The new crown of critical medicine
China News Weekly reporter / Li Mingzi
Issued in the 943th issue of China News Weekly, 2020.4.13
On April 6, several national medical teams from Beijing, Shanghai, Jilin, Shaanxi, and Shandong withdrew from Wuhan one after another. The anti-epidemic war that had been fought for more than three months was coming to an end. The intensive care unit (ICU) wards of the last 10 designated hospitals in Wuhan became the last bastion for the treatment of severe patients with new coronavirus pneumonia. Here, the earliest group of experts from the National Health and Health Commission arrived in Wuhan.
"We probably want to keep to the end." Jiang Li said hastily. She had just pulled away from a conference and had to attend the death case discussion after the interview, which was called "the most rigorous academic discussion" by the doctors of intensive care medicine (ICU). Everyone brought the latest death cases to the meeting for retrospective analysis, whether it is because of the development of the disease itself, or whether the treatment is not in place, which eventually leads to the end of life. The doctor in charge should "pass the hall" to accept all inquiries from experts.
Data graph: Medical staff are preparing futons for critically ill patients with pneumonia infected by the new coronavirus. China News Agency reporter Zhou Qunfeng photo
The new crown virus is very cunning. In general, regardless of viral pneumonia or bacterial pneumonia, when the patient has acute respiratory distress syndrome (ARDS), the concentration of carbon dioxide in the blood is low, and this time the intubated patient has carbon dioxide retention, resulting in hypercapnia, And it is difficult to correct by adjusting the ventilator. Severe patients also have elevated creatinine, and some severe patients also have elevated troponin, which is an indicator of heart damage. "Viruses have been found in organs other than the lung, but the damage to the organs outside the lung is the direct attack of the virus. , Or caused by lack of oxygen, all need to be further explored. "Jiang Li said.
For Jiang Li from Beijing and Guan Xiang from the south to the south, the winter in Wuhan is humid and cold. Every morning in the shift is extremely cold, waiting for them is the number of deaths the previous night and a new day. The important task of treatment. As the epidemic comes to an end, ICU treatment has become more detailed. For example, thrombosis problems that were neglected in the early stage will now be detected and prevented as soon as possible. The reduction in the number of critically ill patients does not reduce the pressure of treatment. Under the pressure of reducing the mortality, ICU doctors are facing higher professional requirements.
At the time of the end of Wuhan Anti-epidemic, two members of the expert team of the National Health and Health Commission-Jiang Li, director of the Department of Critical Medicine of the Xuanwu Hospital of Capital Medical University, and the chairman of the Critical Medicine Branch of the Chinese Medical Association, Department of Critical Medicine of the First Affiliated Hospital of Zhongshan University Director Guan Xiangdong accepted an exclusive interview with China News Weekly.
Intubation
China News Weekly: After three months of fighting the new coronary pneumonia, what treatments have the intensive care experts used to reduce the mortality rate?
Jiang Li: ICU has always been very important. It was precisely in the early stage of the epidemic. Because ICU medical and nursing forces failed to keep up with the surge in patients ’treatment needs, hospital infrastructure, equipment, and personnel did not keep up initially. At that time, critically ill patients did not get timely The treatment and care soon went away. With the availability of personnel, equipment, and materials, the medical run-off has decreased and the case fatality rate has gradually decreased.
The most critical treatment concept is that when a disease does not have so-called special drugs, and the body has certain self-limitation to the virus, that is, when the virus is slowly contained by the body's own immune system, we treat severe and critically ill patients. The most common treatments are organ support, relying on respiratory support, circulatory support, renal replacement therapy, etc., as well as the recently popular extracorporeal membrane oxygenation (ECMO), and prone ventilation during mechanical ventilation, these are not drugs.
The critically ill patients who enter the ICU, like the people walking on the edge of the cliff, may fall at any time. All we have to do is support their lives and hold them. If there is lung failure, support the lungs; if the kidneys are not working, support the kidneys; if the circulatory system fails, support the circulatory system, help the patient protect and support organ functions, so that he can carry it down when he fights the virus , I can win in the end, this is the role played by ICU doctors.
