Long-term quality of life after sepsis and predictors of quality of life in survivors with sepsis.

PURPOSE: To evaluate the quality of life among survivors after sepsis in 2 years, comparing with critical patients without sepsis and the general people, analyze the changes and the predictors of quality of life among septic survivors. METHODS: This prospective case-control study screened the intensive care unit (ICU) patients in Tianjin Third Central Hospital from January 2014 to October 2017, and the Chinese general population in the previous studies was also included. According to inclusion criteria and exclusion criteria, 306 patients with sepsis were enrolled as the observation group, and another 306 patients without sepsis in ICU during the same period, whose ages, gender and Charlson Comorbidity Index matched with observation group, were enrolled as the control group. At 3 mo, 12 mo, and 24 mo after discharge, the Mos 36-item Short Form Health Survey (SF-36), the Euroqol-5 dimension (EQ-5D), and the activities of daily living (ADL) were evaluated in face-to-face for the quality of life among survivors. RESULTS: There were 210 (68.6%) septic patients and 236 (77.1%) non-septic critically ill patients surviving. At 3 months after discharge, the observation and control groups had the similar demographic characteristics (age: 58.8 ± 18.1years vs. 57.5 ± 17.6 years, p = 0.542; male: 52.0% vs. 51.4%, p = 0.926). However, the observation group had higher acute physiology and chronic health evaluation II (APACHEII) scores, higher sequential organ failure assessment (SOFA) scores, longer hospital stay, and longer ICU stay than the control group did (p < 0.05). There were no significant differences in the eight dimensions of the SF36 scale, the EQ-5D health utility scores, and the activities of daily life scores between septic survivors and non-septic survivors (p > 0.05). In addition, compared with the quality of life of the Chinese general population (aged 55-64 years), the quality of life of septic patients were significantly lower at 3 months after discharge (p < 0.05). Comparing the quality of life of the ill patients who had been discharged at 3 mo and 24 mo, the general health improved statistically (p = 0.000) and clinically (score improvement > 5 points). Older age (OR, 1.050; 95% CI, 1.022-1.078, p = 0.000), female (OR, 3.375; 95% CI, 1.434-7.941, p = 0.005) and longer mechanical ventilation time (OR, 3.412; 95% CI, 1.413, 8.244, p = 0.006) were the risk factors for the quality of life of septic survivors. CONCLUSION: The long-term quality of life of septic survivors was similar to that of non-sepsis critically ill survivors. After discharge, the general health of sepsis improved overtime. Age, female and mechanical ventilation time (>5 days) were the predictors of the quality of life after sepsis.

Assessment of 1-year Outcomes in Survivors of Severe Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation or Mechanical Ventilation: A Prospective Observational Study.

BACKGROUND: Little is known about the long-term outcomes of severe acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO). This study aimed to investigate the 1-year outcomes of these patients or patients receiving mechanical ventilation (MV) and compare their health-related quality of life (HRQoL) to the general population. METHODS: Severe ARDS survivors admitted to two ICUs in China between January 2012 and January 2014 were enrolled. Of the severe ARDS survivors enrolled, 1-year postdischarge, HRQoL assessment using the Short-Form 36 (SF-36) and EuroQol questionnaire dimensions, 6-min walking distance, chest computed tomography scan, pulmonary function, and arterial blood gas analysis were compared for ARDS patients with or without ECMO. RESULTS: ARDS patients receiving ECMO had a significantly higher Acute Physiology and Chronic Health Evaluation II score (30.3 ± 6.7 vs. 26.5 ± 7.3, P= 0.036), lung injury score (3.3 ± 0.4 vs. 2.8 ± 0.5, P= 0.000), Sequential Organ Failure Assessment score (10.8 ± 3.5 vs. 7.9 ± 3.1, P= 0.000), lower PaO2/FiO2ratio ([mmHg, 1 mmHg = 0.133 kPa], 68.3 ± 16.1 vs. 84.8 ± 16.5, P= 0.000), and increased extrapulmonary organ failure (2 [1, 3] vs. 1 [1, 1], P= 0.025) compared with patients not receiving ECMO. ECMO and non-ECMO survivors showed similar pulmonary function, morphological abnormalities, resting arterial blood gas values, and 6-min walking distance. Mild pulmonary dysfunction and abnormal morphology were observed in a few survivors. In addition, ECMO and non-ECMO survivors showed a similar quality of life. ECMO survivors showed lower SF-36 physical functioning and role-physical domain scores (minimum clinically significant difference at least 5 points), and non-ECMO survivors had similar outcome. CONCLUSIONS: One-year posthospital discharge, severe ARDS survivors receiving ECMO or MV demonstrated comparable outcomes. Compared with the general population, ARDS survivors showed reduced HRQoL. Pulmonary function and lung morphology revealed sufficient recovery with minor lung impairment.

