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Objective:To investigate the value of high-flow oxygen therapy after weaning in successful extubation of critically ill patients with mechanical ventilation.Methods:A retrospective study was conducted. The weaned patients who were older than 18 years old and underwent mechanical ventilation for the first time due to cerebrovascular accidents, surgical operations, cardiovascular diseases, and pneumonia admitted to the department of critical care medicine of Zhejiang Hospital from January 2018 to June 2020 were enrolled. Among the patients, 40 cases received high-flow oxygen therapy after weaning, and 37 cases received Venturi combined with the humidifier. The patient's gender, age, primary disease, severity score, duration of mechanical ventilation before weaning, heart rate (HR), blood pressure, pulse oxygen saturation (SpO 2) at 0, 6, 12, 18, and 24 hours after weaning, and pH value, arterial partial pressure of oxygen (PaO 2), arterial partial pressure of carbon dioxide (PaCO 2) at 6, 12, 18, and 24 hours after weaning, the rate of performing mechanical ventilation after weaning, extubation time after weaning, and the rate of reintubation after extubation for 72 hours were collected. Results:There was no significant difference in baseline data such as gender, age, primary disease, severity score, and duration of mechanical ventilation before weaning between the two groups. After weaning, the vital signs of the two groups were stable, and there was no significant difference in HR, systolic blood pressure (SBP), diastolic blood pressure (DBP) or SpO 2 at each time point between the two groups. After weaning, the pH of arterial blood gas analysis in the two groups and the fluctuations of PaO 2 and PaCO 2 in the high-flow group were not obvious. In the Venturi group, PaO 2 gradually decreased after weaning, PaCO 2 increased significantly at 12 hours, and slowly decreased after 12 hours. The PaO 2 from 6 hours and PaCO 2 from 12 hours in the high-flow group were significantly lower than those in the Venturi group, and continued to 24 hours [PaO 2 (mmHg, 1 mmHg≈0.133 kPa): 112.34±38.25 vs. 156.76±68.44 at 6 hours, 110.92±38.66 vs. 150.64±59.07 at 12 hours, 111.12±36.77 vs. 141.30±39.05 at 18 hours, 110.82±39.37 vs. 139.65±41.50 at 24 hours; PaCO 2 (mmHg): 41.30±7.51 vs. 47.42±7.54 at 12 hours, 40.97±6.98 vs. 45.83±8.63 at 18 hours, 40.10±7.06 vs. 46.14±9.15 at 24 hours, all P < 0.01]. The rate of performed mechanical ventilation after weaning and the rate of reintubation after extubation for 72 hours in the high-flow group were significantly lower than those in the Venturi group [17.5% (7/40) vs. 40.5% (15/37), 6.2% (2/32) vs. 31.8% (7/22), both P < 0.05], and the extubation time after weaning was significantly shorter than that in the Venturi group (hours: 22.43±11.72 vs. 28.07±10.42, P < 0.05). Conclusion:Using high-flow oxygen therapy to the extubation process of critically ill mechanical ventilation patients can reduce the incidence of carbon dioxide retention and the rate of performed mechanical ventilation after weaning, shorten the extubation time after weaning, and reduce the rate of reintubation after extubation for 72 hours.
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Objective:To investigate the nurses' attitude towards open visitation policy in intensive care unit (ICU) and its potential influence factors, and further to provide evidence for carrying out this policy in ICU.Methods:A self-designed, anonymous online questionnaire of "attitude of ICU nurses to open visiting system in ICU" was performed in 31 provinces, autonomous regions and municipalities in China from October to December 2019, using convenient sampling method approach. Only nurses working in ICU (including specialized ICU, but excluding the critical ward in general ward) and willing to participate in the survey were included. The survey included 35 items, including the general information of each participant, the attitude towards the implementation of the open visitation system in ICU and its potential influencing factors. Ordinal Logistic regression analysis was used to identify the significant influencing factors.Results:A total of 1 558 questionnaires were sent out and 1 546 effective questionnaires were retrieved, with a response rate of 99.2%. Overall, 32.2% of them agreed with the policy, 41.3% of them disagree with the policy and 26.5% of them were uncertain. The Ordinal Logistic regression analysis showed that the independent influencing factors of ICU nurses' attitude towards open visitation policy including the possibility of increasing healthcare-associated infection [disagree: β = 1.327, 95% confidence interval (95% CI) was 0.242 to 2.413, P = 0.017; uncertain: β = 0.697, 95% CI was 0.244 to 1.151, P = 0.003], the improvement of nurses' job satisfaction (disagree: β = -1.406, 95% CI was -1.750 to -1.062, P = 0.000; uncertain: β = -0.748, 95% CI was -1.030 to -0.466, P = 0.000), the information support for medical staffs from family members (disagree: β = -0.644, 95% CI was -1.048 to -0.240, P = 0.002; uncertain: β = -0.422, 95% CI was -0.721 to -0.124, P = 0.006), the feasibility that the family members can assist the nurses in the basic nursing for patients (uncertain: β = -0.465, 95% CI was -0.729 to -0.202, P = 0.001), reducing the time that a nurse spent on caring for the patients (uncertain: β = 0.349, 95% CI was 0.052 to 0.646, P = 0.021), improving early rehabilitation (disagree: β = -0.593, 95% CI was -1.166 to -0.019, P = 0.043), and getting psychological support for patients from family members (disagree: β = 1.293, 95% CI was 0.426 to 2.159, P = 0.003), family members' satisfaction (disagree: β = -0.981, 95% CI was -1.431 to -0.531, P = 0.000). Conclusion:ICU nurses in China have realized that open visitation policy has positive effect on patients' early rehabilitation, willing to live and satisfaction; meanwhile, this policy may need more improvement in many ways such as healthcare-associated infection control, disinfection and isolation, allocation of human resources and time spent treating and caring for patients.
