Mechanism of regulatory T cells in heat stroke-induced acute kidney injury / 中华危重病急救医学

OBJECTIVE@#To investigate the mechanism of regulatory T cells (Treg) in heat stroke (HS)-induced acute kidney injury (AKI).@*METHODS@#Male SPF Balb/c mice were randomly divided into control group, HS group (HS+Rat IgG), HS+PC61 group, and HS+Treg group (n = 6). The HS mice model was established by making the body temperature of the mice reach 42.7 centigrade at room temperature 39.5 centigrade with relative humidity 60% for 1 hour. In HS+PC61 group, 100 μg PC61 antibody (anti-CD25) was injected through the tail vein in consecutive 2 days before the model was established to eliminate Tregs. Mice in HS+Treg group was injected with 1×106 Treg via tail vein immediately after successful modeling. The proportion of Treg infiltrated in the kidney, serum creatinine (SCr) and histopathology, levels of interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) both in the serum and kidney tissue, as well as proportion of neutrophils and macrophages located in the kidney were observed at 24 hours after HS.@*RESULTS@#HS dampened renal function and exaggerated kidney injury, up-regulated levels of inflammatory cytokines both in local kidney and circulation, and increased infiltration of neutrophils and macrophages to the injured kidneys. The proportion of Treg (Treg/CD4+) infiltrated in kidney was significantly decreased in HS group, compared with control group [(3.40±0.46)% vs. (7.67±0.82)%, P < 0.01]. Compared with HS group, local Tregs in kidney were almost completely depleted via PC61 antibody [(0.77±0.12)% vs. (3.40±0.46)%, P < 0.01]. Depletion of Tregs could exacerbate HS-AKI, indicating by increased serum creatinine [SCr (mmol/L): 348.22±35.36 vs. 254.42±27.40, P < 0.01] and pathological injury (Paller score: 4.70±0.20 vs. 3.60±0.20, P < 0.01), incremental levels of IFN-γand TNF-α both in injured kidney and serum [serum IFN-γ (ng/L): 747.70±64.52 vs. 508.46±44.79, serum TNF-α (ng/L): 647.41±26.62 vs. 464.53±41.80, both P < 0.01], and more infiltrated neutrophils and macrophages in the injured kidney [neutrophil proportion: (6.63±0.67)% vs. (4.37±0.43)%, macrophage proportion: (38.70±1.66)% vs. (33.19±1.55)%, both P < 0.01]. On the contrast, adoptive transfer of Tregs could reverse the aforementioned effects of Treg depletion, indicating by incremental proportion of Tregs in the injured kidney [(10.58±1.19)% vs. (3.40±0.46)%, P < 0.01], decreased serum creatinine [SCr (mmol/L): 168.24±40.56 vs. 254.42±27.40, P < 0.01] and pathological injury (Paller score: 2.73±0.11 vs. 3.60±0.20, P < 0.01), reduced levels of IFN-γ and TNF-α both in injured kidney and serum [serum IFN-γ (ng/L): 262.62±22.68 vs. 508.46±44.79, serum TNF-α (ng/L): 206.41±22.58 vs. 464.53±41.80, both P < 0.01], and less infiltrated neutrophils and macrophages in the injured kidney [neutrophil proportion: (3.04±0.33)% vs. (4.37±0.43)%, macrophage proportion: (25.68±1.93)% vs. (33.19±1.55)%, both P < 0.01].@*CONCLUSIONS@#Treg might be involved in HS-AKI, possibly via down-regulation of pro-inflammatory cytokines and infiltration of inflammatory cells.

Clinical treatment guideline for pulmonary blast injury (version 2023) / 中华创伤杂志

Pulmonary blast injury has become the main type of trauma in modern warfare, characterized by externally mild injuries but internally severe injuries, rapid disease progression, and a high rate of early death. The injury is complicated in clinical practice, often with multiple and compound injuries. Currently, there is a lack of effective protective materials, accurate injury detection instrument and portable monitoring and transportation equipment, standardized clinical treatment guidelines in various medical centers, and evidence-based guidelines at home and abroad, resulting in a high mortality in clinlcal practice. Therefore, the Trauma Branch of Chinese Medical Association and the Editorial Committee of Chinese Journal of Trauma organized military and civilian experts in related fields such as thoracic surgery and traumatic surgery to jointly develop the Clinical treatment guideline for pulmonary blast injury ( version 2023) by combining evidence for effectiveness and clinical first-line treatment experience. This guideline provided 16 recommended opinions surrounding definition, characteristics, pre-hospital diagnosis and treatment, and in-hospital treatment of pulmonary blast injury, hoping to provide a basis for the clinical treatment in hospitals at different levels.

