[Risk factors and therapy strategies of acute pulmonary edema in critically ill patients with multiple trauma].

OBJECTIVE: To analyze the risk factors and therapy strategies of acute pulmonary edema (APE) in critically ill patients with multiple trauma. METHODS: We conducted a retrospective analysis with the clinical date of all the critically ill patients with multiple trauma treated in General ICU from Jan. 2009 to Jan. 2012. We compared the clinical characteristics of the patients with or without onset of APE. The patients with APE were divided into young group (< or = 55 yr.) or elderly group (> 55 yr.), then the clinical data were analyzed between the two groups, including the level of hemoglobin (Hb), mean arterial pressure (MAP), central venous pressure (CVP), serum albumin (A1b), as well as complications, liquid balance during 1 week, 3 d, 1 d before the onset of APE. RESULTS: Among the 284 patients with multiple trauma, APE was detected in 47 patients (16.5%) for 68 times, 29 (61.7%) in young group and 18 (38.3%) in elderly group. The ratio of acute renal failure (ARF) and systematic infection were significantly higher in the patients with APE (P < 0.05). Hb, MAP, CVP, A1b and the ratio of ARF, severe infection, extremity lost were not statistically different (P > 0.05) between young and elderly group, while the ratio of primary heart disease was significantly higher in elderly group (P < 0.05). The net balance of liquid during 1 week, 3 d and 1 d before the onset of APE was significantly higher in young group (P < 0.05). CONCLUSION: Mutiple Trauma patients with ARF are prone to encounter APE on the exist of infection and overburden of liquid; young patients tend to develop APE followed by liquid overburden,while elderly patients tend to develop APE because of poor primary heart condition even with more cautious fluid infusion.

[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.

[Influence of hydroxyethyl starch 130/0.4 on renal function of injured patients with acute renal failure after Wenchuan earthquake].

OBJECTIVE: To retrospectively analyze the use of hydroxyethyl starch (HES) 130/0.4 in injured patients with acute renal failure (ARF) in Wenchuan earthquake, and its influence on the renal function. METHODS: Critically ill traumatic patients with ARF admitted to intensive care unit (ICU) of West China Hospital within 1 month after Wenchuan earthquake were divided into two groups according to whether or not HES 130/0.4 was used (Y group for having used it and N group for not). The basic clinical data and acute physiology and chronic health evaluation II (APACHE II) score were obtained on admission. Serum blood urea nitrogen (BUN) and creatinine (SCr) on day 1, 3, 7, 14 and 28 were compared between two groups, as well as the time of continuous renal replacement therapy (CRRT) and mechanical ventilation (MV), transfusion amount, and 28-day mortality rate. The usage of HES 130/0.4 was recorded in Y group, including total days, maximum daily amount, total amount and average amount being used. RESULTS: A total of 39 patients were enrolled into the study, 30 in Y group, 9 in N group. No statistical difference was found in basic clinical data and APACHE II score on admission to ICU. Also there was no difference in days of CRRT and MV, or transfusion amount. Serum BUN and SCr on day 1, 3, 7, 14 and 28 after admission to ICU showed no significant difference between two groups, except for SCr concentration on day 1 (P<0.05). In Y group, the mean duration of using HES 130/0.4 was 3 days, mean daily amount was (529.9+/-226.3) ml, maximum daily amount was 2 500 ml, minimum daily amount was 500 ml (none exceeded recommended dosage), total amount used was 500-13 500 ml. The 28-day mortality rate in Y group was 26.7%, no patient died in N group within 28 days. CONCLUSION: No negative influence on the renal function imparted by HES 130/0.4 is found in critically ill traumatic patients with ARF.

[Clinical implication of blood somatostatin determination in critically ill patients].

OBJECTIVE: To investigate the relationship between contents of blood somatostatin (SST) and inflammatory reaction or severity of illness in critically ill patients, and its value in the evaluation of prognosis. METHODS: Sixty critically ill patients were divided into three groups according to the acute physiology and chronic health evaluation II (APACHE II) score as mild (<16, 23 cases), mediate (16 - 20, 20 cases) and severe (>20, 17 cases) group; and also divided as dead (D, 13 cases) or survival group (S, 47 cases) according to the final outcome; 20 healthy volunteers served as control. The blood SST concentration was detected by radioimmunoassay, while the levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were measured by enzyme linked immunosorbent assay (ELISA). RESULTS: The SST concentration in critically ill patients was significantly lower than normal control [(18.2+/-17.6) ng/L vs. (224.8+/-130.2) ng/L, P<0.05], while the levels of TNF-alpha and IL-6 were significantly higher [TNF-alpha: (32.4+/-14.2) ng/L vs. (14.2+/-5.7) ng/L, IL-6: (131.6+/- 42.7) ng/L vs. (65.8+/-24.3) ng/L, both P<0.05]. The SST concentration in severe group was significantly lower than that of mild and mediate group [(8.1+/-7.2) ng/L vs. (24.7+/-15.9) ng/L and (19.2+/-22.1) ng/L, both P<0.05], while the levels of TNF-alpha and IL-6 were significantly higher than mild group [TNF-alpha: (39.0+/-16.4) ng/L vs. (28.9+/-10.9) ng/L, IL-6: (156.0+/-49.6) ng/L vs. (111.5+/-32.6) ng/L, both P<0.05]. A negative correlation was found between SST and TNF-alpha, IL-6, also between SST and APACHE II score (r(1)=-0.682, r(2)=-0.894, r(3)=-0.327, P<0.05 or P<0.01). The SST concentration in D group was significantly lower than S group [(6.4+/-5.5) ng/L vs. (21.5+/-18.4) ng/L, P<0.05]. CONCLUSION: The SST level in blood can reflect the severity of illness in critically ill patients and shows clinical value in evaluation of prognosis.

[Characteristics and treatment of multiple organ dysfunction syndrome in patients with trauma in the Wenchuan earthquake on 12th May, 2008].

OBJECTIVE: To analyze the characteristics and treatment of the multiple organ dysfunction syndrome (MODS) in patients in the Wenchuan earthquake on 12th May, 2008, in order to provide theoretical reference for future care for such patients. METHODS: Characteristics of MODS in these patients were analyzed, differences between survivors and non-survivors were compared, and therapeutic measures, and the time of the treatment for MODS in patients with earthquake related injury or illness who were admitted to West China Hospital from 12th May to 20th June, 2008, were retrospectively analyzed. RESULTS: A total of 42 MODS patients were admitted to intensive care unit (ICU). Both the acute physiology and chronic health evaluation II (APACHE II) score and predicted death risk were lowering during the course of therapy. Fractures of bones of extremities were predominant in the earthquake related diseases, with an incidence of 45.2%. The actual mortality of MODS (33.3%) was lower than the predicted death risk (41.5%). The age, the time of receiving the first treatment in ICU after the earthquake, the Glasgow score, the oxygen index, blood creatinine level, platelet count, and vasoactive agent pumping velocity were significantly different between survivors and non-survivors (all P<0.05). The overall mortality was 9.8%, the morbidity of cardiac dysfunction, the incidence of acute renal failure (ARF) and sepsis were significantly different between non-survivors and survivors (all P<0.05). The use of mechanical ventilation, continuous renal replacement therapy (CRRT), and vasoactive agent reached peak level on the 14-29 days after the earthquake. CONCLUSION: Fracture of bones of extremities are predominant injury in the earthquake related diseases, and the cause of death is closely associated with multiple trauma and ARF, systemic infection of large wound surfaces. The central nervous system, respiratory system, circulatory system, renal function, circulatory system should be monitored during the treatment. Adequate preparedness is essential in order to cope with the peak period of occurrence of serious complications after a disaster.

