{"id":16824,"date":"2019-02-16T05:34:51","date_gmt":"2019-02-15T21:34:51","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=16824"},"modified":"2019-02-25T05:49:11","modified_gmt":"2019-02-24T21:49:11","slug":"nejm%e4%b8%b4%e5%ba%8a%e5%86%b3%e7%ad%96%ef%bc%9a%e7%96%91%e4%bc%bc%e5%85%a8%e8%ba%ab%e6%80%a7%e6%84%9f%e6%9f%93%e6%82%a3%e8%80%85%e6%97%a9%e6%9c%9f%e4%bd%bf%e7%94%a8%e6%8a%97%e7%94%9f%e7%b4%a01-3","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=16824","title":{"rendered":"[NEJM\u4e34\u5e8a\u51b3\u7b56]\uff1a\u7591\u4f3c\u5168\u8eab\u6027\u611f\u67d3\u60a3\u8005\u65e9\u671f\u4f7f\u7528\u6297\u751f\u7d20[1\/3]"},"content":{"rendered":"\n<h3 class=\"wp-block-heading\"><a href=\"https:\/\/www.nejm.org\/medical-articles\/clinical-decisions\" class=\"\">CLINICAL DECISIONS<\/a><\/h3>\n\n\n\n<h1 class=\"wp-block-heading\">Early Administration of Antibiotics for Suspected Sepsis<\/h1>\n\n\n\n<h3 class=\"wp-block-heading\">Michael Y. Mi, Michael Klompas, Laura Evans<\/h3>\n\n\n\n<h3 class=\"wp-block-heading\">N Engl J Med 2019; 380:593-596<br \/>DOI: 10.1056\/NEJMclde1809210<\/h3>\n\n\n\n<h2 class=\"wp-block-heading\">Case Vigenette \u75c5\u4f8b<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">A Man with Hypoxemia and a Woman with Acute Kidney Injury<\/h3>\n\n\n\n<h3 class=\"wp-block-heading\">\u4e00\u540d\u4f4e\u6c27\u8840\u75c7\u7537\u6027\u60a3\u8005\u53ca\u4e00\u540d\u6025\u6027\u80be\u635f\u4f24\u5973\u6027\u60a3\u8005<\/h3>\n\n\n\n<h3 class=\"wp-block-heading\">Michael Y. Mi, M.D.<\/h3>\n\n\n\n<p>Mr. Shui is a 35-year-old man who is brought to the emergency department by ambulance after falling from the crest of a tall wave while surfing. He had been in the water for approximately 10 minutes before a lifeguard reached him and brought him to shore. At that time, he was unconscious and coughing and had a palpable pulse. A friend accompanied him to the nearest community hospital, where you work. The friend thinks that Mr. Shui is generally in good health and takes no medications regularly, but earlier in the day, Mr. Shui mentioned to his friend that he had felt slightly fatigued and had had a persistent cough for 2 days. He drinks alcohol occasionally. He does not smoke tobacco but smokes marijuana regularly.<\/p>\n\n\n\n<p>Shui\u5148\u751f\u662f\u4e00\u540d35\u5c81\u7537\u6027\u60a3\u8005\uff0c\u56e0\u51b2\u6d6a\u65f6\u4ece\u6d6a\u5cf0\u5904\u6454\u843d\u88ab\u6551\u62a4\u8f66\u9001\u5230\u6025\u8bca\u3002\u6551\u751f\u5458\u627e\u5230\u60a3\u8005\u5e76\u5c06\u5176\u5e26\u81f3\u5cb8\u8fb9\u524d\uff0c\u60a3\u8005\u5df2\u5728\u6c34\u4e2d\u7ea610\u5206\u949f\u3002\u90a3\u65f6\uff0c\u60a3\u8005\u610f\u8bc6\u4e27\u5931\uff0c\u54b3\u55fd\uff0c\u8109\u640f\u53ef\