[Study on present status of ICU in county-level general hospitals of Henan Province].

OBJECTIVE: To investigate the present status of intensive care unit (ICU) in the county-level general hospitals of Henan Province and provide basis for improving the construction level and rational allocation of medical resources of ICU. METHODS: According to The guidelines for the construction and management of critical care medicine (trial implementation) issued by National Health Commission (NHC) (hereinafter referred as the guidelines), a cross-sectional survey was conducted on the present status of ICU in 93 county-level general hospitals in Henan Province in 2018 by using a self-designed questionnaire concerning this topic. The survey included the basic information of ICU (establishment time, organization and management mode, development of special departments in ICU, construction of key disciplines), scale and staffing allocation and training, and the equipment and technology development situation in ICU. RESULTS: The basic aspects of ICU situation were as follows: firstly, the establishment time: the ICU of county-level general hospitals in Henan Province started relatively late. The survey showed that all the 93 hospitals had set up ICU, of which the earliest was the ICU of Xunxian People's Hospital in 1989, only 4 county-level general hospitals established their ICUs before 2000, and 34 before 2009. Secondly, the management mode: the proportion of ICU closely managed was accounting for 68.82% (64/93), while semi-open management was 18.28% (17/93), and 12.90% (12/93) hospitals still adopted the open management mode. Thirdly, development of specialized ICU and construction of key disciplines: comprehensive ICUs were founded in 86 hospitals, and the proportions of specialized ICUs such as neonatal ICU, emergency ICU and coronary heart disease care unit (CCU) were higher than other kinds of special department; the ICUs of 8 hospitals were the key discipline of Henan Provincial Health Commission, and the ICUs of 9 hospitals were the discipline of Municipal Health Commission. Scale and staffing of ICU: a total of 2 189 ICU beds were opened in 93 county-level general hospitals. The utilization rate reaching the targets of ICU beds and the compliance rate of ICU bed area per bed were relatively high, 76.34% and 80.64%, while the compliance rates of ICU doctors/ICU beds, ICU nurses/ICU beds were low, which were 8.60% and 7.52% respectively, indicating that the clinicians and nursing facilities were insufficient. There were 1 tertiary hospital, 76 secondary-A hospitals and 16 secondary-B hospitals in this survey. Compared with secondary-B hospitals in the total number of beds (sheets: 922.22±285.99 vs. 636.75±258.84) and ICU beds (sheets: 25.28±21.15 vs. 14.63±6.89), the secondary-A hospitals were significantly higher (all P < 0.01), and the rate of bed use compliance of secondary-A hospitals was significantly higher than that in secondary-B hospitals [81.6% (62/76) vs. 50.0% (8/16), P < 0.01]. In terms of staffing, the proportion of clinicians and nurses with elementary titles was the highest, the proportion of full-time senior professional titles was relatively low, the proportion of doctors with bachelor's degree was the highest, and that of nurses with junior college degree was the highest. In personnel training, the hospitals surveyed had sent the doctors and nurses mostly to participate in the continuing education and training of critical care medicine at or above the provincial level for 745 person-times and 1 156 person-times, and there were in the mean for 8 and 12 person-times in each hospital, respectively. In terms of equipment configuration and technology development of ICU, mostly the equipment in ICU of county-level general hospitals consisted of microinjection pump, monitor, infusion pump, invasive ventilator, expectorant machine, etc. but the overall equipment was insufficient. Although an extracorporeal membrane oxygenation (ECMO) equipment was introduced in one hospital, it had not been carried out clinically. All county-level general hospitals in Henan Province had set up ICUs, but there were gaps between the compliance rates of many indicators and the requirements of the guidelines, and the medical personnel and equipment were relatively insufficient. CONCLUSIONS: The ICUs of county-level general hospitals in Henan Province have developed rapidly in recent years, but there is still much room for improvement.

[Clinical feature of severe hand, foot and mouth disease with acute pulmonary edema in pediatric patients].

