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Objective To study the predictive value of acute gastrointestinal injury (AGI) grading system introduced into Sequential Organ Failure Assessment (SOFA) score in patients with severe acute pancreatitis (SAP) in order to provide a reliable clinical tool for the evaluation of prognosis of SAP.Methods Patients with acute pancreatitis admitted to ICU from July 2012 to July 2014 were enrolled for study.The criteria of exclusion were the age below 18 years old,pregnancy,or patients without consent to the treatment.A total of 63 patients with 37 males and 26 females aged (47 ± 15.3) years were included.The data of their acute physiology and chronic health evaluation (APACHE) Ⅱ score,the highest SOFA score and AGI grade within the first week,and the 28-day mortality rate were collected.Patients without AGI were defined as zero point,and AGI grade Ⅰ-Ⅳ were defined as 1-4 points.The receiver operating characteristic curve (ROC) was used to evaluate the value of APACHE Ⅱ score,SOFA score,and SOFA + AGI score in predicting the prognosis of SAP.The areas under ROC curve (AUC) of the APACHE Ⅱ score,SOFA score,and SOFA + AGI score were compared with MedCalc software,and P value less than 0.01 was considered to be statistical significance.Results (1) The 28-day mortality of the 63 patients with SAP was 20.6％ (13/63),in which 50 patients in the survival group,13 patients in the death group.The APACHEⅡ scores of two groups were (15.62 ± 4.33 vs.12.10 ± 3.74,P=0.0048),the SOFA scores were (14.77 ± 3.09 vs.9.24 ± 2.88,P ＜0.01),and the SOFA + AGI scores were (18.77 ±3.09 vs.10.74 ± 3.17,P＜0.01).(2) The AUC of APACHEⅡ score was0.748 ± 0.084 (95％ CI:0.622-0.849),the AUC of SOFA score was 0.902 ± 0.059 (95％ CI:0.801-0.962),and the AUC of SOFA +AGI score was 0.963 ± 0.037 (95％ CI,0.882-0.994);There was no significant difference in AUC between APACHE Ⅱ score and SOFA score (P =0.10),and there was statistical significance between the AUC of APACHE Ⅱ score and that of SOFA + AGI score (P =0.013),and the difference in AUC between SOFA score and SOFA + AGI score was statistically significant (P =0.008).The Youden index and the positive likelihood ratio of SOFA + AGI score system were the greatest to be 0.863 and 15.38,respectively.Conclusions SOFA scoring system has better predictive value in patients with SAP when AGI grading system was introduced into it.
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Objective To explore the effect of decoction of four-drug juice plus glutamine on nutritional support in the elderly critically ill patients. Methods One hundred and twenty-four elderly critical ill patients in The First Hospital of Jilin University from May 2010 to May 2012 were randomly divided into treatment group(n = 62)and control group(n = 62). Patients in both two groups were given enteral nutrition(EN)plus parenteral nutrition(PN)after the hemodynamics became stable. In addition,patients in control group were given routine EN + PN,while in treatment group was given decoction o four-drug juice + EN plus glutamine + PN. Prealbumin (PA),serum total protein( TP),transferrin( TF)and serum albumin( ALB)were detected before and after treatment of nutritional support. The informations including recovery of bowel sounds,the occurrence of complications,antibiotic use time and the duration of ICU stay were recorded. Results There were no significant differences between two groups in terms of nutrition indices before treatment(P > 0. 05). After treatment,the contents of pre albumin,transferrin,total serum protein,serum albumin in treatment group were( 145. 24 ± 6. 72)g/ L,(1. 93 ± 0. 98)g/ L,(79. 86 ± 10. 38)g/ L,(54. 91 ± 2. 91)g/ L respectively,better than those in control groups((139. 24 ± 38. 76),(1. 68 ± 0. 33),(74. 73 ± 7. 31),(49. 87 ± 2. 61)g/ L),and the differences were statistically significant( t = 3. 610,2. 929,4. 360,6. 767;P < 0. 05). The incidence of stress ulcer and double infection in treatment group were 42%(26 / 62),37%(23 / 62),significantly lower than the control group(59%(37 / 62),53%(33 / 62)),and the differences were statistically significant( χ2 = 5. 186, 5. 271,P < 0. 05). Antibiotic use time and the duration of ICU stay in treatment group were(8. 82 ± 0. 71)d and(16. 14 ± 3. 01)d,and reaching full eternal nutrition time was(6. 90 ± 1. 01)d,decreased less than that in control group((10. 21 ± 1. 30),(20. 67 ± 2. 29),(13. 91 ± 1. 51)d)and the differences were statistically significant(t = 8. 892,7. 786,3. 609,P < 0. 05). The average recovery time of bowel sounds and first anal exhaust time average in treatment group were(26. 8 ± 3. 6)h,(25. 4 ± 3. 2)h,lower than that in control group ((38. 4 ± 4. 8)h,(37. 6 ± 4. 9)h)and the differences were statistically significant( t = 3. 551,2. 516,P< 0. 05). Conclusion The application of decoction of four-drug juice plus glutamine on nutritional support of the elderly critically ill patients can reduce complications,shorten the duration of ICU,recover the intestinal function as soon as possible. Meanwhile,patients can transit to full eternal nutrition as soon as possible,then the cost of therapy is reduced and rehabilitation is quickly.
