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<Intensive care monitor > March/April 2007 

http://www.intensive-care-monitor.com/issue.php?issue_to_display=MarApr-2007&x=19&y=6
 
CARDIOVASCULAR （心血管）
Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 2007;51:331-340. 71 references.
个体化目标疗法在围术期液体治疗的应用

ENDOCRINOLOGY （内分泌）
Gandhi GY, Nuttall GA, Abel MD et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery. Ann Intern Med 2007; 146: 233Ð243.
还是那篇在《Annuals of inernal medicine》上的发表的心脏手术术中强化血糖控制与常规血糖控制的研究[Evidence Level: II]
 
Schultz MJ, Royakkers AANM, Levi M, Moeniralam HS, Spronk PE. Intensive insulin therapy in intensive care: An example of the struggle to implement evidence-based medicine. PLOS Med 2006;3:e456. 51 references.
ICU的强化血糖控制：实施循证医学引发争端的一个实例！
 
GASTROENTEROLOGY (胃肠病学)
Berger MM, Shenkin A. Update on clinical micronutrient supplementation studies in the critically ill. Curr Opin Clin Nutr Metab Care 2006;9:711-716. 42 references.
危重患者补充微量元素的研究进展

HAEMATOLOGY（血液病学）
Brunskill SJ, Tusold A, Benjamin S, Stanworth SJ, Murphy MF. A systematic review of randomized controlled trials for plasma exchange in the treatment of thrombotic thrombocytopenic purpura. Transfusion Med 2007;17:17-35. 42 references.
血小板减少性紫癜的血浆置换治疗的系统回顾
 
Napolitano LM, Warkentin TE, AlMahameed A, Nasraway SA. Heparin-induced thrombocytopenia in the critical care setting: Diagnosis and management. Crit Care Med 2006;34:2898-2911. 101 references.
 ICIU中的HIT :诊断与治疗(肝素相关性血小板减少症)

NEUROLOGY （神经病学）
Klemen P, Grmec S. Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury. Acta Anaesthesiol Scand 2006; 50: 1250Ð1254.
严重创伤性脑损伤院前高级生命支持中快速序贯插管对预后的影响[Evidence Level: III]

ORGANIZATION (管理组织学)
Barger LK, Ayas NT, Cade BE et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PloS Med 2006; 3(12): e487.
超长时间的交接班对医疗差错、不良事件及注意力差错的影响[Evidence Level: III ]
 

Talmor D, Shapiro N, Greenberg D, Stone PW, Neumann PJ. When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature. Crit Care Med 2006; 34: 2738Ð2747.
危重医学何时物有所值？关于成本-效益研究的系统回顾 [Evidence Level: I]
 
Garland A, Shaman Z, Baron J, Connors Jr AF. Physician-attributable differences in intensive care unit costs. A single-center study. Am J Respir Crit Care Med 2006;174:1206Ð1210.
ICU中由医生造成的成本差异 [Evidence Level: IV]

neman A, Parr M. Medical emergency teams: a role for expanding intensive care? Acta Anaesthesiol Scand 2006;50:1255-1265. 65 references.
急诊队伍：扮演监护治疗的角色？
 
McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care. Chest 2006; 130:1571-1578. 18 references.
将ICU的工作环境改造成以病人为中心

Szklo-Coxe M. Are residentsÕ extended shifts associated with adverse events? PLOS Med 2006;3:e497. 26 references. 嫩
住院医生延长工作时间与医疗差错？
 
Winters BD, Pham J, Pronovost PJ. Rapid response teams Ð walk donÕt run. JAMA 2006;296: 1645-1647. 25 references.
快速反应梯队
 
Wu AW, Sexton B, Pronovost PJ. Partnership with patients: a prescription for ICU safety. Chest 2006;130:1291-1293. 11 references.
与病人的合作：ICU安全的良方

OUTCOME （预后）
Holtfreter B, Bandt C, Kuhn S-O et al. Serum osmolality and outcome in intensive care unit patients. Acta Anaesthesiol Scand 2006; 50: 970Ð977.
ICU患者血清渗透压与预后[Evidence Level: IV ]
 
