Association of Perceived Stress With Depression Among Vaccinated Healthcare Workers During the SARS-CoV-2 Variant Outbreak: The Mediating Role of Compassion Fatigue

Objective@#Depression was common during coronavirus disease-2019 (COVID-19) pandemic, while the association of perceived stress with depression among vaccinated healthcare workers has not been investigated. This study aimed to address this issue. @*Methods@#We included a total of 898 fully vaccinated healthcare workers during the outbreak of severe acute respiratory syndrome coronavirus 2 Delta variant in Nanjing, 2021. Depression was ascertained by Patient Health Questionnaire-9, with a cut-off score of ≥5 indicative of mild-to-severe depression. Perceived stress, resilience, and compassion fatigue were assessed by Perceived Stress Scale-10, Resilience Scale-25, and Professional Quality of Life Scale version-5, respectively. Logistic regression analyses were used to estimate the odds ratio (OR) and 95% confidence interval (CI), along with subgroup and mediation analyses. @*Results@#The prevalence of mild-to-severe depression was 41.1% in vaccinated healthcare workers. The odd of mild-to-severe depression was increased with higher perceived stress. Compared with vaccinated healthcare workers with the lowest tertile of perceived stress, those with the highest tertile had increased odds of mild-to-severe depression by 120% (OR 2.20, 95% CI 1.46 to 3.31) after multivariable-adjustment. However, perceived stress was not associated with mild-to-severe depression in vaccinated healthcare workers with strong resilience, but was in those with weak resilience (pinteraction=0.004). Further analysis showed that compassion fatigue mediated the relationship between perceived stress and mild-to-severe depression, with a mediating effect of 49.7%. @*Conclusion@#Perceived stress was related to an increased odd of mild-to-severe depression in vaccinated healthcare workers during COVID-19 pandemic, and this relationship might be explained by compassion fatigue.

An area under curve-based nomogram to predicts vancomycin-associated nephrotoxicity in critically ill patients: a retrospective cohort study / 中华内科杂志

Objective:To develop an area under curve (AUC)-based nomogram to predict vancomycin-associated nephrotoxicity in critically ill patients.Methods:This retrospective cohort study included adult patients treated with vancomycin in the intensive care unit at a tertiary teaching hospital from January 2015 to December 2017. Baseline clinical characteristics before vancomycin treatment and pharmacokinetic parameters were collected to establish a prediction model of nephrotoxicity. Univariate analysis was used to screen variables, and multivariate logistic regression analysis was used to establish the prediction model and nomogram.Results:A total of 159 patients met the inclusion criteria, sixty-four were included in the final analysis. Sixteen patients (25%, 16/64) developed vancomycin-associated nephrotoxicity. The following variables were incorporated into the prediction model: vancomycin AUC, estimated glomerular filtration rate (GFR), and combined nephrotoxic drugs. The following equation was established to calculate the probability of nephrotoxicity: logit (P)=-4.83+0.009×AUC-2.87×1 (if GFR>60 ml/min)+2.53×1 (if number of combined nephrotoxic drugs≥2). A nomogram was generated based on the equation. The receiver-operating characteristic curve demonstrated that the AUC of the prediction model was 0.927 (95% CI 0.851-1.000). The cut-off value of the probability of nephrotoxicity was 26.48%. The sensitivity and specificity were 87.5% and 87.5% respectively. Conclusion:The incidence of vancomycin-associated nephrotoxicity is high. The AUC-based nomogram can effectively predict vancomycin-associated nephrotoxicity in critically ill patients.

The implementation of hour-1 bundle for sepsis in medical staff / 中华内科杂志

To determine the physicians′compliance of hour-1 bundle for sepsis. A management system of hour-1 bundle for sepsis was established. The clinical data of 286 sepsis patients were collected, who were classified into 3 months before the bundle (control group), 9 months during process (observation group) and 3 months after bundle (study group). The compliance of hour-1 bundle implementation was compared in three groups. The results showed that with the application and implementation of the management system, the compliance of hour-1 bundle for sepsis in the control group, observation group and study group was 58.3%(28/48), 69.1%(105/152) and 88.4%(76/86) respectively (χ 2=7.053, P=0.029). The 28 day mortality in sepsis patients was 41.7%(20/48), 34.9%(53/152) and 23.3%(20/86) respectively (χ 2=5.576, P=0.062).The management system of hour-1 bundle for sepsis can effectively improve the physicians′ compliance.

