[A preliminary study on the classification and prognosis of microcirculation alterations in patients with septic shock].

Objective: To explore the correlation between different types of microcirculation alterations and the prognosis in patients with septic shock. Methods: This research employed a prospective observational study methodology for selecting subjects with septic shock. Side-stream dark field(SDF) was used to monitor the sublingual microcirculation to determine the total vascular density (TVD), perfused vessel density (PVD), the proportion of perfused vessels (PPV), and the microvascular flow index (MFI), heterogeneity index (HI) indicators. At the bedside, patients with microcirculation disorders were divided into four types: stasis, dilution, heterogeneity, and hyperdynamic. The 30-day survival status after enrollment and hemodynamics parameters were recorded. Results: A total of 64 patients with septic shock were selected in the study, including 18 cases of stasis type, 11 of dilution type, 18 of heterogeneous type, and 17 of hyperdynamic type. There were statistical differences in the mean arterial pressure (MAP) [stasis:(77±9) mmHg (1 mmHg=0.133 kPa), dilution:(80±11) mmHg, heterogeneity: (78±12) mmHg, hyperdynamic:(88±12) mmHg], TVD [ stasis:(10.84±3.01) mm/mm2, dilution:(9.64±1.72) mm/mm2, heterogeneity:(11.39±2.18) mm/mm2, hyperdynamic: (11.87±2.67) mm/mm2 ], PVD [stasis:(5.93±1.94) mm/mm2, dilution:(6.86±1.48) mm/mm2, heterogeneity: (8.31±1.78) mm/mm2, hyperdynamic:(9.68±2.46) mm/mm2], PPV [stasis:52.45 (46.25, 63.33)%, dilution:73.70 (61.50, 75.20)%, heterogeneity: 71.25 (67.95, 77.00)%, hyperdynamic:80.70 (77.25, 86.45)%], MFI(stasis:1.34±0.45, dilution: 1.70±0.38, heterogeneity:1.82±0.28, hyperdynamic:2.25±0.33), and HI [stasis:0.68 (0.51, 1.87), dilution: 0.57 (0.49, 0.64), heterogeneity:0.70 (0.59, 0.91), hyperdynamic: 0.40 (0.37, 0.52)] of the four types of microcirculation alterations. The cumulative survival rates in stasis, dilution, heterogeneity and hyperdynamic types at 30 day were 7/18, 4/11, 10/18 and 14/17, respectively, which in stasis and dilution types was significantly lower than that of hyperdynamic type (χ²=7.221, P=0.007;χ2=6.764, P=0.009). Multivariate Cox regression analysis showed the type of microcirculation alterations (stasis:RR=4.551, 95%CI 1.228-16.864, P=0.023; dilution:RR=4.086, 95%CI 1.011-16.503, P=0.048), acute physiology and chronic health evaluation Ⅱ (RR=1.077, 95%CI 1.006-1.153, P=0.032) were independent prognostic risk factors. Conclusions: Microcirculation alterations are common in patients with septic shock, and it is hard to predict the types of microcirculation alterations with hemodynamics parameters. The prognosis of patients with septic shock is related to the types of microcirculation alterations, suggesting that routine monitoring of microcirculation might be helpful to guide hemodynamic therapy.

[The clinical significance of transcranial Doppler in early diagnosis of sepsis-associated encephalopathy].