OBJECTIVE: To explore the clinical feature of severe hand, foot and mouth disease (HFMD) in pediatric patients, and to observe the hemodynamic changes in those with acute pulmonary edema. METHODS: A prospective observation study was conducted. Thirty-five severe HFMD pediatric patients with acute pulmonary edema admitted to the intensive care unit (ICU) and Department of Pediatric of First People's Hospital of Foshan from May 2008 to September 2014 were enrolled. The clinical features were thoroughly investigated. Hemodynamic data were monitored by pulse-indicated continuous cardiac output (PiCCO) in 5 cases, and the changes in PiCCO parameters were observed at ICU admission (0 hour), and 24, 48, 96 hours after treatment. RESULTS: Thirty-five patients who met the diagnostic standard of severe HFMD were enrolled, including 22 male and 13 female, aged from 7 months to 4 years. Six patients were younger than 1 year, 13 1-2 years, 12 2-3 years, and 4 patients 3-4 years old. The most common time of occurrence of pulmonary edema was 3-4 days after the onset of the disease. Fever and central nervous system symptoms were found in all the patients, and examination of the cerebral spinal fluid (CSF) revealed non-bacterial inflammatory changes. PiCCO results showed a tendency of lowering of heart rate (HR), systemic vascular resistance index (SVRI), and extravascular lung water index (EVLWI) after the treatment, and the values obtained at 96 hours were significantly lower than those at 0 hour [HR (bpm): 119.0±14.7 vs. 200.8±19.7, SVRI (kPa×s×L(-1)×m(-2)): 148.9±14.6 vs. 209.6±58.7, EVLWI (mL/kg): 10.5±1.9 vs. 34.8±10.8, P<0.05 or P<0.01], global end-diastolic volume index (GEDVI) was also gradually decreased without significant differences among all the time points, together with a tendency of increase in stroke volume index (SI) and cardiac index (CI). The values of the parameters at 96 hours were significantly higher than those at 0 hour [SI (mL/m2): 38.5±6.5 vs. 17.4±2.8, CI (mL×s(-1)×m(-2)): 75.0±8.0 vs. 55.5±8.5, both P<0.01]. Left atrium was found to be enlarged, and left ventricular systolic function decreased in two patients by cardiac ultrasonic. Four out of 35 patients died, and functional disability of extremities was found in 1 patient. Other patients were cured and discharged without any sequelae. CONCLUSIONS: Severe HFMD complicated by acute pulmonary edema is a perilous condition in children, accompanied commonly by pathologic changes in central nervous system and systolic dysfunction of left ventricle. According to the results with PiCCO monitoring, HFMD patients suffering from acute pulmonary edema may be of cardiac origin in addition to neurogenic origin.

[Impact of hypothermia on Toll-like receptor 4 mRNA transcription and inflammatory balance of macrophage induced by lipopolysaccharide].

OBJECTIVE: To investigate the impact of hypothermia on Toll-like receptor 4 (TLR4) mRNA transcription and downstream inflammatory balance of macrophage induced by lipopolysaccharide (LPS). METHODS: RAW264.7 mouse macrophage cell line was collected and cultivated in incubator at 37 centigrade or 32 centigrade. The cells in stimulation group were incubated with 10 ng/mL LPS, while normal saline was used instead in control group. The cells culture supernatant was collected at 2, 8, 24 hours to determine the interleukin (IL-1ß and IL-10) levels. Total RNA was collected with TRIzol, and TLR4 mRNA transcriptional level was determined by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: Under the intervention of LPS, TLR4 mRNA expression in normal temperature group and hypothermia group was increased first followed by a decreasing trend (both P<0.001), and at the same time point, TLR4 mRNA expression (2(-ΔΔCt)) in hypothermia group was lower than that in normal temperature group (2 hours: 9.19 ± 0.57 vs. 10.08 ± 1.02, t=-2.285, P=0.036; 8 hours: 13.58 ± 1.57 vs. 15.24 ± 1.63, t=-2.201, P=0.042; 24 hours: 6.85 ± 1.17 vs. 8.17 ± 1.21, t=2.353, P=0.032). After the administration of LPS, IL-1ß and IL-10 levels in both normal and hypothermia group were gradually increased (all P<0.001), and at the same time point, the level of IL-1ß in hypothermia group was lower than that in normal temperature group (2 hours: 87.08 ± 29.35 ng/L vs. 110.53 ± 26.58 ng/L, t=1.777, P=0.047; 8 hours: 119.19 ± 49.14 ng/L vs. 173.25 ± 37.21 ng/L, t=2.631, P=0.018; 24 hours: 208.66 ± 53.83 ng/L vs. 346.56 ± 64.30 ng/L, t=4.933, P<0.001), whereas the level of IL-10 of hypothermia group was higher than that in normal temperature group (8 hours: 170.01 ±2 4.90 ng/L vs. 140.02 ± 15.08 ng/L, t=-3.091, P=0.007; 24 hours: 423.10 ± 52.40 ng/L vs. 165.06 ± 31.97 ng/L, t=-12.611, P<0.001). The IL-1ß/IL-10 ratio in normal temperature group was gradually increased (F=20.003, P<0.001), and it was decreased gradually in hypothermia group (F=1.811, P=0.185). At the same time point, IL-1ß/IL-10 ratio in hypothermia group was lower than that in normal temperature group (2 hours: 0.740 ± 0.214 vs. 0.993 ± 0.256, t=2.275, P=0.037; 8 hours: 0.701 ± 0.363 vs. 1.237 ± 0.455, t=2.763, P=0.014; 24 hours: 0.493 ± 0.292 vs. 2.099 ± 0.428, t=9.299, P<0.001). CONCLUSIONS: Hypothermia can reduce TLR4 mRNA transcription level of macrophage after the challenge of LPS, and it can relatively lower the level of IL-1ß, but a higher level of IL-10 is maintained, thus creating a tendency of anti-inflammation.