Lung ultrasound score based on the BLUE-plus protocol is associated with the outcomes and oxygenation indices of intensive care unit patients.

PURPOSE: The primary objective was to demonstrate the relationship between lung ultrasound (LUS) manifestations and the outcomes of intensive care unit (ICU) patients. The secondary objective was to determine the characteristics of LUS manifestations in different subgroups of ICU patients. METHODS: This prospective multi-center cohort study was conducted in 17 ICUs. A total of 1702 patients admitted between August 31, 2017 and February 16, 2019 were included. LUS was performed according to the bedside lung ultrasound in emergency (BLUE)-plus protocol, and LUS scores were calculated. Data on the outcomes and oxygenation indices were analyzed and compared between different primary indication groups. RESULTS: The LUS scores were significantly higher for non-survivors than for survivors and were significantly different between the oxygenation index groups, with higher scores in the lower oxygenation index groups. The LUS score was an independent risk factor for the 28-day mortality. The area under the receiver operating characteristic curve was 0.663 for prediction of the 28-day mortality and 0.748 for prediction of an oxygenation index ≤100. CONCLUSIONS: The LUS score based on the BLUE-plus protocol was an independent risk factor for the 28-day mortality and was important for the prediction of an oxygenation index ≤100. An early LUS score within 24 hours of ICU admission helps predicting the outcome of ICU patients.

Effect of Focused Cardiac Ultrasound in Combination with Lung Ultrasound on Critically Ill Patients: A Multicenter Observational Study in China.

Objective Focused cardiac ultrasound (FCU) and lung ultrasound (LU) are increasingly being used in critically ill patients. This study aimed to investigate the effect of FCU in combination with LU on these patients and to determine if the timing of ultrasound examination was associated with treatment change. Methods This is a multicenter cross-sectional observational study. Consecutive patients admitted to the intensive care unit (ICU) were screened for enrollment. FCU and LU were performed within the first 24 h, and treatment change was proposed by the performer based on the ultrasound results and other clinical conditions. Results Among the 992 patients included, 502 were examined within 6 h of ICU admission (early phase group), and 490 were examined after 6 h of admission (later phase group). The early phase group and the later phase group had similar proportions of treatment change (48.8% vs. 49.0%, χ 2=0.003, P=0.956). In the multivariable analysis, admission for respiratory failure was an independent variable associated with treatment change, with an odds ratio (OR) of 2.357 [95% confidence interval (CI): 1.284-4.326, P=0.006]; the timing of examination was not associated with treatment change (OR=0.725, 95%CI: 0.407-1.291, P=0.275). Conclusions FCU in combination with LU, whether performed during the early phase or later phase, had a significant impact on the treatment of critically ill patients. Patients with respiratory failure were more likely to experience treatment change after the ultrasound examination.

[Reflections on the Application of Critical Care Ultrasound in Viral Pneumonia Patients with Circulatory Dysfunction-New Classification and Precision Treatment Based on Ciritical Care Ultrasound].

Viruses are among the main pathogens of pulmonary infection and tend to cause pandemics of viral pneumonia. Severe viral pneumonia tends to be accompanied by acute respiratory distress syndrome (ARDS) manifestations, displaying highly specific clinical symptoms that are most prominently expressed in the circulatory system. Shock occurred rarely, it occured at a rather late stage in this outbreak of viral pneumonia. However, because of the extensive use of critical care ultrasound, we have a deeper understanding of the characteristics of acute circulatory disorder caused by severe viral pneumonia, prompting us to reflect more thoroughly about circulatory disorders caused by other types of infections. In general, acute circulatory disorder is not uncommon in severe viral pneumonia in this outbreak, and is characterized by vascular damage, volume disorder and cardiac abnormalities of three types, high stress state, acute right ventricular dysfunction and diffuse cardiac inhibition. In the case of poor management in the early stage, these acute circulatory disorders may develop into shock, or directly cause or aggravate other organ dysfunction, for example, acute kidney injury, exacerbating the adverse outcomes. This has allowed us to reflect more thoroughly on the occurrence and development of acute circulatory disorders caused by other infections. Therefore, the classification of acute circulatory disorders based on the modular assessment of critical care ultrasound will help promote better understanding of acute circulatory disorders and further research.

[Critical Care Ultrasound as Core Technology and Visualization Critical Care as Core Skills].

