Pcv-aCO2 and procalcitonin levels for the early diagnosis of bloodstream infections caused by gram-negative bacteria.

BACKGROUND: The central venous-to-arterial carbon dioxide difference (Pcv-aCO2) is a biomarker for tissue perfusion, but the diagnostic value of Pcv-aCO2 in bacteria bloodstream infections (BSI) caused by gram-negative (GN) bacteria remains unclear. This study evaluated the expression levels and diagnostic value of Pcv-aCO2 and procalcitonin (PCT) in the early stages of GN bacteria BSI. METHODS: Patients with BSI admitted to the intensive care unit at Guangdong Provincial People's Hospital between August 2014 and August 2017 were enrolled. Pcv-aCO2 and PCT levels were evaluated in GN and gram-positive (GP) bacteria BSI patients. RESULTS: A total of 132 patients with BSI were enrolled. The Pcv-aCO2 (8.32 ± 3.59 vs 4.35 ± 2.24 mmHg p = 0.001) and PCT (30.62 ± 34.51 vs 4.92 ± 6.13 ng/ml p = 0.001) levels were significantly higher in the GN group than in the GP group. In the diagnosis of GN bacteria BSI, the area under the receiver operating characteristic curve (AUROC) for Pcv-aCO2 was 0.823 (95% confidence interval (CI): 0.746-0.900). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 71.90%, 88.00%, 74.07% and 78.21%, respectively. The AUROC for PCT was 0.818 (95% CI: 0.745-0.890). The sensitivity, specificity, PPV and NPV were 57.90%, 94.67%, 71.93% and 74.67%, respectively. CONCLUSIONS: Pcv-aCO2 and PCT have similar and high diagnostic value for the early diagnosis of BSI caused by GN bacteria.

Red blood cell distribution width: A severity indicator in patients with COVID-19.

Red blood cell distribution width (RDW) was frequently assessed in COVID-19 infection and reported to be associated with adverse outcomes. However, there was no consensus regarding the optimal cutoff value for RDW. Records of 98 patients with COVID-19 from the First People's Hospital of Jingzhou were reviewed. They were divided into two groups according to the cutoff value for RDW on admission by receiver operator characteristic curve analysis: ≤11.5% (n = 50) and >11.5% (n = 48). The association of RDW with the severity and outcomes of COVID-19 was analyzed. The receiver operating characteristic curve indicated that the RDW was a good discrimination factor for identifying COVID-19 severity (area under the curve = 0.728, 95% CI: 0.626-0.830, p < 0.001). Patients with RDW > 11.5% more frequently suffered from critical COVID-19 than those with RDW ≤ 11.5% (62.5% vs. 26.0%, p < 0.001). Multivariate logistic regression analysis showed RDW to be an independent predictor for critical illness due to COVID-19 (OR = 2.40, 95% CI: 1.27-4.55, p = 0.007). A similar result was obtained when we included RDW > 11.5% into another model instead of RDW as a continuous variable (OR = 5.41, 95% CI: 1.53-19.10, p = 0.009). RDW, as an inexpensive and routinely measured parameter, showed promise as a predictor for critical illness in patients with COVID-19 infection. RDW > 11.5% could be the optimal cutoff to discriminate critical COVID-19 infection.

Predictive Value of Prognostic Nutritional Index on COVID-19 Severity.

Background: The prognostic nutritional index (PNI) has been described as a simple risk-stratified tool for several diseases. We explored the predictive role of the PNI on coronavirus disease 2019 (COVID-19) severity. Methods: A total of 101 patients with COVID-19 were included in this retrospective study from January 2020 to March 2020. They were divided into two groups according to COVID-19 severity: non-critical (n = 56) and critical (n = 45). The PNI was calculated upon hospital admission: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/mm3). Critical COVID-19 was defined as having one of the following features: respiratory failure necessitating mechanical ventilation; shock; organ dysfunction necessitating admission to the intensive care unit (ICU). The correlation between the PNI with COVID-19 severity was analyzed. Results: The PNI was significantly lower in critically ill than that in non-critically ill patients (P < 0.001). The receiver operating characteristic curve indicated that the PNI was a good discrimination factor for identifying COVID-19 severity (P < 0.001). Multivariate logistic regression analysis showed the PNI to be an independent risk factor for critical illness due to COVID-19 (P = 0.002). Conclusions: The PNI is a valuable biomarker that could be used to discriminate COVID-19 severity.

Efficacy of vitamin C in patients with sepsis: An updated meta-analysis.

