The ongoing challenge of evaluating rescue therapies in acute respiratory distress syndrome*.
The ongoing challenge of evaluating rescue therapies in acute respiratory distress syndrome*.
复制标题
评估急性呼吸窘迫综合征的救援疗法所面临的持续挑战*。
DOI：
10.1097/ccm.0000000000000390
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发表时间：
2014
影响因子：
8.8
通讯作者：
Rice,ToddW
中科院分区：
文献类型：
--
作者：
Keriwala,RajD;Rice,ToddW
由于高达三分之一的美国成年人被认为是肥胖或病态肥胖，定义为体重指数（BMI）大于或等于30，因此需要不断检查肥胖对创伤和重症监护人群结局的影响，并定制医疗保健以满足这一主要合并症（1-5）。Ditillo等人（1）在2014年的一篇出版物中研究了全球最大的行政创伤数据库，国家创伤数据库，发现肥胖是钝性创伤人群不良结局的独立风险因素。Shashaty等人（6）还发现肥胖是严重创伤患者急性肾损伤（阿基）的独立预测因子，肥胖本身作为阿基的预测因子在该患者人群中是有意义的。许多研究表明，在压力下，脂肪组织释放多种炎症介质，包括白细胞介素-6，这可能导致阿基。此外，脂肪组织和肾素-血管紧张素系统之间的关系已被充分证实，这将使肥胖创伤患者的肾功能障碍变得可预测。肥胖增加也可能导致腹腔间室综合征的一个微妙的组成部分，或者至少是腹内压增加，这可能导致一定程度的肾灌注不足，再次使这些患者易患阿基。肥胖患者往往有更多的合并症，包括高血压和动脉粥样硬化，这可能会导致轻微的基线肾功能不全（7）。然而，Shashaty等人（8）在这期《重症监护医学》上发表的文章的新颖之处，以及作者应该受到祝贺的是，他们成功地设计了一种优秀的可重复的方法，这种方法不是定义肥胖，而是基于创伤CT扫描可重复地测量并因此定义肥胖。利用肥胖作为肥胖的替代品，作者能够显示肥胖和阿基之间的明确联系。这似乎是一个相对良性的发现，但为了理解这篇文章的真正价值，人们必须试图解释为什么文献显示出不一致的结果时，使用肥胖作为预测严重创伤患者的不良后果。
As up to one third of the United States adult population is considered to be obese or morbidly obese, defined as a body mass index (BMI) more than or equal to 30, the impact of obesity on outcomes in both the trauma and critical care populations needs to be constantly examined and healthcare tailored to meet this major comorbidity (1–5). Ditillo et al (1) in a publication in 2014 looked at the largest administrative trauma database globally, the National Trauma Data Bank, and found that obesity was an independent risk factor for adverse outcomes in the blunt trauma population. Shashaty et al (6) also found obesity to be an independent predictor of acute kidney injury (AKI) in the critically injured trauma patient.Obesity in and of itself as a predictor for AKI makes sense within this patient population. Numerous studies have shown that in times of stress, adipose tissue releases multiple inflammatory mediators, including interleukin-6, which can result in AKI. Furthermore, the relationship between adipose tissue and the renin-angiotensin system has been well documented and would make renal dysfunction in obese trauma patients predictable. Increased adiposity may also result in a subtle component of abdominal compartment syndrome—or, at the very least, increased intra-abdominal pressure—which can result in a certain level of renal hypoperfusion, again predisposing these patients to AKI. Obese patients tend to have more comorbid conditions, including hypertension and atherosclerosis, which may yield subtle baseline renal dysfunction (7). Yet, what is novel about the article by Shashaty et al (8) in this issue of Critical Care Medicine, and what the authors should be congratulated for, is their attempt—and success—at devising an excellent and reproducible means of not so much defining obesity but rather reproducibly measuring and hence defining adiposity based on the trauma CT scan. Utilizing adiposity as a surrogate for obesity, the authors were able to show a clear link between obesity and AKI. This may seem like a relatively benign finding, yet in order to understand the true merits of this article, one must attempt to explain why the literature has shown discrepant results when using obesity as a predictor for adverse outcomes in critically injured trauma patients.