“全球疫情会诊室”: 北京大学第三医院医生与巴西同行分享抗疫经验
6月9日晚，北京大学第三医院的医生与巴西同行参加了中央广播电视总台中国国际电视台（CGTN）的“全球疫情会诊室”网络直播节目，通过在线视频会议分享一线救治新冠肺炎患者的经验。
北医三院院长、北京大学援鄂抗疫国家医疗队领导组组长乔杰院士说，北医三院派出了400多名医护人员赴武汉抗击疫情，连续奋战70多天，积累了大量疫情控制和检测、患者检查和救治等方面的经验。乔院士说，把这些经验分享给世界各国同行，是责任也是义务。
目前，巴西新冠肺炎疫情日益严重。美国约翰斯•霍普金斯大学数据显示，截止6月10日，巴西累计新冠肺炎确诊人数接近74万，仅次于美国，其中死亡病例达3万8千多例。
In the latest episode of CGTN's live stream program "COVID-19 Frontline" held on Tuesday, June 9, CGTN invited four prominent health experts from Peking University Third Hospital, one of the top hospitals under China's National Health Commission, to share their treatment strategies with peers from Brazil.
Qiao Jie, an academician at the Chinese Academy of Engineering and president of Peking University Third Hospital, said more than 400 medical workers from the hospital were dispatched to Wuhan to fight against the epidemic and worked continuously for more than 70 days. The medics have accumulated a lot of experience in epidemic control, patient examination and treatment. Qiao said it is also a duty to share these experiences with the world.
Brazil has seen a continuous spike in COVID-19 deaths over the past few weeks. The number of COVID-19 cases in Brazil totals 739,503 with 38,406 deaths, according to the Johns Hopkins University COVID-19 dashboard. So far the country has the second highest number of infections in the world, after the U.S.
为什么中国病亡率相对较低？
巴西美洲医疗集团ICU医学管理部主任维克多•克拉沃（Victor Cravo）说，他在应对疫情过程中发现巴西公立医院重症患者病亡率超过70%，私立医院也有56%，他希望借鉴中方的管理经验，可以帮助降低病亡率。
北医三院急诊科主治医师李姝说，中国疫情暴发初期，病亡率也很高，其中ICU病房重症患者的病亡率也一度达到52%左右，与巴西目前情况类似。李医生说，这主要是因为疫情初期等待入院的患者太多，而医院床位、医疗用品、防护用品都处于短缺状态，再加上很多患者病情发展很快，导致病亡率很高。
李医生说，后来全国支援武汉，她们所在的病房一度调集到30台“人工肺”，设备充足，因此救治效率也得到了显著提高。
Victor Cravo, head of medical management of the ICU at Americas Medical Services, said the mortality rate of patients receiving mechanical ventilation is high in both public and private services in Brazil. So he wanted to know the experience of Chinese doctors and if there is any different approach to managing the patients.
Li Shu, attending physician of Emergency Medicine, Peking University Third Hospital, answered that they also had a high mortality rate at the beginning when ICU mortality rate was around 52 percent, similar to the rate in Brazil today.
"At the beginning, there were too many patients waiting to be admitted in Wuhan, and we lacked medical equipment. I think some patients developed very quickly in the early stage, so the high mortality rate was normal at the beginning," Li said. But later with enough equipment to treat patients, the mortality rate got lower.
糖皮质激素如何使用？
克拉沃医生还问了糖皮质激素的使用情况。他想知道中方医生在救治中是否使用了激素，是在患者病情早期还是晚期使用，使用效果如何。
北医三院副院长、呼吸与危重症医学科主任医师沈宁说，他们在治疗中使用了糖皮质激素。沈医生说，作为一般的抗炎症药物，该药物在病毒性肺炎治疗过程中的使用还是比较有争议的，主要因为2003年抗击非典时期该药物的副作用比较明显。
沈医生说，在抗击新冠肺炎疫情过程中，医生们对糖皮质激素的使用谨慎了很多，只用于重症和危重症患者。用于有糖尿病、高血压及其他基础疾病患者时，都特别小心。在剂量方面，一般使用低剂量或中剂量，例如0.5到1毫克每公斤体重，连续使用3到5天左右。
但沈医生也提醒，对浓毒性休克或者急性呼吸窘迫综合征患者的治疗，要慎用激素。
Victor Cravo also asked about the use of glucocorticoid in the treatment of COVID-19 patients.
