Have your cake and eat it? Insulin strengthens the stunned heart.
Have your cake and eat it? Insulin strengthens the stunned heart.
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蛋糕吃完了吗？
DOI：
10.1097/ccm.0b013e31818723d2
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发表时间：
2008
影响因子：
8.8
通讯作者：
Taegtmeyer,Heinrich
中科院分区：
文献类型：
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作者：
Taegtmeyer,Heinrich
不久前，我们医院一位受人尊敬的同事问我们的重症监护病房（ICU）是否有断奶程序。我很震惊，因为我们有一个5年的时间，由一个热情的团队开发，遵循出版的指导方针(1)。虽然我们定期测量性能，但我们不监控断奶方案的遵守情况。如果被问到这个问题，我会天真地认为我们的实践是优秀的，协议的执行比实际情况更严格。经验教训：如果你不跟踪绩效，你就无法真正了解你的单位发生了什么。推荐和实际做法之间令人沮丧的差距，尤其尖锐的败血症管理。如果使用得当，个体治疗的挽救生命潜力是惊人的：早期目标定向治疗的绝对风险降低16%(2)，低潮气量通气的绝对风险降低9%(3)，严格控制血糖的菌血症患者的绝对风险降低17%(4)，低剂量皮质类固醇的绝对风险降低10%(5)，重组活化蛋白C的绝对风险降低至少6%(6)。这个令人印象深刻的数字曾促使戈登·伯纳德（Gordon Bernard）医生在一次全国会议上提出，我们很快就会有更多的病人离开重症监护室，而不是进入重症监护室。尽管败血症的病死率正在下降(7)，但发病率和死亡率仍然很高，推荐的救命疗法的使用也不一致（8,9）。在本期的《重症监护医学》中，Brunkhorst等人（10）加入了越来越多的研究，描述了未能采用循证实践。在2003年的某一天，调查人员对214家德国icu的随机样本进行了研究，这些icu代表了范围广泛的医院，从小型社区机构到大学附属的大型医院。ICU主任被问及几种循证干预措施的使用频率，包括低潮气量通气治疗急性呼吸窘迫综合征/急性肺损伤、严格控制血糖、激活蛋白C和低剂量氢化可的松。对图表进行了审核，以比较调查结果与实际做法。作者研究了366名随机选择的严重脓毒症或感染性休克患者。共有79.9%的ICU主任报告遵守了低潮气量策略。然而，在急性呼吸窘迫综合征/急性肺损伤患者中，80.3%的被审计患者的体积高于8ml /kg预测体重。同样，65.9%的ICU主任报告坚持严格的血糖控制，而66.2%的审计患者坦率地说血糖过高。在所有被研究的策略中，感知和实际实践之间都显示出类似的差距。所有规模和隶属关系的医院的调查结果都是相同的，尽管在较大的学术机构中，人们认为依从性更高。
Not long ago, a respected col-league at my hospital asked if our intensive care unit (ICU) had a weaning protocol. I was shocked because we had one for 5 yrs, developed by an enthusiastic team, following published guidelines (1). Although we routinely measure performance, we do not monitor adherence to our weaning protocol. If asked, I would have assumed naively that our practice was excellent and the protocol was followed more closely than it really was. Lesson learned: if you do not track performance, you do not really know what is happening in your unit. The frustrating gap between recommended and actual practice is particularly poignant for sepsis management. When used appropriately, the life-saving potential of individual therapies is staggering: a 16% absolute risk reduction for early goal directed therapy (2), 9% for low tidal volume ventilation (3), 17% for bacteremic patients managed with tight glucose control (4), 10% for low-dose corticosteroids (5), and at least 6% for recombinant activated protein C (6). The impressive math once prompted Dr. Gordon Bernard to suggest at a national meeting that we would soon have more patients leaving the ICU than going in. Although sepsis case fatality rates are decreasing (7), morbidity and mortality remain too high and recommended lifesaving therapies are used too inconsistently (8, 9). In this issue of Critical Care Medicine, Brunkhorst et al.(10) add to a growing list of studies describing the failure to employ evidence-based practice. On a single day in 2003, the investigators studied a random sample of 214 German ICUs, representing a wide range of hospitals, from small community institutions to large ones affiliated with universities. ICU directors were asked how often several evidence-based interventions were used, including low tidal volume ventilation for acute respiratory distress syndrome/acute lung injury, tight glycemic control, activated protein C, and low-dose hydrocortisone. Charts were audited to compare survey responses to actual practice.The authors studied 366 randomly selected patients with severe sepsis or septic shock. A total of 79.9% of ICU directors reported adherence to low tidal volume strategies. However, among patients with acute respiratory distress syndrome/acute lung injury, 80.3% audited were managed with volumes above 8 mL/kg predicted body weight. Similarly, 65.9% of ICU directors reported adherence to strict glucose control whereas 66.2% of patients audited were frankly hyperglycemic. Similar gaps between perceived and actual practice were shown for all strategies studied. Findings were the same for hospitals of all sizes and affiliations, although perceived adherence was higher in larger, academic institutions.