Title: Critical care studies in the last 5 years that change our practice
题目：近五年内改变我们临床实践的危重病学文献
Authors 作者: John Greenwood, Mike Winters, Haney Mallemat

1. Fluid management in ARDS 成人呼吸窘迫综合症的液体治疗
a. Patients did better with conservative (“dry”) fluid management at day 7
在7天时，接受保守（“干”）液体治疗的患者恢复的更好
b. No difference in mortality, but there was a difference in:
虽然在死亡率上一样，但在下列几方面确有差别：
i. Oxygenation 氧浓度
ii. Plateau pressures 平台压
iii. Time on ventilator 机械通气时间
iiii. Time in ICU ICU时间
c. PA catheter vs CVP 放置肺动脉导管还是中心静脉管
d. In the ED, still should fluid resuscitate, but once hypotension & markers of end-organ dysfunction improve, back off on fluid (goal is equal I&Os, CVP=4)
在急诊科，仍要进行液体复苏，但一旦低血压和各脏器功能得以改善，就要减少液体（目标是量出为入，维持CVP＝4）

2. Glucose control (permissive mild hyperglycemia) 血糖控制（许可性轻度高血糖）
Intensive control (81-108) has higher incidence of severe hypoglycemia and worsened outcomes compared to conventional control (<180)
于传统控制（低于180）相比，严格控制（81－108）会使严重低血糖发生率增高并预后较差
Too much sugar is bad (>200), but too little sugar is REALLY bad
血糖过高（超过200）不好，但过低更坏
Use insulin drip instead of bolus dose
需要胰岛素时，要持续静脉滴注，不要静推

3. Corticosteroids in septic shock中毒性休克时的皮质激素的应用
Clear that high dose steroids worsen outcomes
很明确，高剂量的激素使预后恶化
Low dose steroids result in shorter duration of shock, but no overall improvement in 28-day mortality, and higher incidence of secondary infections
低剂量激素可缩短休克时间，但不改善28天死亡率，并增加继发性感染的机会
c. Should not be give to all comers 不要给所有的患者
d. Still recommended for patients who have refractory septic shock, not responding to IVF or vasopressors (50mg hydrocortisone IV bolus followed by continuous infusion at 200mg/24h)
建议应用于顽固性休克，对液体或升压药无反应（50mg氢化可的松静脉注射，然后以200mg／24hr持续滴注）
Should see response within 1-2 hours 应该在1－2小时内见效

4. Vasopressor therapy in shock 升压药在休克中的应用
a. As second (add-on) vasopressors, no difference in mortality between vasopressin & norepinephrine
做为第二线升压药，垂体后叶素和去甲基肾上腺素在死亡率方面无区别
Dopamine compared to norepinephrine as first line agents
多巴胺做为第一线药与去甲基肾上腺素比较
No significant difference in mortality at 28 days
在28天死亡率无差别
Higher incidence of arrhythmias in dopamine patients
用多巴胺患者的心律失常发生率较高
iii. Increased mortality in subgroup of patients with cardiogenic shock who got dopamine
对心源性休克患者，多巴胺的使用增加死亡率

Bottom line 要点
Initial fluid resuscitation is still important, but once markers start to improve, back off
早期液体复苏还是很重要的，但一旦指标好转，要减量
Keep glucose<200, but don’t do tight control
维持血糖低于200，不要控制太严格
Give low-dose hydrocortisone to patients with refractory septic shock
小剂量的氢化可的松可用于顽固性感染性休克的患者
Norepinephrine is as good of a vasopressor as we have
去甲基肾上腺素是我们所拥有的一个好的升压药

Reference 参考文献

Diaz-Guzman E, Sanchez J, Arroliga AC. Updates in intensive care medicine: Studies that challenged our practice in the last 5 years. Cleveland Clinic Journal of Medicine 2011; 78(10):665-674.