Extracorporeal Membrane Oxygenation Outcomes in Acute Respiratory Distress Treatment: Case Study in a Chinese Referral Center.

BACKGROUND No definitive conclusions have been drawn from the available data about the utilization of extracorporeal membrane oxygenation (ECMO) to treat severe acute respiratory distress syndrome (ARDS). The aim of this study was to review our center's experience with ECMO and determine predictors of outcome from our Chinese center. MATERIAL AND METHODS We retrospectively analyzed a total of 23 consecutive candidates who fulfilled the study entry criteria between January 2009 and December 2015. Detailed clinical data, ECMO flow, and respiratory parameters before and after the introduction of ECMO were compared among in-hospital survivors and nonsurvivors; factors associated with mortality were investigated. RESULTS Hemodynamics and oxygenation parameters were significantly improved after ECMO initiation. Thirteen patients survived to hospital discharge. Univariate correlation analysis demonstrated that APACHE II score (r=-0.463, p=0.03), acute kidney injury (r=-0.574, p=0.005), membrane oxygenator replacement (r=-0.516, p=0.014) and total length of hospital stay (r=0.526, p=0.012) were significantly correlated with survival to hospital discharge, and that the evolution of the levels of urea nitrogen, platelet, and fibrinogen may help to determine patient prognosis. Sixteen patients referred for ECMO from an outside hospital were successfully transported to our institution by ambulance, including seven transported under ECMO support. The survival rate of the ECMO-transport group was comparable to the conventional transport or the non-transport group (both p=1.000). CONCLUSIONS ECMO is an effective alternative option for severe ARDS. APACHE II score on admission, onset of acute kidney injury, and membrane oxygenator replacement, and the evolution of levels of urea nitrogen, platelet, and fibrinogen during hospitalization may help to determine the in-hospital patient prognosis. By establishing a well-trained mobile ECMO team, a long-distance, inter-hospital transport can be administered safely.

Performance of Multiple Risk Assessment Tools to Predict Mortality for Adult Respiratory Distress Syndrome with Extracorporeal Membrane Oxygenation Therapy: An External Validation Study Based on Chinese Single-center Data.

BACKGROUND: There has been no external validation of survival prediction models for severe adult respiratory distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO) therapy in China. The aim of study was to compare the performance of multiple models recently developed for patients with ARDS undergoing ECMO based on Chinese single-center data. METHODS: A retrospective case study was performed, including twenty-three severe ARDS patients who received ECMO from January 2009 to July 2015. The PRESERVE (Predicting death for severe ARDS on VV-ECMO), ECMOnet, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score, a center-specific model developed for inter-hospital transfers receiving ECMO, and the classical risk-prediction scores of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) were calculated. In-hospital and six-month mortality were regarded as the endpoints and model performance was evaluated by comparing the area under the receiver operating characteristic curve (AUC). RESULTS: The RESP and APACHE II scores showed excellent discriminate performance in predicting survival with AUC of 0.835 (95% confidence interval [CI], 0.659-1.010, P = 0.007) and 0.762 (95% CI, 0.558-0.965, P = 0.035), respectively. The optimal cutoff values were risk class 3.5 for RESP and 35.5 for APACHE II score, and both showed 70.0% sensitivity and 84.6% specificity. The excellent performance of these models was also evident for the pneumonia etiological subgroup, for which the SOFA score was also shown to be predictive, with an AUC of 0.790 (95% CI, 0.571-1.009, P = 0.038). However, the ECMOnet and the score developed for externally retrieved ECMO patients failed to demonstrate significant discriminate power for the overall cohort. The PRESERVE model was unable to be evaluated fully since only one patient died six months postdischarge. CONCLUSIONS: The RESP, APCHAE II, and SOFA scorings systems show good predictive value for intra-hospital survival of ARDS patients treated with ECMO in our single-center evaluation. Future validation should include a larger study with either more patients' data at single-center or by integration of domestic multi-center data. Development of a scoring system with national characteristics might be warranted.