Hepatocyte growth factor protects pulmonary endothelial barrier against oxidative stress and mitochondria-dependent apoptosis / 中华医学杂志(英文版)

BACKGROUND@#Pulmonary microvascular endothelial cells (PMVECs) were not complex, and the endothelial barrier was destroyed in the pathogenesis progress of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). Previous studies have demonstrated that hepatocyte growth factor (HGF), which was secreted by bone marrow mesenchymal stem cells, could decrease endothelial apoptosis. We investigated whether mTOR/STAT3 signaling acted in HGF protective effects against oxidative stress and mitochondria-dependent apoptosis in lipopolysaccharide (LPS)-induced endothelial barrier dysfunction and ALI mice.@*METHODS@#In our current study, we introduced LPS-induced PMEVCs with HGF treatment. To investigate the effects of mammalian target of rapamycin (mTOR)/signal transducer and activator of transcription 3 (STAT3) pathway in endothelial oxidative stress and mitochondria-dependent apoptosis, mTOR inhibitor rapamycin and STAT3 inhibitor S3I-201 were, respectively, used to inhibit mTOR/STAT3 signaling. Moreover, lentivirus vector-mediated mTORC1 (Raptor) and mTORC2 (Rictor) gene knockdown modifications were introduced to evaluate mTORC1 and mTORC1 pathways. Calcium measurement, reactive oxygen species (ROS) production, mitochondrial membrane potential and protein, cell proliferation, apoptosis, and endothelial junction protein were detected to evaluate HGF effects. Moreover, we used the ALI mouse model to observe the mitochondria pathological changes with an electron microscope in vivo.@*RESULTS@#Our study demonstrated that HGF protected the endothelium via the suppression of ROS production and intracellular calcium uptake, which lead to increased mitochondrial membrane potential (JC-1 and mitochondria tracker green detection) and specific proteins (complex I), raised anti-apoptosis Messenger Ribonucleic Acid level (B-cell lymphoma 2 and Bcl-xL), and increased endothelial junction proteins (VE-cadherin and occludin). Reversely, mTOR inhibitor rapamycin and STAT3 inhibitor S3I-201 could raise oxidative stress and mitochondria-dependent apoptosis even with HGF treatment in LPS-induced endothelial cells. Similarly, mTORC1 as well as mTORC2 have the same protective effects in mitochondria damage and apoptosis. In in vivo experiments of ALI mouse, HGF also increased mitochondria structural integrity via the mTOR/STAT3 pathway.@*CONCLUSION@#In all, these reveal that mTOR/STAT3 signaling mediates the HGF suppression effects to oxidative level, mitochondria-dependent apoptosis, and endothelial junction protein in ARDS, contributing to the pulmonary endothelial survival and barrier integrity.

Role of different cells derived extracellular vesicles in acute respiratory distress syndrome / 中华危重病急救医学

Acute respiratory distress syndrome (ARDS) is a common clinical critical condition of the respiratory system, with a high fatality rate and lack of effective drug treatment, hence it is a global medical problem to be solved urgently. Recently, with the in-depth research on extracellular vesicles (EVs) at home and abroad, more and more evidences suggest that EVs play a critical role in the initiation, development and progression of ARDS and have potential clinical application value. The role of different cells derived EVs in ARDS will be reviewed in this paper.

The influencing factors achieving target vancomycin trough level in critically ill patients / 中华内科杂志

Objective To assess the rate achieving the target vancomycin trough level (VTL) and its influencing factors in critically ill patients.Methods The retrospective observational study recruited adult patients treated with intravenous vancomycin in the intensive care unit (ICU) at Zhongda Hospital from January 2015 to December 2017.Serum VTL was tested at steady state.Patients' demographics,the sites of infection,microbial culture results,the severity of illness,laboratory data and vancomycin regimen were obtained at the baseline.The rate achieving target VTL (15-20 mg/L) was analyzed based on renal function.Linear regression was performed to determine the influencing factors of VTL.Results A total of 85 patients were enrolled,among whom only 23.5％ (20/85) achieved the target VTL.In patients with normal renal function,the achieving rate was only 11.4％ (4/35),and 80.0％ (28/35) was lower than the target trough level multiple linear regression analysis showed that procalcitonin (PCT),estimated glomerular filtration rate (eGFR) and acute physiology and chronic health disease classification system Ⅱ (APACHE Ⅱ) score were independent factors associated with VTL.Conclusion Achieving target VTL in critically ill patients is not satisfactory.Further study to optimize the administration is needed to facilitate prompt attainment of target VTL.

