Effect of right stellate ganglion block-serratus anterior plane block combined with general anesthesia in thoracoscopic radical resection of lung cancer / 中国医师杂志

Objective:To investigate the effect of right stellate ganglion block (RSGB)-serratus anterior plane block (SAPB) combined with general anesthesia in thoracoscopic radical resection of lung cancer.Methods:A total of 90 patients who planned to undergo thoracoscopic radical resection of lung cancer in Xiangya Changde Hospital from March 2020 to September 2021 were prospectively selected and divided into 3 groups by random number table method: general anesthesia group (G group), (SAPB)+ general anesthesia group (SG group), RSGB+ SAPB+ general anesthesia group (RSG group), 30 cases in each group. The SG group received SAPB on the operative side before general anesthesia, and the RSG group received RSGB+ SAPB on the operative side before general anesthesia. After the blocking effect was determined, all patients were given general anesthesia in the same scheme according to their weight, and patients were given patient-controlled intravenous analgesia (PCIA) after surgery. The mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthesia (T 0), before intubation (T 1), 1 min after intubation (T 2), 5 min after intubation (T 3), at extubation (T 4) and 5 min after extubation (T 5). The intraoperative dosage of remifentanil, incidence of nausea and vomiting (PONV) within 24 hours after surgery, number of additional PCIA within 24 hours, the Visual Analogue Scale (VAS) of static and dynamic pain, the Bruggrmann Comfort Scale (BCS) and Richard Campbell Sleep Questionnaire (RSCQ) 24 hours after surgery were recorded. Results:Compared with T 0, the MAP and HR in 3 groups were increased 1 min after intubation (T 2) and at extubation (T 4), but the increases in RSG group were significantly less than those in G and SG groups (all P<0.05). The remifentanil dosage, PONV incidence and PCIA supplemental times in SG and RSG groups were less than those in G group, and the BCS score and RSCQ score were higher than those in G group (all P<0.05); the BCS score and RSCQ score in RSG group were higher than those in SG group (all P<0.05). Conclusions:RSGB+ SAPB combined with general anesthesia in thoracoscopic radical resection of lung cancer has little circulation fluctuation, good postoperative analgesia effect, less adverse reactions and high comfort level.

Evaluation of ICUs and weight of quality control indicators: an exploratory study based on Chinese ICU quality data from 2015 to 2020 / 医学前沿

This study aimed to explore key quality control factors that affected the prognosis of intensive care unit (ICU) patients in Chinese mainland over six years (2015-2020). The data for this study were from 31 provincial and municipal hospitals (3425 hospital ICUs) and included 2 110 685 ICU patients, for a total of 27 607 376 ICU hospitalization days. We found that 15 initially established quality control indicators were good predictors of patient prognosis, including percentage of ICU patients out of all inpatients (%), percentage of ICU bed occupancy of total inpatient bed occupancy (%), percentage of all ICU inpatients with an APACHE II score ⩾15 (%), three-hour (surviving sepsis campaign) SSC bundle compliance (%), six-hour SSC bundle compliance (%), rate of microbe detection before antibiotics (%), percentage of drug deep venous thrombosis (DVT) prophylaxis (%), percentage of unplanned endotracheal extubations (%), percentage of patients reintubated within 48 hours (%), unplanned transfers to the ICU (%), 48-h ICU readmission rate (%), ventilator associated pneumonia (VAP) (per 1000 ventilator days), catheter related blood stream infection (CRBSI) (per 1000 catheter days), catheter-associated urinary tract infections (CAUTI) (per 1000 catheter days), in-hospital mortality (%). When exploratory factor analysis was applied, the 15 indicators were divided into 6 core elements that varied in weight regarding quality evaluation: nosocomial infection management (21.35%), compliance with the Surviving Sepsis Campaign guidelines (17.97%), ICU resources (17.46%), airway management (15.53%), prevention of deep-vein thrombosis (14.07%), and severity of patient condition (13.61%). Based on the different weights of the core elements associated with the 15 indicators, we developed an integrated quality scoring system defined as F score=21.35%xnosocomial infection management + 17.97%xcompliance with SSC guidelines + 17.46%×ICU resources + 15.53%×airway management + 14.07%×DVT prevention + 13.61%×severity of patient condition. This evidence-based quality scoring system will help in assessing the key elements of quality management and establish a foundation for further optimization of the quality control indicator system.