It is important to intubate early. The difference between New Coronary Pneumonia and previous pneumonia is that although some patients have low blood oxygen, it is sufficient to look at the fingertip blood oxygen saturation number, but the heart rate is not fast, the breathing rate is not fast, the breathing is not difficult, and there is no acute respiratory distress syndrome ) 'S typical performance.
It now appears that for such patients, if the ARDS treatment standard is used, high-flow oxygen therapy is used first, then non-invasive ventilation is not used, and invasive ventilation is not effective, that is, intubation. This is problematic. In the process of high-flow oxygen inhalation and non-invasive ventilator support, the patient inhales very vigorously, and excessive spontaneous breathing will damage the alveoli. During high-flow oxygen inhalation and non-invasive ventilation, there is not much intuitive data on the machine that prompts the risk of this injury, and it is not easy to find these lung injuries.
I came to the critical ward on the 6th floor of Jinyintan Hospital on January 26. At that time, the patients sent to the ICU had been tortured by the new crown for a while. When I entered the ICU, they were basically near a crash. Everyone has hesitated about tracheal intubation, and I am no exception. There was a very positive and optimistic patient in the early days. He had a strong desire to survive, asked to drink nutrient solution, and still chat with me. The easiest way to judge the degree of respiratory failure clinically is to see if he can say a complete sentence. Although he also had hypoxia at the time, other data did not look so bad, and he did not intubate. In similar cases, patients who did not intubate later, some were better, some left, but looking back now, I will not let them experience noninvasive, and will directly intubate. This also reflects our continuous understanding of new coronary pneumonia.
Many doctors are studying this epidemic. I also learned lessons from successful and failed experiences and gradually recognized the disease. By mid-February, we made it clear that to "increase the intubation rate", everyone had a relatively consistent idea about whether to intubate.
Guan Xiangdong: ICU doctors tend to "can insert all but insert early," doctors in different specialties have different management experience, doctors in respiratory department have rich experience in the management of chronic obstructive pulmonary disease, and more noninvasive treatments are used. In the early days, there were some differences in the concept of treatment.
In early February, the members of the expert group of the National Health and Health Commission wrote the "Recommendations for the Management of Severe New Coronavirus Pneumonia", and proposed to closely observe the effect of patients using high-flow oxygen inhalation and noninvasive ventilation, and closely monitor the patient's general condition and life. Changes in signs and respiratory status, especially oxygenation index, should be changed to invasive mechanical ventilation within 2 to 6 hours if necessary. For patients with oxygenation index ≤150 mmHg, invasive mechanical ventilation should be implemented as early as possible, and follow the lung protection ventilation strategy, and perform prone position, lung recruitment and other lung protective treatment.
These suggestions were later included in the "New Coronavirus Infection Pneumonia Diagnosis and Treatment Program (Trial Version 7)". At the same time, each member of the expert group must run at least four or five hospitals in Wuhan. During the inspection and guidance, the concept of "early intubation and multiple intubation" will also be constantly mentioned. To protect the safety of doctors, it is also recruiting and promoting "positive "Head guard" to prevent the doctor from inhaling the spray when intubating. The intubation rate at that time was disappointing, and the death situation was also regrettable. In the discussion of the death cases in the later period, there were 41 people who died in a hospital after February, and 30 of them did not undergo invasive mechanical ventilation. In layman's terms, these patients were suffocated.
China News Weekly: How were the recommended medications selected in the "Diagnosis and Treatment Program (Trial Version 7)"? How important is it in critical care?
Jiang Li: In this special period, clinical trials of drugs are obviously inadequate. Many of the recommended drugs can only be inferred by the mechanism of action of the drugs, which may have a curative effect on new coronary pneumonia. For example, Kelizhi is a drug for the treatment of AIDS. It is speculated that it may play a role in some links or certain sites. There are also chloroquine and tocilizumab that are currently more discussed.