Intra-aortic balloon counterpulsation for patients with acute myocardial infarction and undergoing percutaneous coronary intervention: a meta-analysis / 中华全科医师杂志

Objective To evaluate the effects of intra-aortic balloon counterpulsation (IABP) on mortality of patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI).Methods Randomized controlled trials (RCTs) of IABP compared with non-IABP control in AMI patients, from January 1970 to May 2015, were searched from MEDLINE, Embase and Web of Science.The data were analyzed with software RevMan 5.0.Results Five RCTs involving 1 450 AMI patients, including 722 treated with IABP (IABP group) and 728 without IABP (non-IABP group), were included for analysis.Compared with non-IABP group, IABP did not significantly decrease the hospital mortality or 30-day mortality (OR=0.92, 95%CI: 0.69-1.25,P=0.61).According to the timing of IABP before or after PCI, it was further divided into IABP-before-PCI subgroup and IABP-after-PCI subgroup.Compared with non-IABP group, the 30-day mortality was not decreased in IABP-before-PCI subgroup or in IABP-after-PCI subgroup (OR=0.64, 95%CI: 0.23-1.78,P=0.39;OR=1.25, 95%CI: 0.42-3.77,P=0.69, respectively).According to complicating with cardiogenic shock (CS) or not, patients were divided to AMI with CS subgroup and AMI with no-CS subgroup;the hospital or 30-day mortality were not significantly decreased in both subgroups (OR=0.96, 95%CI: 0.70-1.32,P=0.80;OR=0.68, 95%CI: 0.28-1.70,P=0.27, respectively).Conclusion IABP does not decrease the 30-day mortality of AMI patients treated with PCI.

Anti-oxidant effect of pirfenidone on acute lung injury induced by paraquat poisoning in mice / 中华危重病急救医学

Objective To investigate the anti-oxidant effect of pirfenidone (PD) at different dosage on acute lung injury (ALI) induced by paraquat (PQ) poisoning in mice. Methods 144 ICR mice were randomly divided into four groups: control group (n = 24), PQ poisoned group (n = 24), high and low doses PD treatment groups (n = 48). ALI induced by PQ poisoning model was reproduced by intraperitoneal injection of 25 mg/kg 20% PQ solution in mice, and the mice in control group was given equal volume of normal saline. Intragastric administration with 30 mg/kg and 70 mg/kg PD suspension [PD was dissolved in 0.4% sodium carboxymethyl cellulose sodium (CMC) solution] after PQ poisoning immediately for 3 days in high and low doses PD treatment groups respectively, while the same volume of 0.4% CMC solution was administrated in control group and PQ poisoned group. Then mice in each group were respectively sacrificed at 2, 6, 12, 24, 48 and 72 hours after PD exposure to harvest the lung tissue, nuclear factor-κB (NF-κB) was determined by enzyme linked immunosorbent assay (ELISA), superoxide dismutase (SOD) and malonaldehyde (MDA) were determined by colorimetry, and pulmonary pathological changes were observed with microscope after hematoxylin-ensin (HE) staining. Results Compared with the control group, NF-κB from 2 hours in PQ poisoned group was significantly increased (pg/mg: 106.65±5.96 vs. 79.04±2.40, P 0.05), but no significant difference in NF-κB activity at all time points was found. Under light microscope, a wide range of red blood cells and serous effusion, alveolar septum fracture and pulmonary interstitial inflammatory cell infiltration were shown by pathologic examination in PQ poisoned group. The pathologic changes in high and low doses PD treatment groups were obviously less than those of PQ poisoned group, and no significant difference was found between the two doses groups. Conclusions The early therapeutic effect of PD may relate to the inhibition of NF-κB and reactive oxygen species, then reduce the inflammation of PQ poisoning. The treatment effectiveness of low dose PD seems better than high dose PD.

