[Predictive value of von Willebrand factor for venous thromboembolism in critically ill patients based on propensity score matching].

OBJECTIVE: To analyze the predictive value of von Willebrand factor (vWF) for venous thromboembolism (VTE) of patients in intensive care unit (ICU) by using propensity score matching (PSM). METHODS: Patients admitted to ICU of the Second Affiliated Hospital of Kunming Medical University from December 2020 to June 2022 who stayed in ICU for ≥72 hours and underwent daily bedside vascular ultrasound screening were included. Baseline data such as age, gender, primary disease, and chronic comorbidities were collected. Coagulation indexes before admission to ICU and 24 hours and 48 hours after ICU admission were collected, including prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), international normalized ratio (INR), fibrinogen (Fib), fibrin monomer (FM), vWF, D-dimer, antithrombin III (ATIII), etc. Patients were divided into VTE group and non-VTE group according to whether they had VTE or not [diagnosis of VTE: patients underwent daily ultrasound screening of bedside blood vessels (both upper and lower limbs, visceral veins), and those suspected of having thrombosis were confirmed by ultrasonographer or pulmonary angiography]. Using PSM analysis method, the VTE group was used as the benchmark to conduct 1 : 1 matching of age, whether there was malignant tumor, whether there was infection, whether there was diabetes, and coagulation indicators before admission to ICU. Finally, the cases with balanced covariates between the two groups were obtained. The risk factors of VTE were analyzed by multivariate Logistic regression analysis. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of vWF in the occurrence of VTE in critically ill patients. RESULTS: A total of 120 patients were enrolled, of which 18 (15.0%) were diagnosed with VTE within 72 hours after admission to ICU, and 102 (85.0%) were not found to have thrombus in ICU. Before PSM, there were significant differences in age, gender, proportion of malignant tumor and infection, and coagulation indexes between VTE group and non-VTE group. After PSM, 14 pairs were successfully matched, and the unbalanced covariables between the two groups reached equilibrium. Multivariate Logistic regression analysis showed that vWF was an independent risk factor for VTE at 48 hours after ICU admission in critically ill patients [odds ratio (OR) = 1.165, 95% confidence interval (95%CI) was 1.000-1.025, P = 0.004]. ROC curve analysis showed that the area under the ROC curve (AUC) of vWF at 48 hours after ICU admission for predicting VTE was 0.782, 95%CI was 0.618-0.945, P = 0.007. When the optimal cut-off value was 312.12%, the sensitivity was 67.7% and the specificity was 93.0. CONCLUSIONS: Dynamic monitoring of vWF is helpful to predict the occurrence of VTE in ICU patients, and vWF at 48 hours after ICU admission has certain value in predicting the occurrence of VTE.

Melatonin intervention to prevent delirium in the intensive care units: a systematic review and meta-analysis of randomized controlled trials.

Objective: To determine the preventive effect of melatonin on delirium in the intensive care units. Methods: We conducted a systematic search of the PubMed, Cochrane Library, Science, Embase, and CNKI databases, with retrieval dates ranging from the databases' inception to September 2022. Controlled trials on melatonin and placebo for preventing delirium in the intensive care units were included. The meta-analysis was performed using Review Manager software (version 5.3) and Stata software (version 14.0). Results: Six studies involving 2374 patients were included in the meta-analysis. The results of the meta-analysis showed that melatonin did not reduce the incidence of delirium in ICU patients (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.46 to 1.12; p = 0.14). There was a strong hetero-geneity between the selected studies (I2 = 74%). Subgroup analysis results showed that melatonin reduced the incidence of delirium in cardiovascular care unit (CCU) patients (OR: 0.52; 95% CI: 0.37 to 0.73; p=0.0001), but did not in general intensive care unit (GICU) patients (OR: 1.14; 95% CI: 0.86 to 1.50; p=0.35). In terms of the secondary outcomes, there were no significant differences in all-cause mortality (OR: 0.85; 95% CI: 0.66 to 1.09; p=0.20), length of ICU stay (mean difference [MD]: 0.33; 95% CI: -0.53 to 1.18; p=0.45), or length of hospital stay (MD: 0.51; 95% CI: -1.17 to 2.19; p=0.55). Conclusion: Melatonin reduced the incidence of delirium in CCU patients, but did not significantly reduce the incidence of delirium in GICU patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022367665.

