ABSTRACT
Objective: To explore the ethical justification of reducing sedation in ICU based on the need of medical treatment but the increase of patient's discomfort and the solution of this ethical conflict. Methods: Quali-tative research was used to conduct the in - depth interview among 15 senior medical staffs. We analyzed the ob-tained information, refined the research contents and formed the research report. Results: In ethics, it was a chal-lenge to achieve a satisfactory balance between the guarantee of the patient's comfortable experience and medical demand for reducing sedation. Conclusions: When making a sedation therapy program, the clinicians should pay more attention to the patient's own comfortable experience, that is, try to minimize the discomfort of patients in the pursuit of the most satisfactory treatment outcome.
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Objective To evaluate the efficacy and safety of short-term deep sedation strategy in patients with spontaneous intracerebral hemorrhage (ICH) after surgery. Methods A perspective, randomized, parallel-group study was conducted. Adult patients with spontaneous ICH and undergoing craniotomy admitted to Daxing Teaching Hospital of Capital Medical University from December 2015 to November 2016 were enrolled. The patients who received surgery were randomly divided into a short-term deep sedation and a slight and middle sedation group. Sufentanil was used as an analgesic drug in all patients and midazolam was used as a sedative after the operation. The patients in the slight and middle sedation group received midazolam 0.05-0.10 mg/kg with a goal of mild sedation [Richmond agitation and sedation scale (RASS) score of -2-1]. The patients in the short-term deep sedation group received midazolam 0.1-0.2 mg/kg with a goal of deep sedation (RASS score of -4 to -3) and a duration of no more than 12 hours. Postoperative sedation, blood pressure changes, laboratory indexes, residual hematoma and clinical outcomes were recorded in two groups. Results During the study, a total of 183 patients with spontaneous ICH were collected, excluding who was older than 65 years, with shock, and with preoperative Glasgow coma score (GCS) of 3. 106 patients were enrolled in this study, and 53 patients were assigned to the short-term deep sedation group and slight and middle sedation group, respectively. In the slight and middle sedation group, 4 patients received reoperation because of repeated hemorrhage and no patient operated repeatedly in the short-term deep sedation group, and there was a significant difference between the two groups (χ2= 4.000, P = 0.045). The number of patients undergoing tracheotomy in the short-term deep sedation group was significantly lower than that in the slight and middle sedation group (9 cases vs. 21 cases,P < 0.05). RASS score within 12 hours after operation of the patients in the short-term deep sedation group was lower than that in slight and middle sedation group [-4 (-4, -2) vs. -2 (-3, -1) at 4 hours, -4 (-4, -2) vs. -1 (-2, 0) at 8 hours,-3 (-4, -2) vs. 0 (-2, 1) at 12 hours, all P < 0.01], sudden restlessness was significantly reduced [times: 1 (0, 1) vs. 3 (2, 3), P < 0.01], and postoperative sedation duration was significantly prolonged [hours: 14.0 (8.3, 20.8) vs. 8.9 (3.4, 15.3), P < 0.05]. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) within 12 hours after operation in the short-term deep sedation group were significantly lower than those of the slight and middle sedation group [SBP (mmHg, 1 mmHg = 0.133 kPa): 136.8±30.5 vs. 149.1±33.5, DBP (mmHg): 85.0 (70.8, 102.3) vs. 89.0 (69.2, 116.7), both P < 0.05]. There were no significant differences in the arterial blood gas, routine blood test or coagulation function between the two groups at 24 hours after operation. The volume of residual hematoma at 2, 7 and 14 days after operation in the short-term deep sedation group was significantly decreased as compared with slight and middle sedation group (mL: 16.4±15.6 vs. 38.2±22.2 at 2 days, 9.6±8.7 vs. 20.6±18.6 at 7 days, 1.2±1.0 vs. 4.4±3.6 at 14 days, all P < 0.05), number of deaths in 3 months were significantly less (5 cases vs. 13 cases), and the patients with favorable prognosis were increased significantly (39 cases vs. 12 cases, both P < 0.05). Conclusion The study results showed that short-term deep sedation strategy after surgery can reduce the incidence of adverse events and improve the prognosis of patients with spontaneous ICH, so it is safe and effective.
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To examine the protective effect of insulin on reoxygenation-induced injury and explore the underlying mechanisms, the model of anoxia/reoxygenation (A/R) injury was established by inducing anoxia for 2 h and reoxygenation for 4 h in cultured cardiomyocytes of neonatal rats. The rats were randomized to four groups receiving vehicle, insulin, LY294002, insulin plus LY294002at the onset of reoxygenation after 2 h of anoxia. At the end of reoxygenation of 4 h, activity of lactate dehydrogenase (LDH) and content of malondialdehyde (MDA) were spectrophotometrically determined, apoptosis of cardiomyocytes were detected by using TUNEL and DNA Ladder, and Western blotting was employed to examine the expression of phosphorylated Akt in all groups. Our results showed that compared with vehicle-treated group, activities of LDH, contents of MDA, apoptosis index (AI) were significantly decreased, and expression of phosphorylated Akt was in creased significantly in insulin-treated group. However, changes in LDH, MDA, AI and phospho rylated Akt resulting from insulin were attenuated or abolished by LY294002 (PI3K inhibitor).These data strongly suggest that early administration of insulin at reoxygenation protects cardiomyocytes from reoxygenation-induced apoptosis through PI3K/Akt signaling pathway.
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Objective To study the mechanism of restenosis following percutaneous transluminal coronary angioplasty(PTCA),and to replicate a dynamic model of cell proliferation and remoulding of vascular wall at different time points in rabbits after intimal injury.Methods The model of restenosis in common carotid artery was established by balloon injury in 70 rabbits.The indexes such as lumen area,thickness and area of intima and media,and cross sectional area bounded by the external elastic lamina(EELA) were respectively measured by computer image analysis technology at the 1st,3rd,5th, 7th,14th,28th and 35th day after the injury.Results Endothelial cells were denudated at the 1st day after injury.The proliferation of vascular smooth muscle cell(VSMC) was detected on the surface of lumen at 3 days after injury.At the 7th day after injury,the neointima was formed and continuously thicken.The thickness and area of the neointima as well as extracellular matrix were gradually increased after 14 days,and were maximal after 35 days.The thickness and area of media were also gradually increased during 3～14 days and decreased after 28 days.Compared with non-injured vessel,the medial area was obviously increased at the 14th day.The lumen area was decreased at the 5th～7th day after injury and was obviously less than that of non~injured vessel after 14 days.The EELA was gradually increased at the 1st～7th day after injury,and reached its maximum at the 14th day.The EELA was declined gradually after 28 days.Conclusion The progress of restenosis(RS) can be simulated through the model of restenosis in common carotid artery of rabbit established by balloon injury.The intimal proliferation and vascular remodeling are the leading pathogenesis of restenosis.