Interpretation of Guidelines for controlling confounding factors and reporting results in causal inference studies / 中华危重病急救医学

Causal inference research is a causal test designed to assess the impact of exposures on outcomes.Both experimental and observational studies can be used to examine causal associations between exposure factors and outcomes. Experimental studies are sometimes limited by factors such as ethics or experimental conditions. Observational studies account for a large proportion in clinical studies, but the effectiveness and research value of observational studies will be affected if the design of observational studies is not rigorous and the confounding factors are not well controlled.The Guidelines for controlling confounding factors and reporting results in causal inference studie formulated by a special group of 47 editors from 35 journals from all over the world provide good guidance to researchers. This article interprets the guidelines and hopes to provide help for clinical researchers.

Strategies for infection control in managing critically ill patients with suspected coronavirus disease 2019 in non-designated hospital / 中华危重病急救医学

The management of healthcare services for the suspected cases in non-designated hospitalsis a serious concern in controlling coronavirus disease 2019 (COVID-19) epidemic. Owing to the complexity of care providers, large requirement of medical supplies as well as the possible needs off frequent transfers, the major difficulty is preventing the coronavirus from spreading while caring the suspected critical cases before the 2019 novel coronavirus ribonucleic acid test results are reported. For the purpose of enhancing the prevention of the propagation of COVID-19, this article puts emphasis on the following aspects in non-designated hospital Peking University Third Hospital: preparatory procedures of receiving critical suspected patients, the management of medical personnel during the waiting session of RNA test results, the delivering procedures of testing samples, the management of referred medical wastes, daily operations including the cleaning and sanitizing of caring units and the management of related patients after the testing session.

The timing of renal replacement therapy on mortality in patients with acute renal injury: a reanalysis of two recently published randomized control trials / 中华内科杂志

To investigate the sources of inconsistent findings between two randomized control trials ["initiation strategies for renal-replacement therapy in the intensive care unit" (AKIKI trial)vs "effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury" (ELAIN trial)],regarding "timing of renal replacement therapy (RRT) on mortality in patients with acute kidney injury (AKI).By reanalysis of the published data,it was found that demographics,severity of primary disease and stage of AKI before initiation of RRT were quite different between AKIKI and ELAIN trials.Interestingly,similar mortalities were demonstrated in late group of ELAIN trial,both of early and late groups of AKIKI trial [all patients were classified at Kidney Disease:Improving Global Outcomes (KDIGO) classification stage 3 of AKI,P＞0.05] although a significant reduction of mortality was determined in early group of ELAIN trial (KDIGO stage 2 of AKI).Therefore,it was concluded that inconsistent results were largely attributable to the heterogeneity of enrolled patients between ELAIN vs AKIKI trials,including demographics and severity of AKI(AKI stage) before initiation of RRT.

Updates in optimizing analgesia/sedation strategy for mechanically ventilated patients / 解放军医学杂志

Optimization of sedation depth has become one of hot spots for critical care medicine research.Previous multiple studies have demonstrated that deep sedation is associated with poor outcomes in patients with mechanical ventilation.But unnecessary deep sedation remained not rare in our clinical practices owing to complex reasons (partially unknown).Maintaining light rather than deep sedation stragey for patients with mechanical ventilation,therefore,was highly recommended.Meanwhile,it was concerned that the depth of sedation was probably proscribed inappropriately in some of lightly sedated patients largely due to lack of well-predefined contraindications,which even likely increased risk of adverse events in our clinical practices.In addition,increasing publications updated the impacts of analgesia/sedation on immune,gastrointestinal and neural-muscular function in the patients with chronic critical illness,a highly concerned critically ill population.Based on available data,less sedatives and opioids were suggested for these patients.Moreover,eCASH concept,a patient-centered,adequate analgesia and light sedation based and humanistic care strengthened comprehensive management strategy was currently proposed to improve the long-term outcomes for patients with mechanical ventilation.It provided us valuable information,in either optimization of clinical practices or research interests,on promoting our medical behaviors and cognition in order to improve patient comfort,safety and clinical outcomes.However,future high-quality clinical researches are needed to verify its feasibility and validity.

