Evaluation index in predicting the prognosis of critical patients post cardiopulmonary resuscitation / 中华急诊医学杂志

Objective To assess the early prognosis of 117 patients after carduopulmonary resuscitation (CPR) in ICU by using the markers of inflammation,Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) scores.Methods A total of 117 CPR patients admitted between 2010 January to 2012 December were enrolled for study.Within 24 h after admission,inflammatory markers,blood routine items,hepatorenal function,electrolytes of blood were measured.The GCS and APACHE Ⅱ scores were recorded.Arterial blood gas analyses were performed at 0,12,and 24 h after hospitalization,and the 12-h and 24-h lactate clearance rates were calculated.Seven days after treatment,according to the outcomes,the patients were divided into survival group and death group,and the clinical data of two groups were analyzed.Results (1) Of them,73 patients died and 44 survived.Factor analysis showed that age,time elapsed from resuscitation to ICU admission,D-dimer,arterial oxygenation index (FiO2),arterial blood pH,arterial blood lactate concentration upon ICU admission,GCS score and APACHE Ⅱ score were significantly different between the two groups (P ＜ 0.05or P ＜ 0.01); (2) Two classification logistic regression analysis showed that D-Dimer,GCS score and APACHE Ⅱ score significantly correlated with the mortality risk of the patients in the wake of CPR with relative odds ratios of 1.000,2.091,and 0.531,respectively (P ＜ 0.05 or P ＜ 0.01) ; (3) Receiver operating characteristic curve analysis indicated that the area under the curve of GCS (0.821) and APACHE Ⅱ (0.869) had higher predictive value than D-dimer (0.655).The highest accuracy (84.6％) in predicting patient survival was achieved when the GCS score was 6.5.Meanwhile,the highest accuracy (82.1％) in predicting patient death was achieved when the APACHE Ⅱ score was 17.5.Conclusions Both GCS score and APACHE Ⅱ score has obvious correlation with the prognosis of the critically ill patients after CPR and could be used to predict prognosis at early stage.

Fluid resuscitation in a patient with severe hypovolemic shock and severe pulmonary capillary leak / 南方医科大学学报

A male patient undergoing extracorporeal ultrasound lithotripsy developed the symptoms of dyspnea, low blood pressure, palpitations, chest tightness, and sweating, and a clinical diagnosis of pulmonary capillary leak and hypovolemic shock was made. Pulse indicator continuous cardiac output (PiCCO) technique was used for resuscitation according to the measurements of extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI). The patient showed low levels of cardiac output (CO) and GEDI with a peak EVLWI of 32 ml/kg and profuse pink and thin sputum overflow from the trachea. The high ventilator support parameters failed to correct low oxygen saturation. Restricted fluid infusion was used to reduce pulmonary edema. Colloidal solution was given when GEDI was below 500 ml/m(2), and the volume and fluid infusion rate were reduced for a GEDI higher than 500 ml/m(2). Pulmonary edema was gradually reduced after the treatments with improvement of lactic acid level and liver and kidney functions. Vasopressors were withdrawn 6 days later, mechanical ventilation was discontinued 10 days later, and tracheal intubation was removed 25 days later, after which the patient was discharged. In the treatment of the patient, PiCCO monitoring played an important role.

Role of central venous pressure, global end diastolic volume index and extravascular lung water index in evaluating fluid resuscitation in patients with septic shock / 南方医科大学学报

