经过数十年全球的共同努力，脓毒血症（Sepsis）在临床治疗以及在病因、病理生理、诊断与治疗策略上都取得了令人鼓舞的成绩，但在ICU的重症患者中，其发病率与死亡率居高不下，仍然是引发脏器功能不全及死亡的高风险因素。在美国，Sepsis是前十位的死亡原因，年死亡约为23万6千人。中国的一项调查显示，在大型医院外科ICU中严重脓毒血症（Severe Sepsis）的发病率为8.68%，死亡率为48.7%，与发达国家的调查相近。在对Sepsis调查及干预研究中，与其相关的综合征的定义及命名仍然主要采用1991年美国胸科医师协会/危重病医学会芝加哥联席会议的建议，包括了从全身炎性反应综合征（systemic inflammatory response syndrome, SIRS）、Sepsis、严重脓毒血症（Severe Sepsis）、感染性休克（Septic Shock）直至多器官功能不全综合征（multiple organ dysfunction syndrome, MODS）的概念与定义，这些概念虽未得到完全的认可，但在建立统一和规范的临床诊断及研究基线和标准上仍然发挥了很大的作用。经过10年的不断改进，2001美国及欧洲的重症医学会，提出了改进的Sepsis诊断标准。
【Abstract】 Objective To discuss the mechanism of growth hormone (GH) in infection and its safety. Methods Advances in the application of GH in infection of recent years were reviewed. Results In infectious patients, GH may promote protein synthesis, strengthen the immunity of body, and protect the integrity of intestinal barrier function. But some patients present GH resistance. The safety of GH for infectious patients needs further evaluation. Conclusion GH may play a supplementary role in infection therapy, but further research is needed.
The publication of the 2016 version of the Surviving Sepsis Campaign guidelines is a further step to the treatment of sepsis worldwide. This version of guidelines approves new definition of Sepsis-3. Overall, the new guidelines do not change the previous principle of treatment significantly. Some detailed and specific modifications have been made. Understanding and rational use of the new guidelines based on clinical practice, are the key to managing sepsis and performing accurate and effective treatment.
Objective To identify evidence-based treatment choices for a patient with increased intracranial pressure after acute traumatic brain injury. Methods We searched The Cochrane Library (Issue 2, 2006), MEDLNE (1981 to August 2006) and CBMdisc (1978 to August 2006) to identity systematic reviews (SRs), randomized controlled trials (RCTs), controlled clinical trials (CCTs) and prospective cohort studies involving the efficacy and safety of pharmacotherapy and non-pharmacotherapy for increased intracranial pressure after acute traumatic brain injury. Results We found 2 SRs and 8 RCTs on pharmacotherapy, and 6 SRs and 2 RCTs on non-pharmacotherapy. Conventional-dose mannitol was no better than hypertonic saline, but was better than other intracranial pressure lowering agents. High-dose mannitol can reduce mortality and the incidence of severe disability compared with conventional-dose mannitol. There were no studies comparing high-dose mannitol and hypertonic saline. Non-pharmacotherapy was not recommended for routine use due to the lack of good quality evidence. Conclusion For patients with increased intracranial pressure after acute traumatic brain injury, mannitol is effective in reducing the mortality and the incidence of severe disability. However, more large-scale RCTs are required to compare high-dose mannitol versus other drugs. Non-pharmacotherapy is not recommended as an adjunct therapy at present.
Objective To discuss the feasibility and safety of early enteral nutrition (EN) on treatment of severe acute pancreatitis (SAP) and its influence. Methods The advancement about application of early EN on treatment of SAP in recent years were reviewed. Results In patients with SAP, early EN via catheter placed in the jejunum could protect the integrity of intestinal barrier and reduce infectious complications. But no consensus had been reached about the starting time, ingredient and infusion mode yet. Conclusion Early EN may have positive effects on treatment of SAP, but further researches are still needed.
