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Enteral nutrition is an indispensable part of the treatment for critically ill patients. Various authoritative guidelines point out that early enteral nutrition is the key to improve the prognosis of disease. The key to improve and promote standardized enteral nutrition for criti-cally ill patients is the application of guidelines in the clinical practice. Based on clinical practice and theoretical basis, the authors propose a new insight into enteral nutrition and a new nutritional strategy of "individual treatment, circular evaluation, channel basis, quality-quatity balance, step-up achievement" for critically ill patients on basis of a 5W1H mindset.
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Objective:To investigate the diagnosis and treatment of hepatic artery thrombosis (HAT) after adult orthotopic liver transplantation.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 411 patients who underwent adult orthotopic liver transplantation in the First Affiliated Hospital of Xi ′an Jiaotong University from December 2011 to July 2018 were collected. There were 328 males and 83 females, aged from 21 to 66 years, with a median age of 46 years. Observation indicators: (1) incidence of HAT and its clinical characteristics; (2) diagnosis of HAT; (3) treatment of HAT; (4) follow-up. Follow-up using outpatient service, telephone interview or WeChat group communication was conducted to detect the incidence of biliary stricture and survival of patients up to August 2018. Measurement data with normal distribution were represented as Mean± SD, measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. Survival rate was estimated using the Kaplan-Meier method. Results:(1) Incidence of HAT and its clinical characteristics: 11 of 411 patients had HAT after orthotopic liver transplantation with the incidence of 2.68%(11/411), including 10 males and 1 female, aged 44 years(range, 22-63 years). The time to occurrence of postoperative HAT was 4 days(range, 1-15 days). The etiologies of 11 patients included 6 cases of hepatitis B virus-related cirrhosis, 1 case of hapatitis related cirrhosis, 1 case of hepato-cellular carcinoma, 1 case of liver cirrhosis, 1 case of alcoholic hepatitis related cirrhosis, 1 case of wilson disease. All the 11 patients were ABO compatible. The cold ischemic time and warm ischemic time of donor liver were (316±89)minutes and (13±4)minutes, respectively. Type Ⅰ arterial anasto-mosis was conducted in 11 patients. The clinical manifestations included asymptomatic type in 10 patients and sepsis type in 1 patient. (2) Diagnosis of HAT: all the 11 patients were confirmed with HAT by endovascular angiography, including 7 cases showed no arterial flow under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. Two patients showed increased hepatic artery resistance index under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated 1 case of HAT and 1 case of anastomotic stenosis. One patient showed slow velocity of hepatic artery blood flow and low resistance index under color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. One patient showed slight blood flow signals under Color Doppler ultrasound, and contrast-enhanced ultrasound indicated HAT. (3) Treatment of HAT: 11 patients received endovascular therapy. Six patients had HAT completely disappeared after thrombolytic therapy, 5 patients with residual thrombosis continued thrombolytic therapy with microcatheter urokinase. Six patients with complications were improved after symptomatic treatment. HAT completely disappeared after (6.7±2.6)days of treatment and the clinical success rate was 11/11. (4) Follow-up: 11 patients were followed up for 19-1 722 days, with a median follow-up time of 46 days. During the follow-up, 4 patients had biliary stricture and underwent stent implantation. Nine patients survived with 1-, 3-, 5-year overall survival rates of 75%, 75%, 75%, and 2 patients died.Conclusions:The incidence of HAT after adult orthotopic liver transplantation is low and clinical manifestations are atypical. Contrast enhanced ultrasound can improve diagnosis of suspected thrombosis. Endovascular therapy is safe and effective, which can significantly improve the blood flow of hepatic artery.
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Source control is the core of intra-abdominal infections (IAIs) treatment, in which precise positioning and effective drainage is the key and aporia. On the basis of membrane anatomy theory and understanding of anatomic structural abnormality under IAIs, the authors propose the concept of 'abdominal partition under IAIs’ in order to locate the source of infection and design of safe drainage path precisely, which could improve the diagnosis and treatment of IAIs and the prognosis.
