[Transcutaneous electrical acupoint stimulation for early enteral nutrition tolerance in patients with sepsis of gastrointestinal dysfunction: a multi-center randomized controlled trial].

OBJECTIVE: To compare the therapeutic effect of transcutaneous electrical acupoint stimulation (TEAS) combined with conventional western medicine and western medicine alone on early enteral nutrition tolerance in patients with sepsis. METHODS: Forty-nine patients with sepsis were randomly divided into an observation group (24 cases) and a control group (25 cases). The control group was treated with conventional western medicine, including limited fluid resuscitation, anti-infection and maintenance of hemodynamics, and enteral nutrition was provided when the hemodynamics became stable and the dosage of vasoactive drugs was reduced. The observation group, on the basis of the treatment of the control group, was treated with TEAS at Tianshu (ST 25), Shangjuxu (ST 37), Jiexi (ST 41), Diji (SP 8), Zusanli (ST 36), Zhongwan (CV 12) and Daheng (SP 15) when the enteral nutrition was provided (dilatational wave, 2 Hz/10 Hz, twice a day, 30 min each time), and the TEAS stopped when enteral nutrition was normal. The antral motility index (MI) was evaluated by ultrasonography on the first, third and fifth day into treatment in the two groups, and the duration from providing enteral nutrition to normal enteral nutrition was recorded. The acute gastrointestinal injury (AGI) classification, admission time of intensive care unit (ICU) and hospitalization time were compared. RESULTS: The antral MI on the third and fifth day into treatment in the observation group was significantly higher than that in the control group (P<0.05). The duration from providing enteral nutrition to normal enteral nutrition was (5.08±0.65) days in the observation group, which was shorter than (5.56±0.65) days in the control group (P<0.05). The improvement of AGI classification after treatment in the observation group was significantly superior to the control group (P<0.05). The hospitalization time in the observation group was shorter than that in the control group (P<0.05). CONCLUSION: TEAS combined with conventional western medicine treatment could significantly promote gastrointestinal peristalsis, improve the early intestinal nutrition tolerance in patients with sepsis, so as to shorten the time of reaching the standard of enteral nutrition and hospitalization time, which is better than conventional western medicine treatment alone.

[Effect of early acupoint electrical stimulation on lower limb muscle strength in patients with septic shock].

OBJECTIVE: To observe the effect of early acupoint electrical stimulation on the decline of lower limbs muscle strength in patients with intensive care unit-acquired weakness (ICU-AW) caused by septic shock. METHODS: A total of 58 patients with ICU-AW caused by septic shock were randomly divided into an observation group (28 cases, 1 case dropped off ) and a control group (30 cases, 2 cases dropped off ). Patients in both groups received routine basic treatment. In the observation group, acupoint electric stimulation therapy was added at Huantiao (GB 30), Futu (ST 32), Zusanli (ST 36), Xuanzhong (GB 39) and Taichong (LR 3). Unilateral point with electrodes were applied, the SDZ-Ⅱ electronic instrument (discontinuous wave, frequency in 2 Hz, strength in 5 mA) was connected and changed to the other side after 30 min of unilateral treatment.The treatment was given 2 times daily, continued for 7 d or until the medical research council (MRC) score being 54 points or more. The changes of lower limb muscle strength MRC score, modified Rankin scale (MRS) score, bilateral quadriceps thickness and gastrocnemius pinnate angle of both groups were observed before treatment and on discharge. The time of admission to ICU, time of hospitalization, mortality during hospitalization, and mortality 28 d after discharge were compared between the two groups. The MRS scores of the two groups were followed up 28 d after discharge. RESULTS: The MRC scores of lower limb muscle strength in the two groups on discharge were higher than those before treatment (P<0.05), and the MRS scores on discharge and 28 d after discharge in the two groups were lower than those before treatment (P<0.05). The MRC scores of lower limb muscle strength on discharge in the observation group were higher than thoes in the control group (P<0.05), and the MRS scores on discharge and 28 d after discharge in the observation group were lower than those in the control group (P<0.05). On discharge, bilateral quadriceps thickness and gastrocnemius pinnate angle in the two groups were increased compared with those before treatment (P<0.05), and thoese in the observation group was higher than the control group (P<0.05). There was no significant difference between the two groups in the time of admission to ICU, time of hospitalization, mortality during hospitalization, and mortality 28 d after discharge (P>0.05). CONCLUSION: Early acupoint electrical stimulation can improve the lower extremity muscle decline in patients with ICU-AW caused by septic shock.