Etiology, clinical features and management of acute recurrent pancreatitis.

OBJECTIVE: To study the etiology and clinical features of acute recurrent pancreatitis (ARP) and to determine its optimal management and outcomes. METHODS: ARP cases among acute pancreatitis patients who were admitted to the West China Hospital, Sichuan University from January 2008 to December 2012 were retrospectively collected. Their etiology, clinical features, treatments and outcomes were analyzed. RESULTS: Of all pancreatitis patients, 8.9% were classified as ARP. The proportions of mild and severe diseases were 85.7% and 14.3%, respectively. The common etiological factors were biliogenic (31.0%), alcohol (26.2%), hyperlipidemia (21.4%) and pancreaticobiliary malformation (15.4%). At first 46 cases were cryptogenic and among them 36 were subsequently confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Among the hyperlipidemic ARP patients, 72.2% failed to routinely monitor and control serum lipids. ERCP was performed in 88 cases, and 48 also required an endoscopic sphincterotomy or calculus removal. Twenty-two patients underwent cholangiopancreatic duct stent placement, and pancreatic necrosectomy was performed on eight severe cases. The overall outcomes indicate that 8.3% of the cases progressed to chronic pancreatitis and 33.3% of the cases receiving etiological treatment were recurrence-free. There were no deaths in this study. CONCLUSIONS: The etiological factors of ARP are similar to those of acute pancreatitis at the first attack. The management of ARP should be fully considered based on etiological investigation.

Intestinal ischemia-reperfusion of macaques triggers a strong innate immune response.

AIM: To investigate inflammatory injury in the intestinal mucosa after intestinal ischemia-reperfusion (IIR) with Toll-like receptor (TLR)-mediated innate immunity. METHODS: Ten macaques were randomized into control and IIR groups. The distribution and expression level of TLR2, TLR4, MD2, nuclear factor (NF)-κB p65 and interferon (IFN)-γ were measured by immunohistochemical stain and western blotting. The mRNA expression of TLR4, TLR2, MD2, interleukin (IL)-1ß and tumor necrosis factor (TNF)-α were measured by reverse transcriptase-polymerase chain reaction. The cytokine levels in blood and intestinal tissues were measured by ELISA. RESULTS: Obvious hemorrhage and erosion of mucosae were seen in the IIR group. Expression of TLR2, TLR4, MD2, NF-κB p65 and IFN-γ was significantly higher in the IIR group than in the control group (0.13 ± 0.04, 0.22 ± 0.04, 0.16 ± 0.06, 0.65 ± 0.12, 0.38 ± 0.10 vs 0.07 ± 0.04, 0.08 ± 0.03, 0.04 ± 0.02, 0.19 ± 0.06, 0.14 ± 0.05, P < 0.05). In addition, the expression of TLR2, TLR4, MD2, IL-1ß and TNF-α mRNA in the IIR group were significantly higher than those of control group(1.52 ± 0.15, 1.39 ± 0.06, 1.94 ± 0.12, 1.48 ± 0.15, 0.66 ± 0.08 vs 0.31 ± 0.05, 0.5 ± 0.04, 0.77 ± 0.05, 0.35 ± 0.08, 0.18 ± 0.04, P < 0.05). Furthermore, IL-1ß, IL-6 and TNF-α levels in the macaques ileum and plasma were significantly higher than in the control group (plasma: 86.3 ± 15.2, 1129 ± 248.3, 77.8 ± 16.2 vs 29.5 ± 7.3, 19.8 ± 8.2, 5.6 ± 1.7; ileum: 273.4. ± 44.7, 1636 ± 168.0, 205.5 ± 30.7 vs 76.8 ± 20.5, 663.4 ± 186.9, 49.0 ± 9.4; P < 0.05). CONCLUSION: After IIR, general inflammatory injury in the intestinal mucosa is correlated with a strong innate immune response, mediated by activation of the TLR-NF-κB-cytokine pathway.