From the first edition of the "Diagnosis and Treatment Program" to the latest seventh edition, which is only more than two months, it is difficult to judge objectively and fully whether a drug is effective. This requires a very rigorous research team to do research. At present, most drug recommendations are based on clinical observation of a certain number of patients. Such evidence is insufficient.
Different doctors have very different attitudes towards medication. When I'm not sure whether a medicine is effective, I would rather not use it. At least for me, the patients in the ICU are mainly organ supportive therapy.
It has been suggested that supplementing albumin to improve immunity, etc., is completely wrong. In the new crown treatment, the use of albumin is very common, but this may have a lot to do with who pays for it. Albumin is more expensive, and we are usually more cautious about using it. I don't think albumin can reverse the process of disease development, especially the supplementation of exogenous protein. The fundamental treatment is to curb the endogenous consumption and stop the progression of the disease. Otherwise, it would not be beneficial to simply supplement it.
The so-called "inflammatory storm"
China News Weekly: Some people have suggested that “inflammatory storms exacerbate ARDS in patients and increase the risk of death.” Li Taisheng, director of the Department of Infectious Medicine at Peking Union Medical College Hospital, believes that “if the inflammatory storm is treated in the critical phase, a large amount of hormones are used to suppress the immune system, but it may help Virus ". Combined with the occurrence of sequelae such as femoral head necrosis after a large amount of hormones during SARS, will this happen in new coronary pneumonia? What should I do?
Jiang Li: Analyzed from the mechanism, the pathogen will inflame after invading the human body. If there is a secondary bacterial infection in the later stage of treatment, it may also cause inflammation, and the inflammatory storm is that the inflammation is too strong. According to my observation, I don't think how severe the inflammatory storm is in patients with new coronary pneumonia. At least most of the patients with new coronary pneumonia don't have the problem of very serious inflammatory storm in the early stage, which is much lighter than the inflammatory storm caused by general bacterial pneumonia.
If there is an inflammatory storm, you will also try a variety of treatments, including a small amount of hormones, tocilizumab, and other so-called methods that may be effective for cytokine storms, such as artificial liver, but I do n’t think these are useful , Some are even harmful, such as hormones.
For example, the patient's physical condition is like a domino. Before the first card falls, we support the organ. If this is held up, it will not continue to fall back. The so-called inflammation storm is just a pile of cards. The first few. The inflammatory system of the human body is very complicated. How it affects each other is not fully understood. The inflammatory factors we can see are nothing more than the ones shown on the test sheet. Factors are suppressed, but what to do with other inflammatory factors that have not been paid attention to, can not be ignored because they do not know.
Inflammation storm is not a new concept. After being proposed in the 1980s, researchers conducted a series of clinical trials to try to block the development of individual cytokines to interrupt systemic inflammation, but all failed because the human inflammatory system is too complicated. You do n’t fully understand it.
I am treating a disease. The inflammatory storm is only a manifestation of the disease's development to a certain degree. The treatment will eventually return to the disease itself. At present, there is no special drug for the treatment of the new crown. Inflammation storm is not my treatment priority. Even if I focus on inflammation storm, the test index under light pressure is useless. The focus is still on organ support treatment.
It is too early to say the sequelae of using hormones.
Guan Xiangdong: We do not recommend the use of hormones, and the attitude of critical care medicine is very firm. At least in the ICU, the use of hormones is not recommended. When it is particularly needed, such as the rapid progress of the lungs, which is manifested by high fever, the hormones can be used for a short time and in small amounts.
China News Weekly: Statistics from mid to late February show that even under medical intervention, 15% to 20% of patients with new coronary pneumonia will develop into critically ill patients, and 25% to 30% of critically ill patients will become dangerous Severe. In this pneumonia epidemic, many hospitals faced a shortage of serious beds and equipment, which increased the proportion of patients with worsening conditions. Looking back on the whole Wuhan epidemic, with the gradual introduction of medical assistance and the doctors' increasingly clear understanding of the disease, has the ratio of these two transformations changed?