Effects of miR-489 targeting on SOX4 gene on proliferation and apoptosis of human hepatocellular carcinoma cells.

BACKGROUND: Hepatocellular carcinoma is one of the most common malignant tumors found all over the globe. Despite advances in surgery and chemotherapy, the five-year survival rate of patients with hepatocellular carcinoma is still low. It is known that the proliferation of hepatocellular carcinoma cells is closely related to the occurrence, development and prognosis of hepatocellular carcinoma. The present work investigates the expression of microRNA-489 (miR-489) in human hepatocellular carcinoma cells and its effect on the biological behavior of human hepatocellular carcinoma cells. METHODS: The expression of miR-489 by fluorescence quantitative PCR detection in 30 patients with hepatoblastoma of liver cancer tissues and adjacent tissues was studied. Also, the determination of hepatoblastoma in four cell lines with different metastatic potential (HR8348, HCT116, HT29 and HEPG2) and the expression of miR-489 during miR-489 simulation process was studied. MTT assay, flow cytometry and Western blot analysis were performed to know the cell proliferation to detect the changes in cell cycle, apoptosis of cells, and SOX4 gene expression respectively. RESULTS: RT-PCR results showed that the cells compared with pre-cancerous tissue, the expression level of miR-489 in hepatocellular carcinoma tissues than in adjacent tissue significantly decreased (P<0.05), and with liver cancer cell metastasis increased (P<0.05); analogue transfection constructed miR-489 overexpressing HEPG2 cell line by microRNA. MTT results showed that miR-489 can inhibit the proliferation of HEPG2 cells, the differences were statistically significant (P<0.05); flow cytometry results showed that miR-489 mimics was transfected into HEPG2 cells at 48 hours had no significant effect on cell cycle distribution (P > 0.05); but miR-489 expression could induce apoptosis, compared with the control group, the apoptosis of miR-489 mimics was significantly increased and the difference was statistically significant (P < 0.05). CONCLUSION: In conclusion, miR-489 can significantly inhibit the occurrence and development of hepatocellular carcinoma cells. The mechanism may be down regulated by the expression of SOX4 and inhibit cell proliferation. Further this study showed that the tumor cells SOX4 gene as a regulatory factor target the genes of miR-489 in hepatocellular carcinoma.

Risk Factors and Outcomes in Patients With Hypernatremia and Sepsis.

BACKGROUND: Hypernatremia is an uncommon but important electrolyte abnormality in intensive care unit patients. Sepsis is one of the most common causes of intensive care unit admission, but few studies about the role of hypernatremia in sepsis has been published yet. In this study, we aimed to explore the risk factors for developing hypernatremia in patients with sepsis, and the prognosis of patients with sepsis with or without hypernatremia was also assessed. MATERIALS AND METHODS: In this retrospective cohort study of 51 septic intensive care unit patients at a single center, we examined the risk factors for the development of hypernatremia and the association of hypernatremia with clinical outcomes using univariate and multivariable analyses. Clinical outcomes such as mortality and hospital duration of patients with or without hypernatremia were also compared. RESULTS: Acute Physiology and Chronic Health Evaluation II score (odds ratio = 1.15; 95% CI: 1.022-1.294) was found to be the only independent risk factor for hypernatremia in patients with sepsis. Moreover, patients developing hypernatremia during hospitalization showed significantly higher morbidity and mortality. CONCLUSIONS: Acute Physiology and Chronic Health Evaluation II score may be an independent risk factor for hypernatremia in patients with sepsis. Moreover, hypernatremia is strongly associated with worse outcome in sepsis.

Efficacy of continuous regional arterial infusion with low-molecular-weight heparin for severe acute pancreatitis in a porcine model.