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Objective@#To investigate the endothelial protective effects of simvastatin on the coagulation system in septic rats.@*Methods@#A total of 54 SD male rats were divided into 3 groups. Six healthy rats were intraperitoneally injected with normal salineas control group. Twenty-four rats in septic group were intraperitoneally injected with normal saline followed by lipopolysaccharide 2.5 mg. Study group had 24 rats intraperitoneally injected with simvastatin followed by lipopolysaccharide. Plasma von Willebrand factor (vWF), thrombomodulin (TM), platelet activating factor (PAF) and antithrombin-Ⅲ (AT-Ⅲ) were tested at 1 h, 3 h, 6 h and 12 h after treatment. Scanning electron microscopy and transmission electron microscopy were used to observe the morphology and apoptosis of rat aorta endothelial cells.@*Results@#Compared with healthy control group, vWF [(68.3±4.8) ng/ml, (59.2±5.1) ng/ml, (74.2±20.1) ng/ml, (53.5±4.0)ng/ml, respectively], TM [(1.4±0.3) ng/ml, (1.6±0.4) ng/ml, (2.8±0.9) ng/ml, (1.4±0.5) ng/ml, respectively], PAF [(29.1±6.5) pg/ml, (28.6±1.5) pg/ml, (28.7±2.7) pg/ml, (18.2±4.1) pg/ml, respectively] and AT-Ⅲ [(262.2±38.1)μg/ml, (233.0±70.4) μg/ml, (218.7±54.7) μg/ml, (162.2±37.2) μg/ml, respectively] were significantly increased in the sepsis group at 1 h, 3 h, 6 h and 12 h (P<0.05). Compared with the sepsis group, the plasma levels of PAF in simvastatin intervention group at 1 h [(15.6±2.5) pg/ml, 3 h(10.4±5.3) pg/ml, 6 h (9.3±1.4) pg/ml, 12 h(11.0±2.7) pg/ml] were significantly decreased, so were the TM level at 6 h (1.6±0.9) ng/ml, and the AT-Ⅲ levels at 1 h[(190.3±29.2) μg/ml],6 h [(104.4±33.6) μg/ml] and 12 h [(73.6±39.0) μg/ml, P<0.05].@*Conclusion@#In the condition of sepsis, toxins and over-activated inflammatory factors damage the vascular endothelium. A large amount of circulating vWF, TM, PAF, and AT-Ⅲ cause early hypercoagulability. Simvastatin significantly reduces plasma amount of these procoagulants, suggesting it smodification of coagulopathy and vascular protective effectsin a septic rat model.
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Aiming at the problem that the small samples of critical disease in clinic may lead to prognostic models with poor performance of overfitting, large prediction error and instability, the long short-term memory transferring algorithm (transLSTM) was proposed. Based on the idea of transfer learning, the algorithm leverages the correlation between diseases to transfer information of different disease prognostic models, constructs the effictive model of target disease of small samples with the aid of large data of related diseases, hence improves the prediction performance and reduces the requirement for target training sample quantity. The transLSTM algorithm firstly uses the related disease samples to pretrain partial model parameters, and then further adjusts the whole network with the target training samples. The testing results on MIMIC-Ⅲ database showed that compared with traditional LSTM classification algorithm, the transLSTM algorithm had 0.02-0.07 higher AUROC and 0.05-0.14 larger AUPRC, while its number of training iterations was only 39%-64% of the traditional algorithm. The results of application on sepsis revealed that the transLSTM model of only 100 training samples had comparable mortality prediction performance to the traditional model of 250 training samples. In small sample situations, the transLSTM algorithm has significant advantages with higher prediciton accuracy and faster training speed. It realizes the application of transfer learning in the prognostic model of critical disease with small samples.
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Objective:To investigate the value of programmed death-1（PD-1） expression on the T lymphocytes for the prognosis of septic patients.Methods:From September 2017 to May 2019, septic patients were included in Department of Intensive Care Unit at 6 hospitals. The PD-1 expression on T cells were measured by flow cytometry. Logistic regression was conducted to analyze independent risk factors related to death within 28 days，and receiver operating characteristic curve(ROC) was conducted to evaluate the prognostic value of PD-1 expression on T cells in septic patients.Results:A total of 64 septic patients were enrolled to this study，including 32 survivors and 32 deaths. The PD-1 expression on T cells in the death group was significantly higher than that in the surviving group ( P<0.05). Correlation analysis showed that the percentages of PD-1 +/CD3 +T cells and PD-1 +/CD8 +T cells were positively correlated with procalciton in ( r=0.313, P =0.015； r=0.375, P=0.003), logistic regression analysis showed that the percentages of PD-1 +/CD3 +，PD-1 +/CD4 +，PD-1 +/CD8 +T cells were independent risk factors for the death of sepsis patients. The percentage of PD-1 +/CD3 +T cell was 3.63%, with AUC 0.842, sensitivity to predict the mortality 96.43% and specificity 59.38%, ( P<0.000 1). The percentage of PD-1 +/CD4 +T cell was 4.65%, with AUC 0.847, sensitivity 96.43%, specificity 62.50%，( P<0.000 1). The percentage of PD-1 +/CD8 +T cell was 3.91%, with AUC 0.771, sensitivity 64.29%, specificity 81.25%，( P=0.000 3). Conclusions:The T cell PD-1 expression is an independent risk factor to predict the 28-day mortality in septic patients. Combining the proportions of PD-1 +/CD3 +, PD-1 +/CD4 +and PD-1 +/CD8 +T cells may further enhance the predictive value for death.
