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强制急救中脓毒症至治疗时间与死亡率关系
Time to Treatment and Mortality during Mandated Emergency Care for Sepsis


Christopher W. Seymour ... 其他 • 2017.06.08
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脓毒症的早期治疗

 

David T Huang†‡*,文小宴‡§

†Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; ‡Clinical Research, Investigation, and Systems Modeling of Acute Illness and Multidisciplinary Acute Care Research Organization, University of Pittsburgh, Pittsburgh, PA, USA; §Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

*通讯作者

 

脓毒症是感染引发的系统性器官功能衰竭导致高死亡率的危重病症1。2016版Surviving Sepsis Campaign官方指南提出了早期治疗的建议2。然而,指南中所推荐早期治疗措施多为非标准化的“优化治疗陈述”,或者是仅基于中、低质量的试验证据而提出的推荐方案。最近发表的一份系统性回顾和荟萃分析结果显示,与延迟治疗相比,针对急诊入院3小时内的脓毒症患者早期给予抗生素治疗,对于降低病死率没有帮助3。而在多中心随机临床试验“早期目标导向治疗重症脓毒症及脓毒症休克”(EGDT for Severe Sepsis and Sepsis Shock)中,因为试验中的多数患者在随机分组之前已接受过治疗,所以该试验的标准化荟萃分析(PRISM meta-analysis)中并没有说明治疗早晚是否会影响死亡率4。因此,我们仍然对脓毒症早期治疗的效果存疑。

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摘要


背景

2013年,纽约州开始要求医院遵守早期诊断和治疗脓毒症的管理方案。然而,脓毒症的快速治疗能否改善患者结局,目前仍存在争议。

 

方法

本研究分析了2014年4月1日至2016年6月30日期间向纽约州卫生署(New York State Department of Health,NYSDOH)报告的脓毒症和感染性休克病例数据。在这些患者到达急诊科6小时内启动了脓毒症管理方案,并在12小时内完成了脓毒症患者3小时集束化方案的所有项目(即血培养、应用广谱抗生素和乳酸水平检测)。利用多水平统计分析模型评价至完成3小时集束化方案的时间与风险校正死亡率之间的相关性。本研究还评价了至给予抗生素治疗的时间和至完成初始静脉液体推注的时间这两项与风险校正死亡率之间的相关性。

 

结果

在149家医院的49,331例患者中,40,696例患者(82.5%)在3小时内完成3小时集束化方案。至完成3小时集束化方案的中位时间为1.30小时(四分位距为0.65~2.35),至给予抗生素治疗的中位时间为0.95小时(四分位距为0.35~1.95),至完成初始静脉液体推注的中位时间为2.56小时(四分位距为1.33~4.20)。在12小时内完成3小时集束化方案的患者中,较长的至完成集束化方案的时间,与较高的风险校正院内死亡率相关(比值比,1.04/小时;95%置信区间[CI],1.02~1.05;P<0.001)。较长的至给予抗生素治疗的时间,也与较高的风险校正院内死亡率相关(比值比,1.04/小时;95% CI,1.03~1.06;P<0.001),而较长的至完成初始静脉液体推注的时间与风险校正院内死亡率无关(比值比,1.01/小时;95% CI,0.99~1.02;P=0.21)。

 

结论

脓毒症患者较低的风险校正院内死亡率与较快地完成3小时集束化方案和快速地给予抗生素治疗相关,但与快速完成初始静脉液体推注无关(美国国立卫生研究院等资助)。





作者信息

Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D.
From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center — both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) — both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research — both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.).Address reprint requests to Dr. Seymour at the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St., Scaife Hall, Rm. 639, Pittsburgh, PA 15261, or at seymourcw@upmc.edu.

 

参考文献

1. Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013;41:1167-1174

2. 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;43:304-377

3. Rhee C, Gohil S, Klompas M. Regulatory mandates for sepsis care — reasons for caution. N Engl J Med 2014;370:1673-1676

4. Kumar A, Haery C, Paladugu B, et al. The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels. J Infect Dis 2006;193:251-258

5. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014;42:1749-1755

6. Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: a systematic review and meta-analysis. Crit Care Med 2015;43:1907-1915

7. New York codes, rules and regulations: 405.4 medical staff. Thomson Reuters, 2017 (https://govt.westlaw.com/nycrr/Document/I4fe39657cd1711dda432a117e6e0f345?viewType=FullText&%3BoriginationContext=documenttoc&%3BtransitionType=CategoryPageItem&%3BcontextData=(sc.Default)(last.)=Default=(sc.Default)).

8. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-1256

9. Dimick JB, Staiger DO, Birkmeyer JD. Ranking hospitals on surgical mortality: the importance of reliability adjustment. Health Serv Res 2010;45:1614-1629

10. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:762-774

11. Banta JE, Joshi KP, Beeson L, Nguyen HB. Patient and hospital characteristics associated with inpatient severe sepsis mortality in California, 2005-2010. Crit Care Med 2012;40:2960-2966

12. Reineck LA, Pike F, Le TQ, Cicero BD, Iwashyna TJ, Kahn JM. Hospital factors associated with discharge bias in ICU performance measurement. Crit Care Med 2014;42:1055-1064

13. Lash TL, Fox MP, Fink AK. Applying quantitative bias analysis to epidemiologic data. New York: Springer-Verlag, 2009.

14. Royston P, Sauerbrei W. Building multivariable regression models with continuous covariates in clinical epidemiology — with an emphasis on fractional polynomials. Methods Inf Med 2005;44:561-571

15. Puskarich MA, Trzeciak S, Shapiro NI, et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011;39:2066-2071

16. Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med 2017 March 27 (Epub ahead of print)

17. The PRISM Investigators. Early, goal-directed therapy for septic shock — a patient-level meta-analysis. N Engl J Med 2017;376:2223-2234

18. Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 2010;182:752-761

19. Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. Crit Care 2016;20:89-89

20. Psaty BM, Koepsell TD, Lin D, et al. Assessment and control for confounding by indication in observational studies. J Am Geriatr Soc 1999;47:749-754

21. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006;34:344-353

22. Gropen TI, Gagliano PJ, Blake CA, et al. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology 2006;67:88-93

23. Cooke CR, Iwashyna TJ. Sepsis mandates: improving inpatient care while advancing quality improvement. JAMA 2014;312:1397-1398

24. Walkey AJ, Wiener RS. Hospital case volume and outcomes among patients hospitalized with severe sepsis. Am J Respir Crit Care Med 2014;189:548-555

25. Vazquez-Guillamet C, Scolari M, Zilberberg MD, Shorr AF, Micek ST, Kollef M. Using the number needed to treat to assess appropriate antimicrobial therapy as a determinant of outcome in severe sepsis and septic shock. Crit Care Med 2014;42:2342-2349

26. Wang HE, Devereaux RS, Yealy DM, Safford MM, Howard G. National variation in United States sepsis mortality: a descriptive study. Int J Health Geogr 2010;9:9-9

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