The Impact of intra-abdominal Pressure on Perioperative Outcomes in Robotic-Assisted Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

Objective: The aim of the study is to analyze the impact of intra-abdominal pressure (IAP) on perioperative outcomes in robotic-assisted radical prostatectomy (RARP). Methods: We searched the PubMed, Cochrane Library, Science, Embase, and CNKI databases systematically, and the retrieval date was from the inception of the databases to April 2022. Randomized controlled trials on high intraabdominal pressure (HIAP) and low intraabdominal pressure (LIAP) in RARP were included. The meta-analysis was performed using Review Manager software (version 5.3). Results: Six studies involving 2,271 patients were included in the meta-analysis. Compared with patients who experienced HIAP, those who experienced LIAP had a lower incidence of postoperative ileus (POI) (risk ratio (RR): 0.42; 95% confidence interval (CI): 0.24 to 0.72; p = 0.002). However, there were no significant differences in hematoma (RR 2.22; 95% CI, 0.61 to 8.15; p = 0.23), positive margin rate (RR, 1.06; 95% CI, 0.84 to 1.32; p = 0.64), urinary retention (RR, 0.99; 95% CI, 0.51 to 1.94; p = 0.98), operative time (mean difference (MD), -0.36; 95% CI, -12.24 to 6.12; p = 0.51), or intraoperative blood loss (MD, -21.80; 95% CI, -55.28 to 11.68; p = 0.20) among patients undergoing LIAP and HIAP. Conclusion: Our study of published trials indicates that using LIAP during RARP may reduce the incidence of POI, and there were no differences in terms of hematoma, positive margin rate, urinary retention, operative time, or intraoperative blood loss.

[Analysis of treatment for 360 critically ill pregnant and parturient women in intensive care unit].

OBJECTIVE: To analyze the clinical characteristics and outcomes of critically ill pregnant and parturient women in intensive care unit (ICU), and to provide clinical experience for the subspecialty construction of critical obstetrics. METHODS: The clinical data of critically ill pregnant and parturient women admitted to the department of critical care medicine, the Second Affiliated Hospital of Kunming Medical University from January 2011 to December 2019 were collected. The main reasons for maternal transfer to ICU, the causes of maternal death, and organ support measures, etc. were summarized. RESULTS: A total of 39 567 critically ill pregnant and parturient women were admitted to the department of obstetrics in our hospital, and 360 were transferred to ICU, with an average ICU transfer rate of 0.91%. Since 2016, the number of obstetric admissions, the number of ICU transfers and the ICU transfer rate had increased significantly. The average age of severe maternals admitted to ICU was (30.9±5.7) years old. The average acute physiology and chronic health evaluation II (APACHE II) score was 7 (4, 10). The average length of ICU stay was 1 (1, 2) day. The average ventilator duration was 9.0 (3.0, 17.5) hours. The main delivery mode of pregnant women in ICU was cesarean section (84.72%). Forty-eight patients (13.33%) underwent hysterectomy, of which 42 (87.5%) due to postpartum hemorrhage. The top 3 causes of ICU admission were severe postpartum hemorrhage [36.94% (133/360)], hypertensive disorders of pregnancy [21.67% (78/360)], pregnancy with cardiac disease [15.00% (54/360)]. The leading cause of postpartum hemorrhage in women transferred to ICU was placental abnormality [63.98% (103/161)], followed by uterine atony [28.57% (46/161)]. The average blood loss was (4 019±2 327) mL within 24 hours after delivery, and the number of women who underwent hysterectomy due to postpartum hemorrhage decreased year by year. During the study period, there were 2 maternal deaths, which were indirect obstetric deaths, 3 cases were discharged against-advice (expected death), including 1 indirect death and 2 direct obstetric death; the mortality in ICU was 1.39% (5/360). CONCLUSIONS: The most common reasons for pregnant and parturient women to be admitted to ICU were severe postpartum hemorrhage and hypertensive disorders of pregnancy. The leading cause of postpartum hemorrhage was placental problem. Indirect obstetric deaths exceeded direct obstetric deaths, mainly due to pregnancy complicated with cardiac disease and severe pneumonia. ICU has become an important battlefield for rescuing critically ill maternal and an important guarantee for reducing the maternal mortality.

[A comparison of clinical characteristics between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome].

