-
摘要: Sepsis不同于感染,是机体对感染的反应失控而导致的危及生命的器官功能障碍。Sepsis的重点在于器官功能障碍而非感染,这可能是美国感染病学会(Infectious Disease Society of America,IDSA)与“拯救Sepsis运动(Surviving Sepsis Campaign,SSC)”在重症感染认知上的分歧。对于Sepsis而言,筛查至关重要,可更早地启动集束性治疗策略,从而改善患者预后。Sepsis的理念来源于循证医学证据及大数据研究结果,二者奠定了其坚实的理论基础。本文根据IDSA提出的争议话题,从SSC角度,阐述重症医学对Sepsis本质的认知。
-
关键词:
- Sepsis /
- 感染 /
- 拯救Sepsis运动 /
- 指南
Abstract: Sepsis is not equal to infection. It is defined as life-threatening organ-dysfunction caused by a dysregulated host response to infection. Sepsis focuses on organ dysfunction instead of the infection, which is the main difference of opinion between Infectious Disease Society of America(IDSA) and Surviving Sepsis Campaign(SSC). Screening is the most important thing for sepsis in order to initialize the sepsis therapy-bundles to improve the patients' outcome. The definition and concept of sepsis originate from the evidence-based medicine and big data study. The methodology of sepsis keeps its development potential. This article interpreted the essence of sepsis to support SSC and disprove the opinions of IDSA.-
Key words:
- sepsis /
- infection /
- Surviving Sepsis Campaign /
- guideline
2017年末,一项来自美国感染病学会(Infectious Disease Society of America,IDSA)的声明搅动了国际医学界的宁静。事情的原委还得从"拯救Sepsis运动(Surviving Sepsis Campaign,SSC) "开始。SSC是由美国重症医学会(Society of Critical Care Medicine,SCCM)、欧洲重症医学会和国际Sepsis论坛于2002年共同参与发起并支持的国际学术组织,旨在针对Sepsis,提高知晓率、明确诊断、改善治疗、培训专业医务人员、完善ICU之后的治疗、颁布指南性文件、实施并完成提升临床医疗水平的专项计划,其目标是Sepsis的病死率在5年内下降25%。成立之后,SSC每年组织多项、不同层次、不同类型的学术活动,一些活动或项目会邀请到十几个甚至更多的国际相关学会参与支持。这些活动中,每4年一次颁布并更新的SSC指南"Surviving Sepsis Campaign:International Guidelines for Management of Sepsis and Septic Shock"受到国际广泛重视。重要的是,随着SSC对指南的不断完善,循证医学证据的支持力度不断增强。越来越多的报道发现,随着对SSC指南依从性的提高,Sepsis的病死率不断下降。2016年版的SSC指南,在对Sepsis和感染性休克重新定义、重新制定诊断标准的基础上,于2017年1月正式发布,引起了国际广泛关注。然而,就在2017年11月,IDSA在其官方期刊Clin Infect Dis发表公开立场声明,对2016年SSC指南中关于感染诊疗的推荐意见提出了质疑。声明指出,在SSC指南发表前,IDSA曾同SCCM就学术分歧点进行磋商,但最终无果,双方坚持自己的学术观点不变。由此,IDSA声明不再支持SSC指南。针对貌似临床常见的Sepsis和感染,为何国际医学权威学会之间会发生如此激烈的争执?我们特开辟此专栏,请专家分别从各自的角度阐述观点,同时给予综合点评。以期和大家共同发现:这个"梗"在哪里,而我自己又在哪里!——北京协和医院重症医学科 刘大为 -
[1] IDSA Sepsis Task Force. Infectious Diseases Society of America (IDSA) Position Statement: Why IDSA Did Not Endorse the Surviving Sepsis Campaign Guidelines[J]. Clin Infect Dis, 2018, 66:1631-1635. doi: 10.1093/cid/cix997 [2] Klein Klouwenberg PM, Cremer OL, van Vught LA, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study[J]. Crit Care, 2015, 19: 319. doi: 10.1186/s13054-015-1035-1 [3] Singer M, Deutschman CS, Seymour CW, et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[J].JAMA, 2016, 315: 801-810. doi: 10.1001/jama.2016.0287 [4] Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program[J]. Crit Care Med, 2014, 42:1749-1755. doi: 10.1097/CCM.0000000000000330 [5] Rhodes A, Evans LE, Alhazzani W, et al.Surviving Sepsis Campaign: International Guidelined for Management of Sepsis and Septic Shock:2016[J]. Crit Care Med, 2017, 43: 486-552. doi: 10.1097/CCM.0000000000002255 [6] Alsolamy S, Al Salamah M, Al Thagafi M, et al.Diagnostic accuracy of a screening electronic alert tool for severe sepsis and septic shock in the emergency department[J].BMC Med Inform Decis Mak, 2014, 14:105. doi: 10.1186/s12911-014-0105-7 [7] Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012[J]. Crit Care Med, 2013, 41:580-637. doi: 10.1097/CCM.0b013e31827e83af [8] Goulden R, Hoyle MC, Monis J, et al.qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergeney admissions treated as sepsis[J]. Emerg Med J, 2018, 35:345-349. doi: 10.1136/emermed-2017-207120 [9] Gyang E, Shieh L, Forsey L, et al.A nurse-driven screening tool for the early identification of sepsis in an intermediate care unit setting[J].J Hosp Med, 2015, 10:97-103. doi: 10.1002/jhm.2291 [10] Jones SL, Ashton CM, Kiehne L, et al.Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program[J].Jt Comm J Qual Patient Saf, 2015, 41:483-491. http://europepmc.org/abstract/MED/26484679 [11] Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study[J].Crit Care Med, 2015, 43:3-12. [12] Cockerill FR 3rd, Wilson JW, Vetter EA, et al. Optimal testing parameters for blood cultures[J]. Clin Infect Dis, 2004, 38:1724-1730. doi: 10.1086/421087 [13] Lee A, Mirrett S, Reller LB, et al.Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed?[J]. J Clin Microbiol, 2007, 45: 3546-3548. doi: 10.1128/JCM.01555-07 [14] Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America[J]. Clin Infect Dis, 2009, 49:1-45. doi: 10.1086/599376 [15] Andes DR, Safdar N, Baddley JW, et al. Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials[J]. Clin Infect Dis, 2012, 54:1110-1122. doi: 10.1093/cid/cis021 [16] Kumar A, Zarychanski R, Light B, et al.Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: a propensity-matched analysis[J].Crit Care Med, 2010, 38:1773-1785. doi: 10.1097/CCM.0b013e3181eb3ccd [17] Brunkhorst FM, Oppert M, Marx G, et al. Effect of empirical treatment with moxifloxacin and meropenem vs meropenem on sepsis-related organ dysfunction in patients with severe sepsis: a randomized trial[J].JAMA, 2012, 307:2390-2399. doi: 10.1001/jama.2012.5833 [18] de Jong E, van Oers JA, Beishuizen A, et al.Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial[J].Lancet Infect Dis, 2016, 16:819-827. doi: 10.1016/S1473-3099(16)00053-0 [19] Prkno A, Wacker C, Brunkhorst FM, et al. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock—a systematic review and meta-analysis[J].Crit Care, 2013, 17:R291. doi: 10.1186/cc13157 [20] Blot SI, Pea F, Lipman J.The effect of pathophysiology on pharmacokinetics in the critically ill patient — concepts appraised by the example of antimicrobial agents[J].Adv Drug Deliv Rev, 2014, 77:3-11. doi: 10.1016/j.addr.2014.07.006 [21] Avni T, Levcovich A, Ad-El DD, et al. Prophylactic antibiotics for burns patients: systematic review and meta-analysis[J].BMJ, 2010, 340:c241. doi: 10.1136/bmj.c241 [22] Barajas-Nava LA, López-Alcalde J, Roquéi Figuls M, et al. Antibiotic prophylaxis for preventing burn wound infection[J].Cochrane Database Syst Rev, 2013, 6:CD008738. http://europepmc.org/abstract/med/23740764 [23] Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection[J].N Engl J Med, 2015, 372:1996-2005. doi: 10.1056/NEJMoa1411162 [24] Eliakim-Raz N, Yahav D, Paul M, et al.Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection-7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials[J].J Antimicrob Chemother, 2013, 68:2183-2191. doi: 10.1093/jac/dkt177 [25] Rattan R, Allen CJ, Sawyer RG, et al. Patients with complicated intra-abdominal infection presenting with sepsis do not require longer duration of antimicrobial therapy[J].J Am Coll Surg, 2016, 222:440-446. doi: 10.1016/j.jamcollsurg.2015.12.050 [26] Hepburn MJ, Dooley DP, Skidmore PJ, et al. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis[J].Arch Intern Med, 2004, 164:1669-1674. doi: 10.1001/archinte.164.15.1669 [27] Seymour CW, Liu VX, Iwashyna TJ, et al.[J].JAMA, 2016, 315:762-774. doi: 10.1001/jama.2016.0288 [28] Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[J].JAMA, 2016, 315:775-787. doi: 10.1001/jama.2016.0289
点击查看大图
计量
- 文章访问数: 203
- HTML全文浏览量: 27
- PDF下载量: 201
- 被引次数: 0