重症医学科住院医生

朱 杰

INTENSIVE CARE MEDICINE

（JUNE-AUGUST）

• Systemic Review

• There is limited supportive evidence that specific

interventions can decrease mortality in ARDS. While low tidal

volumes and prone positioning in severe ARDS seem

effective, most sporadic findings of interventions suggesting

reduced mortality are not corroborated consistently in large-

scale evidence including meta-analyses.

• Introduction and Methods

• This report summarizes the results of the first phase in the development of international guidelines for

death determination, focusing on the biology of death and the dying process, developed by an invitational

forum of international content experts and representatives of a number of professional societies.

• Results and Conclusions

• Precise terminology was developed in order to improve clarity in death discussion and debate. Critical

events in the physiological sequences leading to cessation of neurological and/or circulatory function

were constructed. It was agreed that death determination is primarily clinical and recommendations for

preconditions, confounding factors, minimum clinical standards and additional testing were made. A

single operational definition of human death was developed: ‘the permanent loss of capacity for

consciousness and all brainstem functions, as a consequence of permanent cessation of

circulation or catastrophic brain injury’. In order to complete the project, in the next phase, a broader

group of international stakeholders will develop clinical practice guidelines, based on comprehensive

reviews and grading of the existing evidence.

• Optimal fluid management is one of the main challenges in the care of the critically ill. However, the physiological parameters that are commonly monitored and used to guide fluid management are often inadequate and even misleading. From 1987 to 1989 we published four experimental studies which described a method for predicting the response of the cardiac output to fluid administration during mechanical ventilation. The method is based on the analysis of the variations in the arterial pressure in response to a mechanical breath, which serves as a repetitive hemodynamic challenge. Our studies showed that the systolic pressure variation and its components are able to reflect even small changes in the circulating blood volume. Moreover, these dynamic parameters provide information about the slope of the left ventricular function curve, and therefore predict the response to fluid administration better than static preload parameters.

• Many new dynamic parameters have been introduced since then, including the pulse pressure (PPV) and stroke volume (SVV) variations, and various echocardiographic and other parameters. Though seemingly different, all these parameters are based on measuring the response to a predefined preload-modifying maneuver. The clinical usefulness of these ‘dynamic’ parameters is limited by many confounding factors, the recognition of which is absolutely necessary for their proper use.

• With more than 20 years of hindsight we believe that our early studies helped pave the way for the recognition that fluid administration should ideally be preceded by the assessment of “fluid responsiveness”. The introduction of dynamic parameters into clinical practice can therefore be viewed as a significant step towards a more rational approach to fluid management.

• Purpose

• Ulinastatin, a serine protease inhibitor, inhibits several pro-inflammatory proteases and decreases inflammatory cytokine levels

and mortality in experimental sepsis. We studied the effect of ulinastatin on 28-day all-cause mortality in a double-blind trial in

patients with severe sepsis in seven Indian hospitals.

• Methods

• Patients with sepsis were randomized within 48 h of onset of one or more organ failures to receive intravenous administration

of ulinastatin (200,000 IU) or placebo 12 hourly for 5 days.

• Results

• Of 122 randomized subjects, 114 completed the study (55 receiving ulinastatin, 59 receiving placebo). At baseline, the mean

APACHE II score was 13.4 (SD = 4.4), 48 (42 %) patients were receiving mechanical ventilation, 58 (51 %) were on vasopressors ,

and 35 % had multiple organ failure. In the modified intention-to-treat analysis (patients receiving six or more doses of study

drugs), 28-day all-cause mortality was 7.3 % with ulinastatin (4 deaths) versus 20.3 % (12 deaths) with placebo (p = 0.045). On

multivariate analysis too, treatment with ulinastatin (odds ratio 0.26, 95 % CI 0.07–0.95; p = 0.042) independently decreased 28-

day all-cause mortality. However, the mortality difference did not reach statistical significance in the intention -to-treat analysis

[10.2 % (6/59 deaths) with ulinastatin versus 20.6 % (13/63 deaths) in the placebo group; p = 0.11]. The ulinastatin group had

lower incidence of new-onset organ failure (10 vs. 26 patients, p = 0.003), more ventilator -free days (mean ± SD 19.4 ± 10.6 days vs. 10.2 ± 12.5 days, p = 0.019), and shorter hospital stay (11.8 ± 7.1 days vs. 24.2 ± 7.2 days, p < 0.001).

• Conclusions

• In this pilot study, intravenous administration of ulinastatin reduced mortality in patients with

severe sepsis in the modified intention-to-treat analysis, but not in the intention-to-treat analysis.

• Purpose

• Candida is the most common cause of severe yeast infections worldwide, especially in critically ill patients. In this setting, septic shock attributable to Candida is characterized by high mortality rates. The aim of this multicenter study was to investigate the determinants of outcome in critically ill patients with septic shock due to candidemia.