<p><b>OBJECTIVE</b>To explore the role of central venous pressure (CVP), global end diastolic volume index (GEDI) and extravascular lung water index (ELWI) monitoring in patients with septic shock during fluid resuscitation by pulse induced continuous cardiac output (PiCCO) test.</p><p><b>METHODS</b>Forty-six patients with severe sepsis and septic shock were enrolled in this study. Hemodynamic monitoring was performed during fluid resuscitation and the data including CVP, GEDI and ELWI were collected to analyze their relationship and the clinical values.</p><p><b>RESULTS</b>In patients with septic shock, CVP showed a weak linear correlation with GEDI during fluid resuscitation (r=0.137, P=0.009). In the subgroups stratified with CVP cut-off values of 8 mmHg and 12 mmHg, the correlation coefficient between CVP and GEDI was 0.149 (P=0.029) in CVP<8 mmHg group, 0.075 (P=0.462) in 8 mmHg ≤ CVP ≤ 12 mmHg group, and 0.049 (P=0.726) in CVP>12 mmHg group. In the total of 367 data groups obtained, CVP showed no linear correlation with ELWI (r=0.040, P=0.445). In the CVP subgroups, CVP and ELWI were weakly correlated in CVP<8 mmHg group (r=0.221, P=0.001), but they showed no correlations in 8 mmH g≤ CVP ≤ 12 mmHg and CVP>12 mmHg groups (r=-0.047, P=0.646; r=0.042, P=0.765).</p><p><b>CONCLUSION</b>There is no significant linear correlation between CVP and GEDI or between CVP and ELWI in patients with septic shock. CVP can not reflect the circulatory blood volume or the degree of pulmonary edema.</p>

Effects of different modes of dilution during CVVHDF on the removal of different solutes with different molecular weights / 中华急诊医学杂志

Objective To compare the rates of clearance of different solutes during continuous veno-venous haemodiafiltration (CVVHDF) between pre-dilution and post-dilution.Methods A study in vitro was carried out using model CRRT system with AN69 filter used,which was applied to perform CVVHDF for solutes clearance.The removed amounts of different solutes including potassium ion (K +),creatinine (Cr),vancomycin,insulin,and interleukin-6 (IL-6) were determined in the groups of control (without dilution),pre-dilution and post-dilution during CVVHDF at the same substitution fluid amount.Each group was repeated 4 times (n =4).Results Post-dilution mode increased K +,Cr,vancomycin and insulin clearances significantly.There was no difference in clearance of IL-6 between the pre-and post-dilution groups.In the control group,insulin and IL-6 levels were decreased extremely.Conclusions In general,the rate of clearance using post-dilution of CVVHDF is higher than that using pre-dilution.Among high molecular weight solutes,the difference in clearance is not significant.The control group demonstrates insulin and IL-6 adsorbed by the filter.

Correlation analysis between serum interleukin-6 and central nervous injury in septic patients / 南方医科大学学报

<p><b>OBJECTIVE</b>To explore the relationship between interleukin-6 (IL-6) production and central nervous injury in septic patients.</p><p><b>METHODS</b>Twenty-two septic patients without central nervous system diseases were examined for serum IL-6 and neuron-specific enolase (NSE) levels, and the serum NSE levels and APACHEII scores were compared between patients with low, moderate, and high serum IL-6 levels. The correlations between NSE, APACHEII and serum IL-6 were analyzed.</p><p><b>RESULTS</b>In patients with low, moderate, and high serum IL-6 levels, the serum levels of NSE were 10.29∓4.05, 16.06∓5.84 and 23.97∓3.28 µg/L, respectively, showing a significant difference between the 3 groups (P<0.001). The APACHEII scores also differed significantly between the 3 groups (14.17∓4.67, 16.40∓4.84, and 24.00∓6.26, respectively, P=0.009). Correlation analysis showed significant positive correlations of IL-6 with NSE (r=0.788, P<0.001) and with APACHEII scores (r=0.733, P<0.001).</p><p><b>CONCLUSION</b>In septic patients, serum IL-6 level is significantly correlated with the severity of sepsis and brain injury, and can be used as a marker to monitor brain injury in septic patients.</p>

Organ-protective effect of continuous renal replacement therapy in a patient with severe polymyositis and dermatomyositis / 南方医科大学学报

A patient with skin rash, skin denudation, anuria, general dropsy and dyspnea for unknown etiology underwent continuous renal replacement therapy (CRRT) for 3 consecutive days. The biochemical indexes were monitored during the therapy and biopsy was performed on the right thigh. Pathological examination of the biopsy sample established the diagnosis of polymyositis(PM) and dermatomyositis(DM). After the start of CRRT, the patient's heart, liver, kidney and lung injuries showed obvious improvement, and the urine volume (UV) increased and serum creatinine (Cr), urea, total bilirubin (TBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase (CK), creatine kinase isoenzyme (CK-MB) and lactate dehydrogenase (LDH) levels all decreased promptly. The patient showed progressive improvement of the physiological condition even after CRRT, and was discharged 10 days later. This case suggests the efficacy of CRRT in the management of severe PM/DM and its value as a good option for treatment of severe autoimmune disease, especially systemic inflammatory response syndrome.

