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To investigate the impact of goal directed analgesia on the outcome of patients with mechanical ventilation in intensive care unit. A total of 126 patients who needed mechanical ventilation were recruited. With a method of before and after paired comparison, they were divided into two group:( 1 ) analgesia with empirical administration or control group; ( 2 ) goal directed analgesia based on critical-care pain observation tool (CPOT). Compared with the control group, after goal directed analgesia was applied, the consumption of midazolam significantly dropped from ( 368. 47 ± 27. 41 ) mg to ( 151. 27 ± 29. 31 ) mg (P<0. 05), whereas the consumption of dexmedetomidine significantly increased from ( 623. 62 ± 20. 91) μg to (812. 34 ± 22. 57) μg(P<0. 05). The median score of Richmond agitation-sedation scale increased from -3 to -1. The incidence of delirium significantly reduced from 23. 81% to 17. 46%( P<0. 05). The mean ventilator duration was significantly shortened from (168. 49 ± 11. 41) h to (142. 38 ± 13. 24) h(P<0. 05). ICU length of stay was significantly shortened from (23. 64 ± 9. 26) d to (19. 63 ± 8. 46) d ( P < 0. 05 ) . Due to the mild sedation, patients receiving goal directed analgesia report less delirium, less ventilation time and shorter ICU length of stay, suggesting that the general outcome is improved.
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Standardized pain assessment is a precondition of appropriate analgesia for mechanical ventilation patients. However, routine pain assessment rates remain very low in intensive care unit (ICU). Behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) can be used to assess pain in mechanical ventilation patients who are unable to report pain by themselves. No matter what strategy we taken, analgesia-first sedation should be used in priority. Meanwhile, patient-centered and goal-directed sedation strategy should be adopted based on the individual condition.If condition permits, patients should be maintained in light states of sedation as long as possible, because this is associated with improved clinical outcomes. Humanistic care, multidisciplinary cooperation and comprehensive training are also important components of a perfect analgesia strategy.
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Sepsis is a life-threatening organ dysfunction caused by dys-regulated host response to infection. Acute kidney injury (AKI) caused by sepsis is one of the most common and severe clinical disease, which incidence and mortality remains high level, and has poor clinical outcomes. Continuous renal replacement therapy (CRRT) is an indispensable tool for the treatment of critically ill patients with severe AKI, but there is no consensus on the appropriate treatment dose of CRRT. By reviewing the process of high volume hemofiltration (HVHF) and standard volume hemofiltration (SVHF), comparing their benefits and risks, and making suggestions for therapeutic schedule improvement, reference for clinical work was provided.
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The present review concluded remarkable globe clinical achievements in the field of critical care medicine during 2013.Briefly,new international sepsis management guideline,high frequency oscillatory ventilation,hydroxyethyl starch,immune-nutritional therapy,fecal transplantation and infection controlling became the highlighting topics.Additionally,it is also worthy to note the apparent disparity in the resuhs between meta-analyses suggesting a treatment advantage and following large-scale randomized trials that have failed to detect such differences in treatment outcomes.Nonetheless,we still expect the emerging of ongoing investigations may provide clarity in these area.
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Objective To compare the characteristics and risk factors of prognosis between elder and young patients with acute respiratory distress syndrome(ARDS)in intensive care unit(ICU). Methods The data of 150 patients meeting ARDS Berlin guideline who admitted to ICU of Affiliated First Hospital of Dalian Medical University from August 2011 to November 2013 were retrospectively analyzed. The patients over 65 years old were served as elderly group(n=78),and those younger than 65 years old were served as young group(n=72),and the patients were subdivided into survivors and non-survivors groups. The characteristics of patients at admission was recorded to investigate the characteristics of elder and young patients by univariate analysis. The univariate analysis was also conducted between different prognosis groups,and the risk factors of mortality were demonstrated by multivariate logistic analysis. Results Compared with the young group,the hospital length of stays〔days:27.0 (16.0,36.0)vs. 15.0(8.0,21.0),P=0.000〕,ICU length of days〔days:25.0(15.0,32.0)vs. 13.0(7.0,19.00), P=0.000〕,mechanical ventilation days〔days:19.0(11.0,27.0)vs. 8.0(5.0,15.0),P=0.000〕,the proportion of tracheotomy:〔39.74%(31/78)vs. 18.06%(13/17),P=0.003〕,the