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Objective To explore the effect of goal-directed therapy bundle based on pulse-indicated continuous cardiac output (PiCCO) parameters to the prevention and treatment of acute kidney injury (AKI) in patients after cardiopulmonary bypass cardiac operation. Methods A prospective observational study was conducted. The adult patients with selective cardiopulmonary bypass cardiac operation admitted to the Third People's Hospital of Chengdu from December 2015 to January 2018 were enrolled. All patients were divided into two groups based on informed consent for PiCCO monitor at the time of admission to the intensive care unit (ICU): regular monitoring and treatment group (group A) and goal-directed therapy group based on PiCCO parameters (group B). In group A, the restrictive capacity management strategy was implemented to maintain the mean arterial pressure (MAP) > 65 mmHg (1 mmHg = 0.133 kPa) and the central venous pressure (CVP) between 8 mmHg and 10 mmHg. In group B, volume and hemodynamic status were optimized depending on PiCCO parameters to a goal of cardiac index (CI) > 41.68 mL·s-1·m-2, global end diastolic volume index (GEDVI) > 700 mL/m2 or intrathoracic blood volume index (ITBVI) > 850 mL/m2, extravascular lung water index (EVLWI) < 10 mL/kg, and MAP > 65 mmHg. Then the changes in hemodynamics and different prognosis of the patients in two groups were observed. Risk factors affecting the AKI were analyzed by Logistic regression. Results 171 cases were included, with 68 in group A and 103 in group B. There were no significant differences in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), operation ways, operation time, cardiopulmonary bypass time, intraoperative dominant liquid equilibrium quantity, the use of intra-aortic balloon counterpulsation (IABP) during operation, and serum creatinine (SCr) level at the time of admission to ICU between the two groups. There were no significant differences in CVP within 24 hours after admission to ICU between the two groups. MAP in group B was significantly higher than that in group A at 8 hours and 16 hours after ICU admission (mmHg: 68.9±6.3 vs. 66.7±5.1, 69.0±4.9 vs. 67.0±5.3, both P < 0.05). Sequential organ failure assessment (SOFA) score in group B was significantly lower than that in group A at 24 hours after ICU admission (5.7±2.2 vs. 6.9±2.8, P < 0.05). Dominant liquid equilibrium quantity in group B was significant higher than that in group A at 24 hours after ICU admission (mL/kg: 7.1±6.2 vs. -0.1±8.2, P < 0.01), but there was no significant difference of that between groups at 48 hours and 72 hours after ICU admission. Compared with group A, incidence of combination with AKI during 72 hours after ICU admission was significantly decreased in group B [48.5% vs. 69.1%; odds ratio (OR) =0.422, 95% confidence interval (95%CI) = 0.222-0.802, P < 0.05], and incidence of moderate to severe AKI was also significantly decreased in group B (19.4% vs. 35.3%; OR = 0.442, 95%CI = 0.220-0.887, P < 0.05). There was no significant difference in usage of continuous renal replacement therapy (CRRT) after ICU admission between both groups (group A was 4.4%, group B was 4.9%, P > 0.05). It was shown by correlation analysis that only MAP and CI at 8 hours after ICU admission were significantly negatively correlated with AKI (MAP and AKI: r = -0.697, P = 0.000;CI and AKI: r = -0.664, P = 0.000). It was shown by Logistic regressive analysis that the MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI at 72 hours after ICU admission (MAP:OR = 0.736, 95%CI = 0.636-0.851, P = 0.000; CI: OR = 0.006, 95%CI = 0.001-0.063, P = 0.000). There were no significant differences in the duration of mechanical ventilation, the length of ICU stay, the post-operation complications (except AKI), 7-day and 28-day mortality between the two groups. Conclusions Goal-directed therapy bundle based on PiCCO parameters reduced the incidence of AKI in patients after cardiopulmonary bypass cardiac operation and improved the severity of systemic disease. However, it did not reduce the duration of mechanical ventilation, length of ICU stay, the incidence of complications (except AKI), short-term mortality. The MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI in patients after cardiopulmonary bypass cardiac operation.
