#1
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Ðåêîìåíäàöèè ïî òàêòèêå ëå÷åíèÿ ñåïñèñà è ñåïòè÷åñêîãî øîêà
Ðåêîìåíäàöèè ïðåäñòàâëåíû â ñâîáîäíîì äîñòóïå íà ñàéòå The American College of Critical Care Medicine (ACCM)[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]. Íèæå ïðåäñòàâëåí ïåðåâîä äàííûõ ðåêîìåíäàöèé.
ÇÛ - çàðàíåå ïðèíîøó èçâèíåíèÿ çà êà÷åñòâî òåêñòà, íî íèêàê íå õâàòàåò âðåìåíè ñäåëàòü ëèòåðàòóðíóþ âåðñèþ ïåðåâîäà ÇÇÛ - ïðèøëîñü ïîðåçàòü ôàéë. Ñêà÷èâàåì âñå òðè ÷àñòè, ðàçàðõèâèðóåì â îäíó ïàïêó è çàïóñêàåì ïåðâóþ ÷àñòü. |
#2
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... è íà ñàéòå http://www.survivingsepsis.org
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#3
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Ðîäèëñÿ îòå÷åñòâåííûé âàðèàíò, æåëàþùèå è ìîãóùèå ìîãóò ñðàâíèòü
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] óäà÷íîé îõîòû. |
#4
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À íîðàäðåíàëèí ïðèìåíÿåòå? Ãäå ðàçäîáûëè?
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#5
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Ïîïûòêè "ëåãàëèçîâàòü" â Ðîññèè êðèòåðèè ñåïñèñà ( Members of the American College of Chest Physicians/Society of Crit Care Med Consensus Conference Committee: American College of Chest Physicians/Society of Crit Care Med Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20:864–874. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference Crit Care Med 2003 Vol. 31, No. 4: 1250-1256) ïðåäïðèíèìàëèñü íåîäíîêðàòíî, èì ìåøàëè èñêëþ÷èòåëüíî ñóáúåêòèâíûå ïðè÷èíû.
Êàëóæñêàÿ ñîãëàñèòåëüíàÿ êîíôåðåíöèÿ ÐÀÑÕÈ (èþíü 2004), áåçóñëîâíî, ÿâëÿåòñÿ ñåðüåçíûì äîñòèæåíèåì. Îäíàêî, íà íåé "ïðåäñòàâëåííûå ðåêîìåíäàöèè ïîäãîòîâëåííûå ðàáî÷èìè ãðóïïàìè Êîìèññèè ïî ñåïñèñó ÐÀÑÕÈ, áûëè îáñóæäåíû è â öåëîì îäîáðåíû". Òàê âîò, ñðàçó áûëà âûïóùåíà ìåòîäè÷êà "ÈÍÒÅÍÑÈÂÍÀß ÒÅÐÀÏÈß ÒÅÆÅËÎÃÎ ÑÅÏÑÈÑÀ È ÑÅÏÒÈ×ÅÑÊÎÃÎ ØÎÊÀ. Îñíîâíûå ïîëîæåíèÿ ìåòîäè÷åñêèõ ðåêîìåíäàöèé ÐÀÑÕÈ ïî èíòåíñèâíîé òåðàïèè ñåïñèñà, ïðèíÿòûõ íà Êàëóæñêîé ñîãëàñèòåëüíîé êîíôåðåíöèè â èþíå 2004 ãîäà ïîä ïðåäñåäàòåëüñòâîì àêàä.Â.Ñ.Ñàâåëüåâà". Ê ñîæàëåíèþ, äàííàÿ ìåòîäè÷êà è âûäàåòñÿ çà ìàòåðèàëû ñîãëàñèòåëüíîé êîíôåðåíöèè, è ïî-ïðåæíåìó ïðîäàåòñÿ è ðàçìåùåíà íà ìíîãèõ êîììåð÷åñêèé, ëè÷íûõ ñàéòàõ è ñàéòàõ îðãàíèçàöèé. Îäíàêî, äàííàÿ ìåòîäè÷êà ñîäåðæèò òîëüêî îòäåëüíûå òàáëèöû è ðàçðîçíåííûå ôðàçû, êîòîðûå íå ìîãóò áûòü àäåêâàòíî èíòåðïðåòèðîâàíû. Ìàòåðèàëû, íàñêîëüêî ìíå èçâåñòíî, ïðîäîëæàëè ðåäàêòèðîâàòüñÿ ðàáî÷èìè ãðóïïàìè è èìåþò ñîâåðøåííî äðóãîé âèä. Îíè áûëè îïóáëèêîâàíû â Consilium Medicum "Èíôåêöèè è àíòèìèêðîáíàÿ òåðàïèÿ" ¹2, 2004 ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] , [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] , [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ), îòäåëüíîé êíèãîé èçäàíû òîëüêî â 2006 ãîäó [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] (èçäàòåëüñòâî Ëèòòåððà, èçâåñòíîå ñâîåé âåñüìà ñêàíäàëüíîå ïðàêòèêîé êèäàòü êàê ïåðåâîä÷èêîâ, òàê è ðåäàêòîðîâ) è èìåþòñÿ íà ñàéòå [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] (äîêóìåíò ñîçäàí òîëüêî â ñåíòÿáðå 2004 è ïðîäîëæàë ðåäàêòèðîâàòüñÿ).  ìàòåðèàëàõ èìååòñÿ ññûëêà íà ôèíàíñîâóþ ïîääåðæêó ôèðì Eli Lilly, Bristol-Mayers Squibb, Aventis, ÷òî îáúÿñíÿåò, ê ïðèìåðó, íåïðîïîðöèîíàëüíûé îáúåì èíôîðìàöèè, ïîñâÿùåííûé äðîòðåêîãèíó-àëüôà ñ óïîìèíàíèåì òîëüêî îá èññëåäîâàíèè PROWESS è ò.ä. Äàëåêî íå êàæäàÿ ðåêîìåíäàöèÿ èìååò îáúÿâëåííûå äîêàçàòåëüíîñòè. Äëÿ ïîäðîáíîãî îáñóæäåíèÿ îïóáëèêîâàííûõ ìàòåðèàëîâ ïîòðåáóåòñÿ öåëàÿ âåòêà ôîðóìà. |
#6
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Óäàëîñü îçíàêîìèòüñÿ íå ñ îñíîâíûìè ïîëîæåíèÿìè, à ñ ìàòåðèàëàìè Êàëóæñêîé ñîãëàñèòåëüíîé êîíôåðåíöèè ÐÀÑÕÍÈ?
