Clove Garden (Micro Signal: Dingxiangwang) once published an article < < More than 200 cobras fled from Nanjing. Never do this after poisonous snakes bite! > >.
In the message of the article, many readers raised questions about the point of view in the article: Do you have to listen to the guide?
The guide does not recommend it, is it really impossible to do it? Like the forbidden fruit of Eden?
No-clinicians should have their own judgment and screening process, instead of swallowing it whole and rejecting it completely.
The guidelines [not recommended], there are two situations, one is [done harmful], the other is [done useless]. For the second situation, combined with clinical practice and patient individualization, the treatment [not recommended] in the guidelines can also be selected.
It is harmful to do so and should be avoided.
The first step is to find out why it is not recommended. The situation of [doing harmful] should be avoided. This part, under normal circumstances, belongs to [cannot be done].
For example, some guidelines suggest that this is typical of [doing harmful]:
(1) Digoxin, non-dihydropyridine calcium antagonists or amiodarone (III, B) cannot be used for atrial fibrillation combined with preexcitation. Because these three drugs may accelerate bypass conduction and aggravate the disease condition, they are not recommended-2014 AHA/ACC/HRS atrial fibrillation guidelines.
(2) When insulin therapy is applied in internal medicine or surgical intensive care units, the blood glucose control target is 7.8 ~ 11.1 mmol/L, intensive insulin therapy is not recommended, and blood glucose below 7.8 mmol/L should be avoided. Because when blood glucose below this target, the risk of hypoglycemia is significantly increased and there is a possibility of increasing mortality-2013 American Association of Physicians (ACP) Guidelines for Blood Glucose Control of Inpatients
(3) Hydroxyethyl starch is not recommended for fluid resuscitation of severe sepsis and septic shock (2B) because it increases the probability of acute kidney injury and renal replacement therapy without improving short-term and long-term prognosis-2014 China Guidelines for Treatment of Severe Sepsis/Septic Shock
These are common misunderstandings in clinical practice and are harmful. Therefore, the guidelines clearly suggest that they are not recommended.
However, in our previous article “Poisonous Snake Bite”, the local method mentioned [Don’t Do] may bring unnecessary harm to patients.
It is useless to do so. Why is it still useful?
Medicine is flexible and individualized. There are some methods [not recommended] in clinical guidelines, but they are actually [ineffective], but they can still be used according to the individual situation of patients.
Why is this?
Because the guidelines are mostly useless to the hard end point.
However-
Although some treatment methods have not been found to improve [hard endpoint], they also have definite clinical effects-such as some symptomatic treatment, relieving clinical symptoms, and even bringing comfort to dying patients as part of [soothing medicine].
For example, please look at the following two guidelines:
(1) Diuretics are not recommended to prevent acute kidney injury (AKI) (1B), and diuretics are not recommended to treat AKI (2C) except for treatment volume overload-2012 KDIGO Clinical Practice Guidelines for Acute Kidney Injury
Admittedly, in general, diuretics and dopamine cannot prevent and treat AKI or reduce the probability of renal replacement therapy, but diuretics can definitely increase the urine volume of AKI patients. However, low-dose dopamine can increase urine volume, decrease creatinine and increase GFR (failure after the second day) on the first day of use. The combination of the two is a commonly used diuretic mixture in clinic.
So, since the guidelines say that the prognosis will not be improved, why is it still widely used clinically? Because it is really important to have urine: The capacity balance can be maintained first, Only in this way can we safely enter fluids (such as antibiotics, nutrition, etc.). Second, we can maintain electrolyte balance. Third, we can correct acidosis and maintain the efficacy of vasoactive drugs. Using diuretics to maintain urine volume, thus winning time to correct reversible factors of AKI (such as infection and heart failure), is a commonly used clinical strategy, which does prevent some patients from dialysis.
(2) Routine intra-aortic balloon pump (IABP) implantation in patients with cardiogenic shock is not recommended in patients with myocardial infarction (III, B) unless there are mechanical complications (IIa, C)-2015 ESC Guidelines for the Management of Non-ST Segment Elevation Acute Coronary Syndrome
IABP can definitely improve coronary artery perfusion. In patients with cardiogenic shock where fluid resuscitation and drug support cannot maintain blood pressure, early use of IABP can obtain definite hemodynamic benefits. IABP can also provide circulatory support during complex interventions. However, IABP has not been found to reduce mortality.
The above two examples also suggest that there may be some unreasonable points in the current guideline rating, i.e. Only the [hard endpoint] is emphasized, and those who fail to reach the improvement of the hard endpoint are classified as [not recommended] or [Class III recommended], which is easy for doctors to ignore the benefits beyond the treatment endpoint.
Not recommended now does not mean not recommended in the future
The guide is developed and the concept is updated. Not recommended now does not mean not recommended in the future.
Previously, the guidelines did not recommend percutaneous coronary intervention (PCI) for left main coronary artery lesions, Coronary artery bypass grafting (CABG) should be performed. However, with the advent of technological innovations, including drug stents, intravascular ultrasound (IVUS) and optical coherence tomography (OCT), PCI has now risen to Class I recommendation for patients with low SYNTAX score (complexity of coronary lesions), and the recommendation level has undergone earth-shaking changes.
To give another example, Patients with acute myocardial infarction, Previously, it was thought that criminal vessels (diseased vessels causing myocardial infarction) should be treated separately instead of non-criminal vessels at the same time. However, with the increase of evidence, the 2014 ESC/EACTS myocardial infarction revascularization guidelines proposed changes, pointing out that specific patients can consider direct PCI to treat both criminal vessels and severely stenotic non-criminal vessels (IIb, B).
On the other hand, what is recommended now may be controversial or rejected in the future. Therefore, the guidelines are only the understanding of the treatment of a certain disease at a specific stage and can standardize and guide medical decision-making. However, the guidelines are by no means the same [golden rule] that must be fully accepted.
Measuring the risks and benefits of treatment is a compulsory course for good doctors.
The guidelines are the crystallization of evidence-based medicine, but they cannot cover every patient.
For the content not recommended in the guidelines, it should not be totally denied. Clinicians should have their own judgment and screening process. The guidelines are guidance and standardization for clinical decision-making, but they should also combine clinical practice and the individualized situation of patients to finally make the most reasonable choice.
Therefore, an excellent doctor will definitely not stick to the guidelines dogmatically, but will consider these issues before deciding to do a treatment not recommended by the guidelines:
Why does the guide not recommend this?
- Why do you want to do this to specific patients? Is this treatment the only option? Will it cause additional damage? Is the benefits of this treatment reliable? Is there sufficient evidence to prove it? How does the income compare with the risk? Will other effective treatments recommended by the guidelines be delayed? … …
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Author: Mai Jingting, Department of Cardiovascular Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University