OBJECTIVE: Administration of heparin or its derivatives has been proved to be beneficial in the treatment of severe acute pancreatitis (SAP). However, drugs administered by conventional intravenous way are difficult to reach the pancreatic tissue and may cause bleeding complications due to coagulation and microcirculatory disturbance following initiation of SAP. In this study, we aimed to assess the effects of low-molecular-weight heparin (LMWH) administered with continuous regional arterial infusion (CRAI) technique in a porcine model of SAP. METHODS: Following baseline measurements, 18 animals were divided into three groups: CRAI group (LMWH infused through placed arterial catheter), venous group (LMWH infused through central venous catheter), and SAP control group. We used retrograde intraductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and inflammatory and serum biochemical parameters of the animals were studied. At the end of the experiment, histological examination of pancreas, intestine, and lung was performed. RESULTS: Continuous regional arterial infusion with LMWH remarkably stabilized hemodynamic profiles, improved systemic oxygenation and peripheral perfusion, alleviated histological injury of pancreas (especially for the necrosis scale), and downregulated inflammatory response when compared with the other two groups. Moreover, serum D-dimer level also decreased most significantly in the CRAI group (474 ± 144 vs. 664 ± 155 µg/L in the venous group and 945 ± 351 µg/L in the controls at the end), partly indicating ameliorated coagulation disorders in the study group. No bleeding complication was observed in the CRAI group, whereas two animals in the venous group presented gastrointestinal hemorrhage. CONCLUSIONS: Continuous regional arterial infusion with LMWH exhibits strong therapeutic effects in the course of SAP with great safety. Human studies using this novel therapy are required to assess these potential benefits in the clinical setting.

Codonopsis pilosula polysaccharide attenuates cecal ligation and puncture sepsis via circuiting regulatory T cells in mice.

BACKGROUND: Codonopsis pilosula polysaccharide (CPPS) isolated from one of the Chinese herbs is known to have a variety of immunomodulatory activities. However, it is not clear whether CPPS can exert an effect on the immune functions of regulatory T cells (Tregs). This study was carried out to investigate the effect of CPPS on the immune function of peripheral blood Tregs in sepsis induced by cecal ligation and puncture (CLP). METHODOLOGY AND PRINCIPAL FINDINGS: BALB/c mice were randomly divided into five groups: sham group, CLP group, CLP with CPPS (40, 100, and 250 mg/kg) treatment group, and they were killed on days 1, 2, 3, and 4 after CLP, respectively, with eight animals at each time point. Magnetic microbeads were used to isolate peripheral blood Tregs and CD4 T cells. Phenotypes of Tregs, such as Toll-like receptor 4 (TLR4) and Foxp3, were analyzed by flow cytometry, and coculture medium cytokines levels were determined with enzyme-linked immunosorbent assay. The levels of TLR4 and the expression of Foxp3 in the Treg from CLP group were markedly increased in comparison to the sham group. Administration of CPPS could significantly decrease the TLR4 level and inhibited the expression of Foxp3 on Tregs in sepsis mice. At the same time, proliferative activity and expression of interleukin 2 and interleukin 2Rα on CD4 T cells were restored. In contrast, anti-TLR4 antibody could block the effect of CPPS on Treg immune function. CONCLUSIONS: Codonopsis pilosula polysaccharide might suppress excessive Tregs, at least in part, via TLR4 signaling on Tregs and trigger a shift of TH2 to TH1 with activation of CD4 T cells in sepsis induced by CLP.

Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study.

BACKGROUND: To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP). METHODS: Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded. RESULTS: Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved. CONCLUSIONS: Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3-4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.

The importance of timing of decompression in severe acute pancreatitis combined with abdominal compartment syndrome.

