1. Chest 指南：肺动脉高压的治疗
2. 中性粒细胞/淋巴细胞比例与ARDS预后的回顾性队列分析
3. 肾素作为重症患者的组织灌注与预后的标志物
4. 抗菌药物管理的远期效果 2007-2015
5. 心跳骤停生存者激素改善预后
6. 严重ARDS患者V-V ECMO的经济学分析
7. ARDS早期的自主呼吸
8. 综述：气道压力改变对颅内压、灌注和氧合的影响
9.系统评价：脓毒症患者新发房颤的危险因素
完了，修复RSS之后，昨天就看了3000条目录，今天又出来147条！
吐槽之后，进入今天的正题。先谈一下昨天提到的《Chest》刊登的Paul Marik与SSC 指南编委会的辩论——Should the Surviving Sepsis Campaign Guidelines Be Retired?（拯救SSC指南应该退市不？） 。我这里就用幻灯展示一下辩论的要点：
然后是读书笔记：
1. Chest 指南：肺动脉高压的治疗 Therapy for Pulmonary Arterial Hypertension in Adults 2018: Update of the CHEST Guideline and Expert Panel Report
James R. Klinger,Gregory Elliott,Deborah J. Levine,
https://journal.chestnet.org/article/S0012-3692(19)30002-9/fulltext?rss=yes
Background Pulmonary arterial hypertension (PAH) carries a poor prognosis if not promptly diagnosed and appropriately treated. The development and approval of 14 medications over the last several decades has led to a rapidly evolving approach to therapy, and has necessitated periodic updating of evidence-based treatment guidelines. This guideline statement, which now includes a visual algorithm to enhance its clinical utility, represents the 4th iteration of the American College of Chest Physicians Guideline and Expert Panel Report on Pharmacotherapy for PAH.
Methods The guideline panel conducted an updated systematic review to identify studies published after those included in the 2014 guideline. A systematic literature search was conducted using MEDLINE via PubMed and the Cochrane Library. The quality of the body of evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Graded recommendations and ungraded consensus-based statements were developed and voted on using a modified Delphi technique to achieve consensus.
Results Two new recommendations on combination therapy and two ungraded consensus-based statements on palliative care were developed. An evidence-based and consensus-driven treatment algorithm was created to guide the clinician through an organized approach to management, and to direct readers to the appropriate area of the document for more detailed information.
Conclusions Therapeutic options for the patient with PAH continue to expand through basic discovery, translational science, and clinical trials. Optimal use of new treatment options requires prompt evaluation at an expert center, utilization of current evidence-based guidelines, and collaborative care employing sound clinical judgement.
2. 中性粒细胞/淋巴细胞比例与ARDS预后的回顾性队列分析 The Association Between the Neutrophil-to-Lymphocyte Ratio and Mortality in Patients With Acute Respiratory Distress Syndrome A Retrospective Cohort Study
Li, Weijing*; Ai, Xiaolin†; Ni, Yuenan*; Ye, Zengpanpan†; Liang, Zongan*
doi: 10.1097/SHK.0000000000001136
Purpose: Systemic inflammation relates to the initiation and progression of acute respiratory distress syndrome (ARDS). As neutrophil-to-lymphocyte ratio (NLR) has been shown to be a prognostic inflammatory biomarker in various diseases, in this study, we sought to explore whether NLR is a prognostic factor in patients with ARDS.
Methods: A retrospective study was performed on patients diagnosed as ARDS admitted to the intensive care unit (ICU). We calculated the NLR by dividing the neutrophil count by the lymphocyte count and categorized patients into four groups based on quartile of NLR values. The association of NLR quartiles and 28-day mortality was assessed using multivariable Cox regression. Secondary outcomes included ICU mortality and hospital mortality.
Results: A total of 224 patients were included in the final analysis. The median (interquartile range) NLRs from first quartile to fourth quartile were as follows: 6.88 (4.61–7.94), 13.06 (11.35–14.89), 20.99 (19.09–23.19), and 39.39 (32.63–50.15), respectively. The 28-day mortalities for the same groups were as follows: 10.7%, 19.6%, 41.4%, and 53.6% (P < 0.001).="" cox="" regression="" analysis="" showed="" nlr="" was="" a="" significant="" risk="" factor="" predicting="" 28-day="" mortality="" (first="" quartile,="" reference="" group;="" second="" quartile,="" adjusted="" hazard="" ratio="" [hr]="1.674," 95%="" confidence="" interval="" [ci],="" 0.462–6.063,="" p="0.432;" third="" quartile,="" hr="5.075," 95%="" ci,="" 1.554–16.576,="" p="0.007;" fourth="" quartile,="" hr="5.815," 95%="" ci,="" 1.824–18.533,="" p="0.003)." similar="" trends="" were="" observed="" for="" icu="" mortality="" and="" hospital="">
Conclusions:High NLR was associated with the poor outcome in critically ill patients with ARDS. The NLR therefore seems to be a prognostic biomarker of outcomes in critically ill patients with ARDS. Further investigation is required to validate this relationship with data collected prospectively.