Comparison of the pulmonary dead-space fraction derived from ventilator volumetric capnography and a validated equation in the survival prediction of patients with acute respiratory distress syndrome.

PURPOSE: This prospective observational study aims to evaluate the accuracy of dead-space fraction derived from the ventilator volumetric capnography (volumetric CO2) or a prediction equation to predict the survival of mechanically ventilated patients with acute respiratory distress syndrome (ARDS). METHODS: Consecutive VD/VT measurements were obtained based upon a prediction equation validated by Frankenfield et al for dead-space ventilation fraction: VD/VT = 0.320 + 0.0106 (PaCO2-ETCO2)⁺ 0.003 (RR)⁺0.0015 (age) in adult patients who had infection-related severe pneumonia and were confirmed as having ARDS. Here PaCO2 is the arterial partial pressure of carbon dioxide in mmHg; ETCO2, the end- tidal carbon dioxide measurement in mmHg; RR, respiratory rate per minute; and age in years. Once the patient had intubation, positive end expiratory pressure was adjusted and after Phigh reached a steady state, VD/VT was measured and recorded as the data for the first day. VD/VT measurement was repeated on days 2, 3, 4, 5 and 6. Meanwhile we collected dead-space fraction directly from the ventilator volu- metric CO2 and recorded it as Vd/Vt. We analyzed the changes in VD/VT and Vd/Vt over the 6-day period to determine their accuracy in predicting the survival of ARDS patients. RESULTS: Overall, 46 patients with ARDS met the inclusion criteria and 24 of them died. During the first 6 days of intubation, VD/VT was significantly higher in nonsurvivors on day 4 (0.70 ± 0.01 vs 0.57 ± 0.01), day 5 (0.73 ± 0.01 vs. 0.54 ± 0.01), and day 6 (0.73 ± 0.02 vs. 0.54 ± 0.01) (all p =0.000). Vd/Vt showed no significant difference on days 1e4 but it was much higher in nonsurvivors on day 5 (0.45 ± 0.04 vs. 0.41 ± 0.06) and day 6 (0.47 ± 0.05 vs. 0.40 ± 0.03) (both p=0.008). VD/VT on the fourth day was more accurate to predict survival than Vd/Vt. The area under the receiver-operating characteristic curve for VD/VT and Vd/Vt in evaluating ARDS patients survival was day 4 (0.974 ± 0.093 vs. 0.701 ± 0.023, p = 0.0024) with the 95% confidence interval being 0.857-0.999 vs. 0.525-0.841. CONCLUSION: Compared with Vd/Vt derived from ventilator volumetric CO2, VD/VT on day 4 calculated by Frankenfield et al's equation can more accurately predict the survival of ARDS patients.

Clinical study of midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in intensive care unit.

PURPOSE: To evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU. METHODS: This randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups (40 patients per group). Each patient of group A received an initial loading dose of midazolam at 0.3-3mg/kg·h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2-1 µg/kg·h until extubation. Each patient of group B received midazolam at a dose of 0.3-3 mg/kg·h until extubation. The dose of sedation was regulated according to RASS sedative scores maintaining in the range of -2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate (HR), mean artery pressure (MAP), extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points: 24 h before extubation (T1), 12 h before extubation (T2), extubation (T3), 30 min after extubation (T4), 60 min after extubation (T5). RESULTS: Both groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation (20% (8/40) vs 45% (18/40)), respectively (p= 0.017). There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values (p < 0.05). HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation (both, p <0.05). Compared with preextubation values, MAP was significantly increased at extubation in the group B (p < 0.05) and MAP was significantly higher at T3, T4, T5 in the group B than group A (p < 0.05). There was a significant difference in extubation time ((3.0 ± 1.5) d vs (4.3 ± 2.2) d, p < 0.05), ICU stay ((5.4 ± 2.1) d vs (8.0 ± 1.4) d, p < 0.05), hospital stay ((10.1 ± 3.0) d vs (15.3 ± 2.6) d, p <0.05) between group A and B. CONCLUSION: Midazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.