Chinese consensus of cardiopulmonary resuscitation guides prevention, treatment and rescue of cardiac arrest in pregnancy / 中华危重病急救医学

Pregnant women are a group of people in a special period, once sudden cardiac arrest (CA) occurs, it will threaten the life of both mother and child. It has become a great challenge for hospital, doctors and nurses to minimize maternal mortality during pregnancy. All the efforts should ensure the safety of both mother and child throughout the perinatal period. Because difference of the cardiopulmonary resuscitation strategies for common CA patients of the same age, the resuscitation strategies for CA patients during pregnancy need consider the patient's gestational age and fetal condition. Different resuscitation techniques, such as manual left uterine displacement (MLUD), will involve perimortem cesarean delivery (PMCD). At the same time, drugs should be reasonably used for different causes of CA during pregnancy, such as hypoxemia, hypovolemia, hyperkalemia or hypokalemia and other electrolyte disorders and hypothermia in 4Hs, as well as thrombosis, pericardial tamponade, tension pneumothorax and toxicosis in 4Ts. In view of the fact that many causes of CA in pregnancy are preventable, it is more necessary to introduce guidelines for CA in pregnancy in line with our national conditions for clinical guidance. This paper systematically reviewed the pathophysiological characteristics of CA during pregnancy, the high-risk factors of CA during pregnancy, and identified the correct resuscitation methods and prevention and treatment strategies of CA during pregnancy.

Effect of acute hypoxemia on central venous pressure in patients with respiratory failure / 中国医师杂志

Objective:To examine the influence of acute hypoxemia on central venous pressure (CVP) and diastolic blood pressure (DBP) in critical patients assisted by mechanical ventilation.Methods:We retrospectively analyzed the clinical data of critical patients assisted by mechanical ventilation in Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) database. Influence of acute hypoxemia on CVP and diastolic blood pressure (DBP) were evaluated. Hypoxemia was defined according to oxygenation index (OI) (OI≤100 as severe, 100<OI≤200 as moderate). Two cutoff values were set at OI=100 and OI=200. The primary outcomes were the difference between mean CVP, mean DBP 6 hours after the onset of hypoxemia and 6 hours before the event.Results:Among all critical patients assisted by mechanical ventilation, 508 patients met criteria of severe hypoxemia, and 1 117 patients met criteria of moderate hypoxemia. After adjusting positive expiratory end pressure (PEEP) and heart rate by multiple linear regression, CVP in patients with moderate and severe hypoxia increased significantly during the observation window of acute hypoxemia ( P=0.04, 0.02), but DBP did not change significantly ( P=0.29, 0.31). Conclusions:Acute hypoxemia could increase CVP and probably pulmonary circulation resistance in respiratory failure patients.

Prevention strategies for traumatic cardiac arrest / 中华危重病急救医学

The fatality rate of traumatic cardiac arrest (TCA) is extremely high, and it is very different from that of non-traumatic cardiac arrest (NTCA) in resuscitation strategy. Only when the standard resuscitation process is combined with rapid treatment of various reversible causes can the mortality rate of patients be decreased. In this paper, the key factors leading to TCA are reviewed, such as hypovolemic shock, asphyxia, tension pneumothorax, pericardial tamponade, crush syndrome, craniocerebral injury, cerebral hernia, and the control measures are elaborated respectively, so as to provide references for clinical treatment of patients with severe trauma, and reduce TCA incidence and mortality.

