题目：International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries
作者：Gentle S ShresthaEmail the author Gentle S Shrestha, Arthur Kwizera, Ganbold Lundeg, John I Baelani, Luciano C P Azevedo, Rajyabardhan Pattnaik, Rashan Haniffa, Srdjan Gavrilovic, Nguyen Thi Hoang Mai, Niranjan Kissoon, Rakesh Lodha, David Misango, Ary Serpa Neto, Marcus J Schultz, Arjen M Dondorp, Jonarthan Thevanayagam, Martin W Dünser, A K M Shamsul Alam, Ahmed M Mukhtar, Madiha Hashmi, Suchitra Ranjit, Akaninyene Otu, Charles Gomersall, Jacinta Amito, Nicolas Nin Vaeza, Jane Nakibuuka, Pierre Mujyarugamba, Elisa Estenssoro, Gustavo A Ospina-Tascón, Sanjib Mohanty, Mervyn Mer
Published: September 2017
链接：http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30453-X/fu
PMID: 28845789
DOI: 10.1016/S1473-3099(17)30453-X
在最近的国际“拯救脓毒症运动指南”中，Rhodes与同事精彩地概述了严重脓毒症和感染性休克患者基于循证的治疗意见。然而，值得注意的是，世界上大多数人口居住在脓毒症的负担巨大、预后往往很差、社会经济后果极为可怕的中、低收入国家（LMIC）。支撑新版指南的655个参考文献中，只有少数来自LMICs的研究（约10％）——这种差异引发出指南不能充分解决LMIC固有挑战和问题的担忧。例如，指导主要集中在高收入国家最常遇到的细菌和真菌性脓毒症的治疗，特别值得注意的是，LMICs通常遇到的病原体（如结核分枝杆菌（2015年造成约1800万人死亡）），恶性疟原虫（429 000人死亡）和登革热病毒（1032人死亡） 2016年美洲地区）不包括在内；而艾滋病毒感染，对LMICs，特别是撒哈拉以南非洲和东南亚地区的脓毒症治疗提出了具体的挑战，也未被指南提到。已有超过3500万人因艾滋病毒感染而死亡，其中大多数与脓毒症有关，据估计约有3670万人患有这种疾病，随时处于危险之中。这些疏忽不大可能是由于制定指南的团队的疏忽或缺乏关注造成，而可能与缺乏有力的科学证据以及指南制定委员会缺乏能提供概况的来自的LMIC专家有关。
In the most recent international Surviving Sepsis Campaign guidelines, Rhodes and colleagues excellently outline evidence-based management of patients with sepsis and septic shock. Of note, however, is that most of the world’s population resides in low-income and middleincome countries (LMICs), where the burden of sepsis is enormous, outcomes are often poor, and socioeconomic consequences are dire. Of the 655 references supporting the new sepsis guidelines, only a few pertain to studies in LMICs (about 10%). This disparity raises concerns that the challenges and problems inherent to LMICs remain inadequately addressed. The guidelines, for example, mainly focus on management of bacterial and fungal sepsis as most frequently encountered in high-income countries. Strikingly, the specific diagnosis and management of sepsis due to pathogens commonly encountered in LMICs, such as Mycobacterium tuberculosis (which resulted in about 1·8 million deaths in 2015),Plasmodium falciparum (429 000 deaths), and dengue virus (1032 deaths in the Region of the Americas in 2016), are not included. HIV infection, which poses specific challenges to sepsis care in LMICs, particularly in sub-Saharan Africa and southeast Asia, is also not alluded to. More than 35 million people have lost their lives as a consequence of HIV infection, most related to sepsis, and around 36·7 million people estimated to be living with the disease are potentially at risk. These omissions are unlikely due to oversights or absence of concern of the team producing the guidelines, but rather relate to the paucity of robust scientific evidence, as well as the absence of experts from LMICs in the guidelines group providing appropriate context.
