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Objective:To investigate the different outcomes of two types of acute kidney injury (AKI) according to standard of Kidney Disease: Improving Global Outcomes-AKI (KDIGO-AKI), and to analyze the risk factors that affect the prognosis of intensive care unit (ICU) patients in China.Methods:A secondary analysis was performed on the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a multicenter prospective study involving 3 063 patients in 22 tertiary ICUs in 19 provinces and autonomous regions of China. The demographic data, scores reflecting severity of illness, laboratory findings, intervention during ICU stay were extracted. All patients were divided into pure AKI (PAKI) and acute on chronic kidney disease (AoCKD). PAKI was defined as meeting the serum creatinine (SCr) standard of KDIGO-AKI (KDIGO-AKI SCr) and the estimated glomerular filtration rate (eGFR) at baseline was ≥ 60 mL·min -1·1.73 m -2, and AoCKD was defined as meeting the KDIGO-AKI SCr standard and baseline eGFR was 15-59 mL·min -1·1.73 m -2. All-cause mortality in ICU within 28 days was the primary outcome, while the length of ICU stay and renal replacement therapy (RRT) were the secondary outcome. The differences in baseline data and outcomes between the two groups were compared. The cumulative survival rate of ICU within 28 days was analyzed by Kaplan-Meier survival curve, and the risk factors of ICU death within 28 days were screened by Cox multivariate analysis. Results:Of the 3 063 patients, 1 042 were enrolled, 345 with AKI, 697 without AKI. The AKI incidence was 33.11%, while ICU mortality within 28 days of AKI patients was 13.91% (48/345). Compared with PAKI patients ( n = 322), AoCKD patients ( n = 23) were older [years old: 74 (59, 77) vs. 58 (41, 72)] and more critical when entering ICU [acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score: 23 (19, 27) vs. 15 (11, 22)], had worse basic renal function [eGFR (mL·min -1·1.73 m -2): 49 (38, 54) vs. 115 (94, 136)], more basic complications [Charlson comorbidity index (CCI): 3 (2, 4) vs. 0 (0, 1)] and higher SCr during ICU stay [peak SCr for diagnosis of AKI (μmol/L): 412 (280, 515) vs. 176 (124, 340), all P < 0.01]. The mortality and RRT incidence within 28 days in ICU of AoCKD patients were significantly higher than those of PAKI patients [39.13% (9/23) vs. 12.11% (39/322), 26.09% (6/23) vs. 4.04% (13/322), both P < 0.01], while no significant difference was found in the length of ICU stay. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate in ICU in AoCKD patients was significantly lower than PAKI patients (Log-Rank: χ2 = 5.939, P = 0.015). Multivariate Cox regression analysis showed that admission to ICU due to respiratory failure [hazard ratio ( HR) = 4.458, 95% confidence interval (95% CI) was 1.141-17.413, P = 0.032], vasoactive agents treatment in ICU ( HR = 5.181, 95% CI was 2.033-13.199, P = 0.001), and AoCKD ( HR = 5.377, 95% CI was 1.303-22.186, P = 0.020) were independent risk factors for ICU death within 28 days. Conclusion:Further detailed classification (PAKI, AoCKD) based on KDIGO-AKI SCr standard combined with eGFR is related to ICU mortality in critical patients within 28 days.
