ICU. Jean-Louis Vincent, MD, PhD, FCCP (EBM) 5 y ICU EBM. (randomized controlled trials); (sepsis) (data analysis);

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1 ICU Jean-Louis Vincent, MD, PhD, FCCP (EBM) ( ) 5 y ICU EBM ICU (data analysis); (randomized controlled trials); (sepsis) (evidence-based medicine EBM) (randomized controlled trials, RCTs) RCT [1] RCTs EBM [2] EBM [2] EBM From the Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium. Correspondence to: Jean-Louis Vincent, MD, PhD, FCCP, Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, B-1070 Brussels, Belgium; jlvincen@ulb. ac. be RCT Michand [3] 60% RCT CHEST

2 7% RCT RCT [4] ICU 46 ARDS [5] [8,9] [6] [10] [11] (tumor [12,13] [14] RCT RCT ICU necrosis factor TNF) TNF [15] [16,17] -1 ( (acute lung injury ALI) β- ARDS [18] [19] ) N- [20] ARDS TNF [21] [22] [23] N (G) - -L- ICU RCTs RCTs RCTs ICU RCTs 5 y RCT ( 5 y ) RCT ICU RCT COPD [24,25] ; [7] [26~28] 110

3 ICU Van den Berghe [32] ICU 80 ~ 110 mg / dl 8% 4.6% (P < 0.04) ( ) ICU 14 d ICU (acute physiology and chronic health evaluation, APACHE) [29,30] 9 8% 2 / 3 ICU 12 h ICU Van den Berghe [33] ICU Finney [34] RCT Marenzi [31] ICU 114 ( > 2 mg / dl) 4 ~ 8 h ICU 1 L / h 1 ml / (kg h) 2% 14% (P = 0.02) 1 y 10% Hebert [35] 30% (P = 0.01) RCT 25 9 g / dl ( ICU 10 g / dl ) ( 7 g / dl) [35] CHEST

4 5.6 U 8.2 g / dl ) Drotrecogin-α 10.7 g / dl 2.6 U 8.2 g / dl 8.5 g / dl [42] APACHE 21 2 [43] 28% 22% [44,45] (P = 0.05) ( [36] ) [43] tifacogin 34% % tifacogin 22.7% 17.1% 29.1% (P = 0.006) [37] ( ) C RCTs RCTs [38] [39] Hebert [35] ( Drotrecogin-a ) [46] 393 [40] Drotrecogin-α 9.9% 7.4% (P = 0.48) % 77.3% (P = 0.02) [41] ENHANCE (

5 ICU RCT (30 mg / kg) [47] [21] Rivers [53] RCT ( ) ( 200 mg / d) Annane [48] (early goaldirected therapy, EGDT) RCT (oxygen saturation in the superior vena cava, ScvO 2 ) 28 d ScvO 2 70% 6 h EGDT 1997 Landry [49] 72 h EGDT [50,51] [52] [50] ScvO 2 3. ( ScvO 2 ) CHEST

6 ARDS Network [57] ( 4. ( 361 ) ALI / ARDS 6 ml / kg ) 12 ml / kg ( Hayes [21] ) ( 31.6% 39.8%) 12 ml / kg [58] (septic clock) ICU ALI ( ) 12 ml / kg ICU Groningen [54] 6 ml / kg 6 ml / kg ALI (selective decontamination of the digestive tract SDD) 7 8 ml / kg de Jonge [55] RCT ( 934 ) ICU ICU 23% SDD 15% (P = 0.002) 26% CT 10% (P = 0.001) Kress [59] RCT ( ICU SDD 128 ) [56] ( d P = 0.004) ICU ICU ( d P = 0.02) ( 9% 27% P = 0.02) ( ) ( ) ( ARDS ( ) ) ICU ARDS Amato [5] PEEP 114

