Interview With Expert Group Of Peking Medical Wuhan Front-Line Medical Team, The Key Point Of Changan Zhong Zhong Sniping New Crown Virus: Symptomatic Treatment "Subtraction" To Guard Against Iatrogenic Injuries

As of March 23rd, he had been in Wuhan for 52 days and is still sticking to it. As the head of the expert group of Peking University Medical front medical team in Wuhan, he took the team to participate in the medical treatment work of three wards of the Sino French New Town Hospital of Tongji Hospital Affiliated to Huazhong University of Science and Technology, which is a designated hospital of critical and critical patients. Up to now, nearly 260 critically ill patients have been treated, and 90% patients have been discharged.

He has experienced SARS, Wenchuan, Ya'an earthquake, H1N1, H7N9, avian influenza and other sudden public health emergencies, and now in the "sniper" new crown virus battle field, engaged in critical medicine 27 years An Youzhong believes that the new crown pneumonia is not terrible, patients need early effective intervention, with simple and effective diagnosis and treatment plan, and rational use of critical care medicine. In order to improve the cure rate and reduce the fatality rate, we can help the patients to move forward and recover the normal functions of human organs.

Beida medical Wuhan front-line medical team expert group Changan you Zhong. Data map

Severe treatment emphasizes "barrel theory"

Twenty-first Century: comparing with previous treatment of infectious diseases, what new features do you think there are in the treatment of new crown pneumonia?

An Youzhong: first of all, we should have a clear idea of the number of infected persons as soon as possible. In view of the new crown pneumonia, we need to keep track of the overall changes in the epidemic situation, clarify the measures that the government is prepared to take, and clarify the trajectory of the social population. After a series of large-scale screening, we can determine the scope and quantity of the infected population, and predict and allocate the demand for medical resources.

The overall mortality rate of patients with new crown virus infection in Wuhan is higher than that outside the province. It is because the early diagnosis is difficult and the backlog time is relatively long. It is not timely and effective treatment, and the virus infection is strong and the number of infected people is high, leading to the burden of local medical resources.

After the team arrived in Wuhan, we first investigated and rebuilt the ward to find out the equipment needed for treatment. Then, unified the diagnosis and treatment process of the severe treatment team, and determined a simple and effective treatment plan.

Our team comes from different departments of three hospitals. The level of intensive care is about "barrel theory", such as the technical level and coordination ability of some medical personnel. To this end, we set up an expert group to identify medical practices and nursing routines and improve the team's shortest board. This is also the basis for follow-up work.

The rate of treatment for some ICU units which were not well known in the past may be higher than that of the large experts in large hospitals.

The treatment method is "subtraction".

Twenty-first Century: how will the new crown pneumonia treatment work be more effective?

An Youzhong: at present, the new crown pneumonia has not yet been found and can not be symptomatic for treatment.

Most patients with severe new crown virus infection do not have a very strong inflammatory storm, but an imbalance, that is, the low lymphocytes of patients, resulting in a complete paralysis of the body's immune system. In fact, the inflammatory storm produced by new crown pneumonia may not be as good as bacterial infection.

At present, there is no universally recognized effect of various drugs for the treatment of new crown virus. In fact, no drug does harm to people. In the face of the new crown virus infection, we should keep our normal mind and do what we are good at, and use drugs moderately and moderately.

Twenty-first Century: what is a simple and effective way of treatment? Why should it be implemented?

An Youzhong: the body itself carries a variety of viruses, allowing certain viruses or bacteria to live in the human body. This is the norm in the biological world. For the new crown virus, the human body must first recognize and remove it, minimize the harm to human organ function, and at least temporarily fight for peaceful co-existence without being killed.

Antiviral drugs can also cause side effects, including vomiting, diarrhea, myocardial injury and myelosuppression. For patients, first of all, to see if the patient is life-threatening. If there is no danger, the use of anti viral drugs should be simple and appropriate. According to the progress of the patients, we should make a comprehensive judgement. In our ward, we usually give antiviral drugs for no more than 7 days, because if they are not treated for 7 days, it shows that the drugs do not work for their treatment. The main way is symptomatic support, that is, oxygen therapy or other regulation of human metabolism, acid-base balance and other supporting role. If there is a sudden increase in the patient's condition, a moderate dose of hormone can be used to regulate the host's response. We will also implement endotracheal intubation as early as possible according to the needs of patients.

Of course, when other oxygen therapy methods can not maintain the blood oxygen saturation of patients, it is advisable to intubate as soon as possible and not to rely too much on the patient's efforts to compensate. It should be noted that ventilator related injuries caused by "man machine confrontation" are needed to prevent intubation.

Specifically, positive pressure mechanical ventilation is actually anti physiologic: for example, when the end of the machine is pumped, if the patient inhales vigorously, it will increase the negative pressure of the chest, and increase the alveolar tension and shear force. Similarly, when the patient wants to exhale, the ventilator will aspirate and pull the alveolar of the patient energetically. At this time, the shear force between the alveolar and unopened alveoli in the lung tissue will also increase. At large, the healthy alveoli at the juncture may be damaged again. Some white blood cells or other fibroblasts will infiltrate. The virus will damage the lung tissue and make it more vulnerable to ventilator induced lung injury. This is also part of the reason why some doctors and nurses are against the ventilator on the endotracheal intubation.

So the key is not whether some means are appropriate, but whether they can be correctly, finely and timely adjusted to apply these means. In fact, this problem caused many experts to be depressed in the course of treatment: when a good treatment plan was returned to the next day, the patient deteriorated or even died. The main reason may be whether the operation after tracheal intubation has paid attention to detail management.

Avoid iatrogenic damage

Twenty-first Century: what experience has been summarized before the treatment of critically ill patients?