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Objective To investigate the predict value of interleukin-18 (IL-18) combine with kidney injury molecule-1 (KIM-1) on 28-day mortality in patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT) in intensive care unit (ICU), and to look for the start time of CRRT. Methods A prospective observational study was conducted. The consecutive AKI critical patients who underwent CRRT from June 2017 to February 2018 admitted to ICU of the Fourth Hospital of Hebei Medical University were enrolled. Patients were divided into AKI 2 stage and AKI 3 stage groups according to the guidelines for Kidney Disease: Improving Global Outcomes (KDIGO). Basic vital signs were recorded for all enrolled patients, and ventilator parameters were recorded for patients on ventilation. Urine specimens were collected before CRRT, and IL-18 and KIM-1 levels were measured by enzyme-linked immunosorbent assay (ELISA). The patients were followed up for 28 days. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of urinary IL-18 and KIM-1 for prognosis. Results During the study period, 38 patients were treated. The patients with ICU stayed for less than 3 days, chronic obstructive kidney disease, intra-abdominal hypertension (IAH), diuretics usage within 4 hours or renal replacement therapy before urine collection were excluded. Finally, 30 patients were enrolled, including 12 patients with AKI phase 2 and 18 patients with AKI phase 3. There was no significant difference in basic medical characteristics such as gender, age, height, weight, basic vital signs, basic renal function, or severity of disease between AKI 2 stage and AKI 3 stage groups. Compared with the AKI 2 stage group, the level of urine KIM-1 in the AKI 3 stage group was significantly increased [ng/L: 6 195.6 (5 892.6, 7 935.4) vs. 5 487.5 (4 769.8, 6 353.4), P < 0.01], but urine IL-18 level was not statistically significant [ng/L: 52.1 (48.1, 62.6) vs. 53.9 (52.0, 57.2), P > 0.05]. All patients were followed up for
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OBJECTIVE: To evaluate the application of decision tree method and Logistic regression in the prediction of acute myocardial infarction (AMI) events. METHODS: The clinical data of 295 patients, who underwent coronary angiography due to angina or chest pain with unidentified causes in Zhejiang provincial People's Hospital during October 2018 and April 2019, were retrospectively analyzed. Fifty five patients were identified as AMI. Logistic regression and decision tree methods were performed to establish predictive models for the occurrence of AMI, respectively; and the models created by decision tree analysis were divided into Logistic regression-independent model (Tree 1) and Logistic regression-dependent model (Tree 2). The performance of Logistic regression and decision tree models were compared using the area under the receiver operating characteristic (ROC) curve. RESULTS Logistic regression analysis showed that history of coronary artery disease, multi-vessel coronary artery disease, statin use and apolipoprotein (ApoA1) level were independent influencing factors of AMI events (all P<0.05). Logistic regression-independent decision tree model (Tree 1) showed that multi-vessel coronary artery disease was the root node, and history of coronary artery disease, ApoA1 level (the cutoff value:1.314 g/L) and anti-platelet drug use were descendant nodes. In Logistic regression-dependent decision tree model (Tree 2), multi-vessel coronary artery disease was still the root node, but only followed by two descendant nodes including history of coronary artery disease and ApoA1 level. The area under the curve (AUC) of ROC of Logistic regression model was 0.826, and AUCs of decision tree models were 0.765 and 0.726, respectively. AUC of Logistic regression model was significantly higher than that of Tree 2 (95% CI=0.041-0.145, Z=3.534, P<0.001), but was not higher than that of Tree 1 (95% CI=-0.014-0.121, Z=-1.173, P>0.05). CONCLUSIONS The predictive value for AMI event was comparable between Logistic regression-independent decision tree model and Logistic regression model, implying the data mining methods are feasible and effective in AMI prevention and control.
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Critical ultrasonography(CUS) is different from the traditional diagnostic ultrasound,the examiner and interpreter of the image are critical care medicine physicians.The core content of CUS is to evaluate the pathophysiological changes of organs and systems and etiology changes.With the idea of critical care medicine as the soul,it can integrate the above information and clinical information,bedside real-time diagnosis and titration treatment,and evaluate the therapeutic effect so as to improve the outcome.CUS is a traditional technique which is applied as a new application method.The consensus of experts on critical ultrasonography in China released in 2016 put forward consensus suggestions on the concept,implementation and application of CUS.It should be further emphasized that the accurate and objective assessment and implementation of CUS requires the standardization of ultrasound image acquisition and the need to establish a CUS procedure.At the same time,the standardized training for CUS accepted by critical care medicine physicians requires the application of technical specifications,and the establishment of technical specifications is the basis for the quality control and continuous improvement of CUS.Chinese Critical Ultrasound Study Group and Critical Hemodynamic Therapy Collabration Group,based on the rich experience of clinical practice in critical care and research,combined with the essence of CUS,to learn the traditional ultrasonic essence,established the clinical application technical specifications of CUS,including in five parts:basic view and relevant indicators to obtain in CUS;basic norms for viscera organ assessment and special assessment;standardized processes and systematic inspection programs;examples of CUS applications;CUS training and the application of qualification certification.The establishment of applied technology standard is helpful for standardized training and clinical correct implementation.It is helpful for clinical evaluation and correct guidance treatment,and is also helpful for quality control and continuous improvement of CUS application.
