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Chapter 1158 Decision Making
Chapter 1158 Decision Making
There are three main methods for the treatment of acute hepatitis B—interferon, nucleotide drugs, and immunosuppressive drugs.Among them, interferon is actually a relatively small class of drugs used.
Compared with nucleotide drugs such as lamivudine, adefovir, entecavir, etc., which are widely used in the treatment of hepatitis B, interferon has a narrower range of medication and timing of medication.Once hepatitis B progresses to the decompensated stage of cirrhosis, interferon must be disabled.
Interferon can enhance the immune response.But when hepatitis B causes cirrhosis to go into decompensation, the viral load in the liver is extremely low.Long-term repeated damage can cause the immune system to attack the liver, leading to more severe liver fibrosis and cirrhosis.Therefore, at this stage, the treatment of hepatitis B should be immunosuppressive drugs + nucleotide antiviral drugs instead of interferon that can enhance the immune response.
Although Yu Xin's liver symptoms were very serious, according to the doctors' judgment, he was not a severe, decompensated liver cirrhosis patient.
The reason why nucleotide drugs are not used immediately is mainly due to the consideration of the response to the new coronavirus - among the currently recommended anti-new coronavirus drugs, many of them, including acyclovir and lopinavir, are All these drugs theoretically belong to nucleotide drugs.In clinical use, these drugs may cause adverse reactions including increased creatine phosphokinase, rhabdomyolysis, and inflammatory reactions.The results of these adverse reactions all need to be metabolized in the liver and kidneys.
He already has liver and lung insufficiency, if he adds acute renal insufficiency... Yu Xin is really not far from death.If three organs fail, the patient's mortality rate will directly soar to more than 90%.
For active hepatitis B, it is generally recommended to use a combination of multiple nucleotide drugs for treatment.In the treatment of new coronaviruses, it is not recommended to use more than three antiviral treatments at the same time.Therefore, in Yu Xin's body, a contradictory situation emerged.
If you want to treat active hepatitis B—especially if it is so severe that it is new—you need to use at least a regimen of lamivudine, interferon, and hepatitis B human immunoglobulin.And this solution is too big for new risks.
His lungs are failing, and lung transplantation is the only option.Therefore, the current treatment goal is to protect the liver and suppress the hepatitis B virus.And also to prevent the continued failure and damage of other organs.
"I think it is still necessary to use antiviral drugs, at least lamivudine or human immunoglobulin." At the discussion meeting, Zhou Ce proposed adjustments to the existing treatment plan. "We are now strategically giving up both lungs, so we must find a way to keep the liver."
Zhou Ce’s opinion was endorsed by Bruen, “To perform an organ transplant on a patient, we must first ensure that there is no active hepatitis B in his body.”
"However, nucleotide drugs will increase the risk of kidney damage in patients." Sun Lien still hesitated, "New coronavirus infection will increase the risk of kidney damage in patients, and the widespread use of CRRT in triple therapy is to deal with this situation."
It is a well-established fact that the risk of death in patients with multiple organ failure increases rapidly with the number of organ failures.Physicians tend to be extra cautious when dealing with patients with one organ failure in case other organs are also failing.Once three organ failure occurs, the mortality rate of patients will soar to an unacceptable level.
"The problem of kidney failure can be treated with CRRT or dialysis. As long as we do preventive dialysis before the relevant problems occur." Zhou Ce suggested, "There is nothing wrong with hepatitis B being a self-limiting disease, but it depends on the situation. His hepatitis B outbreak was due to the use of tocilizumab before, and in the patient's medical history records and the five infectious diseases admitted to the hospital, the hepatitis B records were blank and negative. This means that he should be showing acute infection for the first time, Before that, he was only a negative hepatitis B carrier."
"It is almost impossible for such patients to rely on their own immune system to suppress the acute infection. Even if they can, it will take a long time." Ma Yongfang frowned, "I also agree with Dr. Zhou's opinion, now there is ECMO And artificial liver support, preventive dialysis is enough. If the hepatitis B virus and the new coronavirus are not eliminated as soon as possible, it is impossible for him to get the chance of transplantation.”