3. 肾素作为重症患者的组织灌注与预后的标志物 Renin as a Marker of Tissue-Perfusion and Prognosis in Critically Ill Patients*
Gleeson, Patrick J., MB BAO BCh, MSc
doi: 10.1097/CCM.0000000000003544
Objectives: To characterize renin in critically ill patients. Renin is fundamental to circulatory homeostasis and could be a useful marker of tissue-perfusion. However, diurnal variation, continuous renal replacement therapy and drug-interference could confound its use in critical care practice.
Design: Prospective observational study.
Setting: Single-center, mixed medical-surgical ICU in Europe.
Patients: Patients over 18 years old with a baseline estimated glomerular filtration rate greater than 30 mL/min/1.73 m2 and anticipated ICU stay greater than 24 hours. Informed consent was obtained from the patient or next-of-kin.
Interventions: Direct plasma renin was measured in samples drawn 6-hourly from arterial catheters in recumbent patients and from extracorporeal continuous renal replacement therapy circuits. Physiologic variables and use of drugs that act on the renin-angiotensin-aldosterone system were recorded prospectively. Routine lactate measurements were used for comparison.
Measurements and Main Results: One-hundred twelve arterial samples (n = 112) were drawn from 20 patients (65% male; mean ± SD, 60 ± 14 yr old) with septic shock (30%), hemorrhagic shock (15%), cardiogenic shock (20%), or no circulatory shock (35%). The ICU mortality rate was 30%. Renin correlated significantly with urine output (repeated-measures correlation coefficient = –0.29; p = 0.015) and mean arterial blood pressure (repeated-measures correlation coefficient = –0.35; p < 0.001).="" there="" was="" no="" diurnal="" variation="" of="" renin="" or="" significant="" interaction="" of="" renin-angiotensin-aldosterone="" system="" drugs="" with="" renin="" in="" this="" population.="" continuous="" renal="" replacement="" therapy="" renin="" removal="" was="" negligible="" (mass="" clearance="" ±="" sd="" 4%="" ±="" 4.3%).="" there="" was="" a="" significant="" difference="" in="" the="" rate="" of="" change="" of="" renin="" over="" time="" between="" survivors="" and="" nonsurvivors="" (–32 ± 26="" μu/timepoint="" vs="" +92 ± 57="" μu/timepoint="" p="0.03;" mean="" ±="" sem),="" but="" not="" for="" lactate="" (–0.14 ± 0.04 mm/timepoint="" vs="" +0.15 ± 0.21 mm/timepoint;="" p="0.07)." maximum="" renin="" achieved="" significant="" prognostic="" value="" for="" icu="" mortality="" (receiver="" operator="" curve="" area="" under="" the="" curve="" 0.80;="" p="0.04)," whereas="" maximum="" lactate="" did="" not="" (receiver="" operator="" curve="" area="" under="" the="" curve,="" 0.70;="" p="">
Conclusions: In an heterogeneous ICU population, renin measurement was not significantly affected by diurnal variation, continuous renal replacement therapy, or drugs. Renin served as a marker of tissue-perfusion and outperformed lactate as a predictor of ICU mortality.
4. 抗菌药物管理的远期效果 2007-2015 Long-Term Effects of Phased Implementation of Antimicrobial Stewardship in Academic ICUs 2007–2015
*Morris, Andrew M., MD, SM; Bai, Anthony, MD
doi: 10.1097/CCM.0000000000003514
Objectives: Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs.
Design: We conducted a phased, multisite cohort study of a quality improvement initiative.
Setting: Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012.
Patients: All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included.
Interventions: Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured.