Critical Care Ultrasound(CCUS)is the one of the ultrasound technologies which integrates the bedside ultrasound application into daily clinical practice in critical care medicine. It has multiple roles, at first is a non-invasive monitoring tool to measure variables that can reflect the essence of the disease, and then is a comprehensive visualized tool to evaluate the pathophysiological status and structural changes of organs, which facilitates the critical care providers to know more about the patients and provides more reliable evidence to promote the accuracy and efficiency of the diagnosis, the clinical decision-making and the treatment of the critically ill. Therefore, the critical care ultrasound has been used as one of the core technologies of critical care. The characteristics and advantages of CCUS destine it as an orientation and instruction of visualized diagnosis and treatment. We devote ourselves to explore methods of integrating the application of CCUS into clinical management of critically ill, and establish specific approaches and workflows to standardize the clinical practice of clinicians and reduce medical errors. Therefore, a new diagnostic and treatment pattern can be developed, which is called visualized critical care. It is a care pattern of critical illness based on the CCUS visualization evidence including the pathophysiological status and other informations. This article will carefully discuss the connotation of CCUS, the unique clinical value in critically ill patients, and the value of visualized critical care approaches in acute respiratory and circulatory collapse and shock management, etc..

[Influence of Critical Care Ultrasound Oriented Fluid Management in Different Stages of Shock to the Outcome].

OBJECTIVE: To investigate the relationship between fluid management oriented by critical care ultrasound and prognosis in patients with shock. METHODS: We analyzed the data of a randomized controlled trial called Critical Care Ultrasound Oriented Shock Treatment (CCUSOST) in the Department of Critical Care Medicine, West China Hospital retrospectively. 77 patients in the critical care ultrasound oriented treatment group (experimental group) and 70 patients in the conventionally treated group as control were included in the statistics, to evaluate the relationship between fluid intake and prognosis. Univariate and multivariate logistic regression analyses were used to analyze risk factors for ICU mortality. RESULTS: The baseline indexes of the patients in the experimental group and the control group were consistent. The ICU mortality of the experimental group was significantly lower than that of the control group (P < 0.05).The fluid intake in the stabilization and de-escalation phases was less than the the control group (P < 0.05). We divided these shock patients into survival group (92 cases) and non-survival (55 cases) according to whether they died in ICU, and the univariate analysis for ICU mortality showed that acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, SOFA score, Lac, hourly urine output, total fluid intake, fluid intake in the salvage and optimization stages, fluid intake in the stabilization and de-escalation stages were significantly different (P < 0.05) between survivers and non-survivers. Multivariete analysis showed that the fluid intake during the salvage and optimization phases, fluid intake in the stabilization and de-escalation phases were independent risk factors for ICU mortality. CONCLUSION: Critical care ultrasound oriented shock fluid management could reduce fluid intake of stabilization and de-escalation phases, and improved adverse outcome; whether the fluid intake during stabilization and de-escalation phases, or the fluid intake during the salvage and optimization phases, both were associated with patient prognosis.

[The Clinical Value of the Pathophysiology Oriented Critical Care Ultrasound Exam (POCCUE) Protocol in Acute Respiratory and Circulatory Compromise of Critically Ill Patients].

OBJECTIVE: The aim of this study is to explore the diagnostic and therapeutic accuracy of pathophysiology and clinic oriented critical care ultrasound exam (POCCUE) protocol in acute respiratory and circulatory compromise of critically ill patients. METHODS: Prospectively included patients with acute respiratory and circulatory compromise from ICU of West China Hospital of Sichuan University from March to April 2018. The POCCUE protocol designed according to the pathophysiological changes of acute respiratory and circulatory disorders includes: the first part is the acquiring an ultrasound section and measuring corresponding indicators including pulmonary and echocardiographic indicators; the second part is a comprehensive analysis according to the former examination which evaluates the pathophysiological changes of acute respiratory and circulatory disorders, and then establish the initial etiology diagnosis and start treatment. The clinical value of the POCCUE protocol, including the accuracy of diagnosis, and the differences in treatment was verified by comparing the clinical outcome with the traditional treatment group. RESULTS: A total of 82 subjects were used for statistics. Compare with the traditional group, POCCUE can notably increase the diagnostic and therapeutic accuracy of clinic and pathophysiology (diagnostic accuracy: 93.90% vs. 68.29%, P < 0.01; therapeutic accuracy: 93.90% vs. 62.20%, P < 0.01). CONCLUSION: The POCCUE has a higher accuracy of diagnosis and treatment for patients with acute respiratory and circulatory compromise.