u626a\u53ca\u3002\u4ed6\u7684\u670b\u53cb\u8ddf\u4ed6\u4e00\u8d77\u5728\u4f60\u6240\u5de5\u4f5c\u7684\u6700\u8fd1\u7684\u793e\u533a\u533b\u9662\u5c31\u8bca\u3002\u670b\u53cb\u8868\u793a\uff0cShui\u5148\u751f\u5e73\u65f6\u8eab\u4f53\u5065\u5eb7\uff0c\u5e76\u672a\u957f\u671f\u670d\u836f\uff0c\u4f46\u51fa\u4e8b\u5f53\u5929\u65e9\u4e0a\uff0c\u60a3\u8005\u66fe\u63d0\u5230\u81ea\u5df1\u611f\u89c9\u8f7b\u5ea6\u4e4f\u529b\uff0c\u54b3\u55fd\u5df2\u6301\u7eed2\u5929\u3002\u60a3\u8005\u5076\u5c14\u996e\u9152\uff0c\u4e0d\u5438\u70df\uff0c\u4f46\u7ecf\u5e38\u5438\u98df\u5927\u9ebb\u3002<\/p>\n\n\n\n<p>On examination, his temperature is 36.0\u00b0C, blood pressure 98\/65 mm Hg, heart rate 110 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 90% while he is breathing ambient air. He opens his eyes and moves his limbs in response to commands but is confused and disoriented. Breath sounds are diminished at the base of both lungs. There is a 3-cm laceration on the right side of his scalp. The remainder of the physical examination is unremarkable. The complete blood count is notable for a white-cell count of 12,400 per cubic millimeter. Electrolyte levels, renal function, and liver-function tests are within normal limits. Arterial blood gas analysis reveals a pH of 7.37, partial pressure of oxygen (Po<sub>2<\/sub>) of 60 mm Hg, partial pressure of carbon dioxide (Pco<sub>2<\/sub>) of 36 mm Hg, and lactate level of 2.2 mmol per liter. A chest radiograph shows bibasilar air-space opacities. Computed tomography (CT) of the head and neck without administration of contrast material shows no acute intracranial abnormalities and no fractures of the cervical spine.<\/p>\n\n\n\n<p>\u4f53\u683c\u68c0\u67e5\u53d1\u73b0\uff0c\u4f53\u6e2936.0\u00b0C\uff0c\u8840\u538b98\/65 mm Hg\uff0c\u5fc3\u7387110 bpm\uff0c\u547c\u5438\u9891\u738724 bpm\uff0c\u5438\u7a7a\u6c14\u65f6\u6c27\u9971\u548c\u5ea690%\u3002\u60a3\u8005\u53ef\u9075\u5631\u7741\u773c\u53ca\u6d3b\u52a8\u80a2\u4f53\uff0c\u4f46\u610f\u8bc6\u6a21\u7cca\uff0c\u5b9a\u5411\u529b\u969c\u788d\u3002\u53cc\u80ba\u5e95\u547c\u5438\u97f3\u51cf\u4f4e\u3002\u53f3\u4fa7\u5934\u76ae\u67093-cm\u88c2\u4f24\u3002\u5176\u4f59\u4f53\u683c\u68c0\u67e5\u6ca1\u6709\u5f02\u5e38\u53d1\u73b0\u3002\u8840\u5e38\u89c4\u68c0\u67e5\u767d\u7ec6\u80de\u8ba1\u657012,400\/mL\u3002\u7535\u89e3\u8d28\u3001\u80be\u529f\u80fd\u53ca\u809d\u529f\u80fd\u68c0\u67e5\u5747\u6b63\u5e38\u3002\u52a8\u8109\u8840\u6c14\u5206\u6790pH 7.37\uff0cPo<sub>2<\/sub> 60 mm Hg\uff0cPco<sub>2<\/sub> 36 mm Hg\uff0c\u4e73\u9178\u6c34\u5e732.2 mmol\/L\u3002\u80f8\u7247\u663e\u793a\u53cc\u4fa7\u80ba\u5e95\u5b9e\u53d8\u3002\u5934\u9885\u53ca\u9888\u90e8CT\u5e73\u626b\u672a\u53d1\u73b0\u6025\u6027\u9885\u5185\u5f02\u5e38\uff0c\u9888\u690e\u672a\u89c1\u9aa8\u6298\u3002<\/p>\n\n\n\n<p>Ms. Wilkinson