number of organ dysfunction(3.78±0.49 vs. 1.97±1.03,P=0.043)and creatinine(μmol/L:153.85±16.89 vs. 108.26±9.14,P=0.017)of elderly group were significantly increased. The mortality〔67.95%(53/78)vs. 59.72%(43/72),P=0.190〕and acute physiology and chronic health evaluationⅡ(APACHEⅡ)score(17.94±6.04 vs. 15.99±6.93,P=0.068)in the elderly group were higher than those in the young group but without the significant differences. The causes of death in elderly patients were mainly with respiratory failure;the mainly causes in young and middle-aged patients were complex with multiple organ dysfunction syndrome,circulatory failure and other reasons. APACHEⅡscore,the number of organ dysfunction,and maximum positive end-expiratory pressure(PEEP)in the non-survivors of the elderly group were significantly higher than those of the survivors〔APACHEⅡ score:19.45±6.00 vs. 14.72±4.83,the number of organ dysfunction:4.13±0.88 vs. 2.16±1.01,maximum PEEP(cmH2O,1 cmH2O=0.098 kPa):13.93±4.16 vs. 9.72±3.72, all P<0.01〕,and the proportion of tracheotomy and pH value were significantly lower than those of the survivors〔the proportion of tracheotomy:32.08%(17/53)vs. 56.00%(14/25),pH value:7.35±0.14 vs. 7.42±0.08,both P<0.05〕. Logistic analysis showed that APACHEⅡ score〔odds ratio(OR)=7.068,95% confidence interval (95%CI)=1.358-3.273,P=0.023〕,the number of organ dysfunction(OR=2.328,95%CI=1.193-4.520,P=0.029)were related with prognosis in elderly patients with ARDS. APACHEⅡscore,the number of organ dysfunction, blood lactate,maximum PEEP in non-survivors of the young group were significantly higher than those of the survivors〔APACHEⅡ score:18.12±6.88 vs. 12.83± 5.80,the number of organ dysfunction:3.16±1.23 vs. 2.55±1.29, blood lactate(mmol/L):4.84± 4.07 vs. 2.56±1.86,maximum PEEP(cmH2O):13.93±5.50 vs. 10.54±4.05, P<0.05 or P<0.01〕,and the pH value,hospital length of stays,ICU length of days were significantly lower than those of the survivors〔pH value:7.30±0.16 vs. 7.41±0.10,hospital length of stays(days):11.09±10.97 vs. 25.17±19.05,ICU length of days(days):8.0(5.0,13.0)vs. 20.0(12.0,31.0),all P<0.01〕. Multivariate logistic analysis showed that APACHEⅡ score was related with the prognosis in young patients with ARDS(OR=5.735, 95%CI=1.921-3.310,P=0.004). Conclusions Higher APACHEⅡscore and the number of organ dysfunction were independent predictors of worse outcome in elder ARDS patients. Higher APACHEⅡscore was the independent predictor of worse outcome in young ARDS patients.
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Objective To explore the correlation of pulse pressure(PP) and outcome in refractory septic shock patients.Methods A total of 68 patients with refractory septic shock consecutively admitted in our ICU from January 2012 to December 2012 were retrospectively studied.Hemodynamic data and arterial lactate concentration were collected at the time of admission and 24 hours after admission.The outcome of Day 28 post-diagnosis was also recorded.Results (1) Compared with the survivors,heart rate(HR) at 24hours after admission was higher in non-survivors,while 24 h lactate clearance rate (rLac) was lower in them (P ＜ 0.05).Other hemodynamic parameters showed no difference between the non-survivors and the survivors at 24 hours after admission,including central venous pressure (CVP),mean arterial pressure (MAP),systolic blood pressure(SBP),diastolic blood pressure(DBP),PP,pulse pressure/heart rate (PP/HR),pulse pressure/mean arterial pressure(PP/MAP),pulse pressure/systolic pressure(PP/SBP),pulse pressure/diastolic pressure (PP/DBP),the value of SBP above MAP (SMP) and the value of DBP below MAP(MDP).(2)The mortality rate was higher in the patients with HR≥100 b/min than those with HR ＜ 100 b/min,but without statistical significance (56.25％ vs 36.11％,P =0.096).Compared with the survivors,no matter with HR≥100 b/min or HR ＜ 100 b/min,lactate(Lac) at the 24 hours after admission was higher in all the non-survivors (P ＜ 0.05),while with lower rLac (P ＜ 0.05).In those with HR ≥100 b/min,the following hemodynamic parameters were higher in the non-survivors than in the survivors,including PP,PP/HR,PP/MAP,PP/SBP,PP/DBP,SMP and MDP (all P values ＜ 0.05),while no statistical difference was observed in those with HR ＜ 100 b/min.(3)The mortality rate showed no statistical difference in those with MAP≥85 mmHg(1 mmHg =0.133 kPa) and with MAP ＜ 85 mmHg(42.42％ vs 48.57％,P =0.611).No matter MAP≥85 mmHg or MAP ＜ 85 mmHg,compared with the survivors,all the non-survivors had higher Lac at the 24 hours after admission (P ＜ 0.05),while with lower rLac (P ＜ 0.05).In those with MAP≥85 mmHg,HR was higher in the non-survivors than the survivors (P ＜ 0.05).In those with MAP ＜ 85 mmHg,compared with the survivors,the non-survivors had higher PP,PP/MAP,PP/SBP,PP/DBP,SMP and MDP (P ＜0.05),while with lower DBP (P ＜0.05).Conclusion PP is correlated with the outcome in refractory septic shock patients.When the HR and MAP differ,PP has different effect on the outcome and contributes more to the tissue perfusion and outcome in those with higher HR and lower MAP.