BACKGROUND: Surgical decompression is widely considered as an important treatment in patients with severe acute pancreatitis (SAP) and abdominal compartment syndrome (ACS). Until now, the indication and optimal time of decompression remain unknown, and no experimental data exist, although extremely high mortality has been repeatedly reported in these patients. The aim of this study was to evaluate the effects of three different time points for decompression in a 24-hour lasting porcine model. METHODS: Following baseline registrations, 32 animals were divided into four groups (8 animals each group) as follows: one SAP-alone group and three SAP + ACS groups, which received decompression at 6, 9, and 12 hours. We used a N2 pneumoperitoneum to increase the intra-abdominal pressure to 25 mm Hg and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and serum biochemical parameters of the animals were studied. At the end of the experiment, histologic examination of the intestine and lung was performed. RESULTS: The survival time of the 12-hour group was significantly shortened (p = 0.037 vs. 9 hours and p = 0.008 vs. 6 hours). In SAP + ACS animals, decompression at 6 hours restored systemic hemodynamics, oxygen-derived parameters, organ function, and inflammatory intensity to a level comparable with that of the SAP-alone group. In contrast, animals in the 9 hours and 12 hours developed more severe hemodynamic and organ dysfunction. The histopathologic analyses also revealed higher grade injury of the intestine and lung in animals receiving delayed decompression. CONCLUSION: Well-timed decompression in a porcine model of SAP incorporating 25-mm Hg intra-abdominal hypertension/ACS was associated with significantly reduced mortality, improved systemic hemodynamics and organ function, as well as alleviated histologic injury and inflammatory intensity. According to our results and previous reports, both too early and too late decompression should be avoided owing to significant morbidity for the former and unfavorable outcomes for the latter.

Modified gastrointestinal failure score for patients with severe acute pancreatitis.

PURPOSE: No consensus has been reached to define gastrointestinal failure (GIF) associated with severe acute pancreatitis (SAP). Reintam and colleagues proposed a scoring system of GIF for critically ill patients, but its suitability for patients with SAP is questionable. The present study evaluates a modified GIF score we developed to assess the GIF of patients with SAP. METHODS: The subjects of this study were 52 patients with SAP treated between September 2010 and July 2011. We recorded the Reintam's GIF score, our modified GIF score, the acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment (SOFA) score, and other clinical values during the first 3 days after admission. The prognostic value of the modified GIF score, for evaluating the severity and outcomes of SAP, was also assessed. RESULTS: Compared with the Reintam's GIF score, the modified GIF score seemed to be more valuable for predicting hospital mortality (the area under curve, AUC 0.915 vs. 0.850), multiple organ dysfunction syndrome (MODS) (AUC 0.829 vs. 0.766), and pancreatic infection (AUC 0.796 vs. 0.776). Moreover, combining the modified GIF score and the SOFA or APACHEII scores resulted in more accurate prediction of the prognosis of SAP than either score alone. CONCLUSION: The modified GIF score is useful for assessing gastrointestinal system function, which may serve as an early prognostic tool to evaluate the severity and predict the outcomes of SAP.

The effect of intra-abdominal hypertension incorporating severe acute pancreatitis in a porcine model.

INTRODUCTION: Abdominal compartment syndrome (ACS) and intra abdominal hypertension(IAH) are common clinical findings in patients with severe acute pancreatitis(SAP). It is thought that an increased intra abdominal pressure(IAP) is associated with poor prognosis in SAP patients. But the detailed effect of IAH/ACS on different organ system is not clear. The aim of this study was to assess the effect of SAP combined with IAH on hemodynamics, systemic oxygenation, and organ damage in a 12 h lasting porcine model. MEASUREMENTS AND METHODS: Following baseline registrations, a total of 30 animals were divided into 5 groups (6 animals in each group): SAP+IAP30 group, SAP+IAP20 group, SAP group, IAP30 group(sham-operated but without SAP) and sham-operated group. We used a N(2) pneumoperitoneum to induce different levels of IAH and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. The investigation period was 12 h. Hemodynamic parameters (CO, HR, MAP, CVP), urine output, oxygenation parameters(e.g., S(v)O(2), PO(2), PaCO(2)), peak inspiratory pressure, as well as serum parameters (e.g., ALT, amylase, lactate, creatinine) were recorded. Histological examination of liver, intestine, pancreas, and lung was performed. MAIN RESULTS: Cardiac output significantly decreased in the SAP+IAH animals compared with other groups. Furthermore, AST, creatinine, SUN and lactate showed similar increasing tendency paralleled with profoundly decrease in S(v)O(2). The histopathological analyses also revealed higher grade injury of liver, intestine, pancreas and lung in the SAP+IAH groups. However, few differences were found between the two SAP+IAH groups with different levels of IAP. CONCLUSIONS: Our newly developed porcine SAP+IAH model demonstrated that there were remarkable effects on global hemodynamics, oxygenation and organ function in response to sustained IAH of 12 h combined with SAP. Moreover, our model should be helpful to study the mechanisms of IAH/ACS-induced exacerbation and to optimize the treatment strategies for counteracting the development of organ dysfunction.