Effects of sedation with propofol or dexmedetomidine on volume responsiveness in critically ill patients with acute circulatory failure / 中华麻醉学杂志

Objective To evaluate the effects of sedation with propofol or dexmedetomidine on volume responsiveness in critically ill patients with acute circulatory failure. Methods Ninety?one critically ill patients with acute circulatory failure, aged 20-90 yr, weighing 40-80 kg, requiring sedation with propofol or dexmedetomidine, of Acute Physiology and Chronic Health Evaluation Ⅱ scores 12-47, of Sequential Organ Failure Assessment scores 1-18, and of NYHA Ⅰ or Ⅱ, were included. The patients were randomly divided into 2 groups using a random number table: propofol group ( n = 45 ) and dexmedetomidine group ( n=46) . Before and after propofol or dexmedetomidine sedation, when Richmond Agitation Sedation Scale score reached -2 or -1 ( BIS value 60-75) ( after sedation) , passive leg?raising (PLR) test was performed to evaluate volume responsiveness. An increase in cardiac index (ΔCI) ≥10% after PLR was considered to be a positive response, whereas ΔCI<10% after PLR was considered to be a negative response. The patients who presented with negative responses before sedation served as negative volume responsiveness subgroups ( N subgroups ) , that was PN subgroup and DN subgroup. Results The positive rates of volume responsiveness were 64% ( 14 cases) and 25% ( 5 cases) in PN and DN subgroups, respectively. The positive rates of volume responsiveness were significantly higher after sedation than before sedation in PN and DN subgroups. Compared with DN subgroup, the positive rates of volume responsiveness were significantly increased after sedation in PN subgroup. Conclusion For the critically ill patients with acute circulatory failure, both propofol and dexmedetomidine sedation can improve volume responsiveness, and propofol provides better efficacy than dexmedetomidine.

Retrospective survey and inspiration of hospitalized patients with hard-to-heal wounds / 实用医学杂志

Objective To retrospectively investigate the causes , location and the duration of hospital stays of the hospitalized patients with hard-to-heal wounds so as to provide data guidance for the prevention and research of these diseases. Methods Clinical data of hospitalized patients with hard-to-heal wounds in plastic surgery center of General Hospital of Guangzhou Military Command were collected from June , 2011 to December, 2013. Whether ulceration was recovered in the patients with skin tissue defect after 2 months treatment was regarded as the standard to screen the patients with hard-to-heal wounds. The causes , location, age and the duration of hospital stays of the hospitalized patients with hard-to-heal wounds were investigated by retrospective case-control method. Chi-square test and t-test were used in analyzing the investigation. Results 2 136 cases, aged from 20 to 86, were treated in plastic surgery center of the hospital. 120 cases have hard-to-heal wounds, which constituted 5.62% of all hospitalized patients. (1) Metabolic disease was the main causes of wound (43.3%), followed by wound infection and tumor (20.0% for each) (χ2 = 62.917, P < 0.01). ( 2 ) The peak age for patients with hard-to-heal wounds was 40 to 60 years old patients , followed by patients′age from 60 to 80 years. (3) The mostly like hard-to-heal wounds was on limbs (61.6%), especially on the foot (38.3%) (χ2 = 17.546, P = 0.002). (4) The average days for hospitalization of in the plastic surgery center were (7.41 ± 8.98), while the average days for hospitalization of the patients with years were (33.21 ± 28.27)(t = -9.968, P < 0.05). Conclusion The average diagnostic age of patients with hard-to-heal wounds is the middle and old aged patients. Chronic skin ulcers, which often occurs in a limb, seriously affects a person′s ability to move , which can prolong hospital stays , causing serious burden for the families of patients and the society.

Effects of high-frequency oscillatory ventilation and conventional mechanical ventilation on oxygen metabolism and tissue perfusion in sheep models of acute respiratory distress syndrome / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>High-frequency oscillatory ventilation (HFOV) allows for small tidal volumes at mean airway pressures (mPaw) above that of conventional mechanical ventilation (CMV), but the effect of HFOV on hemodynamics, oxygen metabolism, and tissue perfusion in acute respiratory distress syndrome (ARDS) remains unclear. We investigated the effects of HFOV and CMV in sheep models with ARDS.</p><p><b>METHODS</b>After inducing ARDS by repeated lavage, twelve adult sheep were randomly divided into a HFOV or CMV group. After stabilization, standard lung recruitments (40 cmH2O × 40 seconds) were performed. The optimal mPaw or positive end-expiratory pressure was obtained by lung recruitment and decremental positive end-expiratory pressure titration. The animals were then ventilated for 4 hours. The hemodynamics, tissue perfusion (superior mesenteric artery blood flow, pHi, and Pg-aCO2), oxygen metabolism and respiratory mechanics were examined at baseline before saline lavage, in the ARDS model, after model stabilization, and during hourly mechanical ventilation for up to 4 hours. A two-way repeated measures analysis of variance was applied to evaluate differences between the groups.</p><p><b>RESULTS</b>The titrated mPaw was higher and the tidal volumes lower in the HFOV group than the positive end-expiratory pressure in the CMV group. There was no significant difference in hemodynamic parameters between the HFOV and CMV groups. There was no difference in the mean alveolar pressure between the two groups. After lung recruitment, both groups showed an improvement in the oxygenation, oxygen delivery, and DO2. Lactate levels increased in both groups after inducing the ARDS model. Compared with the CMV group, the superior mesenteric artery blood flow and pHi were significantly higher in the HFOV group, but the Pg-aCO2 decreased in the HFOV group.</p><p><b>CONCLUSION</b>Compared with CMV, HFOV with optimal mPaw has no significant side effect on hemodynamics or oxygen metabolism, and increases gastric tissue blood perfusion.</p>