OBJECTIVE: To compare and analyze the clinical characteristics between acute fatty liver of pregnancy (AFLP) and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. METHODS: This is a retrospective cohort study. The clinical data of 13 cases with AFLP and 34 cases with HELLP syndrome were collected from three tertiary referral centers in Yunnan (the First Affiliated Hospital of Kunming Medical University, the Second Affiliated Hospital of Kunming Medical University, and Yan'an Hospital of Kunming City) from January 2016 to December 2021. The patients were diagnosed to AFLP and HELLP syndrome according to the Swansea criteria and the Tennessee classification system. The general characteristics, clinical features, laboratory results within 24 hours after admission, complications, maternal and neonatal outcomes were compared to analysis the differences between the two groups. RESULTS: (1) Maternal characteristics: compared with HELLP syndrome group, AFLP group had lower body mass index (BMI) and blood pressure at admission (both P < 0.01). (2) Clinical features: the most common symptoms in AFLP patients were skin jaundice, abdominal pain, nausea and vomiting, edema. The main manifestations of patients with HELLP syndrome were albuminuria, hypertension, edema, headache. Some patients had multiple symptoms concurrently. (3) Laboratory results: compared with HELLP syndrome group, the levels of platelet count (PLT), total bilirubin (TBil), direct bilirubin (DBil), γ-glutamyl transferase (γ-GGT), alkaline phosphatase (ALP), total bile acid (TBA), serum creatinine (SCr) and international standardized ratio (INR) in AFLP group were significantly increased within 24 hours after admission [PLT (×109/L): 107.69±51.13 vs.76.71±43.25,TBil (µmol/L): 121.60 (83.20, 170.00) vs.15.25 (7.22, 29.05), DBil (µmol/L): 86.50 (58.60, 104.00) vs. 4.30 (2.22,10.10), γ-GGT (U/L): 87.00 (37.00, 127.00) vs. 41.00 (19.00,64.42), ALP (U/L): 199.10 (109.00, 349.20) vs. 125.50 (90.50, 155.25), TBA (µmol/L): 51.50 (16.20, 117.40) vs. 4.15 (2.02, 6.95), SCr (µmol/L): 155.80 (129.00, 237.00) vs. 79.00 (65.43, 113.70), INR: 1.28 (1.17, 1.63) vs. 0.94 (0.88, 1.08), all P < 0.05], prothrombin time (PT) was significantly prolonged [seconds: 16.10 (14.50, 19.20) vs. 12.40 (11.43, 13.40), P < 0.05]. The level of blood glucose (GLU), fibrinogen (FIB) and the activity of antithrombin III (AT III) decreased significantly [GLU (mmol/L): 5.18±1.33 vs. 6.33±1.19, FIB (g/L): 1.96±1.46 vs. 3.81±1.58, AT III (%): 40.61±25.84 vs. 66.39±24.11, all P < 0.05]; (4) Complications: compared with HELLP syndrome group, the incidence of patients with hypoglycemia [30.77% (4/13) vs. 0% (0/34)], acute liver failure [53.85% (7/13) vs. 5.88% (2/34)], acute renal insufficiency [69.23% (9/13) vs. 8.82% (3/34)], coagulopathy [76.92% (10/13) vs. 38.24% (13/34)], disseminated intravascular coagulation (DIC) [53.85% (7/13) vs. 5.88% (2/34)], and multiple organ dysfunction syndrome (MODS) [53.85% (7/13) vs. 5.88% (2/34)] were significantly higher in AFLP group (all P <0.05). (5) Maternal and neonatal outcome: all patients delivered after admission. The total length of hospital and intensive care unit stay were significantly longer in the AFLP group than in the HELLP syndrome group [days: 17.00 (11.00, 25.00) vs. 9.00 (7.00, 12.00), 12.00 (4.00, 22.00) vs. 3.91 (0, 7.00), both P < 0.01]. Two AFLP patients died, including one due to intracranial venous thrombosis and one due to multiple organ failure and cardiopulmonary arrest. There were no deaths in the HELLP syndrome group. CONCLUSIONS: There are significant differences in maternal characteristics, laboratory results and complications between AFLP and HELLP syndrome. TBil, γ-GGT, SCr, FIB, INR and AT III activity may help to distinguish the two diseases.

