1991～2001年ICU严重感染的流行病学调查分析

目的 调查严重感染的病死率和病死危险因素。方法 回顾性调查1991～2001年的383例严重感染患者,计算逐年病死率,进行单因素和多因素逐步logistic回归分析,分析严重感染患者病死危险因素。结果1991～2001年间,严重感染总病死率46％(176/383),11年间逐年病死率无显著变化(P=0.458)。13个因素参与多因素分析,结果显示严重感染病死危险因素有合并器官功能衰竭数目、免疫功能受累、低白蛋白(<35g/L)和接受有创性检查和治疗。严重感染患者合并器官功能衰竭的数目增多,病死率明显增加,合并2个器官衰竭者病死的相对危险度为3.748,3个器官衰竭者为9.663,而合并≥4个器官功能衰竭者病死的相对危险度高达28.810。从器官功能衰竭的分布来看,严重感染患者最常合并循环衰竭(62.9％)和呼吸衰竭(56.9％),而顽固的感染性休克是严重感染患者最主要的直接病死原因(39.8％)。结论 20世纪90年代以来,严重感染的病死率依然很高,探寻严重感染发病的危险因素,积极调控炎症反应,在炎症反应早期及时阻断炎症反应过程,防止发展为感染性休克和多器官功能障碍综合征,是降低严重感染病死率的关键。     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

目的 探讨早期目标导向治疗(EGDT)对严重脓毒症/脓毒性休克患者的影响.方法 采用多中心、前瞻性、随机、对照研究方法,选择2005年1月至2008年1月浙江省8家三级甲等医院重症监护病房(ICU)住院的314例严重脓毒症/脓毒性休克患者,按随机数字表法分为常规组(151例)和EGDT组(163例).常规组以中心静脉压(CVP)、收缩压(SBP)和平均动脉压(MAP)、尿量变化指导液体复苏;EGDT组在此基础上增加中心静脉血氧饱和度(ScvO2)为观测指标进行复苏;对患者进行输液、输血和强等治疗,6 h内达标.比较两组患者28 d生存率、ICU住院病死率(主要终点)以及ICU住院时间、机械通气时间、抗生素使用时间、新发感染率和疾病严重程度评分(次要终点)的差异.结果 可供分析的有效病例中EGDT组为157例,常规组为146例.EGDT组28 d生存率较常规组增高约17.7%(75.2%比57.5%,P=0.001),EGDT组ICU住院病死率较常规组降低约15.7%(35.0%比50.7%,p=0.035).与常规组比较,EGDT能明显善患者的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分(分:14.4±8.5比18.0±7.1,P=0.043)、多器官功能障碍综合征(MODS)评分(分:5.8±3.1比8.9±3.7,P=0.014)和感染相关器官功能衰竭评分系统(SOFA)评分(分:5.6±2.9比10.4±3.7,P=0.001),减少抗生素使用时间(d:13.4±10.0比19.7±13.5,P=0.004),降低新发感染的发生率(37.6%比53.4%,p=0.014);EGDT对ICU住院时间、机械通气间均无明显影响.结论 EGDT能显著改善ICU中严重脓毒症/脓毒性休克患者28 d生存率和临床疾病严重程度评分,减少抗生素使用时间及降低新发感染的发生率.     

Intraincisional antibiotic in addition to systemic antibiotic treatment fails to reduce wound infection rates in contaminated abdominal surgery

One hundred ninety patients with peritonitis at the time of abdominal surgery were allocated at random to systemic antibiotic treatment alone or systemic antibiotic treatment combined with topical application of antibiotics in the wound at the time of wound closure. The overall wound infection rate was 17 percent without significant difference between the two treatment groups (P>0.80).     

Acquired haemophilia in a patient with gram-negative urosepsis and bladder cancer

We here report a patient who developed a high titer antibody to factor VIII (FVIII) during gram-negative urosepsis caused by enterobacter cloacae after complete resection of rectal cancer. The patient initially presented with a life threatening spontaneous hematothorax and multiple large haematomas. Coagulation studies revealed a severe FVIII deficiency <1% with a high FVIII antibody titer of 64 BU. The bleeding responded rapidly to infusions of recombinant factor VIIa. After achievement of a partial remission (FVIII activity 28%) by combined immunosuppressive therapy (prednisone, cyclophosphamide, plasmapheresis and immunoadsorption), subsequently, two relapses occurred following steroid tapering. Resumption of prednisone and cyclophosphamide treatment combined with immunoadsorption induced a second and third remission, respectively. After resection of a papillary carcinoma of the bladder 6 months later and continuous immunosuppressive therapy with cyclophosphamide, FVIII levels remained stable within normal ranges. This clinical course suggests that the cause of inhibitor formation against FVIII resulting in severe acquired haemophilia was multifactorial and was initiated by the gram-negative urosepsis and probably by the underlying malignancies.     

Pilot Study Comparing Sepsis Management with and without Electronic Clinical Practice Guidelines in an Academic Emergency Department

Background

Sepsis is a potentially life-threatening condition that requires urgent management in an Emergency Department (ED). Evidence-based guidelines for managing sepsis have been developed; however, their integration into routine practice is often incomplete. Care maps may help clinicians meet guideline targets more often.

Objectives

To determine if electronic clinical practice guidelines (eCPGs) improve management of patients with severe sepsis and septic shock (SS/SS).

Methods

The impact of an eCPG on the management of patients presenting with SS/SS over a 3-year period at a tertiary care ED was evaluated using retrospective case-control design and chart review methods. Cases and controls, matched by age and sex, were chosen from an electronic database using physician sepsis diagnoses. Data were compared using McNemar tests or paired t-tests, as appropriate.

