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Objective To approach the significance of changes of percutaneous-arterial blood carbon dioxide partial pressure difference [P(tc-a)CO2] in liquid resuscitation of patients with septic shock. Methods One hundred and sixty-eight patients with septic shock admitted and treated in the Department of Intensive Care Unit (ICU) of Quzhou People's Hospital from January 2015 to January 2018 were enrolled, and after early goal-directed therapy (EGDT) for 6 hours, according to central venous oxygen saturation (ScvO2) and lactate clearance (LC), they were divided into ScvO2 and LC achievement group (ScvO2 ≥ 0.7 and LC≥10%), ScvO2 achievement group (ScvO2 ≥ 0.7 and LC < 10%), LC achievement group (ScvO2 < 0.7 and LC≥10%), and un-achievement group (ScvO2 < 0.7 and LC < 10%). The mechanical ventilation time, ICU hospitalization time, 28-day mortality, P(tc-a)CO2 etc. were compared among the four groups; the receiver operating characteristic curve (ROC) was used to evaluate the predictive value of P(tc-a)CO2 for 28-day prognosis in patients with septic shock. Results The trends of mechanical ventilation time, ICU hospitalization time, and 28-day mortality were all ScvO2 and LC achievement group < LC achievement group < ScvO2 achievement group < un-achievement group [the mechanical ventilation times (days) were respectively 6.12±2.59, 8.43±3.24, 11.78±4.12, 13.03±4.75, ICU hospitalization times (days) were 10.31±2.32, 13.85±3.56, 16.41±3.83, 18.52±4.05, and 28-day mortality rates were 28.85% (15/52), 40.91% (18/44), 51.28% (20/39), 69.70% (23/33)] and the differences among the four groups were statistically significant (all P < 0.05). After 6 hours of EGDT, the heart rate (HR), lactate (Lac), and P(tc-a)CO2 were lower than those before fluid resuscitation, but the mean arterial pressure (MAP), central venous pressure (CVP), and ScvO2 were higher than those before fluid resuscitation among four groups. Except CVP, the differences of other indicators compared among the ScvO2 and LC achievement group, ScvO2 achievement group, LC achievement group and un-achievement group were statistically significant (all P < 0.05). After 6 hours of EGDT, HR, Lac, P(tc-a)CO2 in ScvO2 and LC achievement group, ScvO2 achievement group and LC achievement group were significantly lower than those in the un-achievement group [HR (bpm): 89.05±29.43, 98.82±30.21, 94.33±28.64 vs. 112.85±32.74, Lac (mmol/L): 2.97±1.95, 3.87±2.32, 2.69±1.52 vs. 4.17±2.44, P(tc-a)CO2 (mmHg, 1 mmHg = 0133 kPa): 7.18±4.61, 12.61±5.34, 9.71±4.11 vs. 16.56±10.19], MAP and ScvO2 were significantly higher than those of the un-achievement group [MAP (mmHg): 88.05±21.67, 77.33±18.56, 83.11±19.71 vs. 70.32±18.79, ScvO2: 0.76±0.14, 0.75±0.16, 0.67±0.14 vs. 0.63±0.18, all P < 0.05]. The P(tc-a)CO2 of 28 days survivors were significantly lower than that of the deaths among four groups (mmHg: 5.78±2.27 vs. 14.14±3.65, 7.07±2.81 vs. 15.06±4.11, 6.35±2.09 vs. 14.94±4.06, 7.93±3.81 vs. 18.34±4.63, all P < 0.05). When P(tc-a)CO2 > 7.24 mmHg predicted 28-day mortality in ScvO2 and LC achievement group, the sensitivity was 89.29%, specificity was 91.45%, and the area under ROC curve (AUC) was 0.86; when P(tc-a)CO2 > 9.46 mmHg predicted 28-day mortality in LC achievement group, the sensitivity was 88.72%, specificity was 85.83% and AUC was 0.91; when P(tc-a)CO2 >12.05 mmHg predicted 28-day mortality in ScvO2 achievement group, the sensitivity was 82.79%, specificity was 86.90% and AUC was 0.79; when P(tc-a)CO2 > 16.22 mmHg predicted 28-day mortality in un-achievement group, the sensitivity was 73.35%, specificity was 80.68% and AUC was 0.68. Conclusion P(tc-a)CO2 can be used as an indicator to evaluate fluid resuscitation effect and prognosis in patients with septic shock.