[A multicenter study of respiratory multiple index in predicting weaning from mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease].

OBJECTIVE: To study the result of respiratory multiple index(compliance, respiratory rate, oxygenation, pressure, CROP) in predicting weaning from mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: A prospective study was conducted. Two hundred and fifteen patients weaning from mechanical ventilation with AECOPD in intensive care unit (ICU) of five tertiary hospitals from September 2010 to October 2012 were enrolled. All of the AECOPD patients were troubled with respiratory failure and received non-invasive mechanical ventilation for more than 24 hours. They were conscious and cooperative at the time of extubation, and passed the spontaneous breathing trial (SBT) for 30 minutes. Before weaning, the maximal inspiratory pressure (PImax), the peak airway pressure (Ppeak), the total positive end expiratory pressure (PEEPtot), tidal volume (VT) and respiratory frequency (f) were recorded; the arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) were detected; the effective compliance of the respiratory system (Crs) and alveolar oxygen pressure(PAO2) were calculated. The above indexes were substituted into the formula: CROP= Crs × 1/f × PaO2/PAO2× PImax to get the value of CROP. Successful weaning from mechanical ventilation was defined if there was no indication for intubation within 72 hours. The receiver operating characteristic curve (ROC curve) was drawn to analyze the predict value of CROP on result of weaning from mechanical ventilation in patients with AECOPD. RESULTS: In 215 patients, 182 patients successfully weaned from mechanical ventilation, and 33 failed. There were no significant differences in gender, age and the acute physiology and chronic health evaluation II (APACHEII) score between the successfully weaned patients and the failed. Before weaning from mechanical ventilation, PaCO2 in failed group was significantly higher than that in successful group (60.69 ± 10.47 mm Hg vs. 51.24 ± 8.81 mm Hg, P<0.05), the CROP was significantly lowered (10.286 ± 1.392 ml × breath⁻¹ ×min⁻¹ vs. 58.746 ± 7.283 ml×breath⁻¹×min⁻¹, P<0.01), and the duration of mechanical ventilation was prolonged (10.28 ± 3.94 days vs. 6.21 ± 2.87 days, P<0.05). The best critical value of CROP which could predict the result of weaning from mechanical ventilation was 13.521 ml×breath⁻¹×min⁻¹. CROP≥ 13.521 ml×breath⁻¹×min⁻¹ had a specificity of 91.9% and sensitivity of 87.9% in predicting extubation succeed. The positive predicted value was 0.97, and the negative predicted value was 0.58; Odds ratio (OR)<1, which confirmed that CROP was a strong and independent predictor of extubation. CONCLUSIONS: For the AECOPD patients received mechanical ventilation, most extubation parameter was limited. Complex parameter of CROP has higher specificity and sensitivity, and has important value in predicting extubation outcome. When CROP ≥ 13.521 ml×breath⁻¹×min⁻¹, the successful rate is high, otherwise the rate is low.

[A preliminary study of using the expiratory limb of the pressure-volume curve to estimate the dead space in patients suffering from acute respiratory distress syndrome].

OBJECTIVE: To trace pressure-volume curves (P-V curves) with quasi-static technique in acute respiratory distress syndrome (ARDS) patients, and using it to explain the relationship between the end point of the expiratory limb and the change in the dead space of expiration. METHODS: A prospective study was conducted. Fourteen ARDS patients receiving mechanical ventilation were included in the study. When P-V curves were traced with quasi-static technique, the spirometer was connected to the flow sensor. The start point of the expiratory limb was defined as tidal volume 1 (VT1) and the end point as VT2, and the difference between them (ΔVT=VT1-VT2) was calculated. The VT of spirometer (named VT3) and the predetermined VT (VT4) were recorded. Correlations of ΔVT and VT3, as well as VT4 and VT1, were analyzed with correlation analysis. RESULTS: ΔVTwas (417.40±119.68) ml, and VT3 was (399.29±121.36) ml, ΔVT and VT3 showed a good correlation (r=0.99, P=0.000), demonstrating that the ΔVT of the expiratory limb was correlated with the volume trapped in lung. VT4 was (908.21±106.52) ml, and VT1 was(892.26±106.32) ml, and they showed a good correlation (r=0.99, P=0.000). CONCLUSION: Because of part of the gas trapped at the end of expiration in ARDS patients, the dead space is increased, showing that the expiratory limb of the P-V curve cannot return to the base points, and the ΔVT of the expiratory limb is inversely proportional to the gas volume trapped in lung.

