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#46
24.09.2007, 21:34
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Öèòàòà:
Ïî ññûëêàì: ïðè êàðäèîãåííîì øîêå ïðèíöèïèàëüíî âàæíà ðàííÿÿ ðåâàñêóëÿðèçàöèÿ (PCI èëè CABG), îñòàëüíîå íà ïðîãíîç íå âëèÿåò ïî îïðåäåëåíèþ, ïîýòîìó íèêàêèõ èññëåäîâàíèé ïî âàçîïðåññîðàì âû íå íàéäåòå. Åñòü óïîìèíàíèÿ â ðàçëè÷íûõ îáçîðàõ. Âûáîð òîãî èëè èíîãî âàçîïðåññîðà çàâèñèò ñêîðåå îò òðàäèöèé è "àâòîðèòåòíûõ" ìíåíèé.  Îáçîðû ("àâòîðèòåòíûå") ñ óïîìèíàíèåì ìåçàòîíà íàðÿäó ñ äðóãèìè âàçîïðåññîðàìè ìîãó êèíóòü íà ìûëî. Îïàñåíèÿ íà ñ÷åò ìåçàòîíà ïðè ÊØ ñâÿçàíû ñêîðåå ñ äîãìàòè÷åñêèì ïîíèìàíèåì ïàòîãåíåçà ÊØ: ñíèæåíèå ñåðäå÷íîãî âûáðîñà - ïîâûøåíèå ñèñòåìíîãî ñîñóäèñòîãî ñîïðîòèâëåíèÿ. Ïîýòîìó êàæåòñÿ, ÷òî äàëüíåéøåå ïîâûøåíèå ñîñóäèñòîãî ñîïðîòèâëåíèÿ ïî êðàéíåé ìåðå áåñïîëåçíî. Íà ñàìîì äåëå âñå ñëîæíåå. Òàê â íåäàâíåì àíàëèçå èññëåäîâàíèÿ SHOCK [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] èç 297 ïàöèåíòîâ ñ ÊØ ïî÷òè 20% ñîîòâåòñòâîâàëè êðèòåðèÿì SIRS. Èç íèõ ïî÷òè 3/4 èìåëè ïîçèòèâíóþ êóëüòóðó êðîâè (!). 105 ïàöèåíòîâ èìåëè èìåëè íèçêîå ñèñòåìíîå ñîñóäèñòîå ñîïðîòèâëåíèå. Ýòî ñâÿçûâàþò ñ âûçâàííûì ïðîâîñïàëèòåëüíûìè ìåäèàòîðàìè ïîâûøåíèåì êîíöåíòðàöèè NO. Èññëåäîâàëñÿ äàæå èíãèáèòîð NO ñèíòåçà tilarginine acetate ïðè ÊØ (èññëåäîâàíèå TRIUMPH) - ïðàâäà, áåç ýôôåêòà. Òàê ÷òî îïÿòü âîçâðàùàþñü ê ïðåæíåìó: ïðè îòñóòñòâèè íîðàäðåíàëèíà ìåçàòîí âïîëíå ïðèåìëåìàÿ åìó àëüòåðíàòèâà.  
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Íîâûå ãîðèçîíòû..À åñòü ëè ïðîäîëæåíèå?|
#48
14.11.2007, 16:18
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Öèòàòà:
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#49
09.01.2008, 13:35
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Surviving Sepsis Campaign 2008
Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL; for the International Surviving Sepsis Campaign Guidelines Committee. OBJECTIVE:: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN:: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS:: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS:: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure >/=65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose <150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS:: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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#50
09.01.2008, 14:45
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Ãàéäëàéí êñòàòè åùå íå ïîÿâèëñÿ íà ñàéòå Surviving Sepsis Campaign.
