Wachter R M, Luce J M, Hopewell P C
Medical Service, San Francisco, General Hospital Medical Center, University of California 94143-0862.
JAMA. 1992;267(4):541-7.
We sought to review the clinical and ethical issues surrounding critical care for patients with the acquired immunodeficiency syndrome (AIDS).
We reviewed published studies and abstracts dealing with the outcome of critical care for patients with AIDS, decision making about life-sustaining treatments in patients with AIDS, and infection control in the intensive care unit. We also consulted with a number of experts in the field.
We selected outcome studies in which patients with documented AIDS or infection with the human immunodeficiency virus (HIV) were analyzed. We rejected data concerning patients with suspected or presumed AIDS and data concerning presumed cases of Pneumocystis carinii pneumonia (PCP).
Most AIDS patients who require critical care do so because of respiratory failure caused by PCP. Although studies early in the epidemic reported survival rates to hospital discharge of 0% to 14%, recent studies demonstrate improved survival rates of 36% to 55%. Treatment for patients with PCP and respiratory failure should include either intravenous trimethoprim-sulfa-methoxazole or pentamidine isethionate, as well as adjuvant corticosteroids. Patients with AIDS may require critical care for many other indications, including seizures, sepsis, and hypotension, or reasons unrelated to their immunodeficiency. In general, such patients have a better prognosis than those with respiratory failure.
The provision of critical care for PCP and respiratory failure specifically or AIDS generally cannot be considered futile. Therefore, decisions about the use of critical care should be guided by the particular clinical situation and the patient's preferences. More research is needed to elucidate the reasons for the improving survival for patients with PCP and respiratory failure and the predictors of such survival.
我们试图回顾与获得性免疫缺陷综合征（艾滋病）患者重症监护相关的临床和伦理问题。
我们回顾了已发表的研究和摘要，内容涉及艾滋病患者重症监护的结果、艾滋病患者维持生命治疗的决策以及重症监护病房的感染控制。我们还咨询了该领域的多位专家。
我们选择了对有记录的艾滋病患者或感染人类免疫缺陷病毒（HIV）的患者进行分析的结局研究。我们排除了有关疑似或推定艾滋病患者的数据以及有关推定的卡氏肺孢子虫肺炎（PCP）病例的数据。
大多数需要重症监护的艾滋病患者是由于PCP导致的呼吸衰竭。尽管在疫情早期的研究报告称出院生存率为0%至14%，但最近的研究显示生存率提高到了36%至55%。PCP和呼吸衰竭患者的治疗应包括静脉注射甲氧苄啶 - 磺胺甲恶唑或喷他脒异硫氰酸盐，以及辅助性皮质类固醇。艾滋病患者可能因许多其他指征需要重症监护，包括癫痫发作、败血症和低血压，或与免疫缺陷无关的原因。一般来说，这类患者的预后比呼吸衰竭患者要好。
为PCP和呼吸衰竭患者或一般艾滋病患者提供重症监护不能被视为徒劳。因此，关于使用重症监护的决策应以具体临床情况和患者偏好为指导。需要更多研究来阐明PCP和呼吸衰竭患者生存率提高的原因以及此类生存的预测因素。