Objective: To investigate the clinical significance of transcranial Doppler (TCD) in early diagnosis of sepsis-associated encephalopathy(SAE). Methods: Septic patients admitted to the intensive care unit(ICU) were recruited at Xiangya Hospital, Central South University from July 2015 to March 2016. Clinical data and TCD parameters during 24 hours after admission were collected. All patients were screened for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) twice a day. The gold standard of the diagnosis of SAE was positive CAM-ICU evaluation. Patients were divided into SAE group and the non-SAE group. TCD data including systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), pulsatility index (PI) and resistant index (RI) were analyzed to determine the optimal diagnostic cut-off value. Results: A total of 43 patients were enrolled including 12 in SAE group and 31 in non-SAE group. Vm and Vd were lower in SAE group [Vm: (53.50±12.22) cm/s vs. (61.68±9.63) cm/s, P<0.05; Vd: (33.42±10.87) cm/s vs. (43.16±7.84) cm/s, P<0.01] but PI and RI were significant higher in SAE group[PI:(1.16±0.2) vs. (0.90±0.15), P<0.01;RI:(0.65±0.08) vs. (0.56±0.06), P<0.01] than in non-SAE group. The cut-off values of Vs, Vm, Vd, PI and RI for the diagnosis of SAE were 112cm/s, 55.50cm/s, 34.50cm/s, 1.16, 0.65, respectively, with the relevant sensitivities of 19.4%, 83.9%, 93.5%, 58.3%, 58.3% and the specificities of 100.0%, 50.0%, 58.3%, 96.8%, 96.8%, respectively. The diagnostic AUC of Vd, PI and RI were 0.741, 0.808 and 0.808 respectively. Conclusions: The parameter changes of TCD suggest that the pathogenesis of SAE is related to cerebral hypoperfusion, TCD is a helpful method for the early diagnosis of SAE.

[Combining relative alpha variability and electroencephalogram reactivity to predict the prognosis of hypoxic-ischemic encephalopathy in adult patients].

Objective: To evaluate the role of combining relative alpha variability and electroencephalogram (EEG) reactivity to predict the prognosis of hypoxic-ischemic encephalopathy(HIE) in adult patients. Methods: A total of 28 adult patients with HIE admitted to general intensive care unit at Xiangya Hospital in Central South University were enrolled in this observational study from January2016 to April 2017. These patients with body temperature over 35℃ after 72-hour admission could be continuously monitored at least 12 hours byEEG.At the same time,each patient was assessed for EEG reactivity.Then we analyzed the correlation between EEG reactivity, relative alpha variability and clinical prognosis. Results: EEG reactivity was elicited in 15/28 patients, among whom 12 patients had a good outcome. While in the other 13 patients, EEG reactivity was not elicited, among whom only 3 patients had a good outcome. As to the results ofrelative alpha variability,11/13 patients with degree 3-4were of good prognosis; while only 3/15 patients with degree 1-2 were of good prognosis. Glasgow coma scale(GCS), EEG reactivity, and relative alpha variability were correlated with clinical outcome(χ(2)=5.073,9.073,-3.626, respectively,all P<0.05). The sensitivity of GCS, EEG reactivity, and relative alpha variability to predict the poor prognosis were 69.2%, 76.9%, 84.6%, respectively. The specificity were 73.3%, 80.0%, 73.3%, respectively. The consistency rates were 71.4%, 78.6%, 78.6%, respectively. The positive predictive values were 69.2%, 76.9%, 73.3%, respectively. The negative predictive values were 73.3%, 80.0%, 84.6%, respectively. More importantly, the accuracy of the relative alpha variability combined with EEG reactivity for the prediction of poor prognosis was much higher with the positive predictive value of 90.0%,the specificity of 93.3%, the sensitivity of 69.2%, the consistency rate of 82.1%,and the negative predictive values of 77.8%. Conclusions: The combination of relative alpha variability and EEG reactivityis reliable to predict clinical outcome of patients with HIE.

[A survey of fluid therapy in 2 intensive care units].