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Objective@#To observe the effect of different doses and timing of normal saline (NS) resuscitation combined with norepinephrine (NE) on endothelial glycocalyx in rabbits with early septic shock.@*Methods@#Thirty New Zealand male rabbits were randomly divided into sham group, model group, 30 mL and 60 mL timely resuscitation groups (30 mL and 60 mL timely group), and 30 mL delayed resuscitation group (30 mL delayed group) with 6 rabbits in each group. The rabbit model of septic shock was reproduced by cecal ligation and puncture (CLP). The rabbits in sham group were only received abdominal cavity open without cecal and ligation. The rabbits in 30 mL and 60 mL timely groups and 30 mL delayed group were intravenous infused with 30 mL/kg or 60 mL/kg NS immediately or 1 hour after model reproduction for 1 hour, and the mean arterial pressure (MAP) was maintained over 75 mmHg (1 mmHg = 0.133 kPa) compared with intravenous pumping of 0.02-0.05 μg·kg-1·min-1 NE followed by 5 mL/h NS infusion till the end of the experiment. The rabbits in sham and model groups were only given 5 mL/h NS. The changes in arterial blood gas before and immediately after resuscitation were observed in three fluid resuscitation groups. The internal jugular vein blood was collected at 0, 3, 6 hours after model reproduction. The levels of syndecan-1 (polysaccharide envelope marker) in plasma were determined by enzyme linked immunosorbent assay (ELISA). The rabbits were sacrificed at 6 hours after model reproduction, and the lung tissue was harvested. Western Blot was used to determine the protein expressions of intercellular adhesion molecule-1 (ICAM-1), matrix metalloproteinase 2 (MMP-2) and syndecan-1. The positive expression of syndecan-1 in lung tissue was observed by immunohistochemical method.@*Results@#① Blood gas analysis: compared with the results before resuscitation, the levels of lactic acid (Lac) after resuscitation in three fluid resuscitation groups were significantly decreased, especially in 30 mL timely group; the central venous blood oxygen saturation (ScvO2) was significantly increased, especially in 30 mL delayed group. Oxygenation index (PaO2/FiO2) was improved in 30 mL timely and 30 mL delayed resuscitation groups, which was decreased in 60 mL delayed group. ② Plasma marker: compared with sham group, plasma syndecan-1 level in model group was significantly increased with a time-dependent manner. Plasma syndecan-1 levels at 3 hours in 30 mL timely and 30 mL delayed groups were significantly decreased as compared with those of model group (ng/L: 138.0±2.4, 139.7±15.7 vs. 161.5±4.1, both P < 0.05), but it was significantly increased at 6 hours in 30 mL delayed group (ng/L: 213.1±19.4 vs. 206.4±15.5, P < 0.05). The plasma syndecan-1 levels at 3 hours and 6 hours in 60 mL timely group were significantly higher than those in model group (ng/L: 233.0±28.9 vs. 161.5±4.1, 252.3±27.2 vs. 206.4±15.5, both P < 0.05). ③ Protein expression in lung tissue: compared with sham group, the protein expressions of ICAM-1 and MMP-2 in lung tissue of model group were significantly increased, and syndecan-1 protein expression was significantly decreased. After 30 mL timely or 30 mL delayed resuscitation, the protein expressions of ICAM-1 and MMP-2 in lung tissue were significantly decreased, and syndecan-1 protein expression was significantly increased, especially in 30 mL timely group, which showed statistical differences as compared with those of model group (ICAM-1 protein: 0.56±0.09 vs. 1.04±0.05, MMP-2 protein: 0.83±0.15 vs. 1.06±0.06, syndecan-1 protein: 2.09±0.08 vs. 0.99±0.03, all P < 0.05). The change tendency of protein expressions in 60 mL timely group was opposite to the other two resuscitation groups. ④ Immunohistochemistry: the positive expression of syndecan-1 in lung tissues was significant in the sham group, and it was lowered in model group. The positive expression of syndecan-1 was increased after 30 mL timely or 30 mL delayed resuscitation, but further weakened in 60 mL timely group.@*Conclusions@#The dose and timing of resuscitation with NS in septic shock can affect pulmonary vascular endothelial glycocalyx function. The timely resuscitation with 30 mL NS in combination with NE plays a protective effect on endothelial cell and glycocalyx. However, NS resuscitation which was not timely or excessive infusion can make the glycocalyx degradation more obvious, resulting in increased endothelial permeability, microcirculation damaged, thus aggravate lung injury.
