2018年6月28日 星期四

1-Hour Bundle for Sepsis: SSC 2018 Update


SSC Hour-1 Bundle

The most important change in the revision of the SSC bundles is that the 3-h and 6-h bundles have been combined into a single “hour-1 bundle” with the explicit intention of beginning resuscitation and management immediately.
  • Measure lactate level. If initial lactate > 2mmol/L, it should be re-measured within 2−4 h to guide resuscitation to normalize lactate. 
  • Obtain blood cultures prior to administration of antibiotics.
  • Administer broad-spectrum antibiotics.
  • Rapidly administration of 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L. This bolus should be completed within 3 hours.
  • Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mmHg.

References

The Surviving Sepsis Campaign Bundle: 2018 Update 
SSC Hour-1 Bundle: Infograph 
Surviving Sepsis Guidelines 2016

敗血症 一小時組套:2018 SSC 更新摘要

1-h bundles 取代過去的 3-h and 6-h bundles
  • 每 2-4 小時 驗 Lactate level 直到正常
  • Blood cultures
  • 廣效性抗生素
  • 3小時內 給完 Crystalloid fluid 30 ml/kg
  • 升壓劑 維持 MAP ≥ 65 mmHg

2018年6月11日 星期一

2018 Stroke Guidelines



2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Stroke. 2018 Mar;49(3):e46-e110



2018 Stroke Guidelines

 

Class I

  • CT within 20 mins ≥50%
  • Door-to-needle time within 60 mins ≥50%
  • EVT, ECG, troponin should not delay IV t-PA
  • Only the assessment of blood glucose must precede the initiation of IV t-PA
  • Receive IV t-PA: BP < 185/110 mmHg
  • IV t-PA for AIS < 3 hr

    IV t-PA for AIS < 3 – 4.5 hr

    • for pts ≤ 80 y/o, without both DM and stroke hx, NIHSS ≤ 25, not taking any OACs, < 1/3 MCA territory by CT or MRI (Class I)
    • for pts > 80 y/o (Class IIa)
    • taking OACs and INR ≤ 1.7 and/or PT < 15 s (Class IIb)
    • with both DM and stroke hx (Class IIb)

      Endovascular Therapy



          2018 Acute Stroke Guidelines 重要更新摘要

          • 對於 3 – 4.5 小時 的中風,年紀大於80歲 (Class IIa),服用抗凝血劑且 INR ≤ 1.7 and/or PT < 15 秒 (Class IIb),同時有糖尿病和中風病史 (Class IIb),IV t-PA 不再是禁忌症。
          • Endovascular Therapy 適應症 延長至 6 – 24小時。中風 6 –16小時 需符合 DAWN or DEFUSE 3 criteria (Class I);中風 6–24 小時 需符合 DAWN criteria (Class IIa)

          DAWN and DEFUSE 3 trial



          DAWN trial

          The first RCT evidence of a group identifiable by clinical and imaging criteria who derive benefit from mechanical thrombectomy after 6 hours


          General Inclusion Criteria

          • Age ≥ 18;
          • failed or contraindicated for IV t-PA
          • NIHSS ≥10
          • Pre-stroke –mRS 0-1
          • Time last seen well to randomization: 6-24 hrs

          Imaging Inclusion criteria

          • < 1/3 MCA territory by CT or MRI
          • ICA and/or MCA-M1 occlusion
          • Clinical Imaging Mismatch
            • group A: age ≥ 80 y/o, NIHSS ≥ 10 and core infarct size < 20 ml
            • group B: age < 80 y/o, NIHSS ≥ 10 and core infarct size < 30 ml
            • group C: age < 80 y/o, NIHSS ≥ 20 and core infarct size < 50 ml 

            Exclusion Criteria

            • similar to IV alteplase exclusions

              End Point Results

               Co-1 end points:
              90-day disability assessed by utility weighted mRS: 5.5 +/- 3.8 vs 3.4 +/- 3.1
              Adjusted Difference 2.0, 95% CI, 1.1-3.0
              Posterior probability of superiority >0.999
              mRS 0-2 at 90 d: 49% vs 13%
              Adjusted Difference 33%, 95% CI, 21%-44%
              posterior probability of superiority >0.999
              Safety end point:
              Mortality at 90 d: 19% vs 18%, P=1.00
              sICH: 6% vs 3%, P=0.50
              Subgroups by time:
              90-day mRS 0-2
              6-12 hrs: 55.1% vs 20.0%,posterior probability of superiority >0.99
              12-24 hrs: 43.1% vs 7.4%, posterior probability of superiority >0.99
              Stopped early at first interim analysis

              DEFUSE 3 trial

              Expands criteria to identify patients who benefit from mechanical thrombectomy
              after 6 hours


              Inclusion Criteria

              • Age 18-90 years
              • NIHSSS ≥ 6
              • Femoral puncture within 6 -16 hours of stroke onset/last known well
              • Premorbid mRS2 ≤2
              • ICA or M1 occlusion by MRA or CTA AND Target Mismatch Profile on CT perfusion or MRI (ischemic core volume < 70 ml, mismatch ratio > 1.8 and mismatch volume > 15 ml)

              Exclusion Criteria

              similar to IV alteplase exclusions, including:
              • BP > 185/110
              • treated with tPA >4.5 hours after time last known well
              • treated with tPA 3-4.5 hours after last known well AND any of the following: age >80, current anticoagulant use, history of diabetes AND prior stroke
              • NIHSS >25
              • ASPECT score < 6
              • Significant mass effect with midline shift
              • acute symptomatic arterial occlusions in more than one vascular territory

              End Point Results

              mRS 0-2 at 90d: 44.6% % vs 16.7%, Relative risk: 2.67; 95% CI 1.60-4.48; P< 0.0001
              Mortality at 90 d: 14% vs 26%; P= 0.053
              sICH: 6.5% vs 4.4%; P= 0.75
              Stopped early at first interim analysis

              Reference

              Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
              Int J Stroke. 2017 Aug;12(6):641-652.
              Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
              N Engl J Med. 2018 Jan 4;378(1):11-21.
              A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
              Int J Stroke. 2017 Oct;12(8):896-905.
              Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
              N Engl J Med. 2018 Feb 22;378(8):708-718.

              Related Articles: 2018 Stroke Guidelines


              2018年5月11日 星期五

              看名畫 學急診

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               連值四天夜班....

              急診 HIS 系統當機!

               119 通報,患者酒醉路倒


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