Introduction of critical care database based on specialized information systems: a model of critical care medicine database in large Level Ⅲ Grade A hospital / 中华危重病急救医学

Objective:To further improve the department information system, and to establish a multi-parameter critical care medicine database, which can provide data for the analysis and research of big data in critical care medicine, and provide references for other medical institutions to establish relevant databases.Methods:On the premise of fully understanding the needs of clinical and scientific research, based on a Critical Care Medicine Clinical Information System, the department of critical care medicine of the First Medical Center of Chinese PLA General Hospital integrated the patients' case data in hospital information system (HIS), electronic medical records (EMR), monitoring information system (Monitor), laboratory information system (LIS), and radiation information system (RIS), to establish a rudimentary critical care database. On this basis, the related data were analyzed and verified. Further, this database was gradually improved in both its content and structure by referring to Medical Information Mart for Intensive CareⅢ (MIMIC-Ⅲ) database.Results:During the operation of Critical Care Medicine Clinical Information System from September 2017 to February 2020, the database collected diagnosis and treatment data of 2 207 critically ill patients, including data before the patient entering the intensive care unit (ICU) and all data during the ICU, such as demographic data, vital signs, medical treatment, the records of intake and output, sampling time, laboratory examination results, surgical treatment, and a variety of commonly used clinical scoring and diagnosis data. The data in the database were stored in different tables according to different contents, and the tables were connected to each other through the primary key. The data could be analyzed statistically through the information system and has been applied for certain clinical studies, combining clinical practices with scientific studies.Conclusions:The critical care medicine database based on the Critical Care Medicine Clinical Information System can help medical institutions to carry out standardized treatment and clinical research of critically ill patients. With further improvement of the function, the database can be better applied to the data analysis of Chinese critical patients.

Fluid resuscitation for critically ill patients / 解放军医学杂志

Fluid overload is frequently found in patients with intravenous fluid resuscitation,and recent studies showed the potential risks of fluid overload for organ failure and mortality.To avoid volume overload and its associated complications,strategies to identify fluid responsiveness are necessary.Apart from the amount of fluid utilized for resuscitation,the type of fluid used also impacts patient outcome.In recent years,there has also been an increasing focus on comparing various resuscitation fluids with respect to both benefits and risks.In this article,through analyzing the impact of fluid overload on patient outcome,we describe the differences in static and dynamic estimates of fluid responsiveness,and review the current literature regarding choice of intravenous fluids for resuscitation in critically ill patients to help clinicians to make appropriative decision on intravenous fluids prescription and to optimize patient outcome.

Research progress on elderly sepsis / 解放军医学杂志

Sepsis is a serious problem among the elderly population as its incidence and mortality rates dramatically increase with advanced age. More importantly, the elderly has increased vulnerability to developing sepsis due to diminished physiologic reserve, presence of comorbidities, immunosenescence and frequent instrumentation. Those who survive severe sepsis are more likely to have irreversible organ damage, cognitive impairments, and diminished overall function. Additionally, elderly patients with sepsis often present with atypical symptoms which further complicates and potentially delays diagnosis. Although sepsis is a serious life-threatening disease, recognition of this problem is very low compared to other age-associated diseases. Therefore, the purpose of this review is to analyze the challenges facing this cohort and how to optimize their management.

Pathogenic bacteria distribution and risk factors of lower respiratory tract infection in critical patients in neurosurgery department / 中国综合临床

Objective To investigate the pathogenic bacteria types and distribution characteristics of critical patients with lower respiratory tract infection in neurosurgery department,and to analyze the high risk fac?tors of lower respiratory tract infections. Methods A retrospective analysis of 80 cases of critical patients with lower respiratory tract infection in neurosurgery department of General Hospital of People Liberation Army from April 2013 to April 2014 was carried out. The pathogenic bacteria types and distribution characteristics of lower respiratory tract infection were analyzed by means of bacterial identification,and single factor and multi factor Lo?gistic regression analysis was carried out to analyze the related factors of lower respiratory tract infection.Results One hundred and thirty?four strains of pathogenic bacteria were cultured from sputum of 80 cases of patients. Among which the gram negative bacteria were 109 strains,accounting for 81.34%(109/134),while the Gram positive bacteria were 17 strains,accounting for 12.69%(17/134) and the fungi were 2 strains,accounting for 1.49%(2/134).The proportion of three kinds of pathogenic bacteria had statistical significance(P=0.004, 0.001). The single factor Logistic regression analysis showed that,younger age,use of ventilator,use of antimi?crobial drugs and pulmonary infection rate were protective factors of lung infection(OR(95%CI)=0.586(0.475-0.722),0.708(0.574-0.873),0.827(0.697-0.981);P=0.043,0.007,0.000);disturbance of consciousness, tracheotomy,insert gastric tube, surgery and pulmonary infection incidence were risk factors for lung infection (OR(95%CI)=4.769(1.069-21.276),11.612(5.438-24.792),22.989(19.385-27.263),10.426(8.789-12.361);P=0.001,0.008,0.005,0.002).The multi factor Logistic regression analysis showed that there was a significant correlation between the trachea incision, the consciousness and the lower respiratory tract infection (OR(95%CI)=4.627(2.143-20.645),10.412(2.334-46.455);P=0.009,0.002).Conclusion Patients with conscious disturbance and tracheotomy were more likely to have lower respiratory tract infections. The pathogens of lower respiratory tract infections are Gram?negative bacteria,and the majority of pathogens are high resistance, and it is multi drug resistance.

