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objective:To investigate the tolerability of early enteral nutrition (EN), and to further explore the association of early EN with clinical outcome in critically ill patients with hemodynamic instability.Methods:The adult patients from Zhejiang Provincial People’s Hospital with an expected admission to ICU for at least 24 h were consecutively recruited from May 2014 to May 2016, and all clinical, laboratory, and survival data were prospectively collected. The AGI grade was daily assessed on the first week of ICU admission. Enteral nutrition (EN) started after 6 h of hemodynamic stability (MAP ≥ 65 mmHg) when the patients took vasoactive medication. The patients were divided into three groups based on the timing of EN initiation: early EN group (EN initiation within 48 h of ICU admission), late EN group (EN initiation at more than 48 h of ICU admission), and no initiation of enteral feeding within 7 days of ICU admission.Results:Of 201 patients enrolled, the mean age was 65.3 ± 16.4 years, APACHE II score was 22.4 ± 6.85, and 191 patients (95.0%) took mechanical ventilation. There were no differences in high gastric residual volume, diarrhea, and gastrointestinal (GI) bleeding between the early EN group and late EN group ( P>0.05). Whereas, patients in the no initiation of EN within 7 days of ICU admission had a lower prevalence of gastric residual volume (16.7% vs. 33.3%, P=0.05), but higher prevalence of GI bleeding (47.2% vs. 26.1%, P=0.02). Compared with those in the late EN group and in no initiation of EN within 7 days of ICU admission, patients in the early EN group had lower 28- (30.4% vs. 47.9% vs. 55.6%, P=0.01) and 60-day mortality rates (38.0% vs. 53.4% vs. 63.9%, P=0.017). Multivariate Cox regression analysis showed that the timing of EN initiation on the admission to ICU (early EN vs. late EN, χ 2≥5.83, P<0.05; early EN vs. no initiation of EN, χ 2≥7.90, P<0.01), serum creatinine ( χ 2=5.06, P<0.05), plasma albumin ( χ 2≥6.41, P<0.01), AGI grade ( χ 2≥8.15, P<0.01), and APACHE II score ( χ 2≥9.62, P<0.01) were independent predictors for 28- and 60-day mortality. Conclusions:Early EN on admission to ICU could be tolerated, and is significantly associated with lower risk of 28- and 60-day mortality in critically ill patients with vasoactive medication to maintain hemodynamic stability.
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Primary amebic encephalitis (PAM) is a devastating central nervous system infection caused by Naegleria fowleri, a free-living amoeba, which can survive in soil and warm fresh water. Here, a 43-year-old healthy male was exposed to warm freshwater 5 days before the symptom onset. He rapidly developed severe cerebral edema before the diagnosis of PAM and was treated with intravenous conventional amphotericin B while died of terminal cerebral hernia finally. Comparing the patients with PAM who has similar clinical symptoms to those with other common types of meningoencephalitis, this infection is probably curable if treated early and aggressively. PAM should be considered in the differential diagnosis of purulent meningoencephalitis, especially in patients with recent freshwater-related activities during the hot season.
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Adult , Humans , Male , Amoeba , Amphotericin B , Brain Edema , Central Nervous System Infections , Central Nervous System Protozoal Infections , Diagnosis , Diagnosis, Differential , Encephalitis , Encephalocele , Fresh Water , Meningoencephalitis , Naegleria fowleri , Seasons , SoilABSTRACT
Objective To investigate the prevalence of feeding intolerance (FI),and to explore the FI within 7 days of ICU admission in association with clinical outcome in critically ill patients.Methods The adult patients from 14 general ICUs in Zhejiang Province with an expected admission to ICU for at least 24h were recruited from March 2014 to August 2014,and all clinical,laboratory,and survival data were prospectively collected.The AGI (acute gastrointestinal injury) grade was daily assessed based on gastrointestinal (GI) symptoms,feeding details and organ dysfunction within the first week of ICU stay.The intra-abdominal pressures (IAP) was measured using AbViser device.Results Of 550 patients enrolled,418 were assessed in GI symptoms and feeding details within 7 days of ICU stay.The mean age and SOFA score were (65.1 ± 18.3) years and (8.96 ±4.10),respectively.Of them,355 patients (84.9％) were under mechanical ventilation support,and 37 (8.85％) received renal replacement therapy.The mean length of time for enteral feeding was (30.8 ±26.2) h,and the prevalence of FI on the 3rd and 7th day of ICU stay accounted for 39.2％ and 25.4％,respectively.Compared to those with FI within 7 days of ICU stay,the patients without FI had higher rate of successively weaning from mechanical ventilation (21.3％ vs.5.7％,P =0.003) and higher rate of withdrawal of vasoactive medication (45.5％ vs.20.0％,P =0.037),as well as lower mortality rate of 28-day (24.4％ vs.38.7％,P =0.004) and 60-day (29.6％ vs.44.3％,P =0.005).In multivariate Cox regression model with adjustment for age,sex,participant center,serum creatinine and lactate,AGI grade on the first day of ICU stay,and comorbidities,the FI within 7 days of ICU stay (x2 ≥ 7.24,P ＜ 0.01) remained to be independent predictors for 60-day mortality.After further adjusted for SOFA score,the FI within 7 days of ICU stay (HR =1.71,95％ CI:1.18-2.49;P =0.006) and AGI grade on the first day of ICU stay (HR =1.33,95 ％ CI:1.07-1.65;P =0.009) could provide independent prognostic values of 60-day mortality.Conclusions There is high rate of FI occurred within 7 days of ICU stay,and is significantly associated with worse outcome.In addition,this study also provides evidence to further support that measurement of gastrointestinal dysfunction could increase value of SOFA score in outcome prediction for the risk of 60-day mortality.