Results

Overall, 51 cases and controls were evaluated; the average age was 62 years, and 60% were male. eCPG patients were more likely to have a central venous pressure and central venous oxygen saturation measured; however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 h (63% vs. 41%; p = 0.03) and vasopressors (45% vs. 20%; p = 0.02) was more common in the eCPG group; however, use of corticosteroids and other interventions did not differ between the groups. Overall, survival was high and similar between groups.

Conclusion

A sepsis eCPG experienced variable use; however, physicians using the eCPG achieved more quality-of-care targets for SS/SS. Strategies to increase the utilization of eCPGs in Emergency Medicine seem warranted.     

Nicotinamide does not influence cytokines or exhaled NO in human experimental endotoxaemia

This study examined the hypothesis that nicotinamide could attenuate endotoxin-induced inflammatory responses in humans as indicated by levels of cytokines and nitric oxide. Ten healthy male volunteers participated in a randomised, double-blind, cross-over design with regard to the effects of nicotinamide. The volunteers received orally 4 g nicotinamide or placebo at 14 h and at 2 h preceding the experiment (total dose of 8 g). Endotoxin (E. coli, 2 ng/kg), was administered intravenously. Blood samples and haemodynamic data were collected prior to and up to 6 h after the endotoxin infusion. Orally exhaled NO was measured hourly. Following endotoxin, body temperature increased from baseline 36.3 +/- 0.09 degrees C to a maximum of 38.0 +/- 0.1 degrees C for all (mean +/- SEM, P < 0.001) and heart rate increased from 59 +/- 1.9 to 87.0 +/- 2.6 beats/min after 3 h (mean +/- SEM, P < 0.001). Endotoxin challenge also markedly elevated the TNF-alpha, IL-6, IL-8 and IL-10 concentrations (P < 0.001 versus baseline for all) during the study period. Orally exhaled NO also increased (P < 0.01) compared to baseline. Nicotinamide treatment did not influence the patterns of cytokine and NO response to endotoxin. In conclusion, there was no effect on the inflammatory parameters by oral nicotinamide at a dose of 8 g, limiting the potential use of this agent for anti-inflammatory purpose in man.     

Performance evaluation of MR-proadrenomedullin and other scoring systems in severe sepsis with pneumonia

Background

In sepsis, risk assessment is as crucial as early and accurate diagnosis. In this study, we aimed to evaluate the prognostic value of mid-regional proadrenomedullin (MR-proADM) with other scoring systems in severe sepsis and septic shock patients due to community acquired pneumonia (CAP).

Methods

Patients were divided into 2 groups as severe sepsis and septic shock due to CAP (group 1, n=31) and only CAP group (group 2, n=26). Serum MR-proADM, procalcitonin (PCT), C-reactive protein (CRP), and d-dimer level were analyzed. Acute Physiological and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment (SOFA) score, and Pneumonia Severity Index (PSI) were performed for all patients.

Results

There was no difference between groups in terms of serum MR-proADM levels (P=0.780). Serum MR-proADM was not found a significant value for the prediction of death within the 4 and 8 weeks in all patients. SOFA score was the most significant to predict mortality in 4 and 8 weeks (P<0.001). The combination of SOFA score and serum MR-proADM was a strong factor to predict death in 4 weeks (specifity 86.8% and sensitivity 66.7%). The combination of MR-proADM, SOFA score, and APACHE II score was found 75.0% sensitive and 71.4% specific to predict mortality within 4 weeks in group 1.

Conclusions

The MR-proADM does not correlate with mortality or disease severity to predict mortality. The combination of SOFA, APACHE II scores, and MR-proADM was efficient to predict prognosis and mortality rate in severe sepsis or septic shock patients.     

Renal Transplantation: Relationship between Hospital/Surgeon Volume and Postoperative Severe Sepsis/Graft-Failure. A Nationwide Population-Based Study

Background and objects: We explored the relationship between hospital/surgeon volume and postoperative severe sepsis/graft-failure (including death).Methods: The Taiwan National Health Insurance Research Database claims data for all patients with end-stage renal disease patients who underwent kidney transplantation between January 1, 1999, and December 31, 2007, were reviewed. Surgeons and hospitals were categorized into two groups based on their patient volume. The two primary outcomes were severe sepsis and graft failure (including death). The logistical regressions were done to compute the Odds ratios (OR) of outcomes after adjusting for possible confounding factors. Kaplan-Meier analysis was used to calculate the cumulative survival rates of graft failure after kidney transplantation during follow-up (1999-2008).Results: The risk of developing severe sepsis in a hospital in which surgeons do little renal transplantation was significant (odds ratio [OR]; p = 0.0115): 1.65 times (95% CI: 1.12-2.42) higher than for a hospital in which surgeons do many. The same trend was true for hospitals with a low volume of renal transplantations (OR = 2.39; 95% CI: 1.62-3.52; p < 0.0001). The likelihood of a graft failure (including death) within one year for the low-volume surgeon group was 3.1 times higher than for the high-volume surgeon group (p < 0.0001); the trend was similar for hospital volume. Female patients had a lower risk than did male patients, and patients ≥ 55 years old and those with a higher Charlson comorbidity index score, had a higher risk of severe sepsis.Conclusions: We conclude that the risk of severe sepsis and graft failure (including death) is higher for patients treated in hospitals and by surgeons with a low volume of renal transplantations. Therefore, the health authorities should consider exporting best practices through educational outreach and regulation and then providing transparent information for public best interest.