Jiang Li: Has anyone seriously done a conversion rate? Now, based on feelings and impressions, there are a lot of figures, and there are too few objective data. Now it is too early to say that mild to severe, severe to critical, and fatality rate. The statistical caliber and statistical methods are different, and the numerator and denominator are different. It is difficult to generalize. Hopefully after the epidemic is over. We can make more precise and accurate statistics of the patient's data, and we can also compare the changes of relevant figures in different stages.
The new crown itself determines that a certain percentage of patients will become severely ill, which is determined by various factors such as the patient's genes and susceptibility, and cannot be changed. In the early days, due to the medical run-off, a large number of patients were delayed in the treatment time, and the number of patients who turned serious and died was relatively large. There are fewer people who change their weight later, because there are support staff and equipment, etc., but can the number solve all the problems? For example, there are 100 people to support, from the Department of Stomatology, Plastic Surgery, and Endocrinology. They are also anxious and want to contribute, but they cannot make clinical decisions in the treatment of critically ill patients.
Jinyintan staff is not enough, the doctor in charge of the bed generally works continuously for 12 hours or 24 hours. I heard that some ICUs with sufficient staff are shifted every 4 hours. When they come to work the next day or the next day, the patient's situation is different. In addition, there will be errors in any handover shift. For example, there are 8 things to be accounted for, but only 7 are said. When the next shift is handed over, one more thing is forgotten. Six shifts a day will cause problems in the continuity of treatment.
Treatment of critically ill patients also depends on the medical staff of the Department of Critical Care Medicine. We have also seen some medical teams with a large number of members from various departments such as stomatology, orthopedics, and endocrinology. Their understanding of critical illness is different. In major public health emergencies, the treatment of critically ill patients will always be the key, and the cultivation of talents in critical medicine will be an eternal topic.
Wuhan hospital infrastructure needs to be strengthened
China News Weekly: Li Jianguo, chief expert of the Department of Intensive Medicine of Central South Hospital of Wuhan University and former chairman of the Hubei Provincial Intensive Medicine Branch of the Chinese Medical Association, once pointed out that "the ICU level of different levels of hospitals in Wuhan has a large gap, and the overall level cannot be compared with Guangzhou, Beijing, Compared with Shanghai, Jiangsu and other places, the strength of ICU needs to be improved. " Based on the situation reflected in the epidemic, in what ways can Wuhan ICU further improve?
Guan Xiangdong: I do n’t know much about the “encounter war” in early January. Hubei has always been a province with a relatively good level of economic and social development and health development in our country. The early conditions of this epidemic do not reflect the medical level of Hubei. For critical medicine, such as Wuhan Union Medical College and ICU of Central South Hospital, the industry is relatively well-known Relatively strong.
The sudden increase in the number of early patients, inadequate treatment, management, and inadequate infrastructure, and some patients who have not been received by units with good medical standards, will lead to deviations in the effectiveness of treatment. However, in the early days, we also saw that some hospitals that are not too high-level have followed the "intubation, should be inserted early" specification from the beginning. For example, ICU in Caidian District People's Hospital of Wuhan City, I went on February 3 During the inspection, the patient has been fully intubated and prone, and the final treatment effect is also very good. But there were not many such ICUs at that time. To a certain extent, there was a certain gap in the understanding and standardization of treatment among various families.
The hospital's basic construction needs to be strengthened. From the early stage of the onset to the later treatment, including Jinyintan Hospital, even the oxygen supply cannot be met. Once all beds are in high-flow oxygen intake, the oxygen pressure cannot keep up with the needs of the ventilator. pressure. Later, Jinyintan built a new oxygen center to solve this problem. The situation of other hospitals can be imagined.
The first batch of ICU doctors from the Guangdong team went to support a top three hospital in Wuhan in the New Year's Eve. The ICU has no isolation conditions. Almost every bed in the general ward is open with a high flow of oxygen. But the oxygen pressure was not enough and the ventilator was not working. The doctor told me that he wanted to intubate long ago, but it was also in vain that the ventilator could not keep up after intubation, and the doctor was very weak. .