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Objective To investigate the impact of early initiation of continuous renal replacement therapy (CRRT) based on Kidney Disease: Improving Global Outcomes (KDIGO) classification on the prognosis of critically ill patients with acute kidney injury (AKI). Methods A retrospective analysis of clinical data of patients diagnosed as AKI in Department of Critical Care Medicine of Zhejiang Provincial People's Hospital from January 2011 to January 2015 was conducted. All patients included should be 18 years old or older, having stayed in intensive care unit (ICU) for more than 48 hours, and received CRRT. All subjects were divided into three groups according to their renal function before CRRT according to the KDIGO-AKI guideline: AKI-stage 1 group, AKI-stage 2 group and AKI-stage 3 group. The general condition, original disease, severity of disease, duration of mechanical ventilation, the length of ICU or hospital stay, 28-day survival rate and in-hospital mortality rate were compared among these three groups. Additionally, risk factors for the 28-day survival rate and hospital mortality of critically ill patients with AKI were screened by logistic regression analysis. Results A total of 258 critically ill patients with AKI were enrolled, with 64 cases in AKI-stage 1 group, 62 cases in AKI-stage 2 group, and 132 cases in AKI-stage 3 group. 116 patients survived with 28-day survival rate of 44.96%. 154 patients died with hospital mortality 59.69%. The precipitating factors of AKI in all three groups (stage 1, stage 2, and stage 3) were similar, with sepsis, heart failure and poisoning (drugs or poison) being the main triggers for AKI, accounting for 35.66%, 19.38% and 13.18%, respectively. There were significant differences in the rate of vasoactive agent usage (31.25%, 41.94%, 50.00%, χ2 = 6.241, P = 0.044), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score (20.87±7.37, 17.19±7.02, 22.58±7.95, F = 5.292, P = 0.006) and sequential organ failure assessment (SOFA) score (8.41±3.46, 6.22±2.43, 9.58±3.71, F = 10.328, P = 0.000), while there was no significant difference in gender, age, primary disease, time from ICU admission to the beginning of CRRT, mean arterial pressure (MAP), lactate level or 24-hour lactate clearance rate (LCR), mechanical ventilation time, the length of ICU or hospital stay, 28-day survival rate or hospital mortality among these three groups (all P > 0.05). According to the logistic regression analysis, time from ICU admission to start of CRRT and lactate level were the independent risk factors for 28-day survival rate or hospital mortality of critically ill patients with AKI [odds ratio (OR) for 28-day survival rate was 0.850 and 0.774, 95% confidence interval (95%CI) was 0.752-0.960 and 0.638-0.940, P value was 0.009 and 0.010, respectively; OR for hospital mortality was 0.884 and 0.756, 95%CI was 0.781-1.000 and 0.610-0.939, P value was 0.049 and 0.011, respectively]. Conclusion Early initiation of CRRT based on KDIGO-AKI classification could not improve the prognosis of critically ill patients with AKI, the optimal timing of RRT for such patients remains to be further explored.
