谈到。“如果我们能够缩短ICU住院日,不仅能够为治疗其他患者提供空间,而且能够为全球卫生系统节约大量开支。”

Among the other findings by the Venkatesh team:

Venkatesh团队的其他发现包括:

- Hydrocortisone patients got out of the ICU faster; the median stay was 10 days versus 12 days with placebo (P<0.001).

氢化可的松组患者更快转出ICU;ICU住院日中位数10天,安慰剂组为12天(P<0.001)

- The mean number of days alive and out of the ICU was comparable between the hydrocortisone and placebo groups (58.2 vs. 56.0 days, respectively; P=0.047), but only after adjustment for multiple comparisons.

尽在对多重比较进行校正后,氢化可的松组和安慰剂组非ICU住院日相似( 分别为58.2 vs. 56.0 天;P=0.047)。

- Hydrocortisone did not reduce the rate of recurrence of mechanical ventilation, the use of renal replacement therapy or its duration, or the odds of developing new-onset bacteremia or fungemia.

氢化可的松不能减少再次机械通气比例,不能减少肾脏替代治疗使用或治疗时间,也不能减少新发菌血症或真菌血症的风险

- Serious side effects were more common with hydrocortisone than placebo (1.1% vs. 0.3%; P=0.009). Six patients developed hyperglycemia (vs. 3 with placebo), and there were three cases each of hypertension, encephalopathy and myopathy among steroid recipients, but none in the control group.

氢化可的松组严重副作用发生率高于安慰剂 (1.1% vs. 0.3%; P=0.009)。激素治疗组6名患者发生高血糖(安慰剂组仅3名),3名患者分别发生高血压,脑病和肌病,且无1例在对照组。

Given the findings, Dr. Myburgh, George's director of the division of critical care and trauma, predicted, "Clinicians will use steroids for the treatment of septic shock, primarily to reduce the severity and duration of shock and to result in shorter hospital admissions. They will also lead to a reduction in resources."

基于上述发现,乔治全球健康学院重症医学和创伤部主任Myburgh医生预计:“临床医生将使用激素治疗感染性休克,主要目的在于减轻疾病严重程度,缩短休克持续时间和住院日。这样将减少医疗资源的使用。”

SOURCE: http://bit.ly/2DMKIbn

N Engl J Med 2018.

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