A Meta analysis of the effect of enhanced hand hygiene on the morbidity of ventilator-associated pneumonia / 中华危重病急救医学

Objective To determine the effect of enhanced hand hygiene on the morbidity of ventilator-associated pneumonia (VAP).Methods Clinical studies which were related to enhanced hand cleansing to the risk of VAP,which were published between July 1992 and June 2013 in English or Chinese were retrieved via computer and manual screening.Data were extracted according to appropriate inclusion and exclusion criteria and analyzed with RevMan 5.0 software.Results A total of 6 studies,all of which were performed with well controlled protocol,involving 28 461 mechanical ventilator days and 32 428 mechanical ventilator days were analyzed.The morbidity of VAP was 39.5 days per 1 000 mechanical ventilator days and 19.5 days per 1 000 mechanical ventilator days before and after enhanced hand cleaning,respectively.The methods of enhancing hand hygiene included feasible hand hygiene apparatus,long-term education,supervision and feedback,as well as increased hand cleaning compliance.All 6 eligible studies reported that enhanced hand washing lowered the risk of VAP,with risk reduction ranging from 29.8％ to 65.5％ with a mean reduction value of 50.6％.Meta analysis showed that enhanced hand cleaning could protect patients from VAP with odds ratio (OR) varying from 1.43 to 5.82 [pooled OR=2.23,95％ confidence interval (95％CI) 1.62-3.07,P＜0.000 01].It was showed in funnel chart that bias in the published articles was not significant.Conclusions Enhanced hand hygiene has an effect of prevention of VAP morbidity and is associated with lowered morbidity of VAP.However,the reliability of this conclusion is questionable because of poor quality of these studies.

Effects of sucralfate and acid-suppressive drugs on preventing ventilator-associated pneumonia of mechanically ventilated patients: a meta-analysis / 中华内科杂志

Objective To evaluate the effect of sucralfate and acid-suppressive drugs on preventing ventilator-associated pneumonia (VAP) in mechanically ventilated patients.Methods All randomized controlled trials (RCTs),which studied the effect of sucralfate and acid-suppressive drugs on the incidence of VAP in mechanically ventilated patients,were searched from PubMed,Embase and the Cochrane Library during January 1966 to March 2013 via manual and computer retrieval.All related data were extracted.Meta analysis was conducted using the statistical software RevMan 5.2 and the quality of the RCTs was strictly evaluated with the methods recommended by the Cochrane Collaboration.Results A total of 15 RCTs involving 1315 patients in the sucralfate group and 1568 patients in the acid-suppressive drug group were included in this study.The incidence of VAP was significantly reduced in the sucralfate group (RR =0.81,95％ CI 0.7-0.95,P =0.008),while no difference was found between the two groups in the incidence of stress-related gastrointestinal bleeding (RR =0.96,95％ CI 0.59-1.58,P =0.88).No statistical difference was found in the days on ventilator,duration of ICU stay and ICU mortality in the two groups (all P values ＞ 0.05).Conclusion In patients with mechanical ventilation,sucralfate could decrease the incidence of VAP,while has no such effect on the stress-related gastrointestinal bleeding,the days on ventilator,duration of ICU stay and ICU mortality.