Âîçìîæíî àâòîðû îçàáîòÿòñÿ ðóññêèì ïåðåâîäîì îáíîâëåííîãî ãàéäëàéíà. Ïîêà íà ðóññêîì äîñòóïíà ïðåäûäóùàÿ âåðñèÿ 2004 ãîäà - http://ssc.sccm.org/files/translatio...guidelines.pdf
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#51
14.01.2008, 00:09
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Èäóò èññëåäîâàíèÿ:[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ].Öåííîñòü ãèäðîêîðòèçîíà ïðè ñåïò.øîêå ïîä âîïðîñîì..
Ïî çàêëþ÷åíèþ àâòîðîâ "ñåïòè÷åñêèé øîê áûë áîëåå áûñòðî êóïèðîâàí,ãäå ïðèìåíÿëñÿ ãèäðîêîðòèçîí,íî..íà âûæèâàåìîñòü íèêàêîãî âëèÿíèÿ íå áûëî". Ïðè÷¸ì â ãðóïïå ñ ïîëîæèòåëüíûì ÀÊÒÃ-òåñòîì. Ðåçþìå: Öèòàòà:
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#52
14.01.2008, 22:47
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Öèòàòà:
Öèòàòà:
Òàì æå îïóáëèêîâàíû ðåçóëüòàòû äîñðî÷íî ïðåêðàùåííîãî [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ], â êîòîðîì èíòåíñèâíàÿ òåðàïèÿ èíñóëèíîì (4.4 - 6.1 ììîëü/ë) ó ïàöèåíòîâ ICU íå âëèÿëà íà ïðîãíîç è ÷àùå âûçûâàëà ýïèçîäû ãèïîãëèêåìèè è â êîòîðîì ïîêàçàíà îïàñíîñòü 10% ãèäðîêñèýòèëêðàõìàëà 200/0.5 (íåôðîòîêñè÷íîñòü).
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#53
15.01.2008, 18:58
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Ñïàñèáî çà ññûëêè! Íî õî÷ó îáðàòèòü âíèìàíèå(ïîäåëèòüñÿ âïå÷àòëåíèåì)îò äâóõ ôðàç â ïîñëåäíåì(ñ ïåíòàñòàð÷åì è èíñóëèíîì) èññëåäîâàíèè:
1 Öèòàòà:
2.Âñ¸ òàêè ïåðåä çàêëþ÷åíèåì Öèòàòà:
Öèòàòà:
 ÇÛ:ïðàâäà "improves" è "lessens" áûëî ó æèâîòíûõ(ñðàçó íå çàìåòèë  )
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#55
18.11.2009, 18:38
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 êàêîé îáëàñòè - òðàâìà, õèðóðãèÿ, ïåäèàòðèÿ, îíêîëîãèÿ?
Ïî ñåïñèñó è ñåïòè÷. øîêó - Crit Care Med. 2008 Jan;36(1):296-327. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
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#56
18.11.2009, 18:58
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Öèòàòà:
 Åñòü ëè íåêèå óíèâåðñàëüíûå ìåõàíèçìû åãî ðàçâèòèÿ?2. È êàê ñåé÷àñ ñìîòðÿò íà ñèíäðîì ïîëèîðãàííîé íåäîñòàòî÷íîñòè?  ïëàíå ïàòîôèçèîëîãèè.
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#57
18.11.2009, 19:13
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Íå çíàþ äàæå, ïîñìîòðèòå çäåñü - ÷òî-òî òàêîå?:
Systemic inflammatory response syndrome (SIRS): molecular pathophysiology and gene therapy. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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#58
19.11.2009, 12:04
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Íó ìîæåòå çäåñü åùå ÷òî-íèáóäü ïîñìîòðåòü. Êíèãà óæå äîñòàòî÷íî ñòàðà, íî î÷åíü ôóíäàìåíòàëüíàÿ. Îò æèâîãî êëàññèêà ìèðîâîé èíòåíñèâíîé òåðàïèè,. JL Vincent
THE SEPSIS TEXT edited by Jean-Louis Vincent, Jean Carlet, Steven M. Opal, 2002 [Èçîáðàæåíèÿ äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì] ñêà÷àòü çäåñü
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Ëèíåéíûé âèä