Risk factors and outcome of intra-abdominal hypertension in patients with severe acute pancreatitis.

BACKGROUND: Intra-abdominal hypertension (IAH) is common in patients with severe acute pancreatitis (SAP). The aim of the present study was to investigate the risk factors of IAH in SAP patients and assess the prognosis of SAP combined with IAH. METHODS: To analyze the data from patients with SAP, both univariate and multivariate logistic regression analyses were applied, using 16 indices, including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), 24 h fluid balance, hematocrit, serum calcium level, and so on. Clinical prognosis such as mortality, hospital duration, of SAP patients with or without IAH was also compared. RESULTS: First 24 h fluid balance (Odds Ratio [OR], 1.003; 95% Confidence Interval [CI], 1.001-1.006), number of fluid collections (OR, 1.652; 95% CI, 1.023-2.956), and serum calcium level (OR, 0.132; 95% CI, 0.012-0.775) were found to be independent risk factors for IAH in patients with SAP. Moreover, patients with SAP and IAH had significantly longer average length of stay, both in the hospital and in the intensive care unit, higher rates of systemic and local complications, and more invasive treatments. CONCLUSIONS: The significant risk factors for IAH in patients with SAP include 24 h fluid balance (first day), number of fluid collections, and serum calcium level. Additionally, IAH is associated with extremely poor prognosis, evidenced by high rates of mortality, morbidity, and the need for invasive interventions.

D-dimer as a marker of severity in patients with severe acute pancreatitis.

BACKGROUND/PURPOSE: Coagulative disorder is known to occur in the early phase of severe acute pancreatitis (SAP) and D: -dimer is a commonly used clinical parameter of hemostasis. The aim of this study was to assess the value of the plasma D: -dimer level as a marker of severity in the first 3 days after admission in patients with SAP. METHODS: From January 2009 to February 2011, 45 patients admitted for SAP were included in this observational study. The D: -dimer level was measured on a daily basis during days 1-3 after admission and the acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and other clinical parameters were recorded at the same time. The maximum and the mean D: -dimer values were used for analysis and compared with other prognostic factors of SAP. RESULTS: Both the maximum and mean levels of D: -dimer were significantly different between patients with and without clinical variables such as multiple-organ dysfunction syndrome (MODS), need for surgical intervention, and the presence of pancreatic infection. The D: -dimer level also showed great precision for the prediction of MODS and secondary infection. Additionally, the D: -dimer level correlated well with two usual markers of SAP severity-the APACHE II score and the C-reactive protein level. CONCLUSION: D: -dimer measurement is a useful, easy, and inexpensive early prognostic marker of the evolution and complications of SAP.

Beneficial effect of hypertonic saline resuscitation in a porcine model of severe acute pancreatitis.

OBJECTIVE: Hypertonic saline (HTS) solution resuscitation has been used in a variety of clinical settings. The aim of this study was to assess the effect of HTS resuscitation on hemodynamics, systemic oxygenation, and organ damage in a porcine model of severe acute pancreatitis. METHODS: Eighteen anesthetized and mechanically ventilated pigs were divided into 3 groups: HTS group, lactated Ringer solution (LR) group, and sham-operated group. Severe acute pancreatitis was induced in the first 2 groups by injecting 5% sodium taurocholate into the pancreatic duct, and the investigation period was 12 hours. Hemodynamic parameters, urine output, oxygenation parameters, and serum parameters were recorded consecutively. Finally, histologic examinations of the kidney, intestine, pancreas, and lung were performed. RESULTS: In the HTS group, cardiac output decreased less significantly compared with the LR group. Furthermore, aspartate aminotransferase, creatinine, and lactate levels increased significantly in all animals with severe acute pancreatitis, but the increasing tendency was slower in the HTS group. Nevertheless, the histopathologic analysis revealed similar injuries of the kidney, intestine, pancreas, and lung between the HTS and LR groups. CONCLUSIONS: Early administration of HTS generally improves hemodynamics and peripheral oxygenation. Despite these normalized parameters, organ damage could not be diminished to a significant degree during observation.

