RESUMO
BACKGROUND & AIMS: The evolution and clinical significance of abnormal liver chemistries and the impact of hepatitis B infection on outcome in patients with COVID-19 is not well characterized. This study aimed to explore these issues. METHODS: This large retrospective cohort study included 2,073 patients with coronavirus disease 2019 (COVID-19) and definite outcomes in Wuhan, China. Longitudinal liver function tests were conducted, with associated factors and risk of death determined by multivariate regression analyses. A prognostic nomogram was formulated to predict the survival of patients with COVID-19. The characteristics of liver abnormalities and outcomes of patients with COVID-19, with and without hepatitis B, were compared after 1:3 propensity score matching. RESULTS: Of the 2,073 patients, 1,282 (61.8%) had abnormal liver chemistries during hospitalization, and 297 (14.3%) had a liver injury. The mean levels of aspartate aminotransferase (AST) and direct bilirubin (D-Bil) increased early after symptom onset in deceased patients and showed disparity compared to levels in discharged patients throughout the clinical course of the disease. Abnormal AST (adjusted hazard ratio [HR] 1.39; 95% CI 1.04-1.86, p = 0.027) and D-Bil (adjusted HR 1.66; 95% CI 1.22-2.26; p = 0.001) levels at admission were independent risk factors for mortality due to COVID-19. A nomogram was established based on the results of multivariate analysis and showed sufficient discriminatory power and good consistency between the prediction and the observation. HBV infection in patients did not increase the risk of poor COVID-19-associated outcomes. CONCLUSIONS: Abnormal AST and D-Bil levels at admission were independent predictors of COVID-19-related mortality. Therefore, monitoring liver chemistries, especially AST and D-Bil levels, is necessary in hospitalized patients with COVID-19. LAY SUMMARY: Liver test abnormalities (in particular elevations in the levels of aspartate aminotransferase [AST] and direct bilirubin [D-Bil]) were observed after symptom onset in patients who went on to die of coronavirus disease 2019 (COVID-19). Abnormal levels of AST and D-Bil at admission were independent predictors of COVID-19-related mortality. HBV infection in patients did not increase the risk of poor COVID-19-associated outcomes.
Assuntos
Aspartato Aminotransferases/sangue , Bilirrubina/sangue , COVID-19/mortalidade , Mortalidade Hospitalar , Hepatopatias/complicações , SARS-CoV-2 , Idoso , Feminino , Hepatite B/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos RetrospectivosRESUMO
BACKGROUND: This study examined the feasibility of transabdominal intestinal ultrasonography in evaluating acute gastrointestinal injury (AGI). METHODS: A total of 116 patients were included. Intestinal ultrasonography was conducted daily within 1 week after admission to the intensive care unit. Ultrasonography indicators including intestinal diameter, changes in the intestinal folds, thickness of the intestinal wall, stratification of the intestinal wall, and intestinal peristalsis (movement of the intestinal contents) were observed to determine the acute gastrointestinal injury ultrasonography (AGIUS) score. The gastrointestinal and urinary tract sonography ultrasound (GUTS) protocol score was also calculated. During the first week of the study, the gastrointestinal failure (GIF) score was determined daily. The correlations between transabdominal intestinal scores (AGIUS and GUTS) and the GIF score were analyzed to clarify the feasibility of evaluating AGI through observation of the intestine. The utility of intestinal ultrasonography indicators in predicting feeding intolerance was investigated to improve the ability of clinicians to manage AGI. RESULTS: A total of 751 ultrasonic examinations were performed with 511 images (68%) considered to be of "good quality." AGIUS and GUTS scores differed significantly between AGI patients (GIF score 0-2) and non-AGI patients (GIF score 3-4) (p < 0.001). Both scores correlated positively with GIF score (r = 0.54, p < 0.001; r = 0.66, p < 0.001). These ultrasonography indicators could predict feeding intolerance, with an area under the receiver operating characteristic curve of 0.60 (0.48-0.71; intestinal diameter), 0.76 (0.67-0.85; intestinal folds), 0.71 (0.62-0.80; wall thickness), 0.77 (0.69-0.86; wall stratification), and 0.78 (0.68-0.88; intestinal peristalsis). Compared to patients with a normal rate of peristalsis (5-10/min), patients with abnormal peristalsis rates (< 5/min or > 10/min) have increased risk for feeding intolerance (16/83 vs. 25/33, p < 0.001). CONCLUSIONS: The transabdominal intestinal ultrasonography represents an effective means for assessing gastrointestinal injury in critically ill patients. Intestinal ultrasonography indicators, especially the degree of intestinal peristalsis, may be used to predict feeding intolerance. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03589248. Registered 04 July 2018-retrospectively registered.
