重症医学专家评论（英文）

Clinicalmanagement，educationandresearch：anewmustformodernintensivecarephysician!TheKeyLeaders'OpiniononCriticalCareMedicine（AMEMedicalReviewSeries003），withDrs.ZhonghengZhang（Jinhuamunicipalcentralhospital），Dr.jordiRello（Valld'HebronUniversityHospital）andMingZhong（ZhongshanHospital）asEditorsofthebook，focusesonmechanicalventilation，sepsisandinfection，carcliacarrestandcardiopulmonaryresuscitation，extracorporealsupport，deliriumandsedation，outcomeofthecriticallyillpatient，andmethodologyofstudydesign.Clinicalmanagement，educationandtrainingaswellasresearchmustbeconsideredforoptimizingtheoveralltreatmentofcriticallyillpatients.Thesetopicsareofparticularrelevancenotonlyinprovidingupdatedinformationbutalsotosupportcliniciansindevelopingeducationalandtrainingstrategiesaswellasbetterinterpretationanddesignofexperimentalandclinicalstudies.TheFirstsectionofthebookisaboutmechanicalventilation.ThemostchallengingpulmonarydiseaseincriticallyillpatientsisAcuteRespiratoryDistressSyndrome（ARDS），anditsdefinitionisrelevanttoimproveindividualizationoftreatmentandfuturestudydesign.MechanicalventilationplaysarelevantroleinpatientsnotonlyadmittedtoIntensiveCareUnit，butalsointhesurgicalandmedicalwardsaswellasout-of-thehospital.Non-invasiverespiratoryassistanceismorecommonlyusedbutrecentdataprovidednewinformationaboutappropr/ateselectionofpatientsandnewavailabletechniques.ProtectivemechanicalventilationhasbeenproposedinitiallytoimproveoutcomeinpatientswithARDS.However，recentlargeobservationalandrandomizedclinicaltrialsshowedthatprotectivemechanicalventilationwithlowtidalvolumeandinspiratorypressuresisalsousefultoreducecomplicationsandimprovesurvivalinpatientswithoutARDS，eventhoseundergoinghighrisksurgery.Thesecondsectionisfocusingonsepsisandinfection.Newdefinitionofsepsishasbeenrecendyproposedandlargelydiscussedinthepresentbook.Mostimportantly，ithasbeendevelopedtheconceptthatpreventionisbetterthancure，whenpossible.Inotherwords，earlymonitoringofsepsismayprovideadequatetreatmentandclinicalmanagementavoidingpossibleseverecomplications，associatedwithpoorsurvival.Further，thediagnosisandmanagementofsepsisandsepticshockincludesthecontroloffever，optimizationofantibiotictreatment，preventionofcatheterrelatedinfections，hospitalacquiredpneumonia，aswellasnewmonitoringtechniqueslikethoseonmicroarculationmonitoring.Theoptimalhemodynamicmanagementwitharationalechoiceforfluidmanagementisalsodiscussedinthispartofthebook.Thethirdsectionisdedicatedtocardiacarrestandcardiopulmonaryresuscitation，focusingonoptimizationofchestcompressions，aswellastargettemperaturemanagement.Deliriumandsedationaswellasoutcomeofcriticallyillpatientsarediscussedinthefourthandfifthsection.Ithasbeenrecentlypointedoutthatthegoalofintensivecareisnotonlytoprovideassistanceintheacutephaseofthediseasebutalsotoresultinanacceptablegoodqualityoflifeafterdischargeofthehospitalandathome，avoidingtheoccurrenceofsocalled"disabledpatient".Thisdiscussionhasalsorelevantethicalconsequences，withdifferencesbetweencountriestocountries.Controlofdelirium，aswellaspainandagitation，whicharespecificallydiscussed，playamajorroletoimproveoutcomeandqualityoflifeofcriticallyillpatients.Thesixthsectionisdedicatedtoextracorporealsupport，whichismorecommonlyusednotonlyincardiacintensivecarebutalsoforprovidingorgansupportinpatientswithrespiratoryorrenalfailure.Finally，theseventhsectionisaboutthemethodologyofstudydesign.Scientificmedicalliteratureisdramaticallygrowingintheselastyears.Thisismarkedlyimportantfromaneducationalpointofviewsinceitisnowrecommendedthatresearchandcorrectinterpretationanddiscussionofpaperspublishedbecomepartoftheeducationandtrainingofthemodernintensivecarephysician.Inconclusion，thisbookprovidesnewupdatedinformationaboutdebateonclinicaJmanagementofcriticallyillpatients，whichisbecominginterdisciplinary，andrequiringspecificknowledgeindifferentareasofmedicineandsurgery.