[Correlation Between the Severity of Lung Ultrasound Score in Non-gravity Dependent Areas and Poor Prognosis of Patients with Shock and on Mechanical Ventilation].

OBJECTIVE: To explore whether ultrasound abnormalities in the non-gravity dependent areas (area 1-2) of the lungs are associated with poor prognosis in patients with shock and on mechanical ventilation. METHODS: We retrospectively analyzed the data of lung ultrasound from 181 patients with shock from Apr. 2016 to Nov. 2017. The patients were divided into the survival group and the non-survival group according to the 28 d outcome. Single factor and multivariate Cox regression were used to analyze the relationship between lung ultrasound score of the overall and each area and the 28 d mortality.Kaplan-Meier curve was used to analyze the relationship between the severity of ultrasound lesions in area 1-2 and the prognosis at 28 d. RESULTS: 169 patients were included.There were 106 males (62.7%) and 63 females (37.3%).There were 90 patients in the survivel group and 79 patients in the non-survival group.Single factor Cox regression analysis found that adjusting the age, acute physiology and chronic health evaluation (APACHE) Ⅱ score, lactate level, urine output per hour, application of vasoactive agent, oxygenation index, lungs ultrasound score of area 1-6, area 1-2 and area 3-4 were associated with 28 d mortality. Multivariate Cox regression revealed that lung ultrasound score of area 1-2 was the independent risk factor of 28 d mortality, as well as APACHE Ⅱ score and lactate level. The Kaplan-Meier curve found that the more severe the lesion in area 1-2, the lower the survival rate at 28 d. CONCLUSION: Lung ultrasound score of area 1-2 in patients with shock and on mechanical ventilation may be a predictor of poor prognosis at 28 d.

[The Correlation of Fast-track Extubation Ultrasound Score and Clinical Multi-organ Information Indicators of Postoperative of Cardiac Surgery].

OBJECTIVE: To evaluate the correlation of Fast-track extubation ultrasound score (FTEUS) and clinical multi-organ information indicators in post-cardiac surgery patients. METHODS: prospectively recruit post-cardiac surgery patients who were about to extubating from Febuary 2019 to September 2019. A fast-track extubation ultrasound score protocol (FTE-USP) was developed on the basis of the conventional fast-track extubation standard precisely and individualized. Cardiac, pulmonary and inferior vena cava ultrasound examinations were performed by specially trained observers, video data were saved, FTE-USP was used for scoring, Kendall consistency coefficient was used to meature the interobserver consistency. The correlation between the FTEUS and the patients' clinical indicators was evaluated. RESULTS: A total of 207 patients were recruited in the study, including 89 males and 118 females, aged (54.63±11.80) years. The FTEUS was performed at bedside with a mean time of (8.23±2.08) min, Kendall consistency coefficient is 0.941. With the increase of the total score of FTEUS, the incidence of clinical adverse events increased (especially the arrhythmia), and there were significant changes in liver, kidney, heart, lung and other organ function indicators, among which serum creatinine level, serum cystatin C level, serum NT-pro-brain natriuretic peptide, length of stay in intensive care unit, non-invasive mechanical ventilation time after extubation, and incidence of arrhythmia were positively correlated with FTEUS (P < 0.05).With FTEUS increased to 5 points, the incidence of arrhythmia (14/24, 58.3%), cardiopulmonary resuscitation (2/24, 8.3%) and weaning failure (2/24, 8.3%) increased. CONCLUSION: FTE-USP integrates multi-organ informations, can be performed quickly at the bedside and alerts adverse events. It has the potential to be applied to assist clinical decision-making in post-cardiac surgery patients before extubation.

[The Value of Gastric Antrum Cross-sectional Area Mearsured by Bedside Ultrasound Predicted Feeding Intolerance in Critically Ill Patients].

