[JAMA读者来信]:低收入国家全身性感染的早期复苏治疗 | 中国病理生理学会危重病医学专业委员会
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[JAMA读者来信]:低收入国家全身性感染的早期复苏治疗
2018年03月14日 研究点评, 进展交流 暂无评论

Comment & Response

February 13, 2018

Early Resuscitation for Adults With Sepsis in a Low-Income Country

Wagner Luis Nedel, Caroline Deutschendorf

JAMA. 2018;319(6):614. doi:10.1001/jama.2017.20406

To the Editor 致编辑

Dr Andrews and colleagues1 performed a randomized clinical trial of a sepsis protocol for early resuscitation involving intravenous fluids, vasopressors, and blood transfusion compared with usual care among adults with sepsis and hypotension in Zambia. They found that in-hospital mortality was greater in the sepsis protocol group than in the usual care group. However, the difference in mortality may not be attributed solely to the early resuscitation protocol.

Andrews医生及其同事进行了一项随机临床试验,在赞比亚的全身性感染和低血压成年患者,对早期复苏治疗方案(包括静脉输液,升压药物及输血)与常规治疗进行了比较。他们发现,全身性感染方案治疗组患者住院病死率高于常规治疗组。然而,病死率的差异可能并非完全由于早期复苏方案造成。

In addition to receiving less fluid during the first 6 hours, fewer patients allocated to the usual care group received dopamine and there were fewer transfusions even though they presented with similar severity. Patients in the usual care group also received the first dose of antibiotics 30 minutes earlier, and although this result was not statistically significant, there may have been a lack of statistical power to find such a difference. Therefore, the lack of resources may have delayed the initiation of antibiotic therapy in favor of volume replacement in the sepsis protocol group, perhaps due to limited venous access.

除最初6小时接受了更少液体外,常规治疗组患者较少使用多巴胺,输血比例也较低,尽管其疾病严重程度与对照组相似。常规治疗组患者接受首剂抗生素的时间提前30分钟,尽管结果没有统计学差异,但这可能由于缺乏统计学效力从而无法发现上述差异。因此,医疗资源的缺乏可能延误了初始抗生素治疗,从而造成全身性感染方案治疗组患者接受更多的液体治疗。

A large population-based study conducted in the state of New York suggested a greater benefit in survival with the initiation of antibiotics during the first hour, without a clear benefit from the speed of volume replacement.2 This intervention may be relevant in the management of sepsis in any setting.

在纽约州进行了一项基于人口的大样本研究提示,在第一个小时开始抗生素治疗有助于生存率改善,而液体治疗速度则无明显益处。这一措施在任何场合对于全身性感染的救治都有意义。

In addition, the weight of the patients randomized was not measured. The description by the authors of a predominance of malnourished patients suggests that the median volume of fluid administered during the initial phase of resuscitation in the sepsis protocol group (3500 mL) may have been higher than the 30 mL/kg recommended by the Surviving Sepsis Campaign guidelines3 and the median volume received in usual care groups in recent trials during the first 6 hours of resuscitation.4

另外,随机分组时未能测量患者体重。作者描述很多患者营养不良,这一事实提示,在全身性感染方案治疗组最初的复苏阶段,输注的液体中位数 (3500 mL) 可能超过了拯救全身性感染行动指南所推荐的 30 mL/kg,同时也超过了近期临床试验中常规治疗组复苏最初6个小时接受的输液量中位数。

A resuscitation strategy based in part on clinical perfusion targets is inexpensive, easy to perform, and associated with a smaller amount of volume used without changes in clinical outcomes.5 This strategy should be further explored in trials conducted in both low- and high-income countries.

部分基于临床灌注目标的复苏治疗策略价格便宜,简单易行,输液量减少,但不造成临床结局恶化。这一策略应当在低收入和高收入国家经过临床试验的进一步验证。

参考文献

1. Andrews  B, Semler  MW, Muchemwa  L,  et al.  Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial.  JAMA. 2017;318(13):1233-1240. PubMedGoogle ScholarCrossref
2. Seymour  CW, Gesten  F, Prescott  HC,  et al.  Time to treatment and mortality during mandated emergency care for sepsis.  N Engl J Med. 2017;376(23):2235-2244. PubMedGoogle ScholarCrossref
3. Rhodes  A, Evans  LE, Alhazzani  W,  et al.  Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016.  Intensive Care Med. 2017;43(3):304-377. PubMedGoogle ScholarCrossref
4. Jaehne  AK, Rivers  EP.  Early liberal fluid therapy for sepsis patients is not harmful: hydrophobia is unwarranted but drink responsibly.  Crit Care Med. 2016;44(12):2263-2269. PubMed | Google ScholarCrossref
5. Hjortrup  PB, Haase  N, Bundgaard  H,  et al; CLASSIC Trial Group; Scandinavian Critical Care Trials Group.  Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial.  Intensive Care Med. 2016;42(11):1695-1705. PubMedGoogle ScholarCrossref

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