Assuntos
Traumatismos Abdominais/classificação , Trato Gastrointestinal/diagnóstico por imagem , Valor Preditivo dos Testes , Ultrassonografia/normas , APACHE , Traumatismos Abdominais/diagnóstico , Adulto , Idoso , China , Estado Terminal/terapia , Feminino , Trato Gastrointestinal/fisiopatologia , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Prospectivos , Curva ROC , Ultrassonografia/métodos , Ultrassonografia/estatística & dados numéricosRESUMO
BACKGROUND: It has been reported that lipid-rich enteral nutrition (EN) could ameliorate inflammation in various diseases. In this study, we investigated whether lipid-rich EN could control intestinal inflammation, improve intestinal motility and mucosal barrier injury after intestinal ischemia/reperfusion (I/R) injury. METHODS: Male adult rats received saline, conventional EN, or lipid-rich EN via gavage before and after intestinal I/R injury. The superior mesenteric artery was occluded for 60 min. The sham group underwent laparotomy without superior mesenteric artery occlusion and was administrated saline. Intestinal motility was measured 4 h after intestinal I/R injury by fluorescein isothiocyanate-dextran transit assay; the intestinal and systemic inflammation were assessed by analyzing intestinal and serum concentrations of tumor necrosis factor α, interleukin (IL)- 6, and IL-10, separately. The intestinal mucosal barrier injury was assessed by analyzing the serum levels of intestinal fatty acid-binding protein (I-FABP) and intestinal mucosal tight junction (TJ) proteins. RESULTS: The intestinal I/R injury decreased intestinal motility and intestinal mucosal TJs expression significantly when compared with the sham group (P < 0.05). The intestinal and systemic inflammatory parameters and the serum I-FABP were also significantly higher in the I/R groups than those in the sham group (P < 0.05). Both conventional and lipid-rich EN increased the intestinal motility and the intestinal mucosal TJs expression and decreased the intestinal and systemic inflammatory parameter and serum I-FABP levels to different degrees when compared with the I/R group (P < 0.05). However, lipid-rich EN significantly improved the negative alterations in these biochemical parameters when compared with the conventional EN (P < 0.05). CONCLUSIONS: These results suggest that lipid-rich EN might be able to control intestinal inflammation, improve intestinal motility and mucosal barrier injury after intestinal I/R injury. Thus, the administration of lipid-rich EN may be an effective treatment for promoting gastrointestinal function recovery after intestinal I/R injury.
Assuntos
Nutrição Enteral/métodos , Alimentos Formulados , Motilidade Gastrointestinal/fisiologia , Mucosa Intestinal/patologia , Lipídeos/uso terapêutico , Traumatismo por Reperfusão/terapia , Animais , Biomarcadores/metabolismo , Inflamação/etiologia , Inflamação/metabolismo , Inflamação/patologia , Inflamação/prevenção & controle , Mucosa Intestinal/metabolismo , Mucosa Intestinal/fisiopatologia , Masculino , Permeabilidade , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Traumatismo por Reperfusão/metabolismo , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/fisiopatologia , Junções Íntimas/metabolismoRESUMO
BACKGROUND: Peritoneal air exposure is a common phenomenon in abdominal surgery, but long-term exposure could induce intestinal inflammatory responses, resulting in delayed recovery of gastrointestinal motility after surgery. High-fat enteral nutrition has been reported to ameliorate inflammation in many diseases. In the present study, we investigated whether high-fat enteral nutrition could control intestinal inflammation and improve intestinal motility after peritoneal air exposure. METHODS: Male adult rats were administrated saline, low-fat enteral nutrition, or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Control rats underwent anesthesia without laparotomy and received saline. Intestinal motility was assessed 24 h after surgery by charcoal transport assay; systemic inflammation was assessed by analyzing serum levels of tumor necrosis factor α, interleukin (IL)-1ß, IL-6, and IL-10; and intestinal inflammation was assessed by analyzing myeloperoxidase activity and concentrations and gene expression of tumor necrosis factor α, IL-1ß, IL-6, and IL-10 in the intestinal tissue. RESULTS: Peritoneal air exposure decreased intestinal motility significantly compared with the control group (P < 0.05). The systemic and intestinal inflammatory parameters were also much higher in the peritoneal air exposure groups than in the control group. Both low-fat and high-fat enteral nutrition increased intestinal motility and reduced systemic and intestinal inflammatory parameter levels to different degrees. However, high-fat enteral nutrition significantly improved the negative alterations in these biochemical parameters compared with low-fat enteral nutrition (P < 0.05). CONCLUSIONS: These results suggest that high-fat enteral nutrition might be able to control intestinal inflammation and improve intestinal motility after peritoneal air exposure. Thus, the perioperative administration of high-fat enteral nutrition may be a promising treatment to enhance the recovery of intestinal motility after surgery.