Risk factors and prognosis in critical patients with sepsis-related cardiomyopathy / 中华内科杂志

Objective:To explore the risk factors and prognosis of sepsis-related cardiomyopathy.Methods:Patients with sepsis and septic shock admitted to the Critical Care Medicine Department at Peking Union Medical College Hospital from October 2017 to February 2021 were enrolled. Echocardiographic parameters including left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and cardiac index (CI) were obtained within 24 h after admission. Hemodynamic parameters including heart rate, mean arterial pressure and central venous pressure were also collected. The risk factors of 45-day mortality were analyzed using Cox regression analysis. Kaplan-Meier survival analysis was performed to compare 45-day mortality among patients with normal left ventricle (LV) systolic function group, sepsis-related takotsubo cardiomyopathy (ST) and septic cardiomyopathy (SC) group as well as between patients with normal right ventricular (RV) function and patients with RV dysfunction.Results:According to LV systolic function, patients were categorized into three groups: normal group [174 (66.9%)], SC group [66 (25.4%)] and ST group [66 (25.4%)]. In comparison with those in normal group, patients in SC group and ST group had higher acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and sequential organ failure assessment (SOFA) score ( P<0.05). No difference was found between SC group and ST group regarding APACHE Ⅱ score and SOFA score( P>0.05). ST group had lower LVEF [33(28, 41)% vs. 45(38, 48)%, P<0.05], CI [2.29 (1.99, 2.53)L·min -1·m -2 vs. 3.04(2.61, 3.61) L·min -1·m -2, P<0.05] higher TAPSE [18.6(16.0, 21.2)mm vs. 15.1(12.5, 19.0)mm, P<0.05] than SC group. A Cox regression survival analysis showed that right ventricular dysfunction (RVD) was an independent predictor of 45-day mortality ( HR=1.992, 95% CI 1.088-3.647, P=0.025). A Kaplan-Meier analysis revealed no significant difference regarding 45-day mortality among ST group [25.0%(5/20)], SC group [30.3%(20/66)] and normal group 18.4%(32/174)( P=0.158). RVD patients [38.0%(30/79)] had significantly higher 45-day mortality than patients with normal RV function [14.9%(27/181), P<0.001]. Conclusions:In comparison with SC patients, ST patients tend to have worse LV systolic function, lower cardiac output and better RV function. However, neither ST nor SC is associated with 45-day mortality. RVD is a risk predictor of 45-day mortality, which should be monitored in septic patients.

The quality control standards and principles of the application and training of critical ultrasonography / 中华内科杂志

Critical ultrasonography is widely used in ICU and has become an indispensable tool for clinicians. However, besides operator-dependency of critical ultrasonography, lack of standardized training mainly result in the physicians′ heterogenous ultrasonic skill. Therefore, standardized training as well as strict quality control plays the key role in the development of critical ultrasonography. We present this quality control standards to promote better development of critical ultrasonography.

Formation and development of discipline system of critical care medicine / 中华危重病急救医学

The discipline system of critical care medicine consists of the knowledge system and thinking system. The knowledge system includes a series of interrelated knowledge points. Knowledge points are relatively independent and smallest units in knowledge. In the process of development, critical care medicine has formed its own characteristic knowledge points based on the knowledge of medicine. Thinking system refers to the way of thinking which consists of various thinking modes linked inseparably. Thinking system provides an essential driving force for the formation and continuous development of knowledge system. The actual composition of critical care medicine discipline is the professionals who know well the thinking system and knowledge system of critical care medicine.

Clinical value of pulse pressure/central venous pressure ratio in low cardiac output syndrome after cardiac surgery / 中华危重病急救医学