To explore the present status of fluid therapy and clinical outcome in critically ill patients in intensive care units (ICU). ICU patients consecutively admitted to our ICU were prospectively enrolled. Patients' demographics, laboratory data, fluid record and clinical outcome were collected. Fluid intake quantity of all patients was at peak on the fifth day which was 2 806 (1 997, 3 582) ml. From the fourth day in ICU, fluid balance started to benegative as -84 (-1 127, 612) ml and gradually increased. Crystalloid solution was the main components. For treatment purposes, medication injections and nutrients were major fluids. Positive correlations were found between total fluid intake quantity, total crystalloid volume, total colloidal volume and hospital stay, ICU stay, duration of intubation (r values as 0.211, 0.686, 0.282, 0.155, 0.506, 0.174, 0.209, 0.072, 0.292, respectively P<0.05). Moreover, positive correlations were also demonstrated between total colloidal volume and total bilirubin, direct bilirubin, alanine transaminase, aspartate transaminase, blood urea nitrogen, serum creatinine (r values as 0.196, 0.242, 0.190, 0.335, 0.284, 0.223, respectively P<0.05).

[Technical specification for clinical application of critical ultrasonography].

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.

[The application of Critical Care Chest Ultrasonic Evaluation-plus Protocol in the etiological diagnosis of dyspnea and/or hemodynamic instability caused by abdominal abnormality].

Objective: To investigate the application of Critical Care Chest Ultrasonic Examination (CCUE)-plus (CCUE-plus) in the etiological diagnosis in patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities. Methods: Patients who suffered from dyspnea and/or hemodynamic instability in the Department of Critical Care Medicine, Xiangya Hospital, Central South University from September 2013 to September 2016 were recruited in this study. A total of 255 consecutive patients completed CCUE within 2hrs of admission. If the diaphragm could not be seen in the routine phrenic points according to Bedside Lung Ultrasound Evaluation (BLUE) protocol, it would be found along midaxillary line and defined m-point. The 59 patients with altered diaphragmatic position (m-point was more than 2 cm higher than phrenic point) received sequential abdominal ultrasonography. The latter ultrasonographic findings were compared with CT results. Results: There were 42(71.19%) cases with positive findings of abdominal ultrasonography, including 18 cases of seroperitoneum, 16 cases of intestinal obstruction and 8 cases combined. Compared with 56 patients who applied with CT exam, the abdominal ultrasonography revealed a sensitivity of 76.7% and a specificity of 100.0% to diagnose seroperitoneum (AUC(ROC) 0.917); whereas the sensitivity was 75.0% and the specificity was 90.9% (AUC(ROC) 0.778) to diagnose intestinal obstruction. Moreover, there were 44(74.58%) patients with normal left ventricular systolic function; more than three quarters (46/59, 77.97%) patients had pulmonary consolidation. Conclusion: In patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities and altered diaphragmatic position in BLUE protocol, CCUE-plus protocol has a high positive predictive value of more than 90% in abdominal abnormality. The findings of abdominal ultrasonography may change therapeutic target from cardio-pulmonary optimization to relief of intestinal obstruction or drainage of seroperitoneum.

[The diagnostic value of neuron-specific enolase, central nervous system specific protein and interleukin-6 in sepsis-associated encephalopathy].