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Objective To evaluate the effect of enteral immune nutrition on the occurrence of acute kidney injury(AKI) in sepsis patients. Methods A retrospective study was conducted, 80 patients with sepsis admitted and treated in the intensive care unit (ICU) of Quzhou People's Hospital from January 2015 to December 2016 were enrolled, and according to different treatment programs, they were divided into an immune nutrition group and a standard nutrition group, each group 40 cases. The two groups received an equal amount of calories and nitrogen in enteral nutrition (EN). After treatment, the changes of serum total protein (TP), albumin (Alb), prealbumin (PA), hemoglobin (Hb), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin (IL-6, IL-10), infection site, length of stay in ICU, mortality in ICU, AKI incidence, AKI staging, etc in the two groups were observed. Results ① After treatment, the nutritional indicators TP, Alb, PA, Hb levels were significantly increased, the serum inflammatory factors CRP, TNF-α, IL-6 were obviously decreased and IL-10 was markedly increased in the two groups compared with those before treatment (all P < 0.05), the changes in the immune nutrition group were more obvious than those in the standard nutrition group [TP (g/L): 60.84±5.90 vs. 58.32±6.11, Alb (g/L): 33.95±3.83 vs. 31.79±3.44, PA (g/L): 0.24±0.04 vs. 0.21±0.03, Hb (g/L): 117.47±16.15 vs. 112.50±15.71, CRP (mg/L): 53.04±23.76 vs. 82.33±37.09, TNF-α (ng/L): 20.29±17.74 vs. 29.63±18.43, IL-6 (ng/L): 50.74±28.55 vs. 80.32±31.67, IL-10 (ng/L): 41.09±24.65 vs. 40.86±24.73]; ② The length of stay in ICU (days: 10.54±4.33 vs. 14.80±5.19), ICU mortality [15.00% (6/40) vs. 32.50% (13/40)] and the incidence of AKI [22.50% (9/40) vs. 47.50% (19/40)] of immune nutrition group were significantly lower than those of standard nutrition group (all P < 0.05); There were 9 cases of AKI mainly at stage I andⅡ (8 cases) in the immune nutrition group, while in the standard nutrition group there were 19 cases with AKI mainly at stageⅢ (11 cases). Conclusion The enteral immune nutrition can effectively reduce the incidence of AKI in sepsis patients, and the mechanism may be related to the immune nutritional preparation can inhibit the expressions of pro-inflammatory factors such as TNF-α, IL-6, etc.
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Objective To study the clinical effect of psychological intervention combined with trimetazidine and bisoprolol in the treatment of left ventricular ejection fraction with heart failure. Methods 40 patients with heart failure were enrolled in this study. 40 patients were divided into control group and study group by digital randomization. There were 20 patients in each group and the patients in the control group.The patients were treated with trimetazidine and bisoprolol. The study group was treated with psychological intervention on the basis of the treatment. The clinical efficacy, adverse reactions, left ventricular ejection fraction and anxiety self-rating were analyzed (SAS), self-rating depression scale (SDS) score. Results The total effective rate of the clinical treatment group was 90.00％ higher than that of the control group (70.00％)P<0.05. There was no significant difference between the two groups in the adverse reaction. The mean left ventricular ejection fraction of the study group was (40.25 ± 5.24), which was significantly lower than that of the control group (43.92 ± 5.30). The scores of the study group were (50.26 ± 1.35) and (51.38 ± 2.61) respectively in SAS and SDS scores (54.36 ± 2.60), (56.98 ± 3.25) in the control group, (P<0.05). Conclusion The patients with left ventricular ejection fraction retention psychological failure in the application of trimetazidine, bisoprolol treatment based on the necessary psychological intervention, can effectively improve the patient's negative emotions, improve patient compliance, and then improve clinical efficacy, clinical significant application value.
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Objective To evaluate interventional therapy for acute massive and submassive pulmonary embolism.Methods From June 2011 to June 2014.53 patients were enrolled and divided into group massive pulmonary embolism (MPE,n =16) and group submassive pulmonary embolism (SPE,n =37),both receiving catheter thrombectomy + contact thrombolysis within 12 hours after diagnosis.Preand post-interventional measures were assessed,including mean pulmonary arterial pressure (MPAP),cardiac biomarkers,tricuspid regurgitation,right ventricular (RV) dilatation,and massive hemorrhage within 72 hours.Patients were followed up for 6 months for the occurrence of chronic thromboembolic pulmonary hypertension.Results In all 53 patients were successfully completed catheter thrombectomy +contact thrombolysis,the mean pulmonary artery pressure in group MPE decreased from (47 ± 6)mmHg to (34 ± 4) mmHg (P ＜ 0.05),and in group SPE decreased from (44.2 ± 1.5) mmHg to (31.4 ± 6.2) mmHg (P ＜ 0.05).The ventriculus dexter disfunction was alleviated in 78.4％ patient after therapy.Overall 1.9％ patients suffered from massive hemorrhage,(0) in group MPE,and (2.7％)in group SPE.The incidence of chronic thromboembolic pulmonary hypertension during 6 moths follow up was 0.Conclusion Early interventional therapy for massive and submassive pulmonary embolism decreased pulmonary artery pressure,relieved right ventricular dysfunction,reduced bleeding complications and the incidence of chronic thromboembolic pulmonary hypertension.