OBJECTIVE: To explore the feasibility and effectiveness of gastric antrum cross-sectional area (CSA) mearsured by bedside ultrasound for predicting early feeding intolerance (FI) in critically ill patients. METHODS: The data were extracted from a multicenter prospective observation study between February 2018 to December 2018. A bivariate logistic regression model was established to identify the correlation between the gastric antrum cross-sectional area (CSA) and the feeding intolerance (FI). Draw the ROC curve to get the best cut-off value. RESULTS: This study comprises 150 patients. The mean age was (58.63±16.45) yr., the average APACHE Ⅱ score was 17.43±6.99. The incidence of FI for three days (72 h-FI%) was 28.0%. The multivariate analysis demonstrated that the Day 2 CSA-right lateral decubitus (RLD) was an independent risk factor for FI-day 2 (P=0.033), Day 3 CSA -RLD was an independent risk factor for FI-day 3 (P=0.016). Patients with day 3 CSA-RLD ≥7.092 cm2 had significantly higher rates of FI (P=0.001). CONCLUSION: Gastric antrum cross-sectional area measured by ultrasound can predict feeding intolerance during early enteral nutrition. When the Day 3 CSA-RLD is greater than 7.092 cm2, the incidence of feeding intolerance is significantly increased.

[Predictive Value of Early Changes in Sublingual Microcirculation on Organ Failure of Patients with Septic Shock].

OBJECTIVES: To determine the predictive value of early changes in sublingual microcirculation on organ failure of patients with septic shock. METHODS: Side-streamdark field imaging (SDF) videomicroscopy was performed to assess sublingual microcirculation of 34 adult patients at 0 h, 6 h and 24 h after they were diagnosed with septic shock.The patients were subject to sequential organ failure assessment (SOFA24 h-0 h). The patients with ΔSOFA24 h-0 h≥1 (deteriorated conditions) were compared with those with ΔSOFA24 h-0 h<1 in regard to sublingual microcirculation and the traditional hemodynamic indicators such as heart rate, mean arterial pressure, central venous pressure, urine output and lactate. RESULTS: No significant baseline differences were found between the two groups of patients in age, sex and acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ), nor any differences in the traditional hemodynamic indicators, as well as dose of vasopressor, infusion of crystalloids, and colloids after septic shock was diagnosed. The patients with deteriorated conditions had lower proportion of perfused small vessels (PPVs) compared with the non-deteriorated patients at 0 h [(75.96±10.55)% vs.(84.03±10.16)%, P=0.032] and 24 h [(79.43±9.23)% vs.(86.32±9.02)%, P=0.037]. The ROC analysis showed a greater area under the curve (AUC) for PPVs at 0 h [0.750 (95%CI, 0.586-0.914)] compared with the AUC for Lac at 0 h [0.588 (95%CI, 0.370-0.805) ], albeit a lack of statistical significance ( P>0.05). The incidence of organ failure in the patients with a lower than optimal cut-off point (81.5%) of PPVs was significantly higher than that of those above the cut-off point (71.4% vs. 20.0%). CONCLUSIONS: Changes in sublingual microcirculation (e.g. PPVs) can predict the development of organ failure earlier than systemic hemodynamic indicators in patients with septic shock.

[The Value of Early Diastolic Transmitral Velocity to Early Mitral Anulus Diastolic Velocity Ratio for Pulmonary Edema in Severe Sepsis Patients].

OBJECTIVES: To determine the association between the value of early diastolic transmitral velocity to early mitral anulus diastolic velocity ratio (E/E')measured by bedside ultrasound and pulmonary edema in severe sepsis (including septic shock) patients. METHODS: Data were obtained from the critical ultrasound database between November 2014 and August 2015. The severe sepsis (including septic shock) patients were eligible, but those with chronic heart disease or acute heart failure were excluded. Pulmonary edema was quantified by lung ultrasound score. The patients were divided into two groups according to lateral E/E'. E/E'-high group was defined as the lateral E/E'>8, and the others were in E/E'-low group. The severity and distribution of pulmonary edema were compared between the two groups. The correlation analysis and logistic regression analysis were performed to determine whether E/E' was the independent risk factor of pulmonary edma. RESULTS: There were 82 cases included. The lung ultrasound score of E/E'-high group was significantly higher than that of E/E'-low group ( P=0.007). There was no statistic difference of pulmonary edema severity in the bilateral 5 th and 6 th ultrasound exam areas, but E/E'-high group were more severe in the bilateral 1 th to 4 th ultrasound exam areas ( P=0.004). Linear-regression analysis demonstrated that E/E' and inferior vena cava diameter were independent risk factors of pulmonary edema (standardized regression coefficients were 0.425 and 0.249, respectively, P<0.05). CONCLUSIONS: E/E' is the independent risk factor of pulmonary edema in severe sepsis and septic shock patients.