• Methods

• This was a retrospective study in which patients with septic shock attributable to Candida who were treated during the 3-year study period at one or more of the five participating teaching hospitals in Italy and Spain were eligible for enrolment. Patient characteristics, infection-related variables, and therapy-related features were reviewed. Multiple logistic regression analysis was performed to identify the risk factors significantly associated with 30 -day mortality.

• Results

• A total of 216 patients (mean age 63.4 ± 18.5 years; 58.3 % males) were included in the study. Of these, 163 (75 %) were admitted to the intensive care unit. Overall 30-day mortality was 54 %. Significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, dysfunctional organs, and inadequate antifungal therapy were compared in nonsurvivors and survivors. No differences in survivors versus nonsurvivors were found in terms of the time from positive blood culture to initiation of adequate antifungal therapy. Multivariate logistic regression identified inadequate source control, inadequate antifungal therapy, and 1-point increments in the APACHE II score as independent variables associated with a higher 30-day mortality rate.

• Purpose

• Sudden cardiac death (SCD) is a major public health concern, but data regarding epidemiology of this disease in Western Europ ean

countries are outdated. This study reports the first results from a large registry of SCD.

• Methods

• A population-based registry was established in May 2011 using multiple sources to collect every case of SCD in Paris and its sub urbs,

covering a population of 6.6 million. Utstein variables were recorded. Pre-hospital and in-hospital data were considered, and the main

outcome was survival at hospital discharge. Neurologic status at discharge was established as well.

• Results

• Of the 6,165 cases of SCD recorded over 2 years, 3,816 had a resuscitation attempt and represent the study population. Most p atients

were male (69 %), the SCD occurred at home (72 %) with bystanders in 80 % of cases, and cardiopulmonary resuscitation (CPR) w as

performed in 45 % of cases. Initial rhythm was shockable in 26 % of cases. A total of 1,332 patients (35 %) were admitted alive to

hospital. Among hospitalized patients, 58 % had a coronary angiogram, and the same proportion had therapeutic hypothermia. Fi nally,

279 patients (7.5 %) were discharged alive, of whom 96 % had a favorable neurological outcome. In multivariate analysis, byst ander CPR

(OR 2.1, 95 % CI 1.5–3.1) and initial shockable rhythm (OR 11.5, 95 % CI 7.6–17.3) were positively associated with survival at hospital

discharge, whereas age (OR 0.97 per year, 95 % CI 0.96–0.98), longer response time (OR 0.93 per minute, 95 % CI 0.89–0.97),

occurrence at home (OR 0.4, 95 % CI 0.3–0.6), and epinephrine dose greater than 3 mg (OR 0.05, 95 % CI 0.03–0.08) were inversely

associated with survival.

• Conclusion

• Despite being conducted in the therapeutic hypothermia and early coronary angiogram era, hospital discharge survival rate of

resuscitated SCD remains poor. The current registry suggests ways to improve pre -hospital and in-hospital care of these patients.

• Introduction

• The influence of blood glucose (BG) level during the post-resuscitation period after out-of-hospital cardiac arrest (OHCA) is still debated.

To evaluate the relationship between blood glucose level and outcome, we included the median glycemia and its maximal amplitude over

the first 48 h following ICU admission in an analysis of outcome predictors.

• Methods

• We conducted a database study in a cardiac arrest center in Paris, France. Between 2006 and 2010, we included 381 patients wh o were

all resuscitated from an OHCA. A moderate glycemic control was applied in all patients. The median glycemia and the largest change

over the first 48 h were included in a multivariate analysis that was performed to determine parameters associated with a fav orable

outcome.

• Results

• Of the 381 patients, 136 (36 %) had a favorable outcome (CPC 1–2). Median BG level was 7.6 mmol/L (6.3–9.8) in patients with a

favorable outcome compared to 9.0 mmol/L (IQR 7.1–10.6) for patients with an unfavorable outcome (p < 0.01). Median BG level

variation was 7.1 (4.2–11) and 9.6 (5.9–13.6) mmol/L in patients with and without a favorable outcome, respectively (p < 0.01). In

multivariate analysis, an increased median BG level over the first 48 h was found to be an independent predictor of poor issu e [OR =

0.43; 95 % CI (0.24–0.78), p = 0.006]. Finally a progressive increase in median BG level was associated with a progressive incre ase in

the proportion of patients with a poor outcome.

• Conclusion

• We observed a relationship between high blood glucose level and outcome after cardiac arrest. These results suggest the need to test a

strategy combining both control of glycemia and minimization of glycemic variations for its ability to improve post -resuscitation care.

ACEI所致血管性水肿。Icatibant 30mg ih。（1小时前后对比。）