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Objective@#To evaluate the efficacy and safety of oXiris hemofilter for septic shock patients.@*Methods@#Clinical data of septic shock patients receiving continuous renal replacement therapy (CRRT) with oXiris hemofilter in department of surgical intensive care unit (SICU) of the First Affiliated Hospital of Xi'an Jiaotong University from March 1st, 2018 to July 20th, 2019 were retrospectively analyzed. The heart rate (HR), mean arterial pressure (MAP), oxygenation index (PaO2/FiO2), lactate (Lac), platelet count (PLT), serum procalcitonin (PCT), interleukin-6 (IL-6) and C-reactive protein (CRP), noradrenaline (NE) dosage, acute physiology and chronic health evaluationⅡ(APACHEⅡ) and sequential organ failure score (SOFA) were compared before and after oXiris treatment and the prognosis were also analyzed.@*Results@#Six patients with septic shock were included [5 males, the average age was (56.3±11.8) years old]. A total of 13 oXiris hemofilter sets were performed during treatment. Compared with before treatment, the HR, IL-6 and CRP levels were significantly decreased after treatment [HR (bpm): 93.8±9.7 vs. 133.5±18.3, IL-6 (ng/L): 509.2±169.6 vs. 3 739.8±618.2, CRP (mg/L): 169.1±148.3 vs. 277.8±68.7, all P < 0.05], MAP, PaO2/FiO2 and PLT were significantly increased [MAP (mmHg, 1 mmHg = 0.133 kPa): 73.3±2.2 vs. 63.3±1.6, PaO2/FiO2 (mmHg): 166.8±40.4 vs. 95.1±56.2, PLT (×109/L): 73.3±27.5 vs. 41.2±21.4, all P < 0.05]; meanwhile, NE dosage, APACHEⅡ and SOFA scores were significantly decreased [NE (μg·kg-1·min-1): 0.4±0.3 vs. 1.2±0.7, APACHEⅡ: 18.8±6.9 vs. 30.0±7.3, SOFA: 11.7±4.2 vs. 17.3±2.1, all P < 0.05]. Although Lac and PCT decreased after treatment, there was no significant difference [Lac (mmol/L): 3.5±2.1 vs. 6.1±3.2, PCT (μg/L): 37.7±48.3 vs. 85.1±32.8, both P > 0.05]. At the end, 3 of the 6 patients survived and the others were discharged again medical advice. The length of SICU stay was 3 to 23 days, with an average of (13.0±8.5) days. No adverse events occurred during the treatment.@*Conclusion@#oXiris hemofilter can effectively remove inflammatory mediators in circulation, significantly improve hemodynamic status and severity, and may be considered as a safe and reliable treatment modality for septic shock patients.
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Objective To evaluate the efficacy and safety of oXiris hemofilter for septic shock patients. Methods Clinical data of septic shock patients receiving continuous renal replacement therapy (CRRT) with oXiris hemofilter in department of surgical intensive care unit (SICU) of the First Affiliated Hospital of Xi'an Jiaotong University from March 1st, 2018 to July 20th, 2019 were retrospectively analyzed. The heart rate (HR), mean arterial pressure (MAP), oxygenation index (PaO2/FiO2), lactate (Lac), platelet count (PLT), serum procalcitonin (PCT), interleukin-6 (IL-6) and C-reactive protein (CRP), noradrenaline (NE) dosage, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) and sequential organ failure score (SOFA) were compared before and after oXiris treatment and the prognosis were also analyzed. Results Six patients with septic shock were included [5 males, the average age was (56.3±11.8) years old]. A total of 13 oXiris hemofilter sets were performed during treatment. Compared with before treatment, the HR, IL-6 and CRP levels were significantly decreased after treatment [HR (bpm): 93.8±9.7 vs. 133.5± 18.3, IL-6 (ng/L): 509.2±169.6 vs. 3739.8±618.2, CRP (mg/L): 169.1±148.3 vs. 277.8±68.7, all P < 0.05], MAP, PaO2/FiO2 and PLT were significantly increased [MAP (mmHg, 1 mmHg = 0.133 kPa): 73.3±2.2 vs. 63.3±1.6, PaO2/FiO2 (mmHg): 166.8±40.4 vs. 95.1±56.2, PLT (×109/L): 73.3±27.5 vs. 41.2±21.4, all P < 0.05]; meanwhile, NE dosage, APACHEⅡ and SOFA scores were significantly decreased [NE (μg·kg-1·min-1): 0.4±0.3 vs. 1.2±0.7, APACHEⅡ:18.8±6.9 vs. 30.0±7.3, SOFA: 11.7±4.2 vs. 17.3±2.1, all P < 0.05]. Although Lac and PCT decreased after treatment, there was no significant difference [Lac (mmol/L): 3.5±2.1 vs. 6.1±3.2, PCT (μg/L): 37.7±48.3 vs. 85.1±32.8, both P > 0.05]. At the end, 3 of the 6 patients survived and the others were discharged again medical advice. The length of SICU stay was 3 to 23 days, with an average of (13.0±8.5) days. No adverse events occurred during the treatment. Conclusion oXiris hemofilter can effectively remove inflammatory mediators in circulation, significantly improve hemodynamic status and severity, and may be considered as a safe and reliable treatment modality for septic shock patients.