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Objective:To investigate the endothelial protective effects of simvastatin on the coagulation system in septic rats.Methods:A total of 54 SD male rats were divided into 3 groups. Six healthy rats were intraperitoneally injected with normal salineas control group. Twenty-four rats in septic group were intraperitoneally injected with normal saline followed by lipopolysaccharide 2.5 mg. Study group had 24 rats intraperitoneally injected with simvastatin followed by lipopolysaccharide. Plasma von Willebrand factor (vWF), thrombomodulin (TM), platelet activating factor (PAF) and antithrombin-Ⅲ (AT-Ⅲ) were tested at 1 h, 3 h, 6 h and 12 h after treatment. Scanning electron microscopy and transmission electron microscopy were used to observe the morphology and apoptosis of rat aorta endothelial cells.Results:Compared with healthy control group, vWF [(68.3±4.8) ng/ml, (59.2±5.1) ng/ml, (74.2±20.1) ng/ml, (53.5±4.0)ng/ml, respectively], TM [(1.4±0.3) ng/ml, (1.6±0.4) ng/ml, (2.8±0.9) ng/ml, (1.4±0.5) ng/ml, respectively], PAF [(29.1±6.5) pg/ml, (28.6±1.5) pg/ml, (28.7±2.7) pg/ml, (18.2±4.1) pg/ml, respectively] and AT-Ⅲ [(262.2±38.1)μg/ml, (233.0±70.4) μg/ml, (218.7±54.7) μg/ml, (162.2±37.2) μg/ml, respectively] were significantly increased in the sepsis group at 1 h, 3 h, 6 h and 12 h ( P<0.05). Compared with the sepsis group, the plasma levels of PAF in simvastatin intervention group at 1 h [(15.6±2.5) pg/ml, 3 h(10.4±5.3) pg/ml, 6 h (9.3±1.4) pg/ml, 12 h(11.0±2.7) pg/ml] were significantly decreased, so were the TM level at 6 h (1.6±0.9) ng/ml, and the AT-Ⅲ levels at 1 h[(190.3±29.2) μg/ml],6 h [(104.4±33.6) μg/ml] and 12 h [(73.6±39.0) μg/ml, P<0.05]. Conclusion:In the condition of sepsis, toxins and over-activated inflammatory factors damage the vascular endothelium. A large amount of circulating vWF, TM, PAF, and AT-Ⅲ cause early hypercoagulability. Simvastatin significantly reduces plasma amount of these procoagulants, suggesting it smodification of coagulopathy and vascular protective effectsin a septic rat model.
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Objective@#To evaluate the application of heparin-binding protein (HBP) in diagnosis of sepsis in adult patients.@*Methods@#An extensive search for the Chinese and English literatures from the PubMed, Embase, the Cochrane Library, Wanfang data, CNKI and VIP up to July 2019 was performed. The articles regarding HBP for the diagnosing of sepsis in adult patients were enrolled. Two researchers independently extracted related literature. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-Disc 1.4 and STATA 12.0 were used for Meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated. Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to evaluate the diagnostic performance of HBP for sepsis. Deek funnel plot was used to detect publication bias.@*Results@#A total of 10 studies with 1 884 patients were included in this Meta-analysis. The quality of the literature was relatively moderate. HBP in plasma were detected by enzyme linked immunosorbent assay (ELISA) in all studies. The studies showed substantial heterogeneity, and random effect model was used for Meta-analysis. The pooled sensitivity, specificity, PLR, NLR, and DOR were 0.80 [95% confidence interval (95%CI) was 0.77-0.83], 0.80 (95%CI was 0.78-0.82), 3.96 (95%CI was 2.45-6.41), 0.28 (95%CI was 0.20-0.39) and 14.63 (95%CI was 6.83-31.30) respectively. The pooled AUC was 0.86 and the Cochran-Q was 0.79. To explore the potential sources of heterogeneity, subgroup analyses were performed based on the severity of the disease, diagnostic criteria and region. However, the results indicated that no methodological covariates affected the diagnostic accuracy of HBP, indicating that there was still unexplained heterogeneity. In addition, the sensitivity analysis by removing individual studies were performed. No outlier study was identified and the results were relatively stable and reliable. Deek funnel plot showed little publication bias.@*Conclusions@#There is preferable value of HBP for diagnosis of sepsis in adult patients. However, it needs to be further confirmed by large multicenter studies.