[Effect of decompression in different time on hemodynamics and oxygen metabolism of porcine model with severe acute pancreatitis combined intra-abdominal hypertension].

OBJECTIVE: To assess the effect of decompression in different time on systemic hemodynamics and oxygen metabolism in a 24 h lasting porcine model of severe acute pancreatitis (SAP) incorporating intra-abdominal hypertension (IAH). METHODS: Following baseline registrations, SAP was induced in all 18 animals. A N(2) pneumoperitoneum was used to increase the intra-abdominal pressure (IAP) to 25 mmHg (1 mmHg = 0.133 kPa) in 12 of 18 SAP animals. After 6 hours, decompression was applied in 6 of these 12 pigs and the other 6 animals received decompression at 9 h since the induction of IAH. The investigation period was 24 h. Heart rate (HR), cardiac output (CO), central venous pressure (CVP), mean arterial pressure (MAP) and pulmonary arterial wedge pressure (PAWP) were continuously recorded with the aid of Swan-Ganz catheter and electrocardiography monitor; Oxygen partial pressure of artery (PaO(2)), carbon dioxide partial pressure of artery (PaCO(2)) and central venous oxygen saturation (ScvO(2)) were measured by blood-gas analysis. Besides that, systemic oxygen delivery (DO(2)) and systemic oxygen consumption (VO(2)) were calculated according to blood-gas analysis in arterial and central venous blood. RESULTS: After decompression, HR, CO, MAP, CVP, PAWP, PaO(2) and DO(2) showed no significant differences in the 6 h group when compared to SAP pigs. In the 9 h group, however, CO decreased significantly and HR, CVP, PAWP increased significantly after decompression than SAP only animals (all P < 0.05). PaO(2), ScvO(2) and DO(2) showed lower after 3 h of decompression compared with another two groups. VO(2) increased higher in IAH groups during 6 h of experiment than SAP pigs (all P < 0.05). Then VO(2) showed a trend to fall and no differences in three groups. CONCLUSIONS: There are remarkable and relatively irreversible effects on global hemodynamics and oxygen metabolism in response to the decompression in different time after sustained IAH with the underlying condition of SAP. The results of this study are in favor of a decompression in patients of SAP with IAH in early time.

[Effect of mechanical ventilation guided by transpulmonary pressure on hemodynamics and oxygen metabolism of porcine model of intra-abdominal hypertension].

