A new warning scoring system establishment for prediction of sepsis in patients with trauma in intensive care unit / 中华危重病急救医学

Objective To analyze the risk factors of patients with trauma in intensive care unit (ICU), a new warning scoring system is established for predicting the incidence of sepsis in traumatic patients; and to provide a new simple method of clinical score, which could provide a reference for clinical prevention and treatment of sepsis. Methods The clinical data of 591 patients with trauma in the ICU of the Army Specialized Medical Center of Army Medical University and Affiliated Hospital of Zunyi Medical University from January 2012 to December 2017 were retrospectively analyzed. The patients were divided into sepsis group (n = 382) and non-sepsis group (n = 209) according to their clinical outcome. The basic clinical data of all ICU trauma patients were collected, and the differences in gender, age, underlying diseases, and vital signs, critical illness scores, blood culture results and laboratory biochemical examinations within 24 hours of ICU admission between the two groups were analyzed. Univariate Logistic regression analysis was used to screen the related factors leading to sepsis. The indexes with P < 0.12 analyzed by univariate Logistic regression analysis were included in multivariate Logistic regression analysis. The risk factors of sepsis in traumatic patients were screened and assigned, and the total score was sepsis early warning score. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of the warning score of sepsis in patients with trauma. Results The incidence of sepsis in ICU trauma patients was 64.6% (382/591), and the ICU mortality was 10.5% (40/382). The traffic accident was a common cause of ICU trauma patients. Compared with non-sepsis patients, Glasgow coma score (GCS), proportion of past history, red blood cell (RBC), platelet (PLT), albumin (Alb) were lower in patients with sepsis, and body temperature, pulse, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), sequential organ failure assessment (SOFA), injury severity score (ISS), new injury severity score (NISS), fraction of inspired oxygen (FiO2), blood sodium, activated partial thromboplastin time (APTT), prothrombin time (PT), procalcitonin (PCT), C-reactive protein (CRP) levels were higher, blood transfusion, central venous catheterization, mechanical ventilation, shock, multiple organ dysfunction syndrome (MODS), open injury and multiple injuries were more common, the duration of mechanical ventilation, ICU days and total hospital days were longer, and all the differences were statistically significant. Most of the traumatic patients with sepsis were undergone with multiple trauma. Compared with non-sepsis patients, the proportion of multiple position trauma was significantly higher than patients without sepsis. And most traumatic patients were insulted in head, face and neck. The risk factors were screened by univariate and multivariate Logistic stepwise regression analysis, the indexes into the regression model were pulse > 100 bpm [odds ratio (OR) = 1.617, 95% confidence interval (95%CI) = 0.992-2.635, P = 0.044], APTT > 36 s (OR = 2.164, 95%CI =1.056-4.435, P = 0.035), shock (OR = 1.798, 95%CI = 1.056-3.059, P = 0.031), mechanical ventilation (OR = 5.144, 95%CI = 2.302-11.498, P < 0.001), APACHEⅡ > 21 (OR = 3.348, 95%CI = 1.724-6.502, P < 0.001), NISS > 25 (OR = 3.332, 95%CI = 1.154-9.624, P = 0.026), assigning scores were 0.5, 1.0, 0.5, 1.5, 1.5, 1.5, respectively, which were included in the new warning score of sepsis. ROC curve analysis showed that the area under ROC curve (AUC) of warning score for predicting sepsis in patients with trauma was 0.782, which was significantly higher than the APACHEⅡ(AUC = 0.672), APTT (AUC = 0.574) and NISS (AUC = 0.515) with significant difference (all P < 0.01). When the cut-off value of sepsis warning score was 4.0, the sensitivity and specificity were 71.7% and 61.9%, respectively. Conclusions Close monitoring and stabilization of vital signs of traumatic patients within 24 hours of ICU admission and reduction of unreasonable invasive mechanical ventilation time are expected to reduce the incidence of sepsis in traumatic patients. New warning score of sepsis consisted of six factors: pulse, APTT, shock, mechanical ventilation, APACHEⅡ and NISS. Rational use of warning score of sepsis would help us to assess the prognosis of traumatic patients more easily and effectively, and the predicted effect is much better than APACHEⅡ, APTT and NISS.

