感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件

感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)1（優(yōu)選）感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)（優(yōu)選）感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)2補(bǔ)充氧±氣管插管和機(jī)械通氣EARLYGOAL-DIRECTEDTHERAPY,EGDT中心靜脈或者動(dòng)脈穿刺鎮(zhèn)靜，肌松（插管患者）CVPMAPSCVO2達(dá)標(biāo)收住院晶體液膠體液血管活性藥物輸血后紅細(xì)胞壓積≥30%肌力藥物＜8mmHg＜65mmHg＞90mmHg＜70%≥70%＜70%YESNONEnglJMed2001;345:1368-77EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化8-12mmHg≥65或＜90mmHg≥70%補(bǔ)充氧±氣管插管和機(jī)械通氣EARLYGOAL-DIRECT3NEnglJMed2001;345:1368-77NEnglJMed2001;345:1368-774NEnglJMed2001;345:1368-77NEnglJMed2001;345:1368-775感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件6EGDT的提出明顯減少患者死亡率（從46.5%到30.5%）迅速的組織缺氧的糾正可改善生存率。住院天數(shù)從18.4天到14.6天，但無統(tǒng)計(jì)學(xué)差異

Earlygoal-directedtherapy(EGDT)providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.(NEnglJMed2001;345:1368-77.)NEnglJMed2001;345:1368-77EGDT的提出明顯減少患者死亡率（從46.5%到30.5%）7NEnglJMed2001;345:1368-77PaulJYoung,FCICM⑥despitevolumeresuscitationorinitiallactate≥4mmol/LTheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。明顯減少患者死亡率（從46.NEnglJMed2001;345:1368-77②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693早期識(shí)別SEPSIS——關(guān)鍵Bundle帶給我們什么？OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.針對本項(xiàng)研究有較多的疑問？NEnglJMed2001;345:1368-77TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)TOBECOMPLETEDWITHIN3HOURS次要目標(biāo)：靜脈補(bǔ)液量，血管活性藥物，輸血，器官功能支持的評價(jià)Bundle帶給我們什么？針對本項(xiàng)研究有較多的疑問？整個(gè)研究未用盲法？穿刺時(shí)必須的嗎？輸血必須嗎？如此多的液體合適嗎？為什么對照組的死亡率如此之高？為什么本研究是陽性結(jié)果而其他研究是陰性？。。。。。NEnglJMed2001;345:1368-77針8感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件9感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件10SURVIVINGSEPSISCAMPAIGNCAREBUNDLESTOBECOMPLETEDWITHIN3HOURS①M(fèi)easurelactatelevel②Obtainbloodculturespriortoadministrationofantibiotics③Administerbroadspectrumantibiotics④Administer30mL/kgcrystalloidforhypotensionorlactate≥4mmol/LSURVIVINGSEPSISCAMPAIGNCARE11TOBECOMPLETEDWITHIN6HOURS⑤Applyvasopressorstomaintainameanarterialpressure(MAP)≥65mmHg⑥despitevolumeresuscitationorinitiallactate≥4mmol/L-Measurecentralvenouspressure(CVP)*-Measurecentralvenousoxygensaturation(ScvO2)*⑦Remeasurelactateifinitiallactatewaselevated*

SURVIVINGSEPSISCAMPAIGNCAREBUNDLESEGDT是針對血液動(dòng)力學(xué)的優(yōu)化TOBECOMPLETEDWITHIN6HOURS12有關(guān)SEPSIS的新的臨床研究ProCESS-ProtocolizedCareforEarlySepticShock.

ARISE-AustralasianResusitationInSepsisEvaluationProMISe-ProtocolisedManagementInSepsis有關(guān)SEPSIS的新的臨床研究ProCESS-Proto13項(xiàng)目研究地區(qū)起止時(shí)間納入中心數(shù)納入病例場所樣本例數(shù)美國3.2008-12.201331ED1341澳大利亞10.2008-4.201451ED1588英國2.2011-7.201456ED,ICU1260項(xiàng)目研究地區(qū)起止時(shí)間納入中心數(shù)納入病例場所樣本例數(shù)美國3.214ProCESS

多中心N=1341，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：60天死亡率，90天死亡率，1年死亡率，是否需要器官功能支持TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESS多中心TheProCESSInvesti1512701例患者最終納入1341例研究分三組①EGDT組：439例②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例③普通治療組：456例ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-169312701例患者最終納入1341例ProCESSThePr16ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati17ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati18ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati19ARISE