Correlation between gastrointestinal dysfunction and both severity and prognosis in patients suffering from heatstroke / 中华危重病急救医学

ObjectiveTo investigate the relationship between gastrointestinal dysfunction and both severity and prognosis in patients with heatstroke (HS).Methods A retrospective analysis was conducted. Clinical data from 39 patients with HS seeking for treatment in Department of Critical Care Medicine of Chinese PLA General Hospital from January 2013 to September 2014 were enrolled. The patients were divided into two groups: gastrointestinal dysfunction group and non-gastrointestinal dysfunction group. The acute physiology and chronic health evaluationⅡ(APACHEⅡ) score within 24 hours of admission and 28-day mortality were compared between two groups. In gastrointestinal dysfunction group, the gastrointestinal dysfunction score, the duration days of gastrointestinal dysfunction, the length of intensive care unit (ICU) stay, and the duration of mechanical ventilation were collected. Pearson correlation analysis was used to analyze the relationship between gastrointestinal function and the severity of the ailment as well as the prognosis.Results Among 39 patients with HS, 32 of them showed gastrointestinal dysfunction with an incidence of 82.05%. In gastrointestinal dysfunction group, the gastrointestinal dysfunction score was 2.3±0.8, the duration of gastrointestinal dysfunction was (17.3±15.2) days, the length of ICU stay was (37.8±25.0) days, and the duration of mechanical ventilation was (27.8±14.0) days. APACHEⅡ score in gastrointestinal dysfunction group was significantly higher than that of the non-gastrointestinal dysfunction group (26.30±6.00 vs. 17.40±6.00, t = 3.555,P = 0.001). The 28-day mortality in gastrointestinal dysfunction group was slightly higher than that of the non-gastrointestinal dysfunction group without statistically significant difference [43.75% (14/32) vs. 14.29% (1/7),P = 0.216]. It was shown by Pearson analysis that gastrointestinal dysfunction score was positively correlated with APACHEⅡ score (r = 0.727,P = 0.000), and the duration of gastrointestinal dysfunction was positively correlated with the length of ICU stay (r = 0.797,P = 0.000) and the duration of mechanical ventilation (r = 0.634,P = 0.000). Conclusion The results suggest that gastrointestinal function in patients with HS reflects the severity and prognosis of the ailment.

Effect of heat stroke on small intestinal epithelial tight junction protein occludin in rats / 国际外科学杂志