Objective:To explore the relationship between the pulse pressure/central venous pressure (PP/CVP) ratio and the cardiac output (CO) of patients after cardiac surgery from the basic principles of hemodynamics, and to further evaluate the predictive value of PP/CVP ratio in patients with secondary low cardiac output syndrome (LCOS) after cardiac surgery.Methods:A retrospective study was conducted, and patients who received pulse indicator continuous cardiac output (PiCCO) monitoring were enrolled at the department of critical care medicine of Peking Union Medical College Hospital from January 1, 2016, to September 1, 2021. Patients were divided into two groups: the LCOS group [cardiac index (CI) < 33.34 mL·s -1·m -2, 25 cases] and the non-LCOS group (CI ≥ 33.34 mL·s -1·m -2, 125 cases) according to the CI at 6 hours after surgery. The general clinical data and hemodynamic parameters were collected. Correlations between PP/CVP ratio and PiCCO monitoring indicators were performed with Pearson or Spearman correlation test. Receiver operator characteristic curve (ROC curve) analysis was carried out to evaluate the predictive value of the parameters in patients with LCOS after cardiac surgery. Results:A total of 150 patients with PiCCO monitoring after cardiac surgery were included. There were no differences in baseline characteristics between the two groups, while PP in the LCOS group was lower than that in the non-LCOS group [mmHg (1 mmHg ≈ 0.133 kPa): 40 (37, 44) vs. 55 (46, 64)], CVP was higher than that in the non-LCOS group [mmHg: 12 (11, 14) vs. 10 (8, 12)], and PP/CVP ratio in the LCOS group was lower than that in the non-LCOS group [3.3 (2.9, 3.7) vs. 5.5 (4.6, 6.8)], with significant differences (all P < 0.05). Correlation analysis results showed that PP/CVP ratio was positively correlated with CI, CO, and stroke volume index (SVI), respectively ( rs = 0.660, 0.592, 0.600, all P < 0.001). CI was negatively correlated with PP ( rs = 0.509, P < 0.001) and positively correlated with CVP ( rs = -0.297, P < 0.001). ROC curve analysis revealed that compared with PP, CVP, SVI and cardiac function index (CFI), PP/CVP ratio was the best predictor of LCOS after cardiac surgery [area under the ROC curve (AUC) was 0.94±0.02, P < 0.001], when the optimum cut-off value was 4.41, the sensitivity was 80.00%, and the specificity was 96.00%. Conclusion:PP/CVP ratio was moderately positively correlated with CO after cardiac surgery, and PP/CVP ratio could be used as a prognostic predictor for LCOS after cardiac surgery.

Resuscitation fluids as drugs: targeting the endothelial glycocalyx / 中华医学杂志(英文版)

Fluid resuscitation is an essential intervention in critically ill patients, and its ultimate goal is to restore tissue perfusion. Critical illnesses are often accompanied by glycocalyx degradation caused by inflammatory reactions, hypoperfusion, shock, and so forth, leading to disturbed microcirculatory perfusion and organ dysfunction. Therefore, maintaining or even restoring the glycocalyx integrity may be of high priority in the therapeutic strategy. Like drugs, however, different resuscitation fluids may have beneficial or harmful effects on the integrity of the glycocalyx. The purpose of this article is to review the effects of different resuscitation fluids on the glycocalyx. Many animal studies have shown that normal saline might be associated with glycocalyx degradation, but clinical studies have not confirmed this finding. Hydroxyethyl starch (HES), rather than other synthetic colloids, may restore the glycocalyx. However, the use of HES also leads to serious adverse events such as acute kidney injury and bleeding tendencies. Some studies have suggested that albumin may restore the glycocalyx, whereas others have suggested that balanced crystalloids might aggravate glycocalyx degradation. Notably, most studies did not correct the effects of the infusion rate or fluid volume; therefore, the results of using balanced crystalloids remain unclear. Moreover, mainly animal studies have suggested that plasma may protect and restore glycocalyx integrity, and this still requires confirmation by high-quality clinical studies.

Minimally invasive techniques for treatment of special cardiac malformations / 中国胸心血管外科临床杂志

@#Objective    To share the experience of treating special cardiac malformations by applying minimally invasive techniques. Methods    Eight children with special cardiac malformations admitted to our hospital from July 2014 to September 2020 were recruited, including 3 males and 5 females, aged 0.8-1.2 (1.1±0.4) years, and weighted 7.8-11.5 (9.6±2.9) kg. There were 2 patients of huge muscular ventricular septal defect (VSD), 3 perimembranous cribriform VSD, 1 right coronary-right atrial fistula, 1 right coronary-right ventricular fistula, and 1 young, low-weight child with large aortopulmonary. All were treated with minimally invasive techniques using transesophageal echocardiography (TEE) as a guiding tool. All children received intraoperative TEE immediately to evaluate the curative effect of the surgery, and all went to outpatient clinic for reexamination of echocardiography, electrocardiogram and chest X-ray after discharge. Results    Eight children underwent minimally invasive surgery successfully without any incision infection, intracardiac infection, arrhythmia or pericardial effusion. None of the 8 children were lost to follow-up, and the results of all reexaminations were satisfactory. Conclusion    The application of minimally invasive techniques is a bold and innovative attempt for the treatment of a few special types of cardiac malformations. It has significant advantages in reducing trauma and medical costs in some suitable patients, and has certain clinical reference values.