Objective: To investigate the diagnostic value of neuron-specific enolase(NSE), central nervous system specific protein(S100ß), interleukin-6(IL-6) in sepsis-associated encephalopathy(SAE). Methods: Clinical data of patients admitted to ICU and diagnosed with sepsis were collected from January 2015 to June 2016 in Xiangya Hospital, Central South University. SAE was defined as cerebral dysfunction in the presence of sepsis that also fulfilled the exclusion criteria. The acute physiology and chronic health score (APACHE Ⅱ), sequential organ failure assessment (SOFA), NSE, S100ß, IL-6, ICU stay time and 28-day mortality were compared between the two groups. NSE, S100ß and IL-6 were measured on the 1st and 3rd day in ICU to determine the optimal cut-off value of SAE. Results: Among 59 enrolled patients, 36 were assigned to SAE group while 23 were non-SAE group. The SAE group had a significantly higher APACHE Ⅱ and SOFA scores, as well as the length of ICU stay (P<0.01). The levels of NSE, S100ß and IL-6 in the two groups both increased on the 1st day, and decreased on the 3rd day. The level of NSE on the 1st day[19.28(13.00, 30.52) µg/L vs 16.61(7.58, 22.01 µg/L)] and the 3rd day[16.03(9.40, 21.29) µg/L vs 11.39(8.49, 15.00) µg/L, P=0.029], IL-6 on the 1st day[676.25(81.34, 5 000.00) mg/L vs [209.10(42.27, 648.20) mg/L, P=0.005] and the 3rd day[157.10(72.85, 687.63) mg/L vs 55.92(31.62, 177.00) mg/L, P=0.026] of SAE group was significantly higher than those of non-SAE group. However S100ß between groups on the 1st day [0.33(0.15, 0.54) µg/L vs 0.23(0.16, 0.53) µg/L] and the 3rd day[0.19(0.10, 0.29) µg/L vs 0.10(0.05, 0.17) µg/L] was neither significant (P>0.05). The diagnostic values for SAE of NSE, S100ß and IL-6 were 14.36 µg/L, 0.14 µg/L and 91.305 mg/L with sensitivity 61.1%, 61.1%, 72.2% and specificity 73.9%, 69.6%, 69.6%, respectively. The diagnostic AUC of NSE and IL-6 combination was 0.774, 95%CI 0.651-0.896. Conclusion: All sepsis patients have different degrees of brain injury. NSE combined with IL-6 on the 3rd day in ICU demonstrates the diagnostic significance of SAE.

[The role of neuroglobin in oxygen-glucose deprivation and reoxygenation-induced mitochondrial depolarization and reactive oxygen species production in SH-SY5Y cells].

Objective: To investigate the role of neuroglobin (NGB) in oxygen-glucose deprivation and reoxygenation (OGD/R) induced mitochondrial depolarization and reactive oxygen species (ROS)production in a human neuroblastoma cell line (SH-SY5Y). Methods: SH-SY5Y cells were transfected with lentivirus to establish a stable cell line of NGB knockdown (KD). After treated with OGD/R, cells were collected at different time points to analyze NGB mRNA and protein levels. Furthermore, cells were stained with JC-1 and DCFH-DA to evaluate mitochondrial depolarization and ROS production by inverted fluorescence microscope. Also, to determine the neurotoxicity, we measured the lactate dehydrogenase(LDH)level in the cell culture medium. Results: After the treatment of OGD/R, the NGB mRNA and protein started to elevate and peak at 4 h and 8 h (2.04±0.35 fold, 1.69±0.18 fold). Compared with the vector group, NGB KD group had much more mitochondrial depolarization [JC-1 red/green (1.10±0.10) vs (1.46±0.11), P<0.05] and ROS production [DCFH-DA fluorescence (36.30±5.32) vs (16.26±2.97), P<0.05]. Furthermore, NGB KD groups had a higher level of LDH release [(63.42±6.14)%vs (49.65±5.09)%, P<0.05]. Conclusions: NGB plays an important role in the homeostasis of mitochondria. Knockdown of NGB results in increased mitochondrial depolarization, ROS production and neurotoxicity under hypoxia circumstances.

[Experts consensus on the management of the right heart function in critically ill patients].

To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

[Effect of neuroglobin on oxygen-glucose deprivation and reoxygenation induced autophagy in a human neuroblastoma cell line].