Objective To evaluate the effectiveness and safety of total enteral nutrition (TEN) versus total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP). Methods The databases such as Pubmed (1996 to June 2011), EMbase (1984 to June 2011), Cochrane Central Register of Controlled Trials of The Cochrane Library (Issue 6, 2011) and CBM (1978 to June 2011) were electronically searched, and the relevant references of the included papers were also manually searched. Two reviewers independently screened the trials according to inclusion and exclusion criteria, extracted the data, and assessed the methodology quality. Meta-analyses were performed using the Cochrane Collaboration’s RevMan 5.1 software. Results Seven randomized controlled trials (RCTs) involving 379 patients with SAP were included. The results of meta-analyses showed that compared with TPN, TEN could significantly reduce the risk of mortality (RR=0.33, 95%CI 0.20 to 0.55, Plt;0.000 1), pancreatitis-related infections (RR=0.35, 95%CI 0.25 to 0.50, Plt;0.000 01), required rate of surgical intervention (RR=0.43, 95%CI 0.23 to 0.82, P=0.01), and incidence of multiple organ failure (MOF) (RR=0.28, 95%CI 0.17 to 0.46, Plt;0.000 01). There was no significant difference in the nutrition strategies associated complications between TPN and TEN (RR=1.16, 95%CI 0.42 to 3.22, P=0.78). Conclusion Meta-analyses show that compared with TPN, TEN can reduce the risk of mortality, pancreatitis-related infections, required rate of surgical intervention, and incidence of MOF; and it will not increase the nutrition strategies associated complications. Consequently, TEN should be considered a better choice for SAP patients as early as possible.
ObjectiveTo explore the clinical value of fibrinogen-albumin-ratio (FAR) in adult extracorporeal membrane oxygenation (ECMO) hemorrhage. MethodsThe clinical data of adult patients receiving ECMO in the West China Hospital from 2018 to 2020 were analyzed retrospectively. Patients were divided into a bleeding group and a non-bleeding group based on whether they experienced bleeding after ECMO. Logistic regression analysis was used to study the relationship between FAR and bleeding, as well as risk factors for death. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive ability of FAR. According to the optimal cut-off value of FAR for predicting hemorrhage, patients were divided into a high-risk group and a low-risk group, and the occurrence of bleeding was compared between the two groups. ResultsA total of 125 patients were enrolled in this study, including 85 males and 40 females, aged 46.00 (31.50, 55.50) years. Among them, 58 patients received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 67 patients received veno-venous extracorporeal membrane oxygenation (VV-ECMO). There were 49 patients having bleeding, and the lactate level was higher (P=0.026), the platelet count before ECMO initiation and 24 h after ECMO initiation was lower (P=0.031, 0.020), the fibrinogen level 24 h after ECMO initiation was lower (P=0.049), and the proportion of myocarditis patients was higher (P=0.017) in the bleeding group than those of the non-bleeding group. In the subgroup analysis of ECMO mode, the higher D-Dimer, lactate level and lower FAR before and 24 h after ECMO initiation were associated with bleeding in the VA-ECMO group (P=0.017, 0.011, 0.033, 0.005). The 24 h FAR was independently correlated with bleeding (P=0.048), and AUC was 0.714. The cut-off value was 55.73. According to this optimal cut-off value, 25 patients were divided into the high-risk group (≤55.73) and 33 into the low-risk group (>55.73). There was a higher incidence of bleeding in the high-risk group compared to the low-risk group (unadjusted P=0.002; P=0.013 for multivariable adjustment). In the VV-ECMO group, the relationship between FAR and bleeding events was not significant (P>0.05). ConclusionLow 24 h FAR is an independent risk factor for bleeding in VA-ECMO patients, and the diagnostic cut-off value is 55.73.
ObjectiveTo investigate the antibody concentration and immune status of intensive care medical staff after vaccination against COVID-19. Methods From October 1, 2021 to February 28, 2022, the serial numbers of 47 hospitals were randomly selected by cluster stratified random sampling method. Blood samples were collected from 192 medical staff in intensive care department who had received inactivated novel coronavirus vaccine in 7 hospitals. The antibody concentration was determined by chemiluminescence method to find the antibody rule. Logistic regression analysis was used to determine the related factors affecting the production of antibodies. ResultsTotal antibody concentration of 192 blood samples was 23.25 (5.09, 270.22), IgG concentration was 0.94 (0.15, 4.48), IgM concentration was 0.05 (0.03, 0.12). Logistic regression analysis showed that the total antibody concentration might be related to gender and age, and the IgG concentration was significantly related to whether the third injection was administered. One hundred and twenty-seven people received 2 doses of inactivated vaccine, and the positive rate of IgG was the highest within 1 to 2 months, and decreased significantly after 3 months. The positive rate of IgG antibody was 95.4% within 60 days after receiving 3 doses of vaccine, 70% within 1 month after receiving the third dose of vaccine, and 100.0% within 1 to 2 months (P<0.05). The total antibody positive rate was 96.3% in people aged 17 to 35 years and 73.3% in people aged 36 to 58 years, showing statistical difference (P<0.05). The total antibody production rate of those who received the third dose of vaccine was 100.0%, and no severe case of COVID-19 occurred during the sampling period. Conclusions After the first, second, and third doses of COVID-19 vaccine, the total antibody concentration of the virus gradually increases to 100.0%, indicating initial immunity. However, the antibody concentration decreased gradually after 3 months of inoculation. The concentration of IgG in women is higher than that in men, and the concentration of antibody in young people is higher than that in middle-aged and elderly people during the same period.