Academic oriented team building and management in critical care medicine / 中华危重病急救医学

Team building and teamwork mode have become the important parts in scientific research and clinical approach of critical care medicine (CCM). Team is a group composed of several individuals with different abilities, complementary roles and mutual dependence based on the common goal. Teamwork mode refers to that each member of the team, as a part of the community, completes the common goal through synergy based on the common knowledge system, according to the unified way of thinking. With the characteristics of CCM and the improvement of knowledge system and thinking system, the team building and teamwork mode of CCM has experienced a chaotic period, a molding period, an excitation period and a mature period. The team building and teamwork mode provide a strong internal impetus for the development of CCM.

Diagnosis and treatment of primary cardiac tumors in pediatric patients / 中华实用儿科临床杂志

Objective:To summarize the experience in diagnosis and treatment of primary cardiac tumors in pediatric patients.Methods:Retrospectively analyzing 7 pediatric patients who were suspected as primary cardiac tumors and diagnosed and treated in Department of Heart Center, Children′s Hospital of Dalian Medical University from August 2013 to February 2019.All patients underwent echocardiography and other examinations, so as to confirm the diagnosis and the treatment plan was chosen based on the size and location of the tumor.All patients were followed up after discharge.Results:A total of 7 patients were diagnosed as primary cardiac tumors by echocardiography, among which 5 cases underwent surgical treatment, and 2 cases were diagnosed with tuberous sclerosis without surgery.In children undergoing surgery, 1 patient underwent autologous heart transplantation to remove the tumor, 1 patient had arrhythmia, 1 patient had mitral regurgitation after surgery, and the mitral regurgitation was corrected again.The remaining children had no adverse complications and were discharged successfully.Histologic examination revealed rhabdomyoma in 4 patients, and fibroma in 1 patient.The patients were followed up for 2-66 months after discharge, and no tumor recurrence was observed in the children who performed surgery.There was a trend of spontaneously regress of cardiac tumor in 2 patients without surgery.Conclusions:Echocardiography is the first choice for the diagnosis of primary cardiac tumors in Pediatric patients.Rhabdomyoma is the most prevalent histologic type of primary cardiac tumors, and tuberous sclerosis should be excluded during the diagnosis process.Patients with tuberous sclerosis selected conservative treatment, and surgical treatment was selected for children with obvious symptoms.According to the location and size of lesion, therapy strategies should be chosen and autologous heart transplantation can be adopted to remove the tumor for children with large tumors.Autologous heart transplantation to remove the tumor is a good surgical treatment.

Retrospective study of the diagnosis and treatment of culture-negative aortic infective endocarditis / 中国胸心血管外科临床杂志

@#Objective    To discuss the diagnosis and treatment of culture-negative aortic infective endocarditis. Methods    The clinical data of 73 patients with infective endocarditis of the aortic valve whose results of bacteria culture were negative from January 2013 to January 2018 were retrospectively analyzed, including 59 males and 14 females aged 14-71 (39.2±14.8) years. Results    Sixty seven (91.8%) patients received aortic valve replacement, 2 (2.7%) patients received the second operation in hospital, and 12 (16.4%) patients had concomitant mitral valvuloplasty. In-hospital death occurred in 8 (11.0%) patients. Postoperatively, 11 (20.7%) patients had a low cardiac output and 4 (11.0%) patients had heart block, and 1 patient required implantation of a permanent pacemaker. The 1- and 5- year survival rates were 92.3%±2.3% and 84.5%±4.5%, respectively. Conclusion    There are difficulties in the diagnosis and treatment of culture-negative infective endocarditis. Most of the affected patients are in a healed status, which could be a cause of negative culture results. In-hospital mortality in the patients is associated with a history of previous cardiac surgery, whereas the long-term survival rate is good for the patients after surgery.

Efficacy of percutaneous intervention for patent ductus arteriosus guided by transesophageal echocardiography in obese teenagers / 中国胸心血管外科临床杂志

@#Objective    To explore the safety and efficacy of transesophageal echocardiography (TEE)-guided percutaneous intervention for patent ductus arteriosus (PDA) in obese teenagers. Methods    From January 2018 to June 2019, 21 obese teenagers with PDA treated with femoral artery occlusion guided by TEE in the Department of Cardiac Surgery, Dalian Children's Hospital of Dalian Medical University were included in this study, including 13 males and 8 females aged 12.8-17.3 (15.1±1.7) years, with an average weight of 51.0-89.0 (73.4±10.1) kg. The operative effect was evaluated. Results    All patients successfully received the surgery, and none was changed to radiation-guided or thoracotomy ligation. The average operating time was 23.9±6.8 min, the average postoperative hospitalization time was 3.8±0.6 d. No peripheral vascular injury, intracardiac infection or pericardial effusion occurred. The mean follow-up time was 19.5±4.9 months, and the results of all reexaminations were good. Conclusion    For some PDA children with obesity, emphysema or thoracic malformation, it is difficult to block PDA by transthoracic ultrasound-guided percutaneous intervention, and TEE can avoid the interference of chest wall and lung qi, or other factors. It is an effective supplementary guidance method worthy of promotion.

