AME证据系列001--转化医学协会:脓毒症诊断和早期识别的临床实践指南

脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊断需要不断改变来满足临床和研究的要求。然而,尽管有许多新型的生物标记和筛选工具去预测脓毒症发生的风险,但是这些措施的诊断价值和有效性不足以让人满意,并且没有充分的证据去建议临床使用这些新技术。因此,脓毒症的临床诊断标准需要定期更新去适应不断产生的新证据。这篇综述旨在呈现当前脓毒症的诊断和早期识别方面的最新研究证据。临床运用不同的诊断方法的推荐意见依赖于推荐、评价、发展和评估分级体系(Grades of Recommendation Assessment,Development and Evaluation,GRADE),因为大部分的研究是观察性研究,并没有对这些方法进行可靠评估,采用的是两步推理方法。未来需要更多研究来确认或者反驳某一特殊的指标检测,同时应该直接采用相关病人的结果数据。

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background:The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the(1)setting of infection onset(community-acquired,early onset,or late-onset hospital-acquired),(2)presence or absence of either localized or diffuse peritonitis,and(3)severity of disease expression(infection,sepsis,or septic shock).This classification system demonstrated reliable risk stratification in intensive care unit(ICU)patients with intra-abdominal infection.This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.Methods:This was a secondary analysis of an international observational study(“AbSeS”)investigating ICU patients with intra-abdominal infection.Only patients with pancreatic infection were included in this analysis(n=165).Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU.Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio(OR)and 95%confidence interval(CI).Results:The overall mortality was 35.2%(n=58).The independent risk factors for mortality included older age(OR=1.03,95%CI:1.0 to 1.1 P=0.023),localized peritonitis(OR=4.4,95%CI:1.4 to 13.9 P=0.011),and persistent signs of inflammation at day 7(OR=9.5,95%CI:3.8 to 23.9,P<0.001)or after the implementation of additional source control interventions within the first week(OR=4.0,95%CI:1.3 to 12.2,P=0.013).Gramnegative bacteria were most frequently isolated(n=58,49.2%)without clinically relevant differences in microbial etiology between survivors and non-survivors.Conclusions:In pancreatic infection,a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome.In this limited series,essentials of the AbSeS-classification,such as the setting of infection onset,diffuse peritonitis,and severity of disease expression,were not associated with an increased mortality risk.

Latest Updates and Challenges in infections in intensive care medicine

In a rapidly changing world,the role of intensive care has become increasingly relevant.Critical care medicine was born during the polio pandemic nearly 50 years ago and the COVID-19 pandemic has stringed its visibility.In this issue,a distinguished selection of the world’s leading experts will address some of the most intriguing issues,sharing their insights and experience in a collection of original articles,narrative reviews,and systematic reviews focusing on hot topics in intensive care units(ICU).Developing and tropical countries have particularities that need to be addressed.Malaria,dengue,and causes of unknown origin fever in this setting are detailed in three articles in the current issue.

Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation(MV)is a life-support therapy that may predispose to morbid and lethal complications,with ventilator-associated pneumonia(VAP)being the most prevalent.In 2013,the Center for Disease Control(CDC)defined criteria for ventilator-associated events(VAE).Ten years later,a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published.Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher thanlower severity.To date,it is estimated that around 30%of ventilated patients in the intensive care unit(ICU)develop VAE.While surveillance enhances the detection of infectious and non-infectious MV-related complicationsthat are severe enough to impact the patient’s outcomes,there are still many gaps in its classification and management.In this review,we provide an update by discussing VAE etiologies,epidemiology,and classification.Preventive strategies on optimizing ventilation,sedative and neuromuscular blockade therapy,and restrictivefluid management are warranted.An ideal VAE bundle is likely to minimize the period of intubation.We believethat it is time to progress from just surveillance to clinical care.Therefore,with this review,we have aimed toprovide a roadmap for future research on the subject.

Prevention of ventilator-associated pneumonia through care bundles:A systematic review and meta-analysis

Background Ventilator-associated pneumonia(VAP)represents a common hospital-acquired infection among mechanically ventilated patients.We summarized evidence concerning ventilator care bundles to prevent VAP.Methods A systematic review and meta-analysis were performed.Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation(MV)for at least 48 h were considered for inclusion.Outcomes of interest were the number of VAP episodes,duration of MV,hospital and intensive care unit(ICU)length of stay,and mortality.A systematic search was conducted in the MEDLINE,the Cochrane Library,and the Web of Science between 1985 and 2022.Results are reported as odds ratio(OR)or mean difference(MD)with 95%confidence intervals(CI).The PROSPERO registration number is CRD42022341780.Results Thirty-six studies including 116,873 MV participants met the inclusion criteria.A total of 84,031 participants underwent care bundles for VAP prevention.The most reported component of the ventilator bundle was head-of-bed elevation(n=83,146),followed by oral care(n=80,787).A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles,compared with the non-care bundle group(OR=0.42,95%CI:0.33,0.54).Additionally,the implementation of care bundles decreased the duration of MV(MD=−0.59,95%CI:−1.03,−0.15)and hospital length of stay(MD=−1.24,95%CI:−2.30,−0.18)in studies where educational activities were part of the bundle.Data regarding mortality were inconclusive.Conclusions The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs.Their application in combination with educational activities seemed to improve clinical outcomes.