The effect of ω-3 fatty acid supplementation in parenteral nutrition on the outcome of patients with sepsis:a systematic review and Meta-analysis / 中华危重病急救医学

Objective To determine whether the supplementation of ω-3 polyunsaturated fatty acids in parenteral nutrition (PN) confers treatment benefits to outcomes of septic patients.Methods The databases of MEDLINE,EMBASE,Cochrane central register of controlled trials,the CNKI and the Wanfang biomedicine were searched to identify prospective randomized controlled trials (RCTs) which compared the ω-3 polyunsaturated fatty acids supplemented with the standard PN on outcomes of adult patients with sepsis from January 1996 to June 2013.The methodological quality of the included studies was evaluated,and the Cochrane Collaboration RevMan 5.0 was used for data analysis.Results A total of 12 studies enrolling 721 patients were included.Significant reduction in 28-day mortality [relative risk (RR) 0.77,95％ confidence interval (95％CI) 0.59 to 0.99,P=0.04],short intensive care unit [ICU,weighted mean difference (WMD)=-3.10,95％CI-5.98 to-0.21,P=0.04] and hospital length of stay (WMD =-3.12,95％CI-4.65 to-1.60,P＜0.000 1) were observed in patients receiving ω-3 polyunsaturated fatty acids supplemented PN.There was no differences in days of mechanical ventilation between patients with or without adding ω-3 polyunsaturated fatty acids in PN (WMD =1.33,95％ CI-5.09 to 7.75,P=0.69).Conclusions Meta-analysis results demonstrated that PN supplemented with ω-3 polyunsaturated fatty acids was beneficial in improving the outcomes of patients with sepsis.However,this conclusion must be interpreted with caution due to the low quality of the enrolled trials.

Continuous renal replacement therapy for rhabdomyolysis-induced acute renal failure following trauma / 中华创伤杂志

Objective To improve diagnose and therapy of post-traumatic acute renal failure induced by rhabdomyolysis. Methods A total of 20 patients with post-traumatic acute renal failure induced by rhabdomyolysis were analyzed retrospectively in aspects of clinical manifestation, laboratory examination and treatment. Of all, there were 9 patients treated with continuous renal replacement therapy (CRRT), while the other 11 were set as control, receiving no CRRT. Results After treatment with CRRT, 7 patients obtained clinical curing, with 2 deaths. As for control patients, there were 5 patients with secondary chronic renal insufficiency, 1 with clinical curing and 5 deaths. Conclusions Early diagnosis, CRRT, sufficient hydration, hematedialysis and supportive treatment are key points to improve the cure rate. It is important to apply CRRT for patients with renal inadequacy.

Sequential administration with midazolam-propofol effectively improved the daily arousal safety of patients with mechanical ventilation / 解放军医学杂志

Objective To compare the incidences of agitation and circulatory fluctuation in mechanically ventilated patients receiving different sedatives for daily arousal,and develop a safe sedation strategy.Methods Ninety four patients in ICU,who received mechanical ventilation over 24 hours,were selected from five clinical centers.Based on the analgesia with continuous pumping of fentanyl,patients were randomly given midazolam(M group),propofol(P group)or sequential midazolam-propofol(M-P group)for sedation.The depth of sedation was maintained within SAS 2-4 by close monitoring.The administration of all sedatives and analgesics was terminated at 9:00 am till patients were fully waked up.The incidence of agitation,blood pressure,heart rate fluctuation,patients' arousal time,and their recollection to actual mechanical ventilation events after been transferred out of ICU were investigated.Results The mean SAS scores showed no difference in each group.The arousal time was significantly longer in group M than that in other two groups(P

A nationwide multi-center survey on the relationship between ICU uncomfortable experiences and sedation-analgesic strategy in mechanically ventilated patients / 解放军医学杂志

0.05).61 patients received no sedatives nor analgesics showed significantly higher incidence of SUE compared with those patients received either sedatives or analgesics(73.8% vs 37.3%,P

Clinical research on the secondary fulminant multiple organ dysfunction syndrome caused by rhabdomylysis / 解放军医学杂志