Clinical Observation of Cefoperazone Sodium and Sulbactam Sodium Combined with Shenmai Injection in the Treatment of Elderly Stroke Associated Pneumonia / 中国药房

OBJECTIVE:To observe therapeutic efficacy and safety of cefoperazone sodium and sulbactam sodium combined with Shenmai injection in the treatment of elderly stroke associated pneumonia(SAP). METHODS:A total of 84 SAP patients in Dazhou Municipal Central Hospital during Mar. 2016-Mar. 2017 were divided into control group(42 cases)and observation group (42 cases)according to random number table. Based on routine treatment,control group was additionally given Cefoperazone sodium and sulbactam sodium for injection 3 g added into 5% Glucose injection 100 mL,intravenously,twice a day;suitable antibiotics were selected according to the results of pathogenic examination and drug sensitivity test. Observation group was additionally given Shenmai injection 100 mL added into 5% Glucose injection 250 mL intravenously,once a day,on the basis of control group. Both groups were treated for consecutive 2 weeks. Clinical efficacies of 2 groups were observed,and the levels of T-lymphocyte subsets(CD4+,CD8+,CD4+/CD8+)and inflammatory markers(TNF-α,hs-CRP,PCT),length of hospital stay before and after treatment. The ADR was recorded. RESULTS:The total response rate(95.24%)and marked response rate (47.62%)of observation group were significantly higher than those of control group(83.33%,23.81%);length of hospital stay in observation group [(15.24±3.53)d] was significantly shorter than control group [(18.43±4.21)d],with statistical significance (P<0.05).After treatment,the levels of CD4+and CD4+/CD8+in 2 groups were significantly higher than before treatment,and the observation group was significantly higher than the control group;the levels of CD8 +,TNF-α,hs-CRP and PCT in 2 groups were significantly lower than before treatment;the observation group was significantly lower than the control group,with statistical significance(P<0.05);there was no statistical significance in the incidence of ADR between 2 groups(P>0.05). CONCLUSIONS:Based on routine treatment,cefoperazone sodium and sulbactam sodium combined with Shenmai injection treat SAP significantly,can effectively improve immune function, reduce inflammation level and shorten the length of hospital stay without increasing the occurrence of ADR.

Predictive value of combining of anatomy scoring system and physiological scoring system for the diagnosis of multiple organ dysfunction syndrome in patients with severe trauma / 中华烧伤杂志

<p><b>OBJECTIVE</b>To evaluate the predictive value of a combination of anatomy scoring system and physiological scoring system for the diagnosis of multiple organ dysfunction syndrome (MODS) in patients with severe trauma.</p><p><b>METHODS</b>The clinical data of 539 patients with severe trauma hospitalized in ICUs of the First Affiliated Hospital of Chengdu Medical College, Daping Hospital of the Third Military Medical University, and the Affiliated Hospital of Zunyi Medical College from January 2010 to December 2014, conforming to the study criteria, were retrospectively analyzed. The patients were divided into MODS group (n=361) and non-MODS group (n=178) according to the diagnostic criteria of MODS. The data of Injury Severity Score (ISS), New Injury Severity Score (NISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ISS+ APACHE II score, and NISS+ APACHE II score of patients on the first day of ICU admission were calculated and compared between the two groups. Data were processed with t test, chi-square test, and receiver operating characteristic (ROC) curves of the various scoring systems in 539 patients with severe trauma were plotted, and DeLong-DeLong non parametric test was used to evaluate the predictive ability for MODS of the various scoring systems.</p><p><b>RESULTS</b>The scores of ISS, NISS, APACHE II, ISS+ APACHE II, and NISS+ APACHE II of patients in MODS group were respectively (26±8), (36±12), (21±7), (47±10), and (56±14) points, and they were significantly higher than those of patients in non-MODS group [respectively (24±6), (28±7), (16±5), (39±8), and (44±9) points, with t values from 4.970 to 12.120, P values below 0.01]. The total areas under ROC curves (95% confidence interval) of ISS, NISS, APACHE II score, ISS+ APACHE II score, and NISS+ APACHE II score in MODS prediction of patients with severe trauma were respectively 0.611 (0.569-0.653), 0.693 (0.652-0.731), 0.719 (0.679-0.756), 0.727 (0.687-0.764), and 0.764 (0.726-0.799). The total areas under ROC curves of NISS, APACHE II score, ISS+ APACHE II score, and NISS+ APACHE II score were significantly larger than the total area under ROC curve of ISS (with Z values from 3.505 to 7.179, P values below 0.001). The total areas under ROC curves of APACHE II score and ISS+ APACHE II score were larger than the total area under ROC curve of NISS, but there were no significant differences (with Z values respectively 0.931 and 1.657, P values above 0.05), while the total area under ROC curve of NISS+ APACHE II score was significantly larger than that of NISS (Z=5.478, P<0.001). The total area under ROC curve of ISS+ APACHE II score was larger than that of APACHEⅡ score, but there was no significant difference (Z=0.450, P=0.653), and the total area under ROC curve of NISS+ APACHE II score was significantly larger than that of APACHE II score (Z=2.554, P<0.05). The total area under ROC curve of NISS+ APACHE II score was significantly larger than that of ISS+ APACHE II score (Z=2.989, P<0.01).</p><p><b>CONCLUSIONS</b>The combination of NISS and APACHE II score is more significant than ISS, NISS, APACHE II score, and ISS+ APACHE II score in prediction of MODS in patients with severe trauma.</p>