Assuntos
Gorduras na Dieta/uso terapêutico , Nutrição Enteral , Enterite/prevenção & controle , Motilidade Gastrointestinal , Complicações Pós-Operatórias/prevenção & controle , Animais , Citocinas/metabolismo , Mucosa Intestinal/metabolismo , Masculino , Peroxidase/metabolismo , Distribuição Aleatória , Ratos Sprague-DawleyRESUMO
BACKGROUND: Peritoneal air exposure is needed in open abdominal surgery, but long-time exposure could induce intestinal mucosal barrier dysfunction followed by many postoperative complications. High-fat enteral nutrition can ameliorate intestinal injury and improve intestinal function in many gastrointestinal diseases. In the present study, we investigated the effect of high-fat enteral nutrition on intestinal mucosal barrier after peritoneal air exposure and the underlying mechanism. METHODS: Male adult rats were administrated saline, low-fat or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Rats undergoing anesthesia without laparotomy received saline as control. Twenty four hours after surgery, samples were collected to assess intestinal mucosal barrier changes in serum D-lactate levels, intestinal permeability, intestinal tight junction protein ZO-1 and occludin levels, and intestinal histopathology. The levels of malondialdehyde and the activity of superoxide dismutase in the ileum tissue were also measured to assess the status of intestinal oxidative stress. RESULTS: High-fat enteral nutrition significantly decreased the serum D-lactate level and increased the intestinal tight junction protein ZO-1 level when compared to the group treated with low-fat enteral nutrition (P < 0.05). Meanwhile, histopathologic findings showed that the intestinal mucosal injury assessed by the Chiu's score and the intestinal epithelial tight junction were also improved much more in the high-fat enteral nutrition-treated group (P < 0.05). In addition, the intestinal malondialdehyde level was lower, and the intestinal superoxide dismutase activity was higher in the high-fat enteral nutrition-treated group than that in the low-fat enteral nutrition-treated group (P < 0.05). CONCLUSIONS: These results suggest that high-fat enteral nutrition could reduce intestinal mucosal barrier damage after peritoneal air exposure, and the underlying mechanism may be associated with its antioxidative action. Perioperative administration of high-fat enteral nutrition may be a promising intervention to preserve intestinal mucosal barrier function in open abdominal surgery.
Assuntos
Ar , Dieta Hiperlipídica , Nutrição Enteral/métodos , Íleo/metabolismo , Mucosa Intestinal/metabolismo , Laparotomia/efeitos adversos , Peritônio , Animais , Biomarcadores/metabolismo , Íleo/patologia , Mucosa Intestinal/patologia , Masculino , Assistência Perioperatória/métodos , Permeabilidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Distribuição Aleatória , Ratos , Junções Íntimas/metabolismoRESUMO
BACKGROUND: Sympathetic hyperactivity occurs early in acute traumatic coagulopathy (ATC) and is closely related to its development. ß-adrenoceptor antagonists are known to alleviate adverse sympathetic effects and improve outcome in various diseases. We investigated whether ß-blockers have protective effects against inflammation and endothelial and hemostatic disorders in ATC. MATERIAL AND METHODS: ATC was induced in male Sprague-Dawley rats by trauma and hemorrhagic shock. Rats were randomly assigned to the sham, ATCC (ATC control), and ATCB (ATC with beta-adrenoceptor blockade) groups. Rats were injected intraperitoneally with propranolol or vehicle at baseline. Heart rate variability (HRV) and markers of inflammation, coagulation, and endothelial activation were measured, and Western blotting analysis of nuclear factor (NF)-κB was done after shock. Separate ATCC and ATCB groups were observed to compare overall mortality. RESULTS: HRV showed enhanced sympathetic tone in the ATCC group, which was reversed by propranolol. Propranolol attenuated the induction of pro-inflammatory cytokines TNF-α and IL-6, as well as fibrinolysis markers plasmin antiplasmin complex and tissue-type plasminogen activator. The increased serum syndecan-1 and soluble thrombomodulin were inhibited by propranolol, and the NF-κB expression was also decreased by propranolol pretreatment. But propranolol did not alter overall mortality in rats with ATC after shock. CONCLUSIONS: Beta-adrenoceptor blockade can alleviate sympathetic hyperactivity and exert anti-inflammatory, anti-fibrinolysis, and endothelial protective effects, confirming its pivotal role in the pathogenesis of ATC. Its mechanism in ATC should be explored further.