Measurements and Main Results: A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect –12.12 defined daily dose/100 patient-days; 95% CI, –16.75 to –7.49; p < 0.001)="" and="" total="" antifungal="" use="" decreased="" from="" 30.53="" to="" 27.37="" defined="" daily="" doses/100="" patient-days="" (adjusted="" intervention="" effect="" –3.16="" defined="" daily="" dose/100="" patient-days;="" 95%="" ci,="" –8.33="" to="" 0.04;="" p="0.05)." monthly="" antimicrobial="" costs="" decreased="" from="" $3195.56="" to="" $1998.59="" (adjusted="" intervention="" effect="" –$642.35;="" 95%="" ci,="" –$905.85="" to="" –$378.84;="" p="">< 0.001)="" and="" total="" antifungal="" costs="" were="" unchanged="" from="" $1771.86="" to="" $2027.54="" (adjusted="" intervention="" effect="" –$355.27;="" 95%="" ci,="" –$837.88="" to="" $127.33;="" p="0.15)." mortality="" remained="" unchanged,="" with="" no="" consistent="" effects="" on="" antimicrobial="" resistance="" and="">
Conclusions: Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.
5. 心跳骤停生存者激素改善预后 Postarrest Steroid Use May Improve Outcomes of Cardiac Arrest Survivors
Tsai, Min-Shan, MD, PhD; Chuang, Po-Ya, MHA
doi: 10.1097/CCM.0000000000003468
Objectives: To evaluate the ramifications of steroid use during postarrest care.
Design: Retrospective observational population-based study enrolled patients during years 2004–2011 with 1-year follow-up.
Setting: Taiwan National Health Insurance Research Database.
Patients: Adult nontraumatic cardiac arrest patients in the emergency department, who survived to admission.
Interventions: These patients were classified into the steroid and nonsteroid groups based on whether steroid was used or not during hospitalization. A propensity score was used to match patient underlying characteristics, steroid use prior to cardiac arrest, the vasopressors, and shockable rhythm during cardiopulmonary resuscitation, hospital level, and socioeconomic status.
Measurements and Main Results: There were 5,445 patients in each group after propensity score matching. A total of 4,119 patients (75.65%) in the steroid group died during hospitalization, as compared with 4,403 patients (80.86%) in the nonsteroid group (adjusted hazard ratio, 0.74; 95% CI, 0.70–0.77; p < 0.0001).="" the="" mortality="" rate="" at="" 1="" year="" was="" significantly="" lower="" in="" the="" steroid="" group="" than="" in="" the="" nonsteroid="" group="" (83.54%="" vs="" 87.77%;="" adjusted="" hazard="" ratio,="" 0.73;="" 95%="" ci,="" 0.70–0.76;="" p="">< 0.0001).="" steroid="" use="" during="" hospitalization="" was="" associated="" with="" survival="" to="" discharge,="" regardless="" of="" age,="" gender,="" underlying="" diseases="" (diabetes="" mellitus,="" chronic="" obstructive="" pulmonary="" disease,="" asthma),="" shockable="" rhythm,="" and="" steroid="" use="" prior="" to="" cardiac="">
Conclusions: In this retrospective observational study, postarrest steroid use was associated with better survival to hospital discharge and 1-year survival.
6. 严重ARDS患者V-V ECMO的经济学分析Economic Evaluation of Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome*
Barrett, Kali A., MD, MSc, FRCPC; Hawkins, Neil, MBA, PhD
doi: 10.1097/CCM.0000000000003465
Objectives: Venovenous extracorporeal membrane oxygenation is increasingly being used to support patients with severe acute respiratory distress syndrome, but its cost-effectiveness is unknown. We assessed the cost-utility of venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in adults compared with standard lung protective ventilation from the perspective of the healthcare system.
Design: We conducted a cost-utility analysis with a cohort state transition decision model using a lifetime time horizon, 1.5% discount rate, and outcomes reported as cost per quality-adjusted life year. Literature reviews were conducted to inform the model variables. Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in the model.
Setting: Canadian publicly funded healthcare system.
Patients: Hypothetical cohort of adults with severe acute respiratory distress syndrome.
Interventions: Venovenous extracorporeal membrane oxygenation or standard lung protective ventilation.
Measurements and Main Results: In our model, the use of venovenous extracorporeal membrane oxygenation compared with lung protective ventilation resulted in a gain of 5.2 life years and 4.05 quality-adjusted life years, at an additional lifetime cost of $145,697 Canadian dollars. The incremental cost-effectiveness ratio was $36,001/quality-adjusted life year. Sensitivity analyses show that the incremental cost-effectiveness ratio is sensitive to the efficacy of extracorporeal membrane oxygenation therapy and costs.
Conclusions: Based on current data, venovenous extracorporeal membrane oxygenation is cost-effective for patients with severe acute respiratory distress syndrome. Additional evidence on the efficacy of venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome and in different subgroups of patients will allow for greater certainty in its cost-effectiveness.