Efficacy and safety of early low-molecular-weight heparin sodium in prevention of posttraumatic venous thromboembolism / 中华创伤杂志

Objective To evaluate the efficacy and safety of early anticoagulation therapy using low-molecular-weight heparin sodium against venous thromboembolism (VTE) in traumatic patients.Methods A total of 120 severely traumatized patients were assigned to convention group (n =60) and anticoagulation group (n =60) according to the random number table.Patients in convention group were given physical therapy against VTE,while in anticoagulation group were given add-on low-molecularweight heparin sodium against VTE once the stopping of blood bleeding was achieved.Safety parameters were recorded including VTE incidence,blood loss indexes,hemorrhage-related complications,incidence of heparin-induced thrombopenia (HIT) and blood coagulation function indicators.Results Thirteen patients presented with VTE,with 10 patients (17％) in convention group versus 3 patients 5％) in anticoagulation group (P ＜ 0.05).Blood loss index in convention group was 1.252 ± 1.033 versus 1.447 ± 1.196 in anticoagulation group;two patients (3％) developed gastrointestinal bleeding in convention group versus five patients (8％) in anticoagulation group;five patients (8％) had wound bleeding in convention group versus eight patients (13％) in anticoagulation group (all P ＞ 0.05).HIT was not noted in anticoagulation group.At the endpoint of evaluation,no significant differences were noted between the two groups with regard to changes in prothrombin time (PT),activated partial thromboplastin time (APTT) and D-dimers (P ＞ 0.05);however,convention group versus anticoagulation group showed significant differences in international normalized ratio (INR) (0.97 ± 0.10 vs.1.03 ±0.17),fibrin (Fib) [(4.85-± 1.37) g/L vs.(4.01 ± 1.16) g/L] and platelet (PLT) [(317.68 ±141.71) ×109/Lvs.(422.20±178.16) ×109/L] (P＜0.05).Conclusion Inthe earlystage of trauma,low-molecular-weight heparin anticoagulation therapy can significantly reduce the incidence of VTE without increasing the risk of bleeding.

The predictive value of combination of anatomic scoring system and physiological scoring system in prediction of death in patients with severe trauma：a multicenter analysis of 614 cases / 中华危重病急救医学