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Objective To evaluate the accuracy of color Doppler in predicting acute kidney injury ( AKI) . Methods Patients of both sexes with AKI risk factors not diagnosed with AKI, aged ≥18 yr, were enrolled in this study. Within 1 h after inclusion, the renal blood flow ( RBF) grade was monitored u-sing color Doppler, and renal resistive index ( RRI) value of renal interlobar artery was monitored at the level of renal interlobar or arcuate arteries, and corrected RRI value was calculated. The development of AKI was recorded within 24 h through measuring serum creatinine and urine volume, and the receiver oper-ating characteristic curve was plotted. Results Thirty-eight patients were included in non-AKI group and 40 ones in AKI group. Compared with non-AKI group, RBF grade was significantly decreased, RRI value was increased ( P<0. 05) , and no significant change was found in the corrected RRI value in AKI group ( P>0. 05) . The area under the curve of RBF grade and RRI value in predicting AKI occurred within 24 h and 95％ confidence interval were 0. 659 ( 0. 561-0. 747) and 0. 669 ( 0. 572-0. 756) , respectively. Con-clusion Color Doppler has a certain value in predicting AKI within 24 h.
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OBJECTIVE@#To observe the effect of different doses and timing of normal saline (NS) resuscitation combined with norepinephrine (NE) on endothelial glycocalyx in rabbits with early septic shock.@*METHODS@#Thirty New Zealand male rabbits were randomly divided into sham group, model group, 30 mL and 60 mL timely resuscitation groups (30 mL and 60 mL timely group), and 30 mL delayed resuscitation group (30 mL delayed group) with 6 rabbits in each group. The rabbit model of septic shock was reproduced by cecal ligation and puncture (CLP). The rabbits in sham group were only received abdominal cavity open without cecal and ligation. The rabbits in 30 mL and 60 mL timely groups and 30 mL delayed group were intravenous infused with 30 mL/kg or 60 mL/kg NS immediately or 1 hour after model reproduction for 1 hour, and the mean arterial pressure (MAP) was maintained over 75 mmHg (1 mmHg = 0.133 kPa) compared with intravenous pumping of 0.02-0.05 μg×kg-1×min-1 NE followed by 5 mL/h NS infusion till the end of the experiment. The rabbits in sham and model groups were only given 5 mL/h NS. The changes in arterial blood gas before and immediately after resuscitation were observed in three fluid resuscitation groups. The internal jugular vein blood was collected at 0, 3, 6 hours after model reproduction. The levels of syndecan-1 (polysaccharide envelope marker) in plasma were determined by enzyme linked immunosorbent assay (ELISA). The rabbits were sacrificed at 6 hours after model reproduction, and the lung tissue was harvested. Western Blot was used to determine the protein expressions of intercellular adhesion molecule-1 (ICAM-1), matrix metalloproteinase 2 (MMP-2) and syndecan-1. The positive expression of syndecan-1 in lung tissue was observed by immunohistochemical method.@*RESULTS@#(1) Blood gas analysis: compared with the results before resuscitation, the levels of lactic acid (Lac) after resuscitation in three fluid resuscitation groups were significantly decreased, especially in 30 mL timely group; the central venous blood oxygen saturation (ScvO2) was significantly increased, especially in 30 mL delayed group. Oxygenation index (PaO2/FiO2) was improved in 30 mL timely and 30 mL delayed resuscitation groups, which was decreased in 60 mL delayed group. (2) Plasma marker: compared with sham group, plasma syndecan-1 level in model group was significantly increased with a time-dependent manner. Plasma syndecan-1 levels at 3 hours in 30 mL timely and 30 mL delayed groups were significantly decreased as compared with those of model