今日急危重症醫學資訊從36篇文獻中選擇了4篇文獻推送給您。本期關鍵詞：（1）認知；偏見；流行。（2）急性肺損傷；新型果膠基；胸膜封閉；創傷；漏氣。（3）老年營養風險指數；老年；急診手術；不良預後；預測。（4）高呼吸驅動；過度呼吸；預測；新冠肺炎；危重患者；呼吸衰竭；復發。請您批評指正。
（1）偏見，偏見源於傲慢。分享一篇Intensive Care Med 的Editorial——認知偏見的流行。
Intensive Care Med. 2020 Oct 27. doi: 10.1007/s00134-020-06293-y.
A pandemic of cognitive bias
Francesco Landucci 1, Massimo Lamperti 2
The Sars-CoV-2 pandemic is an unprecedented challenge to today’s clinicians: the urgent need to act, the lack of time to collect robust evidence and the collective fear of failure have created ideal conditions for cognitive biases to flourish.
A cognitive bias is a systematic pattern of deviation from an established norm or rationality in judgment [1]. Individuals create their own 「subjective reality」 from their perception of the input. As a result, individuals』 construction of reality may guide their behavior in the world.
Although some cognitive biases can be adaptive since they may lead to more effective actions in a given context, especially when timeliness is more valuable than accuracy, they may also lead to perceptual distortion, inaccurate judgment and illogical decisions as they result from our limited capacity for information processing.
The current pandemic has given us many examples of cognitive biases. Hoarding food and toilet paper despite official assurances of sufficient and stable supply are examples of impaired decision-making: stressed people often believe that taking action, any action, no matter the kind, tends to resolve problems, a phenomenon known as action bias. Such a bias will naturally be amplified in a social context because of the human tendency to follow blindly the actions of the others (the 「bandwagon effect」) out of fear of missing out on something [2]. Unfortunately, queuing in front of a supermarket can only create dangerous vicious circles by spreading infection and panic. The same happened with the use of hydroxychloroquine leading to misleading and harmful consequences [3].
Cognitive biases have been responsible for flawed narratives around key parts of our health system. For example, the notion that coronavirus disease 2019 (COVID-19) mortality rates are strictly dependent on the availability of ventilators has enabled a focus on one objective element of the system. However, this has come at the expense of forgetting that the patients on mechanical ventilation need a comprehensive healthcare support system, with a range of other equipment as well as suitably trained manpower and ventilators are a minimal part in the system. This is an example of what is called substitution bias, where, faced with a complex and difficult question (how to make sure the healthcare system is capable of delivering that support), an easier one (how to increase the supply of ventilators) is substituted.
While intensivists may find it ridiculous to focus only on available ventilators, they have not been immune from cognitive bias. Notably, we lacked suitable definitions of what we were facing and have merely used the labels we had, an example of representativeness bias. As result, we named diffuse COVID-19 pneumonia as acute respiratory distress syndrome (ARDS) and accordingly we used ARDS ventilation protocols [4]. Similarly, once we labelled the problem as a 「viral infection」 we started using antiviral drugs developed for Ebola and HIV despite the absence of evidence to support their use in this context [5, 6].
Scientific research, whose role should be to guide our decisions, has not helped.
The need to share information as quickly as possible has legitimized poor quality literature: EBM has stopped being Evidence-Based Medicine and has given way to Emergency-Based Medicine, with clinicians making decisions on the basis of hypotheses, anecdotes, case reports and ambiguous data.
Without evidence to guide us, and therefore the ability to offer the right quality of care to patients, we have reacted to the pandemic by offering a 「fruit salad」 of different drugs whose efficacy is far to be recognized.
Psychosocial norms teach us that inconsistency is not a desirable trait and consequently people try hard to maintain their intellectual commitments and beliefs even against evidence (known as commitment bias) [7]. It can, therefore, be difficult to admit one’s own irrational and faltering reactions to an emergency. However, it is only by accepting our limitations and understanding our cognitive biases that we can turn the current chaos into an opportunity.
複製連結閱讀全文：https://pubmed.ncbi.nlm.nih.gov/33108517/
（2）急性肺損傷後使用新型果膠基胸膜封閉劑改善預後，基於果膠的生物粘合劑在應用於豬模型時有效地密封了創傷性空氣洩漏，進一步的測試是有效的，因為它們可以為創傷性空氣洩漏提供更好的實質保護治療選擇。
J Trauma Acute Care Surg. 2020 Nov;89(5):915-919. doi: 10.1097/TA.0000000000002754.