[Mutation analysis for GJB2 and LOR genes in two patients with Vohwinkel syndrome].

OBJECTIVE: To detect potential mutations of gap junction protein beta 2 (GJB2) and loricrin (LOR) genes in two patients with Vohwinkel syndrome. METHODS: Polymerase chain reaction and DNA sequencing were used for detecting potential mutations in the GJB2 and LOR genes. Parents of one patient and 50 healthy individuals were used as controls. RESULTS: A novel homozygous missense mutation (c.A796G) of LOR gene was detected in one patient. The same mutation was not found in the other patient, their relatives and the 50 healthy controls. CONCLUSION: A missence mutation of LOR gene was detected in a patient with Vohwinkel syndrome.

[Influence of pulse indicator continuous cardiac output in monitoring on the volume parameters of different tidal volume under pressure control ventilation mode and volume-controlled ventilation mode in sheep].

OBJECTIVE: To compare the influence of pulse indicator continuous cardiac output (PiCCO) in monitoring tidal volume (V(T)) under pressure control ventilation mode and volume-controlled ventilation mode in sheep. METHODS: After anesthesia and tracheotomy, 5 sheep, which were apneic and receiving mechanical ventilation. Twenty minutes later, central venous pressure (CVP) and cardiac function were monitored with different selected V(T) levels of 6, 10, 15, 20 ml/kg under bi-level positive airway pressure (BiPAP) mode by changing the pressure of inspiration, or under the synchronized intermittent mandatory ventilation (SIMV) mode with the same ventilation conditions. RESULTS: In both modes, the increase in V(T) led to an decrease of cardiac index (CI) and intrathoracic blood volume index (ITBVI), reaching a statistically significant difference at 15 ml/kg [SIMV mode: CI (3.94 + or - 1.03) L x min(-1) x m(-2), ITBVI (707 + or - 105) ml/m(2); BiPAP mode: CI (4.11 + or - 1.11) L x mi(-1) x m(-2), ITBVI (715 + or - 122) ml/m(2)] and 20 ml/kg [SIMV mode: CI (3.87 + or - 1.04) L x min(-1) x m(-2), ITBVI (705 + or - 116) ml/m(2); BiPAP mode: CI (3.64 + or - 0.96) L x min(-1) x m(-2), ITBVI (694 + or - 114) ml/m(2)] compared with 6 ml/kg [SIMV mode: CI (4.96 + or - 1.58) L x min(-1) x m(-2),ITBVI(811 + or - 169) ml/m(2); BiPAP mode:CI(5.67 + or - 1.96) L x min(-1) x m(-2), ITBVI (823 + or - 182) ml/m(2), all P<0.05]; an increase in systemic vascular resistance index (SVRI) and mean airway pressure (Pmean) at 15 ml/kg [SIMV mode: SVRI (237.6 + or - 56.2) kPaxs(-1) x L(-1), Pmean (14.0 + or - 3.2) cm H(2)O (1 cm H(2)O=0.098 kPa); BiPAP mode: SVRI (230.8 + or - 32.9) kPaxs(-1) x L(-1), Pmean (13.0 + or - 2.2) cm H(2)O] and 20 ml/kg [SIMV mode: SVRI (253.1 + or - 76.7) kPaxs(-1) x L(-1), Pmean (18.2 + or - 4.8) cm H(2)O ; BiPAP mode: SVRI (246.7 + or - 48.8) kPaxs(-1) x L(-1), Pmean (16.8 + or - 3.3) cm H(2)O] compared with 6 ml/kg [SIMV mode: SVRI (184.8 + or - 47.5) kPaxs(-1) x L(-1); Pmean (8.8 + or - 1.6) cm H(2)O; BiPAP mode: SVRI (184.5 + or - 51.5) kPaxs(-1) x L(-1), Pmean (8.6 + or - 0.5) cm H(2)O, all P<0.05]; but there was no significant effects on CVP, heart rate (HR), mean blood pressure (MBP). There was no significant difference of CI, ITBVI, SVRI and Pmean between the two ventilation modes with various V(T) levels. CONCLUSION: When the cardiac function was normal, the increase in V(T) led to a decrease of CI and ITBVI, but it had no significant effects on CVP. There was no significant difference of CI and ITBVI in the two ventilation modes, both were decreased. So a relatively constant V(T) should be maintained in determining ITBVI.