group (ng/L: 138.0±2.4, 139.7±15.7 vs. 161.5±4.1, both P < 0.05), but it was significantly increased at 6 hours in 30 mL delayed group (ng/L: 213.1±19.4 vs. 206.4±15.5, P < 0.05). The plasma syndecan-1 levels at 3 hours and 6 hours in 60 mL timely group were significantly higher than those in model group (ng/L: 233.0±28.9 vs. 161.5±4.1, 252.3±27.2 vs. 206.4±15.5, both P < 0.05). (3) Protein expression in lung tissue: compared with sham group, the protein expressions of ICAM-1 and MMP-2 in lung tissue of model group were significantly increased, and syndecan-1 protein expression was significantly decreased. After 30 mL timely or 30 mL delayed resuscitation, the protein expressions of ICAM-1 and MMP-2 in lung tissue were significantly decreased, and syndecan-1 protein expression was significantly increased, especially in 30 mL timely group, which showed statistical differences as compared with those of model group (ICAM-1 protein: 0.56±0.09 vs. 1.04±0.05, MMP-2 protein: 0.83±0.15 vs. 1.06±0.06, syndecan-1 protein: 2.09±0.08 vs. 0.99±0.03, all P < 0.05). The change tendency of protein expressions in 60 mL timely group was opposite to the other two resuscitation groups. (4) Immunohistochemistry: the positive expression of syndecan-1 in lung tissues was significant in the sham group, and it was lowered in model group. The positive expression of syndecan-1 was increased after 30 mL timely or 30 mL delayed resuscitation, but further weakened in 60 mL timely group.@*CONCLUSIONS@#The dose and timing of resuscitation with NS in septic shock can affect pulmonary vascular endothelial glycocalyx function. The timely resuscitation with 30 mL NS in combination with NE plays a protective effect on endothelial cell and glycocalyx. However, NS resuscitation which was not timely or excessive infusion can make the glycocalyx degradation more obvious, resulting in increased endothelial permeability, microcirculation damaged, thus aggravate lung injury.
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Animals , Male , Rabbits , Fluid Therapy , Glycocalyx , Matrix Metalloproteinase 2 , Resuscitation , Shock, SepticABSTRACT
Objective To observe and explore the effects of different tidal volume (VT) ventilation on right ventricular (RV) function in patients with critical respiratory failure.Methods Consecutive respiratory failure patients who were treated with invasive ventilator over 24 h in the Department of Critical Care Medicine at the Fourth Hospital of Hebei Medical University from June to December in 2015 were enrolled in this study.Clinical data including patients′ vital signs, ventilator parameters and RV echocardiography were collected within 6 h (D0), day1(D1), day2 (D2) and day3 (D3) after ventilation started.According to the VT, patients with acute respiratory distress syndrome (ARDS) were assigned to low VT group [S6, ≤6 ml/kg predicted body weight (PBW)] and high VT group (L6, >6 ml/kg PBW), while non-ARDS patients were also assigned to low VT group (S8, ≤8 ml/kg PBW) and high VT group (L8, >8 ml/kg PBW).Results A total of 84 patients were enrolled in this study.44.2% ARDS patients and 58.5% non-ARDS patients were in low VT groups.After ventilation, tricuspid annulus plane systolic excursion(TAPSE)decreased progressively in S6 [from 18.30(16.70,20.70) mm to 17.55(15.70,19.50) mm, P=0.001], L6 [from 19.50(17.00,21.00) mm to 16.30(15.00,18.00) mm P=0.001], S8[from 18.00(16.00,21.00) mm to 16.50(15.50,18.00) mm, P=0.001] and L8 [from 19.00(17.50,21.50) mm to 16.35(15.15,17.00) mm, P=0.001] groups.However, TAPSE decreased less in small VT groups (S6 and S8) than those of in large VT groups (S8 and L8) without significant differences.There were not statistical differences between different VT groups in terms of ventilation days, including right ventricle area/left ventricle area (RVarea/LVarea),TAPSE,peak mitral