多中心N=1588，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISE多中心TheARISEInvestigati20ARISE3559例患者最終納入1588例研究分組EGDT組：792例

普通治療組：796例TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISE3559例患者最終納入1588例TheARISE21NEnglJMed2001;345:1368-77①EGDT組：439例①EGDT組：439例12701例患者最終納入1341例作者們都明顯高估了基線病死率（28天病死率）和預(yù)計(jì)的組間差異，導(dǎo)致納入病例不足TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311如何看待這三項(xiàng)研究的陰性結(jié)論EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。⑤Applyvasopressorstomaintainameanarterialpressure(MAP)≥65mmHg感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)尋找更適合的目標(biāo)值（目標(biāo)必須存在）9Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.PaulJYoung,FCICMTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTvidessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.SURVIVINGSEPSISCAMPAIGNCAREBUNDLES普通治療組：796例TOBECOMPLETEDWITHIN3HOURS-Measurecentralvenousoxygensaturation(ScvO2)*TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,NEnglandJMed,2014,371:1496-1506NEnglJMed2001;345:1368-77A22ARISEARISE23TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,NEn24ARISETheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,25ProMISe

多中心N=1260，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：90天死亡率

次要目標(biāo)：靜脈補(bǔ)液量，血管活性藥物，輸血，器官功能支持的評價(jià)TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISe多中心TheProMISeInvesti26ProMISe6192例患者最終納入1260名患者研究分組

EGDT組630例

普通治療組630例TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISe6192例患者最終納入1260名患者TheP27TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311TheProMISeInvestigations,N28終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持①M(fèi)easurelactatelevel6天，但無統(tǒng)計(jì)學(xué)差異TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.明顯減少患者死亡率（從46.DirectoroftheIntensiveCareResearchProgramme,如何看待這三項(xiàng)研究的陰性結(jié)論輸血后紅細(xì)胞壓積≥30%PaulJYoung,FCICMLESSISMORE?Bundle帶給我們什么？TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506針對本項(xiàng)研究有較多的疑問？providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.(NEnglJMed2001;345:1368-77.EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-13119Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.如何看待這三項(xiàng)研究的陰性結(jié)論TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官29ProMISeTheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISeTheProMISeInvestigati30ProMISeInconclusion,ourresultssuggestthattechniquesusedinusualresuscitationhaveevolvedoverthe15yearssincethelandmarkstudybyRiversetal.9Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.ProMISeInconclusion,ourres31ProMISeTheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.ProMISeTheadditionofcontinu32如何看待這三項(xiàng)研究的陰性結(jié)論多中心大樣本隨機(jī)對照試驗(yàn)前瞻性研究如何看待這三項(xiàng)研究的陰性結(jié)論多中心33如何看待這三項(xiàng)研究的陰性結(jié)論試驗(yàn)預(yù)計(jì)探查到的組間病死率差異的范圍疾病的基線病死率等因素作者們都明顯高估了基線病死率（28天病死率）和預(yù)計(jì)的組間差異，導(dǎo)致納入病例不足如何看待這三項(xiàng)研究的陰性結(jié)論試驗(yàn)預(yù)計(jì)探查到的組間病死率差異的34OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311尋找更實(shí)用而有效的監(jiān)測指標(biāo)進(jìn)行適時(shí)補(bǔ)充NEnglJMed2001;345:1368-77終點(diǎn)目標(biāo)：60天死亡率，90天死亡率，1年死亡率，是否需要器官功能支持providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持NEnglJMed2001;345:1368-77N=1588，大樣本6192例患者最終納入1260名患者LESSISMORE?廣譜抗生素的應(yīng)用——降階梯治療-Measurecentralvenouspressure(CVP)*①M(fèi)easurelactatelevelNEnglJMed2001;345:1368-77TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例Bundle帶給我們什么？≥65或＜90mmHg如何看待這三項(xiàng)研究的陰性結(jié)論EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。EGDT，我們還需要嗎？Ourresultscompletetheplann35剩下什么？早期識(shí)別SEPSIS——關(guān)鍵廣譜抗生素的應(yīng)用——降階梯治療進(jìn)行適當(dāng)?shù)娜萘繌?fù)蘇剩下什么？早期識(shí)別SEPSIS——關(guān)鍵36Bundle帶給我們什么？