The value of renal resistance index and urine oxygen pressure for prediction of acute kidney injury in patients with septic shock / 中华内科杂志

Objective To explore the value of renal resistance index (RI) and urine oxygen pressure for early prediction of acute kidney injury (AKI) in patients with septic shock.Methods Patients with septic shock were enrolled from August 2018 to November 2018 in intensive care unit (ICU) at Peking Union Medical College Hospital.Subjects' general information and AKI characteristics were assessed.Area under the receiver operating characteristic (ROC) curve was used to analyze the predictive value of RI,urine oxygen pressure,or combination of RI on the occurrence of AKI.Results A total of 72 septic shock patients were enrolled including 29 patients with AKI and 43 without.Logistic regression analysis of AKI risk factors found that RI (OR=1.139,95％CI 1.029-1.261,P=0.012) and urine oxygen pressure (OR=0.957,95％CI 0.923-0.991,P=0.014) at admission were independent risk factors for AKI in patients with septic shock.The sensitivity and specificity of dual RI and urine oxygen pressure in predicting AKI were 65.5％and 76.7％ respectively (AUCROC 0.772,Youden index 0.423).We selected the cut-off value of RI as 0.70,and urine oxygen pressure as 48 mmHg (1 mmHg=0.133 kPa).According to this two cut-off values patients were divided into four groups,those with RI≥0.70 and urine oxygen pressure≤48 mmHg showed the highest incidence of AKI (75％).There was no statistically difference in 28-day survival rate between the four groups (P=0.197).Conclusion High RI and low urine oxygen pressure are independent risk factors for the development of AKI in patients with septic shock.The predictive cut-off values are 0.70 for RI and 48 mmHg for urine oxygen pressure.Combination of RI and urine oxygen pressure has a practical predictive value for AKI in patients with septic shock.

Personalized therapy: the cornerstone of development in critical care medicine / 中华危重病急救医学

Critical therapy is a goal-directed personalized treatment according to the real-time changes of critical illness and the body's response to intervention,based on the theory of critical care medicine.The combination of a unified theoretical system and different interventional options for each patient promotes therapeutic process.The continuous completion of basic research and clinical evidence expands the basic theory of critical care medicine.At the same time,the rapid increase of bedside monitoring information will lead to a deeper understanding of critical illness.The personalized critical therapy is moving towards more feasible and accurate,and is promoting the overall development of critical care medicine.

Total pancreatic necrosis after organophosphate intoxication / 医学前沿

Cases of acute pancreatitis induced by organophosphate intoxication are encountered occasionally in clinics, but very few of them develop into severe pancreas necrosis and irreversible pancreatic function impairment. Here, we report a 47-year-old female organophosphate poisoning case after ingestion of massive insecticides; she was considered to have total necrosis and function failure of the pancreas via serum amylase test, glucose level test, and CT imaging. The patient exhibited no relief under the regular medicine treatment, which included sandostatin, antibiotics, intravenous atropine, and pralidoxime methiodide. She received percutaneous catheterization and drainage of pancreatic zone to expel hazardous necrotic waste, also by which the pathogenic evidence was obtained and the antibiotics were adjusted subsequently. The patient recovered gradually, was discharged after 2 weeks, and was prescribed with oral pancreatin capsules before meals and hypodermic insulin at meals and bedtime to compensate the impaired pancreatic function.

