Bundled care for septic shock: an analysis of clinical trials.
Bundled care for septic shock: an analysis of clinical trials.
复制标题
DOI：
10.1097/ccm.0b013e3181cb0ddf
复制
发表时间：
2010-02
影响因子：
8.8
通讯作者：
Eichacker PQ
中科院分区：
文献类型：
--
作者：
Barochia AV;Cui X;Vitberg D;Suffredini AF;O'Grady NP;Banks SM;Minneci P;Kern SJ;Danner RL;Natanson C;Eichacker PQ
脓毒症捆绑治疗已开发出来，通过结合成分疗法来改善患者的预后。有效的捆绑包需要具有附加优势的有效组件。支持者鼓励对捆绑包进行评估，既可以作为一个整体，也可以基于每个组件的性能。评估脓毒症捆绑研究中结局与成分治疗利用率之间的相关性。检索PubMed、Embase和科克伦图书馆的数据库（1980年1月至2008年7月），检索词为脓毒症、捆绑治疗、指南和早期目标导向治疗。纳入需要比较接受捆绑式治疗与非协议治疗的脓毒症成人。提取了个体干预措施的生存率和使用率。确定了8项揭盲试验，1项随机试验和7项历史对照试验。脓毒症捆绑与生存率的一致（I2 = 0%，p = 0.87）和显著增加相关（比值比，1.91; 95%置信区间，1.49-2.45; p <0.0001）。对于报告此类数据的所有研究，使用抗生素的时间一致（I2 = 0%，p ≥ .64）缩短，抗生素的适当性增加（两者均为p < .0002）。相比之下，所有其他治疗（在指定时间段内使用抗生素;给予液体、血管加压药、正性肌力药和滴定至血流动力学目标的浓缩红细胞;使用皮质类固醇和人重组活化蛋白C）的试验之间存在显著异质性（所有I2 ≥ 67%，p < .002）。除抗生素外，脓毒症束成分的有效性仍在随机对照试验中进行研究。集束使用与生存率和抗生素使用的一致和显著改善相关。其他束成分的使用在研究中变化不均匀，使其对生存的影响不确定。然而，应谨慎解释该分析，因为这些研究均为揭盲研究，只有1项研究为随机研究。
Sepsis bundles have been developed to improve patient outcomes by combining component therapies. Valid bundles require effective components with additive benefits. Proponents encourage evaluation of bundles, both as a whole and based on the performance of each component. Assess the association between outcome and the utilization of component therapies in studies of sepsis bundles. Database searches (January 1980 to July 2008) of PubMed, Embase, and the Cochrane Library, using the terms sepsis, bundles, guidelines, and early goal directed therapy. Inclusion required comparison of septic adults who received bundled care vs. nonprotocolized care. Survival and use rates for individual interventions were abstracted. Eight unblinded trials, one randomized and seven with historical controls, were identified. Sepsis bundles were associated with a consistent (I2 = 0%, p = .87) and significant increase in survival (odds ratio, 1.91; 95% confidence interval, 1.49–2.45; p < .0001). For all studies reporting such data, there were consistent (I2 = 0%, p ≥ .64) decreases in time to antibiotics, and increases in the appropriateness of antibiotics (p < .0002 for both). In contrast, significant heterogeneity was seen across trials for all other treatments (antibiotic use within a specified time period; administration of fluids, vasopressors, inotropes, and packed red blood cells titrated to hemodynamic goals; corticosteroids and human recombinant activated protein C use) (all I2 ≥ 67%, p < .002). Except for antibiotics, sepsis bundle components are still being investigated for efficacy in randomized controlled trials. Bundle use was associated with consistent and significant improvement in survival and antibiotic use. Use of other bundle components changed heterogeneously across studies, making their impact on survival uncertain. However, this analysis should be interpreted cautiously as these studies were unblinded, and only one was randomized.