Objective To analyze the causes of rhabdomylysis (RM), pathogenetic mechanisms and possible effective interventions for secondary multiple organ dysfunction syndrome (MODS) caused by RM. Methods causes of RM, clinical manifestations, severity of disease evaluated by APACHE Ⅱ and Marshall MODS Score, results of laboratory, clinical interventions and outcome were analyzed in all three MODS cases secondary to RM. Results The specific causes of RM were not clear. However, persistent acute twitch and hyperthermia occurred very early in all three cases. Plasma CK was increased 50 fold over the normal level. Number of injured organs was 7, 4 and 6, respectively. Marshall MODS score ranged from 15 to 21. APACHE Ⅱ scores were greater than 20 in all cases. One patients survived, the other two died. CRRT started early had been shown to be beneficial to decrease the markedly elevated plasma CK, CK-Mb, ALT, ALT and LDH. Conclusion Although the mechanism of RM with secondary MODS has not been elucidated yet, deep sedation as well as effective hypothermia to control acute twitch and hyperthermia should be the essential interventions to attenuate further organ injury. Additionally, based on effective advanced life support, CRRT started early could be an important therapy for MODS secondary to RM.

Nosocomial infection in patients underwent orthotopic liver transplantation / 解放军医学杂志

Objective To investigate morbidity and analyze high risk factors of nosocomial infection in patients who underwent orthotopic liver transplantation (OLT) in our ICU, in order to draft possible preventive strategies. Methods The clinical data of 56 OLT patients from Apr 2002 to Dec 2004 were analyzed. Results Significantly high APACHE Ⅱ scores and total plasma bilirubin, low platelet count were found in patients with nosocomial infection. The number of patients who had received an additional operation and broad-spectrum antibiotics before OLT were greater in nosocomial infection (NI) group than in none-nosocomial infection (NNI) group. Notably, the longer the broad-spectrum antibiotics used before OLT, the higher the morbidity rate of nosocomial infection. No significant difference was found in age, Child-Pugh grade and plasma albumin level between the two groups. In addition, APACHE Ⅱ scores and total bilirubin level were significantly higher in patients acquired enterococcal infection than in those infected with other pathogenic microorganisms. Conclusions High APACHE Ⅱ score, high total bilirubin level, low platelet count and length of use of broad-spectrum antibiotics before OLT were closely associated with nosocomial infection. As an important indicator, change in total bilirubin level not only represented the liver function ,but also was one of the high risk factors to nosocomial infection in patients undergoing OLT.

Hyperoxia solution improves oxygenation in patients with hypoxemia after orthotopic liver transplantation / 解放军医学杂志

Objective Post-operative hypoxemia occurred frequently after extubation in patients who underwent orthotopic liver transplantation (OLT) in ICU. This study is to investigate the efficiency of hyperoxia solution in improving oxygenation. Methods Ten OLT cases, who post-operatively manifested hypoxemia after extubation, were enrolled in this study. Hyperoxia Ringer's solution (500ml) prepared by Jing-Shu-Yang (an apparatus of oxygen supply, Vanform Co., Shandong) was infused at a rate of 200ml/hr. Hemodynamic parameters, blood gas, and blood lactate were determined at the beginning, end of infusion, and 1 hour after the infusion, with recording of the following data: heart rate (HR), mean arterial pressure (MAP), pulmonary arterial pressure (PAP), and pulmonary capillaries wedged pressure (PCWP). Results Compared with the levels at the beginning of infusion, SpO2 and SvO2 increased significantly at the end of the infusion of 500 ml hyperoxia Ringer's solution, and they returned to the baselines 1 hour later, although regular Ringer′s solution was coutinuously given by the same infusion rate. HR, MAP and PCWP were kept stable with the solution infusion. Notably, PAP was decreased markedly at the end of infusion, and blood lactate level remained unchanged after the intervention. Conclusion Hyperoxia Ringer's solution infusion improved oxygenation in OLT patients who suffered from acute lung injury with hypoxemia postoperatively. PAP decreased markedly as hypoxemia was corrected.