flow velocity of the early rapid filling wave (E),peak mitral flow velocity of the late rapid filling wave (A),early diastolic velocity of the tricuspid annulus (e′),pulmonary artery systolic pressure,inferior vena cava diameter (all P>0.05).Compared to L6 group, low VT (S6 group) resulted in decreased mortality at 28 days [1/19 vs 37.5%(9/24), P=0.014].There were not statistical differences between different VT groups in terms of ventilation days, length of intensive care unit stay, length of hospital stay (all P>0.05).Logistic regression analysis showed that VT could be the independent factor of TAPSE (OR=1.104,95%CI 0.100-1.003,P=0.049).Conclusions Positive pressure mechanical ventilation resulted in RV systolic dysfunction.Lower VT may have the protective effect on RV function.Trial registration Chinese Clinical Trial Registry,ChiCTR-POC-15007563.
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Objective To observe the influence of ulinastatin (UTI) on curative effect,inflammatory response and cellular immune function in patients with acute respiratory distress syndrome (ARDS).Methods 96 patients with ARDS were randomly divided into two groups:the control group (48 cases) were treated with conventional treatment,and the UTI group (48 cases) were added with UTI injection based on the control group treatment.The changes of oxygenation index,vital signs,inflammatory factors and T lymphocyte subsets of patients in the two groups were compared before treatment and after treatment in 7 days,recorded the duration of mechanical ventilation time,ICU treatment time and mortality rate in ICU in the two groups.Results After treatment in 7 days,the vital signs (RF,HR,MAP),inflammatory factors (TNF-α,IL-6,IL-8,PCT,CRP,WBC),liver function (AST,ALT),renal function (BUN,Cr) and APACHE Ⅱ score,MODS score of UTI patients in the UTI group were lower than those in the control group (P ＜ 0.05 or P ＜ 0.01).Oxygenation index (PaO2/FiO2) and cellular immunity (CD4+,CD4+/CD8+) in the UTI group were higher than those in the control group (P ＜ 0.01).Mechanical ventilation time,ICU treatment time in the UTI group were shorter than those in the control group (all P ＜ 0.05),the mortality rate of ICU in the UTI group was lower than that in the control group (P ＜ 0.05).There was no significant difference in the incidence of adverse reactions between the two groups (P ＞ 0.05).Conclusions UTI can more effectively improve oxygen metabolism,vital signs for ARDS,liver and kidney function,reduce the APACHE Ⅱ score and MODS score,shorten the mechanical ventilation time and ICU treatment time,reduce the mortality rate of ICU.Its mechanism may relate to clearance of inflammatory factors and regulate cellular immune function of UTI.
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Objective To investigate the quality control indexes of intensive care units in Hebei province.Methods Statistical analysis was made on the quality control indexes of 48 hospitals in Hebei, which were registered in the critical medical quality management and control website of Hebei province. Results The physician-bed ratio of ICUs was (0.699 ± 0.231):1, with the beds accounting for (1.5 ± 0.5)% of the total beds in the hospital; nurse-bed ratio was (1.956 ± 0.544):1. The patients with APACHE II score greater than 15 accounted for (57.6 ± 23.2)%. In the course of treatment for septic shock patient,their 3h/6h bundle treatment completion rate was (57.0 ± 39.1)% and (57.0 ± 37.8)% respectively. Actual mortality of Hebei ICUs was(21.2 ± 16.5)%,and their unplanned tracheal intubation rate was (7.9 ± 7.7)%. Conclusions Given the overall capacity of ICUs in Hebei, there exist such shortcomings as insufficient beds and irrational staffing, which calls for better intensive care education and greater manpower for healthy development of critical care medicine.