Shen Ning, vice president of Peking University Third Hospital and professor of pulmonary and critical care medicine, said they did use glucocorticoid to treat COVID-19 patients. It's a common anti-inflammatory drug that is used to treat other coronavirus infections such as SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome), but it's still controversial as it may cause sequelaes of varying degrees.
"We used some glucocorticoid in some critically ill COVID-19 patients," Shen said. "We need to use it very cautiously, especially on patients with underlying diseases including diabetes and hypertension, or who have fungal or bacterial infections. The recommended dosage of glucocorticoid is also low."
危重症患者系统性凝血问题
巴西圣保罗大学医学院重症医学专家路易斯•马尔伯伊松（Luiz Malbouisson）说，很多ICU里的重症患者都出现了肺部微小血栓的问题，他希望中方医生介绍一下相关情况，以及在治疗中肝素的使用情况。
李姝医生说，中国的重症患者中也普遍存在着D-二聚体升高现象，也有部分患者出现了其他的凝血指标。
李医生说，在治疗中，中方医生使用了低分子肝素和肝素，一般都按照非标准剂量来用。对于确诊出现血栓的患者，使用标准剂量的肝素，而考虑到早期对新冠肺炎了解有限，这种治疗只应用于不到20位患者。根据全球范围内的研究结论，以及世卫组织的建议，我们根据患者的情况进行用药，确诊患者使用标准剂量，对于有凝血风险的患者则使用干预剂量。
李医生补充说，现有研究已经证明，对于D-二聚体升高和接受机械通气的重症、危重症患者而言，肝素的使用可以有效降低院内病亡率。
Luiz Malbouisson, professor of anesthesiology at University of the Sao Paulo Medical School, said 40 percent of patients have microthrombi in the lungs. So he wanted to know about Chinese doctors' experience in using heparin.
Li Shu said among the patients they treated, some had elevated D-dimer, and one or two patients had other clotting indicators. They used low molecular weight heparin (LMWH) and heparin with non-standard doses, but for patients with confirmed thrombus, full dose of heparin was applied. Study shows heparin can effectively reduce the death rate in severe and critical patients with elevated D-dimer, according to Dr Li.
患者的出院标准是什么？
圣保罗圣路易斯医院传染病医学顾问丹尼尔•瓦格纳•桑托斯（Daniel Wagner Santos）问到IgM和IgG血清检测，以及患者出院标准的问题。
北医三院危重症医学科主治医师李超说，IgM一般会在发病后3到5天内检测到，而IgG则是患者体内的抗体浓度，患者在出院前需要接受血清检测，以判断是否痊愈。
李超医生说，上海的医生们近期发表了一篇论文，指出中和抗体在新冠肺炎患者发病15天之后就会产生，并保持在一个稳定的水平，但有一部分患者的抗体滴度会比较低，甚至无法被检测到。
李姝医生补充说，患者出院主要有三个临床指标，第一是体温连续三天保持正常，第二是肺部症状好转，第三是连续两次PCR测试为阴性。她同时提到，患者出院之后仍然需要经过14天隔离并再接受两次PCR测试，才能解除隔离。
Daniel Wagner Santos, an infectious disease consultant of Sao Luiz Hospital, asked about the IgM and IgG tests and when can patients be discharged from hospital.
Li Chao, attending physician of critical care medicine at Peking University Third Hospital, said IgM is generally detected within 3 to 5 days after the onset of illness, and the patient needs to receive a serological test before discharge to determine whether he or she is fully recovered.
Li Shu added that there are three main requirements for patients to be discharged from hospital. The first is that their body temperature needs to remain normal for three consecutive days; the second is that their lung symptoms improve, and the third is that their PCR tests are negative for two consecutive days. She added that after being released from the hospital, the patient still needs to undergo 14 days of isolation and two more PCR tests.
在一个小时的直播节目中，双方医生还讨论了呼吸机撤离和拔管标准，以及操作中需要注意的问题；抗病毒药物的使用；“人工肺”的使用标准和经验等。对于巴西医生们的问题，中方医生结合一线经验和具体指标、数据等进行了详细解答。
In later episodes of "COVID-19 Frontline," more frontline doctors and experts from Wuhan will join in to share their experience with their colleagues from other parts of the world. If you have any questions regarding COVID-19, you can share them with us using #MyOpinionOnCOVID19 on Facebook.
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