[Influence of 20% lipid emulsion on drug concentration, distribution volume and pharmacology effect of continuous infusion of propofol in rabbits].

OBJECTIVE: To investigate the influence of 20% lipid emulsion on drug plasma concentration, distribution volume and pharmacology effect of propofol administered with constant rate intravenous infusion in rabbits. METHODS: Propofol was intravenously administrated at a constant rate of 70 mg/(kg x h) in propofol group (P group, n = 8), low rate lipid group (L group, n = 8), high rate lipid group (H group, n = 8) and saline group (S group, n = 8) within 2 h. After 60 min, different agents were administrated in L group (20% lipid emulsion with rate of 0.3 mL/(kg x h)), H group (20% lipid emulsion with rate of 15 mL/(kg x h)), S group (saline with rate of 15 mL/(kg x h)) for another 60 min respectively. Blood samples were taken to measure the plasma concentration and calculate the pharmacokinetic parameters at the following time points: 30, 60, 65, 70, 80, 90, 120 min after the start of propofol infusion and 10, 20, 30, 60, 120, 180 min after the termination of propofol infusion. Brain tissues were also taken to measure propofol concentration. Related information about vital signs and pharmaceutical effects were recorded. RESULTS: High rate lipid infusion was associated with elevated propofol plasma concentration and reduced volume of distribution. The volume of distribution based on the terminal phase (V): P group, (34.56 +/- 16.11) mL; L group, (33.37 +/- 29.87) mL; H group,(7.29 +/- 3.20) mL; S group,(35.46 +/- 13.58) mL; P < 0.05). The volume of distribution at steady state (Vss): P group, (11.13 +/- 3.21) mL; L group, (13.87 +/- 4.09) mL; H group, (4.82 +/- 1.46) mL; S group, (11.61 +/- 4.11) mL P < 0.05)). Painful stimulation existences were higher at 90,120 min and the mean arterial pressure and heart rate were higher in H group (P < 0.05). The propofol concentration in brain tissue was lower in H group at 120 min (P < 0.05). CONCLUSION: Amelioration of pharmacology effect of propofol with high rate lipid infusion is associated with reduced V, Vss, elevated propofol plasma concentration and lowered propofol brain tissue concentration. 20% lipid will not influence these indice when infused with low rate, indicating that lipid in TPN will not change the sedation effects of propofol.

[Measurement of peak velocity variation of common carotid artery with bedside ultrasound to estimate preload in surgery ICU].

OBJECTIVE: To investigate the feasibility and accuracy of bedside ultrasound measuring peak velocity variation of common carotid artery to estimate preload of the patients in surgery ICU. METHODS: In this prospective cohort study, SICU patients with sinus rhythm and positive pressure ventilation were included. The peak velocity variation in common carotid artery (delta V peak) during each respiratory circle was measured by ICU resident with short-term training and experienced attending songrapher. Stroke volume before and after the fluid challenge was also measured by the experienced songrapher as the gold standard of fluid responsiveness. Then the ROC, feasibility and accuracy of the diagnosis trial were analyzed. RESULTS: There were 46 patients included. The peak velocity variation of common carotid artery measured by the attending (delta V peak) is highly related with delta SV (r1 = 0.76, P < 0.05). Area under the receiver operating characteristic curve was 0.95 (P < 0.05). The peak velocity variation of common carotid artery (delta V peak) > 12.1% predicted fluid responsiveness with sensitivity of 90.9%, specificity of 83.3%, positive predictive value of 83.3% and negative predictive value of 90.9%. The peak velocity variation of common carotid artery measured by the resident (delta V peak2) were highly related with delta V peak1 (R2 = 0.68, P < 0.05), the AUC was 0.94. CONCLUSION: Measurement of peak velocity variation of common carotid artery with bedside ultrasound can accurately estimate the volume status of the patients in surgery ICU, and it is easy to be performed by the residents of ICU.

[Relationship between early serum albumin variation and prognosis in patients with severe acute pancreatitis treated in ICU].

