icu

提高严重败血症患者的存活率

Increasing Survival in Patients With Severe Sepsis: Evidence-Based Studies
Disclosures
Antonios Liolios, MD
Introduction
After several years of intense research and multiple unsuccessful trials, a drug other than an antibiotic has demonstrated a positive therapeutic effect on sepsis. Activated protein C was shown to decrease mortality in patients with severe sepsis, and its worldwide use is expected soon. Along with this success, other measures such as tight blood glucose control and administration of steroids were increasingly recognized as having markedly beneficial effects for patients with severe sepsis and septic shock. A review of these newer strategies and the data supporting their effectiveness were presented in this session.
　　A Look at Evidence-Based Therapies in Critical Care
　　Drotrecogin Alfa (Activated) in Severe Sepsis: Long-Term Outcomes
　　Application of Newer Principles in Sepsis Treatment
Conclusions
For the first time, physicians caring for critically ill patients have an array of evidence-based interventions available to them. Severe sepsis continues to be a major cause of inhospital mortality and morbidity. Despite the availability of level 1 evidence, these data may not have been adequately incorporated in the everyday clinical practice when caring for the septic patient. Drotrecogin alfa (activated) was shown to decrease mortality in severely septic patients, an effect that persists after 30 months of follow up. Its effect is less clear in less sick patients (APACHE II score less than 25), and a study to evaluate this group is currently underway. An important yet unanswered question is whether all of these practices can be used simultaneously for an additive effect. It is hoped that future research will elucidate this issue. Finally, individual decisions should be made when caring for the patient at the bedside. Patient safety should be the absolute priority, and helpful input from colleagues caring for the same patient should be sought.
References
1. Dellinger RP. Daybreak panel discussion: increasing survival in the severe sepsis patient: applying evidence-based medicine into your practice. Recent evidence-based therapy in critical care medicine. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
2. 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.
3. Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med. 2001;345:568-573.
4. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699-709.
5. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.
6. Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med. 2002;346:305-310.
7. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871.
8. Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000;283:1038-1045.
9. Angus DC. Daybreak panel discussion: increasing survival in the severe sepsis patient: applying evidence-based medicine into your practice. Long-term outcomes of the severe sepsis patient treated with drotrecogin alfa (activated). Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
10. Quartin AA, Schein RM, Kett DH, et al. Magnitude and duration of the effect of sepsis on survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group. JAMA. 1997;277:1058-1063.
11. Cohen J, Guyatt G, Bernard GR, et al. New strategies for clinical trials in patients with sepsis and septic shock. Crit Care Med. 2001;29:880-886.
12. Schmidt G. Daybreak panel discussion: increasing survival in the severe sepsis patient: applying evidence-based medicine into your practice. Appropriate patient care and therapy selection. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
13. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.
14. Kress JP, Pohlman AS, O'Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471-1477.