經過數十年全球的共同努力，膿毒血癥（Sepsis）在臨床治療以及在病因、病理生理、診斷與治療策略上都取得了令人鼓舞的成績，但在ICU的重癥患者中，其發病率與死亡率居高不下，仍然是引發臟器功能不全及死亡的高風險因素。在美國，Sepsis是前十位的死亡原因，年死亡約為23萬6千人。中國的一項調查顯示，在大型醫院外科ICU中嚴重膿毒血癥（Severe Sepsis）的發病率為8.68%，死亡率為48.7%，與發達國家的調查相近。在對Sepsis調查及干預研究中，與其相關的綜合征的定義及命名仍然主要采用1991年美國胸科醫師協會/危重病醫學會芝加哥聯席會議的建議，包括了從全身炎性反應綜合征（systemic inflammatory response syndrome, SIRS）、Sepsis、嚴重膿毒血癥（Severe Sepsis）、感染性休克（Septic Shock）直至多器官功能不全綜合征（multiple organ dysfunction syndrome, MODS）的概念與定義，這些概念雖未得到完全的認可，但在建立統一和規范的臨床診斷及研究基線和標準上仍然發揮了很大的作用。經過10年的不斷改進，2001美國及歐洲的重癥醫學會，提出了改進的Sepsis診斷標準。
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 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.
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 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.
【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.
目的：了解ICU病房地震傷員的功能障礙的特點，為臨床康復治療提供依據。方法：運動功能評定應用MMT方法；運用關節角度尺評定關節活動度（ROM）；利用被動關節活動法評定肌張力、痙攣評定選用改良的Ashworth分級法；坐位平衡和站位平衡采用平衡反應試驗評定；日常生活活動（ADL）能力選用國際通用的Barthel指數量表評定。由我科研究生作為評定人員。結果：①ICU病房地震傷員以骨折患者為主,占70%，神經系統損傷占20%，擠壓綜合癥和肺挫傷各占5%；②女性骨折比例高于男性，為11∶3；神經系統損傷沒有多大差異；截肢和癱瘓的患者中，男性高于女性，比例分別為4∶1和3∶2；肺部感染以女性更為明顯，為7∶1；③47.6%的地震傷員關節活動受限（評定21人），93.3%的肌力下降（評定15人），15.8%肌張力下降（評定19人），36.8%肌張力增高（評定19人），30.0%的坐位平衡下降（評定10人），96.4%站立平衡下降；④ADL能力100%受限（評定20人），其中洗澡、修飾、如廁、平地行走45 m、上下樓梯受限均為100%，95%地震傷員進食能力下降，90%穿衣能力受限，35%大便失禁，60%小便控制能力下降，多數使用導尿管，95%地震傷員床椅轉移能力下降；⑤40%出現肺部感染。結論：關節活動度受限、肌力下降、肌張力異常、平衡功能障礙、ADL能力受限及肺部感染是ICU地震傷員主要功能障礙。早期康復介入、維持和改善關節活動度、肌力訓練、減張和牽伸訓練、平衡訓練、呼吸訓練、站立和行走訓練及ADL能力訓練應當作為康復治療的基本原則和方法。
Objective?To evaluate the diagnostic accuracy of procalcitonin (PCT) for ventilator-associated pneumonia (VAP). Methods?We searched MEDLINE, EMbase, The Cochrane Library, CBM, BIOSIS to identify all diagnostic tests which evaluated the diagnostic value of PCT in patients with VAP. QUADAS items were used to evaluate the quality of the included studies. Pooled sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), summary receiver operating characteristic (SROC) curve, and the heterogeneity of the included studies were calculated by using the Meta-disk software. Results?Five studies which were identified from 103 references met the inclusion criteria. The summary sensitivity, specificity, +LR, and –LR values were 0.70 (95%CI 0.62 to 0.77), 0.76 (95%CI 0.69 to 0.82), 5.651 (95%CI 1.237 to 25.810), and 0.349 (95%CI 0.155 to 0.784), respectively. Overall area under the curve (AUC) of SROC curve was 0.884 (DOR=19.416, 95%CI 2.473 to 152.47), demonstrating significant heterogeneity (I2gt;50%). Conclusion?The use of PCT for VAP diagnosis has only a moderate sensitivity and specificity. Although the overall accuracy of VAP diagnosis is relatively high, there is significant heterogeneity between the studies, so more high-quality studies are needed. Besides, using PCT alone to diagnose VAP is not sufficient, and a combination with other clinical evaluations is necessary.
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.
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.