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Objective To understand the internal circuit contamination of ventilator in mechanical ventilation patients, to evaluate the effect of ventilator internal circuit disinfection and the impact on the incidence of ventilator-associated pneumonia (VAP). Methods A total of 39 patients with mechanical ventilation admitted to intensive care unit (ICU) of Hangzhou Geriatric Hospital from January 2017 to June 2018 were enrolled. Routine mechanical ventilation treatments for patients included pipeline replacement, aseptic operation, prevention of infection, etc. After 2 weeks of mechanical ventilation, the internal circuit of the ventilator was disinfected using the internal circuit sterilizer of the ventilator. Microorganism sampling and detection at 3 cm to the exhalation port of the internal circuit of the ventilator was performed before and after disinfection. The number of colonies was < 5 cfu/cm2 and no pathogenic bacteria could be detected. During the observation period, if the patient was complicated by VAP for anti-infective treatment, the ventilator with internal loop disinfection was replaced after infection control, and was incorporated again into the group for observation. The number of microbial colonies in the internal circuit of the ventilator before and after disinfection, the microbiological test pass rate and the incidences of VAP during the 2 weeks were observed. Results All 39 patients were included in the analysis, with 23 male and 16 female; with age of 65-97 years old, average (78.7±7.6) years old. Before the disinfection, 9 604 strains were detected in the internal circuit of the ventilator, including 8 687 strains of Gram-negative bacilli (90.4%), 902 strains of Gram-positive cocci (9.4%), and 15 strains of fungi (0.2%), which were detected in the lower respiratory tract of the patients. The strain concordance rate was 41%. The qualified rate of microbial detection in the internal circuit of the ventilator was 5.1%; 13 cases (33.3%) of VAP occurred during 2 weeks of mechanical ventilation. After disinfection, 785 strains of pathogens were detected in the internal circuit of the ventilator, and the number of colonies was significantly reduced compared with that before disinfection [cfu/cm2: 0 (0, 20) vs. 150 (15, 500), P < 0.01], of which 688 strains of Gram-negative bacilli (87.7%), 92 strains of Gram-positive cocci (11.7%) and 5 strains of fungi (0.6%) were found; the qualified rate of microbial detection in the internal circuit of ventilator reached 71.8%, which was significantly higher than that before disinfection (P < 0.01); 2 weeks after mechanical ventilation the incidence of VAP decreased slightly during the period [20.5% (8/39) vs. 33.3% (13/39)], but there was no significant difference (P > 0.05). Conclusions The internal circuit of the ventilator can be used to detect the pathogen and the sputum culture of the patients on mechanical ventilation with a high consistency. The disinfection of the pathogen could significantly reduce the air pollution of the ventilator and reduce the occurrence of VAP in the patients.
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Objective To evaluate the application of heparin-binding protein (HBP) in diagnosis of sepsis in adult patients. Methods An extensive search for the Chinese and English literatures from the PubMed, Embase, the Cochrane Library, Wanfang data, CNKI and VIP up to July 2019 was performed. The articles regarding HBP for the diagnosing of sepsis in adult patients were enrolled. Two researchers independently extracted related literature. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-Disc 1.4 and STATA 12.0 were used for Meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated. Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to evaluate the diagnostic performance of HBP for sepsis. Deek funnel plot was used to detect publication bias. Results A total of 10 studies with 1 884 patients were included in this Meta-analysis. The quality of the literature was relatively moderate. HBP in plasma were detected by enzyme linked immunosorbent assay (ELISA) in all studies. The studies showed substantial heterogeneity, and random effect model was used for Meta-analysis. The pooled sensitivity, specificity, PLR, NLR, and DOR were 0.80 [95% confidence interval (95%CI) was 0.77-0.83], 0.80 (95%CI was 0.78-0.82), 3.96 (95%CI was 2.45-6.41), 0.28 (95%CI was 0.20-0.39) and 14.63 (95%CI was 6.83-31.30) respectively. The pooled AUC was 0.86 and the Cochran-Q was 0.79. To explore the potential sources of heterogeneity, subgroup analyses were performed based on the severity of the disease, diagnostic criteria and region. However, the results indicated that no methodological covariates affected the diagnostic accuracy of HBP, indicating that there was still unexplained heterogeneity. In addition, the sensitivity analysis by removing individual studies were performed. No outlier study was identified and the results were relatively stable and reliable. Deek funnel plot showed little publication bias. Conclusions There is preferable value of HBP for diagnosis of sepsis in adult patients. However, it needs to be further confirmed by large multicenter studies.