[The lung protection strategy under the support of extracorporeal membrane oxygenation in patients suffering from influenza A H1N1].

OBJECTIVE: To study the effect of extracorporeal membrane oxygenation (ECMO) in patients suffering from severe pneumonia complicating influenza A H1N1 by putting lungs in rest to protect the latter. METHODS: Five patients with severe pneumonia following influenza A H1N1 were treated with ECMO and different modes of mechanical ventilation at the same time. Two patients died, both of them received synchronized intermittent mandatory ventilation (SIMV) and bi-level positive airway pressure (BiPAP) modes, with airway pressure release ventilation (APRV) to control lung expansion with expansion pressure 40 cm H(2)O (1 cm H(2)O=0.098 kPa). In 3 survivors, the strategy of lung rest was performed by giving an optimized positive end expiratory pressure (PEEP) with an optimal compliance by gradually elevation of PEEP, and high-level pressure (Phigh) at 20 cm H(2)O by application of BiPAP mode. RESULTS: One patient died due to lung damage and repeated spontaneous pneumothorax and sepsis; 1 patient died due to multiple organ dysfunction syndrome. Three patients recovered after following the strategy of lung rest. CONCLUSION: When ECMO is used for severe pneumonia complicating influenza A H1N1, prognosis can be obviously improved, with decrease in the occurrence of lung damage through the protection strategy of lung rest.

[Study on the effect of control mode of pressure and volume on cardiac index and intrathoracic blood volume index in critically ill patients].

OBJECTIVE: To compare the effect of control mode of pressure and volume of mechanical ventilation on cardiac index (CI), intrathoracic blood volume index (ITBVI) in patients. METHODS: Twenty-four patients in whom mechanical ventilation and pulse indicator continuous cardiac output (PiCCO) monitoring were necessary were involved, and they were divided into normal heart function group (9 cases) and heart dysfunction group (15 cases) on the base of CI. Mechanical ventilation was used with the mode of bi-level positive airway passage (BIPAP), and the inspiratory pressure was maintained at the tidal volume (V(T)) of 6, 10, 15 ml/kg. After the mechanical ventilation mode was changed to synchronized intermittent mandatory ventilation (SIMV) and maintained for 20 minutes, breathing mechanics and central venous pressure (CVP), CI, ITBVI were measured. RESULTS: In the normal heart function group, there were decrease in mean arterial pressure (MAP), CI and ITBVI, increase in heart rate (HR), mean airway pressure (Pmean) and intrinsic positive end expiratory pressure (PEEPi) in both modes of mechanical ventilation without significant difference (P values were 0.067, 0.124, 0.348, 0.328, 0.110, 0.187, respectively). Systemic vascular resistance index (SVRI) was higher in the BIPAP group compared with SIMV group (P=0.030). In the heart dysfunction group, the CI and ITBVI were decreased in the SIMV mode, and CI was decreased significantly in the 10 ml/kg group (P<0.05). Pmean in BIPAP group was increased than that in SIMV group in all V(T) levels (P values were 0.003, 0.000, 0.004, respectively). There was no significant difference in SVRI, HR, MAP and PEEPi in all groups. CONCLUSION: In the two mechanical ventilation modes, with an increase in V(T), CI and ITBVI may decrease. The Pmean is lower when BIPAP mode in used compared with SIMV, when V(T) is same. So mechanical ventilation and V(T) can influence the readings of CI and ITBVI when PiCCO monitoring is employed.

[The preemptive treatment of invasive Candida infection with reference of corrected colonization index in critically ill patients: a multicenter, prospective, randomized controlled clinical study].