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Objective To discuss the effects of pressure control (PC) and positive end-expiratory pressure (PEEP) incremental method lung recruitment maneuver (RM) on haemodynamics in piglets with acute lung injury (ALI) induced by paraquat (PQ) poisoning. Methods The ALI/acute respiratory distress syndrome (ARDS) model was reproduced by intraperitoneal injection of 20% PQ (20 mL) in 10 healthy female piglets, and they were randomly divided into PC lung RM group (RM1 group) and PEEP incremental method lung RM group (RM2 group), with 5 piglets in each group. Heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) were monitored by pulse-indicated continuous cardiac output (PiCCO) monitoring before model reproduction (baseline), on the time of successfully set up of model and at 5, 15 and 30 minutes after RM. At the same time the arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) were recorded, and oxygenation index was calculated. Lung tissues were collected before model reproduction, on the time of successfully set up of model, and at 30 minutes after RM respectively, and pulmonary pathology changes were observed after hematoxylin and eosin (HE) staining under light microscopy. Results The HR, MAP, and PaCO2 on the time of successfully set up of model in both groups were increased obviously while CI, PaO2, and oxygenation index were decreased obviously as compared with those at baseline, all of which conformed to the expression of ALI/ARDS. With RM time extended, the HR in both groups was declined while MAP and CI were increased gradually. The HR and MAP at 5 minutes after RM of RM1 group were significantly lower than those of the RM2 group [HR (bpm): 126.8±5.2 vs. 134.0±3.8, MAP (mmHg, 1 mmHg = 0.133 kPa): 98.4±3.3 vs. 102.8±2.6, both P 0.05). The lung tissue in both groups showed a variety of pathological changes at 30 minutes after RM. The main performances were the loss of alveolar epithelial cells, the further wideness of alveolar interval and the distension of alveolar, and the part breakage of alveolar interval. The wideness of alveolar interval was more significant in RM2 group than that of RM1 group, and alveolar cleft was more common too. Conclusion Both PC and PEEP incremental method lung RM can improve the oxygenation of the piglets with ALI/ARDS induced by PQ, and the PC lung RM has less impact on haemodynamics.
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ObjectiveTo investigate the incidence of hypomagnesemia and the effect of serum magnesium levels on the prognosis of critically ill patients in intensive care unit (ICU).Methods A single-center prospective observation was conducted. The adult patients admitted to ICU of Zhejiang Provincial People's Hospital from January 2012 to January 2014 were enrolled, and they were expected to stay in hospital for more than 48 hours. All the patients who had been diagnosed with hypomagnesemia before ICU admission, or those who had received magnesium supplement therapy were excluded. All patients were monitored for serum magnesium levels within 24 hours after ICU admission, and they were divided into three groups: normomagnesemic group (serum magnesium levels 0.7-1.2 mmol/L), hypomagnesemic group (serum magnesium levels 1.2 mmol/L). Various parameters were recorded for every patient, including general information, disease composition, laboratory indexes, duration of mechanical ventilation, ICU stay days and final outcome. The acute physiology and chronic health evaluationⅡ (APACHEⅡ) score and sequential organ failure assessment (SOFA) score during the first 24 hours after ICU admission were calculated. The risk factors for the death in critically ill patients were postulated by logistic regression analysis.Results A total of 374 critically ill patients were enrolled, with 242 patients (64.71%) in normomagnesemic group, 102 (27.27%) in hypomagnesemic group, and 30 (8.02%) in hypermagnesemic group. As to the disease composition, although the patients in normomagnesemic group and hypomagnesemic group were mainly consisted of patients with nervous system diseases (33.06%, 31.37%) or pneumonia(25.62%, 25.49%), the proportion of patients with major abdominal and thoracic surgery (15.69% vs. 5.78%,χ2= 8.837, P= 0.003) or severe sepsis (7.84% vs. 1.65%,χ2= 9.935,P= 0.007) was significantly greater in the hypomagnesemic group compared with that of normomagnesemic group, and most hypermagnesemic patients were complicated by renal dysfunction in different degrees. Compared with the normomagnesemic group, the hypomagnesemic group was found to have higher SOFA scores (6.86±3.12 vs. 5.46±2.75,t= -2.930,P= 0.004), longer stay in ICU (days: 15.98±13.29 vs. 12.43±7.14,t= -2.318,P= 0.034) and higher mortality [54.90% (56/102) vs. 33.88% (82/242),χ2= 6.587, P= 0.010], but no statistically significant differences were found in gender composition, age, levels of other electrolytes (natrium, potassium, calcium, phosphorus), and APACHEⅡ score. As shown by the result of the logistic regression analysis, APACHEⅡ score [odds ratio (OR) = 1.129, 95% confidence interval (95%CI) = 1.064-1.197,P= 0.000] and serum magnesium level (OR= 2.163, 95%CI= 1.015-4.610,P= 0.046) were independent risk factors for death in critically ill patients.Conclusion Serum magnesium levels are closely related to mortality rate in patients in ICU, so more attention should be paid to the occurrence of hypomagnesemia in critically ill patients.
