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題 名 | 重症醫師的神奇子彈--從抗生素,類固醇到活性蛋白質C=Intensivist's Magic Bullets--From Antibiotic, Steroid to Activated Protein C |
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作 者 | 余文良; 陳欽明; 侯清正; 鄭高珍; | 書刊名 | 中華民國重症醫學雜誌 |
卷 期 | 6:3 民93 |
頁 次 | 頁197-210 |
分類號 | 418 |
關鍵詞 | 抗生素; 類固醇; 活性蛋白C; Antimicrobial agent; corticosteroid; Drotrecogin alfa; Protein C; |
語 文 | 中文(Chinese) |
中文摘要 | 長久以來,敗血症一直是加護病房的頭號死因。對它治療也一直沒有什麼進展。直到二十一世紀初才有重大的突破,在支持性的療法有early goal-di-rected therapy和intensive insulin therapy而在特殊療法有抗生素降階療法、類固醇(steroids)及活性蛋白質(activated protein C)。 在加護病房,嚴重敗血症的病患早期使用具感受性的抗生素對病患的預後有顯著的影響。因此許多學者專家都提倡在這類病患應使用"抗生素降階療法"希冀早期控制感染。但國內抗生素感制不甚理想,且多重抗藥性菌株橫行的情況下,若抗生素降階療法未進一步規範,恐怕對降低或預防抗藥性菌株之產生,有負面的效果。 俗稱"美國仙丹"的類固醇,長久以來一直受醫界的關愛,也毀譽參半。在敗血症和急性呼吸窘迫症,早期許多研究使用單次或短期投與大量的類固醇治療法,均不見療效。近來陸續有文獻發表使用較長時間的壓力(stress)劑量類固醇,可改善腎上腺功能不足的敗血性休克病患的死亡率。但合宜的用法及病患的選擇,仍需更多的研究。 活性蛋白質C(rh APC)是FDA第一個認可對於使用在嚴重敗血症病人的治療,可降低死亡率24%之生物製劑。在APACHE II較高(大於或等於25分)、年紀大於50歲、兩個以上之器官衰竭、給藥時已有休克、嚴重散佈性血管內凝血的情形、血中protein C缺乏(<正常值之80%)的病人,療效較好。但昂貴的藥價若無適當的規範,勢必對有限的資源產生排擠效應。 以上的治療都有設計良好的大規模研究佐證。但臨床上仍有許多灰色地帶,有待厘清。 |
英文摘要 | For a long time, severe sepsis is the leading cause of the death of non-coronary intensive care unit. There was some important break-through since the beginning of 21st century, the supporting treatment are early goal-directed therapy and intensive insulin therapy and the specific treatment are "de-escalation" antibiotic therapy, corticosteroids and active protein C. In ICU, early and accurate antibiotics therapy to treat severe sepsis or septic shock has great impact on patients' outcome. "De-escalating" therapy, in contrast to escalating, had been proved to be efficacy to reduce mortality. However, without clear policy and execution ability of antibiotics regulation, Pan-antibiotic resistant strains will emerge in acute care units quickly. Setup clear guideline, strong policy and antibiotic cycling had been proved to be effective in preventing the emergence of multiple drugs resistant strains. Corticosteroids had been prescribed to treat adrenal insufficiency and variety inflammatory disease including septic shock and acute respiratory distress syndrome. It was ineffective to treat septic shock with large single dose steroid. Recently, relative long term "supra-physiology dose" was prove to improve the survival in patients with septic shode, but appropriate timing, dosage and duration require more study. Active protein C (rh APC) is the first FDA approved biologic product which can reduce mortality rate by 20% in severe sepsis patient accompanied with APACHE II score more than 25, age more than 50 and two or more organs failure. The only adverse effect is bleeding. However, without clear and restrictive indication this costly medication may threaten the limited medical resource. Although the efficacy of above mention therapy had been proved by large scale and well design studies, there still have a lot of grey areas required further evaluation. |
本系統中英文摘要資訊取自各篇刊載內容。