"This is a big gamble." Even Dr. Bernard is on Zhou Ce's side, although his opinions are a bit more entangled, "Either the patient can clear the virus in a short time and wait for the transplant, or the patient will be transplanted in a short time." There is multiple organ failure. To put it bluntly, this is a bet on whether he can turn the crisis to safety in a short time..." Bernard hesitated for a long time and said, "If you have to choose, I think it is better to take the initiative."
Sun Lien also hesitated because his team had a different opinion from him.
As the main person in charge of the treatment group, Sun Lien's pressure mainly comes from the consideration of the patient's life safety.Whether it is the central, provincial or even local health commissions, everyone has repeatedly emphasized the issue of reducing mortality.This is not only a professional issue, but also a political issue.
The life safety of the people is the biggest political issue. With sufficient medical resources, doctors have the ability and must carefully wrestle with each case carefully.
Starting a month ago, all deaths need to be brought to a meeting of experts for careful discussion.There were many deaths before, and everyone's main point of view was to find a new entry point for treatment.With the recent rapid decrease in the number of patients who died of the disease, the case discussion meeting has almost become "everyone find fault".
For every treatment decision, every specific step, and even every change in the patient's examination results, the expert team will ask the doctor in charge of the treatment again and again, "Why did you do this", "Why didn't you do this" and "Since you After everything has been done, why the patient still didn’t get it back.”
No doctor can bear this kind of death triple question.
Regardless of whether it was due to personal reasons or to be responsible for the lives of patients, Sun Lien did not intend to turn Yu Xin into a death case and bring it to an expert meeting for discussion.
"You can't talk about this kind of thing with your family members." Xu Yourong's attitude became clearer, and she said seriously to Sun Li'en, "You have to make a decision as soon as possible—whether to continue the conservative treatment like this, or talk to the doctors from the Infectious Disease Hospital Discuss and start a more aggressive treatment plan.”
In order to celebrate EDG's championship, today's update.
However, Luo's condition is not good recently, and it is unknown how much more will come out.I can only keep my words down for now, write as much as I have, and go all out.
According to the old rules, 2K counts as one update.Depending on the situation, there may be 4K or 6K chapters in the future, so it will be counted as two or three.
(End of this chapter)
There are three main methods for the treatment of acute hepatitis B—interferon, nucleotide drugs, and immunosuppressive drugs.Among them, interferon is actually a relatively small class of drugs used.
Compared with nucleotide drugs such as lamivudine, adefovir, entecavir, etc., which are widely used in the treatment of hepatitis B, interferon has a narrower range of medication and timing of medication.Once hepatitis B progresses to the decompensated stage of cirrhosis, interferon must be disabled.
Interferon can enhance the immune response.But when hepatitis B causes cirrhosis to go into decompensation, the viral load in the liver is extremely low.Long-term repeated damage can cause the immune system to attack the liver, leading to more severe liver fibrosis and cirrhosis.Therefore, at this stage, the treatment of hepatitis B should be immunosuppressive drugs + nucleotide antiviral drugs instead of interferon that can enhance the immune response.
Although Yu Xin's liver symptoms were very serious, according to the doctors' judgment, he was not a severe, decompensated liver cirrhosis patient.
The reason why nucleotide drugs are not used immediately is mainly due to the consideration of the response to the new coronavirus - among the currently recommended anti-new coronavirus drugs, many of them, including acyclovir and lopinavir, are All these drugs theoretically belong to nucleotide drugs.In clinical use, these drugs may cause adverse reactions including increased creatine phosphokinase, rhabdomyolysis, and inflammatory reactions.The results of these adverse reactions all need to be metabolized in the liver and kidneys.
He already has liver and lung insufficiency, if he adds acute renal insufficiency... Yu Xin is really not far from death.If three organs fail, the patient's mortality rate will directly soar to more than 90%.
For active hepatitis B, it is generally recommended to use a combination of multiple nucleotide drugs for treatment.In the treatment of new coronaviruses, it is not recommended to use more than three antiviral treatments at the same time.Therefore, in Yu Xin's body, a contradictory situation emerged.
If you want to treat active hepatitis B—especially if it is so severe that it is new—you need to use at least a regimen of lamivudine, interferon, and hepatitis B human immunoglobulin.And this solution is too big for new risks.