Assuntos
Antagonistas Adrenérgicos beta/farmacologia , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico , Ferimentos e Lesões/complicações , Análise de Variância , Animais , Transtornos da Coagulação Sanguínea/etiologia , Western Blotting , Citocinas/metabolismo , Frequência Cardíaca/efeitos dos fármacos , Estimativa de Kaplan-Meier , Masculino , NF-kappa B/metabolismo , Propranolol/farmacologia , Ratos , Ratos Sprague-DawleyRESUMO
BACKGROUND/AIMS: In critically ill patients, gastrointestinal function plays an important role in multiple organ dysfunction syndrome. Patients suffering from acute lower gastrointestinal dysfunction need to be performed a temporary fecal diversion after the failure of conservative treatment. This study aims to determine which type of fecal diversion is associated with better clinical outcomes in critically ill patients. METHODOLOGY: Data of critically ill patients requiring surgical decompression following acute lower gastrointestinal dysfunction between January 2008 and June 2013 were retrospectively analyzed. Comparison was made between ileostomy group and colostomy group regarding the stoma-related complications and the recovery after stoma creation. RESULTS: 63 patients consisted of temporary ileostomy group (n = 35) and temporary colostomy group (n = 28) were included in this study. First bowel movement and length of enteral nutrition intolerance after fecal diversion were both significantly shorter in the ileostomy group than in the colostomy group (1.70 ± 0.95 vs. 3.04 ± 1.40; p < 0.001 and 3.96 ± 2.84 vs. 8.12 ± 7.05; p = 0.009). In comparison of the complication rates, we found a significantly higher incidence of dermatitis (31.43% vs. 7.14%; p = 0.017), hypokalemia (25.71 vs. 3.57; p = 0.017) and hypocalcemia (28.57 vs. 7.14; p = 0.031), and slightly lower incidence of stoma prolapse (0% vs. 10.71%; p = 0.082) in the ileostomy group than in the colostomy group. CONCLUSIONS: Both procedures provide an effective defunctioning of the distant gastrointestinal tract with a low complication incidence. We prefer a temporary ileostomy to temporary colostomy for acute lower gastrointestinal dysfunction in critically ill patients.
Assuntos
Colostomia , Descompressão Cirúrgica/métodos , Gastroenteropatias/cirurgia , Ileostomia , Adulto , Colostomia/efeitos adversos , Estado Terminal , Descompressão Cirúrgica/efeitos adversos , Defecação , Nutrição Enteral , Feminino , Gastroenteropatias/diagnóstico , Gastroenteropatias/etiologia , Gastroenteropatias/fisiopatologia , Humanos , Ileostomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: Superior mesenteric artery (SMA) syndrome may occur in patients with constipation, whereas the association between these two distinct diseases has not been confirmed yet. We investigated the incidence, risk factors and treatment strategy associated with SMA syndrome in constipated patients. METHODOLOGY: We conducted a prospective nested case-control study from a 9-year hospitalization cohort (n=973). Cases were matched to controls 1:4 on factors of age and gender. Cases developed SMA syndrome in long term follow-up (n=26) and controls did not (n=104). Independent risk factors were identified by using univariate analysis and conditional logistic regression analysis. Enteral nutritional support was applied in all cases and its curative effect was evaluated by retrospective analysis. RESULTS: The incidence of SMA syndrome was 2.67%. The risk factors under scrutiny were body mass index (BMI)≤18 (odds ratio (OR) 2.89, 95% CI 1.14 to 9.31) and abnormal colon transit time (OR 3.57, 95% CI 1.36 to 9.35). Twenty-two patients recovered after treatment of nutritional support, and the success rate of conservative treatment was 84.6%. CONCLUSIONS: BMI≤18 and prolonged colon transit time both were risk factors associated with SMA syndrome in constipated patients. Enteral nutritional support should be adopted as the first-line treatment for this condition.
Assuntos
Constipação Intestinal/epidemiologia , Síndrome da Artéria Mesentérica Superior/epidemiologia , Adulto , Índice de Massa Corporal , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , China/epidemiologia , Colo/fisiopatologia , Constipação Intestinal/diagnóstico , Constipação Intestinal/fisiopatologia , Nutrição Enteral , Feminino , Trânsito Gastrointestinal , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Fatores de Risco , Síndrome da Artéria Mesentérica Superior/diagnóstico , Síndrome da Artéria Mesentérica Superior/fisiopatologia , Síndrome da Artéria Mesentérica Superior/terapia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: Hemorrhage after abdominal surgery remains a frequent clinical complication, and associated with prolonged length of stay, increased complications and mortality. Indication of blood product requirements accurately and promptly is very important for recovery of patients. Thrombelastography (TEG) as a tool for evaluation of bleeding and effects of blood components and blood products is increasing. We investigated that whether TEG can identify postoperative active bleeding and evaluate blood product requirements in abdominal surgery. METHODOLOGY: Between June to December in 2012, there were 55 patients who had bleeding after operation in SICU of Jinling Hospital. Recorded data included vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour, blood routine (Hb, Hct, Plt), the coagulation tests (Fib, PT, aPTT, INR), TEG parameters (R, K, Angle, MA, Cl) and blood product requirements within 24h. Patients were divided into active bleeding group and non-active bleeding group based on the findings of reoperation or digital subtraction angiography (DSA). To compare vital signs, laboratory values, TEG values and blood product requirements in two groups. RESULTS: Vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour and the coagulation tests (Fib, PT, INR) showed no significant correlations with subsequent blood product requirements, but aPTT (R = 0.546, P = 0.000) and MA (R = 0.665, P = 0.000) correlated with the blood products use. MA values of patients had more blood loss was significantly lower and had a descending tendency which did not showed in aPTT values. 25 patients had postoperative active bleeding confirmed by reoperation or DSA. They had significantly increased use of blood products, and significantly lower MA, Hb, Hct, and Fib values, whereas aPTT exhibited no significant differences. CONCLUSION: MA can not only identify postoperative active bleeding together with hemoglobin, hematocrit, and fibrinogen, but also evaluate blood product requirements in abdominal surgery.