7 1 3 Michaud G, et al. Arch Intern Med 1998; 158: Vincent JL. Crit Care Med 2000; 28: / 5 Amato MB, et al. N Engl J Med 1998; 338: Ferreira F, et al. Intensive Care Med 2001; 27: Levy MM, et al. Crit Care Med 2003; 31: Vincent JL, et al. Clin Infect Dis 2002; 34: Opal SM, et al. Infect Dis Clin North Am 1999; 13: Bone RC, et al. N Engl J Med 1987; 317: Bernard GR, et al. N Engl J Med 1997; 336: Abraham E, et al. Lancet 1998; 351: Reinhart K, et al. Crit Care Med 2001; 29: [60~62] Pronovost [63] 14 Abraham E, et al. Crit Care Med 2001; 29: Opal SM, et al. Crit Care Med 1997; 25: Dhainaut JF, et al. Crit Care Med 1998; 26: ICU 1 44: Lundin S, et al. Intensive Care Med 1999; 25: Anzueto A, et al. N Engl J Med 1996; 334: EBM RCT 25 Plant PK, et al. Lancet 2000; 355: RCTs 26 Antonelli M, et al. N Engl J Med 1998; 339: RCT 28 Girou E, et al. JAMA 2000; 284: RCT 29 Bernard SA, et al. N Engl J Med 2002; 346: RCT 346: Marenzi G, et al. N Engl J Med 2003; 349: EBM 34 Finney SJ, et al. JAMA 2003; 290: Hebert PC, et al. N Engl J Med 1999; 340: Vincent JL, et al. JAMA 2002; 288: Hebert PC, et al. JAMA 2003; 289: ( ) 39 Fergusson D, et al. JAMA 2003; 289: Bernard GR, et al. N Engl J Med 2001; 344: Sackett DL, et al. BMJ 1996; 312: Cook DJ, et al. Crit Care Med 1996; 24: ( ) 17 Suputtamongkol Y, et al. Antimicrob Agents Chemother 2000; 20 Fisher CJ Jr, et al. N Engl J Med 1996; 334: Hayes MA, et al. N Engl J Med 1994; 330: Sloan EP, et al. JAMA 1999; 282: Takala J, et al. N Engl J Med 1999; 341: Brochard L, et al. N Engl J Med 1995; 333: Nourdine K, et al. Intensive Care Med 1999; 25: Hypothermia after Cardiac Arrest Study Group. N Engl J Med 2002; 32 Van den Berghe G, et al. N Engl J Med 2001; 345: Van den Berghe G, et al. Crit Care Med 2003; 31: Vincent JL, et al. Am J Respir Crit Care Med 2003; 167: A Wheeler AP, et al. Chest 2003; 124 (Suppl): 91S 42 Warren BL, et al. JAMA 2001; 286: Abraham E, et al. JAMA 2003; 290: Joyce DE, et al. Crit Care Med 2002; 30: S288-S Esmon CT. Chest 2003; 124(Suppl): 26S-32S 46 Levin M, et al. Lancet 2000; 356: Bone RC, et al. N Engl J Med 1987; 317: Annane D, et al. JAMA 2002; 288: CHEST

8 49 Landry DW, et al. Circulation 1997; 95: Patel BM, et al. Anesthesiology 2002; 96: Malay MB, et al. J Trauma 1999; 47: Sun Q, et al. Am J Respir Crit Care Med 2003; 168: Rivers E, et al. N Engl J Med 2001; 345: Stoutenbeek CP, et al. Intensive Care Med 1984; 10: de Jonge E, et al. Lancet 2003; 362: Vincent JL. Lancet 2003; 362: The ARDS Network, et al. N Engl J Med 2000; 342: Eichacker PQ, et al. Am J Respir Crit Care Med 2002; 166: Kress JP, et al. N Engl J Med 2000; 342: Pronovost PJ, et al. JAMA 2002; 288: Higgins TL, et al. Crit Care Med 2003; 31: Blunt MC, et al. Lancet 2000; 356: Pronovost PJ, et al. JAMA 1999; 281: Vincent JL. Lancet 2000; 356: CHEST, 2004; 126: CHEST No.15 The health department of a large city received several reports of cases of a flu-like illness that often had a fulminant course leading to respiratory failure, shock, and death. A previously healthy 29-year-old office worker now presents with 3 days of fever, nonproductive cough, and myalgia. He denies risk factors for HIV infection. Physical examination is remarkable only for a pulse of 100/min, blood pressure 80/50 mm Hg, and reduced breath sounds at the lung bases. A chest radiograph shows clear lungs, mediastinal widening, and bilateral pleural effusions. Which test is mostly likely to confirm the correct diagnosis? A. Sputum induction for Gram's stain and culture. B. Sputum induction for acid-fast smear and culture. C. Nasal swabs for viral culture. D. Blood culture. E. Pleural biopsy. 136 CHEST 116

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