摘要
重型/危重型占所有新型冠状病毒肺炎(COVID-19)患者的比例为18%~20%,但病死率高达49.0%~61.5%,占所有COVID-19死亡的100%。高龄(>60岁)和合并基础疾病是造成重型/危重型高病死率的主要原因。这主要与合并基础疾病的老年患者器官功能下降,耐受缺氧、炎症等损害的代偿能力降低,使其病程进展加速有关。因此,必须组建多学科团队,制定个体化方案,准确预判病情进展,及时干预,才能有效地降低病死率。我们具体的做法是施行了“多学科立体管理、个体化综合方案”的救治模式。方案遵守“三个原则”:患者的多学科管理、诊疗方案的个体化和病情监测干预的及时性。救治团队构成以重症医学、感染及呼吸学科为主体,还包括心血管、肾脏、内分泌、消化、神经、营养、康复、精神心理和专科护理,以危及患者生命最主要的疾病为切入点来构建多学科的综合诊疗团队,做到统筹兼顾,重点突出。针对患者具体的病情制定“一人一案”的个体化诊疗方案。在选择抗病毒、抑制炎症反应和免疫调节治疗个体化的同时,重视营养支持、心理干预和综合康复及时、全程的介入,并制定详尽的整体护理计划与特殊患者专人护理相结合的“一人一案”护理方案。针对重型/危重型患者病情进展迅速的特点,多学科团队的医生和护士需要形成立体的管理模式,密切观察、及时评估;以主要疾病所属专科医生为首席专家的多学科团队早、晚隔离病房内集体查房和夜间危重患者重点查房的“24 h全天候查房管理”,以准确预判病情进展,迅速干预,及时阻断疾病的快速恶化。抗疫50 d,团队累计收治77例重型/危重型新冠肺炎病例,其中重型占80.5%(62/77)、危重型19.5%(15/77),平均年龄63.8岁,合并1种以上基础疾病的患者68.8%(53/77),累积治愈65例,平均住院日22 d,病死率2.6%(2/77例),病死率和平均住院日分别显著低于文献报道的49.0%~61.5%和30~40 d。多学科、立体、个体化综合治疗模式可以有效地降低重型/危重型COVID-19的病死率,提高治愈率。
Severe/critical type accounted for 18%to 20%of the overall novel coronavirus disease 2019(COVID-19)cases,while the case fatality rate(CFR)was 49.0%~61.5% among severe/critical cases which accounted for 100% among overall CFR of COVID-19 cases.Advanced age(older than 60)and comorbid conditions with underlying diseases were the main causes of the high CFR in severe/critical cases,which was mainly related to the decline of organ function and the reduced capability to tolerate hypoxic inflammation in aged patients with combined basic diseases.Therefore,accelerated disease progression commonly happened in most elderly patients.In order to increase the cure rate and reduce the CFR of severe/critical cases,it was urgently needed to establish a multidisciplinary team,which will develop individualized treatment plan,predict the disease progression accurately and take measures timely and effectively.Our detailed measures included the multi-disciplinary all-round management and individual comprehensive projects,which should adhere to the following“three principles”:multidisciplinary managements,individualized tailored treatment plan as well as timely monitoring and intervention during the whole hospital stay.Our multidisciplinary treatment team consisted of specialists(experts)mainly from critical care medicine,infectious diseases and respiratory diseases specialties.At the same time,it also had experts specializing in cardiovascular medicine,nephrology,endocrinology,gastroenterology,neurology,nutri?tion,rehabilitation,psychiatry and specialist nursing.The working group would make a multidisciplinary comprehensive diagnosis and the treatment team would treat each patient with overall consideration and keep a wary eye on the most critical diseases which could threaten the life of the patients.An individualized tailored treatment plan was developed based on the specific situation of each patient.Antiviral therapy,suppression of inflammatory response as well as immunoregulatory therapy were applied in an individualized manner.At the same time,nutrition support,psychological intervention,compre?hensive rehabilitation were also timely added,and they occupied the whole-process if necessary.Meanwhile,a detailed overall nursing plan was made for special patient care individually,which is called the“one plan for each patient”nursing program.In view of the characteristics of rapid progression of severe/critical patients’diseases,doctors and nurses of multidisciplinary teams needed to form the All-round(Three-dimensional)Management Model,to observe closely and to assess timely.One specialist in a major disease was designated as the chief expert of a multidisciplinary team,who should take charge of 24 h round-up management including morning and evening isolation ward rounds and night intensive ward rounds for those critical patients for accurately predicting the disease progression,intervening rapidly,and stopping the rapid progression of the disease.In the 50 days of fighting against COVID-19,a total of 77 severe/critical COVID-19 cases were admitted to the wards managed by our team.The average age of the patients was 63.8 years.Among them,68.8%(53/77)had comorbid conditions of more than one underlying disease,80.5%(62/77)were severe,and 19.5%(15/77)were critical.Sixty-five cases were successfully cured with the average length of stay of 22 days in hospital of severe/critical cases.The CFR of severe/critical cases was 2.6%(2/77).The CFR and average length of stay in hospital were significantly lower than those reported in the literature,which were 49.0%to 61.5%and 30~40 days,respectively.In conclusion,our multidisciplinary,all-round and individualized comprehensive treatment model can effectively reduce the CFR of severe/critical COVID-19 and increase the cure rate.
作者
中山大学附属第三医院重型/危重型新冠肺炎推荐方案编写组
毕筱刚
李新华
杨扬
Medical Panel of Severe/Critical COVID-19,The Third Affiliated Hospital of Sun Yat-sen University;BI Xiao-gang;LI Xin-hua;Yang yang(The Third Affiliated Hospital of Sun Yat-sen University,Guangzhou 510630,China;不详)
出处
《中山大学学报（医学科学版）》
CAS
CSCD
北大核心
2020年第3期321-338,共18页
Journal of Sun Yat-Sen University:Medical Sciences
基金
国家重点研发计划项目(2017YFA0104304)
国家自然科学基金(81770648,81972286)
广东省自然科学基金团队项目(2015A030312013)
广州市科技项目(201508020262,201400000001-3)。
关键词
新型冠状病毒
重型新型冠状病毒肺炎
危重型新型冠状病毒肺炎
治疗
方案
2019 novel coronavirus(SARS-CoV-2)
severe novel coronavirus disease 2019(Critical COVID-19)
critical novel coronavirus disease 2019(COVID-19)
management
program
