Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China.
Chin Med J (Engl). 2013;126(10):1809-13.
The lowering of body temperature is a common, almost reflexive step in the daily care of septic shock patient. However, the effect of different magnitudes of fever control on the outcome of refractory septic patients with a very poor outcome is controversial and has yet to be explored.
This prospective trial examined sixty-five refractory septic shock patients with a core temperature higher than 38.5°C. Patients were randomly assigned to a group achieving a "low temperature" range (LT group: 36.0 - 37.5°C) or to a group achieving a "high temperature" range (HT group: 37.5 - 38.3°C) by physical methods including a water-flow cooling blanket and ice packs. A target core temperature was achieved in 1 - 2 hours post-treatment, and maintained for 72 hours. Averaged values of core temperature as well as hemodynamic, respiratory, and laboratory variables were analyzed at baseline and during the first 72 hours after fever control.
Thirty-four (52.31%) patients were assigned to the LT group and thirty-one (47.69%) patients were assigned to the HT group. The mean core temperature was significantly lower in the LT group than in the HT group (36.61 vs. 37.85°C, respectively; P < 0.0001). The average heart rate (HR) (75.5 vs. 91.9 beats/min, respectively; P < 0.0001) and the mean cardiac output (CO) (5.35 vs. 6.45 L/min, respectively; P = 0.002) were also statistically significant lower in the LT group than in the HT group. The averaged serum lactate level was significantly higher in the LT group compared to the HT group (5.59 vs. 2.82 mmol/L, respectively; P = 0.008). Fibrinogen and activated partial thromboplatin time were also different between the two groups. The 28 days mortality was significantly higher in the LT group than in the HT group (61.8 vs. 25.8%, respectively; P = 0.003). A Cox-regression model analysis showed that mean core temperature during the 72 h period was an independent predictor of 28 days mortality (odds ratio (OR) = 0.42, 95%CI 0.25, 0.6; P = 0.001).
Controlling fever to a lower range (36.0 - 37.5°C) may be harmful to patients with refractory septic shock by worsening tissue perfusion, compared to controlling it within a higher range (37.5 - 38.3°C). An understanding of the mechanisms responsible for these observations requires further investigation.
在败血症性休克患者的日常护理中，降低体温是一种常见的、几乎是反射性的步骤。然而，控制不同程度的发热对预后极差的难治性败血症患者的结局的影响仍存在争议，尚未得到探讨。
本前瞻性试验纳入了 65 例核心体温高于 38.5°C 的难治性败血症性休克患者。患者随机分为低温组（LT 组：36.0-37.5°C）或高温组（HT 组：37.5-38.3°C），通过包括水流量冷却毯和冰袋在内的物理方法来达到目标核心温度。治疗后 1-2 小时达到目标核心温度，并维持 72 小时。分析治疗前和治疗后 72 小时内的核心温度、血流动力学、呼吸和实验室变量的平均值。
34 例（52.31%）患者被分配至 LT 组，31 例（47.69%）患者被分配至 HT 组。LT 组的平均核心温度明显低于 HT 组（分别为 36.61°C 和 37.85°C；P<0.0001）。LT 组的平均心率（75.5 次/分比 91.9 次/分；P<0.0001）和平均心输出量（5.35L/min 比 6.45L/min；P=0.002）也明显低于 HT 组。LT 组的平均血清乳酸水平明显高于 HT 组（5.59mmol/L 比 2.82mmol/L；P=0.008）。两组的纤维蛋白原和活化部分凝血活酶时间也不同。LT 组 28 天死亡率明显高于 HT 组（61.8%比 25.8%；P=0.003）。Cox 回归模型分析显示，72 小时内的平均核心温度是 28 天死亡率的独立预测因子（比值比（OR）=0.42，95%CI 0.25-0.6；P=0.001）。
与控制在较高范围（37.5-38.3°C）相比，将发热控制在较低范围（36.0-37.5°C）可能通过恶化组织灌注对难治性败血症性休克患者有害。需要进一步研究以了解导致这些观察结果的机制。