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Objective To evaluate the clinical efficacy and safety of continuous renal replacement therapy (CRRT) in patients with severe acute pancreatitis (SAP) receiving percutaneous drainage (PCD). Methods Clinical data of SAP patients receiving PCD admitted to department of hepatobiliary surgery of the First Affiliated Hospital of Xi'an Jiaotong University from November 11th 2015 to May 13th 2018 were retrospectively analyzed. The patients were divided into CRRT group and control group according to whether or not receiving CRRT. Demographic data, relevant variables before and after PCD, complication and outcome were all compared. Results A total of 75 patients were included in the study, 30 were treated with application of CRRT and 45 without CRRT. ① There was no significant difference in gender, age, body mass index (BMI), medical history (smoking, drinking), complications (cardiovascular disease, chronic lung disease, diabetes, chronic renal insufficiency), etiology (gallstone, alcohol abuse, hyperlipidemia and others), or white blood cell count (WBC), C-reactive protein (CRP), serum procalcitonin (PCT), fluid resuscitation, mechanical ventilation, vasoactive agent or intra-abdominal pressure within 48 hours after admission between the two groups. However, acute physiology and chronic health evaluationⅡ(APACHEⅡ) score within 48 hours after admission of CRRT group was significantly higher than that of control group (18.3±4.5 vs. 12.8±6.2, P < 0.05). ② There was no significant difference in WBC, PCT, APACHEⅡ score or computed tomography severity index (CTSI) before PCD between the two groups. There was no significant difference in the position or times of PCD procedure between the two groups, but the time interval of PCD in the CRRT group was significantly longer than that in the control group (days: 19.4±5.4 vs. 12.8±2.2, P < 0.05). Meanwhile, there was no significant difference in drainage of fluid properties, incidence of abdominal bleeding, infection, gastrointestinal fistula, endoscopic removal of necrotic tissue, laparotomy for removal of necrotic tissue or the time from PCD to endoscopy or laparotomy between two groups. However, the length of intensive care unit (ICU) stay and the length of hospital stay in the CRRT group were significantly longer than those in the control group (days: 23.2±8.5 vs. 15.3±12.1, 51.2±21.2 vs. 31.2±14.0, both P < 0.01). ③ Kaplan-Meier survival analysis showed that there was no significant differences in 1-year or 3-year cumulative survival rates between the two groups (χ21 = 0.097, P1 = 0.755; χ22 = 0.013, P2 = 0.908). Conclusions CRRT is safe and feasible in the treatment of SAP patients receiving PCD procedure. It does not increase the risk of bleeding and may delay the time interval of PCD intervention. However, it may prolong the length of ICU stay and the length of hospital stay. It should be worthy of much attention for clinicians.
