急诊

急诊科救治脓毒症病人治疗时机和死亡率之间的关系

作者:张雅芝 来源:急诊界 日期:2017-07-14
导读

         自2013年开始,纽约要求所有医院遵循有关流程对脓毒症进行早期识别和治疗。但是,这种更快的对脓毒症患者进行治疗是否能够改善病人预后,仍存有争议。

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

急诊科救治脓毒症病人治疗时机死亡率之间的关系

 

Background

In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients.

自2013年开始,纽约要求所有医院遵循有关流程对脓毒症进行早期识别和治疗。但是,这种更快的对脓毒症患者进行治疗是否能够改善病人预后,仍存有争议。

 

Methods

We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid.

该研究是对纽约州卫生部2014年4月1日——2016年6月30日脓毒症和脓毒性休克的患者收集信息。对脓毒症患者到达急诊科后6小时内启动脓毒症处理流程,在12小时内对其在进行一个3小时诊疗流程(如血培养、广谱抗生素使用和乳酸水平测量)。用多层次模型评估3小时诊疗流程的完成时间和风险调整后的死亡率之间的关系。同时,该试验也评估抗生素使用时间和初始液体复苏时间与死亡率的关系。

 

Results

Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21).

该试验共收集了149家医院的49331名患者,其中40696(82.5%)完成了3个小时诊疗流程。3小时诊疗流程完成时间的中位值为1.30小时(四分位范围,0.65到2.35);抗生素应用的平均时间为0.95小时(四分位范围,0.35 - 1.95);液体复苏完成时间中位值为2.56小时(四分位范围,1.33到4.20)。在12小时内完成3小时诊疗流程的患者中,更长的完成时间与更高的风险调整后的院内死亡率相关(OR 1.04/h;95%CI1.02—1.05;P < 0.001);抗生素使用时间延长也与更高的风险调整后的院内死亡率相关(OR 1.04/h,95%CI 1.03—1.06;P < 0.001);但是液体复苏时间与死亡率无明显关系。(OR 1.01/h,95%CI,0.99—1.02;P = 0.21)。

 

Conclusions

More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.

患者接受更快完成3小时诊疗流程的脓毒症和快速抗生素使用,与较低的风险调整后的住院死亡率相关,但是快速完成初始液体复苏并无明显优势。

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