7. ARDS早期的自主呼吸 Spontaneous Breathing in Early Acute Respiratory Distress Syndrome Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study*
van Haren, Frank, MD, PhD; Pham, Tài, MD and the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) and the European Society of Intensive Care Medicine (ESICM) Trials Group
https://journals.lww.com/ccmjournal/Fulltext/2019/02000/Spontaneous_Breathing_in_Early_Acute_Respiratory.11.aspx
Objectives: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity.
Design: Planned secondary analysis of a prospective, observational, multicentre cohort study.
Setting: International sample of 459 ICUs from 50 countries.
Patients: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days.
Interventions: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation.
Measurements and Main Results: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92–1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93–1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0–22] vs 8 [0–20]; p = 0.014) and shorter duration of ICU stay (11 [6–20] vs 12 [7–22]; p = 0.04).
Conclusions: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required.
有自主呼吸好，那么肌松剂怎么办？
8. 综述：气道压力改变对颅内压、灌注和氧合的影响 Impact of Altered Airway Pressure on Intracranial Pressure, Perfusion, and Oxygenation: A Narrative Review
Chen, Han; Menon, David K.; Kavanagh, Brian P.
doi: 10.1097/CCM.0000000000003558
Objectives: A narrative review of the pathophysiology linking altered airway pressure and intracranial pressure and cerebral oxygenation.
Data Sources: Online search of PubMed and manual review of articles (laboratory and patient studies) of the altered airway pressure on intracranial pressure, cerebral perfusion, or cerebral oxygenation.
Study Selection: Randomized trials, observational and physiologic studies.
Data Extraction: Our group determined by consensus which resources would best inform this review.
Data Synthesis: In the normal brain, positive-pressure ventilation does not significantly alter intracranial pressure, cerebral oxygenation, or perfusion. In injured brains, the impact of airway pressure on intracranial pressure is variable and determined by several factors; a cerebral venous Starling resistor explains much of the variability. Negative-pressure ventilation can improve cerebral perfusion and oxygenation and reduce intracranial pressure in experimental models, but data are limited, and mechanisms and clinical benefit remain uncertain.
Conclusions: The effects of airway pressure and ventilation on cerebral perfusion and oxygenation are increasingly understood, especially in the setting of brain injury. In the face of competing mechanisms and priorities, multimodal monitoring and individualized titration will increasingly be required to optimize care.
9.系统评价：脓毒症患者新发房颤的危险因素 Risk Factors for New-Onset Atrial Fibrillation in Patients With Sepsis A Systematic Review and Meta-Analysis
Bosch, Nicholas A., MD; Cohen, David M., MD; Walkey, Allan J., MD, MSc
doi: 10.1097/CCM.0000000000003560
Objective: Atrial fibrillation frequently develops in patients with sepsis and is associated with increased morbidity and mortality. Unfortunately, risk factors for new-onset atrial fibrillation in sepsis have not been clearly elucidated. Clarification of the risk factors for atrial fibrillation during sepsis may improve our understanding of the mechanisms of arrhythmia development and help guide clinical practice.
Data Sources: Medline, Embase, Web of Science, and Cochrane CENTRAL.
Study Selection: We conducted a systematic review and meta-analysis to identify risk factors for new-onset atrial fibrillation during sepsis.
Data Extraction: We extracted the adjusted odds ratio for each risk factor associated with new-onset atrial fibrillation during sepsis. For risk factors present in more than one study, we calculated pooled odds ratios (meta-analysis). We classified risk factors according to type and quantified the factor effect sizes. We then compared sepsis-associated atrial fibrillation risk factors with risk factors for community-associated atrial fibrillation.
Data Synthesis: Forty-four factors were examined as possible risk factors for new-onset atrial fibrillation in sepsis, 18 of which were included in meta-analyses. Risk factors for new-onset atrial fibrillation included demographic factors, comorbid conditions, and most strongly, sepsis-related factors. Sepsis-related factors with a greater than 50% change in odds of new-onset atrial fibrillation included corticosteroid use, right heart catheterization, fungal infection, vasopressor use, and a mean arterial pressure target of 80–85 mm Hg. Several cardiovascular conditions that are known risk factors for community-associated atrial fibrillation were not identified as risk factors for new-onset atrial fibrillation in sepsis.
Conclusions: Our study shows that risk factors for new-onset atrial fibrillation during sepsis are mainly factors that are associated with the acute sepsis event and are not synonymous with risk factors for community-associated atrial fibrillation. Our results provide targets for future studies focused on atrial fibrillation prevention and have implications for several key areas in the management of patients with sepsis such as glucocorticoid administration, vasopressor selection, and blood pressure targets.
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