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Objective To evaluate the application of heparin-binding protein (HBP) in diagnosis of sepsis in adult patients. Methods An extensive search for the Chinese and English literatures from the PubMed, Embase, the Cochrane Library, Wanfang data, CNKI and VIP up to July 2019 was performed. The articles regarding HBP for the diagnosing of sepsis in adult patients were enrolled. Two researchers independently extracted related literature. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-Disc 1.4 and STATA 12.0 were used for Meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated. Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to evaluate the diagnostic performance of HBP for sepsis. Deek funnel plot was used to detect publication bias. Results A total of 10 studies with 1 884 patients were included in this Meta-analysis. The quality of the literature was relatively moderate. HBP in plasma were detected by enzyme linked immunosorbent assay (ELISA) in all studies. The studies showed substantial heterogeneity, and random effect model was used for Meta-analysis. The pooled sensitivity, specificity, PLR, NLR, and DOR were 0.80 [95% confidence interval (95%CI) was 0.77-0.83], 0.80 (95%CI was 0.78-0.82), 3.96 (95%CI was 2.45-6.41), 0.28 (95%CI was 0.20-0.39) and 14.63 (95%CI was 6.83-31.30) respectively. The pooled AUC was 0.86 and the Cochran-Q was 0.79. To explore the potential sources of heterogeneity, subgroup analyses were performed based on the severity of the disease, diagnostic criteria and region. However, the results indicated that no methodological covariates affected the diagnostic accuracy of HBP, indicating that there was still unexplained heterogeneity. In addition, the sensitivity analysis by removing individual studies were performed. No outlier study was identified and the results were relatively stable and reliable. Deek funnel plot showed little publication bias. Conclusions There is preferable value of HBP for diagnosis of sepsis in adult patients. However, it needs to be further confirmed by large multicenter studies.
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Objective To systematically evaluate the effects of left ventricular global longitudinal strain (GLS) determined by two dimensional speckle tracking imaging technology (2D-STI) and left ventricular ejection fraction (LVEF) on the prognosis of patients with sepsis/septic shock.Methods Databases such as the National Library of Medicine PubMed database, Dutch medical abstracts Embase, Cochrane Library, Netherlands Elsevier, Springer and China biomedical literature database (CBMdisc), China National Knowledge Internet (CNKI), Wanfang database, China science and technology journal full-text database, Vip Chinese biomedical journal database were searched from the establishment of literature database to April 2018 to study GLS, LVEF and their relationships with mortality of septic/septic shock patients. The literatures screening and data collecting were independently conducted by two researchers, and the quality of the included literature was evaluated. The sensitivity and heterogeneity analysis were performed with RevMan 5.3 software, and the combined effects were calculated. Funnel plot was used to evaluate publication bias.Results A total of 6 articles including 5 English articles and 1 Chinese article were enrolled. There were 503 patients, 333 in the survival group and 170 in the death group. The quality of the literature was high, and the Newcastle-Ottawa scale (NOS) score was 8-9. Meta-analysis showed that short-term mortality was associated with higher GLS in patients with sepsis/septic shock [standardized mean difference (SMD) = -0.47, 95％ confidence interval (95％CI) = -0.76 to -0.18, Z = 3.16,P = 0.002], and there was no significant difference in LVEF between the survival group and the death group (SMD = 0.18, 95％CI = -0.03-0.39,Z = 1.64, P = 0.10). Sensitivity analysis was carried out for each effect index by removing each document one by one, and the results showed that there was no significant change in the combined effect before and after each document, indicating that the results were stable. The funnel plot showed that the effect points of each literature were roughly in the form of "inverted funnels" with a large symmetric distribution centered on the combined effect, but the number of studies included in this study was too small, so the publication bias could not be completely excluded.Conclusion Compared with LVEF, GLS might be a more sensitive indicator for detecting myocardial dysfunction in patients with sepsis/septic shock and might have important predictive value for short-term mortality.
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Objective To establish a severe sepsis/septic shock prognosis prediction model based on randomize forest law (RF model), and to evaluate the prognostic value of this model for patients with severe sepsis/septic shock. Methods 497 patients with severe sepsis/septic shock admitted to intensive care unit (ICU) of Zhejiang Hospital from September 2013 to May 2017 were enrolled. The basic data, vital signs and symptoms, biochemical indexes and blood routine indexes on the 1st, 3rd, 5th day and prognosis were collected. According to the 28-day prognosis, the patients were divided into death group and survival group, and the specific indicators about the prognosis of severe sepsis/septic shock were screened. A RF model was constructed by using the specificity indicators. The assessment effectiveness of RF model, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) were evaluated by receiver operating characteristic (ROC) curve analysis. Results In 497 cases of severe sepsis/septic shock, 201 cases died, 28-day mortality was 40.4%. ① According to the index difference of death group and survival group, 19 specific parameters of the RF model were selected, which included the age; 24-hour urine output, urea nitrogen (BUN), serum creatinine (SCr), platelet count (PLT) on the 1st day; heart rate (HR), mean arterial pressure (MAP), cyanosis and clammy skin on the 3rd day; temperature, HR, MAP, 24-hour urine output, PLT, fever, cyanosis, dyspneic, clammy skin, piebald on the 5th day. ② ROC curve analysis showed that the area under the ROC curve (AUC) of RF model predicting 28-day mortality was higher than that of SOFA and APACHE Ⅱ score on the 1st, 3rd, 5th day (AUC: 0.836 vs. 0.643, 0.554, 0.766 and 0.590, 0.670, 0.758). The sensitivity of RF model to predict the 28-day mortality was 86.1%, the specificity was 77.0%, the accuracy was 80.7%. Conclusion The evaluation model based on random forest can effectively predict the death risk of 28-day in patients with severe sepsis/septic shock, and its predictive efficiency is better than that of the SOFA and APACHE Ⅱ score.