Assuntos
Abdome/cirurgia , Transfusão de Sangue/métodos , Hemorragia Pós-Operatória/diagnóstico , Hemorragia Pós-Operatória/terapia , Tromboelastografia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Digital , Biomarcadores/sangue , China , Feminino , Fibrinogênio/metabolismo , Hematócrito , Hemoglobinas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.
Assuntos
Fístula Biliar/etiologia , Embolização Terapêutica , Hemoperitônio/terapia , Fígado/lesões , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Adulto , Idoso , Fístula Biliar/cirurgia , Feminino , Hemodinâmica , Hemoperitônio/etiologia , Hemoperitônio/fisiopatologia , Veias Hepáticas/lesões , Humanos , Fígado/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Veia Porta/lesões , Radiografia , Estudos Retrospectivos , Taxa de Sobrevida , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos não Penetrantes/classificação , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/classificação , Ferimentos Penetrantes/complicações , Adulto JovemRESUMO
BACKGROUND/AIMS: Recent studies indicate that perioperative fluid restriction leads to better preserved clinical data as well as reduced complication rates. This study aimed to determine the probable mechanism of fluid restriction influence on the complication rate of patients undergoing gastrointestinal surgery for malignancy. METHODOLOGY: Patients (n = 174) undergoing restricted fluid regimen (R group) or standard fluid regimen (S group) were included in this prospective, randomized trial over 16 months. Fluid distribution was determined by Bioelectrical Impedance Analyzer (BIA) and the difference between two groups was compared regarding complications and the relationship between complications and fluid distribution changes. RESULTS: The restricted intravenous fluid regimen significantly reduced perioperative intravenous fluid volume. Weight gained in S group and was not significantly changed in R group after surgery, especially in POD2 (media; R vs. S; 61.17 vs. 65.40 kg, p = 0.017). The number of patients with postoperative complications was reduced in R group compared with in S group (34.5% vs. 47.8%, p = 0.076). Systemic complications were significantly reduced in R group (t = -5.895, p = 0.000). Patients with complications had an average of 1.6 complications in R group vs. 2.0 in S group (t = -1.345, p = 0.183). The multivariate analysis suggested that perioperative fluid distribution changes were associated with the development of postoperative complications. CONCLUSIONS: Perioperative fluid restriction could effect on fluid distribution and reduce tissue and cellular edema, and further, could reduce postoperative complication rates.
Assuntos
Neoplasias Abdominais/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Deslocamentos de Líquidos Corporais , Hidratação/métodos , Idoso , Distribuição de Qui-Quadrado , China , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Impedância Elétrica , Feminino , Hidratação/efeitos adversos , Humanos , Infusões Intravenosas , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Aumento de PesoRESUMO
OBJECTIVE: To retrospectively analyze the bacteriological spectrum and drug susceptibility of pus flora from abdominal traumatic patients with severe intra-abdominal infection. METHODS: A total of 41 severe intra-abdominal infected patients with abdominal trauma were recruited to collect 123 abdominal pus specimens. And the results of laboratory microbiology and drug sensitivity were analyzed with the WHONET 5.4 software. RESULTS: A total of 297 strains of bacteria were isolated at (7.2 ± 2.3) strains for each patient. Gram-positive bacteria accounted for 44.1% (131/297) , Gram-negative bacteria 55.2% (164/297) and fungi 0.7% (2/297). The top five isolates were Escherichia coli, Staphylococcus aureus, Klebsiella pneumonia, Enterococcus faecalis and Pseudomonas aeruginosa. Those antibiotics highly sensitive (>90%) to Escherichia coli included cefoperazone (91%), imipenem (98%); highly sensitive to Gram-positive cocci included teicoplanin (100%) and linezolid (100%). Staphylococcus aureus was 100% sensitive to vancomycin. The agents with a high susceptibility to Klebsiella pneumonia included imipenem (100%) and amikacin (79%). Ciprofloxacin (90%) had the highest sensitivity to Pseudomonas aeruginosa. CONCLUSIONS: The predominant bacteria of causing severe intra-abdominal infection of traumatic patients is Gram-negative bacteria, but the infection of Gram-positive bacteria, especially the ratio of Staphylococcus aureus infection is also comparatively high. Cefoperazone, ciprofloxacin, imipenem, vancomycin, teicoplanin and linezolid have higher antibacterial activity.