A Chinese consensus statement on the clinical application of transesophageal echocardiography for critical care (2019) / 中华内科杂志

Transesophageal echocardiography(TEE) is valuable in intensive care unit (ICU) because its application meets the requirements of diagnosis and treatment of critically ill patients.However, the current application has not fully adapted to the specialty of critical care. TEE could be more valuablein ICU when used with a new way that under the guidance of the theory of critical care and embedded into the treatment workflow. We have expanded and improved the application of traditional TEE and integrated the concept of critical care, established the concept of transesophageal echocardiography for critical care (TEECC). Chinese Critical Ultrasound Study Group (CCUSG) organized experts in the area to form the consensus based the previous studiesand the long term practice of critical care ultrasound and TEE, aiming at clarifying the nature and characteristics of TEECC, promoting the rational and standardized clinical application and the coming researches.The consensus of Chinese experts on clinical application of TEECC (2019) were 33 in total, of whichthe main items were as follows: (1) TEECC is a significant means, which is expanded and improved from the traditional transesophageal echocardiography according to characteristics of critically ill patients and is applied in ICU based on critically clinical scenarios and requirements by the critical care physician, to promote visualized, refined and precisely management of critically ill patients.(2) TEE possesses distinctive superiority in implementation in ICU. It has characteristics of images with good quality, operations with good stability and low-dependent of operators, monitoring with continuity, and visualization with all-dimensional and detail of heart and blood vessels.(3)As a means of refined monitoring that could resulted in precise diagnosis and treatment, TEECC expands the dimension of intensive monitoring and improves the performance of critical care. (4) Indications of TEECC application include clinical etiological searching and invasive procedures guiding when it acted as a traditional role; and also refined hemodynamic monitoring based on critical care rationale and over-all management under specific critical clinical scenarios. (5) TEE and TTE assessments are complementary; they are not alternative. Integrated assessment of TTE and TEE is required under many critical clinical scenarios.(6) TEE should be a necessary configuration in ICU. (7) All-round and significant information regarding to the mechanism of acute circulatory disorders can be provided by TEECC; it is a non-substitutable means of identifying the causes of shock under some special clinical scenarios. (8) Focal extracardiac hematoma can be accurately and rapidly detected by TEE in patients with open-thoracic cardiac surgery or severe chest trauma when highly suspected pericardial tamponade.(9) The priority of pathophysiologic mechanism of septic shock can be rapidly and accurately identified by TEE; even if its pathophysiological changes are complex, including hypovolemia and/or vasospasm and/or left and right heart dysfunction. (10) Causes of hemodynamic disorders can be rapidly and qualitatively evaluated so that the orientation of treatment can be clarified by TEECC. (11) A full range of quantitative indicators for refined hemodynamic management in critically ill patients can be provided by TEECC. (12) TEECC helps to accurately assess volume status and predict fluid responsiveness.(13) TEECC is specially suitable for accurate quantitative assessment of cardiac function.(14) Mini TEE provides long-term continuous hemodynamic monitoring. (15) Standard views are easy to be acquired by TEECC, which is a premise for accurate and repeatable measurements, and a guarantee for assessment of effect and risk of therapy. (16) Compared with invasive hemodynamic monitoring, TEECC is minimally invasive, with low infection risk and high safety.(17) In patients with acute cor pulmonale (ACP) under condition of right ventricular dysfunction and low cardiac output, TEECC is a key tool for assessment. (18) TEECC should be implemented actively when suspicious of left to right shunt in critically ill patients who occurred hypotension that hard to explain the cause. (19) TEECC should be implemented actively when suspicious of right to left shunt in critically ill patients who occurred hypoxemia that hard to explain the cause. (20) TEECC is preferred in hemodynamics monitoring under prone position of ventilated patients.(21) TEECC is an imperative means to achieve over-all management of extracorporeal membrane oxygenation (ECMO) therapy, especially for all-round hemodynamic monitoring. (22) Three basic views is recommended to be used to simplify TEE assessment during cardiac arrest so that reversible causes could be identified, and resuscitation could be guided. (23) The flow related echodynamic evaluation (TEECC-FREE) workflow is preferred in refined hemodynamics monitoring and therapy. (24) Simple workflow of TEECC could be implemented in special critical clinical scenarios. (25) Application of TEECC is highly secure; however, impairments of procedure should also be alert by operators. (26) Pitfalls in application of TEE should be paid attention to by the critical care physician. (27) Timely and rationally application of TEECC is in favor of diagnosis and treatment of critically ill patients and may improve the prognosis.