通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.0%下降至18.4%Bundle帶給我們什么？通過對171個(gè)ICU101037Bundle帶給我們什么？同樣提示實(shí)施BUNDLE以來，重癥感染和感染性休克的住院病死率在下降，存在統(tǒng)計(jì)學(xué)意義。Bundle帶給我們什么？同樣提示實(shí)施BUNDLE以來，重38當(dāng)指南遭遇臨床？總是在評價(jià)。。。常常會(huì)疑惑。。。偶爾很堅(jiān)定。。。PaulJYoung,FCICMIntensiveCareSpecialist,WellingtonHospital,NewZealandandDirectoroftheIntensiveCareResearchProgramme,MedicalResearchInstituteofNewZealand,Wellington,NewZealandLESSISMORE?當(dāng)指南遭遇臨床？總是在評價(jià)。。。PaulJYoung,39TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ARISE-AustralasianResusitationInSepsisEvaluation如何看待這三項(xiàng)研究的陰性結(jié)論N=1341，大樣本如何看待這三項(xiàng)研究的陰性結(jié)論TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506明顯減少患者死亡率（從46.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311≥65或＜90mmHg12701例患者最終納入1341例TOBECOMPLETEDWITHIN3HOURSprovidessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.迅速的組織缺氧的糾正可改善生存率。TOBECOMPLETEDWITHIN3HOURS終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持(NEnglJMed2001;345:1368-77.Bundle帶給我們什么？次要目標(biāo)：靜脈補(bǔ)液量，血管活性藥物，輸血，器官功能支持的評價(jià)N=1260，大樣本針對本項(xiàng)研究有較多的疑問？(NEnglJMed2001;345:1368-77.針對本項(xiàng)研究有較多的疑問？通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.⑤Applyvasopressorstomaintainameanarterialpressure(MAP)≥65mmHg9Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.NEnglJMed2001;345:1368-77Bundle帶給我們什么？DirectoroftheIntensiveCareResearchProgramme,普通治療組630例TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506如何看待這三項(xiàng)研究的陰性結(jié)論輸血后紅細(xì)胞壓積≥30%TOBECOMPLETEDWITHIN3HOURSEGDT是針對血液動(dòng)力學(xué)的優(yōu)化TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506DirectoroftheIntensiveCareResearchProgramme,我們需要做的？尋找更適合的目標(biāo)值（目標(biāo)必須存在）更加細(xì)化、標(biāo)準(zhǔn)化提高可操作性和依從性尋找更實(shí)用而有效的監(jiān)測指標(biāo)進(jìn)行適時(shí)補(bǔ)充

也許它并不完美

但并不能否認(rèn)它的價(jià)值和它的可塑性TheProCESSInvestigations,N40感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)41（優(yōu)選）感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)（優(yōu)選）感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)42補(bǔ)充氧±氣管插管和機(jī)械通氣EARLYGOAL-DIRECTEDTHERAPY,EGDT中心靜脈或者動(dòng)脈穿刺鎮(zhèn)靜，肌松（插管患者）CVPMAPSCVO2達(dá)標(biāo)收住院晶體液膠體液血管活性藥物輸血后紅細(xì)胞壓積≥30%肌力藥物＜8mmHg＜65mmHg＞90mmHg＜70%≥70%＜70%YESNONEnglJMed2001;345:1368-77EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化8-12mmHg≥65或＜90mmHg≥70%補(bǔ)充氧±氣管插管和機(jī)械通氣EARLYGOAL-DIRECT43NEnglJMed2001;345:1368-77NEnglJMed2001;345:1368-7744NEnglJMed2001;345:1368-77NEnglJMed2001;345:1368-7745感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件46EGDT的提出明顯減少患者死亡率（從46.5%到30.5%）迅速的組織缺氧的糾正可改善生存率。住院天數(shù)從18.4天到14.6天，但無統(tǒng)計(jì)學(xué)差異