Assuntos
Abscesso Abdominal/microbiologia , Traumatismos Abdominais/microbiologia , Farmacorresistência Bacteriana , Abscesso Abdominal/etiologia , Traumatismos Abdominais/complicações , Adolescente , Adulto , Antibacterianos/uso terapêutico , Infecção Hospitalar/microbiologia , Feminino , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Estudos Retrospectivos , Supuração/microbiologia , Adulto JovemRESUMO
BACKGROUND: Perioperative fluid restriction can lead to better clinical outcomes and reduced complications. However, whether perioperative fluid restriction can alter the patient's postoperative cellular immunity is unknown. Therefore, a randomized, prospective clinical study was designed to determine whether fluid restriction improves immunological outcome in elderly patients who undergo gastrointestinal surgery for cancer removal. METHODS: A total of 179 patients aged 65 years or older were recruited for the study and were randomly assigned to receive the restricted fluid regimen (R group) or the standard fluid regimen (S group). Postoperative T-lymphocyte subpopulations (CD3(+), CD4(+), and CD8(+)) frequencies and monocyte HLA-DR expression was investigated. Perioperative complications and cellular immunity changes were analyzed comparatively between the two groups. RESULTS: The restricted intravenous fluid regimen was associated with significantly less postoperative complications (1.5 complications/patient vs. S group: 2.2 complications/patient), especially for infection complications (15% vs. S group: 27%, p = 0.04). Circulating CD3(+) T-cells were suppressed after surgery in both treatment groups, but the cell frequency (cell/µL) was higher in the R group (746 vs. S group: 480 at postoperative day (POD) 2, p = 0.022; 878 vs. 502 at POD 3, p = 0.005; 892 vs. 674 at POD 5, p = 0.042). Similarly, the HLA-DR expression (% of all T cells) in monocytes were decreased in both groups, but the expression remained higher in the R group (66.20 vs. S group: 51.97 at POD 1, p = 0.029; 68.19 vs. 51.26 at POD 2, p = 0.039; 72.19 vs. 57.45 at POD 3, p = 0.014; 73.92 vs. 60.46 at POD 5, p = 0.036). Multivariate analysis suggested that perioperative CD3(+) T cell changes were associated with the development of postoperative complications [odds ratio (OR) = 1.963; 95% confidence interval (CI) 1.019-3.782; p = 0.044] and postoperative infections (OR = 3.106; 95% CI 1.302-7.406; p = 0.011). CONCLUSIONS: In elderly gastrointestinal cancer patients, cellular immunity is better preserved by the perioperative fluid restriction regimen. The better preserved cellular immunological function is correlated with a reduced perioperative complications rate.
Assuntos
Hidratação/métodos , Neoplasias Gastrointestinais/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/metabolismo , Feminino , Antígenos HLA-DR/metabolismo , Humanos , Imunidade Celular , Infusões Intravenosas , Modelos Logísticos , Masculino , Monócitos/metabolismo , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/imunologia , Estudos Prospectivos , Método Simples-Cego , Subpopulações de Linfócitos T/metabolismo , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the clinical effectiveness of percutaneous US- or CT-guided drainage and laparotomy for patients with infective pancreatic necrosis. METHODS: Data of 90 infective pancreatic necrosis patients admitted from January 2008 to December 2009 were included. They were divided into two groups by the different treatment choices. Twenty-seven patients in the percutaneous group received percutaneous US- or CT-guided drainage as first choice. After that a sump suction apparatus was applied for controlled drainage. If no improvement was achieved after 3 days, they would received operation soon. While patients in the laparotomy group received surgical drainage at the time when the diagnosis of infected pancreatic necrosis was confirmed. Continuous drainage was also applied for these ones. RESULTS: The percutaneous group had a significant low rate of reoperation (7.1% vs. 14.3%, P < 0.05) and postoperative residual abscesses (7.1% vs. 28.6%, P < 0.05). Furthermore, 48.1% of patients in percutaneous group successfully avoid laparotomy. In the regard of complications, the percutaneous group presented lower incidence of both single organ dysfunction (7.4% vs. 28.6%, P < 0.05), intestinal fistula (7.4% vs. 27.0%, P < 0.05) and long-term complications (3.7% vs. 22.2%, P < 0.05). In addition, the percutaneous group costed less medical resources as evidenced by shorter ICU duration (21.2 ± 9.7 vs. 28.7 ± 12.1, P < 0.01), shorter hospital duration (48.2 ± 12.5 vs. 59.6 ± 17.5, P < 0.05) and less expenditure (191 762 ± 5892 vs. 341 689 ± 10 854, P < 0.05). CONCLUSIONS: Percutaneous drainage can effectively lower the surgical rates and the rates of complications and reoperations in patients with infective pancreatic necrosis. Besides that, it could also reduce the cost of medical resources.
