EGDTプロトコール

出典
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1: Early goal-directed therapy in the treatment of severe sepsis and septic shock.
著者: Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group.
雑誌名: N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.
Abstract/Text: BACKGROUND: Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.
METHODS: We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.
RESULTS: Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P < or = 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001).
CONCLUSIONS: Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.
N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.

感染巣の診断のために必要な評価

SOFA（sequential organ failure assessment）スコア

重要臓器の障害度を数値化した指数である。呼吸器、凝固系、肝機能、心血管系、中枢神経系、腎機能の6項目について、臓器障害の程度を0から4点の5段階で評価する。スコアが5を超えると死亡率は20％といわれている。
出典
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1: Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine.
著者: Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S.
雑誌名: Crit Care Med. 1998 Nov;26(11):1793-800. doi: 10.1097/00003246-199811000-00016.
Abstract/Text: OBJECTIVE: To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients.
DESIGN: Prospective, multicenter study.
SETTING: Forty intensive care units (ICUs) in 16 countries.
PATIENTS: Patients admitted to the ICU in May 1995 (n = 1,449), excluding patients who underwent uncomplicated elective surgery with an ICU length of stay <48 hrs.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The main outcome measures included incidence of dysfunction/failure of different organs and the relationship of this dysfunction with outcome. In this cohort of patients, the median length of ICU stay was 5 days, and the ICU mortality rate was 22%. Multiple organ dysfunction and high SOFA scores for any individual organ were associated with increased mortality. The presence of infection on admission (28.7% of patients) was associated with higher SOFA scores for each organ. The evaluation of a subgroup of 544 patients who stayed in the ICU for at least 1 wk showed that survivors and nonsurvivors followed a different course. This subgroup had greater respiratory, cardiovascular, and neurologic scores than the other patients. In this subgroup, the total SOFA score increased in 44% of the nonsurvivors but in only 20% of the survivors (p < .001). Conversely, the total SOFA score decreased in 33% of the survivors compared with 21% of the nonsurvivors (p < .001).
CONCLUSIONS: The SOFA score is a simple, but effective method to describe organ dysfunction/failure in critically ill patients. Regular, repeated scoring enables patient condition and disease development to be monitored and better understood. The SOFA score may enable comparison between patients that would benefit clinical trials.
Crit Care Med. 1998 Nov;26(11):1793-800. doi: 10.1097/00003246-1998110...

APACHE IIスコア

APACHE IIスコア＝A＋B＋Cの合計
A：Total Acute Physiology Score（APS）：12の生理機能パラメーターの合計点数（表a）
＃：通常はFiO2＝1.0の場合のPaCO2とPaO2を求めて右の計算式で求める：A－aDO2＝713－PaCO2－PaO2
FiO2＜1.0の場合は右の簡略式を用いると便利である：A－aDO2＝{FiO2×713－（PaCO2/0.8）}－PaO2
＊：Glasgow Coma scale＝a（開眼）＋b（発語）＋c（運動機能）
挿管および処置による鎮静によってスコアの判定が難しい場合は、その要因がない場合を想定しスコアを判定する。
B：年齢ポイント（表b）
C：慢性併存病態ポイント
重篤な臓器（肝、循環器、呼吸器、腎）不全あるいは免疫能低下がある場合
1）非手術あるいは緊急手術患者：5ポイント
2）予定手術患者：2ポイント
出典
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1: APACHE II: a severity of disease classification system.
著者: Knaus WA, Draper EA, Wagner DP, Zimmerman JE.
雑誌名: Crit Care Med. 1985 Oct;13(10):818-29.
Abstract/Text: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
Crit Care Med. 1985 Oct;13(10):818-29.

NEWS（National Early Warning Score）スコア

出典
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1: The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death.
著者: Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI.
雑誌名: Resuscitation. 2013 Apr;84(4):465-70. doi: 10.1016/j.resuscitation.2012.12.016. Epub 2013 Jan 4.
Abstract/Text: INTRODUCTION: Early warning scores (EWS) are recommended as part of the early recognition and response to patient deterioration. The Royal College of Physicians recommends the use of a National Early Warning Score (NEWS) for the routine clinical assessment of all adult patients.
METHODS: We tested the ability of NEWS to discriminate patients at risk of cardiac arrest, unanticipated intensive care unit (ICU) admission or death within 24h of a NEWS value and compared its performance to that of 33 other EWSs currently in use, using the area under the receiver-operating characteristic (AUROC) curve and a large vital signs database (n=198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions.
RESULTS: The AUROCs (95% CI) for NEWS for cardiac arrest, unanticipated ICU admission, death, and any of the outcomes, all within 24h, were 0.722 (0.685-0.759), 0.857 (0.847-0.868), 0.894 (0.887-0.902), and 0.873 (0.866-0.879), respectively. Similarly, the ranges of AUROCs (95% CI) for the other 33 EWSs were 0.611 (0.568-0.654) to 0.710 (0.675-0.745) (cardiac arrest); 0.570 (0.553-0.568) to 0.827 (0.814-0.840) (unanticipated ICU admission); 0.813 (0.802-0.824) to 0.858 (0.849-0.867) (death); and 0.736 (0.727-0.745) to 0.834 (0.826-0.842) (any outcome).
CONCLUSIONS: NEWS has a greater ability to discriminate patients at risk of the combined outcome of cardiac arrest, unanticipated ICU admission or death within 24h of a NEWS value than 33 other EWSs.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Resuscitation. 2013 Apr;84(4):465-70. doi: 10.1016/j.resuscitation.201...

EGDTプロトコール

出典
imgimg
1: Early goal-directed therapy in the treatment of severe sepsis and septic shock.
著者: Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group.
雑誌名: N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.
Abstract/Text: BACKGROUND: Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.
METHODS: We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.
RESULTS: Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P < or = 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001).
CONCLUSIONS: Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.
N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307.

感染巣の診断のために必要な評価