Previous studies have suggested the beneficial effects of vitamin C in patients with sepsis. However, the results could not be reproduced in the subsequent studies. This meta-analysis aimed to reevaluate the value of vitamin C treatment in patients with sepsis. Electronic databases were searched from inception to August 2019 for the studies comparing the effect of vitamin C versus non-vitamin C infusion in patients with sepsis. Data from 10 studies (4 randomized controlled trials [RCTs] and 6 retrospective studies) involving 1671 patients (495 in the vitamin C treatment group and 1176 in the control group) were included. The use of vitamin C did not reduce the risk of 28-day (OR = 0.84, P = 0.611, I2 = 56.3%), intensive care unit (ICU; OR = 0.79, P = 0.319, I2 = 46.2%), or in-hospital mortality (OR = 0.76, P = 0.251, I2 = 51.0%). No difference in the duration of vasopressor usage and the length of ICU or hospital stay was present. The subgroup analysis for two RCTs suggested that vitamin C treatment showed reduced 28-day mortality (OR = 0.22, P = 0.014, I2 = 35.7%), whereas this beneficial effect did not occur in subgroup analysis for three retrospective studies (OR = 1.11, P = 0.527, I2 = 0%). Retrospective meta-analysis could not reveal the beneficial effect of vitamin C on patients with sepsis. Therefore, in order to clarify the role of vitamin C in sepsis the high-quality RCTs will be required in the future study.

Role of Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial. METHODS: We systematically reviewed randomized controlled trials investigating the use of NMBA in ARDS patients from inception to July 2019. Relative risk (RR) was calculated for the incidence of barotrauma and mortality using the random-effect or fixed-effect model according to heterogeneity analysis. RESULTS: Data were combined from five randomized controlled trials that included 1,461 patients (724 in the NMBA group and 737 in the control group). Pooled analysis showed that NMBA infusion did not reduce 28-day mortality (RR = 0.72, 95% confidence interval (CI) 0.44 to 1.17, P=0.180, I-squared = 62.8%), but was associated with lower intensive care unit (ICU) mortality (RR = 0.60, 95% CI 0.41 to 0.88, P = 0.009, I-squared = 9.2%). In addition, the incidence of barotrauma was significantly lower in patients treated with NMBA (RR = 0.53, 95% CI 0.33 to 0.84, P = 0.007, I-squared = 0). However, infusion of NMBA might increase the risk of ICU-acquired weakness (RR = 1.34, 95% CI 0.97 to 1.84, P = 0.066, I-squared = 0). CONCLUSION: Infusion of NMBA could reduce ICU mortality and the incidence of barotrauma. The risk of ICU-acquired weakness was higher in moderate-to-severe ARDS patients treated with NMBA. The real effects of NMBA need to be further evaluated and confirmed by a study with a stricter design.

Joint effects of uric acid and lymphocyte count on adverse outcomes in elderly patients with rheumatic heart disease undergoing valve replacement surgery.

OBJECTIVES: Increased uric acid and decreased lymphocyte count are common in elderly patients or those with heart failure, which were prognostic markers. We aimed to investigate the joint effect of uric acid and lymphocyte count for risk stratification in elderly patients with rheumatic heart disease undergoing valve replacement surgery. METHODS: Uric acid to lymphocyte ratio was calculated as serum uric acid (mg/dL)/lymphocyte count (×109/L). Univariate and multivariate analyses were performed to investigate the association of uric acid to lymphocyte ratio, with adverse events in 949 elderly patients with rheumatic heart disease undergoing valve replacement surgery. For clinical use, the uric acid to lymphocyte ratio was classified into 3 groups by the tertile, and a cutoff was also selected according to the receiver operator characteristic curve. RESULTS: Uric acid to lymphocyte ratio produced relatively higher predictive value (area under the curve, 0.703; 95% confidence interval [CI], 0.630-0.776; P < .001) than uric acid or lymphocyte count for in-hospital mortality, and the optimal cutoff was 3.7 (sensitivity, 82.1%; specificity, 52.4%). Uric acid to lymphocyte ratio was an independent predictor for in-hospital (adjusted odds ratio, 1.17; 95% CI, 1.07-1.29; P = .001) and 1-year mortality (adjusted hazard ratio, 1.13; 95% CI, 1.03-1.25; P = .010). The in-hospital mortality increased from the lowest to the highest uric acid to lymphocyte ratio tertile (P < .001) and significantly higher in patients with uric acid to lymphocyte ratio greater than 3.7 (P < .001). The cumulative 1-year postoperative mortality risk was significantly higher in patients with uric acid to lymphocyte ratio greater than 3.7 (P < .001) or upper uric acid to lymphocyte ratio tertile (P < .001). CONCLUSIONS: Uric acid to lymphocyte ratio, combining the effect of uric acid and lymphocyte count, produced more prognostic value in elderly patients with rheumatic heart disease undergoing valve replacement surgery, which could be considered as a preoperative risk-stratified method.

The cardiothoracic ratio: a neglected preoperative risk-stratified method for patients with rheumatic heart disease undergoing valve replacement surgery.