Objective To evaluate the feasibility of hyperinsulinemic normoglycemia strategy in critically ill patients. Methods Between January 2020 and October 2021, the critically ill patients with stress hyperglycemia in the Emergency Intensive Care Unit of the Fourth People’s Hospital of Langfang were randomly assigned into a trial group or a control group. The trial group adopted hyperinsulinemic normoglycemia therapy, while the control group adopted conventional glucose control therapy. The mean and variability (standard deviation) of blood glucose, incidences of severe hypoglycemia and abnormal hyperglycemia, as well as the percentage of blood glucose values within the target range were compared between the two groups, to evaluate the feasibility of hyperinsulinemic normoglycemia strategy in critically ill patients from the perspective of safety and effectiveness. The non-normally distributed measurement data were presented as median (lower quartile, upper quartile). Results A total of eighty patients were included, with forty cases in each group. The mean blood glucose level [6.00 (5.74, 6.70) vs. 9.51 (8.74, 10.01) mmol/L, P<0.001], the standard deviation of glucose level [1.58 (1.11, 2.15) vs. 2.20 (1.21, 2.76) mmol/L, P=0.028], and the glycemic lability index [175.52 (100.51, 346.69) vs. 408.51 (205.56, 651.91) mmol2/(L2·h·d), P<0.001] were all smaller in the trial group than those in the control group. The percentage of blood glucose values within the target range was 77.34% in the trial group and 5.33% in the control group, respectively, and the difference was statistically significant (P<0.001). No patients experienced severe hypoglycemia. There was a significant difference in the incidence of abnormal hyperglycemia between the two groups (5.08% vs. 36.16%, P<0.001). Conclusions Hyperinsulinemic normoglycemia strategy can effectively and safely provide normoglycemia, reduce glycemic variability, and achieve good glycemic control in critically ill patients. Hyperinsulinemic normoglycemia strategy may be a new approach to glycemic control in critically ill patients.
目的：了解ICU病房地震伤员的功能障碍的特点，为临床康复治疗提供依据。方法：运动功能评定应用MMT方法；运用关节角度尺评定关节活动度（ROM）；利用被动关节活动法评定肌张力、痉挛评定选用改良的Ashworth分级法；坐位平衡和站位平衡采用平衡反应试验评定；日常生活活动（ADL）能力选用国际通用的Barthel指数量表评定。由我科研究生作为评定人员。结果：①ICU病房地震伤员以骨折患者为主,占70%，神经系统损伤占20%，挤压综合症和肺挫伤各占5%；②女性骨折比例高于男性，为11∶3；神经系统损伤没有多大差异；截肢和瘫痪的患者中，男性高于女性，比例分别为4∶1和3∶2；肺部感染以女性更为明显，为7∶1；③47.6%的地震伤员关节活动受限（评定21人），93.3%的肌力下降（评定15人），15.8%肌张力下降（评定19人），36.8%肌张力增高（评定19人），30.0%的坐位平衡下降（评定10人），96.4%站立平衡下降；④ADL能力100%受限（评定20人），其中洗澡、修饰、如厕、平地行走45 m、上下楼梯受限均为100%，95%地震伤员进食能力下降，90%穿衣能力受限，35%大便失禁，60%小便控制能力下降，多数使用导尿管，95%地震伤员床椅转移能力下降；⑤40%出现肺部感染。结论：关节活动度受限、肌力下降、肌张力异常、平衡功能障碍、ADL能力受限及肺部感染是ICU地震伤员主要功能障碍。早期康复介入、维持和改善关节活动度、肌力训练、减张和牵伸训练、平衡训练、呼吸训练、站立和行走训练及ADL能力训练应当作为康复治疗的基本原则和方法。