早期目标导向治疗在严重脓毒症和脓毒性休克治疗中的应用

Early goal-directed therapy in the treatment of severe sepsis and septic shock.

作者信息

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M

机构信息

Department of Emergency Medicine, Henry Ford Health Systems, Case Western Reserve University, Detroit, MI 48202, USA.

出版信息

N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.

DOI:10.1056/NEJMoa010307

PMID:11794169

Abstract

BACKGROUND

Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.

METHODS

We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.

RESULTS

Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P < or = 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001).

CONCLUSIONS

Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.

摘要

背景

目标导向治疗已用于重症监护病房的严重脓毒症和脓毒性休克。这种方法涉及调整心脏前负荷、后负荷和收缩力，以平衡氧输送和氧需求。本研究的目的是评估在进入重症监护病房之前进行早期目标导向治疗的疗效。

方法

我们将抵达城市急诊科的严重脓毒症或脓毒性休克患者随机分配，使其在进入重症监护病房之前接受6小时的早期目标导向治疗或标准治疗（作为对照）。随后负责治疗这些患者的临床医生对治疗分配情况不知情。连续72小时获取院内死亡率（主要疗效指标）、复苏终点以及急性生理学与慢性健康状况评估（APACHE II）评分，并在研究组之间进行比较。

结果

在263例登记患者中，130例被随机分配接受早期目标导向治疗，133例接受标准治疗；两组的基线特征无显著差异。接受早期目标导向治疗组的院内死亡率为30.5%，而接受标准治疗组为46.5%（P = 0.009）。在7至72小时期间，接受早期目标导向治疗的患者平均（±标准差）中心静脉血氧饱和度显著更高（70.4±10.7% 对65.3±11.4%），乳酸浓度更低（3.0±4.4对3.9±4.4 mmol/L），碱缺失更低（2.0±6.6对5.1±6.7 mmol/L），pH值更高（7.40±0.12对7.36±0.12），均优于接受标准治疗的患者（所有比较P≤0.02）。在同一时期，接受早期目标导向治疗的患者平均APACHE II评分显著更低，表明器官功能障碍较轻，低于接受标准治疗的患者（13.0±6.3对15.9±6.4，P < 0.001）。