A mouse is not a man: should we abandon murine models in critical care research?
A mouse is not a man: should we abandon murine models in critical care research?
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小鼠不是人：我们应该在重症监护研究中放弃小鼠模型吗？
DOI：
10.1097/ccm.0b013e318224995d
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发表时间：
2011
影响因子：
8.8
通讯作者：
Wagner F
中科院分区：
文献类型：
--
作者：
Wagner K;Calzia E;Georgieff M;Radermacher P;Wagner F
社区获得性肺炎(CAP)管理中持续存在的矛盾之一是首次进入重症监护病房(ICU)而不是普通病床的标准(1，2)。尽管多年来一直被建议(3)，但最近的数据巩固了证据，即最初入院但随后在接下来的48小时内转到ICU的患者比直接进入ICU的具有同等危险因素的患者的死亡率、并发症和住院时间更差(4，5)。虽然ICU转院延迟的问题已经得到普遍承认，但在急诊科(ED)识别这些患者的最佳标准仍然不清楚。指南开发人员发现，选择严重CAP(SCAP)的标准比最初预期的要困难。早期，肺炎严重性指数和抑制(混淆、尿素、呼吸频率、血压)评分不能准确地识别SCAP患者是公认的(6)。早期美国胸科学会CAP指南中的一组标准似乎效果更好，但仍不足以用于个人决定。根据美国传染病学会/美国胸科学会的最新指南，SCAP的标准被重新设计为两个主要标准(是否需要机械通气或血管加压药)和九个次要标准，建议只有三个次要标准的患者考虑入院ICU(2)。此后的几项后续研究证实了这些标准(7-9)，并将其用于前瞻性干预试验(10)。在这项前瞻性研究中，最初只有较小标准的患者的死亡率为10%，大约25%的患者继续需要机械通气或血管加压剂。由于纳入了明显需要ICU的患者，特别是在急诊室插管或需要血管升压药的患者，对各种建议的SCAP标准的操作特征的分析受到影响(7)。对于这些患者，ICU入院的必要性是明确的，不需要额外的风险分层。此外，即使在同一城市，在不同的医疗保健环境中，获得ICU床位的机会也不同。Charles等人(11)的一项研究试图通过确定需要有创呼吸机和呼吸支持的危险因素来解决这一问题。最近的验证研究已经考虑了这些问题(4，12)。美国传染病学会/美国胸科学会指南的SCAP标准基于文献中报告的独立风险和专家意见(2)。其他几个SCAP分数是用更复杂的多变量技术开发的(11，13，14)。令人放心的是，这些多变量技术最终得出的标准彼此非常相似，而且美国传染病学会/美国胸科学会的次要标准也非常相似。不幸的是，所有这些都以复杂的评分标准结束，类似于肺炎严重性指数。SMART-COP(收缩压、多叶渗透、白蛋白、呼吸频率、心动过速、神志不清、氧合、pH)，虽然显然是组中唯一好的助记器，但对于八个因素中的每一个都有不同的分数，并且对基于年龄的几个变量有不同的标准(11)。这种复杂的评分方式使得在没有电子决策支持工具的情况下很难在急诊室中应用。然而，所有SCAP标准的主要问题是它们过于敏感，建议许多在ICU外得到充分管理的患者进入ICU。结合临床SCAP标准和使用生物标记物是一种潜在的解决方案。降钙素原(PCT)似乎提供了最大的潜力。PCT已经是食品和…
One of the continuing contro-versial issues in the manage-ment of community-acquired pneumonia (CAP) is criteria for initial admission to an intensive care unit (ICU) rather than a general medical bed (1, 2). Although suggested for many years (3), recent data have solidified the evidence that patients admitted to the floor initially but subsequently transferred to the ICU within the next 48 hrs have worse mortality, complications, and length of stay than patients with equivalent risk factors admitted directly to the ICU (4, 5). Although this issue of delayed ICU transfers is generally acknowledged, the best criteria to identify these patients in the emergency department (ED) remain unclear. Guideline developers found selecting criteria for severe CAP (SCAP) more difficult than initially anticipated. Early on, the inability of the Pneumonia Severity Index and CURB (Confusion, Urea, Respiratory rate, Blood pressure) scores to accurately identify patients with SCAP was recognized (6). A set of criteria from an early American Thoracic Society CAP guideline appeared to work better but was still inadequate for individual decisions. The criteria for SCAP were redesigned for the most recent Infectious Diseases Society of America/American Thoracic Society guidelines as two major criteria (need for mechanical ventilation or vasopressors) and nine minor criteria with a suggestion that consideration of ICU admission is appropriate for patients with three minor criteria alone (2). Several subsequent studies have since validated these criteria (7–9) and they have been used for a prospective interventional trial (10). In this prospective study, mortality for patients with only minor criteria initially was 10% and roughly 25% went on to require mechanical ventilation or vasopressors. Analysis of the operating characteristics of various proposed SCAP criteria is compromised by inclusion of patients with obvious need for ICU, specifically patients intubated or requiring vasopressors in the ED (7). For these patients, the need for ICU admission is clear and no additional risk stratification is needed. In addition, access to ICU beds varies in different healthcare settings even within the same city. A study by Charles et al (11) attempted to address this issue by determining risk factors for need for invasive ventilatory and respiratory support. The most recent validation studies have taken these issues into account (4, 12).The Infectious Diseases Society of America/American Thoracic Society guideline’s SCAP criteria were based on independent risks reported in the literature and expert opinion (2). Several other SCAP scores were developed with more sophisticated multivariable techniques (11, 13, 14). Reassuringly, these multivariate techniques end up with very similar criteria to each other and the Infectious Diseases Society of America/American Thoracic Society minor criteria. Unfortunately, all end up with complex scoring criteria, similar to the Pneumonia Severity Index. SMART-COP (Systolic blood pressure, Multilobar infiltrate, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygenation, pH), although clearly the only good mnemonic in the group, has a variable number of points for each of the eight factors and different criteria for several variables based on age (11). This complex scoring makes application in the ED difficult without electronic decision support tools. However, the major problem with all SCAP criteria is that they are overly sensitive, suggesting ICU admission for many patients who are adequately managed outside the ICU. Combing clinical SCAP criteria with use of biomarkers is one potential solution. Procalcitonin (PCT) seemed to offer the greatest potential. PCT is already Food …
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过期一氧化氮和高阶物种休克。
影响因子：
8.8
作者：
D. Traber
通讯作者：
D. Traber
揭示年龄对重症监护病房结果的影响。
影响因子：
8.8
作者：
N. Desbiens
通讯作者：
N. Desbiens
影响因子：
8.8
作者：
Barth, E;Radermacher, P;Albuszies, G
通讯作者：
Albuszies, G
来自小鼠和 MOF：啮齿动物模型、免疫调节和重症患者的结果。
影响因子：
8.8
作者：
M. Bauer;K. Reinhart
通讯作者：
K. Reinhart
影响因子：
2.3
作者：
Haouzi, Philippe;Notet, Veronique;Bihain, Bernard
通讯作者：
Bihain, Bernard