治療指引改善肺移植後ICU照護


  May 3, 2007(洛杉磯訊)-過去的回溯性研究已經證實,接受移植病患其中央靜脈壓力(CVP)高或是PaO2/FiO2(動脈氧氣分壓/吸氣氧氣濃度)低,在手術後,相較於沒有這些症狀的病患,仍然需要呼吸器輔助、或是早期死亡風險較高。根據一項發表於國際心臟與肺臟移植學會第27屆年會與科學座談的研究,現在,研究者已經發現在手術後加護時使用一種標準治療流程,可以縮短病患仍然需要呼吸器的時間、且降低發生重大移植器官功能不全的機率。
  
  為了要降低這類併發症,David Pilcher醫師,澳洲墨爾本Alfred醫院一位資深加護病房(ICU)醫師與其同事發展一種治療指引,在移植後前72個小時進行;在簡單一張雙面表格,被設計可以掛在病床邊,且實用到足以讓護理人員與年輕醫師使用,該流程包括一面的血液動力學照護指引、與另一面的呼吸照護。
  
  血液動力學照護指引是根據病患的中央靜脈壓力是否低於7 mmHg,這是過去被認為與併發症有關的閥值;該流程建議根據病患目前的血壓、心臟作工指標使用血管收縮藥物、靜脈輸注液體、與利尿劑。
  
  同樣的,呼吸照護指引是根據PaO2/FiO2比值,這提供了如何以及何時協助病患脫離呼吸器;該流程也提供一份清單,內容包括許多有關於移植的因素,也包含何時應該尋求資深醫師協助的相關資訊。
  
  Pilcher醫師的團隊前瞻性地針對56位於2005年10月至2007年1月之間接受移植的病患進行研究,並找了53位於2004年3月與2005年9月之間於同樣醫院接受肺臟移植病患作為控制組,這兩組病患是相似的,雖然控制組病患發生阻塞性肺部疾病的機率較高,且接受指引治療的病患CVP升高的人數較多;Pilcher醫師表示,這兩個變項被預期偏好控制組。
  
  Pilcher醫師發現接受指引治療的病患相較於控制組,少部份會發生第2或3級原始移植物功能異常(於48小時時的P值為0.03),之間的差異在72小時時,雖然有偏向接受指引治療組較佳的趨勢(P=0.11),但研究者也發現,接受指引治療組病患,接受呼吸器輔助呼吸的時間較短(於24小時與之後的P<0.02);在試驗期間,接受指引治療組累積體液顯著較低(P<0.02)、且使用的正腎上腺素劑量也較低(P=0.01)。
  
  早期與晚期病患族群在死亡率(兩組皆為1.9%)、ICU住院率(9.4%比上10.7%)、或是待在ICU的時間(3.1比上3.6天)皆無差異。
  
  Pilcher醫師表示,我的結論是,一項處理流程或是治療指引已經引領出改善早期預後的趨勢,且實際執行是可行的,而順從性是可接受的。
  
  Pilcher醫師向Medscape表示,這項研究提供了一群我們不熟悉且反應與你們一般ICU病患不太一樣病患處理的架構,舉例來說,透過這個指引,可以避免不適當地使用輸液,這可能使肺部功能更糟,另一方面可以使病患早點拔管脫離呼吸器;護理人員與年輕醫師可以使用這個清單來看他們做的是否正確?而不是總是依賴較資深的醫師。
  
  這項座談會的主持人,德國Ziekenhuizen Leuven大學Dirk Van Raemdonck醫師向Medscape表示,通常是ICU的醫師在決定是否嘗試新的療法,其他醫院也有類似的指引,但是我認為(Pilcher醫師的團隊)是第一個證實,如果你照著一個嚴謹的指引做,可以改善肺臟移植後病患的預後。
  