Protective effects of Baicalin injection on severe acute pancreatitis through regulating follistatin-like-1 signaling pathway by down-regulating miR-429 expression in mice

Abstract In China, Scutellaria is used for treating inflammatory-related diseases. Baicalin is the main active component of Scutellaria and has protective effects on acute pancreatitis. However, the mechanism of Baicalin is still unclear. In this study, the protective effects of baicalin on acute pancreatitis induced by taurocholate and its mechanism are investigated. In this study, mice were randomly divided into three groups: sham operation, model, and treatment groups. Acute pancreatitis in mice was induced by intraperitoneal injection of taurocholate (35 mg/kg). The treatment group was given baicalin (100 mg/kg) 2 h before acute pancreatitis induction. The mRNA expression levels of miR-429, nuclear factor kappa B65(NF-kB65), toll-like receptor 4(TLR4), TNF receptor associated factor6 (TRAF6), NF-kappa-B inhibitor(IkB), Follistatin-like 1 (FSTL1), and interleukin-1 receptor-associated kinase (IRAK) in the liver tissues 24 h after intraperitoneal injection were detected by RT-PCR. Then, the expression levels of NF-kB65, p-NF-κB65, TLR4, TRAF6, IkB, FSTL1, IRAK, p- IRAK, and p- IkB-а proteins were detected by Western blot. IL-6, TNF-α and IL-1 ß in plasma were measured by ELISA, and histopathological changes in the pancreases of the mice were observed. The results showed that after baicalin treatment, miR-429 expression in the pancreatic tissues and the expression levels of NF-kB65, TLR4, TRAF6, p-IkB-а, FSTL1, and p-IRAK decreased. Similarly, pancreatic myeloperoxidase (MPO) activity and the plasma levels of IL-6, TNF-а, IL-12, IL-1ß1, endotoxin, serum amylase, and lipase were reduced. Thus, the pancreatic injury induced by taurocholate was alleviated. The present study indicates that pretreatment with Baicalin can alleviate acute pancreatic injury induced by taurocholate in mice. The mechanism may be associated with the decreased miR-429 expression, reduced FSTL1 signaling pathway activity, TLR4 and TLR4/MyD88 signaling pathway inhibition, and reduced pancreatic inflammation. FSTL1 is the regulatory target for miR-429

Shock in China 2018 (SIC-study): a cross-sectional survey.

BACKGROUND: Shock is a critical illness that seriously threatens the lives of patients. This study explains the epidemiology of shock, mortality of shock, and identify factors that related to hospital death. METHODS: This is a multi-centre cross-sectional survey, which included 1,064 tertiary hospitals in 31 provinces, municipalities, and autonomous regions across China mainland. Totally 289,428 patients who diagnosed with shock based on the ICD-10 abstracted from the Hospital Quality Monitoring System (HQMS) in 2018, a national database administrated by National Health Commission of the PRC. RESULTS: Patients diagnosed with shock were screened and classified according to the type of shock. Regression analysis was used to identify factors that related to death. A total of 79,668,156 medical records were included in HQMS in 2018, from which a total of 289,428 records with shock were identified. Hypovolemic shock occurred in 128,436 cases (44.38%), septic shock occurred in 121,543 cases (41.99%), cardiogenic shock occurred in 44,597 cases (15.41), and obstructive shock occurred in 3,168 cases (1.09%). Of these, 8,147 cases (2.81%) had mixed shock, which means had two or more types of shock. For all the shock cases, the top three frequent concomitant diseases recorded were circulatory system diseases (55.22%), digestive system diseases (53.64%), and respiratory system diseases (53.31%). Of the four types of shock, cases with cardiogenic shock had the highest in-hospital mortality (31.6%), followed by those with obstructive shock (25.2%), septic shock (22.9%), and hypovolemic shock (15.5%). Interestingly, the combination of shock and malignant tumors is one of the major factors that related to hospital deaths. CONCLUSIONS: Shock is a serious disease with a high fatality rate and huge clinical costs. According to this epidemiological survey of shock in China 2018, we should clarify the factors related to the hospital death in shock cases.

Swertianolin ameliorates immune dysfunction in sepsis via blocking the immunosuppressive function of myeloid- derived suppressor cells.