ObjectiveTo compare the predictive value of anatomic scoring system, physiological scoring system, and the combination of two systems in death prediction of patients with severe trauma in intensive care unit (ICU). Methods A retrospective analysis of patients with severe trauma admitted to department of critical care medicine of Daping Hospital, the Third Military Medical University, and Zunyi Medical University from January 2011 to December 2014 was conducted. The patients meeting the following criteria were enrolled: over 16 years old, admitted to hospital shorter than 24 hours after trauma, length of ICU stay≥48 hours, and injury severity score (ISS)≥16. Patients were divided into two groups: survivors and non-survivors. The data of anatomic scoring system, including ISS and new injury severity score (NISS), and physiological scoring system, including acute physiology and chronic health evaluationⅡ(APACHEⅡ) score were collected. The predictive power for death of the scoring system alone or combination in patients with severe trauma was evaluated.Results A total of 614 patients with severe trauma were enrolled, and there were 153 deaths with a mortality rate of 24.9%. ISS, NISS, APACHEⅡ, ISS+ APACHEⅡ, NISS+ APACHEⅡ of non-survivors were significantly higher than those of survivors (ISS: 29.15±7.75 vs. 24.31±6.50, NISS: 41.96±12.01 vs. 29.64±8.19, APACHEⅡ: 23.71±6.58 vs. 17.02±5.49, ISS+ APACHEⅡ: 52.86±10.00 vs. 41.33±8.70, NISS+ APACHEⅡ: 65.67±13.46 vs. 46.66±10.43, allP< 0.01). The area under receiver operating characteristic curve (AUC) of ISS, NISS, APACHEⅡ, ISS+ APACHEⅡ, NISS+ APACHEⅡ was 0.687, 0.792, 0.782, 0.809, and 0.860, respectively. Both of ISS+ APACHEⅡ and NISS+ APACHEⅡ had higher AUC than that of ISS, NISS or APACHEⅡ alone; and the AUC of NISS+ APACHEⅡ was significantly larger than that of ISS+ APACHEⅡ(allP< 0.05). NISS+ APACHEⅡ showed the largest AUC in death prediction of severe trauma patients. The cut-off value, sensitivity, specificity, positive predict value (+PV), negative predict value (-PV), positive likelihood ratio (+LR), negative likelihood ratio (-LR), and Youden index of NISS+ APACHEⅡ, which had the greatest AUC, were 56, 75.2%, 82.0%, 58.1%, 90.9%, 4.17, 0.30, and 0.572, respectively.Conclusion The combination of anatomic scoring system and physiological scoring system is better than single scoring system for death prediction in patients with severe trauma in ICU, and it may be considered to be a new method for early identification of death risk in patients with severe trauma.

Epidemiological analysis and thinking on infections in the 533 trauma patients following Chinese Wenchuan earthquake / 中华创伤杂志

Objective To provide better emergency and patient services in well-equipped comprehensive hospitals, the organization and wisdom therapeutic strategy are of great importance for the recovery of injured patients from the earthquake zone. Method From 12 May 2008, following the 8.0 Magnitude earthquake in Wenchuan county of Sichuan Province, six Chongqing hospitals with third class in grade A were involved in the rescue of the injured patients with great effort. A total of 533 patients were retreated and followed up from quake zone. All the patients were scored with ISS and AIS system. The profiles of the patients examined, operated and clinical infection investigation were documented. Results Of 533 patients, the number of the patients whose ISS is below 16 is 456 (83.6%), the number between 16 and 25 is 65 (12.2%), and the humor above 25 is 12 (2.3%). The patients were classfled based on their fracture parts as follows: head and neck (n = 42), face (n = 7), chest (n = 114), abdominal and cavitas pelvis (n =81), limb and pelvis (n =314), body surface (n =205), with 180 single fracture site, 139 of them being two combined fracture sites, and 114 of them being above three combined fracture sites. Thirty-two of the patients were suffered from amputation. The number of patients suffered from crushing syndrome reached 21, with 281 surgical operations in hospitals. Seventy-nine patients were suffered from infections including 87.3% of pre-hespital infections. The results from bacteria culture and antibiotic susceptibility showed that the infected bacteria mainly involved in Escherichia coli, Staphylococcus anreus, Staphylococcus haemolyticns, Klebsiella pneumoniae, Baumanii, Aerobacter cloacae, Pseudomonas aeruginosa, C type chain coccus, Bacillus aerogenes capsulatus. The antibiotic susceptibility to diverse bacteria has no obvious changes and exists partial overlapping, and infected patients should be given the treatment of cephalosporin, macrolide antibiotic and so on. Conclusions For the emergency conditions after the catastrophe, the comprehensive hospitals must be prepared to meet large quantities of severe trauma and infection therapy. The scientific selection of antibiotics in the combinative therapy is of great importance to the enhancement of early specific treatment, prevention of severe trauma complications and rehabilitation of patients.