The future of training in intensive care medicine: A European perspective

Introduction Intensive care medicine(ICM)is the science and art of preventing,caring for,and curing acutely ill patients.The specialty originated from the need to provide technology-centered organ support to the most fragile patients presenting with sequential and progressive organ failure.[1]Despite its genesis in Europe and extensive clinical and research achievements in the field,ICM has not been recognized as a distinct discipline in the European Union(EU).This has a negative impact on the free movement of intensivists across Europe.In fact,it has been a major obstacle for knowledge and competence sharing,communication,and professional interweaving across borders—all of which are crucial requirements,especially when contending with pandemics and disasters.

COVID-19-Associated Pulmonary Aspergillosis (CAPA)

Invasive Pulmonary Aspergillosis(IPA)has been recognized as a possible secondary infection complicating Coronavirus disease 2019(COVID-19)and increasing mortality.The aim of this review was to report and summarize the available data in the literature concerning the incidence,pathophysiology,diagnosis,and treatment of COVID-19-Associated Pulmonary Aspergillosis(CAPA).Currently,the incidence of CAPA is unclear due to different definitions and diagnostic criteria used among the studies.It was estimated that approximately 8.6%(206/2383)of mechanically ventilated patients were diagnosed with either proven,probable,or putative CAPA.Classical host factors of invasive aspergillosis are rarely recognized in patients with CAPA,who are mainly immuno-competent presenting with comorbidities,while the role of steroids warrants further investigation.Direct epithelial injury and diffuse pulmonary micro thrombi in combination with immune dysregulation,hyper inflammatory response,and immunosuppressive treatment may be implicated.Discrimination between two forms of CAPA(e.g.,tracheobronchial and parenchymal)is required,whereas radiological signs of aspergillosis are not typically evident in patients with severe COVID-19 pneumonia.In previous studies,the European Organization for Research and Treatment of Cancer/Mycoses Study Group(EORTC/MSG)criteria,a clinical algorithm to diagnose Invasive Pul-monary Aspergillosis in intensive care unit patients(AspICU algorithm),and influenza-associated pulmonary aspergillosis(IAPA)criteria were used for the diagnosis of proven/probable and putative CAPA,as well as the differentiation from colonization,which can be challenging.Aspergillus fumigatus is the most commonly isolated pathogen in respiratory cultures.Bronchoalveolar lavage(BAL)and serum galactomannan(GM),𝛽-d-glucan(with limited specificity),polymerase chain reaction(PCR),and Aspergillus-specific lateral-flow device test can be included in the diagnostic work-up;however,these approaches are characterized by low sensitivity.Early treatment of CAPA is necessary,and 71.4%(135/189)of patients received antifungal therapy,mainly with voriconazole,isavuconazole,and liposomal amphotericin B.Given the high mortality rate among patients with Aspergillus infection,the administration of prophylactic treatment is debated.In conclusion,different diagnostic strategies are necessary to differentiate colonization from bronchial or parenchymal infection in intubated COVID-19 patients with Aspergillus spp.in their respiratory specimens vs.those not infected with severe acute respiratory syndrome Coronavirus 2(SARS-CoV-2).Following confirmation,voriconazole or isavuconazole should be used for the treatment of CAPA.

Female representation in intensive care medicine:Challenges and perspectives from China

The gender gap in the practice of intensive care medicine has increasingly been recognized as a problem in recent years.Despite limited information,the available data suggest that representation of women in the physician workforce,academic positions,and leadership roles in intensive care is inadequate globally.In this article,we describe the situation of female intensive care unit(ICU)physicians from the perspective of Chinese intensivists.The proportion of female ICU physicians in China has been increasing in recent years.The biggest challenges faced by female ICU physicians include balance of work and life,difficulties in career planning,and lack of academic influence.More attention and policy support should be provided to help them play a better role in intensive care medicine.

Management of hypoxemia in SARS-CoV-2 infection:Lessons learned from one year of experience,with a special focus on silent hypoxemia

Silent hypoxemia is common in patients with severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)in-fection.In this article,the possible pathophysiological mechanisms underlying respiratory symptoms have been reviewed,and the presence of hypoxemia without hypoxia is also discussed.The experience we have gained since the start of the Coronavirus disease 19(COVID-19)pandemic has changed our point of view about which patients with respiratory involvement should be admitted to the intensive care unit/high-dependency unit for mechan-ical ventilation and monitoring.In patients with clinically well-tolerated mild to moderate hypoxemia(silent hypoxemia),regardless of the extent of pulmonary opacities found in radiological studies,the administration of supplemental oxygen therapy may increase the risk of endothelial damage.The risk of sudden respiratory arrest during emergency intubation,which could expose healthcare workers to infection,should be considered along with the risks of premature intubation.Criteria for intubation need to be revisited based on updated evidence showing that many patients with severe hypoxemia do not show increased work of breathing.This has implica-tions in patient management and may explain in part reports of broad differences in outcomes among intubated patients.