Ïî÷óñòâîâàëè ðàçíèöó? Åñòü ëè íåîáõîäèìîñòü äèñêóññèè? |
#7
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Öèòàòà:
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#8
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Öèòàòà:
Crit Care Med. 2005 Apr;33(4):760-5. Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Conrad SA, Gabrielli A, Margolis B, Quartin A, Hata JS, Frank WO, Bagin RG, Rock JA, Hepburn B, Laine L. Louisiana State University, Shreveport, LA, USA. OBJECTIVE: To demonstrate that a new immediate-release omeprazole oral suspension is effective in preventing upper gastrointestinal bleeding in critically ill patients. DESIGN: A noninferiority analysis was used to compare rates of clinically significant upper gastrointestinal bleeding in a prospective, phase 3, double-blind trial with parallel omeprazole suspension and cimetidine treatment groups. SETTING: A total of 47 intensive care units in the United States. PATIENTS: A total of 359 critically ill patients who required mechanical ventilation for > or =48 hrs, had an Acute Physiology and Chronic Health Evaluation score of > or =11 at baseline, had an intact stomach with a nasogastric or orogastric tube in place, and had at least one additional risk factor for upper gastrointestinal bleeding. INTERVENTIONS: Patients were randomized to treatment with omeprazole suspension (two 40-mg doses on day 1, via orogastric or nasogastric tube, and 40 mg each day thereafter) or intravenous cimetidine (300-mg bolus and 50 mg/hr thereafter) for up to 14 days. Gastric aspirates were sampled for bleeding and pH. Medication doses were doubled for failure of pH control (two successive aspirates with pH < or = 4). MEASUREMENTS AND MAIN RESULTS: Clinically significant upper gastrointestinal bleeding (bright red blood not clearing after 5-10 mins of lavage or persistent Gastroccult-positive "coffee-grounds" material for 8 hrs on days 1-2 or for 2-4 hrs on days 3-14 and not clearing with > or =100 mL of lavage) was the primary end point of the trial. The rate of clinically significant bleeding in the per-protocol population was 4.5% with omeprazole suspension and 6.8% with cimetidine, meeting the criteria for the noninferiority of omeprazole suspension. Median gastric pH was > or =6 on all trial days with omeprazole suspension treatment and on 50% of days with cimetidine treatment (p < .001, all trial days). In the omeprazole suspension group, median gastric pH was >4 on each trial day in 95% of patients. CONCLUSIONS: Immediate-release omeprazole suspension is effective in preventing upper gastrointestinal bleeding and more effective than intravenous cimetidine in maintaining gastric pH of >4 in critically ill patients. Ïðåäûäóùeå èññëåäîâàíèe ïîêàçàëo, ÷òî â/â îìåïðàçîë êàæäûå 12 ÷ âûãëÿäèò íåñêîëüêî ïîëó÷øå, ÷åì ñóêðàëüôàò èëè â/â ðàíèòèäèí: In a small randomized study of 108 patients who were at risk for SRMD, the efficacy of the PPI omeprazole (50 mg i.v. every 12 hours) in preventing overt GI bleeding was compared with that of sucralfate (1 g orally every 6 hours) and i.v. ranitidine (150 mg/day). The incidence of overt bleeding was 0% with omeprazole, 9.3% with sucralfate, and 10.5% with ranitidine. Azevedo JR, Soares MG, Silva C et al. Prevention of stress ulcer bleeding in high risk patients: comparison of three drugs. Crit Care Med. 1999; 27:A145 -- Íåêîòîðûå ñîîáðàæåíèÿ ýêñïåðòîâ: For the past several years, H2RAs