2016年 · 第55卷第06期

Severe infection is the main cause of death in critically ill patients, and correct antibiotic treatment strategy is crucial to improve the clinical prognosis of severe infection. Clinical practice guidelines on severe infections suggest that in order to effectively reduce the mortality rate of patients with severe infections, broad-spectrum antibiotics should be combined within 3 or even 1 h of onset to cover all possible pathogenic microorganisms. At present, this strategy has become the "golden rule" for clinicians to diagnose and treat severe infections. In fact, the recommendations of international guidelines are not completely correct, and some clinicians' too simple interpretation and thinking have led to the current abuse of broad-spectrum antibiotics and the prevalence of drug-resistant bacteria. Professor Du Bin was invited to write a monograph "Empirical antibiotic treatment of severe infection: getting out of the misunderstanding", analyzing the misunderstandings in the current empirical antibiotic treatment of severe infection, and putting forward corresponding solutions.

severe sepsis is the leading cause of death in critically ill patients^[1,2,3,4,5]。 In the past 20 years, the incidence of severe infection has increased year by year. The number of severe infection patients in western developed countries needs to be hospitalized for treatment is 148 cases/100,000 people every year^[1], even more than 240 cases/100,000 people in the United States^[2,3]。 There is still a lack of epidemiological data of severe infection in China^[4,5]。 Our preliminary two-year epidemiological study of about 130,000 people in Yuetan Street, Beijing, showed that the annual incidence of severe infection was about 117 cases per 100,000 people. According to this estimate, about 1.2 million people in China suffer from severe infections every year, and nearly 400,000 of them die.

Pathogenic microorganisms invade sterile parts of the human body to cause infection, and Sepsis is a clinical syndrome caused by organ dysfunction. With the progress of medical technology, the treatment period of Sepsis patients has been prolonged, and more and more patients need to be treated in ICU. The severity of the disease and the increase of medical expenses make Sepsis always attract the attention of clinical diagnosis and treatment. For more than ten years, with the deepening of the research on organ and cell dysfunction and the understanding of pathophysiological mechanism of Sepsis, the need for updating the definition and diagnosis of Sepsis is increasingly urgent.

Organ function damage caused by infection is one of the important causes of death for critically ill patients. Rapid and effective anti-infectious treatment is an important means to save patients' lives. Related infectious diagnosis and treatment guidelines and expert consensus have increasingly become the basis for clinicians to formulate treatment plans. Based on, how to formulate more accurate treatment plans on the basis of guidelines and consensus in clinical practice is also the key to determining the success or failure of treatment.

Severe infection and septic shock are clinical problems faced by ICU doctors. Despite active treatment, the mortality rate is still as high as 20% ~30%^[1]。 Actively searching for infection foci, adequate drainage, active fluid resuscitation and lactic acid monitoring are all important anti-infective treatment measures. Selecting appropriate antibiotics at the right time is an important strategy for clinical anti-infective treatment.

De-escalation Therapy is an anti-infective treatment strategy for severe bacterial infections^[1], often referred to in daily work as wide coverage therapy or hammer slam. The change in the name inadvertently reflects the simplification trend of clinical thinking. In fact, several key problems of descending ladder treatment are constantly needed to be faced and considered in the process of anti-infective treatment.

June 2015Crit CareThe cross-controlled study "Neural and pneumatic pressure-supported ventilation under different exogenous positive end-expiratory pressures in patients with chronic obstructive pulmonary disease" (Liu L, Xia F, Yang Y, et al. Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study. Crit Care, 2015, 19: 244). The feasibility of neural-controlled pressure-supported ventilation was confirmed for the first time in patients with chronic obstructive pulmonary disease (COPD) with endogenous positive end-expiratory pressure (PEEP). Compared with traditional pneumatic-controlled pressure-supported ventilation, it can significantly improve human-machine synchronization and reduce respiratory muscle work and trigger work. Neurotropic pressure-supported ventilation can overcome the adverse effects triggered by endogenous PEEP in patients with COPD.

diabetic kidney disease or diabetic nephropathy refers to chronic kidney disease (CKD) caused by diabetes and is the main cause of end-stage renal disease (ESRD). In developed countries, about 50% of ESRD is caused by diabetic nephropathy, and about 20% in China. The onset of diabetic nephropathy is insidious, with a slight increase in urinary albumin excretion rate (microalbuminuria) in the early stage, which can be reversed by active intervention in the early stage. Once in the phase of massive proteinuria, the rate of progression to ESRD is approximately 14 times that of other kidney lesions; However, the gradual decline of renal function is significantly related to the increase of cardiovascular risk in diabetic patients. Therefore, early diagnosis, prevention and delaying the occurrence and development of diabetic nephropathy is of great significance to improve the survival rate and quality of life of diabetic patients.