Improved outcomes utilizing a novel pectin-based pleural sealant following acute lung injury
John Kuckelman 1, Jeffrey Conner, Yifan Zheng, Aidan Pierce, Ian Jones, Daniel Lammers, Dan Cuadrado, Matthew Eckert, Steven Mentzer
Background: Persistent air leaks after thoracic trauma are associated with significant morbidity. To evaluate a novel pectin sealant in a swine model of traumatic air leaks, we compared a pectin biopolymer with standard surgical and fibrin-based interventions.
Methods: A standardized lung injury was created in male Yorkshire swine. Interventions were randomized to stapled wedge resection (n = 5), topical fibrin glue (n = 5), fibrin patch (n = 5), and a pectin sealant (n = 6). Baseline, preintervention and postintervention tidal volumes (TV) were recorded. Early success was defined as the return to near-normal TV (>95% of baseline). Late success was defined as no detectable air leak in the chest tube after chest closure.
Results: There were no differences in injury severity between groups (mean TV loss, 62 ± 17 mL, p = 0.2). Early success was appreciated in 100% (n = 6) of the pectin interventions which was significantly better than the fibrin sealant (20%, n = 1), fibrin patch (20%, n = 1), and stapled groups (80%, n = 4, p = 0.01). The percent of return to baseline TV after sealant intervention was significantly increased in the pectin (98%) and staple arms (97%) compared with the fibrin sealant (91%) and fibrin patch arms (90%) (p = 0.02; p = 0.03). Late success was also improved with the pectin sealant: no air leak was detected in 83% of the pectin group compared with 40% in the stapled group (p = 0.008)-90% of the fibrin-based interventions resulted in continuous air leaks (p = 0.001).
Conclusion: Pectin-based bioadhesives effectively seal traumatic air leaks upon application in a porcine model. Further testing is warranted as they may provide a superior parenchymal-sparing treatment option for traumatic air leaks.
（3）老年營養風險指數是老年急診手術患者不良預後的有力預測指標，使用Geriatric Nutritional Risk Index (GNRI)測量的營養不良是老年emergency surgery (ES) 患者不良結局的一個強有力的獨立預測因子，可用於術前評估營養狀況和指導患者(和家屬)。
J Trauma Acute Care Surg. 2020 Aug;89(2):397-404. doi: 10.1097/TA.0000000000002741.
The Geriatric Nutritional Risk Index is a powerful predictor of adverse outcome in the elderly emergency surgery patient
Zhenyi Jia 1, Mohamad El Moheb, Ask Nordestgaard, Jae Moo Lee, Karien Meier, Napaporn Kongkaewpaisan, Kelsey Han, Majed W El Hechi, April Mendoza, David King, Peter Fagenholz, Noelle Saillant, Martin Rosenthal, George Velmahos, Haytham M A Kaafarani
Background: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES.
Methods: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed.
Results: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES.
Conclusion: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively.
（4）分享一篇多中心研究，雖然是新冠的，但其結論對病毒性肺炎，ARDS都是有參考價值的。高呼吸驅動和過度呼吸努力預測新冠肺炎病危重患者呼吸衰竭的復發，在新冠肺炎大流行的背景下，在有限的時間和物質資源下，p0.1和δpocc的系列測量可能是一種有價值的床邊臨床工具，用於預測未來24小時內呼吸衰竭的復發，並因此潛在地延遲機械通氣的撤機過程，特別是當p 0.1≥4cm H2O且δpocc < 15cm H2O時。
Am J Respir Crit Care Med. 2020 Oct 15;202(8):1173-1178.doi: 10.1164/rccm.202005-1582LE.
High Respiratory Drive and Excessive Respiratory Efforts Predict Relapse of Respiratory Failure in Critically Ill Patients with COVID-19
Pierre Esnault 1, Michael Cardinale 1, Sami Hraiech 2 3, Philippe Goutorbe 1, Karine Baumstrack 4 5, Eloi Prud'homme 4, Julien Bordes 1 5, Jean-Marie Forel 3 4, Eric Meaudre 1 5, Laurent Papazian 3 4, Christophe Guervilly 3 4
複製連結閱讀全文：
https://www.atsjournals.org/doi/10.1164/rccm.202005-1582LE?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed