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By consulting the ancient and moderm literature， this paper makes a textual research on the name， origin， quality evaluation， harvesting and processing of Olibanum， so as to provide a basis for the development of the famous classical formulas containing this medicinal material. According to the herbal textual research， the results showed that Olibanum was first described as a medicinal material by the name of Xunluxiang in Mingyi Bielu（《名医别录》）， until Ruxiang had been used as the correct name since Bencao Shiyi（《本草拾遗》） in Tang dynasty. The main origin was Boswellia carterii from Burseraceae family. The mainly producing areas in ancient description were ancient India and Arabia， while the modern producing areas are Somalia， Ethiopia and the southern Arabian Peninsula. The medicinal part of Olibanum in ancient and modern times is the resin exuded from the bark， which has been mainly harvested in spring and summer. It is concluded that the better Olibanum has light yellow， granular， translucent， no impurities such as sand and bark， sticky powder and aromatic smell. There were many processing methods in ancient times， including cleansing（water flying， removing impurities）， grinding（wine grinding， rush grinding）， frying（stir-frying， rush frying， wine frying）， degreasing， vinegar processing， decoction. In modern times， the main processing methods are simplified to cleansing， stir-frying and vinegar processing. Nowadays， the commonly used specifications include raw， fried and vinegar-processed products. Among the three specifications， raw products is the Olibanum after cleansing， fried products is a kind of Olibanum processed by frying method， vinegar-processed products is the processed products of pure frankincense mixed with vinegar. Based on the research results， it is recommended to select the resin exuded from the bark of B. carterii for the famous classical formulas such as Juanbitang containing Olibanum， processing method should be carried out in accordance with the processing requirements of the formulas， otherwise used the raw products if the formulas without clear processing requirements.
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In order to provide the basis for the development of famous classical formulas， the name， origin， quality evaluation， harvesting and processing of Eucommiae Cortex were systematically researched by consulting the ancient herbal and medical books， combining with the modern literature. According to the textual research， materia medica in the past dynasties used Eucommiae Cortex as the correct name. Combined with characteristics， origin and efficacy， Eucommiae Cortex in ancient times to the present is the dry bark of Eucommia ulmoides from family Eucommiaceae. The earliest producing areas of Eucommiae Cortex are Henan， Shanxi， Shaanxi and Sichuan. Since the Ming dynasty， the producing areas have expanded to most of the regions in the country， and Sichuan， Shaanxi， Chongqing， Guizhou and Hubei are regarded as the authentic producing areas. It has been concluded that the quality of Eucommiae Cortex is best if the bark has thick body， large block， scraped rough skin， multi silk section and dark purple internal surface. In ancient times， the processing methods of Eucommiae Cortex were mainly included removing rough bark and cutting for raw use， processing with auxiliary materials such as honey， ginger juice， salt water， wine， and so on. While in modern times， the processing methods have become increasingly simplified which are mainly cutting raw materials after cleansing and salt processing. It is need to excavate the connotation of different processed products and restore the traditional main processing methods through standards. Based on the requirement of Eucommiae Cortex in Sanbitang， it is suggested to use ginger-processed products according to the research results， which is used ginger juice as auxiliary material and processed with stir frying method according to the 2020 edition of Chinese Pharmacopoeia.
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To further standardize the sedation and analgesia treatment for neurocritical care patients, the National Center for Healthcare Quality Management in Neurological Diseases and Chinese Society of Critical Care Medicine organized national experts in this fields to form Working group of the Expert consensus on sedation and analgesia for neurocritical care patients in order to update the Expert consensus on sedation and analgesia for patients with severe brain injury (2013) based on evidence-based medicine. This update aims to provide scientific guidance for the clinical diagnosis and treatment of neurocritical care patients. The working group followed the definition of clinical practice guidelines by the Institution of Medicine (IOM) and the World Health Organization guidelines development handbook and Guidelines for the formulation/revision of clinical guidelines in China (2022) to register and draft the Expert consensus on sedation and analgesia for neurocritical care patients. The working group will strictly adhere to the consensus development process to formulate and publish the Expert consensus on sedation and analgesia for neurocritical care patients (2023). This protocol primarily introduces the development methodology and process of the Expert consensus on sedation and analgesia for neurocritical care patients (2023), including the purpose of the update, the target population, the composition of the consensus development working group, the presentation and collection of clinical questions, evidence evaluation and summarization, and the generation of recommended opinions. This will make the consensus development process more standardized and transparent.
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Humans , Consensus , Analgesia , Analgesics/therapeutic use , Pain Management , Critical CareABSTRACT
Due to primary diseases of neurocritical care unit (NCU) patients, they have particularities with low level of consciousness, poor airway protective ability, damaged respiratory drive and respiratory motor conduction pathway. Such patients have higher rates of weaning difficulty, delayed extubation, extubation failure and tracheostomy. There are several guidelines on weaning and extubation for intensive care unit (ICU) patients, while there are no guidelines for for NCU patients. Therefore, we reviewed current guidelines and recommendations on weaning and extubation in both ICU and NCU patients suggesting considerations of neurological condition, level of consciousness and presence of airway protective reflexes before extubation, moreover, we introduced researches about protocols of weaning for NCU patients and related predictors.
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Physical restraints are widely used in hospitalized and critically ill patients, especially in intensive care unit (ICU), to prevent adverse events such as the accidental removal of various monitoring leads, therapeutic tubes, and self-injury or injury to others due to delirium and irritation. The existing restraint measures directly bind the upper limbs of the patients to the hospital bed, which often brings psychological harm to the patients and leads to disuse muscular atrophy. Early rehabilitation therapy can help improve the prognosis of patients, but it is difficult to be widely used in ICU due to being heavily dependent on nursing and rehabilitation physicians. A novel restraint device to facilitate rehabilitation training for critically ill patients was designed by the medical staff from the department of critical care medicine of Beijing Tiantan Hospital, Capital Medical University and obtained the National Utility Model Patent of China (ZL 2020 2 2492749.6). The device is mainly composed of a cross beam and a locking device whose two ends are connected by a rocker arm, an upper limb stopper and an upper body stopper. The upper limb and body restraint provide restrictions on the movement of the head, the upper limb, and the upper body. The angle limiter prevents the patient from pulling out the treatment tube by himself, and at the same time retains the ability to grasp the crossbar and rotate it, and the sliding block further increases the activity space, to meet the exercise of the patient's upper limb muscle strength. Carrying out physical rehabilitation training as early as possible during ICU treatment can relieve the patient's resistance to passive restraint, reduce the incidence of disuse muscle atrophy, eliminate the potential hidden dangers of medical disputes, and ultimately improve the prognosis of patients.
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Using artificial dead space to correct hypocapnia or induce hypercapnia is of particular significance for diagnosing and treating specific neurocritical diseases. At present, the above purpose is mainly achieved by adding an extension tube between the Y-type connector of the ventilator and the artificial airway in clinical practice. However, its volume is often fixed and cannot adapt to the individualized diagnosis and treatment in different clinical scenarios. The research group led by Professor Zhou Jianxin from the department of critical care medicine of Beijing Tiantan Hospital, Capital Medical University, has designed an artificial dead cavity with adjustable volume based on years of research in the respiratory field and has been granted a national utility model patent (patent number: ZL 2020 2 0496413.4). The artificial dead chamber is simple in structure, composed of a barrel body, a piston head, and a push-pull rod. By freely adjusting the size of the artificial dead chamber volume, it can accurately regulate the target carbon dioxide, correct the spontaneous hyperventilation, terminate intractable hiccup, and shorten the operation time of asphyxia test in clinical diagnosis of brain death while correcting hypocapnia or inducing hypercapnia. It has the advantages of solid reliability, convenient operation, and low production cost, which significantly facilitates scientific research and clinical diagnosis and treatment.
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Objective:To investigate the relationship between double-triggering and abnormal movement of air in the lungs (pendelluft phenomenon) under pressure support ventilation (PSV).Methods:A prospective observational study was conducted, postoperative patients admitted to department of critical care medicine of Beijing Tiantan Hospital, Capital Medical University from April 1, 2019 to August 31, 2020 and received invasive mechanical ventilation with PSV mode were enrolled. Electrical impedance tomography (EIT) monitoring was performed. Airway pressure-time, flow-time, global and regional impedance-time curves were synchronously collected and analyzed offline. The volume of abnormal movement of air in the lungs at the beginning of inspiration was measured and defined as pendelluft volume. Double-triggered breaths were identified by trained researchers. Pendelluft volume during double-triggering was measured including the first triggered breath, the double-triggered breath, and the breath immediately following the double-triggered breath. Pendelluft volume was also measured for normal breath during the study. According to the frequency of double-triggering, patients were divided into severe (≥1 time/min) and non-severe double-triggering group. Pendelluft volume, parameters of respiratory mechanics, and clinical outcomes between the two groups were compared.Results:In 40 enrolled patients, a total of 9 711 breaths [(243±63) breaths/patient] were collected and analyzed, among which 222 breaths (2.3%) were identified as double-triggering. The Kappa of interobserver reliability to detect double-triggering was 0.964 [95% confidence interval (95% CI) was 0.946-0.982]. In 222 double-triggered breaths, pendelluft volume could not be measured in 7 breaths (3.2%), but the pendelluft phenomenon did exist as shown by opposite regional impedance change at the beginning of double-triggered inspiration. Finally, pendelluft volume was measured in 215 double-triggered breaths. Meanwhile, 400 normal breaths (10 normal breaths randomly selected for each patient) were identified as control. Compared with normal breath, pendelluft volume significantly increased in the first breath, the double-triggered breath, and the following normal breath [mL: 3.0 (1.4, 6.4), 8.3 (3.6, 13.2), 4.3 (1.9, 9.1) vs. 1.4 (0.7, 2.8), all P < 0.05]. Patients in severe double-triggering, pendelluft volume of normal breath and double-triggered breath were significantly higher than those in non-severe double-triggering group [mL: 1.8 (0.9, 3.2) vs. 1.1 (0.5, 2.1), P < 0.001; 8.5 (3.9, 13.4) vs. 2.0 (0.6, 9.1), P = 0.008]. Patients in severe double-triggering group had significantly higher respiratory rate than that in the non-severe double-triggering group (breaths/min: 20.9±3.5 vs. 15.2±3.7, P < 0.001). There were no significant differences in other respiratory mechanics parameters and main clinical outcomes between the two groups. Conclusions:During PSV, the abnormal movement of air in the lungs (pendelluft phenomenon) was more likely to occur in double-triggering especially in double-triggered breath. The more frequent the double-triggering occurred, the more serious the pendelluft phenomenon was. A higher pendelluft volume of normal breath and a higher respiratory rate were related to severity of double-triggering.
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Objective:To evaluate the feasibility of esophageal pressure (Pes) calibration by the esophageal balloon pressure-volume (P-V) curve during assisted mechanical ventilation.Methods:A prospective study was conducted. The postoperative patients admitted to intensive care unit of Beijing Tiantan Hospital Affiliated to Capital Medical University from June 2017 to January 2019 who needed pressure support ventilation by tracheal intubation and Pes monitoring with stable breath were enrolled. The Pes monitoring was performed by the esophageal balloon with a small geometric volume (2.8 mL). ① Balloon volume tests of esophageal balloon were performed by inflating intermittently 0.5 mL increments up to 2.5 mL, the end-expiratory and end-inspiratory Pes were recorded to obtain end-expiratory and end-inspiratory P-V curves. The intermediate section in end-expiatory P-V curve that showed linear correlation was identified (as intermediate linear section), whose volume range was balloon working volume ( Vwork) and slope was esophageal wall elastance (Ees), the balloon volume with the largest difference between end-expiratory and end-inspiratory Pes was the best balloon volume ( Vbest), and the product of Ees and Vbest was esophageal wall recoil pressure reacting to balloon filling. To minimize the effect of esophageal wall on Pes, the calibrated Pes was the difference of Pes and esophageal wall recoil pressure. The consistency of calibrated Pes obtained by balloon volume at Vbset and other Vwork were analyzed. ② For the convenience of clinical application, a simplified method was introduced to calibrate Pes. Based on all Vwork of patients located in 0.5-1.5 mL, the difference of end-expiratory Pes between balloon volume at 0.5 mL and 1.5 mL divided by 1.0 mL was used to estimate Ees, and the Pes among 0.5-1.5 mL was calibrated by Ees obtained by the simple method. The consistency of calibrated Pes obtained by the simple method and standard method were observed. Results:Totally 30 patients were enrolled, all end-expiratory and end-inspiratory P-V curves existed the intermediate linear section, the calibrated Pes at Vwork did not increase with the balloon being inflated and had a good consistency with the calibrated Pes at Vbest, mean difference and 95% confidence interval (95% CI) was -0.02 (-1.50-1.50) cmH 2O (1 cmH 2O = 0.098 kPa). The Ees and calibrated Pes estimated by the simple method had a good agreement with the standard method, mean difference and 95% CI was -0.2 (-1.0-0.6) cmH 2O/mL and 0.2 (-1.1-1.4) cmH 2O, respectively. Conclusions:During assisted mechanical ventilation, the use of a small geometric volume esophageal balloon to monitor Pes and balloon P-V curve to calibrate Pes is feasible. The simple method can be used for simplifying clinical application, that's only by monitoring Pes at balloon volume at 0.5, 1.0 and 1.5 mL to evaluate the Ees and calibrate Pes.
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The ventilator-induced lung injury (VILI) was centered on the "static" characteristics of the mechanical ventilation in early phases (tidal volume, plateau pressure, positive end-expiratory pressure and driving pressure). But the "dynamic" characteristics of ventilation must not be ignored (respiratory rate and flow). Mechanical energy and mechanical power (the pace of performing energy load) regarding all factor have won wide spread attention. The energy generated by mechanical ventilation is mainly used to expand respiratory system and overcome resistance, a fraction of energy acts on lung tissues probably inducing "heat" and inflammation that is related to lung injury. The review described recent conceptual advances regarding the mechanical energy and power, and the relationship with VILI, hoping to help further understanding the risk factors for VILI.
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The ventilator-induced lung injury (VILI) was centered on the "static" characteristics of the mechanical ventilation in early phases (tidal volume, plateau pressure, positive end-expiratory pressure and driving pressure). But the "dynamic" characteristics of ventilation must not be ignored (respiratory rate and flow). Mechanical energy and mechanical power (the pace of performing energy load) regarding all factor have won wide spread attention. The energy generated by mechanical ventilation is mainly used to expand respiratory system and overcome resistance, a fraction of energy acts on lung tissues probably inducing "heat" and inflammation that is related to lung injury. The review described recent conceptual advances regarding the mechanical energy and power, and the relationship with VILI, hoping to help further understanding the risk factors for VILI.
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Objective To compare the differences in biochemical and routine manifestations of cerebrospinal fluid (CSF) in critically ill patients with intracranial infection caused by different pathogens in department of neurosurgery. Methods The patients with intracranial infection after neurosurgery were admitted in the department of intensive care unit (ICU) of Beijing Tiantan Hospital, Capital Medical University from January 1, 2013 to December 31, 2016, their examination results of positive CSF samples were obtained, and the differences in biochemical and routine test results among different classes of bacterial pathogens in CSF were compared. Results A total of 404 samples of 310 patients were analyzed; Gram-positive (G+) bacteria were the major cause of infection (308 case-times, 76.2%), among which, Staphylococci epidermidis was the leading causative pathogen (115 cases, 37.3%), followed by coagulase-negative Staphylococci (76 cases, 24.6%), and Staphylococcus aureus (52 cases, 16.9%); bacteria were detected in 96 case-times, accounting for 23.8% and occupying the secondary position. The overall indicator levels of CSF with G- pathogen were higher than those with G+bacteria, among which CSF with G- bacteria pathogen protein content [mg/L: 1 795 (1 999) vs. 1 068 (1 251)], white blood cell (WBC) count [×106/L: 1 069.5 (5 295.8) vs. 446.5 (1 689.3)], proportion of neutrophils [N: 0.877 (0.218) vs. 0.788 (0.416)] were obviously higher than those in CSF with G+bacteria pathogen, however, glucose (Glu) concentration level was lower than that in CSF with positive G- bacteria [mmol/L: 1.7 (2.5) vs. 2.6 (1.7), P < 0.05]. Simultaneously, it was also found that in culture G- bacteria appeared slightly later than G+bacteria [days: 9.0 (10.0) vs. 8.0 (7.0)], Acinetobacter and other negative bacteria being obvious, but as a whole there was no statistical significant difference. Conclusions G+bacteria are the major pathogens for intracranial infections patients after neurosurgery, and its time of isolation in bacterial culture has a tendency of being earlier than that of G- bacteria; in the comparisons between biochemical and routine results of CSF with positive G- bacteria and with positive G+bacteria, there are protein, glucose, WBC and N levels having statistical significant differences, suggesting that these indicators have potential values to differentiate these two kinds of bacteria.
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Esophageal pressure monitoring provides a minimally invasive method to assess the pleural pressure, which can be used to differentiate the lung and chest wall mechanics. The information of transpulmonary pressure, work of breathing, intrinsic positive end-expiratory pressure and respiratory muscle performance can facilitate the proper setting of mechanical ventilation. Esophageal pressure monitoring is still not routinely used in the clinical setting because of difficulty in esophageal balloon catheter placement and data interpretation due to esophageal pressure monitoring has certain technical requirements, and the measurement results are influenced by many factors such as airbag volume, location, esophageal wall elasticity and mediastinal organ weight. In this review, we introduced technique for esophageal pressure measurement and calculation of transpulmonary pressure aiming to promote the clinical application of esophageal pressure monitoring.
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Objective To explore the application value of short latency somatosensory evoked potentials (SLSEP) as a tool for preoperative assessment of surgical or interventional treatment in patients with severe aneurysmal subarachnoid hemorrhage (aSAH). Methods A prospective observational cohort study was conducted. The patients with severe aSAH with a WFNS grade of Ⅳ or Ⅴ admitted to intensive care unit (ICU) of Beijing Tiantan Hospital of Capital Medical University from November 2016 to April 2017 were enrolled. The patients received SLSEP monitoring within 12 hours after onset, and the monitoring results were classified according to the Judson scale. Meanwhile, the findings on cerebral CT scans at admission were evaluated by the modified Fisher classification. The follow-up was performed at 3 months after aSAH ictus based on the modified Rankin scale (mRS), and a mRS score 0-3 was defined as favorable outcome, 4-6 was defined as unfavorable outcome. For statistical evaluation, demographic, clinical, neuroimaging and SLSEP data were evaluated by univariate analysis to identify the risk factors associated with prognosis;afterwards, those factors were analyzed by multivariate Logistic regression; also the validity was assessed by calculating the respective sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results A total of 41 patients with aSAH were selected, of which 7 were excluded because of the interference of the SLSEP monitoring results, 34 patients with aSAH were enrolled finally. Among them, 21 were classified in the unfavorable outcome group, while the rest (n = 13) were allocated into the favorable outcome group. No significant difference was found in gender, age, body mass index (BMI), time delay from ictus to treatment or the options for therapeutic methods between the two groups. The findings of univariate analysis, however, showed statistically differences in WFNS grade, the modified Fisher scale and Judson scale of SLSEP between the two groups. Yet, the further validity evaluation for these predictors demonstrated that the sensitivity, specificity, PPV and NPV of WFNS grade of Ⅴ and modified Fisher scale of Ⅳ were all less than 85%, whereas the results for SLSEP Judson scale of Ⅲ were much better (sensitivity: 90.5% vs. 71.4% and 71.4%, specificity: 84.6% vs. 69.2% and 76.9%, PPV: 90.5% vs. 79.0% and 83.3%). In the following multivariate Logistic analysis, only Judson scale of Ⅲ was identified to be the independent risk factor for poor outcome [odds ratio (OR) = 45.73, 95% confidence interval (95%CI) = 4.25-499.31, P = 0.002], while the WFNS grade of Ⅴ (OR = 1.14, 95%CI = 0.12-13.06, P = 0.912) and the modified Fisher scale of Ⅳ (OR = 7.22, 95%CI = 0.51-113.20, P = 0.160) were merely associated with poor outcomes without significant independence. Conclusion In comparison with WFNS grade and the modified Fisher scale, SLSEP seems more accurate in the prediction of long-term outcome of severe aSAH prior to surgical or interventional treatment, and thus may be applied as an effective aid in preoperative assessment.
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Objective To evaluate the diagnostic validity of application of brainstem auditory evoked potential (BAEP) as an ancillary test in patients with brain death.Methods A prospective observational study was conducted. Adult patients (≥ 18 years) with brain death were consecutively admitted to the Department of Intensive Care Unit (ICU) of Beijing Tiantan Hospital Affiliated to Capital Medical University from July 2015 to June 2017, and they further underwent BAEP monitoring. The following findings: absence of all waveforms at bilateral sides, absence of all waveforms except wave-Ⅰonly present at bilateral orunilateral side were set as the positive criteria of BAEP for the diagnosis of brain death, and its diagnostic sensitivity (SEN), positive predictive value (PPV) and false negative rate (FNR) were further assessed.Results A total of 47 patients were enrolled in the study, and the 43 complete BAEP results were analyzed. The SEN, PPV and FNR of the above 3 types of diagnostic criteria (absence of all waveforms, and unilateral or bilateral presence of wave-Ⅰ only) were 100% [95% confidence interval (95%CI) 90-100], 100% (95%CI 89-100), and 0% (95%CI 0-9), respectively.Conclusion As an ancillary test, BAEP has extremely high validity for the diagnosis of patients with brain death, thus it should be used more extensively in clinical practice.
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Objective To evaluate the safety and feasibility of injection test which is used to locate esophageal balloon catheter.Methods A prospective study was conducted. The patients undergoing invasive mechanical ventilation (MV) admitted to general intensive care unit (ICU) of Beijing Tiantan Hospital Affiliated to Capital Medical University from May 2015 and March 2017 were enrolled. The commercially available esophageal balloon catheter was modified to perform injection test. The catheter was withdrawn step by step and the injection test was repeated until the presence disturbance wave presented, which indicated that the balloon had just entered the esophagus. The position where disturbance wave appears was named 0 cm. End-expiratory occlusions were performed at the positions of+15,+10,+5, 0, -5, -10 and -15 cm, respectively, and the changes of esophageal pressure (Pes) and airway pressures (Paw) were measured in the spontaneous breathing and passive ventilation, and the ratio between the changes (ΔPes/ΔPaw) was calculated.Results A total of 20 patients were enrolled, of which 15 patients finished both the spontaneous and the passive ventilation parts, and 2 patients finished only the spontaneous part and 3 patients finished only passive part. ① Disturbance waves could be induced by injection test in all patients. The average depth of disturbance wave in spontaneous breathing was deeper than that in passive ventilation (cm: 42.4±3.8 vs. 41.8±3.3), but there was no significant difference between the two ventilation settings (P = 0.132). No adverse events occurred during the study period. ② Pes increased with the stepwise withdraw of esophageal catheter, reached the maximal value at+5 cm, and then decreased when the catheter was further withdrawn, no matter in the spontaneous or the passive ventilation. In spontaneous breathing, the ΔPes/ΔPaw was within the ideal range (0.8-1.2) at the positions of 0, -5 and -10 cm. The ΔPes/ΔPaw was closest to unity at the positions of 0 cm (0.98±0.15). The ΔPes/ΔPaw at -15 cm (0.66±0.26) was significantly lower than that at 0 cm (P < 0.05). For passive ventilation, the ΔPes/ΔPaw was within the ideal range at the positions of -5 cm and -10 cm, and the ΔPes/ΔPaw was closest to unity at the positions of-10 cm (0.94±0.12). The ΔPes/ΔPaw at 0 cm and -5 cm was significantly higher than that at -10 cm (1.43±0.31 and 1.12±0.14, respectively); while the ΔPes/ΔPaw at -15 cm (0.68±0.23) was significantly lower than that at -10 cm (allP < 0.01).Conclusions Ideal position of the esophageal balloon catheter could be determined quickly and easily by using injection test. The method is safe and clinically feasible.Clinical Trial Registration Clinical Trials, NCT02446938.
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Objective To evaluate the dose of vancomycin for the treatment of central nervous system (CNS) infection after neurosurgery. Methods The information of hospitalized patients treated by vancomycin after neurosurgery from January 2011 to December 2015 at Beijing Tiantan Hospital, Capital Medical University was collected retrospectively. The patients with CNS infection were retrieved, the relevant data were extracted and systemized. A daily dose of 2 g or 30-60 mg/kg of vancomycin was thought as the standard, and the difference between the actual dose and the guidelines was analyzed. Results There were 5 816 patients used vancomycin for a total of 46 787 days. The number of patients with CNS infection after neurosurgery was 1 198 (20.6%), the total treatment course was 14 083 days (30.1%), the median treatment days was 9, the median daily dose was 26.0 mg/kg; and the percentage of male patient was 50.8%, the median age was 42.0 years, and the median body weight was 68.0 kg. The most commonly used dose and frequency of vancomycin was 1.0 g every 12 hours with 6 957 days (49.4%) and 60.3% daily dose of vancomycin reached the standard. 355 patients were treated to the target and 843 patients were treated empirically, the age of targeted treatment group was older than empirical treatment group [years: 44.0 (32.5, 54.0) vs. 41.0 (31.0, 52.0), P 0.05], and daily dose of both groups did not reached the standard goal. 16.3% patients (195/1 198) received multi-courses therapy and there was no difference among the first course of dose. The clinical mortality of all patients was 1.5% (18/1 198). The targeted treatment and multi-courses had a higher proportion in the death group, and the treatment durations were longer than the non-death group [the targeted treatment proportion: 72.2% (13/18) vs. 29.0% (342/1 180), the multi-courses proportion: 83.3% (15/18) vs. 15.3% (180/1 180), the total treatment duration: 29.0 (17.8, 45.0) vs. 9.0 (6.0, 14.0), the days of the first course: 11.5 (7.5, 21.5) vs. 8.0 (6.0, 12.0), all P < 0.05]. Conclusions The dose of vancomycin to treat postoperative CNS infection was inappropriate in a majority of patients. Clinician's education regarding appropriate vancomycin dosing is recommended to achieve compliance with the guidelines.
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The iatrogenic cause of bile duct stone formation is mainly due to suture materials, especially silk sutures. In recent years, Prolene and Vicryl sutures have been widely used in biliary surgery, and bile duct stone formation related to sutures are seemingly becoming rare, as there has only been one report of bile duct stone formation caused by Prolene sutures in the literature. In the last few years we have had two cases of Prolene suture-related bile duct stone formation within our unit. We therefore suggest that Vicryl sutures should be used as the first choice in biliary surgery, in order to prevent the formation of iatrogenic bile duct stones
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Objective To determine the optimal cut-off value of critical-care pain observation tool (CPOT) in assessing degree of pain in patients undergone craniotomy, and to determine the sensitivity and specificity of CPOT with this cut-off value. Methods A prospective observational study was conducted in Beijing Tiantan Hospital. A total of 118 patients admitted to intensive care unit (ICU) after craniotomy was consecutively enrolled during August 2014 to August 2015. CPOT and visual analogue scale (VAS) were used to assess the pain before, during and 20 minutes after the removal of central venous catheters, and the difference was compared between two scores at three time points. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for evaluation of the sensitivity and specificity of CPOT. Patients' complaint of pain was considered the gold-standard. Results CPOT values (inter-quartile range) before, during and after the procedure were 0 (0-3), 0 (0-6) and 0 (0-2), respectively; while VAS values were 4 (1, 6), 3 (1, 6) and 4 (1, 6), respectively. CPOT value during the procedure was significantly higher than CPOT values before and after the procedure (both P < 0.01). When the optimal cut-off value of CPOT was 1, CPOT showed the highest Youden index before, during and after the procedure (1.183, 1.515, and 1.438, respectively), and showed high specificity (all 100%) and low sensitivity (18.3% and 43.8%, respectively) when assessing the pain before and after the removal of the catheter. The sensitivity and the specificity were high when assessing the pain during the procedure, the sensitivity was 69.4%, and the specificity was 82.1%. When the optimal cut-off value of VAS was 2 before and during the procedure, and was 4 after the procedure, VAS showed the highest Youden index, 1.568, 1.452, and 1.509, respectively. VAS demonstrated high sensitivity and specificity before, during and after the procedure (sensitivity was 97.2%, 95.2% and 75.0%, respectively; specificity was 59.6%, 50.0% and 75.9%, respectively). The area under ROC curve (AUC) of CPOT before, during and after the procedure were 0.592 [95% confidence interval (95%CI) = 0.490-0.693], 0.778 (95%CI= 0.693-0.863) and 0.719 (95%CI = 0.627-0.811), respectively; the AUC of VAS before, during and after the procedure were 0.846 (95%CI = 0.771-0.920), 0.767 (95%CI = 0.681-0.854) and 0.838 (95%CI = 0.767-0.909), respectively. The AUC of VAS before and after the procedure was significantly higher than the AUC of CPOT (P < 0.001 and P = 0.006), while there was no significant difference between the AUC of VAS and CPOT during the procedure (P = 0.826). Conclusion CPOT can be used to assess the pain during painful procedure, and it shows high accuracy, but with poor evaluation effect on pain in rest.