The professional development of modern medicine is driven by two forces. One force is science, which divides medicine into different parts based on reductionism, forming various branches and sub-branches; Another force is culture. Modern societies, with industrial models and commercial trade at their core, are accustomed to dividing the continuity of human life into many fragments and many separate problems, each dealt with by a different professional department or expert^[1]。 It is believed that this can significantly improve the efficiency of problem handling. In fact, in many cases, the result is not so. At least in dealing with human body problems, the development mode of modern medicine, which is mainly divided, has encountered a bottleneck. More and more medical workers and researchers realize that medical knowledge is being fragmented, diagnosis and treatment practice is moving towards mechanization, and medical activities are gradually moving away from the core value of people-oriented. Therefore, the development of modern medicine also needs transformation.

mesenchymal stem cells (MSC) are a kind of pluripotent stem cells that can differentiate into various mesenchymas. They can be derived from a variety of tissues and have regenerative and immune regulatory functions, so they are widely used in clinical practice. However, the effect of MSC-based therapy largely depends on its ability to migrate and homing specifically to the lesion site. Because the therapeutic effect of MSC depends on its production of paracrine or paracrine factors and enhances the proliferation ability of endogenous stem cells, in order to fully exert its paracrine effect, migration of MSC to injured organs or tissues becomes necessary. Therefore, a deep understanding of the mechanism of MSC specific homing to the injury site can better improve its clinical transplantation efficiency and enhance the therapeutic effect.

early goal directed therapy (EGDT) has been developed since 2001 by Rivers et al.^[1]Since it was proposed, it has been used for early resuscitation of severe sepsis and septic shock, and has attracted great attention from the critical care medicine community because it can significantly improve the rescue success rate and prognosis of critically ill patients. In recent years, with the wide application of EGDT in clinical practice and the publication of many high-quality studies related to it, it has been found that EGDT has no significant advantage in reducing case mortality. This may be related to the critical and complicated condition of patients with severe sepsis and septic shock, or may be related to the progress of critical care medicine. The current research status of EGDT is summarized as follows, so as to understand EGDT more comprehensively and make it better applied in clinical practice.

acute pancreatitis (AP) is a clinically critical disease in which pancreatic enzymes in the pancreas are prematurely activated, the pancreas digests itself, and rapidly progresses to systemic inflammatory response syndrome (SIRS), resulting in extensive pancreatic inflammation, necrosis and multiple organ failure. Although mild/mild acute pancreatitis (MAP) can be relieved in 3-5 days, 30.0%-41.7% and 11.0%-39.1% of patients rapidly progressed to moderately severe acute pancreatitis (MSAP) and severe/severe acute pancreatitis (SAP) in the early stage, respectively. The mortality rate of SAP can be as high as 20%-50%. Therefore, the prevention and treatment of SAP has been concerned by physicians in gastroenterology and related disciplines.

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The patient was a 50-year-old male. He was admitted to the Department of Nephrology of our hospital on October 15, 2014 due to pretibial edema for 5 months and left hydronephrosis for 2 months. In May 2014, the patient developed bilateral pretibial depressible edema without obvious trigger, mild in the morning and heavy in the evening, accompanied by fatigue, reduced activity tolerance, muscle soreness in both lower limbs, no eyelid and facial edema, no macroscopic hematuria, foamy urine, headache, sore throat, fever, rash, joint pain and other discomfort. Local clinic urine routine: specific gravity 1.010, negative urine protein, negative occult blood; Serum creatinine (SCr) 104 μ mol/L. In August 2014, I developed discomfort such as loss of appetite and nausea, and the SCr was 150 μ mol/L after re-examination. The local clinic gave me ready-for-use traditional Chinese medicine treatment to strengthen the stomach and digest food. Visited the outpatient clinic of our hospital in October 2014, blood pressure 110/85 mmHg (1 mmHg =0.133 kPa); Blood test routine: WBC 5.05×10⁹/L, percentage neutrophils 58.5%, eosinophils 0.03×10⁹/L, Hb 102 g/L, PLT 244×10⁹/L; Urinary routine: specific gravity 1.006, urine protein negative, occult blood 5.3 red blood cells/μ L, WBC 2.6 cells/μ L; 24 h urine protein 0.627 g; SCr 345.9 μ mol/L. Ultrasound revealed suspected subcapsular effusion in the left kidney, ranging from 0.6 cm ×4.4 cm; The kidney collection system was separated, approximately 2.3 cm wide on the left and 2.6 cm wide on the right. CT scan of thorax, abdomen and pelvis (Figure 1): retroperitoneal soft tissue density shadow, surrounding the abdominal aorta, inferior vena cava and bilateral common iliac arteries and veins, considering the possibility of retroperitoneal fibrosis (RPF), bilateral pelvic calyx dilation and hydrops. Radionuclide renal blood flow diagram: the left renal blood perfusion was significantly reduced, and the filtration function was seriously impaired; Blood perfusion in the right kidney was slightly reduced, and filtration function was moderately impaired. GFR was 37.5 ml/min, right kidney GFR was 22.3 ml/min and left kidney GFR was 15.2 ml/min.