OBJECTIVE: To evaluate preemptive treatment for invasive Candida infection (ICI) with reference of corrected colonization index (CCI) in critically ill patients with high risk factors of Candida infection, and to collect the epidemiology data of Candida infection. METHODS: One hundred and ten critically ill patients with acute physiology and chronic health evaluation II (APACHE II) score>10 were selected from intensive care units (ICUs) of 5 grade III class A hospitals in Tianjin from October 1st 2008 to April 30th 2009, and they were randomly divided into two groups: CCI group and control group (55 cases in each group). CCI was monitored in all patients. In control group the responsible intensivists ordered the treatment according to their own experience, and in CCI group, when the patient's CCI> or =0.4 and with evidence of sepsis, the patients were given anti-Candida immediately. When CCI<0.4, anti-Candida treatment was not given. But when the patients' condition became worse or unstable, complementary anti-Candida treatment was given. RESULTS: There were no significant differences in general data, treatment of diseases of the patients, APACHE II scores, incidence of sepsis and length of ICU stay (LOS) between two groups ( all P>0.05 ). There were 50 patients and 48 patients developing sepsis in control group and CCI group, respectively. In CCI group, the time between the onset of sepsis to beginning of anti-Candida treatment was significantly shorter than the control group [(0.94+/-0.67) days vs. (3.75+/-3.62) days, P<0.05]. In the group of CCI> or =0.4 (57 patients) the LOS [(15.34+/-6.63) days] and the incidence of failure in establishing enteral nutrition (64.9%) were significantly higher than that of the group of CCI<0.4 [53 patients, (7.24+/-3.75) days, 43.4%, both P<0.05]. There was no significant difference in APACHE II scores, incidence of mechanical ventilation and blood purification between two groups ( all P>0.05 ). Analysis of 575 strains of Candida colonized in 110 patients, revealed that C. albicans ranked first (59.3%), C. tropicalis ranked second (10.8%), followed by C. glabrata, Cryptococcus and C. krusei. CONCLUSION: Application of CCI may enhance the accuracy of timely preemptive treatment for ICI, and facilitate the collection of epidemiological data of Candida in critically ill patients.

[A study of cough peak expiratory flow in predicting extubation outcome].

OBJECTIVE: To study the value of cough peak expiratory flow (CPEF) in predicting extubation outcome of patients. METHODS: A prospective study of 200 adult patients was conducted and treated in the Third Central Hospital intensive care unit (ICU), receiving mechanical ventilation (MV) via an endotracheal tube during November 2006 through December 2007. All the patients received MV longer than 24 hours. They were conscious and cooperative at the time of extubation. Extubation was successful after 30 minutes of spontaneous breathing trial (SBT). They were asked to cough for three times, during which CPEF was measured with an in-line spirometer, and the average value was recorded. They were classified as strong, moderate, and weak according to the ability to cough. If the patients did not require reintubation within 72 hours, extubation was noted as successful. RESULTS: In 200 patients, in 172 patients extubation was successful and failed in 28 patients. Sex, age, severity of illness and vital signs during SBT showed no difference between patients with successful extubation and patients with unsuccessful extubation. CPEF was the independent predictor for the extubation outcome [odds ratio (OR) < 1]. The cut-point was 58.5 L/min. CPEF< or =58.5 L/min had a specificity of 68.0% and sensitivity of 71.4% in predicting extubation failure. The positive predicted value was 0.16, and the negative predicted value was 0.94. The cough strength in patients with successful extubation was almost always "strong", and in very few it was "medium". In those extubation failed, there were only 3 patients showed strong cough strength, and for the rest it was "moderate" or "weak". CONCLUSION: After patients have recovered from respiratory failure and SBT is successful, factors affecting airway competence, such as cough strength, may be important predictors of extubation outcome. The study confirms that CPEF is a strong and independent predictor of extubation outcome when the patient is mentally clear and has a successful SBT. When the CPEF>58.5 L/min, the successful rate is high. On the contrary, when the CPEF< or =58.5 L/min, the unsuccessful rate is high. Failure is often due to poor cough. The extubation outcome is highly correlated with cough strength. The prognosis in patients with failure is poor.