20岁华裔感冒入院11天死亡 医院回应

张三2012

不是肺炎，是sepsis，败血症，死亡率20-30%。如果是septic shock，死亡率可能高过60-70%。

sepsis不容易诊断，来得快，死得也快，表征和肺炎差不多，短时间变成败血症，变之前没有人能预测。sepsis是美国、加拿大急症、内科头号谈虎色变病变。

http://en.wikipedia.org/wiki/Sepsis

张三2012

Prognosis
The mortality rate of severe sepsis and septic shock is frequently quoted as anywhere from 20% to 50%. In some studies, the mortality rate specifically caused by the septic episode itself is specified and is 14.3-20%.

In recent years, mortality rates seem to have decreased. The National Center for Health Statistics study showed a reduction in hospital mortality rates from 28% to 18% for septicemia over the years; however, more overall deaths occurred due to the increased incidence of sepsis. The study by Angus et al, which likely more accurately reflects the incidence of severe sepsis and septic shock, reported a mortality rate of about 30%.[19]

Given that there is a spectrum of disease from sepsis to severe sepsis to septic shock, mortality varies depending on the degree of illness. The following clinical characteristics are related to the severity of sepsis:

?An abnormal host response to infection
?Site and type of infection
?Timing and type of antimicrobial therapy
?Offending organism
?Development of shock
?Any underlying disease
?Patient’s long-term health condition
?Location of the patient at the time of septic shock
Factors consistently associated with increased mortality in sepsis include advanced age, comorbid conditions, and clinical evidence of organ dysfunction.[19, 24] One study found that in the setting of suspected infection, just meeting SIRS criteria without evidence of organ dysfunction did not predict increased mortality; this emphasizes the importance of identifying organ dysfunction over the presence of SIRS criteria.[24] However, there is evidence to suggest that meeting increasing numbers of SIRS criteria is associated with increased mortality.[26]

In patients with septic shock, several clinical trials have documented a mortality rate of 40-75%. The poor prognostic factors are advanced age, infection with a resistant organism, impaired host immune status, poor prior functional status, and continued need for vasopressors past 24 hours. Development of sequential organ failure, despite adequate supportive measures and antimicrobial therapy, is a harbinger of poor outcome. The mortality rates were 7% with SIRS, 16% with sepsis, 20% with severe sepsis, and 46% with septic shock.[27]

A link between impaired adrenal function and higher septic shock mortality has been suggested. The adrenal gland is enlarged in patients with septic shock compared with controls. A study by Jung et al found that an absence of this enlargement, indicated by total adrenal volume of less than10 cm3, was associated with increased 28-day mortality in patients with septic shock.[28]

In 1995, a multicenter prospective study published by Brun-Buisson (1995) reported a mortality rate of 56% during ICU stays and 59% during hospital stays.[4] Twenty-seven percent of all deaths occurred within 2 days of the onset of severe sepsis, and 77% of all deaths occurred within the first 14 days. The risk factors for early mortality in this study were higher severity of illness score, the presence of 2 or more acute organ failures at the time of sepsis, shock, and a low blood pH (< 7.3).

Studies have shown that appropriate antibiotic administration (ie, antibiotics that are effective against the organism that is ultimately identified) has a significant influence on mortality. For this reason, initiating broad-spectrum coverage until the specific organism is cultured and antibiotic sensitivities are determined is important.

The long-term use of statins appears to have a significant protective effect on sepsis, bacteremia, and pneumonia.[29]

End-organ failure is a major contributor to mortality in sepsis and septic shock. The complications with the greatest adverse effect on survival are ARDS, DIC, and ARF. (See Clinical Presentation.)

The frequency of ARDS in sepsis has been reported from 18-38%, the highest with gram-negative sepsis, ranging from 18-25%. Sepsis and multiorgan failure are the most common cause of death in ARDS patients. Approximately 16% of patients with ARDS died from irreversible respiratory failure. Most patients who showed improvement achieved maximal recovery by 6 months, with the lung function improving to 80-90% of predicted values.

Controversy exists over the use of etomidate as an induction agent for patients with sepsis, with debate centered on its association with adrenal insufficiency. Sprung et al, in the CORTICUS study, reported that patients who received etomidate had a significantly higher mortality rate than those who did not receive etomidate.[30]

However, the authors did not address the fact that those patients receiving etomidate required orotracheal intubation and thus were a sicker subset. There have been no studies to date that have prospectively evaluated the effect of single-dose etomidate on the mortality of septic shock.

