Kortgen Andreas, Niederprüm Petra, Bauer Michael
Department of Anaesthesiology and Intensive Care Therapy, Friedrich-Schiller University, Jena, Germany.
Crit Care Med. 2006 Apr;34(4):943-9. doi: 10.1097/01.CCM.0000206112.32673.D4.
To assess the impact of an algorithm defining resuscitation according to early goal-directed therapy, glycemic control, administration of stress doses of hydrocortisone, and use of recombinant human activated protein C (rhAPC) on measures of organ dysfunction and outcome in septic shock.
Retrospective cohort study.
Multidisciplinary ten-bed intensive care unit of a university hospital.
Sixty patients were analyzed: 30 consecutive patients fulfilling criteria for diagnosis of septic shock, treated from September 2002 until December 2003 after implementation of a standard operating procedure (SOP) for severe sepsis and septic shock; and 30 patients with septic shock treated from January until August 2002 in the same unit, who served as controls.
Data for blood gas analysis, lactate, glucose, serum creatinine, bilirubin, white blood cells, platelets, and C-reactive protein were obtained from patient files on admission or at time of diagnosis of septic shock and at 7:00 a.m. on days 2 and 4; Sequential Organ Failure Assessment scores were calculated and 28-day survival was assessed. With implementation of the SOP, use of dobutamine (12/30 vs. 2/30), insulin (blood glucose <150 mg/dL, day 4: 26/28 vs. 13/25), hydrocortisone (30/30 vs. 13/30), and rhAPC (7/30 vs. 0/30) significantly increased, whereas volume for resuscitation and use of packed red blood cells were unaffected. Mortality was 53% in the historical control group and 27% after implementation of the SOP (p < .05).
The combined approach of early goal-directed therapy, intensive insulin therapy, hydrocortisone administration, and additional application of rhAPC in selected cases seems to favorably influence outcome. The implementation of a "sepsis bundle" can be facilitated by a standardized protocol while significantly reducing the time until the defined therapeutic measures are realized in daily practice.
评估一种根据早期目标导向治疗、血糖控制、应激剂量氢化可的松的使用以及重组人活化蛋白C（rhAPC）定义复苏的算法对脓毒性休克患者器官功能障碍指标和预后的影响。
回顾性队列研究。
一所大学医院的拥有十张床位的多学科重症监护病房。
分析了60例患者：30例连续符合脓毒性休克诊断标准的患者，于2002年9月至2003年12月在实施严重脓毒症和脓毒性休克标准操作程序（SOP）后接受治疗；以及2002年1月至8月在同一科室接受治疗的30例脓毒性休克患者，作为对照组。
从患者入院时或脓毒性休克诊断时以及第2天和第4天上午7点的病历中获取血气分析、乳酸、血糖、血清肌酐、胆红素、白细胞、血小板和C反应蛋白的数据；计算序贯器官衰竭评估分数并评估28天生存率。随着SOP的实施，多巴酚丁胺（12/30对2/30）、胰岛素（血糖<150mg/dL，第4天：26/28对13/25）、氢化可的松（30/30对13/30）和rhAPC（7/30对0/30）的使用显著增加，而复苏液体量和浓缩红细胞的使用未受影响。历史对照组的死亡率为53%，SOP实施后的死亡率为27%（p<.05）。
早期目标导向治疗、强化胰岛素治疗、氢化可的松给药以及在特定病例中额外应用rhAPC的联合方法似乎对预后有有利影响。标准化方案有助于实施“脓毒症集束化治疗”，同时显著缩短在日常实践中实现既定治疗措施所需的时间。
