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今天收到SHEA信件，在即将举行的 ID Week会上介绍今年8月美国治疗2例埃博拉病人的经验。原信及译文附上，供参考。无关紧要的客套话就不翻译了。
Dear Colleagues,
We write to provide a summary of the presentation at IDWeek by Dr. Bruce Ribner on caring for Ebola patients in the US1. Dr. Ribner led the team at Emory University that cared for two patients with Ebola virus disease (EVD) in August. In light of the recent Ebola cases in Dallas and Spain he agreed that a summary could be provided to assist ID specialists in their ongoing preparedness efforts.
亲爱的同道：
我们书面提供Dr. Bruce Ribner将在ID Week上所做关于美国埃博拉病人护理的演讲的概要。今年8月，Dr. Ribner在Emory大学带领团队照护2名埃博拉病（EVD）患者。鉴于最近在达拉斯和西班牙出现的埃博拉病例，他同意分享本概要以帮助传染病专家进行准备努力。
Planning for the care of patients
This involves the entire institution, and needs many sections to coordinate their work. EMS services were an important coordination point for the transport of the 2 patients to Emory. On the medical staff, many types of expertise were needed for clinical management: ID, critical care, anaesthesiology and several other subspecialities. Nursing, environmental management, facilities, security and media relations were all intensively involved ahead of time so that expected roles were defined. Even so, there were times when questions arose after the patients arrived.
制定病人护理计划
该计划涉及全院，并且需要多方面协调工作。对2名病例转运到Emory大学来说，EMS服务是重要合作节点。对医务工作人员来说，需要各种专家进行临床处置：传染病，危重病，麻醉和若干其他亚专科。护理、环境管理、设施设备、保安和媒体联系人员都要提前确定好，明确预期作用。即使这样，在病人到达后还是出现几次问题。
Clinical Care
Ebola patients in Africa have only limited clinical evaluations and essentially no laboratory testing due to the lack of any infrastructure to support this. The Emory team was able to make careful clinical evaluations over time in their 2 patients and Dr. Ribner summarized the main points as follows:
1. Despite weight gains of 15-20 kg, the patients were profoundly hypovolemic due to their low serum albumin and vascular leak with third spacing. Fluid losses in their patients were 5-10 L/day.
2. Electrolyte losses were significant and included profound hyponatremia, hypokalemia and hypocalcemia. At initial assessment at Emory the patients were one week into illness yet these were their first laboratory determinations. Arrhythmias were noted, and both intravenous and oral electrolyte repletion was necessary.
3. Nutritional depletion was evident as well.
4. Ebola virus RNA was detected in blood, urine, vomitus, stool, endotracheal suctioning and semen and on skin. It was not detected in dialysate. Environmental testing in the patient rooms had no detection of viral RNA and included many high touch surfaces such as bed rails and surfaces in the bathroom.
5. Intensive 1:1 nursing care was necessary around the clock. Patients were monitored continuously and this level of nursing care allowed for rapid response to clinical changes. Nursing and other team members provided emotional support, and as the patients improved, help with self-care and physical therapy.
临床护理
在非洲的埃博拉病人仅有有限的临床评估，因缺少基础设施的支持，基本上没有实验室检查。Emory大学团队能够对2个病人进行随时间变化的细致临床评估。Dr. Ribner。概括如下：
1. 尽管病人体重增加15-20kg，由于低白蛋白血症及血管渗漏到第三间隙，病人有严重的低容量。这些病人的液体损失达到5-10L/天；
2. 电解质丢失明显，包括严重的低钠血症、低钾血症和低钙血症。在Emory大学的初次评估，也就是病人发病一周，第一次有实验室报告。注意有心律失常，必须进行静脉和口服电解质补充。
3. 同时营养损耗明显；
4. 在血、尿、呕吐物、粪便、气管吸取物、精液和皮肤上发现埃博拉病毒RNA。但在透析液中没有发现。病房的环境监测中没有发现病毒RNA，包括高频接触物体表面，如床栏，卫生间表面。
5. 必须采取24小时 1:1重症护理。病人持续监护，要求护理水平能对临床变化快速反应。护理和其他团队成员提供情感支持，当病人情况改善时，协助病人自理和物理治疗。
Experimental Interventions
While there are no approved vaccines or treatments for EVD, the WHO has noted that it is ethically acceptable to consider use of experimental agents. Categories of agents under study include candidate vaccines, whole blood and immune serum, and novel therapeutic agents (monoclonal antibodies, antivirals and RNA-based drugs). Most have not been evaluated in phase 1 human studies and are in limited supply. The Emory team engaged the FDA, CDC and pharmaceutical manufacturers in active discussions as they weighed additional interventions.
实验性干预
对EVD没有批准的疫苗或治疗，WHO已经提出伦理上可接受使用实验性药物的考虑。在研的药物种类包括候选疫苗，全血和免疫血清，新型治疗药物（单克隆抗体，抗病毒和RNA基础药物）。绝大部分没有经过1期药物研究评价，且供给有限。当权衡其他干预时，Emory团队与FDA，CDC和药物生产商主动讨论。
Laboratory Testing and Diagnostics
Differences in guidance for laboratory testing were noted between CDC and ASM. The CDC guidance indicates that testing can be performed in a main lab with attendant infection control and analyzer safeguards that are specified by the instrument’s manufacturer, while the ASM guidance specified that point of care (POC) instruments located very close to the patient should be used. The reality the Emory team noted was that if a specimen from one of their EVD patients spilled in the main lab, it would be closed for hours to accomplish decontamination, thus impacting function of the entire hospital. There was realistic concern that technologists would not perform testing on EVD blood. These considerations prompted the Emory team to set up a POC testing area adjacent to the patient care unit2. Lab testing was kept to a minimum.