have been preferentially used over PPIs in the hospital setting because H2RAs are available in liquid and intravenous formulations, easing administration problems in the critically ill. However, extemporaneously compounded oral PPI suspensions and the recently approved intravenous formulations of pantoprazole and lansoprazole have eliminated some of the administration issues previously associated with PPIs. Additionally, study data with PPI formulations suggest efficacy in stress ulcer prophylaxis compared with H2RAs. Metz DC. Preventing the gastrointestinal consequences of stress-related mucosal disease. Curr Med Res Opin. 2005 Jan;21(1):11-8. Review
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#9
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Öèòàòà:
Õî÷åòñÿ òàêè îòìåòèòü, ÷òî íåò íóæäû â òðàíñôóçèè ýðèòðîìàññû, åñëè ãåìîãëîáèí íå íèæå 70 ã/ë, (ïðè÷åì 70-90 - ýòî öåëåâûå öèôðû, à íå ðóêîâîäñòâî ê òðàíñôóçèè), äàæå ñðåäè êàðäèîïàöèåíòîâ. Ýòî î÷åíü ïîäðîáíî (ïî ãðóïïàì áîëüíûõ - òðàâìà, îæîãè, êàðäèî) ðàñïèñûâàåòñÿ â íåäàâíåì îáçîðå ñ âûâîäîì "Overall, critically ill patients who received red blood cell transfusions had worse outcomes." Packed Red Blood Cell Transfusion in the Intensive Care Unit: Limitations and Consequences Gould et al. Am J Crit Care 2007;16:39-48. Picture: Summary of main articles on clinical effects of red blood cell transfusions
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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Ñïàñèáî! À íåò ñðàâíèòåëüíûõ äàííûõ î ðèñêå ðàçâèòèÿ ÂÀÏ ñ îìåïðàçîëîì,Í2,ñóêðàëüôàòîì? È ïî ïîâîäó ñðàâíåíèÿ êðàõìàëîâ-æåëàòèíà..Åñòü ïðîñïåêòèâíîå ðàíäîìèçèðîâàííîå èññëåäîâàíèå(Pierre Asfar,Nadia Kerkeni,Francois Labadie,Jean Paul Gjuello,...,Intensive Care Med(2000)26 1282-1287 DOI 10 1007/s001340000606)-ñðàâíåíèå âëèÿíèÿ íà ãåìîäèíàìèêó è àöèäîç ñëèçèñòîé îáîëî÷êè æåëóäêà ìîäèô.æåëàòèíà è 6%ãèäðîêñèýòèëêðàõìàëà. ðåçóëüòàòå æåëàòèí -óëó÷øàåò ïîêàçàòåëè àöèäîçà ñëèçèñòîé ïî ñðàâíåíèþ ñ HES200000/0,62. Ò.î.ïðè ñåïñèñå ïðåäïî÷òèòåëüíåå ïðåïàðàòû ìîäèôèö.æåëàòèíà?
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#11
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ß áû íå ñîâåòîâàë â íàøåé ñïåöèàëüíîñòè îðèåíòèðîâàòüñÿ íà èññëåäîâàíèÿ, êîòîðûå èñïîëüçóþò ñóððîãàòíûå ïîêàçàòåëè èñõîäà, êàê òî âëèÿíèå íà êèñëîòíîñòü æåëóäêà èëè êîàãóëÿöèþ. Ó êàæäîé ôèðìû â çàíà÷êå äåñÿòêè èññëåäîâàíèé, êîòîðûå äåìîíñòðèðóþò íàèëó÷øèå ñòîðîíû ïðåïàðàòà. Äëÿ ðåàíèìàöèè êîíå÷íûé ðåçóëüòàò äîëæåí áûòü îäèí - âëèÿíèå íà ñìåðòíîñòü. À ïðè ñõîæèõ êîíå÷íûõ ðåçóëüòàòàõ âûáèðàåòñÿ òà ñòðàòåãèÿ, êîòîðàÿ ïðåäïî÷òèòåëüíà ýêîíîìè÷åñêè. Âñå åñòåññòâåííî ñ ïîïðàâêîé íà êîíêðåòíîãî èíäèâèäà, ñ ó÷åòîì ïîêàçàíèé è ïðîòèâîïîêàçàíèé.
Âîîáùå â ãàéäëàéíå surviving sepsis campaign óêàçàíî : Öèòàòà:
PS .. êàê ìû ïëàâíî ïåðåøëè íà ñåïñèñ |
#12
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Öèòàòà:
ÇÛ: îïå÷àòêà...ÖÂÄ 8 - 12 mmHg... â ñì. âîä. ñò. ýòî áóäåò 10.88 - 16.31 |
#13
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Êàêàÿ æå ÈÒ ïàíêðåîíåêðîçà áåç îêòðåîòèäà, êàêîé æå ïàíêåðîíåðîç áåç ÑÂÐ, êàêîé æå ÑÂÐ áåç ÑÈÑÒÅÌÍÎÃÎ ÌÅÇÅÍÕÈÌÀËÜÍÎÃÎ ÂÎÑÏÀËÅÍÈß
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#14
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Öèòàòà:
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#15
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Öèòàòà:
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