OBJECTIVES: It is common for patients with rheumatic heart disease to have an enlarged heart. We investigated the prognostic value of cardiothoracic ratio (CTR) in patients with rheumatic heart disease undergoing valve replacement surgery. METHODS: A total of 1772 patients were divided into 4 groups based on the quartiles of preoperative CTR: <0.56 (n = 349), 0.56-0.61 (n = 488), 0.61-0.66 (n = 449) and ≥0.66 (n = 486). The CTR was measured from postero-anterior chest radiographs. We then investigated the association between the CTR and adverse outcomes. RESULTS: In-hospital mortality was 4.0% (71/1772). Analyses of receiver operating characteristic curves showed that, at a cut-off of 0.6, the CTR exhibited 66.2% sensitivity and 64.0% specificity for detecting in-hospital death (area under curve 0.671, P < 0.001). The prevalence of in-hospital death was 7.1% in males with a CTR >0.6, which was significantly higher in males without a CTR. A similar result was observed in females (1.9 vs 5.1%, P = 0.004). Multivariable regression showed that a CTR >0.6 was an independent predictor of in-hospital (odds ratio 2.36, P = 0.005) and 1-year mortality (hazard ratio 2.06, P = 0.006). Kaplan-Meier curves, for the cumulative rate of 1-year mortality among groups, indicated that the risk of death was increased if the CTR >0.6 (log-rank 16.36, P < 0.001). CONCLUSIONS: CTR, as a simple and reproducible indicator, was identified as a prognostic factor for predicting poor outcomes in patients with rheumatic heart disease undergoing valve replacement surgery.

Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study.

BACKGROUND: Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. METHODS: We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. RESULTS: Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss's kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). CONCLUSIONS: The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (registration number NCT01704066 ) on 6 October 2012.

Value of Kidney Disease Improving Global Outcomes Urine Output Criteria in Critically Ill Patients: A Secondary Analysis of a Multicenter Prospective Cohort Study.

BACKGROUND: Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGOUO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGOSCr). METHODS: We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGOUOand KDIGOSCr. Hospital mortality of patients with more severe AKI classification based on KDIGOUOwas compared with other patients by univariate and multivariate regression analyses. RESULTS: The prevalence of AKI increased from 52.4% based on KDIGOSCrto 55.4% based on KDIGOSCrcombined with KDIGOUO. KDIGOUOalso resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGOUO. Compared with non-AKI patients or those with maximum AKI classification by KDIGOSCr, those with maximum AKI classification by KDIGOUOhad a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141-13.873, P< 0.001). In a multivariate logistic regression analysis, AKI based on KDIGOUO (OR: 2.891, 95% CI: 1.964-4.254, P< 0.001), but not based on KDIGOSCr (OR: 1.322, 95% CI: 0.902-1.939, P = 0.152), was an independent risk factor for hospital mortality. CONCLUSION: UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.

Prevalence, risk factors, clinical course, and outcome of acute kidney injury in Chinese intensive care units: a prospective cohort study.

BACKGROUND: Acute kidney injury (AKI) has been recognized as a major healthcare problem affecting millions of patients worldwide. However, epidemiologic data concerning AKI in China are still lacking. The objectives of this study were to characterize AKI defined by RIFLE criteria, assess the association with hospital mortality, and evaluate the impact of AKI in the context of other risk factors. METHODS: This prospective multicenter observational study enrolled 3,063 consecutive patients from 1 July 2009 to 31 August 2009 in 22 ICUs across mainland China. We excluded patients who were admitted for less than 24 hours (n = 1623), younger than 18 years (n = 127), receiving chronic hemodialysis (n = 29), receiving renal transplantation (n = 1) and unknown reasons (n = 28). There were 1255 patients in the final analysis. AKI was diagnosed and classified according to RIFLE criteria. RESULTS: There were 396 patients (31.6%) who had AKI, with RIFLE maximum class R, I, and F in 126 (10.0%), 91 (7.3%), and 179 (14.3%) patients, respectively. Renal function deteriorated in 206 patients (16.4%). In comparison with non AKI patients, patients in the risk class on ICU admission were more likely to progress to the injury class (odds ratio (OR) 3.564, 95% confidence interval (CI) 1.706 - 7.443, P = 0.001], while patients in the risk class (OR 5.215, 95% CI 2.798-9.719, P < 0.001) and injury class (OR 13.316, 95% CI 7.507-23.622, P < 0.001) had a significantly higher probability of deteriorating into failure class. The adjusted hazard ratios for 90-day mortality were 1.884 for the risk group, 3.401 for the injury group, and 5.306 for the failure group. CONCLUSIONS: The prevalence of AKI was high among critically ill patients in Chinese ICUs. In comparison with non-AKI patients, patients with RIFLE class R or class I on ICU admission were more susceptibility to progression to class I or class F. The RIFLE criteria were robust and correlated well with clinical deterioration and mortality.