Host response in vivo and the expression of IL-4 in different cross-linked hyaluronic acid composite gels / 国际生物医学工程杂志

Objective To observe the host response and the expression of interleukin-4 (IL-4) in different cross-linked hyaluronic acid composite gels at different time points after the implantation in vivo, and to explore the significance of biocompatibility and macrophage polarization in post-implantation inflammatory response and tissue remodeling. Methods New Zealand white rabbits were respectively injected with crosslinked hyaluronic acid-crosslinked hydroxypropyl methylcellulose gel (sample 1), crosslinked hyaluronic acid-hydroxypropyl methylcellulose gel (sample 2) and commercially available modified sodium hyaluronate gel (control) in subcutaneous tissue at both sides of the spine. Then the rabbits were dissected at 1, 4 and 12 weeks after the implantation. The tissues were fixed with 10％formaldehyde solution, embedded in paraffin and sliced. Hematoxylin-eosin (HE) staining was performed to observe the degree of inflammation and fibrosis. Masson staining was performed to observe the formation of collagen fibers. Immunohistochemical staining was performed to observe the expression of IL-4. Results The results of HE staining showed that the inflammatory reaction in the sample 1 and sample 2 groups was significantly higher than that in the control group 1 and 4 weeks after the implantation. The inflammatory cells aggregated, and the wall of capsule and microcapsule was thick. The sample 1 group was more obvious, and the result was mild stimulation. For all the groups, the results were all non-irritating at 12 weeks after the implantation. The results of Masson staining showed that the collagen fibers in the sample 1 and sample 2 groups were increased compared with the control group, mainly distributed around the implantation site, and a small amount among the gels after 1 and 4 weeks. After 12 weeks, the collagen fibers were further increased, especially among the gels, which were consistent with the control group. The results of immunohistochemical staining showed that, at the same time point, the expression of IL-4 in sample 1 and sample 2 groups was higher than that in the control group, and the expression of IL-4 increased gradually with time. The expression of IL-4 in the control and sample 1 group at 12 weeks after the implantation was higher than that at 1 and 4 weeks respectively, and the differences were statistically significant (all P<0.05). In the sample 1 group, the expression of IL-4 at 12 weeks after the implantation was higher than that at 1 week, and the difference was statistically significant (P<0.05). The expression of IL-4 in the sample 1 group was significantly higher than that in the control group at 4 weeks after the implantation, and the difference was statistically significant (P<0.05). Conclusions The two different cross-linked sodium hyaluronate composite gels have good biocompatibility. The formation of collagen fiber and the expression of IL-4 can gradually increased within 12 weeks after the subcutaneous implantation, which is beneficial to the tissue remodeling.

Experts consensus on the management of delirium in critically ill patients / 中华内科杂志

To establish the experts consensus on the management of delirium in critically ill patients.A special committee was set up by 15 experts from the Chinese Critical Hypothermia-Sedation Therapy Study Group.Each statement was assessed based on the GRADE (Grading of Recommendations Assessment,Development,and Evaluation) principle.Then the Delphi method was adopted by 36 experts to reassess all the statements.(1) Delirium is not only a mental change,but also a clinical syndrome with multiple pathophysiological changes.(2) Delirium is a form of disturbance of consciousness and a manifestation of abnormal brain function.(3) Pain is a common cause of delirium in critically ill patients.Analgesia can reduce the occurrence and development of delirium.(4) Anxiety or depression are important factors for delirium in critically ill patients.(5) The correlation between sedative and analgesic drugs and delirium is uncertain.(6) Pay attention to the relationship between delirium and withdrawal reactions.(7) Pay attention to the relationship between delirium and drug dependence/ withdrawal reactions.(8) Sleep disruption can induce delirium.(9) We should be vigilant against potential risk factors for persistent or recurrent delirium.(10) Critically illness related delirium can affect the diagnosis and treatment of primary diseases,and can also be alleviated with the improvement of primary diseases.(11) Acute change of consciousness and attention deficit are necessary for delirium diagnosis.(12) The combined assessment of confusion assessment method for the intensive care unit and intensive care delirium screening checklist can improve the sensitivity of delirium,especially subclinical delirium.(13) Early identification and intervention of subclinical delirium can reduce its risk of clinical delirium.(14) Daily assessment is helpful for early detection of delirium.(15) Hopoactive delirium and mixed delirium are common and should be emphasized.(16) Delirium may be accompanied by changes in electroencephalogram.Bedside electroencephalogram monitoring should be used in the ICU if conditions warrant.(17) Pay attention to differential diagnosis of delirium and dementia/depression.(18) Pay attention to the role of rapid delirium screening method in delirium management.(19) Assessment of the severity of delirium is an essential part of the diagnosis of delirium.(20) The key to the management of delirium is etiological treatment.(21) Improving environmental factors and making patient comfort can help reduce delirium.(22) Early exercise can reduce the incidence of delirium and shorten the duration of delirium.(23) Communication with patients should be emphasized and strengthened.Family members participation can help reduce the incidence of delirium and promote the recovery of delirium.(24) Pay attention to the role of sleep management in the prevention and treatment of delirium.(25) Dexmedetomidine can shorten the duration of hyperactive delirium or prevent delirium.(26) When using antipsychotics to treat delirium,we should be alert to its effect on the heart rhythm.(27) Delirium management should pay attention to brain functional exercise.(28) Compared with non-critically illness related delirium,the relief of critically illness related delirium will not accomplished at one stroke.(29) Multiple management strategies such as ABCDEF,eCASH and ESCAPE are helpful to prevent and treat delirium and improve the prognosis of critically ill patients.(30) Shortening the duration of delirium can reduce the occurrence of long-term cognitive impairment.(31) Multidisciplinary cooperation and continuous quality improvement can improve delirium management.Consensus can promote delirium management in critically ill patients,optimize analgesia and sedation therapy,and even affect prognosis.

