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; e-mail: jlvincen@ulb. ac. be RCT Michand [3] 60% RCT www.chestjournal.org.cn CHEST 2005 2 2 2 109
7% RCT RCT [4] ICU 46 ARDS [5] [8,9] 1999 19 [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
ICU Van den Berghe [32] 1 500 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] www.chestjournal.org.cn CHEST 2005 2 2 2 111
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] ) 3 500 1999 11 [43] 1 700 tifacogin 34% 722 38.9% tifacogin 22.7% 17.1% 29.1% (P = 0.006) [37] ( 3 000 722 2002 5 ) C RCTs RCTs [38] [39] Hebert [35] ( Drotrecogin-a ) [46] 393 [40] Drotrecogin-α 9.9% 7.4% (P = 0.48) 2 300 66.3% 77.3% (P = 0.02) [41] ENHANCE (2003 112
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] 1. 2. ScvO 2 3. ( ScvO 2 ) www.chestjournal.org.cn CHEST 2005 2 2 2 113
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] (4.9 7.3 d P = 0.004) ICU ICU (6.4 9.9 d P = 0.02) ( 9% 27% P = 0.02) ( ) ( ) ( ARDS ( ) ) ICU ARDS Amato [5] PEEP 114
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49 Landry DW, et al. Circulation 1997; 95: 1122-1125 50 Patel BM, et al. Anesthesiology 2002; 96: 576-582 51 Malay MB, et al. J Trauma 1999; 47: 699-703 52 Sun Q, et al. Am J Respir Crit Care Med 2003; 168: 481-486 53 Rivers E, et al. N Engl J Med 2001; 345: 1368-1377 54 Stoutenbeek CP, et al. Intensive Care Med 1984; 10: 185-192 55 de Jonge E, et al. Lancet 2003; 362: 1011-1016 56 Vincent JL. Lancet 2003; 362: 1006-1007 57 The ARDS Network, et al. N Engl J Med 2000; 342: 1301-1308 58 Eichacker PQ, et al. Am J Respir Crit Care Med 2002; 166: 1510-1514 59 Kress JP, et al. N Engl J Med 2000; 342: 1471-1477 60 Pronovost PJ, et al. JAMA 2002; 288: 2151-2162 61 Higgins TL, et al. Crit Care Med 2003; 31: 45-51 62 Blunt MC, et al. Lancet 2000; 356: 735-736 63 Pronovost PJ, et al. JAMA 1999; 281: 1310-1317 64 Vincent JL. Lancet 2000; 356: 695-696 CHEST, 2004; 126: 592-600 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