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Objective To investigate the clinical significance of invasive hemodynamic monitoring in early interventional treatment of acute massive pulmonary embolism.Methods From 2010 June to 2014 January,40 cases of acute massive pulmonary embolism admitted to the ICU in our hospital were analyzed divided into experimental group (20 cases) and control group (20 cases):while receiving conventional dose of peripheral venous thrombolytic therapy,the therapeutic effect of thrombolysis was evaluated by different ways.In experimental group,adopted Vigileo technology for continuous monitoring SVV,CI and ScvO2,guiding thrombolytic and interventional therapy after 12 hrs.If after 24 hrs the right ventricular ejection fraction (RVEF) and pulmonary artery systolic pressure (PSAP) did not improve,patients were converted to interventional therapy.We compared the CVP,MAP,PO2/FIO2,RVEF,PSAP,28-day mortality and the change in pulmonary vascular after 6 month.Result In two groups,CVP,MAP,PO2/FIO2 improved similarly after thrombolytic therapy.The experimental group were under the continuous monitoring of hemodynamic,12 patients were shifted to interventional therapy when ScvO2,SVV,CI did not increase after 12 hours.While 4 patients in control group were converted to interventional therapy after 24 hours.In the experimental group after 24 hours thrombolytic,the PO2/FIO2,RVEF and PSAP were higher than those in the control group.Compared with the control group,28-day mortality were same,but after follow up six moths RVEF,PSAP significantly improved.Conclusions FloTrac/Vigileo monitoring technology can be applied in assessment of massive pulmonary embolism thrombolytic to guide early interventional therapy,improve the oxygenation and right heart failure in the early stage,reduce the occurrence of pulmonary hypertension,improve the long-term pulmonary function.
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Objective To investigate the effect of non-alcoholic fatty liver disease (NAFLD) on virologic response in chronic hepatitis B patients treated with nucleos(t)ide analogues.Methods Three hundred and thirty-two treatment-naive patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) who visited clinic or hospitalized in the First Affiliated Hospital of Wenzhou Medical College from January 2007 to December 2009 were enrolled and finally 316 patients completed the research.Among them,106 patients were diagnosed with CHB complicated with NAFLD by ultrasonography (NAFLD group),and the remaining 210 patients were diagnosed with simple CHB (CHB group).Patients in both groups were treated with combination therapy of lamivudine (LAM) plus adefovir dipivoxil (ADV) or entecavir (ETV) monotherapy for 96 weeks.Alanine aminotransferase (ALT) levels,virologic response and serological response were compared pre-and post-treatment in both groups.Enumeration data was compared using x2 test,and correlation analysis was performed using Logistic multivariate regression analysis.Results Rates of hepatitis B virus (HBV) DNA clearance in the NAFLD group at week 12,24 and 48 were 46.2％,61.3％ and 74.5％,respectively,which were all significantly lower than those in CHB group (61.9％,73.8％ and 83.8％,x2 =7.051,5.195,3.895,respectively; all P＜0.05).However,rates of HBV DNA clearance were 85.8％ in the NAFLD group and 91.9％ in the CHB group at week 96.This difference did not reach the level of significance (x2 =2.838,P＞0.05).Rates of HBeAg loss in the NAFLD group were 27.4％ at week 48 and 37.7％ at week 96,compared to 33.3％ and 44.8％ in the CHB group.There was no significant difference in these two groups (x2 =1.169,1.424,both P＞0.05).Rate of HBeAg seroconversion in the NAFLD group was significantly lower than that in the CHB group at week 96 (17.9％ vs29.5％,x2=4.972,P＜0.05).Rates of ALT normalization were also found to be significantly lower in the NAFLD group than those in the CHB group at week 48 (69.8％ vs 80.5％,P＜0.05) and at week 96 (82.1％ vs 91.0％,P＜0.05).Multivariate regression analysis demonstrated that serum levels of triacylglycerol (OR=3.725,P=0.000),uric acid (OR=1.005,P=0.040) and fasting blood-glucose (OR=3.067,P=0.000) were independent risk factors associated with NAFLD.NAFLD was found to be a risk factor of virologic response at each time point throughout the treatment.(week 12,OR=2.749,P=0.001; week 24,OR=1.981,P=0.030; week48,OR=2.348,P=0.021; week 96,OR=8.053,P=0.001).Conclusions During antiviral therapy,NAFLD may affect biochemical and serological responses in CHB patients treated with nucleos(t) ide analogues,and may affect early virologic response in these patients.