OBJECTIVE: To investigate the relationship between serum albumin variation within 24 hours of ICU admission and prognosis in critically ill patients with sever acute pancreatitis (SAP). METHODS: We retrospectively analyzed all the clinical data of the patients with SAP treated in ICU from Jul. 2005 to Jun. 2010. The patients were divided into two groups, survival group (n = 131) and death group (n = 108). Clinical and laboratory data, outcomes, and serum albumin within 24 hours after admission to ICU of those patients were evaluated respectively, and Logistic regression analysis was performed. RESULTS: Significant differences were existed between two groups (P < 0.01) in average age, the score of acute physiology and chronic health evaluation II (APACHE II), Ranson criteria, the score of sequential organ failure assessment (SOFA), and albumin variation within 24 hours (Serum albumin descent degree and ratio in early stage). However, sex ratio, mean serum albumin concentration within 24 hours, and onset time did not have significant differences (P > 0.05). The area under ROC curve for albumin variation within 24 hours were 0. 728 and 0. 742, the best cut-off values were 4.25 g/L (sensitivity 61.45%, specificity 81.67%) and 13.5% (sensitivity 62.65%, specificity 78.33%), respectively. Multiple logistic regression analysis showed that albumin variation within 24 hours was associated with death. CONCLUSION: The albumin variation within 24 hours was the risk factors for poor prognosis of critically ill SAP in early stage.

[Short-term intensive glucose control in patients with severe acute pancreatitis].

OBJECTIVE: To investigate effects of intensive glucose control (IGC) on glucose variability (GV) and clinical outcomes in patients with severe acute pancreatitis (SAP), and to assess predictive values of different measures of GV on intensive care unit (ICU) death. METHODS: A prospective, randomized, non-blinded clinical trial was conducted. All adult patients with diagnosis of SAP, who were admitted to ICU of West China Hospital between July 1st 2010 and July 1st 2011, were enrolled. Eligible patients were randomly assigned to receive either IGC to maintain glucose level between 6.1 mmol/L and 8.3 mmol/L or control group (none intervention was given). GV, ICU mortality, the incidence of infection, length of mechanical ventilation and ICU stay of the two groups were compared. The standard deviation of blood glucose level [GLU(SD)], mean amplitude of glycemic excursion [GLU(MAGE)] and glycemic lability index [GLU(GLI)] were chosen as measures of GV to analyze the multi variable correlation between them and ICU mortality, and the ability of these three parameters was assessed in predicting ICU death using area under a receiver operating characteristic curve (AUC). RESULTS: One hundred and twenty-two patients were eligible for the study, and 30 patients with SAP were enrolled in the study, with 15 cases in each group. The basic data of the two groups were comparable. Compared with control group, IGC showed an effect to reduce GV, including GLU(SD) [mmol/L: 1.81 (0.97, 2.65) vs. 2.48 (1.29, 2.87)], GLU(MAGE) [mmol/L: 3.76 (3.67, 5.85) vs. 5.30 (4.35, 6.80)], GLU(GLI) [306.8 (220.6, 613.3) vs. 339.5 (218.4, 423.1)], and lower ICU mortality (13.3% vs. 40.0%), but the difference showed no significant difference (all P > 0.05). It could also shorten the length of ICU stay (days: 11.3 ± 9.9 vs. 15.8 ± 7.6, P < 0.01), decrease the incidence of infection of blood stream and the lung (6.7% vs. 40.0%; 33.3% vs. 73.3%, both P < 0.05). A positive correlation between GLU(GLU) and ICU mortality was found (r = 0.371, P = 0.044), but no correlation was found between GLU(SD) or GLU(MAGE) and ICU mortality (r value was -0.144 and -0.065, P value was 0.448 and 0.731). AUC for GLU(SD), GLU(MAGE) and GLU(GLI) was 0.594 [95% confidence interval (95%CI) 0.382-0.805], 0.543 (95%CI 0.287-0.798) and 0.751 (95%CI 0.548-0.954) respectively, and GLU(GLI) was the best predictor of ICU death. CONCLUSIONS: IGC had an effect to reduce GV, decrease ICU mortality, shorten length of ICU stay, and lower the incidence of infection. Compared with GLU(SD) and GLU(MAGE), GLU(GLI) was the best predictor of ICU death.