OBJECTIVE: To assess the effect of mechanical ventilation (MV) guided by transpulmonary pressure (Ptp) on hemodynamics and oxygen metabolism of porcine model of intra-abdominal hypertension (IAH). METHODS: All 6 pigs were anesthetized and received MV. Volume-assist control was set: tidal volume (V(T)) was 10 ml/kg, respiratory rate (RR) was 16 bpm, inhaled oxygen concentration (FiO(2)) was 0.40 and positive end-expiratory pressure (PEEP) was set at 5 cm H(2)O (1 cm H(2)O=0.098 kPa). Following baseline observations, high intra-abdominal pressure (IAP) with intraperitoneal nitrogen inflation was induced in all 6 pigs. The IAP was increased to 25 mm Hg (1 mm Hg=0.133 kPa). Two hours later, PEEP was adjusted to such a level that Ptp during end-expiratory occlusion remained at a level above 0 cm H(2)O for 2 hours by measuring esophageal pressure, and with the rest parameters of breathing machine remaining constant. During the experimental period, hemodynamic parameters including heart rate (HR), mean arterial pressure (MAP), cardiac output index (CI), central venous pressure (CVP), pulmonary arterial wedge pressure (PAWP), and respiratory mechanics index of peak airway pressure (Ppeak), plateau pressure (Pplat), esophageal pressure (Pes) and static compliance (Cst) were continuously recorded with the aid of Swan-Ganz catheter and electrocardiogram. Oxygen partial pressure of arterial blood (PaO(2) ) and carbon dioxide partial pressure of arterial blood (PaCO(2)) were measured by blood-gas analysis. Systemic oxygen delivery (DO(2) )and systemic oxygen consumption(VO(2) )were calculated according to blood-gas analysis of arterial and central venous blood. RESULTS: No porcine model showed barotrauma and death. Compared with baseline, at 1 hour and 2 hours after induction of IAH in the animals, HR(bpm) increased significantly (134.3±5.8, 127.3±3.3 vs. 117.7±1.5). MAP(mm Hg), CVP (mm Hg) and PAWP (mm Hg) became higher (MAP:120.7±3.8, 117.3±4.8 vs. 100.4±6.6; CVP: 7.3±0.3, 7.6±0.9 vs. 5.6±0.2; PAWP: 14.0±0.6, 14.0±1.0 vs. 12.3±0.3), CI (L×min(-1)×kg(-1)) was lowered (0.150±0.019, 0.137±0.014 vs. 0.179±0.021), Ppeak(cm H(2)O), Pplat (cm H(2)O), Pes (cm H(2)O) were increased significantly (Ppeak: 46.3±2.3, 47.0±3.2 vs. 11.0±1.6; Pplat: 25.7±1.3, 26.0±1.6 vs. 9.0±0.6; Pes: 13.7±0.3, 14.3±0.3 vs. 2.3±0.3), Cst (ml/cm H(2)O), PaO(2) (mm Hg) and DO(2) (ml×min(-1)×kg(-1)) showed significant lowering (Cst: 8.3±0.3, 9.0±0.6 vs. 23.0±1.6; PaO(2) : 142.0±13.2, 140.0±16.0 vs. 166.3±11.3; DO(2) : 19.40±2.90, 19.88 ±4.14 vs. 25.07±6.30, all P<0.05).However, compared to routine ventilation, at 1 hour and 2 hours after PEEP had been adjusted according to measurements of esophageal pressure, PaO(2) , DO(2) and Cst increased significantly (PaO(2) : 161.6±11.9, 164.0±13.6; DO(2) : 21.90±6.21, 21.16±2.78; Cst: 12.0±1.6, 12.7±2.9). CI became lower (0.121±0.013, 0.120±0.012)and Pplat was higher(31.3±3.4, 31.7±3.2, all P<0.05). The lactate (mmol/L) was also decreased significantly (1.60±0.12 vs. 2.70±0.44, 1.67±0.07 vs. 2.27±0.13, both P<0.05). PaCO(2), HR, MAP, CVP and PAWP showed no significant differences compared to IAH pigs ventilated with lower PEEP (all P>0.05). CONCLUSION: There were remarkable effects on oxygen metabolism and Cst and less influence on hemodynamics in response to MV guided by Ptp. The results of this study are in favor of setting Ptp according to measurements of esophageal pressure in pigs with IAH.

[The effect of intra-abdominal hypertension on hemodynamics of acute necrotizing pancreatitis in porcine model].