实验室检测和诊断
CDC和ASM对实验室检测的指导不同。CDC指导显示可以主要实验室进行检测，同时要有感染控制和由设备制造商规定的分析者安全防护措施，而ASM指导特别针对非常接近病人使用的护理点设备。Emory团队注意的实际情况是：如果来自他们EVD病人的标本在主要实验室溢出，应关闭实验室数小时直至完全去污，这会影响整个医院的功能。实际考虑是技术人员不应对EVD病人血样进行检测。这些考虑促使Emory团队在靠近病人护理病区建立检测区域。实验室检测保持在最少水平。
Surprises in Shipping
Ebola virus is considered a category A agent which requires special packaging and shipping arrangements for clinical specimens. Despite meeting these requirements, the Emory team learned that commercial carriers refused to transport the specimens even when the carriers were licensed for Category A agents.
运送的惊讶
埃博拉病毒是A类物品，临床标本需要特殊包装和运送。虽然满足这些要求，但Emory团队得知商业运送公司拒绝运送这些标本，尽管这些运送者有A类资质。
Staff and Environmental Safety
The hospital safety officer needed to navigate multiple regulatory requirements at the federal, state and local level. Familiarity with the regulatory documents and jurisdiction was necessary.
工作人员和环境安全
医院安全部门官员需要指导完成多种联邦、政府和当地水平的法规要求。必须熟悉这些法规文件和司法管辖。
Personal Protective Equipment
Their staff was trained in the use of PPE that included impermeable body protection (gown, leg and shoe covers), face mask or N95, eye and face protection (goggles and face shield) and gloves. Practical considerations led them to use full body suits and PAPRs. Their decision was based on the need to work for extended periods of time using PPE, the aim of decreasing physical discomfort working in multi-component PPE and the avoidance of difficulties like fogged faceshields. The donning and doffing of PPE was always observed by another staff member, and the importance of adhering to safe removal of PPE was emphasized.
个人防护设备
Emory团队的工作人员都被培训使用PPE，包括不透水的身体保护（隔离衣，腿和鞋套），面罩或N95，眼部和面部保护（护目镜和面罩）以及手套。实际考虑让他们使用全身连体服和PAPRs。他们的决定根据工作需要延长PPE的使用时间，目的是减少多种PPE工作的不适，避免像面罩起雾这样的困难。在其他工作人员的观察下穿脱PPE，强调遵守PPE安全取出的重要性。
Unexpected Adventures in Waste Management
Although the CDC guidance indicates that sanitary sewers are acceptable for patient waste, the local water authority disagreed. The Emory team had to disinfect all patient liquid waste with bleach or quaternary detergents for 5 minutes before it could be flushed. The hospital’s waste disposal contractor would only pick up materials that were certified as free of Ebola virus. As a consequence, the hospital had to dedicate an autoclave and move it to process all materials used in clinical care in order for it to be accepted for disposal as regulated medical waste. By the end of the patients’ stay the autoclaved and boxed materials filled several trailers.
废物处置中未预料的冒险
尽管CDC指南中显示可以接受病人废物经公厕排放，但地方水质管理部门不同意。Emory团队对所有病人的液体废物使用漂白剂或季胺盐消毒剂进行5分钟的消毒后排放。医院废物处置承包商仅需要提取样品确定没有埃博拉病毒。最后，医院不得不使用专用高压锅处理临床护理过程产生的所有物品，确保达到医疗废物处置的强制标准。在病人住院的最后阶段，高压锅和盒装的材料堆满了好几拖车。
Media and Communications
Three key messages were used to manage the tsunami of media attention: first, that the Emory team had expertise in treating serious infectious diseases; second, that the staff and hospital were trained and prepared to care for the patients; and third, that the preparations included protection of Emory patients, staff and the community. Patient confidentiality was also underscored. For the hospital staff, multiple communications were done, using town hall meetings, email and other modes. For inpatients and all new admissions, letters were given that explained the situation and reiterated the key messages, and senior administrative leaders delivered the messages as well answered questions. No decrease in admissions or elective surgeries at the hospital was noted.
媒体与沟通
3个关键信息用于处理媒体关注的“海啸”：首先Emory团队有处理严重传染病的专家；第二，工作人员和医院都经过训练，准备照护这种病人；第三，有保护Emory病人、工作人员和社会的准备。病人的自信也需要强调。对于医院工作人员，需要进行多次沟通，使用市政会议厅，电子邮件和其他方式。对于住院患者和新入院患者，给予信件详细解释情况，重复关键信息，高级管理者发布信息同时回答问题。医院的住院病人或选择性手术没有下降。
Lessons Learned
Patients with EVD can be safely cared for in developed countries with appropriate safeguards. This opportunity affords close clinical observation and experience in clinical management that could be relayed to facilities with lesser infrastructure. Communication, both internal and external, is critical to manage the situation surrounding a hospitalized EVD patient.
教训
在发达国家，在适合的安全措施下，EVD病人可以得到安全的护理。这个机会提供了密切临床观察和临床处置的经验，可以传播到基础设施很少的 医疗机构。对内、对外沟通对控制EVD住院病人的环境非常重要。
The Society thanks Dr. Ribner and his team for their astute observations, their compassion and their willingness to share what they have learned.
Sincerely,
Marguerite A. Neill, MD FIDSA, Chair, Rapid Communications Task Force, IDSA
References
1. Ribner BS. Treating patients with Ebola virus infections in the US: lessons learned. Presented at IDWeek, October 8, 2014. Philadelphia PA
2. Hill CE, Burd EM, Kraft CS, et al. Laboratory test support for Ebola patients within a high-containment facility. Lab Medicine 2014:45(3):e109-111.
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发表于 2014-10-12 16:38
发表于 2014-10-12 19:12
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