[Prognostic value of plasma N-terminal pro-B-type natriuretic peptide in patients with severe sepsis and septic shock].

OBJECTIVE: To evaluate the prognostic value of plasma N-Terminal Pro-B-type Natriuretic Peptide (NT-proBNP) in severe sepsis and septic shock. METHODS: The blood samples were collect in 72 patients with severe sepsis and septic shock staying in intensive care unit (ICU) at consecutive days. The levels of plasma NT-proBNP, lactate at the 1, 2, 3, 5, 7 day, as well as the levels of CK-MBmass, cTnT and procalcitonin at the 1, 3, 7 day were measured. All the patients were subjected to the calculation of APACHE (acute physiology and chronic ealth evaluation) II scores and SOFA (sequential organ failure assessment) scores,and the clinical outcome, ICU mortality, hospital mortality, ICU time, hospital time, 28-day mortality were collected. The prognostic value of plasma NT-proBNP was analyzed. RESULTS: Plasma NT-proBNP levels were markedly increased in the patients in our study. The level of NT-proBNP in nonsurvivors at 28 days was higher than that of survivors, and the peak level was emerged on the second day after admission. In multivariate logistic regression analyses, NT-proBNP level at day 3 after inclusion and APACHE II Score were independent predictors of hospital mortality, and only APACHE II Score is the independent predictor for 28-day mortality. CONCLUSION: Plasma NT-proBNP level shows obvious increase in patients with severe sepsis and septic shock. NT-proBNP on day 3 in ICU is an independent prognostic marker of hospital mortality in severe sepsis and septic shock.

[Role of procalcitonin in the diagnosis of ventilator-associated pneumonia].

OBJECTIVE: To evaluate the diagnostic value of procalcitonin (PCT) in ventilator-associated pneumonia (VAP). METHODS: Prospective study was performed. All adult patients who were admitted into the intensive care unit (ICU) of West China Hospital of Sichuan University between June 1st and October 1st and were clinically suspected of having developed VAP after 48 hours of mechanical ventilation were enrolled. Patients who had active infection or lung cancer at ICU admission or developed extrapulmonary infection during the study period were excluded. PCT and C-reactive protein (CRP) levels were measured and the clinical pulmonary infection score (CPIS) was calculated at study entry and on the day of VAP suspicion. RESULTS: In total, 49 suspected episodes of VAP in 31 cases were microbiologically confirmed in 23 and refuted in 26. Median PCT levels were 0.68 microg/L (interquartile range 0.28, 2.31) and 0.18 microg/L (0.06, 0.28) respectively in patients with and without VAP on the suspicion day (P<0.01). Using 0.31 microg/L as the best cutoff, PCT had 73.9% sensitivity and 80.8% specificity. The CPIS resulted in higher sensitivity (95.7%) but lower specificity (53.8%) when the cutoff of CPIS > or = 5. CRP had the lowest sensitivity and specificity (56.5%, 61.5%) when the cutoff of CRP was 109.5 mg/L. A CPIS > or = 5 combined with serum levels of PCT > or = 0.31 microg/L did not improve the sensitivity (69.6%), but resulted in 88.5% specificity. CONCLUSION: PCT had better specificity than CRP and CPIS in early diagnosis of VAP. Combined values of PCT and CPIS below the cut-off points could effectively exclude false-positive diagnosis of VAP.

[Clinical features and treatment of seventh day syndrome following living donor liver transplantation].

OBJECTIVE: To investigate the clinic features and treatment of seventh day syndrome (7DS) following living donor liver transplantation (LDLT). METHODS: From January 2002 to March 2009, 8 patients were diagnosed with 7DS following LDLT. A retrospective analysis was made on the clinical data containing liver and renal functions, coagulation function, sonographic and histological features and effectiveness of the treatments. RESULTS: Rapid deterioration of liver function happened 1-2 weeks after operations, followed by renal dysfunction. There was a reduction of velocity or bidirectional blood flow in the portal vein. Massive coagulative necrosis with disruption of lobular architecture occurred in 3.3% of cases, with a mortality of 87.5%. The steroid pulse and OKT3 (anti-CD3 antibody) therapy showed minimal effects. Prolonged application of i.v. methylprednisolone may be helpful with the delay of 7DS. CONCLUSION: The 7DS may be an immune-mediated graft failure. The prevention and control of 7DS is difficult due to lack of research evidence.