In this study, we studied the long-term proliferation trajectory of myeloid-derived suppressor cells (MDSCs) in murine sepsis model and investigated whether swertianolin could modulate the immunosuppressive function of MDSCs. A murine sepsis model was established by cecal ligation and perforation (CLP), according to the Minimum Quality Threshold in Pre-Clinical Sepsis Studies (MQTiPSS) guidelines. The bone marrow and spleen of the mice were collected at 24 h, 72 h, 7 and 15 d after sepsis induction. The proportions of monocytic-MDSCs (M-MDSCs; CD11b+LY6G-LY6Chi) and granulocytic-MDSCs (G-MDSC, CD11b+ Ly6G+ Ly6Clow) were analyzed by flow cytometry. Then, we have investigated whether swertianolin could modulate the immunosuppressive function of MDSCs in in vitro experiments. G-MDSCs and M-MDSCs increased acutely after sepsis with high levels sustained over a long period of time. G-MDSCs were the main subtype identified in the murine model of sepsis with polymicrobial peritonitis. Furthermore, it was found that swertianolin reduced significantly interleukin-10 (IL-10), nitric oxide (NO), reactive oxygen species (ROS), and arginase production in MDSCs, while reducing MDSC proliferation and promoting MDSC differentiation into dendritic cells. Swertianolin also improved T-cell activity by blocking the immunosuppressive effect of MDSCs. Both subsets of MDSCs significantly increased in the bone marrow and spleen of the mice with sepsis, with G-MDSCs being the main subtype identified. Swertianolin effectively regulated the functions of MDSCs and reduced immune suppression.

[Severe influenza A (H1N1) in late pregnancy: a case report].

OBJECTIVE: Pregnancy has increased susceptibility to H1N1 influenza virus infection. Maternal influenza infection is associated with increased risk of morbidity and mortality. A case of influenza A (H1N1) during late pregnancy (pregnancy 1, birth 0, pregnancy 30+2 weeks) was admitted to the Second Affiliated Hospital of Kunming Medical University on December 16th, 2018. The patient was set on mechanical ventilation with a FiO2 of 1.0, a positive end-expiratory pressure (PEEP) of 15 cmH2O (1 cmH2O = 0.098 kPa), and a tidal volume of 4-6 mL/kg (ideal body weight). However the pulse oxygen saturation (SpO2) could only be maintained at about 0.85. The disease was controlled by the treatments of anti-infection, mechanical ventilation, immune therapy, nutritional support, preventive anticoagulant treatment by heparin sodium, adequate negative fluid balance, and other organ support therapy. This article introduced the treatment process of the patient in detail, and provided experience for clinical treatment.

Nomogram for the prediction of postoperative hypoxemia in patients with acute aortic dissection.

BACKGROUND: Postoperative hypoxemia is quite common in patients with acute aortic dissection (AAD) and is associated with poor clinical outcomes. However, there is no method to predict this potentially life-threatening complication. The study aimed to develop a regression model in patients with AAD to predict postoperative hypoxemia, and to validate it in an independent dataset. METHODS: All patients diagnosed with AAD from December 2012 to December 2017 were retrospectively screened for potential eligibility. Preoperative and intraoperative variables were included for analysis. Logistic regression model was fit by using purposeful selection procedure. The original dataset was split into training and validating datasets by 4:1 ratio. Discrimination and calibration of the model was assessed in the validating dataset. A nomogram was drawn for clinical utility. RESULTS: A total of 211 patients, involving 168 in non-hypoxemia and 43 in hypoxemia group, were included during the study period (incidence: 20.4%). Duration of mechanical ventilation (MV) was significantly longer in the hypoxemia than non-hypoxemia group (41(10.5140) vs. 12(3.75,70.25) hours; p = 0.002). There was no difference in the hospital mortality rate between the two groups. The purposeful selection procedure identified 8 variables including hematocrit (odds ratio [OR]: 0.89, 95% confidence interval [CI]: 0.80 to 0.98, p = 0.011), PaO2/FiO2 ratio (OR: 0.99, 95% CI: 0.99 to 1.00, p = 0.011), white blood cell count (OR: 1.21, 95% CI: 1.06 to 1.40, p = 0.008), body mass index (OR: 1.32, 95% CI: 1.15 to 1.54; p = 0.000), Stanford type (OR: 0.22, 95% CI: 0.06 to 0.66; p = 0.011), pH (OR: 0.0002, 95% CI: 2*10- 8 to 0.74; p = 0.048), cardiopulmonary bypass time (OR: 0.99, 95% CI: 0.98 to 1.00; p = 0.031) and age (OR: 1.03, 95% CI: 0.99 to 1.08; p = 0.128) to be included in the model. In an independent dataset, the area under curve (AUC) of the prediction model was 0.869 (95% CI: 0.802 to 0.936). The calibration was good by visual inspection. CONCLUSIONS: The study developed a model for the prediction of postoperative hypoxemia in patients undergoing operation for AAD. The model showed good discrimination and calibration in an independent dataset that was not used for model training.

[Analysis of high risk factors of intensive care unit-acquired weakness in patients with sepsis].