The role of I-Ab/I-E expression in dendritic cells of acute lung injury mice / 中华内科杂志

Objective To observe the expression of I-Ab/I-E on circulating,lung and splenic dendritic cells (DC) in acute lung injury (ALI) mice.Methods Twenty-four C57BL/6 mice were randomly divided into four groups:control group,ALI 6 h,ALI 12 h and ALI 24 h group.Blood,lungs and spleens were harvested after lipopolysaccharide or phosphate butter solution administration.The expression of I-Ab/I-E on DC was assessed by flow cytometry (FCM).IL-6 level in the lung was measured by enzymelinked immunosorbent assay (ELISA).Lung wet weight/body weight (LW/BW) was recorded to assess lung injury.Meanwhile,pathological changes were examined under optical microscope.Results (1) lipopolysac charide-induced ALI mice resulted in a significant increase in lung LW/BW ratio.(2) Histologically,widespread alveolar wall thickening caused by edema,marked and diffuse interstitial infiltration with inflammatory cells,and severe hemorrhage in the interstitium and alveolus were observed in the ALI groups.(3) The level of IL-6 in lung tissue was significantly enhanced in ALI mice.(4) FCM analysis showed that I-Ab/I-E expressions on lung DC [(73 ±9)％],and splenic DC [(81 ±8)％] were significantly higher than that on circulating DC [(24 ± 7) ％ ; P ＜ 0.05] in control mice.(5) In ALI mice,the expressions of I-Ab/I-E on peripheral blood DC were (34 ± 17)％ at 6 h,(51 ± 16)％ at 12 h,(50 ± 17)％ at24 h respectively; I-Ab/I-E expressions on lung DC were (82 ± 14)％ at 6 h,(88 ±6)％ at 12 h,(90 ±10)％ at 24 h respectively; the expressions of I-Ab/I-E on splenic DC were (88 ± 8)％ at 6 h,(89 ± 4)％ at 12 h,(93 ± 9)％ at 24 h respectively,which were also significantly higher than those on the peripheral blood DC (P ＜ 0.05).(6) The I-Ab/I-E expressions on circulating DC in ALl mice at 12 h and 24 h was significantly higher than that on circulating DC in control mice (P ＜ 0.05).(7) The I-Ab/I-Eexpressions on lung DC and splenic DC in ALI mice at 24 h were significantly higher than those on lung DC and splenic DC in control mice (P ＜ 0.05).(8) There was a significant correlation of I-Ab/I-E expression on respiratory DC with the IL-6 level and lung injury score in LPS-induced ALI group (P ＜ 0.05).Conclusions There is a dynamic characteristic in the expression I-Ab/I-E on circulating,lung and splenic DC populations in ALI mice.I-Ab/I-E on pulmonary DC seems to play an important role in the pathogenesis of ALI.

The effect of stress dose glucocorticoid on patients with acute respiratory distress syndrome combined with critical illness-related corticosteroid insufficiency / 中华内科杂志

Objective To investigate the effect of stress dose glucocorticoid on patients with acute respiratory distress syndrome (ARDS) combined with critical illness-related corticosteroid insufficiency (CIRCI).Methods All early ARDS patients combined with CIRCI were screened by an adrenal corticotrophic hormone (ACTH) test and randomly divided into treatment group (hydrocortisone 100 mg intravenous,3 times/day,consecutively for 7 days,n =12 ) and control group (equivalent normal saline,n =14 ).General clinical data,changes of arterial blood gas,hemodynamics and respiratory mechanics were observed and recorded at admission and at 7 days after treatment.Ventilator-free and shock-free days,ICU stay within 28 days after admission were recorded and 28-day mortality was used as judge prognosis index.Results CIRCI rate in 45 early ARDS patients was 57.8％ ( 26 patients),and the shock rate was markedly higher in ARDS patients with CIRCI than patients without CIRCI (46.2％ vs 5/19 ).There were no significant differences in baseline parameters,oxygenation and illness severity between the treatment and control groups,except for markedly lower lactic level in the treatment group [ 2.7 ( 1.2,3.9 ) mmol/L vs 4.6 ( 2.5,6.3 ) mmol/L,P ＜ O.05].After 7 days of treatment,PaO2/FiO2 markedly increased,while heart rate obviously decreased in the both groups.Compared with the control group,survival time of patients was significantly longer and shock rate of the patients was markedly lower in treatment group within 28 days (5/12 vs 10/14,P ＜ 0.05).The 28-day mortality,which were adjusted by baseline arterial lactic,was lower in the treatment group (2.6/12 ) than in the control group (5.8/14) while with no significant difference ( P ＞ 0.05 ).There was no significant difference in complication incidence between the two groups.Conclusion Stress dose glucocorticoid could reduce shock incidence and prolong survival time,and has a tendency of lower 28-day mortality in early ARDS patients combined with CIRCI.