Objective A stable rat model of heat stroke was established to investigate heat stroke-induced changes of the intestinal epithelial tight junction (TJ) barrier permeability, and to investigate the mechanism by observing the changes of TJ protein (occludin) expression and TJ morphology. Methods SD rats were randomly divided into two groups(n = 10): heat stroke group and normal control group. Stable model of heat stroke was established. Anesthetized rats were exposed to 42 ℃ in a ventilated chamber for 50min, after heat exposure, the rats were placed in room temperature(26 ℃ ) for 2 h. Then the rats were sacrificed and samples were taken. The effect of heat stroke on intestinal epithelial barrier permeability was observed through changes of plasma FD4 and endotoxin concentration, cytokines concentration was detected as inflammatory indicators. The general and micro pathology was observed by light microscope (hematoxylin and eosin-staining, HE staining) and transmission electron microscope (TEM). Occludin expression was investigated by Western bloting and immunochemistry. Results At 2 h after heat exposure, intestinal epithelial barrier permeability( FD4 and endotoxin concentration), and cytokines levels of heat stroke group were significantly higher than normal control group(P ＜ 0. 05 ). In morphology, by observing the light micrographs of HE jejunal tissue, the sloughing of epithelium off the basement membrane at the villus tips of the heat stroke group compared with the normal controlgroup. In many visual fields (VF)( ≥6VF/slice), this phenomenon was not universal. Under TEM, TJ of normal enterocytes was integrated with the compact zonal structure. At 2 h after heat exposure, TJ of heat stroke group was broken with widen intercellular space, and the density of TJ was decreased. In immunochemistry assay, the positive signal was distributed along the cell membrane in normal small intestinal tissue, while the signal was obviously decreased in heat stroke group.The results of Western bloting showed that occludin expresion of heat stroke group was significantly lower than normal control group(P ＜0.05). Conclusion Heat stroke decreased occludin expression, opened the intestinal epithelial TJ, which destroyed intestinal epithelial tight junction barrier, induced high intestinal epithelial barrier permeability, produced endotoxemia and systemic inflammatory response syndrome (SIRS).

Antibiotic Pretreatment and Bacterial Colonization in Respiratory Tract in Liver Transplanted Patients / 中华医院感染学杂志

OBJECTIVE To investigate the epidemiological conditions of bacterial colonization in respiratory tract,and antibiotic resistance under the antibiotic pretreatment in liver transplanted patients. METHODS From Oct 2002 to Jan 2005,121 liver transplanted patients were admitted to ICU.Among them,45 patients who were intubated more than 48 hours were included in this study.All of the patients received antibiotic pretreatment after operation.Sputum specimens were collected after 24 hours and 48 hours in ICU via the intubated tube with bronchoscopy. RESULTS Thirty nine pathogens were isolated from 36 patients during 48 hours.Pseudomonas aeruginosa was the predominant pathogen.Only 8 bacilli were susceptible to the antibiotics. CONCLUSIONS Although antibiotic pretreatment performed,bacterial colonization in respiratory tract emerges early in liver transplanted intubated patients.Antibiotic pretreatment may make the susceptible bacteria escape.

Microbial Population Distribution in Intensive Care Unit: Analysis of Its Alteration / 中华医院感染学杂志

OBJECTIVE To study the alteration of microbial population distribution in intensive care unit (ICU) for the reference to clinical drug administration. METHODS The distributed features of 413 strains of infection germs detected among the patients of ICU were statistically analyzed during the years of 2002 to 2005. RESULTS The main germs of 413 strains were Pseudomonas aeruginosa(87 strains), Acinetobacter baumannii(48 strains), Stenotrophomonas maltophilia(34 strains), Staphylococcus epidermidis(30 strains), S. aureus (20 strains) and Escherichia coli (19 strains). The first 3 species were P. aeruginosa (21.07%), A. baumannii(11.62%) and Sten. maltophilia (8.23%). CONCLUSIONS Most pathogens in ICU are Gram-negative bacteria and the proportion of Sten. maltophilia increases gradually. It is a very important clinical value to inspect the bacterial distribution and antibiotics should be used rationally.

Effect of continuous renal replacement therapy on the elderly patients with acute renal function failure / 中国康复理论与实践

@#ObjectiveTo investigate the effect of continuous renal replacement therapy (CRRT) on the elderly patients with acute renal function failure.Methods11 elderly patients with acute renal function failure were treated with continuous renal replacement therapy. The average time of CRRT was 24.8 h. The ultrafiltration rate during CRRT was 2～4 L/h and blood flow rate was 150～250 ml/min. Normal heparin was used as anticoagulant.ResultsAmong 11 patients, 7 were mend, 3 died. The blood urea nitrogen (BUN) and creatinine (Cr) levels of all patients obviously declined (P<0.01). The haemodynamic variables of all patients were stabilized during CRRT and no obvious side-effect related to CRRT was found.ConclusionThe treatment of CRRT can improve the sufferer prognosis to the elderly patients with acute renal function failure, not restricted by age, and is the effective means to the elderly patients with acute renal function failure.