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Objective To evaluate the clinical effect and safety of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) after hepatectomy.Methods A retrospective analysis of the clinical data of all patients with AKI after hepatectomy for CRRT admitted to surgical intensive care unit (ICU) of the First Affiliated Hospital of Xi'an Jiaotong University from January 19th, 2013 to January 19th, 2018 was performed. According to the different anticoagulants, the patients were divided into no anticoagulant group (NA group), low molecular heparin anticoagulation (LMHA) group and RCA group. The general data of patients during the perioperative period; renal function, the internal environment, electrolyte and blood coagulation function before and after CRRT; the filter time, the number of filters and adverse events (bleeding, frequent filter blood coagulation, metabolic alkalosis, metabolic acidosis, hypocalcemia, citrate accumulation, etc.) during CRRT were collected. Kaplan-Meier survival curve was used to analyze the life span of the first filter during different anticoagulation. Results A total of 67 cases were included in this study, including 11 in the NA group, 25 in the LMHA group and 31 in the RCA group. There was no significant difference in gender, age, underlying disease, etiology (tumor), Child-Pugh stage (A or B), CT angiography (CTA), basic renal function [serum creatinine (SCr), cystatin C (Cys C)], the American Society of Anesthesiologists (ASA) stage; surgical approach; intraoperative bleeding volume, blood transfusion, blood pressure, time of duration of low blood pressure; and postoperative circulatory failure, hepatic insufficiency and sepsis among three groups. However, the length of ICU stay in RCA group was significantly less than the LMHA group and NA group (days: 8.16±2.24 vs. 10.48±5.11, 13.29±6.64, bothP< 0.05). Compared with before CRRT, the levels of SCr, Cys C and Lac were significantly decreased in RCA group and LMHA group after CRRT [SCr (μmol/L): 89.02±21.90 vs. 248.30±55.32, 105.10±49.00 vs. 270.10±156.00; Cys C (mg/L): 2.18±0.95 vs. 2.94±1.26, 2.26±0.76 vs. 3.07± 0.90; Lac (mmol/L): 2.21±1.46 vs. 3.62±1.73, 2.37±1.24 vs. 4.03±1.69, allP < 0.05]; in addition, LMHA group and NA group had significant effects on hemoglobin (Hb), platelet count (PLT) and activated partial thromboplastin time (APTT) after CRRT [Hb (g/L): 85.4±5.1 vs. 99.6±23.6, 80.0±7.6 vs. 101.4±7.8; PLT (×109/L): 27.60±8.22 vs. 62.04±16.49, 21.36±3.91 vs. 61.45±17.69; APTT (s): 63.07±10.25 vs. 41.52±3.65, 49.56±5.77 vs. 41.09± 3.45, allP < 0.05]; at the same time, Cys C level and prothrombin time (PT) in the NA group after CRRT treatment were significantly increased compared with the others [Cys C (mg/L): 3.59±0.64 vs. 2.29±0.51, PT (s): 26.41±2.43 vs. 23.64±1.92 , bothP < 0.05]. Finally, the time of filters (hours: 60.52±8.82, 31.04±7.03, 13.73±6.26,F = 183.412, P < 0.001) and the number of filter during treatment (number: 2.03±0.60, 3.12±0.73, 4.64±1.29,F = 45.933,P <0.001) in the RCA group, LMHA group and NA group had statistically significant difference. Meanwhile, the incidence of adverse events such as bleeding (0 vs. 4, 7,χ2 = 23.961,P < 0.001) and frequent filter coagulation (1 vs. 10, 11,χ2 =35.413,P < 0.001) in RCA group was significantly lower than that in LMHA group and NA group. Kaplan-Meier survival analysis showed that the life time of the first filter in RCA group was significantly longer than that in LMHA group and NA group (χ2 = 139.45,P < 0.05).Conclusion The application of RCA in patients with AKI after hepatectomy during CRRT is safe and effective, which can significantly prolong the life of the filter and reduce the risk of bleeding.
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<p><b>OBJECTIVE</b>Cellular senescence as one of the important steps against tumor is observed in many cancer patients receiving chemotherapy and is related to chemotherapeutic response. To investigate the effect of cisplatin on hepatocellular carcinoma, we treated HepG2 cells exhibiting wild-type TP53 with gradient concentrations of cisplatin.</p><p><b>METHODS</b>The inhibitory effects of cisplatin on human hepatoma HepG2 cells were detected by MTT assay and colony formation test. The changes in cell cycle were analyzed by flow cytometry, and cellular senescence was detected with senescence associated β-galactosidase (SA β-gal) staining. The relative mRNA expression levels of TP53, P21 and P19 was estimated using semi-quantitative real-time RT-PCR, and the protein expressions of P53 and P21 were detected using Western blotting.</p><p><b>RESULTS</b>Cisplatin induced irreversible proliferation inhibition and G1 phase arrest of HepG2 cells. Elevated levels of senescence-associated β-galactosidase was observed in HepG2 cells exposed to low doses of cisplatin. P19 expression immediately increased following cisplatin exposure and reached the maximum level at 48 h, followed then by a rapid decrease to the baseline level, whereas the expressions levels of TP53 and P21 mRNA increased continuously. Western blotting confirmed P53 and P21 expression changes similar to their mRNA expressions during cisplatin-induced cellular senescence in HepG2 cells.</p><p><b>CONCLUSION</b>Our results revealed a functional link between cisplatin and hepatocellular senescence. Cellular senescence induced by cisplatin as a stabile senescent cellular model can be used for further research.</p>