OBJECTIVE: To investigate high risk factors of intensive care unit-acquired weakness (ICUAW) in patients with sepsis. METHODS: A retrospective study was conducted. 164 patients with mechanical ventilation (MV) who were diagnosed sepsis and multiple organ dysfunction syndrome (MODS), admitted to intensive care unit (ICU) of the Second Affiliated Hospital of Kunming Medical University from January 1st, 2015 to September 30th, 2017 were enrolled. The general situation, the basic diseases (hypertension, diabetes), body mass index (BMI), protopathy diseases, the level of albumin before ICU admission, the MV time, whether to use glucocorticoid and continuous renal replacement therapy (CRRT) or not, nutrition supply (nutritional way, nutrition initiation time, amino acid/protein supply, nutritional status on ICU 3 days and 7 days), myoglobin, the length of ICU stay, the length of hospital stay, and acute physiology and chronic health evaluation II (APACHE II) score were collected. The high risk factors of ICUAW in patients with sepsis complicated with MODS were analyzed further using multi-factor Logistic regression analysis. Multiple linear regression analysis was used to analyze the myoglobin related factors in sepsis patients. RESULTS: The ICUAW incidence was 25.6% (42/164). The risk factors with differences in univariate analysis were included in the multivariate Logistic regression analysis, and it was shown that the level of albumin before ICU [odds ratio (OR) = 0.232, 95% confidence interval (95%CI) = 0.061-0.885, P = 0.032], the MV time (OR = 0.380,95%CI = 0.154-0.935, P = 0.035), nutrition initiation time (OR = 2.642, 95%CI = 1.100-6.346, P = 0.030), myoglobin (OR = 4.129, 95%CI = 1.681-10.142, P = 0.002) were the independent risk factors for ICUAW in sepsis patients with MODS. The linear regression showed that the level of myoglobin was positively correlated with APACHE II score (ß= 38.297, P = 0.000), negatively correlated with the length of hospital stay (ß= -7.071, P = 0.048), and it had nothing to do with the MV time and the length of ICU stay. CONCLUSIONS: Evaluation of muscle function should be a routine part of ICU examination. The levels of albumin, MV time, hemoglobin and nutritional start-up time were independent risk factors for ICUAW in sepsis patients with MODS. Myoglobin levels can be used as an indicator of severity.

[Measurement of brachial artery velocity variation and inferior vena cava variability to estimate fluid responsiveness].

OBJECTIVE: To investigate the accuracy and feasibility of brachial artery peak velocity variation (ΔVpeakbrach) and inferior vena cava variability (VIVC) as indicators of fluid responsiveness in critically ill patients. METHODS: A single-center prospective observation was conducted. The patients on mechanical ventilation with spontaneously breathing admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from June 2013 to August 2015 were enrolled. The patients were diagnosed as severe sepsis or sepsis shock. The peak velocity in brachial artery and diameter of the inferior vena cava at the end of inspiration and expiration was measured by bedside portable ultrasonic machine, and then ΔVpeakbrach and VIVC were calculated. The hemodynamic parameters were collected at baseline and after volume expansion (VE). The stroke volume (SV) was measured by pulse-indicated continuous cardiac output (PiCCO). Patients were classified as responders or non-responders according to the variation of SV (ΔSV) increased ≥ 15% or not after VE. Receiver operating characteristic curve (ROC) was plotted to evaluate the sensitivity and specificity of ΔVpeakbrach and VIVC in predicting volume responsiveness. RESULTS: Among 58 patients after VE, 32 patients were defined as responders and the rest 26 were defined as non-responders.There were no differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) score, dose of vasoactive agent, ventilator parameters and infection site. Compared with baseline hemodynamic parameters, heart rate (HR) was decreased (bpm: 95±18 vs. 103±21), and systolic blood pressure (SBP) was increased [mmHg (1 mmHg = 0.133 kPa): 92±8 vs. 80±7] after VE in responders; central venous pressure (CVP) was increased after VE in non-responders (mmHg: 11±4 vs. 8±3, all P < 0.05). The ΔVpeakbrach [(15.4±4.3)% vs. (11.2±3.5)%] and VIVC [(18.6±4.1)% vs. (14.3±3.6)%] in responders were significantly increased as compared with those of non-responders (both P < 0.05). The area under ROC curve (AUC) of ΔVpeakbrach for predicting volume responsiveness was 0.816. When the cut-off value of ΔVpeakbrach was ≥ 13.3%, the sensitivity was 71.9%, and the specificity was 80.8%. AUC of VIVC for predicting volume responsiveness was 0.733. When the cut-off value of VIVC was ≥ 19.25%, the sensitivity was 53.1%, and the specificity was 88.5%. CONCLUSIONS: ΔVpeakbrach and VIVC are reliable indicators for predicting volume responsiveness in critical patients.