ABSTRACT
Objective To discuss the clinical significance of fluid management of severe patients according to arterial pressure-based cardiac output (APCO) monitoring volume responsiveness index.Methods A retrospective cohort study was conducted.The severe patients were selected from the intensive care unit (ICU) of the First Hospital of Jilin University from June 1st,2012 to December 31st,2013.The hemodynamic parameters were monitored by APCO,and the fluid resuscitation was managed by stroke volume variation (SVV) and passive leg-raising test (PLR) when the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score ≥ 15,heart rate ＞ 100 bpm with the result that the preload and heart function could not be evaluated.The heart rate,SVV,lactic acid (Lac) and central venous pressure (CVP) and curative effect were recorded before and after carrying out fluid management strategy.The criteria of clinical effective was defined as heart rate decreased and (or) stroke volume (SV) increased ≥ 10％,accompanied by blood Lac and SVV decreased,other than,the cases did not meet above criteria were considered ineffective.Results Sixty-eight patients were enrolled in the study.① Before carrying out fluid management strategy:40 cases with CVP＞ 12 cmH2O (1 cmH2O=0.098 kPa),and 16 cases with 5-12 cmH2O,12 with ＜5 cmH2O.SVV＞13％ in 35 cases,SVV ＜ 13％ in 9 cases.PLR positive in 18 cases,and PLR negative in 6 cases.It was implicated that the patients with poor preload (SVV ＞ 13％ and PLR positive) accounted by 77.9％ (53/68).② There were 49 effective cases and 19 ineffective cases 4 hours after carrying out fluid management strategy,and the effective rate was 72.06％ (49/68).While there were 56 effective cases and 12 ineffective cases after 12 hours,and the total effective rate was 82.35％ (56/68).③ In effective group,heart rate,SVV,Lac after fluid management strategy were significantly lower than those before fluid management strategy [4 hours after fluid management strategy:heart rate (bpm) 112.45 ± 13.53 vs.129.55 ± 15.49,SVV (15.47 ± 6.32)％ vs.(21.20 ± 7.40)％,Lac (mmol/L) 4.16 ± 3.12 vs.6.21 ± 4.11 ; 12 hours after fluid management strategy:heart rate (bpm) 110.02 ± 13.92 vs.129.61 ± 14.93,SVV (14.61 ± 15.52)％ vs.(20.66 ± 7.40)％,Lac (mmol/L) 3.35 ± 2.26 vs.6.11 ± 4.02,P＜0.05 or P＜0.01],while there was no significant difference in those markers between before and after fluid management strategy in ineffective group [4 hours after fluid management strategy:heart rate (bpm) 119.53 ± 11.68 vs.125.79 ± 11.58,SVV (16.95 ±6.48)％ vs.(18.47 ±4.96)％,Lac (mmol/L) 5.55 ± 3.80 比 6.54 ± 3.72 ; 12 hours after fluid management strategy:heart rate (bpm) 115.92 ± 11.71 vs.123.40 ± 11.59,SVV (17.17 ± 6.09)％ vs.(19.42 ± 8.25)％,Lac (mmol/L) 6.33 ± 3.40 vs.7.21 ± 3.81,all P＞ 0.05].CVP only at 12 hours after fluid management strategy in effective group was significantly higher than that before fluid management strategy (cmH2O:12.88 ± 3.38 vs.11.27 ± 4.97,P＜0.05).Conclusion SVV monitored by APCO is a good indicator of volume responsiveness index,which can be used as an important reference combined with PLR for fluid management of severe patients.