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Objective To assess the value of procalcitonin (PCT) for the differential diagnosis between infectious and non-infectious systemic inflammatory response syndrome (SIRS) after cardiac operation.Methods Patients diagnosed with SIRS after cardiac surgery and admitted to Department of Cardiovascular Surgery of Tokyo Medical and Dental University Graduate School between April 1st,2011 and March 31st,2013 were retrospectively studied.A total of 142 patients with SIRS were included,and they were divided into infectious group (n =47) or non-infectious group (n =95) according to the diagnostic criteria of the Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock:2012 (SSCG2012).The patients with infectious SIRS were included,and there were 11 with sepsis,12 with severe sepsis without shock,and 24 with septic shock respectively.The clinical data of patients were compared,and the receiver operating characteristic curve (ROC curve) was plotted to assess the diagnostic value of infection and non-infectious diseases for PCT,C-reactive protein (CRP) and white blood cell count (WBC),as well as the diagnosis of the severity of sepsis.Results PCT,CRP,and WBC were significantly higher in the infectious SIRS group than those in the non-infectious SIRS group [PCT (μg/L):2.80 (1.24,10.20) vs.0.10 (0.06,0.21),Z=-9.020,P=0.001; CRP (mg/L):158.0 (120.0,199.0) vs.58.0 (25.0,89.0),Z=-7.264,P=0.001; WBC (× 109/L):15.5 (11.0,22.6) vs.9.3 (7.2,12.6),Z=-5.792,P=0.001].PCT had the highest sensitivity (91.5％) and specificity (93.7％) for differential diagnosis,with a cut-off value for infectious SIRS of 0.47 μg/L,and the cut-offvalue of CRP and WBC were 119.5 mg/L and 10.85 × 109/L,respectively.There was no significant difference in WBC among sepsis group,severe sepsis group,and septic shock group [× 109/L:12.40 (9.10,24.20),13.30 (9.93,16.93),20.40 (13.45,28.6),x2=5.638,P=0.060],while PCT,CRP had significant difference [PCT(μg/L):1.37 (0.72,1.85),3.16 (0.48,13.24),3.68 (1.67,20.96),x2=7.422,P=0.024; CRP (mg/L):120.0(74.0,180.0),135.7 (81.7,181.3),171.1 (151.5,306.0),x2=9.524,P=0.009].PCT was more reliable than CRP in diagnosing severe sepsis without shock,but it was ineffective for diagnosing septic shock.The cut-off value of PCT for diagnosing severe sepsis without shock was 2.28 μg/L,and the sensitivity was 66.7％,specificity was 90.9％.Cut-off value of CRP for the diagnosis of septic shock was 149.5 mg/L,with the sensitivity of 83.3％,and the specificity of 66.7％.Conclusions PCT was a useful marker for the diagnosis of infectious SIRS after cardiac operation as compared with WBC and CRP.The optimal PCT cut-off value for diagnosing infectious SIRS was 0.47 μg/L.
ABSTRACT
Objective By comparing the therapeutic effects of different nutrition support,to elementarily evaluate the protocol of nutrition support with ω-3 polyunsaturated fatty acids in patients undergoing hepatectomy.Methods Retrospective and comparative analysis was applied.From January 2009 to January 2011,82 patients undergoing liver resection were selected from Nanjing Drum Tower Hospital and divided into three groups according to different nutrition supporting protocol:total parenteral nutrition group (23,TPN for short),combined enteral nutrition group (30,EN for short),ω-3 PUFAs group (29).TPN group was given total parenteral nutrition.EN group was given both parenteral and enteral nutrition.ω-3 PUFAs group was given parenteral nutrition,enteral nutrition and ω-3 PUFAs.By comparing the general situation,the incidence of post-operation complications and index of liver function,the effect of different nutrition supporting plans could be comprehensively evaluated.Results (1) None patients from any groups had severe complications such as bile leakage and hemobilia.Slight complications included ascites and pleural effusion.No difference is of significance in statistics science.(2) Compared with TPN group,patients from EN and ω-3 PUFAs group had shorter defecating time and post-surgery hospital stay,the difference is of significance in statistics science (P =0.001,t =4.624; P =0.001,t =5.019).There was no significant difference between EN and ω-3 PUFAs group (P ＞ 0.05).(3) For patients received operation with major hepatectomy (≥4 segments),ALT in ω-3 PUFAs group was lower than EN group in the 3rd and 5th day after operation (P=0.024,t =2.432; P=0.042,t =2.144).(4) For patients with cirrhosis,TB in ω-3 PUFAs group was lower than EN group in the 3rd and 5th day after operation (P =0.032,t =2.202; P =0.035,t =2.183).Conclusions It is beneficial to use nutritional support in patients received hepatectomy.For patients received major hepatectomy and patients with cirrhosis,nutrition support with ω-3 PUFAs had better protective effects.