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Objective To approach the effect of ulinastatin (UTI) on protection of vascular endothelial cells in rats with sepsis and its mechanism.Methods Fifty-two Sprague-Dawley (SD) male rats were randomly divided into a normal saline pretreatment group (control group) and a UTI pretreatment group (UTI group), each groupn = 26. The rats in two groups were given lipopolysaccharide (LPS, 10 mg/kg) intra-peritoneal injection for the establishment of rat septic models. In UTI group, 18 hours before LPS injection, intraperitoneal injection of UTI 100 kU/kg dissolved in 5 mL normal saline was given, while in the control group, 3 hours before LPS injection, intraperitoneal injection of 5 mL normal saline was given to the rats for pretreatment. Respectively, at 0.5, 2, 4, 12, 24, 72 hours after model establishment, tail venous blood and myocardial tissue were taken. The levels of tumor necrosis factor-α (TNF-α), interleukins (IL-6, IL-10), vascular cell adhesion molecule (VCAM) and intercellular adhesion molecule-1 (ICAM-1) were detected by enzyme-linked immunosorbent assay (ELISA); the correlation between TNF-α and ICAM-1 was analyzed; the expression of ICAM-1 in myocardial cell was determined by immunohistochemistry.Results After model establishment, the levels of TNF-α, IL-6, IL-10, ICAM and VCAM in two groups were gradually increased, reaching the peaks at 24, 12, 12, 72, 72 hours, respectively. Compared with control group, the levels of TNF-α, IL-6, ICAM-1, VCAM of UTI group were significantly lower at various time points [24 hours TNF-α (ng/L): 119.8±28.9 vs. 190.2±30.4, 12 hours IL-6 (ng/L): 327.8±26.9 vs. 948.7±63.8, 72 hours VCAM (ng/L): 36.3±3.2 vs. 68.8±2.4, 72 hours ICAM-1 (ng/L): 115.6±11.6 vs. 129.4±8.2,P < 0.05 orP < 0.01], IL-10 was significantly increased [12 hours (ng/L): 80.7±1.9 vs. 42.3±4.9,P < 0.01]. TNF-αwas positively correlated to ICAM significantly (UTI group:r = 0.907,P = 0.050; control group:r = 0.961, P = 0.010). Immunohistochemistry showed that after modeling for 0.5 hour, basically no positive expression of ICAM-1 in myocardial cells was found in the two groups; in the control group, at 12 hours the positive expression of ICAM-1 was increased, and in UTI group, a little expression of ICAM-1 was seen; at 72 hours, the expression of ICAM-1 was significantly increased in both groups.Conclusion UTI can protect the function of endothelial cells in rats with sepsis by regulating the expressions of proinflammatory cytokine, anti-inflammatory cytokine, adhesion molecules, and improving the microvascular permeability.
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Objective To investigate whether early goal-directed therapy ( EGDT ) could lower the mortality rate in patients with severe sepsis and septic shock. Methods Articles with items sepsis, severe sepsis, septic shock, EGDT were retrieved from MEDLINE, EMBASE, Cochrane, Wanfang Data and CNKI. Inclusion criteria included randomized controlled trial, subjects concerning patients with severe sepsis or septic shock, endpoints with short-term mortality [ in-hospital, intensive care unit ( ICU ) or 28-day ] and long-term mortality ( 60-day or 90-day ). Related risk ( RR ) and 95% confidence interval ( 95%CI ) were used as indices to judge the difference in mortality rate between EGDT group and standard treatment group. RevMan 5.2 software was used for Meta analysis. Results There were 8 studies meeting inclusive criteria with a total of 4 853 patients. For patients with severe sepsis and septic shock, compared with the group with routine treatment, EGDT showed a decrease in the short-term mortality ( RR = 0.74, 95%CI=0.66-0.82, P<0.000 01 ), but did not decrease the long-term mortality ( RR=0.99, 95%CI=0.92-1.06, P=0.81 ). Conclusion EGDT strategy may decrease the short-term mortality in patients with severe sepsis and septic shock, but it showed no influence on the long-term mortality.