The evaluation value of severity and prognosis of septic shock patients based on the arterial-to-venous carbon dioxide difference / 中华内科杂志

Objective To assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO2 ] in evaluation of disease severity and prognosis in patients with septic shock.Methods There were 45 consecutive resuscitated septic shock patients from April 2009 to October 2010 included immediately after their admission into our ICU.The patients were divided into low P(cv-a) CO2 group and high P(cv-a) CO2 group according to a threshold of 6 mm Hg ( 1 mm Hg=0.133 kPa).All patients were treated by early goal directed therapy (EGDT).The parameters of hemodynamics,lactate clearance rate,the Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ ) score,the sequential organ failure assessment (SOFA)score,6 h rate of EGDT achievement,the ICU mortality and 28 days in-hospital mortality were recorded for all patients.Results There were 30 patients in the low P(cv-a) CO2 group,and 15 in the high P(cv-a)CO2group.There were no significant differences between low P(cv-a) CO2 and high P(cv-a) CO2 patients in age,APACHE Ⅱ score and SOFA score (all P ＞ 0.05 ).Compared with the high P(cv-a)CO2 group,the low P(cv-a) CO2 group had higher cardiac index ( CI ) and 24 h CI,higher delivery O2 ( DO2 ) and 24 h DO2,higher central venous oxygen saturation ( ScvO2 ) [ (74 ± 9) ％ vs (67 ± 8) ％ ],lower lactate [ ( 3.4 ± 2.1 )mmol/L vs (5.7 ± 4.5 ) mmol/L] and higher △SOFA score [ (0.7 ± 1.8 ) vs ( - 0.4 ± 1.1 ) ],lower 24 h SOFA score [ (7.8 ± 2.0) vs (9.8 ± 2.0 ) ],higher 6 h rate of EGDT achievement ( 83.3％ vs 53.3 ％ )(P ＜ 0.05 ),however,there were no differences in 28 days mortality and ICU mortality between the two groups ( P ＞ 0.05 ).Conclusion P(cv-a) CO2 might be an indicator for predicting the severity of patients with septic shock and evaluating tissue perfusion.

Prognostic value of the pulmonary dead-space fraction in patients during the early phases of acute respiratory distress syndrome / 中华急诊医学杂志

ObjectiveTo evaluate the association between alveolar dead space fraction and the prognosis of patients with acute respiratory syndrome in the early phase ( ＜ 3 days).MethodsTwentythree patients with ARDS were enrolled in this study.The VD/VT was measured by the single breath test of CO2 (SBT-CO2).The age,heart rate,mean arterial pressure,APACHE Ⅱ,Murray lung injury score,functional residual capacity ( FRC ),PaO2/FiO2,tidal volume,airway plateau pressure ( Pplat ),static pulmonary compliance (Cst),28-day mortality were recorded.ResultsThe alveolar dead-space fraction was markedly elevated (0.59 ±0.06) and the mean FRC was markedly decreased (1643 ±409) ml in the early phase of ARDS.The mortality of 28 days was 52.2％.The mean dead-space fraction was significantly higher in non-survived patients than that in survival [(0.64 ± 0.08 ) vs.(0.53 ±0.04 )].VD/VT was correlated significantly with Murray lung injury score ( r=0.464,P =0.026).The area under the ROC curve for dead space fraction was 0.867,with sensitivity of 83％,and specificity of 82％.Conclusions Increased alveolar dead-space fraction of patients in the early phases of ARDS is associated with greater risk of death.