  Pilcher醫師表示,在他們的團隊分享他們的指引之前,他們希望這項結果可以在更大型的多中心研究中得到證實。
  
  該研究由該醫院一項小型計畫經費資助,作者表示無相關資金上的往來。

Treatment Guideline Improves P

By
Medscape Medical News

May 3, 2007 (San Francisco) –– Previous retrospective studies have suggested that lung transplant patients who have a high central venous pressure (CVP) or a low PaO2/FiO2 (arterial oxygen partial pressure/inspired oxygen concentration) shortly after surgery are likely to remain on ventilation longer and have a higher risk for early death than those lacking such symptoms. Now, researchers have found that the use of a standardized treatment algorithm during postoperative intensive care shortens the time patients remain on ventilator support and reduces the likelihood of developing primary graft dysfunction, according to work presented at the 27th annual meeting and scientific sessions of the International Society for Heart and Lung Transplantation.

To try to limit such complications, David Pilcher, MD, a senior intensive care unit (ICU) physician at Alfred Hospital in Melbourne, Australia, and colleagues developed a treatment guideline to direct care in the first 72 hours after transplant. On a simple 2-sided sheet of paper, designed to be hung at the bedside and practical enough to be useful to nurses and junior physicians, the algorithm includes direction on hemodynamic care on 1 side and respiratory care on the other.

Hemodynamic management was based on whether a patient had a CVP above or below 7 mmHg, which is the cutoff previously associated with complications. The algorithm advises on the use of vasoconstrictors, intravenous fluids, and diuretics, based on the patient’s current blood pressure and cardiac index.

Similarly, the respiratory guideline is based on the PaO2/FiO2 ratio, and provides directions about how and when to wean a patient from ventilation. It provides a checklist for a number of factors regarding the transplant and includes information on when senior help should be called.

Dr. Pilcher’s team tested the algorithm prospectively in 56 lung transplant patients who underwent surgery between October 2005 and January 2007. A historical cohort of 53 patients who had undergone lung transplantation at the hospital between March 2004 and September 2005 served as a control group. The 2 groups were similar, although obstructive lung disease occurred in more patients in the control group and there were more patients with elevated CVP in the guideline-treated group. Both variables would be expected to favor the control group, Dr. Pilcher said.

Dr. Pilcher found that a smaller proportion of patients in the guideline-treated group developed grade 2 or 3 primary graft dysfunction than in the control group (P = .03 at 48 hours). The difference was not significant at 72 hours, although there was a trend toward benefit in the guideline group (P = .11). The researchers also saw a nonsignificant trend for shorter times on ventilation in the guideline-treated group (P ≤ .02 at 24 hours and beyond). Cumulative fluid balance was significantly lower at all time points as well (P ≤ .02), and noradrenaline dose was reduced at all time points (P = .01).

There was no difference in mortality (1.9% in each), ICU readmission rate (9.4% vs 10.7%), or duration of ICU stay (3.1 vs 3.6 days) between the early and late cohorts, respectively.

“My conclusions are that a management algorithm or guideline has led to a trend in improved early outcomes, and its implementation is feasible, and compliance is acceptable,” Pilcher said.

“It provides a framework for the management of an unfamiliar group of patients who respond slightly differently compared to your normal ICU patients,” Dr. Pilcher told Medscape. “Use of the guidelines, for example, can help avoid the inappropriate use of fluids, which can make the lungs worse, and also gets the patient to a point where they can be extubated more quickly. Nurses and junior physicians can use the checklist to see that they are doing something right, ... rather than relying on someone more senior to do that all the time.”

“It is usually the ICU doctor who decides to try this or that,” Dirk Van Raemdonck, MD, PhD, of Universitaire Ziekenhuizen Leuven, Germany, who chaired the session, told Medscape. “I think other hospitals have guidelines as well, but I think [Dr. Pilcher’s group is] the first to show that if you follow a strict guideline, patient outcomes improve” in the post lung transplant setting.

Dr. Pilcher said that before his team shares the guidelines widely, they want to see the outcomes replicated in a bigger multicenter study.

The study was funded by a small projects grant from the hospital. The authors report no relevant financial relationships.

ISHLT 27th Annual Meeting and Scientific Sessions: Abstract 17. Presented April 25, 2007.

    
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