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<p><b>BACKGROUND</b>Few studies have reported the effect of different volume responsiveness evaluation methods on volume therapy results and prognosis. This study was carried out to investigate the effect of two volume responsiveness evaluation methods, stroke volume variation (SVV) and stroke volume changes before and after passive leg raising (PLR-ΔSV), on fluid resuscitation and prognosis in septic shock patients.</p><p><b>METHODS</b>Septic shock patients admitted to the Department of Critical Care Medicine of Zhejiang Hospital, China, from March 2011 to March 2013, who were under controlled ventilation and without arrhythmia, were studied. Patients were randomly assigned to the SVV group or the PLR-ΔSV group. The SVV group used the Pulse Indication Continuous Cardiac Output monitoring of SVV, and responsiveness was defined as SVV ≥12%. The PLR-ΔSV group used ΔSV before and after PLR as the indicator, and responsiveness was defined as ΔSV ≥15%. Six hours after fluid resuscitation, changes in tissue perfusion indicators (lactate, lactate clearance rate, central venous oxygen saturation (SCVO2), base excess (BE)), organ function indicators (white blood cell count, neutrophil percentage, platelet count, total protein, albumin, alanine aminotransferase, total and direct bilirubin, blood urea nitrogen, serum creatinine, serum creatine kinase, oxygenation index), fluid balance (6- and 24-hour fluid input) and the use of cardiotonic drugs (dobutamine), prognostic indicators (the time and rate of achieving early goal-directed therapy (EGDT) standards, duration of mechanical ventilation and intensive care unit stay, and 28- day mortality) were observed.</p><p><b>RESULTS</b>Six hours after fluid resuscitation, there were no significant differences in temperature, heart rate, blood pressure, SpO2, organ function indicators, or tissue perfusion indicators between the two groups (P > 0.05). The 6- and 24-hour fluid input was slightly less in the SVV group than in the PLR-ΔSV group, but the difference was not statistically significant (P > 0.05). The SVV group used significantly more dobutamine than the PLR-ΔSV group (33.3% vs. 10.7%, P = 0.039). There were no significant differences in the time ((4.8±1.4) h vs. (4.3±1.3) h, P = 0.142) and rate of achieving EGDT standards (90.0% vs. 92.9%, P = 0.698), or in the length of mechanical ventilation and ICU stay. The 28-day mortality in the SVV group (16.7% (5/30)) was slightly higher than the PLR-?SV group (14.3% (4/28)), but the difference was not statistically significant (P = 0.788).</p><p><b>CONCLUSIONS</b>In septic shock patients under controlled ventilation and without arrhythmia, using SVV or PLR-ΔSV methods to evaluate volume responsiveness has a similar effect on volume therapy results and prognosis. The evaluation and dynamic monitoring of volume responsiveness is more important for fluid resuscitation than the evaluation methods themselves. Choosing different methods to evaluate volume responsiveness has no significant influence on the effect of volume therapy and prognosis.</p>
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Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hidratação , Monitorização Fisiológica , Métodos , Choque Séptico , Patologia , Terapêutica , Volume Sistólico , FisiologiaRESUMO
Objective To investigate the effects of ω-3 fish oil lipid emulsion via vein on the inflammatory response,immune and organ function in patients with severe acute pancreatitis.Methods A total of 53 patients with severe acute pancreatitis were randomized into conventional therapy plus fish oil group (FO group) and conventional therapy group (CON group).The patients in FO group were treat with ω-3 fish oil lipid emulsion (0.2 g · kg-1 · d-1,10％) based on conventional therapy for 14 days.The level of C-reactive protein (CRP),TG and TC were detected before treatment and at day 7 and day 14 after treatment.CD4+,CD4+/CD8+ and C3,C4 were also detected at day 1 and day 14 after treatment.At the same time,acute physiology and chronic health evaluation Ⅱ score (APACHE Ⅱ score),intra-abdominal pressure,negative fluid balance time,enteral nutrition start-time and ICU stay time were observed and recorded.Results Forty-five out of 53 patients were finally recruited into results statistics.The level of CD4+,CD4+/CD8+ and C3 at day 14 after treatment in FO groups improved significantly than that in the CON group (P ＜0.05).The levels of CRP,intra-abdominal pressure and APACHE Ⅱ score at day 7 and day 14in FO group descended more obviously than that in the CON group (P ＜ 0.05).The negative liquid balance time in FO group (3.55 ±0.86) days was obvious shorter than that in CON group (4.61 ± 1.12) days,while enteral nutrition start-time (3.86 ± 1.17) days was significantly earlier compared with CON group (5.30 ± 1.61) days (P ＜ 0.05),however ICU stay time and 28 days mortality rate had no significant difference between the two groups.Conclusions ω-3 fish oil lipid emulsion can decrease the inflammatory response and the negative liquid balance time,improve the immune function and restore bowel function in severe acute pancreatitis patients.Therefore,it maybe provide a new and effective means for severe acute pancreatitis.
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Objective To investigate the clinical values of central venous pressure (CVP) versus stroke volume variation (SVV) in patients with severe sepsis after early goal-directed therapy (EGDT).Methods Totally 30 mechanically ventilated patients with severe sepsis who underwent goal-achieved EGDT were enrolled and randomly divided into CVP group (study group) and SVV group (control group) according to the data detected by pulse contour continuous cardiac output (PiCCO) analysis device.The differences in 28-day survival,3-day APACHE Ⅱ score,time of ICU stay,duration of mechanical ventilation,number that need CRRT,entral venous pressure (CVP),heart end-diastolic volume index (GEDVI),intrathoracic blood volume index (ITBVI),extravascular lung water index (EVLWI),cardiac index (CI),central venous oxygen saturation (ScvO2),lactate clearance rate and APACHE Ⅱ score were compared between the 2 groups.Results The death rate had no difference between the 2 groups(x2=0.240,P=0.624).Among survival patients in the CVP group,the time of ICU stay and duration of mechanical ventilation were shorter in study group than in control group(t=2.166,P=0.041;t=2.104,P=0.046),APACHE Ⅱ score at 3th day was decreased(t=2.20,P =0.038).The values of ITBVI,GEDVI,CI,lactate clearance rate were higher in study group than in control group (t=2.759,2.146,2.199,2.654,3.362,P=0.011,0.043,0.038,0.014,0.003).EVLWI and APACHE Ⅱ score were not different (P＞0.05) between the two groups.Conclusions SVV as a recovery target for fluid resuscitation can reach a better recovery results and improvement of prognosis than CVP goal-achieved EGDT.