Objective: To investigate the effect of neuroglobin on oxygen-glucose deprivation and reoxygenation (OGD/R) induced autophagy in a human neuroblastoma cell line (SH-SY5Y). Methods: SH-SY5Y cells were transfected with plasmids (or vector) to establish a stable cell line of NGB overexpression (OE). After treated with OGD/R, cells were collected for the analyses of mRNA (Atg5, Atg7, BECN1 and FUNDC1) and protein levels of LC3. Furthermore, mitochondrial and cytosolic fractions were isolated for protein levels of PINK1 and Parkin. Results: Treatment of OGD/R significantly increased the levels of mRNA of Atg5, Atg7, BECN1 and FUNDC1 (peak levels were 4.90±0.71, 6.72±0.75, 2.71±0.39 and 3.96±0.78 fold, all P<0.05). The protein level of Parkin increased in mitochondria and decreased in cytoplasm after the treatment. Compared with the vector group, Ngb OE group showed a significant higher level of FUNDC1 mRNA (3.96±0.78 versus 6.86±0.63 fold, P<0.05), while Atg5, Atg7 and BECN1 mRNA levels showed no significant difference. Moreover, the mitochondrial or cytosolic protein levels of PINK1 or Parkin showed no significant difference between Ngb OE and vector group. Conclusions: Overexpression of Ngb can not affect autophagy or mitohpagy in OGD/R treated SH-SY5Y cells. Overexpression of Ngb can increase the mRNA level of FUNDC1 and the mechanism needs further study.

[Influences of DNA methylation upon neuroglobin sustained expression in oxygen- glucose deprivation model].

Objective: To investigate the influences of genomic DNA methylation upon neuroglobin sustained expression in oxygen- glucose deprivation model. Methods: With A549 cell strain as the research object, the control group were cultivated in the complete medium containing 10 µmol/L of 5-azacytidine for 4 days, and the control group was cultivated in the complete medium for 4 days.Then carried out oxygen glucose deprivation treatment for 4 h.Detecting neuroglobin expression, DNA methyltransferase expression, cell inhibition ratio and DNA methylation level at different time points. Results: DNA methylation level of the experimental group declined apparently[6 h : (1.0±0.0) vs (2.1±0.3); 12 h: ( 0.9±0.0) vs (1.4±0.0); 24 h: (0.9±0.0) vs (2.6±0.2); 36 h: (0.9±0.0) vs (2.9±0.1)], neuroglobin expression of the experimental group continued and was obviously higher than that of the control group at the same time point[NGB-PCR: 6 h: (3.3±1.1) vs (0.4±0.1); 12 h: (3.2±0.8) vs (0.1±0.1); 24 h: (4.6±0.6) vs (0.2±0.0); 36 h : (5.1±0.3) vs (0.1±0.1)], while the Cell inhibition ratio of the experimental group was obviously lower than that of the control group at the same time point[(6 h: (10.4±0.5) vs (14.1±0.7); 12 h: (22.0±1.3) vs (35.1±0.5); 24 h: (25.7±1.0) vs (40.6±1.3); 36 h: (30.0±0.8) vs (44.4±0.7)], differences had statistical significance (P<0.05).mRNA expression of three methyltransferases of the experimental group was higher than that of the control group at different time points, where, DNMT1 and DNMT3B showed great differences (P<0.05), while differences in DNMT3A of two groups had no statistical significance (P>0.05). Conclusions: In the OGD/R model of A549 cell strain, genomic DNA methylation resulted in unsustained expression of neuroglobin, but neuroglobin expression increased after demethylation inhibitor was used.

[Evaluation of organ function monitoring and supporting during the treatment of multiple trauma].

OBJECTIVE: To analyse the evaluation of organ function monitoring and supporting during the treatment of multiple trauma. METHODS: Eighty-eight patients with severe multiple trauma were admitted into Department of Intensive Care Unit(ICU) and the cardiovascular, respiratory, renal, and coagulation functions, milieu interieur, and infectious sources were monitored. RESULTS: Seventy-six cases survived and twelve cases died. The major delayed diagnoses included pneumothorax hematopneumothorax, intraperitoneal organ injury, and fracture. The major complications were severe infection, hypotension, acute renal failure, adult respiratory distress syndrome (ARDS), and multiple organ disfunction syndrome(MODS). CONCLUSION: Active monitor and support of organ function can lower the rate of missed or delayed diagnoses and also decrease complications.