Assuntos
Drenagem/métodos , Pancreatite Necrosante Aguda/cirurgia , Adulto , Feminino , Humanos , Laparotomia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Massive pulmonary haemorrhage can spoil the entire lung and block the airway in a short period of time due to severe bleeding, which quickly leads to death. Alveolar lavage is an effective method for haemostasis and airway maintenance. However, patients often cannot tolerate alveolar lavage due to severe hypoxia. We used extracorporeal membrane oxygenation (ECMO) to overcome this limitation in a patient with massive pulmonary haemorrhage due to severe trauma and succeeded in saving the life by repeated alveolar lavage. CASE SUMMARY: A 22-year-old man sustained multiple injuries in a motor vehicle accident and was transferred to our emergency department. On admission, he had a slight cough and a small amount of bloody sputum; computed tomography revealed multiple fractures and mild pulmonary contusion. At 37 h after admission, he developed severe chest tightness, chest pain, dizziness and haemoptysis. His oxygen saturation was 68%. Emergency endotracheal intubation was performed, and a large amount of bloody sputum was suctioned. After transfer to the intensive care unit, he developed refractory hypoxemia and heparin-free venovenous ECMO was initiated. Fibreoptic bronchoscopy revealed diffuse and profuse blood in all bronchopulmonary segment. Bleeding was observed in the trachea and right bronchus, and repeated alveolar lavage was performed. On day 3, the patient's haemoptysis ceased, and ECMO support was terminated 10 d later. Tracheostomy was performed on day 15, and the patient was weaned from the ventilator on day 21. CONCLUSION: Alveolar lavage combined with ECMO can control bleeding in trauma-induced massive pulmonary haemorrhage, is safe and can be performed bedside.
RESUMO
The aim of this study was to investigate the correlations between serum calcium and clinical outcomes in patients with coronavirus disease 2019 (COVID-19). In this retrospective study, serum calcium levels, hormone levels and clinical laboratory parameters on admission were recorded. The clinical outcome variables were also recorded. From February 10 to February 28, 2020, 241 patients were enrolled. Of these patients, 180 (74.7%) had hypocalcemia on admission. The median serum calcium levels were 2.12 (IQR, 2.04-2.20) mmol/L, median parathyroid hormone (PTH) levels were 55.27 (IQR, 42.73-73.15) pg/mL, and median 25-hydroxy-vitamin D (VD) levels were 10.20 (IQR, 8.20-12.65) ng/mL. The serum calcium levels were significantly positively correlated with VD levels (P =0.004) but negatively correlated with PTH levels (P =0.048). Patients with lower serum calcium levels (especially ≤2.0 mmol/L) had worse clinical parameters, higher incidences of organ injury and septic shock, and higher 28-day mortality. The areas under the receiver operating characteristic curves of multiple organ dysfunction syndrome, septic shock, and 28-day mortality were 0.923 (P <0.001), 0.905 (P =0.001), and 0.929 (P <0.001), respectively. In conclusion, serum calcium was associated with the clinical severity and prognosis of patients with COVID-19. Hypocalcemia may be associated with imbalanced VD and PTH levels.
Assuntos
Betacoronavirus , Cálcio/sangue , Infecções por Coronavirus/sangue , Infecções por Coronavirus/patologia , Pneumonia Viral/sangue , Pneumonia Viral/patologia , Idoso , Biomarcadores/sangue , COVID-19 , Infecções por Coronavirus/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Prognóstico , Estudos Retrospectivos , SARS-CoV-2RESUMO
OBJECTIVE: To summary the treatment experience of severe acute pancreatitis (SAP). METHODS: From January 1997 to March 2009, a total of 1033 patients suffered SAP were admitted with a mean APACHE II score 12.0 +/- 4.3. There were 622 males and 411 females, aged from 13 to 98 years old. All patients were cared by the multidisciplinary team with intensivist, endoscopists, gastroenterologists, radiologist, nephrologist and surgeons.Patients treated in SICU in the early phase of the disease. In these 1033 patients, 365 cases received mechanical ventilation, 218 with tracheotomy, 159 cases received high-volume continuous venovenous hemofiltration (CVVH), 179 received nasobiliary drainage, 513 were treated with early enteral nutrition. CT-guided percutaneous catheter drainge for peripancreatic fluid collection was pefromed for 477 times and 438 patients received surgical debridement for infected pancreatic necrosis. RESULTS: In all these 1033 cases, 975 patients (94.4%) survived, and 38 patients died (3.7%). The mortality of patients who received surgical debridement for infected pancreatic necrosis was 7.1% (31/438). CONCLUSION: The muti-discipline management of severe acute pancreatitis can remarkably improve the prognosis of patients.