China News Weekly: The Department of Critical Care Medicine is the only second-level clinical medicine discipline in China that does not have resident training. Is there any national plan for strengthening resident training for ICU?
Guan Xiangdong: We are calling for standardized training for ICU residents.
The cultivation of young doctors has to undergo 3 years of standardized training for residents and 3 years of standardized training for specialists. Since the establishment of the ICU in China in the 1980s, for a long period of time, ICU did not have a systematic training recognized at the national level. Only the training organized by the Chinese Medical Association Critical Medicine Branch, the Chinese Medical Doctors Association Critical Medicine Branch and other academic institutions or medical units Or study class.
The state-approved ICU training began in June 2018, and training bases were established in more than 70 hospitals across the country. The first batch of training doctors will come out in the summer of 2021. But so far, due to various reasons, the Department of Critical Care Medicine has not lived as a clinical secondary discipline. Doctors cannot live in training without live training. Newly recruited young ICU doctors have to live in non-ICU specialties first. How can they Meet the professional foundation and operating specifications required by ICU? This is not conducive to individuals, but also to professional development. This is the case in Wuhan. Facing the huge clinical demand, the strength of young doctors in intensive care needs to be further standardized and improved.
Millions of people enter the ICU every year in the United States, and a lot of evidence shows that their survival status is highly dependent on the professional status of the ICU. There are 1.4 billion people in China, and at least 10 million critically ill patients want to enter the ICU every year. This part of the patients is the most expensive and the most serious in the hospital. There is a threat to life at any time. If the doctors cannot be professional, these patients cannot get Professional care and management. The epidemic situation was reflected, and the deaths caused by irregular operation due to the failure to implement the training existed.
Some people say that the current ICU doctor's regulatory system in China is based on the United States. This is exactly what I want to say. Lewis Kaplan, the current chairman of the American Academy of Critical Care Medicine, published an article in the Journal of the American Medical Association in 2011 to reflect on American critical illness Resident training, there are 6 ways of anesthesia, emergency, internal / respiratory training alone or joint, neurology and surgery, resulting in different training content and certification standards, he proposed that he should accept a separate critical care training exam standard It should not reappear and only requires a few other professional trainings. No longer can imitate the wrong experience that others have discovered.
From the perspective of the development of critical medicine, comprehensive ICU is integrated from the development of various disciplines in the history of ICU. This is the only way for medical advancement. If we now turn critical medicine back into a specialty ICU, it is in Going back in management is not conducive to discipline development. No matter which department of the patient, in the critical stage, they face multiple organ dysfunction and need life support technology. Intensive medicine is an important barrier to stop patients from dying when the entire system of multiple organs of the human body collapses. Intensive medicine is not only breathing support, but also blood purification technology, hemodynamic management, shock, severe infection, nutrition and so on. For example, the relationship between respiratory critical care, emergency department, surgery, and intensive care should be a relationship between an original ICU and an ICU that has developed into a systematic discipline.
In times of peace, virus warfare and natural disasters are the biggest threats. The next time we face the virus, we must be prepared and have enough talents for critical medicine. After the end of SARS in 2003, the Intensive Medicine Branch was established; after the Wenchuan earthquake in 2008, the State Standardization Committee of the State Council recognized the Department of Intensive Medicine as a secondary discipline. The ICU not only has to deal with major disasters and epidemics, it also needs more and more in daily medical treatment. When I started to work in ICU in 1988, there were only 5 beds in the department, and now there are 150 beds. According to the national standard of beds, doctors and nurses ratio of 1: 0.8 ~ 1: 3, the demand for talents has doubled, and now ICU also has Faced with the current situation of green and yellow, especially the lack of young doctors.
Critical medicine is further developed in response to the needs of society. Talent training is the cornerstone. Whether it is to be a solid clinician in the future, or to train everyone in medicine, the foundation is not good, and there is no way for the upper layers to talk about it. I hope to be able to appeal at different levels and at different stages to develop the resident doctors of critical medicine.
"China News Weekly" No.13, 2020
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