Earlygoal-directedtherapy(EGDT)providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.(NEnglJMed2001;345:1368-77.)NEnglJMed2001;345:1368-77EGDT的提出明顯減少患者死亡率（從46.5%到30.5%）47NEnglJMed2001;345:1368-77PaulJYoung,FCICM⑥despitevolumeresuscitationorinitiallactate≥4mmol/LTheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。明顯減少患者死亡率（從46.NEnglJMed2001;345:1368-77②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693早期識(shí)別SEPSIS——關(guān)鍵Bundle帶給我們什么？OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.針對本項(xiàng)研究有較多的疑問？NEnglJMed2001;345:1368-77TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)TOBECOMPLETEDWITHIN3HOURS次要目標(biāo)：靜脈補(bǔ)液量，血管活性藥物，輸血，器官功能支持的評價(jià)Bundle帶給我們什么？針對本項(xiàng)研究有較多的疑問？整個(gè)研究未用盲法？穿刺時(shí)必須的嗎？輸血必須嗎？如此多的液體合適嗎？為什么對照組的死亡率如此之高？為什么本研究是陽性結(jié)果而其他研究是陰性？。。。。。NEnglJMed2001;345:1368-77針48感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件49感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)課件50SURVIVINGSEPSISCAMPAIGNCAREBUNDLESTOBECOMPLETEDWITHIN3HOURS①M(fèi)easurelactatelevel②Obtainbloodculturespriortoadministrationofantibiotics③Administerbroadspectrumantibiotics④Administer30mL/kgcrystalloidforhypotensionorlactate≥4mmol/LSURVIVINGSEPSISCAMPAIGNCARE51TOBECOMPLETEDWITHIN6HOURS⑤Applyvasopressorstomaintainameanarterialpressure(MAP)≥65mmHg⑥despitevolumeresuscitationorinitiallactate≥4mmol/L-Measurecentralvenouspressure(CVP)*-Measurecentralvenousoxygensaturation(ScvO2)*⑦Remeasurelactateifinitiallactatewaselevated*

SURVIVINGSEPSISCAMPAIGNCAREBUNDLESEGDT是針對血液動(dòng)力學(xué)的優(yōu)化TOBECOMPLETEDWITHIN6HOURS52有關(guān)SEPSIS的新的臨床研究ProCESS-ProtocolizedCareforEarlySepticShock.

ARISE-AustralasianResusitationInSepsisEvaluationProMISe-ProtocolisedManagementInSepsis有關(guān)SEPSIS的新的臨床研究ProCESS-Proto53項(xiàng)目研究地區(qū)起止時(shí)間納入中心數(shù)納入病例場所樣本例數(shù)美國3.2008-12.201331ED1341澳大利亞10.2008-4.201451ED1588英國2.2011-7.201456ED,ICU1260項(xiàng)目研究地區(qū)起止時(shí)間納入中心數(shù)納入病例場所樣本例數(shù)美國3.254ProCESS

多中心N=1341，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：60天死亡率，90天死亡率，1年死亡率，是否需要器官功能支持TheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESS多中心TheProCESSInvesti5512701例患者最終納入1341例研究分三組①EGDT組：439例②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例③普通治療組：456例ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-169312701例患者最終納入1341例ProCESSThePr56ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati57ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati58ProCESSTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693ProCESSTheProCESSInvestigati59ARISE

多中心N=1588，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISE多中心TheARISEInvestigati60ARISE3559例患者最終納入1588例研究分組EGDT組：792例

普通治療組：796例TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISE3559例患者最終納入1588例TheARISE61NEnglJMed2001;345:1368-77①EGDT組：439例①EGDT組：439例12701例患者最終納入1341例作者們都明顯高估了基線病死率（28天病死率）和預(yù)計(jì)的組間差異，導(dǎo)致納入病例不足TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311如何看待這三項(xiàng)研究的陰性結(jié)論EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。⑤Applyvasopressorstomaintainameanarterialpressure(MAP)≥65mmHg感染性休克早期目標(biāo)復(fù)蘇治療的幾種觀點(diǎn)尋找更適合的目標(biāo)值（目標(biāo)必須存在）9Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.PaulJYoung,FCICMTheProCESSInvestigations,NEnglandJMed,2014,370:1683-1693TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTvidessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.SURVIVINGSEPSISCAMPAIGNCAREBUNDLES普通治療組：796例TOBECOMPLETEDWITHIN3HOURS-Measurecentralvenousoxygensaturation(ScvO2)*TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,NEnglandJMed,2014,371:1496-1506NEnglJMed2001;345:1368-77A62ARISEARISE63TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,NEn64ARISETheARISEInvestigations,NEnglandJMed,2014,371:1496-1506ARISETheARISEInvestigations,65ProMISe

多中心N=1260，大樣本前瞻性隨機(jī)對照研究

終點(diǎn)目標(biāo)：90天死亡率

次要目標(biāo)：靜脈補(bǔ)液量，血管活性藥物，輸血，器官功能支持的評價(jià)TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISe多中心TheProMISeInvesti66ProMISe6192例患者最終納入1260名患者研究分組