不仅疾病模式不同，许多LMIC中脓毒症诊疗的有效运作均受到受训的医护人员（医师，护士和有关保健人员），物资（设备，药物和供应材料），配套基础设施（如成像技术），实验室设施（如乳酸盐测量）和基础物流（如水，电，氧气或加压空气供应）不足的挑战。仅有的几种临床诊治方案以及普遍的抗菌素耐药性则构成了进一步的障碍。LMIC内部和之间的资源限制差异很大，一些农村地区只有极其基础的设施。许多脓毒症患者由卫生保健专业人员照护，但他们很少或没有正式的关于危重病或脓毒症患者诊疗的受训经验。在这些领域中，获得医疗服务存在着严重的不平等现象，复杂的治疗往往只适用于中等收入国家的私人医疗机构和综合医院。鉴于这些情况，并非所有新指南的建议都适用于LMIC，在某些情况下可能会有问题甚至是有害的。例如，报告说，在儿童和成人脓毒症患者中提倡体积复苏后的高死亡率；而缺乏机械通气或训练有素的工作人员可能是引起死亡人数增加的重要因素。
Not only is the disease pattern different, but effective delivery of sepsis care in many LMICs is challenged by the shortage of suitably trained health-care personnel (physicians, nurses, and allied health-care personnel), material resources (equipment, drugs, and supply materials), supporting infrastructure (eg, imaging technology), laboratory facilities (eg, lactate measurement), and basic logistics (eg, water, electricity, and oxygen or pressurised air supply).7–9 A few clinical protocols as well as widespread antimicrobial resistance constitute further major obstacles.7–9 Resource limitations vary considerably between and within LMICs, and only extremely elementary facilities are available in some rural areas. Many patients with sepsis are looked after by health-care professionals with little or no formal training in management of patients with critical illnesses or sepsis. Profound inequities in terms of access to medical care are common in these domains, with sophisticated care often only available in private health-care facilities and general hospitals of middle-income countries. Given these circumstances, not all of the recommendations of the new guidelines are necessarily applicable to LMICs and in some instances could prove problematic and even deleterious. For example, high mortality after advocated volume resuscitation in both children and adult patients with sepsis has been reported. The absence of mechanical ventilation or insufficiently trained staff could have been important contributing factors to the noted increased mortality.
需要做什么？既往在资源有限的环境中管理脓毒症的建议大多数是由低水平的科学证据支持，因为LMICs的脓毒症研究仅来自少数几个选定的中心。迫切需要有高质量的研究工作，重点是需求评估，收益-风险比和治疗干预的成本效益，从而可以开发比当前脓毒症治疗指南更强的适用于LMICs的推荐。郑钧脓毒症运动委员会应该同意在资源有限的国家倡议中引入脓毒症来解决其中的一些关键条目。为了救护尽可能多的生命，未来的国际脓毒症指南应比目前的指南更全球适用，并提供有关LMICs败血症治疗的专门建议。这些建议应承认由结核病，严重疟疾，登革热和其他传染病引起的危重病人，其病理生理和管理与在高收入国家普遍存在的细菌或真菌性败血症有差异。此外，未来的国际脓毒症指南应该批判性地考虑有关资源潜在可用性以及在实施LMIC方面的有效性，安全性和可负担性方面的循证建议。这些措施应联合改进脓毒症管理和一般重症监护培训举措。通过协调一致的集体努力，.....
What needs to be done? Previous recommendations for management of sepsis in resource-limited settings have most of their statements supported by low levels of scientific evidence, as sepsis research in LMICs has only emanated from a few selected centres. High-quality research focused on needs assessment, benefit to risk ratios, and cost-effectiveness of therapeutic interventions is desperately required such that stronger ecommendations than the current guidelines for sepsis management in LMICs can be developed. The Surviving Sepsis Campaign committee needs to be commended for having introduced the sepsis in resource-limited nations initiative to address some of these elements. To save as many lives as possible, future international sepsis guidelines should aim to be more globally applicable than the current guidelines, with dedicated recommendations for management of sepsis in LMICs. These recommendations should specifically acknowledge the care of critically ill patients with sepsis due to tuberculosis, severe malaria, dengue, and other infectious diseases for which the pathophysiology and management differs from bacterial or fungal sepsis, as commonly seen in high-income countries. Furthermore, future international sepsis guidelines should critically consider evidence-based recommendations for the potential availability of resources as well as their efficacy, safety, and affordability with respect to implementation in LMICs.12,13 These measures should be accompanied by initiatives to improve training in sepsis management and general intensive care. With a concerted collective effort, a better understanding than at present and heightened awareness of the true global challenges of sepsis being faced, and committed collaborations, the practice and delivery of sepsis care could be optimised globally and enhanced in a most favourable fashion for all.
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