[A survey of present situation of general intensive care unit in second grade hospitals and construction of intensive care network in Guangdong province].

OBJECTIVE: To investigate the present situation of general intensive care unit (ICU) in second grade hospitals, and to establish intensive care network for the Department of Public Health of Guangdong province in Guangdong province. METHODS: Data from ICU of 26 hospitals in Guangdong were collected through questionnaire concerning different aspects of critical care medicine. RESULTS: (1) ICU size was (10.12+/-3.82) beds per unit, ratios of doctors to beds and nurses to beds were 0.73+/-0.25 and 1.80+/-0.57 respectively, and proportions of closed model or semi-closed model of ICU management were 69.2% and 26.9% respectively. (2) Area occupied by per bed was (17.57+/-7.58) m2, ratio of basins with infrared control facet to beds was 0.47+/-0.33, proportions of ICU equipped with room equipped with positive or negative air pressure, laminar flow, or with room for preparing nutrition support were 15.4%, 30.8%, and 23.1% respectively. (3) All the ICU were capable of institution and management of artificial airway, mechanical ventilation, placement of deep vein line, cardioversion and defibrillation, parenteral nutrition, and sedation. Ninety-six point two percent of the ICU could accomplish trachea intubation independently. Fifty-three point eight percent of the ICU could perform hemodynamic monitoring. Continuous blood purification could be done in 73.1 % of the ICU. (4) Ninety-six point two percent of the ICU were equipped with continuous bedside multifunctional electrocardiogram monitor and ratio of the monitors to beds was 0.89+/-0.29. Ratios of resuscitation air bags to beds and ventilators to beds were 0.71+/-0.34 and 0.71+/-0.24 respectively. Portable ventilator was equipped in 34.6 % of the ICU. Forty percent of the ICU could not perform non-invasive ventilation, 65.4 % of the ICU were equipped with fiberoptic bronchoscope, blood gas analysis could be done during 24 hours round in 92.3 % of the ICU. (5) Twenty-six ICU investigated were found to be distributed over the district of Zhujiang delta, and east, north and west regions of Guangdong, forming the base of intensive care network in Guangdong province. CONCLUSION: Most of the general ICU in second grade hospitals in Guangdong province have fulfilled the main requirement for ICU in accordance with the guidelines for construction of ICU in Guangdong province and of guidelines for construction and management of ICU in China. The average level of the ICU is close to level II. It is possible for the intensive care network to integrate, the present resources effectively and then enhance the level of treatment of critical illness in the said district.

[Efficacy and safety of coupled plasma filtration adsorption combined with continuous veno-venous hemofiltration for multiple organ dysfunction syndrome patients with acute liver failure].

OBJECTIVE: To evaluate efficacy and safety of coupled plasma filtration adsorption (CPFA) combined with continuous veno-venous hemofiltration (CVVH) for the treatment of multiple organ dysfunction syndrome (MODS) patients with acute liver failure (ALF), and to evaluate the effect of CPFA plus CVVF on inflammatory mediators in these patients. METHODS: A total of 38 cases of 11 MODS patients with ALF (male 6, female 5) were treated with CPFA plus CVVH, and the following clinical indicators including changes in mean arterial pressure (MAP), oxygen index (PaO(2)/FiO(2)), tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), IL-6, IL-8, biochemical parameters of liver and kidney function, parameters of systemic inflammatory response syndrome (SIRS) score, and acute physiology and chronic health evaluation II (APACHE II) score were determined before and after the treatment. The degree of improvement in clinical symptoms, feasibility, tolerance toward CPFA plus CVVH, therapy-related adverse reactions and security were simultaneously evaluated. RESULTS: MAP increased by 12 mmHg (1 mmHg=0.133 kPa), and PaO(2)/FiO(2) increased by 40 mmHg after the application of CPFA plus CVVH (both P<0.05), along with significant decrease in TNF-alpha, IL-1 beta, IL-6, IL-8 and markedly lowered levels of serum total bilirubin (IBIL), direct bilirubin (DBIL), blood urea nitrogen (BUN), serum creatinine (SCr) and blood ammonia (all P<0.05). Besides, clinical symptoms, including urinary volume, mental disturbance, jaundice, debility, nausea, vomiting, fever, abdominal distention, anepithymia, and SIRS, APACHE II scores were improved significantly after the CPFA plus CVVH (all P<0.05). No therapy-related adverse reactions, including severe haemorrhage, shock, hypersensitivity, were noted, and patients tolerated well toward CPFA plus CVVH. The total survival rate of patients was 45.5% (5/11 cases) at the end of the treatment. CONCLUSION: Our data indicate that CPFA combined with CVVH is an effective and safe method to improve the prognosis of MODS patients with ALF, the mechanism of which may be related to its effective removal of inflammatory cytokines.