EGDT組630例

普通治療組630例TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISe6192例患者最終納入1260名患者TheP67TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311TheProMISeInvestigations,N68終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持①M(fèi)easurelactatelevel6天，但無統(tǒng)計(jì)學(xué)差異TheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.明顯減少患者死亡率（從46.DirectoroftheIntensiveCareResearchProgramme,如何看待這三項(xiàng)研究的陰性結(jié)論輸血后紅細(xì)胞壓積≥30%PaulJYoung,FCICMLESSISMORE?Bundle帶給我們什么？TheARISEInvestigations,NEnglandJMed,2014,371:1496-1506針對本項(xiàng)研究有較多的疑問？providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.(NEnglJMed2001;345:1368-77.EGDT主要是針對sepsis或者septicshock血液動(dòng)力學(xué)的優(yōu)化通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-13119Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.如何看待這三項(xiàng)研究的陰性結(jié)論TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官69ProMISeTheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311ProMISeTheProMISeInvestigati70ProMISeInconclusion,ourresultssuggestthattechniquesusedinusualresuscitationhaveevolvedoverthe15yearssincethelandmarkstudybyRiversetal.9Inourstudy,NHShospitalsachievedlevelsofin-hospitalsurvivalinpatientsreceivingusualcarethatweresimilartothoseachievedwithEGDTintheearlierstudyforpatientswithsepticshockwhowereidentifiedearlyandreceivedintravenousantibioticsandadequatefluidresuscitation.ProMISeInconclusion,ourres71ProMISeTheadditionofcontinuousScvO2monitoringandstrictprotocolizationdidnotimproveoutcomesintheEGDTgroup.OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.ProMISeTheadditionofcontinu72如何看待這三項(xiàng)研究的陰性結(jié)論多中心大樣本隨機(jī)對照試驗(yàn)前瞻性研究如何看待這三項(xiàng)研究的陰性結(jié)論多中心73如何看待這三項(xiàng)研究的陰性結(jié)論試驗(yàn)預(yù)計(jì)探查到的組間病死率差異的范圍疾病的基線病死率等因素作者們都明顯高估了基線病死率（28天病死率）和預(yù)計(jì)的組間差異，導(dǎo)致納入病例不足如何看待這三項(xiàng)研究的陰性結(jié)論試驗(yàn)預(yù)計(jì)探查到的組間病死率差異的74OurresultscompletetheplannedtrioofstudiesofEGDT,allofwhichshowedthatEGDTwasnotsuperiortousualcare.TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311尋找更實(shí)用而有效的監(jiān)測指標(biāo)進(jìn)行適時(shí)補(bǔ)充NEnglJMed2001;345:1368-77終點(diǎn)目標(biāo)：60天死亡率，90天死亡率，1年死亡率，是否需要器官功能支持providessignificantbenefitswithrespecttooutcomeinpatientswithseveresepsisandsepticshock.通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.終點(diǎn)目標(biāo)：生存時(shí)間，住院期間的病死率，住院時(shí)間，是否需要器官功能支持NEnglJMed2001;345:1368-77N=1588，大樣本6192例患者最終納入1260名患者LESSISMORE?廣譜抗生素的應(yīng)用——降階梯治療-Measurecentralvenouspressure(CVP)*①M(fèi)easurelactatelevelNEnglJMed2001;345:1368-77TheProMISeInvestigations,NEnglandJMed,2014,372:1301-1311②基于規(guī)范的標(biāo)準(zhǔn)治療組：446例Bundle帶給我們什么？≥65或＜90mmHg如何看待這三項(xiàng)研究的陰性結(jié)論EGDT，這個(gè)在“Bundle”中擔(dān)當(dāng)核心的主策略終于在強(qiáng)大的證據(jù)面前顯示出裂痕。EGDT，我們還需要嗎？Ourresultscompletetheplann75剩下什么？早期識(shí)別SEPSIS——關(guān)鍵廣譜抗生素的應(yīng)用——降階梯治療進(jìn)行適當(dāng)?shù)娜萘繌?fù)蘇剩下什么？早期識(shí)別SEPSIS——關(guān)鍵76Bundle帶給我們什么？

通過對171個(gè)ICU101064例患者的回顧性調(diào)查發(fā)現(xiàn)澳大利亞和新西蘭地區(qū)10余年間重癥感染和感染性休克的住院病死率由35.0%下降至18.4%Bundle帶給我們什么？通過對171個(gè)ICU101077Bundle帶給我們什么？同樣提示實(shí)施BUNDLE以來，重癥感染和感染性休克的住院病死率在下降，存在統(tǒng)計(jì)學(xué)意義。Bundle帶給我們什么？同樣提示實(shí)施BUNDLE