星期六, 11月 03, 2012

嚴重敗血症患者,接受膠體溶液hydroxyethyl starch 130/0.4,可能導致死亡與急性腎衰竭

From Evernote:

嚴重敗血症患者,接受膠體溶液hydroxyethyl starch 130/0.4,可能導致死亡與急性腎衰竭

Clipped from: http://www.sem.org.tw/tsem/?search_key=all&key_word=&piPerReadPage=10&p=1&menuID=1181570657&doActionValueID=843&doAction=detail&OrderBy=editTimeStamp&OrderMethod=DESC&hnCategoryNo=66&hnTeamNo=6&hnDoAction=self

標  題:醫學新知-101年9月
刊登日期:

2012-09-27

 

嚴重敗血症患者,接受膠體溶液hydroxyethyl starch 130/0.4,可能導致死亡與急性腎衰竭

Hydroxyethyl starch 130/0.4 may cause more deaths and acute kidney injury in patients with severe sepsis

 

 

 

 

 

詹逸凌

長庚醫療財團法人林口長庚紀念醫院 急診醫學部

執行編輯:臺大醫院急診醫學部 黃建華醫師

振興醫療財團法人振興醫院急診重症醫學部 林健盛主任

 

敗血症常引發血管通透性增加,導致血漿滲出與血管內容積下降。敗血性休克的治療,首要之務為補充血管內容積之不足。常用的靜脈輸液主要有晶體輸液(crystalloid solutions,包括生理食鹽水、lacated Ringer's溶液等)以及膠體輸液(colloid solutions,包括白蛋白溶液、hydroxyethyl starch [HES]dextrangelatin等)兩大類。一般認為膠體輸液具有晶體輸液沒有的優點,如輸液擴張血管內容積的效果較好,留存在血管內的時間較久,也較能抵抗血管通透性增加所導致的異常。然而,膠體溶液的價格較高,似乎帶來較多的出血與腎功能惡化,也似乎會影響免疫力。最重要的,膠體溶液似乎未能改善病患預後。新一代的膠體溶液(如HES 130/0.4)似乎較能避免上述的缺點,但HES 130/0.4真的是好的選擇嗎?

 

今年七月和九月,NEJMCritical Care Medicine分別刊出兩篇臨床試驗,比較HES 130/0.4和晶體溶液對嚴重敗血症患者的影響。兩篇研究都沒有顯示HES 130/0.4對這群患者的預後有好處,反而都增加了急性腎衰竭發生的機率;NEJM刊登的6S trial甚至發現跟Ringer's acetate溶液相比,HES 130/0.4增加病患的死亡率。

 

Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012; 367:124-34.

 

又稱Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial,為多國(丹麥、挪威、芬蘭與冰島)多中心(13所大學醫院、13所非大學醫院之一般加護病房)之隨機分配、雙盲試驗,比較嚴重敗血症患者於隨機分配後90日之死亡率與進入末期腎病的比率。治療分別為6% HES 130/0.42Ringer's acetate溶液,每天最多可給到每公斤理想體重給33毫升。結果:接受HES 130/0.42的患者的死亡率為51%,而接受Ringer's acetate的患者為43%risk ratio 1.17 [95% CI 1.01 – 1.36]p = 0.03);隨機分配後90日內,接受renal replacement therapy的比例分別為22%16%risk ratio 1.35 [95% CI 1.01 – 1.80]p = 0.04),而嚴重出血的比例則分別為10%6%risk ratio 1.52 [95% CI 0.94 – 2.48]p = 0.09)。

 

Bayer O, Reinhart K, Kohl M, et al. Effects of fluid resuscitation with synthetic colloids or crystalloids alone on shock reversal, fluid balance, and patient outcomes in patients with severe sepsis: A prospective sequential analysis. Crit Care Med 2012; 40:2543-51.

 

這是個單中心(50床的大學醫院外科加護病房)的研究,比較嚴重敗血症患者休克回復的時間,以及是否發生急性腎衰竭。治療分三組,但非同時進行,而是先第一組(n = 360),給予HES 130/0.4;然後第二組(n = 352),給予4% gelatin;最後是第三組(n = 334),給予晶體溶液。三組的死亡率沒有差異,其休克回復的時間也沒有差異。接受晶體溶液的患者前四天需要較多的靜脈輸液(為HES 130/0.41.4倍),但最後反而是接受膠質溶液的患者接受了較多的靜脈輸液,因為他們在加護病房的住院天數較長,也有較多患者接受輸血治療。接受HES 130/0.4的患者較多發生急性腎衰竭(70.6%;接受晶體溶液患者發生比率為58%p <0.001),需要洗腎的比率則為34.2%27.8%p = 0.085);HES 130/0.4gelatin則是急性腎衰竭的危險因子(HES 130/0.4odds ratio2.55 [95% CI 1.76-3.69]p <0.001)。

 

所以,即使合理的想法也未必能達成確切的療效;各種治療可能帶來好處的同時,也可能產生意想不到的副作用,所以需要臨床試驗來佐證,以及上市後的後續追蹤。


星期四, 11月 01, 2012

MgSO4 (magnesium sulfate) dosing, indications, interactions, adverse effects, and more

From Evernote:

MgSO4 (magnesium sulfate) dosing, indications, interactions, adverse effects, and more

Clipped from: http://reference.medscape.com/drug/mgso4-magnesium-sulfate-344444

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magnesium sulfate (Rx) - MgSO4

Dosing & Uses

AdultPediatric

Dosing Forms & Strengths

Hypomagnesemia

Mild: 1 g IM q6hr for 4 doses
Severe 5 g IV over 3 hours
Daily Maintenance: 30-60 mg/kg IV qDay

Toxemia of Pregnancy

4-5 g (diluted in 250 mL NS/D5W) IV infusion in combination with up to 10 g (10 mL of the undiluted 50% solution) administered IM divided into each buttock OR after initial IV dose, 1-3 g/hr continuous IV infusion

Preterm Labor (Off-label)

Load: 4-6 g IV infusion over 20 minutes
Maintenance: 2-4 g/hr for 12-24 hours as tolerated after contractions cease

Torsades de Pointes

With pulse (ACLS): 1-2 g slow IV (diluted in 50-100 mL D5W) over 5-60 minutes, THEN 0.5-1 g/hr IV infusion
Cardiac Arrest (ACLS): 1-2 g slow IV (diluted in 10 mL D5W) over 5-20 minutes

Other Indications & Uses

ACLS indications include refractory VF/VT, cardiac arrest
Pediatric asthma
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