Adjustment of positive end-expiratory pressure during presence of tonic diaphragm electrical activity in rabbits with acute respiratory distress syndrome / 中华急诊医学杂志

Objective To study the positive end-expiratory pressure (PEEP) adjustment after recruitment maneuver during acute respiratory distress syndrome (ARDS) especially in the presence of tonic diaphragm electrical activity (Tonic EAdi) in order to obtain optimum PEEP and in turn to get successful oxygenation.Methods Rabbit model of ARDS was nade by intratracheal instillation of hydrochloric acid.After sufficient recruitment maneuvers,the rabbits were randomly (random number) divided into two groups,namely Tonic EAdi group ( n =5 ) and maximum oxygenation group ( n =5 ).In Tonic EAdi group,the regulation of PEEP was guided by Tonic EAdi.In maximum oxygenation group,PEEP was adjusted as per maximum oxygenation.The differences in magnitude of PEEP,pulmonary mechanics,gas exchange and hemodynamics were compared between two groups.The t-test was used to compare continuous variables between the two independent samples,and the difference was statistically significant when P ＜ 0.05.Results (1) PEEP:The PEEP was (10.7 + 1.4) cmH2O (1 cm H2O=0.098 kPa) in Tonic EAdi group and (10.0 ± 2.8) cm H2O in maximum oxygenation group (P ＞ 0.05). (2) Pulmonary mechanics:After PEEP adjustment,there was no significant difference in tidal volume ( Vr),peak pressure (Ppeak) and mean pressure (Pmean) between the two groups (P ＞ 0.05 ).(3) Gas exchange:After PEEP adjustment,there was no significant difference in oxygenation index (PaO2/FiO2) and partial pressure of arterial carbon dioxide ( PaCO2 ) between the two groups (P ＞ 0.05).Conclusions Tonic EAdi could be a good indicator for regulating PEEP in ARDS.

Impact of a computer-driven knowledge-based system of SmartCare on weaning patients with chronic obstructive pulmonary diseases detached from mechanical ventilation / 中华急诊医学杂志

ObjectiveTo compare the outcomes of 3 modes of weaning,e.g.SmartCare (a computerdriven knowledge-based system),spontaneous breathing trials (SBBT) and empirical methods,used in patients with chronic obstructive pulmonary diseases (COPD) weaned off mechanical ventilation.MethodsSixty-eight COPD patients were enrolled and randomly (random number) assigned to receive SmartCare (SC group,n =24),SBT (SBT group,n=24) or empirical methods (EM group,n =20).The following data were recorded including beginning of weaning:time consumed for weaning,duration of mechanical ventilation,length of ICU stay,success rate of weaning,survival rate during hospitalization and the complications of mechanical ventilation.The patients were considered as successfully weaned when they were able to tolerate at least 48 consecutive hours of spontaneous breathing.ResultsTime required for weaning and total time for mechanical ventilation in SC group were greatly shorter than those in EM group (P =0.002,0.002),but there were no differences between SC group and SBT group (P =0.540,0.573).Though the length of ICU stay (7.5 d) in SBT group was notably shorter than that in EM group (82.5 d) (P=0.015),there was no difference between SBT group and SC group (8.0 d).Weaning success rate was greater in the SC group (88.3％) than that in EM group (50.0％),but there was no difference between SBT group (66.7％ ) and SC group.No significant differences in survival rate during hospitalization,rate of re-intubation,self-extubation and need for noninvasive ventilation were found among three groups.ConclusionsCompared to empirical methods for weaning,SmartCare could greatly increase the success rate of weaning,but it was not superior to SBT.

The clinical application of pulmonary vascular permeability index on differential diagnosis of acute pulmonary edema / 中华内科杂志

Objective To assess the value of pulmonary vascular permeability index in differentiating acute lung injury (ALI) from cardiac pulmonary edema. Methods Critically ill patients with acute pulmonary edema were included from May, 2004 to September, 2008. Patients were divided into two groups, the ALI group and the cardiac pulmonary edema group (C group). Pulmonary vascular permeability index (PVPI) , intrathoracic blood volume (ITBVI) were determined by pulse indicator continuous cardiac output(PiCCO) system. Results ( 1 ) Thirty-four patients were enrolled, 22 cases in ALI group and 12 cases in C group. (2) The PVPI in patients of ALI group (2.7 ± 1.4) was higher than that of C group (1.9 ±0.6 ;P＜0.05). EVLWI and ITBVI did not have the significant difference between the two groups (P ＞0. 05). (3) PVPI was positively correlated with EVLWI(r = 0. 762) , negatively correlated with PaO2/ FiO2(r= -0.478). (4)ARDS was diagnosed in 13 cases, including 8 pulmonary cause(ARDSp) and 5 extra-pulmonary cause ( ARDSexp). PVPI, EVLW/ITBV and EVLWI of patients with ARDSexp were obviously higher than those with ARDSp. Conclusions PVPI may be useful for differentiating the types of pulmonary edema in the critically ill.