全身炎症和MODS认识的变化及现状(4)
5. 问题及展望
虽然近年对脓毒症和MODS从认识到治疗均有新的进展，但问题依然不少。脓毒症和MODS的机理迄今仍未完全阐明，参与炎症反应介质种类和其生物学活性、在病因学中的地位等仍在探讨中；CARS等新假说目前还主要停留在理论上，需要实验和临床研究的进一步验证和完善；免疫调理治疗看来是解决脓毒症和MODS的根本途径，但无论赖以指导治疗的免疫学指标还是纠正免疫紊乱的手段目前都还处在起步阶段，而且十分有限；支持治疗的各项改进措施有许多还未获确切的结论，即使已经确切地显示了积极效果的，与脓毒症和MODS本身甚高的死亡率相比，还不能说已经取得实质性的突破；研究方法也需要改进，统一用28天死亡率来作为异质性很大的脓毒症病人评判预后的标准是不恰当的，应该对不同原发病种进行分类研究。还应该对疾病的严重性进行筛选，剔除病情明显偏轻或过重而不可能从治疗中真正受益的病例。在总结抗炎治疗失败的教训时，已故的美国学者Bone曾经指出，不能指望仅靠一、二颗“魔弹”就能够解决象脓毒症和MODS这样复杂的问题。因此，在继续对各种单项治疗进行研究的同时，或许我们需要对综合了各种新治疗方法的病例行评估，才能够更确切地反映当前治疗脓毒症和MODS的完整能力。
, 百拇医药
参考文献
1. Adrie C, Pinsky MR. The inflammatory balance in human sepsis. Intensive Care Med, 2000; 26:364-375.
2. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Incidence, cost, outcome of severe sepsis in the United states. Crit Care Med, 2001(in press).
3. Bernard GR, Vincent JL, Laterre P-F, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New Eng J Med, 2001, 344(10):699-709.
, 百拇医药
4. Bone RC. Sir Isaac Newton,sepsis, SIRS, and CARS. Crit Care Med, 1996; 24(7):1125-1128.
5. Bone RC. Immunologic Dissonance: A Continuing Evolution in Our Understanding of the Systemic Inflammatory Response Syndrome (SIRS) and the Multiple Organ Dysfunction Syndrome (MODS). Ann Intern Med, 1996; 125(8):680-687.
6. Hoffmann JN, Faist E. Removal of Mediators by Continuous Hemofiltration in Septic Patients. World J Surg, 2001; 25:651-659.
, 百拇医药
7. Kox WJ, Volk T, Kox SN, et al. Immunomodulatory therapies in sepsis. Intensive Care Ned, 2000; 26:S124-S128.
8. Reinhart K, Wiegand-Lohnert C, Grimminger F, et al. Asessment of the safety and efficacy of the monoclonal anti-tumor necrosis factor antibody-fragment, MAK 195F, in patients with sepsis and septic shock: a multicenter, randomized, placebo-controlled, dose-ranging study. Crit Care Med, 1996; 24:733-742.
9. Reinhart K, Menges T, Gardlund B, et al. Randomized, Placebo-Controlled Trial of the Anti-tumor Necrosis Factor Antibody Fragment Afelimomab in Hyperinflammatory Response During Severe Sepsis: The RAMSES Study. Crit Care Med. 2001; 29:765-769
, 百拇医药
10. Tsuneyoshi I, Yamada H, Kakihana Y, et al. Hemodynamic and metabolic effects of low-dose vasopressin infusions in vasodilatory septic shock. Crit care Med, 2001; 28:487-493.
11. Volk HD, Reinke P, Krausch D, et al. Monocyte deactivation-rationale for a new therapeutic strategy in sepsis. Intensive Care Med, 1996; 22:S474-S481.
12.Vincent J-L. Hemodynamic support in septic shock. Intensive Care Med, 2001; S80-S92., 百拇医药(林洪远)
虽然近年对脓毒症和MODS从认识到治疗均有新的进展，但问题依然不少。脓毒症和MODS的机理迄今仍未完全阐明，参与炎症反应介质种类和其生物学活性、在病因学中的地位等仍在探讨中；CARS等新假说目前还主要停留在理论上，需要实验和临床研究的进一步验证和完善；免疫调理治疗看来是解决脓毒症和MODS的根本途径，但无论赖以指导治疗的免疫学指标还是纠正免疫紊乱的手段目前都还处在起步阶段，而且十分有限；支持治疗的各项改进措施有许多还未获确切的结论，即使已经确切地显示了积极效果的，与脓毒症和MODS本身甚高的死亡率相比，还不能说已经取得实质性的突破；研究方法也需要改进，统一用28天死亡率来作为异质性很大的脓毒症病人评判预后的标准是不恰当的，应该对不同原发病种进行分类研究。还应该对疾病的严重性进行筛选，剔除病情明显偏轻或过重而不可能从治疗中真正受益的病例。在总结抗炎治疗失败的教训时，已故的美国学者Bone曾经指出，不能指望仅靠一、二颗“魔弹”就能够解决象脓毒症和MODS这样复杂的问题。因此，在继续对各种单项治疗进行研究的同时，或许我们需要对综合了各种新治疗方法的病例行评估，才能够更确切地反映当前治疗脓毒症和MODS的完整能力。
, 百拇医药
参考文献
1. Adrie C, Pinsky MR. The inflammatory balance in human sepsis. Intensive Care Med, 2000; 26:364-375.
2. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Incidence, cost, outcome of severe sepsis in the United states. Crit Care Med, 2001(in press).
3. Bernard GR, Vincent JL, Laterre P-F, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. New Eng J Med, 2001, 344(10):699-709.
, 百拇医药
4. Bone RC. Sir Isaac Newton,sepsis, SIRS, and CARS. Crit Care Med, 1996; 24(7):1125-1128.
5. Bone RC. Immunologic Dissonance: A Continuing Evolution in Our Understanding of the Systemic Inflammatory Response Syndrome (SIRS) and the Multiple Organ Dysfunction Syndrome (MODS). Ann Intern Med, 1996; 125(8):680-687.
6. Hoffmann JN, Faist E. Removal of Mediators by Continuous Hemofiltration in Septic Patients. World J Surg, 2001; 25:651-659.
, 百拇医药
7. Kox WJ, Volk T, Kox SN, et al. Immunomodulatory therapies in sepsis. Intensive Care Ned, 2000; 26:S124-S128.
8. Reinhart K, Wiegand-Lohnert C, Grimminger F, et al. Asessment of the safety and efficacy of the monoclonal anti-tumor necrosis factor antibody-fragment, MAK 195F, in patients with sepsis and septic shock: a multicenter, randomized, placebo-controlled, dose-ranging study. Crit Care Med, 1996; 24:733-742.
9. Reinhart K, Menges T, Gardlund B, et al. Randomized, Placebo-Controlled Trial of the Anti-tumor Necrosis Factor Antibody Fragment Afelimomab in Hyperinflammatory Response During Severe Sepsis: The RAMSES Study. Crit Care Med. 2001; 29:765-769
, 百拇医药
10. Tsuneyoshi I, Yamada H, Kakihana Y, et al. Hemodynamic and metabolic effects of low-dose vasopressin infusions in vasodilatory septic shock. Crit care Med, 2001; 28:487-493.
11. Volk HD, Reinke P, Krausch D, et al. Monocyte deactivation-rationale for a new therapeutic strategy in sepsis. Intensive Care Med, 1996; 22:S474-S481.
12.Vincent J-L. Hemodynamic support in septic shock. Intensive Care Med, 2001; S80-S92., 百拇医药(林洪远)