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Objective To investigate the protective mechanisms of ulinastatin (UTI) in lung injury in septic rats.Methods Thirty healthy SD rats of clean grade were randomly (random number) divided into saline control group,lipopolysaccharide (LPS) group and lipopolysaccharide + ulinastatin (LPS + UTI) group (n =10,in each).The lung tissues were obtained for morphological observation at the 24th-hour after LPS injection.RT-PCR or Western blot,ELISA methods were applied to measure the expressions of Toll-like receptor 4 (TLR4),nuclear factor (NF)-κB,tumor necrosis factor (TNF)-α mRNA and their protein levels.Results LPS injection could result in lung injury.UTI could down-regulate the expressions of TLR4 mRNA (t =3.563,P =0.032),TNF-α mRNA (t =5.147,P =0.028),TLR4 protein (t =2.692,P =0.041),NF-κB protein (t =2.459,P =0.024) and TNF-α protein (t =3.336,P =0.037) in lung,and could in turn alleviate lung injury.Conclusions UTI showed protective effects on LPS induced lung injury,and one of the mechanisms was perhaps associated with the inhibition of TLR4-NF-κB signal transduction pathway.
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Objective To study the foxml gene and its protective effect on the lung tissue of rats with acute lung injury (ALI) induced by lipopolysaccharide (LPS), and to observe the dexamethason' s (DEX) impacts on foxml gene and the prognosis of ALI. Method Seventy-two healthy mice were randomly(random number) divid-ed into three groups: control group (A group, n = 24), model group (B group, n = 24) and DEX treatment group (C group, n = 24). The observing intervals were respectively set in 24 h, 48 h and 72 hours. At each ob-serving interval, the foxml protein in lung tissue of mice was detected by using immunohistochemistry (IHC), and the expression of foxml gene in lung tissue was detected by using RT-PCR, as well as to observe the pathological changes in lung tissue. Results Comparisons were made between paired groups at 24 h,48 h and 72 h intervals in which the expression of foxml mRNA and the level of foxml protein in lung tissue of mice in C group were signifi-cantly higher than those in B group (P < 0.05), and those in B group were significantly higher than those in A group (P < 0.05). The expression of foxml mRNA and the level of foxml protein in lung tissue of mice in B group at 48 h interval were significantly higher than those both at intervals of 72 h and 24 h (P < 0.05), and the those at 72 interval were significantly higher than those at 24 h interval (P < 0.05). Compared with B group, the pathologi-cal changes in lung tissue of mice in C group were lessened. Conclusions In both model group and dexamethasone treatment group, the expression of foxml mRNA and the level of foxml protein in lung tissue of mice are increased significantly. Dexamethasone lessens the injury of both vascular endothelial cells and alveolar epithelial ceils of lung tissue, and it also significantly increases the expression of foxml mRNA and the level of foxml protein.
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AIM: To study the inhibitory effect of IGF binding protein-4(IGFBP-4),especially in corporation with heparin on the pathopoiesis of insulin-like growth factor-1(IGF-1) in alveolitis and fibrosis.METHODS: The diploid human embryonic lung(HEL) fibroblasts were incubated respectively with control,100 ?g/L IGF-1,100 ?g/L IGF-1+100 ?g/L IGFBP-4,100 ?g/L IGF-1+200 ?g/L IGFBP-4,100 ?g/L IGF-1+100 ?g/L IGFBP-4+100 ?g/L heparin,100 ?g/L IGF-1 + 100 ?g/L IGFBP-4+200 ?g/L heparin,100 ?g/L IGF-1+100 ?g/L heparin,100 ?g/L IGF-1+200 ?g/L heparin for 24 h.Then the content of glucose transporter-4(GLUT-4),hexokinase-2(HK-2),collagen-4 and elastin were detected,respectively.RESULTS: Compared with control group,HK-2,GLUT-4,elastin and collagen-4 expressed in IGF-1 group were increased obviously.The expression in the group of IGFBP-4 plus IGF-1 was more than that in IGF-1 group.However,all expression was depressed strikingly when heparin was added.CONCLUSION:(1) IGF-1 apparently stimulates HK-2,GLUT-4,elastin and collagen-IV secretions from lung fibroblasts.(2) The intact IGFBP-4 associated with heparin can inhibit the pathopoiesis of IGF-1.