Effect of low-dose ketamine on ⅡmGluR and learning and memory function impairment in depression rats undergoing electroconvulsive shock / 中国神经精神疾病杂志

Objective To explore the effect of low-dose ketamine on IImGluR and learning and memory function impairment in depression rats undergoing electroconvulsive shock. Methods In behavioral and molecular biology experiments, thirty depressed rats were randomly divided into 3 groups(n=10): depression group (group D), MECS group (group M) and MECT+Ket group (group KM). Ten healthy rats served as control group (group C). Control group received no treatment. Group D received intraperitoneal injection of normal saline plus sham ECS. Group M received intraperitoneal injection of propofol and group KM received propofol plus ketamine. Both group M and group KM received ECS once a day for 7 consecutive days.Sucrose preference test and Morris water maze were performed to assess depressed behavior and learning and memory function before and after treatment. Western-blot assay was used to detect the expression of mGluR2 and mGluR3. Another 12 depressed rats were divided into control group (group P) and IImGluR antagonist group (group L), brain slices were perfused with artificial cerebrospinal fluid and artificial cerebrospinal fluid containing IImGluR antagonist respectively. LTP in hippocampus SC-CA1 were measured using electrophysiological techniques. Results After MECS,compared with group D,SPP was obviously increased in group M and group KM (P<0.01). Group M showed prolonged escape latency and shortened space exploration time. On the contrary,group KM showed shortened escape latency and prolonged space exploration time(P<0.01).Compared with group C,the expression of mGluR2 and mGluR3 were significantly lower in group D,group M,and group KM (P<0.05)and was the lowest in group M among the four groups (P<0.05).Compared with group P,group L showed a significantly lower LTP in hippocampus SC-CA1 (P<0.05). Conclusion Low-dose ketamine reduces learning and memory function impairment after electroconvulsive shock in depression rats possibly through up-regulation the expression of mGluR2 and mGluR3.

Effect of transthoracic minimally invasive intervention in treatment on congenital heart disease complicated with compound deformities / 中华实用儿科临床杂志

Objective To explore the safety and therapeutic effect of transesophageal echocardiography(TEE)-guided transthoracic minimally invasive intervention for congenital heart disease complicated with compound heart ab-normalities in children.Methods From September 2013 to January 2018,32 children with congenital heart disease complicated with compound heart abnormalities were collected,who undergoing TEE-guided transthoracic minimally invasive intervention at the Department of Cardiothoracic Surgery,Dalian Children's Hospital were collected.There were 6 cases of ventricular septal defect (VSD)combined with atrial septal defect (ASD),11 cases of VSD combined with patent ductus arteriosus (PDA),9 cases of ASD combined with PDA,3 cases of VSD combined with pulmonary stenosis (PS),and 3 cases of ASD combined with PS.TEE-guided transcatheter closure was performed within a minimally in-vasive transthoracic minimal incision (1 -2 cm)under non-cardiopulmonary bypass.The efficacy of the procedure was evaluated by TEE.The transthoracic echocardiography,chest film and cardiogram after post-procedure examina-tions were followed.Results TEE-guided transthoracic minimally invasive perventricular intervention was successfully performed in all the sick children.The mean duration of operation,intensive care unit monitoring and ventilation were (54.2 ± 21.8)min,(14.3 ± 8.7)h and (3.7 ± 2.9)h,respectively.No patient received diuretic drugs,sedation drugs,blood transfusion or conventional surgical repair. The follow - up period for all the patients lasted 12 -48 months.No arrhythmias,residual shunts or occluder detachments,or thrombosis,hemorrhage,or new valve regurgitation occurred.Conclusions TEE -guided transthoracic minimally invasive intervention is feasible and has a promising prognosis for young children with congenital heart disease combined with compound heart abnormalities.