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Objective To investigate the role of damaged mitochondria in cardiac cell apoptosis in septic rats and the possible mechanism involved.Methods Seventy-two Sprague-Dawley rats were randomly (random number) divided into negative control group (n =18) and septic group (further divided into three groups as per rats sacrificed 6 h,12 h,and 24 h after endotoxin injection intra-peritoneally,n =18).The hearts of rats were taken.The changes of cardiac morphology were observed under light microscope and scanning electron microscope.Cell apoptosis in situ were examined by using terminal transferase-mediated dUTP nick end-labeling assay and nuclear factor-kappa B (NF-κB) activation in myocardium was detected by using Western blotting to estimate myocardial cell apoptosis.Mitochondrial lipid and protein oxidation were measured to assess oxidative stress,and mitochondrial superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities were determined to estimate antioxidant defense.Results Septic induced inflammatory cells infiltration,myocardium degeneration and effusion in a time-dependent manner.A remarkable expansion of capillaries could be observed in the hearts of infected rats at post-challenge of 24 h.Compared with sham-treated rats,the percentage of apoptosis increased in a time-dependent manner in the hearts of infected rats at 6 h,12 h,24 h of post-injection (P ＜0.05).The concentration of NF-κB p65 in the cytosol decreased gradually and increased in the nucleus during sepsis in a time-dependent manner (P ＜0.05),indicating that septic challenge provoked progressive activation of NF-κB.Mitochondrial cristae disappeared in 6 h of challenge,and significant mitochondrial cristae disappearance,vacuolization,and rupture of mitochondria membrane became markedly obvious 12 and 24 h later.Both SOD and GPx activities decreased,while mitochondrial lipid and protein oxidation increased in a time-dependent manner after 6-24 h of challenge (P ＜ 0.05).Conclusions Septic challenge induced myocardial apoptosis and mitochondrial damage.Further,damaged mitochondria might play an important role by means of alteration of defenses against reactive oxygen species in myocardial cell apoptosis during sepsis.
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Objective To investigate the prognostic value of stroke volume variation (SVV) in patients with severe sepsis after early goal-directed therapy (EGDT). Method Thirty-eight mechanically ventilated patients with severe sepsis underwent EGTD were divided into high SVV (≥10%) group and low SW (< 10%) group according to the data obtained from pulse contour continuous cardiac output (PiCCO) analysis device. The differ-enees in the rate of 28-day survival, length of ICU stay, duration of meehanical ventilation and eomplieation of in-fection between two groups of patients were compared. The rate of 28-day survival of patients was analyzed by using Kaplain-Meier survival analysis, and the relationship between SVV and mortality within 28 days was analyzed by using logistic regression model. Results In comparison with low SVV group, the rate of 28-day survival of high SVV group was signifieantly increased (87.5 % vs. 57.1%, P = 0.032), the length of ICU stay was significantly shortened (27.1±9.2) vs. (41.6±10.0) (P = 0. 004) and duration of mechanical ventilation was significantly more brief (20.4±7.3) vs. (28.5±8.3) (P = 0.038). The rate of cumulative survival of patients in high SVV group was higher than that in low SVV group. In addition, logistie analysis showed SW < 10% increased the risk of 28-day mortality (OR = 3.97; 95% CI 1.63 - 9.21, P = 0. 014). Conclusions The SVV can be served as a prognostic indicator in patients with severe sepsis after EGDT.
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Objective To explore the significance of the plasma procalcitonin (PCT) level for directing antibiotic therapy in elderly patients with ventilator-associated pneumonia (VAP).Methods The 50 elderly patients with VAP were randomly separated into the regular therapy group and the PCT-directed therapy group. The regular therapy group was given regular antibiotic therapy, while the antibiotic therapy was decided according to the plasma level of PCT in the PCT-directed therapy group. The used time and utilization rate of antibiotics, as well as inflammatory indicators including white blood cells, neutrophils, C-reactive protein (CRP) and clinical pulmonary infection score (CPIS) were compared between the two groups. Results After treatment, there were no significant differences in white blood cells, neutrophils and CRP between the PCT-directed therapy group and regular therapy group [(8.9 ± 3.5 ) × 109/L vs. (9.4 ± 3.7) × 109/L, 0.62 ± 0.04 vs.0.60±0.04, (18.7±8.5) mg/Lvs. (21.6±6.0) mg/L, t=0.47, 1.84 and 1.37, allP＞0.05],but the CPIS was markedly lower in PCT-directed therapy group than in regular therapy group [(4.0± 1.4) scores vs. (4.7± 1.0) scores, t= 2. 18, P＜0.05]. The neutrophils, CRP and CPIS were significantly lower after treatment than before in the both groups. The concentration of PCT was decreased after treatment than before [(0.5 ± 0.9) mg/L vs. (1.7 ± 0.7) mg/L]. Meanwhile, the time using antibiotics was longer in regular treatment group than in PCT-directed therapy group [(8.72±1.32) d vs. (5.17±0.72) d, t=11.96, P＜0.01], the utilization rate of antibiotics was higher (95.2 % vs. 55.2 %, χ2 = 12.41, P＜0.01) in regular treatment group. Conclusions Using PCT levels for directing treatment in elderly patients with VAP can achieve better curative effect and reduce the use of antibiotics.