[The study of pro-B-type natriuretic peptide in the evaluation of the cardiac function in patients with severe sepsis].

OBJECTIVE: To evaluate plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels as a marker of cardiac function during severe sepsis and septic shock. METHODS: A prospective study was conducted, and 44 patients without history of heart diseases but suffering from severe sepsis and septic shock underwent the transesophageal echocardiography (TEE) to obtain data about left and right ventricular function on 1, 3, 7 days in intensive care unit (ICU). At the same time, blood samples were collected to measure the levels of plasma NT-proBNP, quality of creatine kinase isoenzyme (CK-MBmass), troponin T (cTnT) and lactate. The factors affecting plasma NT-proBNP levels in patients with severe sepsis and septic shock were analyzed, and correlation between NT-proBNP and cardiac function indexes were evaluated. RESULTS: Of 44 patient with severe sepsis and septic shock, 21 cases died in 28 days, with the mortality rate of 47.73%. The plasma NT-proBNP values on 1, 3, 7 days in ICU of 21 non-survivors were obviously higher than those of 23 survivors [10 112 (855-35 000) ng/L vs. 4 116 (185-28 437)ng/L, Z=-2.622, P=0.009; 13 811 (1 127-35 000) ng/L vs. 899 (116-35 000)ng/L, Z=-3.459, P=0.000; 6 786 (398-35 000) ng/L vs. 623 (98-4 118)ng/L, Z=-3.001, P=0.003]. Non-conditional logistic regression analysis and linear regression analysis, plasma lactate (t=2.420, P=0.020) and acute physiology and chronic health evaluation system II (APACHEII) score (t=3.482, P=0.001) on day 1, and left ventricular ejection fraction (LVEF, t=-2.326, P=0.029) on day 7 showed that they were independent affecting factors for plasma NT-proBNP levels. Patients were subdivided into two groups based on LVEF. It was found that the plasma NT-proBNP values in abnormal group (LVEF<0.50, n=8) were significantly higher than those in normal group (LVEF≥0.50, n=17) on day 7 [1 231 (398-5 000) ng/L vs. 513 (98-10 047) ng/L, Z=-1.831, P=0.047]. CONCLUSIONS: Plasma NT-proBNP levels on day 7 in ICU could reflect the left ventricular systolic dysfunction in patients with severe sepsis and septic shock.

The association of mean glucose level and glucose variability with intensive care unit mortality in patients with severe acute pancreatitis.

PURPOSE: The objective of this study was to retrospectively analyze the association of mean glucose level (MGL) and glycemic lability index (GLI; as a measure of glucose variability) with intensive care unit (ICU) mortality in patients with severe acute pancreatitis (SAP). MATERIALS AND METHODS: Paper-based medical records of patients with SAP who were admitted to the ICU of West China Hospital between July 1, 2005, and July 1, 2010, were analyzed. Glucose measurements, demographic characteristics, clinical features, data on the first and second 24-hour Acute Physiology and Chronic Health Evaluation (APACHE) II scores, and outcomes were obtained. Time-weighted glucose parameters were used. We statistically analyzed the relationship between these variables and both ICU and hospital mortality. RESULTS: A total of 294 patients with 34,796 glucose measurements were included in the final analysis. The time-weighted MGL was 9.31 ± 1.91 mmol/L, and the median of GLI was 55.27 (mmol/L)(2) h-(1) wk-(1). Intensive care unit mortality was 43.5% and increased progressively as GLI increased, reaching 62.5% of patients with GLI above 115.89 (mmol/L)(2) h-(1) wk-(1). The highest odds ratio for ICU death was found in patients with the highest quartile of GLI: odds ratio, 3.47 (95% confidence interval, 1.76-6.86; P < .000). No such relationship could be found with MGL. Glycemic lability index was better able to predict ICU death than was MGL (the area under the curves were 0.642 vs 0.561, respectively; z test was 2.677; P = .0074). The logistic regression analysis showed that GLI, the second 24-hour APACHE II score, and the number of organ failures upon ICU admission contributed independently to the risk of mortality. CONCLUSIONS: We observed that GLI was a better predictor of ICU and hospital mortality than was MGL. Together with the second 24-hour APACHE II score and the number of organ failures upon ICU admission, GLI is an independent predictor of mortality in patients with SAP.