Assuntos
Hemofiltração , Pancreatite , Drenagem , Nutrição Enteral , Humanos , Pancreatite/terapiaRESUMO
BACKGROUND: Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing, the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear. Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS. METHODS: We conducted a multi-center, retrospective, cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018. Patients with severe ARDS who received VV-ECMO support were included. The detailed demographic data and physiologic data were used to match ARDS patients without ECMO. The primary endpoint was the 28-day mortality. RESULTS: Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study. The acute physiology and chronic health evaluation II score was 23.1â±â6.3 in the ECMO group and 24.8â±â8.5 in the control group (Pâ=â0.1195). The sequential organ failure assessment score was 12.8â±â3.4 in the ECMO group and 13.7â±â3.5 in the control group (Pâ=â0.0848). The 28-day mortality of patients with ECMO support was 39.4%, and that of the control group was 55.6%. The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (Pâ=â0.0097). Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]: 1.006; 95% confidence interval [CI]: 1.001-1.013; Pâ=â0.030) and duration of mechanical ventilation before ECMO (HR: 3.299; 95% CI: 1.264-8.609; Pâ=â0.034). CONCLUSIONS: This study showed that ECMO improved the survival of patients with severe ARDS. The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.
Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Estudos RetrospectivosRESUMO
BACKGROUND: Transversus abdominis plane (TAP) block reduces opiate requirements and pain scores in abdominal surgery, but the effect has not been evaluated in hernia surgery. The aim of this study was to evaluate the efficacy of TAP block in hernia surgery. METHODS: A meta-analysis of randomized clinical trials (RCTs) evaluating the effect of TAP block in adults undergoing hernia surgery was performed. The primary outcomes were morphine requirements 24 hours after surgery and the number of rescue analgesia patients. Secondary outcomes were pain scores on rest and on movement at 24 hours after surgery, postoperative nausea and vomiting and general postoperative complications. RESULTS: The search strategy yielded 231 articles after duplicates have been removed, and finally 8 RCTs with a total of 791 patients were included. In patients who received a TAP block, the cumulative morphine utilization was significantly reduced at 24 hours (weighted mean difference [WMD] -11.40 mg, -22.41 to -0.39; P=0.04). The number of patients needing a rescue analgesia (relative risk: 0.35, 0.22 to 0.55; P<0.001), the pain scores on rest 24 hours after surgery (WMD: -0.29, -0.55 to -0.04; P=0.02) and the pain scores on movement or coughing 24 hours after surgery (WMD: -0.70, -1.33 to -0.06; P=0.03) were all lower in patients who received a TAP block. There was also significant reduction in the postoperative nausea and vomiting, and the general postoperative complications in TAP block group. CONCLUSIONS: Within a heterogeneous group of RCTs, TAP block reduces postoperative morphine requirements and the severity of pain after hernia surgery.
Assuntos
Herniorrafia , Bloqueio Nervoso , Músculos Abdominais , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: To investigate the effect of a tight control of blood glucose by intensive insulin therapy on human sepsis, and to explore the potential mechanism of the intensive insulin therapy. METHODS: Eligible patients were randomized by a blinded pharmacist to receive tight control of blood glucose by intensive insulin therapy (maintenance of blood glucose at a level between 4.4 and 6.1 mmol/L) or to receive conventional treatment (maintenance of glucose at a level between 10.0 and 11.1 mmol/L). The expression of HLA-DR on peripheral monocytes was measured in 54 patients by flow cytometry on 24 h, 3 d, 5 d, 7 d, 10 d and 14 d of intensive care in parallel with serum c-reactive protein (CRP), severity of the disease (APACHE II score, SOFA score) and clinical data collection. RESULTS: Patients receiving intensive insulin therapy were less likely to require prolonged mechanical ventilation. Tight control of blood glucose significantly reduced the number of days during which leukopenia or leukocytosis and the days with hypo- or hyperthermia (P < 0.05). Hypoglycemia occurred in 3 patients (10.7%) in the tight control of blood glucose group. There were no instance of hemodynamic deterioration or convulsions. Compared with the conventional treatment, tight control of blood glucose also increased the HLA-DR expression of peripheral monocytes, and there were significantly difference on 3 d, 5 d and 7 d (P < 0.05). Whereas it suppressed the elevated serum CRP concentrations, there was significantly difference on 7 d (P < 0.05). CONCLUSIONS: Tight control of blood glucose by intensive insulin therapy expedited healing of human sepsis, and increased the HLA-DR expression of peripheral and suppressed the elevated serum CRP. So, it is necessary to use insulin to strict control the glucose levels in human sepsis.