Li LLM, Cheong KYP, Yaw LK, Liu EHC. The accuracy of surrogate decisions in intensive care scenarios. Anaesth Intensive Care 2007; 35: 46Ð51.
ICU内代理人决定的准确性[Evidence Level: IV ]

Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006;130:869-878. 53 references.
危重疾患后的长期认知功能
PAEDIATRIC （儿科）
Akech S, Gwer S, Idro R et al. Volume expansion with albumin compared to Gelofusine in children with severe malaria: results of a controlled trial. PloS Clin Trials 2006; 1(5): e21.
严重疟疾氯化钠+明胶与白蛋白扩容治疗的对照研究[Evidence Level: III ]
 
RENAL （肾脏）
Vinsonneau C, Camus C, Combes A et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006; 368: 379Ð385.
MODS患者CVVH与间断血透治疗急性肾衰的对中心随机研究[Evidence Level: II]
 
Bagshaw SM, Bellomo R. Fluid resuscitation and the septic kidney. Curr Opin Crit Care 2006;12:527-530. 35 references.
液体复苏与肾脏感染
 
RESPIRATORY （呼吸）
Frutos-Vivar F, Ferguson ND, Esteban A et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130: 1664Ð1671.
自主呼吸试验成功的患者拔管失败的危险因素[Evidence Level: I ]
 
Pasquina P, Tram?r MR, Granier J-M, Walder B. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest 2006; 130: 1887Ð1899.
腹部手术后呼吸理疗预防肺部并发症：系统回顾[Evidence Level: I ]

Crummy F, Naughton MT. Non-invasive positive pressure ventilation for acute respiratory failure: justified or just hot air? Intern Med J 2007;37:112-118. 36 references.
急性呼衰的无创正压通气：正当亦或炒作！
 
Frank JA, Parsons PE, Matthay MA. Pathogenic significance of biological markers of ventilator-associated lung injury in experimental and clinical studies. Chest 2006;130:1906-1914.
呼吸机相关性肺损伤试验和临床研究中生物标志物的病因学意义
 
SEPSIS （脓毒症）
Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725Ð2732.
减少ICU内导管相关性血行感染的措施 [Evidence Level: III ]
 
Ricard J-D, Wolff M, Lacherade J-C et al. Levels of vancomycin in cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter observational study. Clin Infect Dis 2007; 44: 250Ð255.
接受激素治疗的肺炎球菌脑膜炎患者脑脊液中万古霉素水平：前瞻性多中心观察研究[Evidence Level: IV ]
 
Stryjewski ME, Szczech LA, Benjamin DK et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis 2007; 44: 190Ð196.
患有金葡菌菌血症的持续血滤患者应用万古霉素或一代头孢菌素类治疗 [Evidence Level: IV ]

Mandell LA, Wunderinck RG, Anzueto A et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44:S27-S72. 335 references.
IDSA与ATS关于成人社区获得性肺炎治疗的共识性指南

TRAUMA （创伤）
Rizoli SB, Nascimento B, Osman F et al. Recombinant activated coagulation factor VII and bleeding trauma patients. J Trauma 2006; 61: 1419Ð1425.
重组活性凝血因子VII与出血性创伤 [Evidence Level: IV ]