is a 72-year-old woman with a history of hypertension and urgency urinary incontinence who presents to the emergency department with a 1-day history of acute-onset abdominal pain in the left lower quadrant. Before the onset of abdominal pain, she had had constipation for 3 days and had not urinated for 1 day despite her efforts to drink plenty of water. She takes extended-release oxybutynin, at a dose of 30 mg daily, and she was recently given a prescription for hydrochlorothiazide, 25 mg daily. She does not smoke or drink alcohol.<\/p>\n\n\n\n<p>Wilkinson\u5973\u58eb\u662f\u4e00\u540d72\u5c81\u5973\u6027\u60a3\u8005\uff0c\u6709\u9ad8\u8840\u538b\u53ca\u5c3f\u6f74\u7559\u75c5\u53f2\u3002\u60a3\u8005\u56e0\u6025\u6027\u8d77\u75c5\u7684\u5de6\u4e0b\u8179\u75bc\u75db1\u5929\u5230\u6025\u8bca\u5c31\u8bca\u3002\u5728\u8179\u75db\u53d1\u751f\u524d\uff0c\u60a3\u8005\u4fbf\u79d83\u5929\uff0c\u5c3d\u7ba1\u5927\u91cf\u996e\u6c34\uff0c\u4f46\u4e00\u6574\u5929\u672a\u6392\u5c3f\u3002\u60a3\u8005\u670d\u7528\u7f13\u91ca\u5965\u897f\u5e03\u5b8130 mg qd\uff0c\u8fd1\u671f\u5f00\u59cb\u670d\u7528\u53cc\u6c22\u514b\u5c3f\u585e25 mg qd\u3002\u60a3\u8005\u4e0d\u5438\u70df\u4e5f\u4e0d\u996e\u9152\u3002<\/p>\n\n\n\n<p>Her temperature is 36.7\u00b0C, blood pressure 126\/75 mm Hg, heart rate 100 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 99% while she is breathing ambient air. On examination, she has tenderness to palpation of the left lower quadrant of the abdomen. She is alert and fully oriented. Cardiac and pulmonary examinations are normal. Laboratory studies show a creatinine level of 2.0 mg per deciliter (180 \u03bcmol per liter), anion gap 21 mmol per liter, white-cell count 24,200 per cubic millimeter with a predominance of neutrophils, hematocrit 45.0%, and lactate 3.9 mmol per liter. CT of the abdomen and pelvis with administration of contrast material shows large stool volume in the descending and sigmoid colon without evidence of gastrointestinal wall edema or hypoenhancement. A chest radiograph shows clear lungs without focal consolidations. An indwelling urinary catheter is placed, and 1 liter of urine is drained. Results of urinalysis are within normal limits.<\/p>\n\n\n\n<p>\u60a3\u8005\u4f53\u6e29 36.7\u00b0C\uff0c\u8840\u538b126\/75 mm Hg\uff0c\u5fc3\u7387100 bpm\uff0c\u547c\u5438\u9891\u738718 bpm\uff0c\u5438\u7a7a\u6c14\u65f6\u6c27\u9971\u548c\u5ea699%\u3002\u4f53\u683c\u68c0\u67e5\u53d1\u73b0\uff0c\u89e6\u8bca\u5de6\u4e0b\u8179\u65f6\u6709\u538b\u75db\u3002\u60a3\u8005\u610f\u8bc6\u6e05\u695a\uff0c\u5b9a\u5411\u529b\u6b63\u5e38\u3002\u5fc3\u80ba\u68c0\u67e5\u6b63\u5e38\u3002\u5b9e\u9a8c\u5ba4\u68c0\u67e5\u53d1\u73b0\u808c\u91502.0 