[The incidences of organ dysfunction in the early resuscitation of severe sepsis and septic shock patients:a retrospective analysis].

Objective: To investigate the potential risk factors of organ dysfunction and mortality in the early resuscitation of severe sepsis and septic shock patients. Methods: Data were retrospectively analyzed from patients with severe sepsis and septic shock receiving non-cardiac operation and admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from January 1st,2013 to December 31st,2015.The patients were divided into the senior group (≥ 65 years old) and the younger group (＜ 65 years old),the high-procalcitonin (PCT) group (PCT ＞ 100 µg/L) and the control group (PCT ≤ 100 µg/L).The stage of early resuscitation was set to the first 6 hours. The diagnostic time and the incidence of acute respiratory distress syndrome (ARDS),acute kidney injury (AKI),and cardiac insufficiency were observed, which also included the usage of continuous renal replacement therapy (CRRT).The total fluid volume and the time of vasopressor usage during the first 6 hours of early goal-directed therapy (EGDT) were also recorded, which aslo included the 28-day mortality. Results: 512 patients with severe sepsis and septic shock receiving non-cardiac operation were treated according to the guidelines of "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock:2012".EGDT was used during the early resuscitation. The incidence of ARDS, AKI, and cardiac insufficiency was 80.9％ (414/512),71.3％ (365/512),and 61.9％ (317/512) respectively. There were 205 senior patients and 307 younger, as well as 154in high-PCT group and 358 in control group. The 28-day mortality was 30.3％ (155 died).90.8％ of patients (376/414)combined with ARDS were diagnosed before EGDT.95.1％ of patients (347/365) combined with AKI were diagnosed before EGDT, among whom 14.0％ (51/365) were treated with CRRT.153 senior patients combined with cardiac insufficiency were diagnosed no longer than 12 hours after EGDT. Compared with the younger group, the incidences of ARDS and cardiac insufficiency were higher in the senior group [85.9％ (176/205) vs.77.5％ (238/307),82.9％(170/205) vs.32.9％ (147/307),both P ＜ 0.05],so were the time of vasopressor usage during EGDT (hours:5.81 ±0.28vs.5.68 ± 0.52,P ＜ 0.05) was prolonged markedly and the 28-day mortality [42.9％ (88/205) vs.21.8％ (67/307),P ＜0.05] was increased significantly. But the incidence of AKI and the total fluid volume during EGDT were not significantly different between the senior group and the younger group [incidence of AKI:74.1％ (152/205) vs.69.4％ (213/307),total fluid volume (mL):2 769 ± 1 589 vs.2 804± 1 611,both P ＞ 0.05].Compared with the control group, the incidence of ARDS was higher in the high-PCT group [86.4％ (133/154) vs.78.5％ (281/358),P ＜ 0.05].But the incidences of AKI and cardiac insufficiency were not significantly differentiated between the high-PCT group and the control group [77.9％ (120/154) vs.68.4％ (245/358),58.4％ (90/154) vs.63.4％ (227/358),both P ＞ 0.05].Multiple logistic regression analysis showed that the risk factors of increase in mortality in patients with severe sepsis and septic shock included old age [odds ratio (OR) =1.782,95％ confidence interval (95％CI) =1.173-2.708,P =0.007],ARDS (OR =1.786,95％CI =1.028-3.102,P =0.040),AKI (OR =1.878,95％CI =1.145-3.079,P =0.012),and cardiac insufficiency (OR =4.177,95％CI =2.505-6.966,P =0.000),except for gender (OR =1.112,95％CI =0.736-1.680,P =0.614). Conclusions: In the senior postoperative patients with severe sepsis or septic shock, the incidence of ARDS and cardiac insufficiency, and the mortality were increased. The incidence of ARDS was correlated to the severity of infection.Old age, surgery, and EGDT could be the potential risk factors of cardiac insufficiency.

[Comparison of sedative effect of dexmedetomidine and midazolam for post-operative patients undergoing mechanical ventilation in surgical intensive care unit].