Although sepsis mortality is known to be high, its effect on the quality of life of survivors was previously not well characterized. New evidence shows that septic shock in elderly persons leads to significant long-term cognitive and functional disability compared with those hospitalized with nonsepsis conditions. Septic shock is often a major sentinel event that has lasting effects on the patient’s independence, reliance on family support, and need for chronic nursing home or institutionalized care.[31]

http://emedicine.medscape.com/article/168402-overview#aw2aab6b2b5

张三2012

对不幸的家人感到同情，发生这样的事谁也不想。虽然本人不清楚整个病情的经过，但是从描述的细节上看，这病人貌似像得了Histoplasmosis （组织胞浆菌病）。这种病很少见， 由呼吸入侵肺部，通过血液传播感染。 一般免疫系统正常的人得了此真菌不会有什么症状，但是免疫系统有缺陷的人（比如艾滋病患者， 先天免疫系统缺陷）的人被感染后会产生严重的肺炎，肝脾肿大，发高烧，还有各项血液指数下降（比如白血球，红血球，血小板），然后休克，多器官衰竭，直至死亡。发病的状况跟上述的案例十分相似。此真菌生活在土壤中，一般常出现在美国中部（多伦多以南）OHIO 和 MISSISSIPPI 的河峡谷区， 加拿大十分少见，只有从美国疫区回来的群众当中才会考虑这种感染的可能性。在未了解病人本身的病史和可能存在的免疫系统缺陷时指责医生失职有失公平。本人也从未见过此病，但内科修传染性疾病时读过这样的案例：24岁男士，艾滋病患者，在Kansas（真菌区）得肺炎，高烧，肝脾肿大，等等，跟此案列非常相似。文中提到医院诊断是真菌感染，并用相应的抗菌药治疗（应该是两性霉素），还送到了深切治疗中心（ICU），就证明医院已经竭尽所能抢救病人。医生不是神，不是所有的生命都可以挽的了，我们追求的是尽力，做到问心无愧，然后只有听天由命了。这位病人很不幸无法战胜病魔，但希望大家能够客观对待病情。

This case most likely represents histoplasma capsulatum, which is a dimorphic fungus most commonly found in mid USA near the Ohio and Mississippi river valleys. We don't see this very often in Canada, mostly in travelers from endemic regions. People get infected with histoplasmosis via inhalation of the fungal spores into the lungs, which then gets disseminated to the body. Most healthy and immunocompetent individuals do not get symptoms. People with HIV/AIDS or some form of immunideficiency can get severe disseminated disease, often presenting with cough, pneumonia, fever, pancytopenia (low white blood count, low hemoglobin, and low platelets), which later develops into septic shock, DIC, and multi-organ failure, which is what eventually claimed the life of this unfortunate young man. I can only suspect that this is the infection responsible for this man's death based on the limited description of his illness from the above article. It seems like St. Michael's Hospitak had indeed diagnosed him with a fungal infection and treated him appropriately, including resuscitation in the ICU. Until we know what his medical history and whether or not he has an undiagnosed immune deficiency (I.e. HIV), it would not be fair to lay all the blame on the medical system.
janie 发表于 2012-7-30 23:48

说的很有道理，不过组织胞浆菌病在加拿大很罕见，死者病情也很像sepsis，所以我选择了sepsis.无论如何，二者都是在鬼门关门口转。

张三2012

同情死者的父母, 节哀! 不过感冒发烧是可以死人的, 我的一亲属38岁男的, 还有 一同事的妈妈53岁, 十几年前在中国都是感冒发烧死的, 平时都是非常健康的.

我在加拿大生活了十几年, 也去过几个不同的医院和急疹, 我觉得不论医疗设施, 技术水平, 还是服务都是非常好的, 是国内的医院赶不上的. 这里和国内不同, 用药很谨慎, 不象国内, 小病也挂滴流, 人体的自身免疫力都破坏了, 我很赞同这里的做法. 至于看病等候时间长, 那要看是什么情况, 如果真是危险的急诊, 是一分钟都不等的, 我就亲身经历过, 登记都是进到急疹病房后才做的.
冷悦 发表于 2012-7-31 11:57

这样中肯评论，在51算异类。

张三2012

加国除了心脏架桥手术还算成熟，技术不错，其他的我没听说过好，这话可能太绝对了，但给我的印象就这样。就最简单的生孩子一事儿。我认识的人中，有8个在加国生孩子的，两个是生第二胎，还不错，比较顺利。另4个大人孩子都死了，还一个只保住了小孩，但妈妈死了。最后一个，九死一生。破腹产，结果伤口感染，拆线时，线没有了，只有一个大窟窿，痛苦了很久，她说想起来就害怕，也不敢要第二胎了。
david19 发表于 2012-8-8 23:12

加拿大这些狗头医疗制度，他妈的，生个小孩，小孩死亡率50%，大人死亡率62.5%。