mg\/dL (180 \u03bcmol\/L)\uff0c\u9634\u79bb\u5b50\u95f4\u969921 mmol\/L\uff0c\u767d\u7ec6\u80de\u8ba1\u657024,200\/mL\uff0c\u4e2d\u6027\u7c92\u7ec6\u80de\u4e3a\u4e3b\uff0c\u8840\u7403\u538b\u79ef45.0%\uff0c\u4e73\u91783.9 mmol\/L\u3002\u8179\u90e8\u53ca\u76c6\u8154\u589e\u5f3aCT\u663e\u793a\u964d\u7ed3\u80a0\u53ca\u4e59\u72b6\u7ed3\u80a0\u5185\u5927\u91cf\u7caa\u4fbf\uff0c\u6ca1\u6709\u80c3\u80a0\u9053\u6c34\u80bf\u6216\u4f4e\u5bc6\u5ea6\u8868\u73b0\u3002\u80f8\u7247\u663e\u793a\u80ba\u90e8\u6b63\u5e38\uff0c\u672a\u89c1\u5c40\u7076\u5b9e\u53d8\u3002\u60a3\u8005\u7559\u7f6e\u5c3f\u7ba1\uff0c\u5f15\u6d41\u5c3f\u6db21 L\u3002\u5c3f\u5e38\u89c4\u68c0\u67e5\u7ed3\u679c\u6b63\u5e38\u3002<\/p>\n\n\n\n<p>You are the on-call provider caring for both Mr. Shui and Ms. Wilkinson. You suspect that there may be infections underlying the presentations of both patients, but you are not certain. You believe that early administration of antibiotics to patients with sepsis may save lives, but antibiotics can have serious adverse effects. Your task is to decide whether to administer antibiotics in addition to providing supportive care.<\/p>\n\n\n\n<p>\u4f60\u8d1f\u8d23\u4e0a\u8ff0\u4e24\u540d\u60a3\u8005\u7684\u8bca\u6cbb\u3002\u4f60\u6000\u7591\u4e24\u540d\u60a3\u8005\u7684\u57fa\u7840\u75c5\u56e0\u5747\u53ef\u80fd\u4e3a\u611f\u67d3\uff0c\u4f46\u5e76\u4e0d\u786e\u5b9a\u3002\u4f60\u76f8\u4fe1\u65e9\u671f\u4f7f\u7528\u6297\u751f\u7d20\u53ef\u80fd\u633d\u6551\u8113\u6bd2\u75c7\u60a3\u8005\u751f\u547d\uff0c\u4f46\u6297\u751f\u7d20\u4e5f\u53ef\u4ee5\u5bfc\u81f4\u4e25\u91cd\u4e0d\u826f\u53cd\u5e94\u3002\u9664\u652f\u6301\u6cbb\u7597\u5916\uff0c\u4f60\u7684\u4efb\u52a1\u662f\u786e\u5b9a\u662f\u5426\u5e94\u5f53\u4f7f\u7528\u6297\u751f\u7d20\u3002<\/p>\n\n\n\n<ol><li>Do not administer antibiotics. \u4e0d\u5e94\u4f7f\u7528\u6297\u751f\u7d20<\/li><li>Administer antibiotics immediately. \u7acb\u5373\u4f7f\u7528\u6297\u751f\u7d20<\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"<p>CLINICAL DECISIONS Early Administration of Antibiotics  [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[13,18],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16824"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16824"}],"version-history":[{"count":2,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16824\/revisions"}],"predecessor-version":[{"id":16853,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16824\/revisions\/16853"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16824"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16824"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16824"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}