Spahn DR, Cerny V, Coats TJ et al. Management of bleeding follow major trauma: a European guideline. Crit Care 2007;11;R17. 220 references.
大面积创伤后的出血管理：欧洲指南
这个我还没有看，在：http://ccforum.com/content/11/1/R17  可免费看全文。 但我估计上面的重组活性凝血因子VII会被提及，现在我已经对这种事情很敏感又很无奈了。因迄今关于此药的几个多中心研究并没结束，而且上文中也就是IV水平，因此下定论为时尚早。不过好奇心还是驱使我看了这个指南，事实确实如此，被专门放在凝血因子替代治疗一节中给予推荐，推荐等级2C! 看推荐理由，书面提到的唯一一个多中心研究来自南非，结论是这个药物可以显著减少用血量，但是仅发现了降低病死率的趋势，没有显著差异的！你说我的怀疑对不对。
Recommendation 24
We suggest that the use of recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding in blunt trauma persists despite standard attempts to control bleeding and best-practice use of blood components. We suggest an initial dose of 200 μg/kg followed by two doses of 100 μg/kg administered at 1 and 3 hours following the first dose (grade 2C).
理由是：Rationale
rFVIIa is not a first-line treatment for bleeding and will be effective only once sources of major bleeding have been controlled. Once major bleeding from damaged vessels has been stopped, rFVIIa may be helpful to induce coagulation in areas of diffuse small vessel coagulopathic bleeding. rFVIIa should be considered only if first-line treatment with a combination of surgical approaches, best-practice use of blood products (RBCs, platelets, FFP, and cryoprecipitate/fibrinogen resulting in Hctabove 24%, plateletsabove 50,000 × 109/l, and fibrinogenabove 0.5 to 1.0 g/l) and correction of severe acidosis, severe hypothermia, and hypocalcaemia (resulting in pHabove 7.20, temperatureabove 32°C, and ionised Ca++above 0.8 mmol/l, respectively) fail to control bleeding. Because rFVIIa acts on the patient's own clotting system, a sufficient number of platelets are needed to allow a thrombin burst to be induced by the pharmacological, supraphysiological doses of rFVIIa through direct binding to activated platelets [193,194]. Reduction in platelet count may lead to impaired thrombin generation [195]. Moreover, fibrinogen is required to ensure formation of a stable clot [158,196]. A recent study showed that a pH below 7.20 substantially reduced rFVIIa activity but that a temperature above 32°C only slightly improved rFVIIa activity [197]. Independent of rFVIIa activity, however, pH and body temperature should be restored as near to physiological levels as possible since even small reductions in pH and temperature may result in slower coagulation enzyme kinetics [133,134,198]. Moreover, hypocalcaemia is frequently present in severely injured patients [199] and may require the administration of intravenous calcium with frequent ionised serum calcium measurement [200].
A number of case studies and case series have reported that treatment with rFVIIa can be beneficial in the treatment of coagulopathic bleeding following trauma [201-204]. A recently published multi-centre, randomised, double-blind, placebo-controlled study examined the efficacy of rFVIIa in patients with blunt or penetrating trauma [205]. Patients were randomly assigned to receive either three doses of rFVIIa (200, 100, and 100 μg/kg) or placebo after they had received 6 units of RBCs. The first dose of their assigned medication was administered after transfusion of a further 2 units of RBCs (8 units in total), and a second and third dose were administered 1 and 3 hours later. Treatment with rFVIIa in blunt trauma produced a significant reduction in RBC transfusion requirements and the need for massive transfusions (>20 units of RBCs) in patients with blunt trauma surviving for more than 48 hours and also significantly reduced the incidence of acute respiratory distress syndrome in all patients with blunt trauma. In contrast, no significant effects were observed on RBC transfusion requirements in the penetrating trauma patients in this study, although trends toward reduced RBC requirements and fewer massive transfusions were observed. Therefore, no recommendation to use the drug in this group can be made.
The required dose(s) of rFVIIa is still under debate. Whereas the above dosing recommendation is based on the only published RCT available in trauma patients and is also recommended by a group of European experts [206], Israeli guidelines based on findings from a case series of 36 patients who received rFVIIa on a compassionate-use basis in Israel [201] propose an initial dose of 120 μg/kg (between 100 and 140 μg/kg) and (if required) a second and third dose. Further support for the dose regimen recommended here comes from pharmacokinetic modelling techniques, which have shown that the dose regimen for rFVIIa treatment used in the above-cited RCT is capable of providing adequate plasma levels of drug to support haemostasis [207]. If rFVIIa is administered, the patient's next of kin should be informed that rFVIIa is being used outside the currently approved indications (off-label use), especially since the use of rFVIIa may increase the risk of thromboembolic complications [208].