OBJECTIVE: To assess the effect of intra-abdominal hypertension (IAH) on hemodynamics of severe acute pancreatitis (SAP) in porcine model. METHODS: Following baseline registrations, SAP was induced in 12 animals. The N(2) pneumoperitoneum was used to increase the intra-abdominal pressure to 30 mmHg (1 mmHg = 0.133 kPa) in 6 of 12 SAP animals thereafter and keep constant during the experiment. The investigation period was 12 h. Heart rate, cardiac output (CO), central venous pressure (CVP), mean arterial pressure and pulmonary arterial wedge pressure (PAWP) were continuously measured with the aid of balloon tipped flow-directed catheter and electrocardiography monitor. Oxygen partial pressure of artery (PaO(2)), carbon dioxide partial pressure of artery (PaCO(2)), ScvO(2), base excess (BE), and blood lactic acid (LAC) were measured by acid-base analysis. RESULTS: In the IAH group, CO decreased significantly at 12 h, CVP and PAWP increased significantly at 3 h, 6 h and 12 h compared with SAP group (all P < 0.05). Peak inspiration pressure increased immediately after pneumoperitoneum in the IAH group, to (50.2 ± 3.1) cmH(2)O (1 cmH(2)O = 0.098 kPa) and (49.8 ± 0.9) cmH(2)O at 6 h and 12 h respectively. The pH, PaO(2), ScvO(2) and BE showed a tendency to fall in the IAH group. PaCO(2) and LAC were increased significantly in the IAH group (all P < 0.05). CONCLUSIONS: There were remarkable and relatively irreversible effects on global hemodynamics in response to sustained IAH of 12 h with the underlying condition of SAP. Abdominal decompression is beneficial for patients of SAP with IAH.

Intra-abdominal pressure and abdominal perfusion pressure: which is a better marker of severity in patients with severe acute pancreatitis.

BACKGROUND: Intra-abdominal hypertension is common in patients with severe acute pancreatitis. The aim of this study was to assess the clinical relevance of intra-abdominal pressure and abdominal perfusion pressure in the first 72 h after admission during severe acute pancreatitis. METHODS: From January 2009 to February 2011, 50 patients admitted for severe acute pancreatitis were included in this prospective, observational study. The intra-abdominal pressure and abdominal perfusion pressure level were repeatedly measured every 12 h during the first 72 h. The maximum and the mean values of intra-abdominal pressure and the minimum and mean values of abdominal perfusion pressure were used for analysis. RESULTS: Both the maximum and mean levels of intra-abdominal pressure were significantly different between patients with or without kinds of clinical variables. But for abdominal perfusion pressure, difference could only be detected in terms of need of vasoactive drugs. Besides that, different from abdominal perfusion pressure, intra-abdominal pressure is associated with high incidence rates of MODS and secondary infection. CONCLUSION: Compared with abdominal perfusion pressure, intra-abdominal pressure is much more valuable as an early marker of the evolution and complications of severe acute pancreatitis.

Protective effect of glutamine in critical patients with acute liver injury.

BACKGROUND: Glutamine (Gln) supplementation is known to decrease oxidative stress and inflammatory response, enhance resistance to infectious pathogens, shorten hospital stay, and decrease medical costs of patients. This study was undertaken to evaluate the relationship between the effect of early parenteral glutamine (Gln) supplement on acute liver injury (ALI) and heat shock protein 70 (HSP-70) expression in critical patients. METHODS: Forty-four patients who had been admitted to the emergency intensive care unit (EICU) of Nanjing First Hospital Affiliated to Nanjing Medical University were randomly divided into a control group (n=22) and a Gln group (n=22). The patients of the two groups received enteral and parenteral nutrition. In addition, parenteral Gln 0.4 g/kg per day was given for 7 days in the Gln group. Serum HSP-70 and Gln were measured at admission and at 7 days after admission. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBiL), serum levels of HSP-70 and Gln, mechanical ventilation (MV) time, ICU stay, peripheral blood of TNF-α, IL-6, CD3, CD4 and CD4/CD8 levels were also measured in the two groups. RESULTS: In the Gln group, the levels of serum HSP-70 and Gln were significantly higher after Gln treatment than those before the treatment (P<0.01). HSP-70 level was positively correlated with the Gln level in the Gln group after administration of parenteral Gln (P<0.01). The levels of serum ALT, AST, TBiL and TNF-α, IL-6 were lower in the Gln group than in the non-Gln group (P<0.01). MV time and ICU stay were significantly different between the two groups (P<0.05). The levels of CD3, CD4 and CD4/CD8 were significantly higher in the Gln group than in the control group after treatment (P<0.05). CONCLUSION: Parenteral Gln significantly increases the level of serum HSP70 in critically ill patients. The enhanced expression of HSP70 is correlated with improved outcomes of Gln-treated patients with acute liver injury.