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<p><b>BACKGROUND</b>Severe sepsis and septic shock are the leading causes of morbidity and mortality in hospitalized patients. This study aimed to investigate the association of poly (ADP-ribose) polymerase-1 (PARP-1) activity in circulating mononuclear cells with myocardial dysfunction in patients with septic shock.</p><p><b>METHODS</b>A total of 64 patients with septic shock were divided into the survival group (n = 41) and the nonsurvival group (n = 23) according to mortality at 28 days after enrollments. PARP-1 activity in circulating mononuclear cells, brain natriuretic peptide, Acute Physiology and Chronic Health Evaluation II score, the cardiac index (CI), the cardiac function index (CFI), global ejection fraction (GEF), and the left ventricular contractility index (dp/dt max) were measured after admission to the intensive care unit.</p><p><b>RESULTS</b>PARP-1 activity in circulating mononuclear cells of nonsurvival patients with septic shock was significantly higher than that in survival patients. PARP-1 activity in circulating mononuclear cells was strongly, negatively correlated with the CI, the CFI, GEF, and dp/dt max. Multiple Logistic regression analysis showed that PARP-1 activity in circulating mononuclear cells was an independent risk factor of myocardial dysfunction. The optimal cutoff point of PARP-1 activity for predicting 28-day mortality was 942 nmol/L with a sensibility of 78.2% and specificity of 65.1%.</p><p><b>CONCLUSION</b>PARP-1 activity in circulating mononuclear cells is significantly associated with myocardial dysfunction and may have prognostic value in patients with septic shock.</p>
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Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Leukocytes, Mononuclear , Poly(ADP-ribose) Polymerases , Metabolism , Shock, SepticABSTRACT
Objective To investigate the changes of CD4+CD25+ regulatory T (Treg) cells in elderly patients with septic shock, and to evaluate the effects of the changes on 28-day mortality rate.Methods The 75 consecutive elderly patients with septic shock were recruited from December 2006to December 2008, and the general states and clinical characteristics of them were analyzed. The CD4+ CD25+ FoxP3 regulatory T cells and human leucocyte antigen DR (HLA-DR) were measured by flow cytometer at the 1st, 4th and 7-10th day of septic shock after being diagnosed. Results The patients were at an average age of (69.2±7.5) years, and the 28-day mortality rate was 53.3%.There were no significant differences in the percentage of CD4 + CD25+ FoxP3/CD4+T cells between the survivors and the non-survivors at the 1st day (1.76 % ±0.31% vs. 1.68 %±0.24 %, P＞0.05)and the 4th day (1.94%±0.32% vs. 1.82% ±0.28%, P＞0.05). However, compared with the survivors, non-survivors had a higher percentage of CD4+ CD25+ FoxP3/CD4+ T cells (2.65%±0.28% vs. 1.79%±0.27%, P＜0.01) at the 7-10th day of septic shock after being diagnosed.Furthermore, from the 4th day to the 7-10th day, the expressions of monocyte HLA-DR in the nonsurvivors were significantly lower than in the survivors (P＜0. 01), and they were inversely correlated with the percentage of CD4+ CD25+ FoxP3/CD4+ T cells at the 4th day (r=-0.39, P=0.023) and the 7-10th day (r= -0. 58, P＜0. 01) respectively. The multiple logistic regression analysis showed that the percentages of CD4+ CD25+ FoxP3/CD4+ T cells (OR = 3.47, 95% CI: 1.33-10.0) and HLA-DR (OR= 0. 27, 95% CI: 0.14-0.73) were independent predictors of 28-day mortality rate.Conclusions Persistent higher percentage of CD4+ CD25+ Treg cells in the elderly patients with septic shock indicates that the patients are under the states of immunosuppression and have a higher risk ofmortality in intensive care unit at admission.
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Objective To evaluate the efficacy and safety of Caspofunjin on invasive fungal infections in patients refractory to Fluconazole in ICU.Methods The open clinical trial was conducted in 44 invasive fungal infections patients who was refractory to Fluconazole,including 7 cases of confirmed,28 cases of suspected and 9 cases for empire treatment.They were treated with Caspofunjin in a dose of 70 mg in the first day,and then in a dose of 50 mg/d for 10～40 d.Results The cure rate of patients was 42.86%,the effective rate was 76.19%,and the eradication rate was 65.22%.All patients were well tolerated.Conclusion Caspofunjin is effective and safe in the treatment of severe invasive fungal infections.