OBJECTIVE: To study sedative effect and safety of dexmedetomidine and midazolam for post-operative patients undergoing mechanical ventilation(MV) in surgical intensive care unit(SICU). METHODS: Two hundred cases of post-operative patients undergoing MV with tracheal intubation in SICU were enrolled and divided into two groups by random numerical table method. They were treated either with midazolam (98 cases) or dexmedetomidine (102 cases). In both groups fentanyl was given intravenously continually for analgesia. The amount of fentanyl was adjusted according to Prince-Henry analgesic score to keep on 1-2 analgesic score; the dose of sedation was regulated by Riker sedative and restless score (SAS) maintain 2-4 sedative score. During the course, parameters of the ventilator, electrocardiogram, heart rate(HR), blood pressure, respiratory rate, pulse oxygen saturation (SpO(2)), blood gas analysis were observed and registered continuously. The amount of the drug, duration of MV, and incidence of side-effects such as hypotension, bradycardia, delirium, nausea, etc. were recorded in two groups. RESULTS: In all the patients in two groups taking dexmedetomidine or midazolam expected sedative and analgesia scores were obtained. In the group with dexmedetomidine, the patients were aroused easier with adequate sedation, and when compared with the group with midazolam, dose of fentanyl (µg× kg(-1)×h(-1) ) was significantly smaller (0.23±0.13 vs. 0.41±0.12, P<0.01), duration of MV (hours) was clearly shorter (7.20±6.29 vs. 12.44±8.96, P<0.01), the rates of hypotension (27.45% vs. 11.22%) and bradycardia (24.51% vs. 10.20%) were significantly higher (both P<0.05), the rate of delirium was clearly lower (3.92% vs. 31.63%, P<0.01), the rate of nausea showed a slight decrease (9.80% vs. 11.22%, P>0.05). The patients in the group with dexmedetomidine were divided into two subgroups of hypotension and non-hypotension. The quantity of blood loss during operation (ml/kg), amount of fluid infusion during operation (ml× kg(-1)×h(-1) ), blood lactic acid concentration (mmol/L) on the day of surgical operation and the 1st day post-operative showed no significant difference between these subgroups (quantity of blood loss on the day of surgical operation: 12.79±12.13 vs. 13.52±11.62; amount of fluid infusion during surgical operation: 11.91±4.59 vs. 13.09±7.05;blood lactic acid concentration on the day of operation: 1.88±1.07 vs. 1.71±0.87, blood lactic acid concentration on the 1st day post-operative:1.43±0.98 vs. 1.37±0.79, all P>0.05). CONCLUSION: Sedative effect of dexmedetomidine is satisfactory for patients undergoing MV after operation, with the property of easier arousal, lower delirium rate, and it helps to shorten the duration of MV with reduction the dosage of fentanyl by 50%. However, it is necessary to enhance observation in order to prevent and control hypotension and bradycardia.

[Security evaluation of bupivacaine, ropivacaine combined with fentanyl in postoperative continuous epidural analgesia].

OBJECTIVE: To investigate the effects, side-effects and security of bupivacaine, ropivacaine combined with fentanyl in postoperative continuous epidural analgesia. METHODS: A total of 1 600 postoperative continuous epidural analgesia patients receiving different agents in SICU were divided into two groups: 0.1% bupivacaine +5 microg/ml fentanyl group (group B, n = 920) and 0.2% ropivacaine +2 microg/ml fentanyl group (group R, n = 680). The effects (visual analog-scale score and content to analgesia), side effects were analyzed retrospectively in the two groups. RESULTS: Compared with group B, patients in group R had higher analgesia contentment (P < 0.05), but no difference in visual analog-scale score was found in the two groups. The incidences of urinary retention, nausea and vomiting, skin itching in group B were significantly higher than those in group R (P < 0.05). In each group, patients over sixty had higher ratio of hypotension than those under sixty (P < 0.05); The female patients had a higher incidence of nausea and vomiting than male patients (P < 0.05); The incidence of debility and numbness of lower limbs in patients with lumbar segments epidural analgesia was higher than those with thoracic analgesia (P < 0.05). CONCLUSIONS: 0.1% bupivacaine +5 microg/ml fentanyl and 0.2% ropivacaine +2 microg/ml fentanyl can provide adequate pain relief in postoperative continuous epidural analgesia, and 0.2% ropivacaine +2 microg/ml fentanyl comes with less side effects. The incidence of complication is related with analgesics, age, gender and the position of epidural puncture.