An Youzhong: the standardization of oxygen therapy needs to be strengthened. The earliest oxygen inhalation is nasal catheter and nasal obstruction. After inhaling oxygen, the respiratory rate should be reduced, but the blood oxygen saturation should go up. If the patient still breathes quickly after inhaling oxygen, the lung shear injury can not be suppressed. At this point, if the oxygen is inhaled vigorously, the ratio of ventilation and heart blood flow is disrupted, which may aggravate further damage to the lungs and heart function. Therefore, in addition to observing oxygen saturation, we need to observe respiratory rate and heart rate.

This observation has also had some misunderstanding before, which has brought some regrets on treatment. For example, the sudden death of a patient with a state of improvement is actually a miscarriage of justice. In the initial treatment, when the blood oxygen saturation was only 80% or more, the patient had poor heart rate and poor breathing. At that time, the concept of treatment was considered to be a patient's tolerance to hypoxia. But in fact, when hypoxia occurs, the heart rate of the normal people should come up. If it does not come up, it will indicate that the compensatory function of the heart is impaired. This kind of patient will be more dangerous and not getting better. Therefore, in support of treatment, the assessment of organ function can not just look at the appearance, but also see the underwater parts of the iceberg.

There are still some lack of standardized training in the early stage of treatment. Because oxygen therapy is effective, doctors give oxygen to patients through the way of oxygen masks, but if they are small enough, there will not be enough oxygen in the mask and the exhaled carbon dioxide will gather. If they are large enough, they should have enough ventilation. If they are still embarrassed, they should actively consider replacing other oxygen therapies, such as noninvasive positive pressure ventilation or airway intubation. Long term non positive pressure oxygen therapy, with the increasing oxygen concentration, oxygen can freely pass through the alveolar wall into the blood exchange, alveoli may collapse, may also cause viral damage besides the medical damage. This is why early intubation and early mechanical ventilation are the reasons for the move of the gateway.

Therefore, we should closely observe the changes of patients, and do all kinds of observation indicators in the diagnosis and treatment plan in detail. For example, we can set up surveillance systems such as cameras or monitoring devices in the ward. If the patient's respiratory rate or heart rate changes alarm, doctors can take a look in time, we may observe these details, and adopt more accurate support measures as soon as possible. Deadweight damage.

Currently, simple and effective treatment regimens are effective, and the mortality rate in the three wards is probably less than 10%.

Twenty-first Century: what is the efficacy and side effects of ECMO in the treatment of critically ill patients?

An Youzhong: the main purpose of using ECMO in critically ill patients is to allow organs to rest. After ECMO, the breathing rate of the patients is still very fast. Every breath of the lung is subjected to very high open pressure. The shear force is still very large, and the lung can not get effective rest. So we should not only use the machine but also use the machine according to the physiological conditions of human beings. This process must be based on human beings, rather than on the parameters and indicators of the machine. This aspect is relatively weak in this process.

In fact, in the early years, ECMO was used less. The survival rate of adult patients was only more than 20% points. In recent years, the number of adult patients has increased, especially in cardiac surgery and macrovascular surgery, and the survival rate of adult patients has increased to about 40%. It is estimated that the effective rate of new crown pneumonia patients can reach about 30%.

However, ECMO also has side effects. First, because ECMO needs to be placed, there may be vascular damage. Secondly, anticoagulation, blood coagulates with artificial materials, this process of coagulation disrupts the internal coagulation state of human body, and then there will be hemolysis, that is, blood cells injury occurs through pumps and pipelines in vitro. Another problem is the imbalance of blood supply in different parts of the body, for example, using V A mode, some organs and tissues of the patient are stolen, and there will be partial blood deficiency. In addition, ECMO is advection blood supply, unlike the heart is pulse type, may not be able to transport blood to the end of organs, after a long time, there may be some organs or limbs distal ischemia, so the application of ECMO is a good progress, but it is not purely physiological things, but only a replacement.

We need to remain vigilant at all times.

Twenty-first Century: is there sufficient clinical support for the autopsy of new crown pneumonia patients?

An Youzhong: forensic medicine and real clinical pathology are two systems. Forensic doctors are more concerned about the cause of death. Tissue sections of all organs are needed in clinic. Now the autopsy cases are not enough for clinical help, and more anatomic cases are needed. We carefully observe the types and degrees of virus invasion and damage of various organs and tissues, and explain them from a professional clinical point of view. This part of the work must be meticulous, pathology is a doctor's doctor, hope clinical pathology teachers can provide more help.

Twenty-first Century: how do you see the phenomenon of partial healing in patients? Are there any conclusions about the infectivity of these patients?

An Youzhong: the duration of new crown virus infection is mostly self limiting. After cure, it is necessary to find out whether it is true or false positive. The same positive nucleic acid: true positivity means that the virus is still alive. False positive may still be a dead virus after excluding the kit, and the organism will be removed after a period of time, but it needs further observation.

In addition, it is also necessary to pay attention to whether the antibody is effective or not. Now, some patients, especially those with severe diseases, have not produced antibodies yet. In addition, some patients entered the convalescent plasma of the rehabilitative patients. The initial IgG increased rapidly, but fell down a few days later, indicating that the patients themselves did not produce antibodies. It is also necessary to pay attention to antibody IgM and antibody IgG, such as persistent high level, indicating that there may be some memory and protective effects. If it can not continue to show that antibodies are not protected, then the role of vaccine development is not clear. We should also pay attention to the antibody positive and nucleic acid positive cases of individual patients, indicating that there may still be viruses in the body. Although the body has identified antibodies to the virus, it is not enough to kill the virus or the antibody is lacking in protection. Once the body's immune function is weak, the condition may revive. It remains to be seen whether the patient is still infectious. Therefore, there is still much work to be done in the research of new crown pneumonia, and we need to be vigilant at all times.