严重感染集束治疗的依从性研究

Evaluation of compliance with bundle treatment in the management of severe infection

目的评价三级医院严重感染集束治疗的依从性，为推广指南积累相关数据。方法在广州医学院第一附属医院呼吸重症监护病房中选择2006年11月1日--2007年12月31日43例重症肺炎及感染性休克患者进行前瞻性观察研究（集束治疗组），分教育、试验和运作3个阶段实施6h严重感染集束治疗和24h严重感染集束治疗。选择2004年1月1日2006年10月31日在院治疗的43例患者作为历史对照组。结果①6h集束治疗中：血清乳酸测定率为20．9％（9／43）；抗生素治疗前获取血培养的实施率为7．0％（3／43）；100．0％（43／43）能在1h内给予经验性抗生素治疗；44．2％（19／43）输入20ml／kg的晶体液或等量胶体液（20％白蛋白1．1ml／kg或6％羟乙基淀粉4．8ml／kg），6h内输入液体量（折算为6％羟乙基淀粉剂量）为（603．95±176．19）ml；94．7％（18／19）应用血管收缩剂；7．0％（3／43）使用正性肌力药多巴酚丁胺和（或）输浓缩红细胞。②24h集束治疗中：小剂量类固醇使用率为31．6％（6／19）；34．9％（15／43）的患者血糖控制在8．3mmol／L以内；吸气末平台压〈30cmH2O（1cmH2O=0．098kPa，潮气量为6ml／kg）的机械通气患者占97．6％（40／41）。③6h和24h严重感染集束治疗的依从性分别是0和21．4％，整体依从性为0。④与对照组比较，集束治疗组病死率绝对值下降了23．3％（18．6％比41．9％，P=0．019）。结论目前本院严重感染集束治疗仅能达到部分依从。提示国内推广严重感染和感染性休克管理指南依然任重道远。

Objective To evaluate compliance with bundle treatment in the management of severe infection in a tertiary hospital, aiming at analyzing clinical data in order to popularize guidelines for management of severe sepsis and septic shock. Methods A 14-month （from November 1, 2006 to December 31, 2007） prospective observational study of a group of 43 patients admitted to the respiratory intensive care unit in First Affiliated Hospital （tertiary hospital） of Guangzhou Medical College meeting the criteria for severe pneumonia and septic shock was carried out. Implementation of 6-hour and 24-hour bundle treatment for severe infection was divided into three phases consisting of education, trial, and application. A cohort of 43 patients with matched disease history admitted during January 1, 2004 to October 31, 2006 were enrolled as control group. Results ① In 6-hour bundle treatment for severe infection, 20.9%o （9/43） had serum lactate meassured, blood culture was obtained prior to antibiotic administration in 7.0% （3/43） of patients, 100% （43/43） had empirical antibiotics administration within 1 hour, an injusion of an initial minimum of 20 ml/kg of crystalloid or colloid equivalent （1.1 ml/kg of 20% albumin or 4.8 ml/kg of 6% hydroxyethyl starch） was given in 44.2%/00 （19/43）, with infused fluid （converted into 6% hydroxyethyl starch） reaching （503.95±176.19） ml within 6 hours, in 94.7% （18/19） of patients had received vasopressors, and inotropic dobutamine and/or transfusion of packed red blood cells were administered in 7.0% （3/43）. ② In 24-hour bundle treatment for severe infection group, 31.6% （6/19） had received low-dose steroids, 34.9% （15/43） had their blood glucose controlled〈8. 3 mmol/L, mechanical ventilation with inspiratory plateau pressures maintained〈30 cm H2O （1 cm H2O= 0. 098 kPa, 6 ml/kg tidal volume） was instituted in 97.6% （40/41） of patients.③The percentage of compliance with 6-hour and 24-hour bundle treatment for severe infection were 0 and 21.4% respectively, total compliance was also 0. ④ As compared with control group, a 23.30% absolute mortality reduction was found in bundle group （18.6% vs. 41.9%, P= 0. 019）. Conclusion Bundle treatment for severe infection is complied with partially in our hospital, suggesting that it is still quite arduous to popularize guidelines for management of severe sepsis and septic shock in our country.