His lungs are failing, and lung transplantation is the only option.Therefore, the current treatment goal is to protect the liver and suppress the hepatitis B virus.And also to prevent the continued failure and damage of other organs.
"I think it is still necessary to use antiviral drugs, at least lamivudine or human immunoglobulin." At the discussion meeting, Zhou Ce proposed adjustments to the existing treatment plan. "We are now strategically giving up both lungs, so we must find a way to keep the liver."
Zhou Ce’s opinion was endorsed by Bruen, “To perform an organ transplant on a patient, we must first ensure that there is no active hepatitis B in his body.”
"However, nucleotide drugs will increase the risk of kidney damage in patients." Sun Lien still hesitated, "New coronavirus infection will increase the risk of kidney damage in patients, and the widespread use of CRRT in triple therapy is to deal with this situation."
It is a well-established fact that the risk of death in patients with multiple organ failure increases rapidly with the number of organ failures.Physicians tend to be extra cautious when dealing with patients with one organ failure in case other organs are also failing.Once three organ failure occurs, the mortality rate of patients will soar to an unacceptable level.
"The problem of kidney failure can be treated with CRRT or dialysis. As long as we do preventive dialysis before the relevant problems occur." Zhou Ce suggested, "There is nothing wrong with hepatitis B being a self-limiting disease, but it depends on the situation. His hepatitis B outbreak was due to the use of tocilizumab before, and in the patient's medical history records and the five infectious diseases admitted to the hospital, the hepatitis B records were blank and negative. This means that he should be showing acute infection for the first time, Before that, he was only a negative hepatitis B carrier."
"It is almost impossible for such patients to rely on their own immune system to suppress the acute infection. Even if they can, it will take a long time." Ma Yongfang frowned, "I also agree with Dr. Zhou's opinion, now there is ECMO And artificial liver support, preventive dialysis is enough. If the hepatitis B virus and the new coronavirus are not eliminated as soon as possible, it is impossible for him to get the chance of transplantation.”
"This is a big gamble." Even Dr. Bernard is on Zhou Ce's side, although his opinions are a bit more entangled, "Either the patient can clear the virus in a short time and wait for the transplant, or the patient will be transplanted in a short time." There is multiple organ failure. To put it bluntly, this is a bet on whether he can turn the crisis to safety in a short time..." Bernard hesitated for a long time and said, "If you have to choose, I think it is better to take the initiative."
Sun Lien also hesitated because his team had a different opinion from him.
As the main person in charge of the treatment group, Sun Lien's pressure mainly comes from the consideration of the patient's life safety.Whether it is the central, provincial or even local health commissions, everyone has repeatedly emphasized the issue of reducing mortality.This is not only a professional issue, but also a political issue.
The life safety of the people is the biggest political issue. With sufficient medical resources, doctors have the ability and must carefully wrestle with each case carefully.
Starting a month ago, all deaths need to be brought to a meeting of experts for careful discussion.There were many deaths before, and everyone's main point of view was to find a new entry point for treatment.With the recent rapid decrease in the number of patients who died of the disease, the case discussion meeting has almost become "everyone find fault".
For every treatment decision, every specific step, and even every change in the patient's examination results, the expert team will ask the doctor in charge of the treatment again and again, "Why did you do this", "Why didn't you do this" and "Since you After everything has been done, why the patient still didn’t get it back.”
No doctor can bear this kind of death triple question.
Regardless of whether it was due to personal reasons or to be responsible for the lives of patients, Sun Lien did not intend to turn Yu Xin into a death case and bring it to an expert meeting for discussion.
"You can't talk about this kind of thing with your family members." Xu Yourong's attitude became clearer, and she said seriously to Sun Li'en, "You have to make a decision as soon as possible—whether to continue the conservative treatment like this, or talk to the doctors from the Infectious Disease Hospital Discuss and start a more aggressive treatment plan.”
In order to celebrate EDG's championship, today's update.
However, Luo's condition is not good recently, and it is unknown how much more will come out.I can only keep my words down for now, write as much as I have, and go all out.
According to the old rules, 2K counts as one update.Depending on the situation, there may be 4K or 6K chapters in the future, so it will be counted as two or three.
(End of this chapter)
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