Influence of different immunosuppressants on monocyte chemoattractant protein-1 secretions in the whole blood / 中国组织工程研究

BACKGROUND: In the field of organ transplantation, patients often take immunosuppressants after organ transplantation, such as CsA, FK506, DEX and MPA. However, their mechanisms of immunosuppression are different. The effect of immunosuppressive drugs on monocyte chemoattractant protein-1 (MCP-1) remains poorly understood. OBJECTIVE: To investigate the effects of different immunosuppressants on the secretions of MCP-1 in whole blood. METHODS: The whole blood of healthy volunteers was mixed with different immunosuppressants for 6 hours, such as CsA, FK506, DEX and MPA, which included low, middle and high concentrations, followed by PMA and IONO stimulation for 6 hours. MCP-1 levels in whole blood samples were compared. The whole blood cultured alone served as control. RESULTS AND CONCLUSION: MCP-1 secretion was inhibited by DEX (1, 10 mg/L) and CsA (0.25,1.25 mg/L)- However, FK and MPA exhibited no such effect. Therefore, DEX and CsA may inhibit the function of monocytes and macrophages in immune system by diminishing the secretion of MCP-1. The combination of FK (5 μg/L), MPA (10 mg/L) and DEX (1 mg/L) or CsA (0.25 mg/L), MPA (10 mg/L) and DEX (1 mg/L) can inhibit the secretion of MCP-1, but only DEX among all the immunosuppressants mentioned above exhibited significant effect on inhibiting the secretion of MCP-1 when using alone.

Monitoring human leukocyte antigen humoral immunity sensitization in renal transplant recipients and its clinical significance / 中国组织工程研究

