stroke 4.5小時內可以用 tPA，每過90分鐘就會效果減半，4.5小時後用會增加mortality

No Benefit from Intravenous Alteplase When Given After 4.5 Hours of Stroke Onset

Risk for favorable outcomes decreases with increasing time to treatment from stroke onset, and, after 4.5 hours, alteplase treatment might increase mortality.

What is the optimal interval between stroke onset and intravenous recombinant tissue plasminogen activator (rt-PA) administration? Researchers conducted an updated analysis of pooled data from eight trials involving 3670 patients (median age, 68; age range, 19–101) who were randomized to receive rt-PA or placebo within 360 minutes of onset of stroke symptoms.

In multivariate logistic regression analysis, the odds of a favorable 3-month outcome (based on modified Rankin scale score, Barthel index score, and National Institutes of Health Stroke Scale score) were inversely related to time from onset of symptoms to rt-PA treatment, with no treatment benefit after about 270 minutes. Adjusted odds of favorable 3-month outcomes were 2.55 for 0–90 minutes, 1.64 for 91–180 minutes, 1.34 for 181–270 minutes, and 1.22 for 271–360 minutes. Adjusted odds of mortality increased with time to treatment, ranging from 0.78 for 0–90 minutes to 1.49 for 271–360 minutes. Large parenchymal bleeds occurred in 5.2% of rt-PA patients versus 1% of controls and were independent of time-to-treatment interval. The authors conclude that time from stroke onset to treatment should be minimized and that after 4.5 hours, "risk might outweigh benefit." An editorialist adds that, in large middle cerebral artery infarcts, "20 million additional neurons die every 10 min[utes] if reperfusion is not achieved."

Comment: These data suggest that the risk for favorable outcomes decreases by a factor of about two for every 90-minute delay in treatment from stroke onset and that after 4.5 hours, rt-PA treatment might increase mortality. Lytic therapy for acute stroke must be given at the earliest possible time. Extension of the window for treatment to 4.5 hours is not a license for delay; every minute counts.

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine May 28, 2010


看到沒，MCA infarction,每10分死 2000萬個細胞，用tPA會有5.2% ICH , 不用約有 1%，和你何時用倒是沒有相關

留言

張貼留言

這個網誌中的熱門文章

即便是用IGRA, 有時也要等大於三個月才能決定TB contact

圖片
接觸TB後，TST大抵上2-12週轉陽，IGRA大抵上6-10週，但IGRA可以長到3個月以上 TB Tests Can Have a Lengthy Window Period Two studies suggest that interferon- release assay conversion sometimes occurs more than 3 months after exposure to active tuberculosis. Increasingly, interferon- release assays (IGRAs) are being used for diagnosing latent tuberculosis (TB). Although the tuberculin skin test (TST) traditionally used for this purpose converts to positive within 2 to 12 weeks after an individual is exposed to someone with active TB, the interval for IGRA conversion has remained unclear. Current guidelines recommend repeating an initially negative IGRA after 6 to 10 weeks, but this recommendation is not based on controlled studies. Two recent investigations address this issue. Anibarro and colleagues conducted a longitudinal prospective analysis among contacts of TB patients in Spain. The 152 contacts received a TST and an IGRA at first visit; for individuals with negative or conflicting results, t
閱讀完整內容

early vs late tracheostomy, 早切不會降低死亡率，不會降低VAP，不會降低LOS, wait!

April 27, 2010 — Early vs late tracheotomy (6 - 8 days vs 13 - 15 days after mechanical ventilation) may not significantly lower the risk for ventilator-associated pneumonia in adult patients in the intensive care unit (ICU), according to the results of a randomized controlled trial reported in the April 21 issue of the Journal of the American Medical Association . "Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy," write Pier Paolo Terragni, MD, from Università di Torino in Turin, Italy, and colleagues. "This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources." The goal of this study was to compare early tracheotomy vs late tracheotomy in the incide
閱讀完整內容