"Lost in translation?" Noninvasive cerebral monitoring after cardiac arrest.
"Lost in translation?" Noninvasive cerebral monitoring after cardiac arrest.
复制标题
“迷失在翻译中？”
DOI：
10.1097/ccm.0b013e31822b3863
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发表时间：
2011
影响因子：
8.8
通讯作者：
Clark,RobertS
中科院分区：
文献类型：
--
作者：
Manole,MioaraD;Kochanek,PatrickM;Clark,RobertS
在社区获得性肺炎（CAP）的治疗中，一个持续存在争议的问题是最初入住重症监护室（ICU）而不是普通医疗床的标准（1，2）。尽管多年来一直有人提出这一建议（3），但最近的数据已经证实，最初在地板上入院但随后在接下来的48小时内转入ICU的患者的死亡率、并发症和住院时间比直接进入ICU的具有相同风险因素的患者更差（4，5）。虽然ICU延迟转移的问题已被普遍承认，但在急诊科（艾德）识别这些患者的最佳标准仍不清楚。指南制定者发现选择严重CAP（SCAP）的标准比最初预期的要困难。早期，人们认识到肺炎严重程度指数和CURB（意识模糊、尿素、呼吸频率、血压）评分无法准确识别SCAP患者（6）。早期美国胸科学会CAP指南中的一套标准似乎效果更好，但仍不足以用于个人决策。根据最新的美国传染病学会/美国胸科学会指南，重新设计了SCAP的标准，作为两个主要标准（需要机械通气或血管加压药）和九个次要标准，并建议仅考虑三个次要标准的患者就应考虑ICU入院（2）。随后的几项研究验证了这些标准（7-9），并将其用于前瞻性干预试验（10）。在这项前瞻性研究中，最初只有次要标准的患者死亡率为10%，大约25%的患者需要机械通气或血管加压药。由于纳入了明显需要ICU的患者，特别是在艾德中插管或需要血管加压药的患者，因此对各种拟议SCAP标准的操作特征的分析受到影响（7）。对于这些患者，ICU入院的需求是明确的，不需要额外的风险分层。此外，即使在同一个城市，不同的医疗机构对ICU床位的使用也各不相同。Charles等人（11）的一项研究试图通过确定需要侵入性呼吸和呼吸支持的风险因素来解决这一问题。最近的验证研究已经考虑到了这些问题（4，12）。美国传染病学会/美国胸科学会指南的SCAP标准是基于文献和专家意见中报告的独立风险（2）。其他几个SCAP评分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具有彼此非常相似的标准，以及美国传染病学会/美国胸科学会的次要标准。不幸的是，所有这些最终都有复杂的评分标准，类似于肺炎严重程度指数。SMART-COP（收缩压、多叶浸润、白蛋白、呼吸频率、心动过速、意识模糊、氧合、pH）虽然显然是该组中唯一的好记忆法，但八个因素中的每一个都有不同的点数，并且基于年龄的几个变量有不同的标准（11）。这种复杂的评分使得在没有电子决策支持工具的情况下难以在艾德中应用。然而，所有SCAP标准的主要问题是它们过于敏感，这意味着许多在ICU外得到充分管理的患者需要进入ICU。将临床SCAP标准与生物标志物的使用相结合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…
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 …