BACKGROUND: Panel reactive antibodies (PRA) easily appear in the peripheral blood of organ transplant recipients sensitized by allogeneic human leukocyte antigen (HLA).How to enhance the success rate of renal transplantation.and long-term survival rate of renal allografts in sensitized recipients should be further studied.OBJECTIVE: This study was to detecthuman leukocyte antigen immunoglobulin G(HLA-IgG) antibody level and its specificity in renal transplant recipients,evaluate humoral immunity sensitization,and investigate the relationship of the acceptable mismatching of HLA cross-reactive group and survival rate of renal allograft.DESIGN: A clinical observation.SETTING: Zhujiang Hospital Affiliated to Southern Medical University.PARTICIPANTS: A total of 1297 patients,824 males and 473 females,averaging (42±16) years of age,received renal transplantation in the Department of Organ Transplantation,Zhujiang Hospital,Southern Medical University between January 1998 and December 2005,were recruited for this study.Among these patients,165 were HLA-IgG antibody-positive recipients,1132 were HLA-IgG antibody-negative ones,1217 received renal transplantation for the first time,77 received renal transplantation twice,2 three times,and 1 four times.Written informed consent was obtained from each subject for related laboratory measurements and treatment.The protocol was approved by the Hospital's Ethics Committee.Reagents:Lamhda antigen tray (LAT),Lambda antigen tray mixed (LATM),Special Monocloneal Tray-Asian HLA Class Ⅰ,and Micro SSP? Generic HLA Class Ⅱ were purchased from One Lambda Company,USA.Taq polymerase was purchased from PE Company,USA. DNA extract reagent was from Qiagen Company,Germany.Anti-human complement 4d (C4d) polyclonal antibody and chrornogenic substrate DAB were purchased from Biomedica Company,Austria.METHODS: Prior to operation,serum HLA-IgG antibody in the recipients was determined by an enzyme linked immunosorbent assay (ELISA).HLA-IgG antibody-positive serum was further detected by antigen tray (LAT1240 and LATIHDS) for antibody-positive rate and specificity.HLA genotyping was performed by a sequence specific primer polymerase chain reaction (PCR-SSP).For 40 recipients who had elevated serum creatinine (Scr),anti-HLA antibody detection and renal transplant needle biopsy were conducted.At the same time,C4d deposition on the capillary wall around the renal tubule was observed by immunohistochemical staining.Survival rate of renal allografts in recipients 1,3,and 5 years after transplantation,and relationships of gender and renal transplantation and antibody-positive rate were investigated.Survival rate of renal allograft in recipients that received different mismatch of HLA cross-reactive group was analyzed.MAIN OUTCOME MEASURES: Prior to and after renal transplantation,HLA-IgG antibody-positive rate and HLA genotyping in renal transplant recipients.Characterization of C4d deposition on the capillary wall around the renal tubule in the renal transplant biopsy tissue.Difference of survival rate of renal allograft.RESULTS: All 1297 recipients were included in the final analysis.Among them,1132 were HLA-IgG antibody-negative recipients,165 were HLA-IgG antibody-positive ones,126 were anti-HLA class Ⅰ IgG antibody-positive ones,90 were anti-HLA class Ⅱ IgG antibody-pesitive ones,51 were anti-HLA class Ⅰ and Ⅱ IgG antibody-positive ones,and 94 were highly sensitized ones (antibody-positive rate ＞50%).Among 40 recipients with needle biopsy,C4d deposition was found in the 13 recipients,but not found in the 27 recipients.Ten out of thirteen C4d-positive recipients presented with anti-HLA antibody-positive in the peripheral circulation.The incidence for delayed graft function (DGF) was significantly higher in recipients with HLA-IgG antibody-positive than in recipients with HLA-IgG antibody-negative (P ＜ 0.01).There was no significant difference in the survival rates of renal allografts between recipients with HLA-IgG antibody-positive and with HLA-IgG antibody-negative 1 ,3,and 5 years after renal transplantation (P ＞ 0.05).Antibody-positive rate was significantly higher in female recipients than in male recipients (P ＜ 0.01).Antibody-positive rate was significantly higher in recipients that received renal transplantation for the second time than in recipients that received renal transplantation for the first time (P ＜ 0.01).With HLA cross-reactive group mismatching increasing,survival rate of renal allograft presented a tendency of decline.One,three and five years after renal transplantation,the survival rate of renal allograft was respectively 97%,94%,and 92% for recipients with no mismatching,and 91%,82%,and 77% for recipients with two mismatches,which was respectively decreased by 6%,12%,and 15% compared to recipients that received no mismatching.For recipients with three mismatches,the survival rate of renal allograft was respectively decreased by 9%,15%,and 24% compared to recipients with no mismatching.CONCLUSION: C4d deposition on the capillary wall around the renal tubule can be detected as an indicator of antibody-mediated humoral rejection.A good HLA matching can noticeably decrease the incidence of rejection and improve the survival of renal allograft.

A study on application of an external fixator for close reduction of tibial fractures / 中华创伤骨科杂志

Objective To design and manufacture an external fixator for close reduction of fibu la and tibial fractures.Methods The all-ring reduction and fixation system made of duroplasts comprises three main parts:two reduction rings with gears and worms,two modulation frames to correct lateral or anteroposterior re-placement,and four connecting rods.By cranking the handle,the gears wi ll be driven,which may in turn shift t he modulation frame,then the needle co nnecting the bone with the frame can s hift the fracture ends in three dimen sions and six freedom degrees.After reduction,the fracture is fixed by the cro ssed needles linked to several groups of half-ring fixation arms,which can b e shifted and locked onto the linking rod properly.Results The apparatus was used in 32patients.All cases got anatomic reduction,and the curativ e ratio was 100%.Conclusion The external fixator for close reductio n of tibial and fibula fractures has g ood reduction and fixation effect,a nd the design provides a very good clinical therap eutic method for close reduction of t ibial and fibula fractures.[