Etiology of fatal exertional heat stroke induced by military training / 解放军医学杂志

Objective To investigate the etiopathogenesis of exertional heat stroke(EHS)induced by military training of those patients admitted in military hospitals,and analyze the influence of EHS as a predisposing factor on prognosis.Methods Eighteen patients with EHS were admitted in 6 military hospitals from Sep.1995 to Aug.2007,their clinical data were retrospectively analyzed.All cases were evaluated according to Minard's EHS predisposing factors including the individual's physiologic limitations,environmental conditions and the organizational predisposing factors.According to the final treatment outcome,18 cases of EHS were divided into fatal group(Group F)and survival group(Group S).The significance of deviation on the predisposing factors,and of the differences on the accumulated predisposing factors between the two groups,was analyzed.Results All the 18 cases of EHS occurred after military training,and complicated with multiple organ dysfunction syndrome(MODS).Hyposthenia,excessive physical efficiency training,incorrect disease classification to the patients,and inappropriate diagnosis and treatment were found to be the strong predictors to a grave prognosis.The effect of accumulated predisposing factors of EHS in group F was significantly higher than that in group S(10.0?1.41 vs 5.64?1.96,P

Application of continuous renal replacement therapy to the patients with acute renal failure after liver transplantation / 解放军医学杂志

Objective To study the curative effect of continuous renal replacement therapy (CRRT) to the patients with acute renal failure after liver transplantation. Methods From Mar. 2004 to Jan. 2005, the continuous renal replacement therapy was applied to 7 patients with acute renal failure after liver transplantation. The average time of CRRT was 36.1h. The volume of fluid displacer during CRRT was 2-4L/h and the volume of blood flow was 150～250ml/min. Normal heparin was used as anticoagulant. Results For the 7 patients, 4 improved, 2 died. The contents of blood urea nitrogen (BUN) and blood Cr of all the 7 patients have obviously declined(P0.05). The haemodynamic variables were stabilized during CRRT and no obvious side-effect related to CRRT was found. Conclusions CRRT improved the prognosis to the patients with acute renal failure after liver transplantation, showed a favorable tolerance, and may be applied as a emergency measure to the patients with acute renal failure.

Application of SEHNFU (ginseng-aconite) injection on post-operation of liver transplantation / 解放军医学杂志

Objective To study the therapeutic action of SHENFU (ginseng-aconite) injection on post-operation of liver transplantation. Methods From Jan. 2004 to Mar. 2005, 30 cases underwent orthotopic liver allotransplantation were divided into two groups randomly. The patients in control group received routine transfusion, while the patients in SHENFU injection group, besides the routine transfusion, received SHENFU injection as well. Results 120 minutes after the SHENFU treatment, the mean arterial pressure (MAP) of the patients was raised from 53.21?8.52mmHg to 75.62?7.58mmHg, meanwhile the heart rate (HR) declined from 115.3?13.2/min to 90.1?7.2/min. At the same time, the contents of lactic acid, IL-6, IL-8 and TNF-? in the patients also declined from 9.82?3.96mmol/L, 89.02?43.75pg/ml, 58.24?33.61 pg/ml and 42.33?28.15pg/ml to 4.31?2.11mmol/L, 30.08?25.12pg/ml, 29.83?20.05pg/ml and 24.52?15.61pg/ml, respectively. Compared with the control group, there existed significant differences (P

Treatment on the patients of heat stroke associated with MODS resuled from cross-country training / 解放军医学杂志

Objective To analyze the possible effective intervention for heat stroke(HS)associated with multiple organ dysfunction syndrome(MODS)as a result of cross-country training.Methods All the data of causes of HS,clinical manifestations,laboratory findings,clinical interventions and outcome were collected and analyzed in five cases of HS associated with MODS.Results Four patients survived and one died of severe DIC and MODS.The levels of creatin kinase and myoglobulin in survived patients lowered gradually 4-5 days after effective treatments.No sequela was found in survived patients.Conclusions The therapeutic principle for the patients of HS associated with MODS is early commencement of hypothermia,fluid expansion,anticoagulation,blood purification and deep-sedation.