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Objective To assess the value of end-tidal carbon dioxide partial pressure (PETCO2) combined passive leg raising (PLR) test on volume responsiveness assessment in shocked patients post cardiac operation.Methods A prospective,self-controlled,and observational study was conducted.The shocked patients post cardiac operation undergoing complete mechanical ventilation admitted to Department of Critical Care Medicine of First Affiliated Hospital of College of Medicine,Zhejiang University from June 2014 to October 2015 were enrolled.PETCO2 and hemodynamic parameters including stroke volume variation (SVV),cardiac index (CI),mean arterial pressure (MAP) monitored by a pulse indicator continuous cardiac output (PiCCO) were determined before and after PLR and volume expansion (VE).Volume responsiveness was defined as an increase in CI (△ CI) of 15％ or greater after VE,namely response group (△ CI ≥ 15％) and non-response group (△ CI ＜ 15％).The value of PLR-induced PETCO2 change (△PETCO2 PLH) to predict volume responsiveness was evaluated by receiver operating.characteristic curves (ROC).Results Among the 41 patients enrolled,21 had volume responsiveness (response group),and 20 had no responsiveness (non-response group).After PLR,the changes in CI and PETCO2 were both significantly increased in the response group compared with non-response group [△ CI:(13.5 ± 4.6)％ vs.(3.6± 3.5)％,△ PETCO2:(7.4 ± 3.4)％ vs.(2.8 ± 2.5)％,both P ＜ 0.05].△ PETCO2 PLR and baseline SVV were positively correlated with PLR-induced CI change (△ CI PLR) (r1 =0.50,r2 =0.38,both P ＜ 0.05).VE-induced PETCO2 change (△ PETCO2 VE),baseline SVV and △ CI PLR were positively correlated with VE-induced CI (△ CI VE) (r1 =0.58,r2 =0.56 and r3 =0.84,all P ＜ 0.01).The area under ROC curve (AUC) of △ PETCO2 PLR was 0.875±0.054 [95％ confidence interval (95％CI) =0.769-0.981,P ＜ 0.05].△ PETCO2 PLR ≥ 5.8％ predicted volume responsiveness with sensitivity of 76.2％ and specificity of 90.0％.AUC of △CI PLR was 0.933±0.036 (95％CI =0.862-1.000,P ＜ 0.05).△CI PLR ≥ 10.4％ predicted volume responsiveness with sensitivity of 81.0％ and specificity of 90.0％.AUC of baseline SVV was 0.831 ±0.066 (95％CI =0.702-0.960,P ＜ 0.05).Baseline SVV ≥ 12.5％ predicted volume responsiveness with sensitivity of 85.7％ and specificity of 75.0％.Conclusion The change in PETCO2 induced by PLR is a convenient,reliable and non-invasive indicator to predict volume responsiveness in shocked patients post cardiac operation with mechanical ventilation.
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Objective To explore the clinic values of intraoperative fluid overload in evaluating the perioperative prognosis of patients after cardiopulmonary bypass cardiac operation. Methods A prospective observational study was conducted. The adult patients admitted to the Third People's Hospital of Chengdu from April 2014 to March 2016 for selective cardiopulmonary bypass cardiac operation monitored by pulmonary artery catheter or pulse-indicated continuous cardiac output (PiCCO) were selected. All patients received therapy with restrictive fluid management strategy after admission to the intensive care unit (ICU) and were divided into two groups based on the value of intraoperative fluid accumulation ratio at the time of admission to the ICU: group A with intraoperative fluid accumulation ratio of less than 10% and group B with equal to or more than 10%. Then the changes and different prognosis of the patients in groups were observed. Risk factors affecting the prognosis were analyzed using logistic regression, and the predictive values of various parameters on prognosis were analyzed using receiver operating characteristic curve (ROC). Results 224 cases were included, with 172 in group A and 52 in group B. No significant differences were found between both groups in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and sequential organ failure assessment (SOFA), operation ways, operation time, cardiopulmonary bypass time and blood loss (all P > 0.05). Both APACHE Ⅱ score and SOFA score in group B were significantly higher than those in group A at admission and 24, 48 and 72 hours after ICU admission (APACHE Ⅱ: 24.5±4.1 vs. 21.8±3.5, 14.8±6.5 vs. 9.9±3.9, 12.3±5.4 vs. 9.4±3.7, 10.9±5.0 vs. 8.9±3.3, SOFA: 12.3±2.9 vs. 10.6±2.1, 8.8±2.8 vs. 5.7±1.7, 7.2±3.0 vs. 5.0±2.0, 6.4±3.6 vs. 5.2±1.7, all P < 0.05). Compared with group A, incidence of combination with acute kidney injury (AKI) was significantly increased in group B (92.3% vs. 68.6%, P < 0.01), the level of post operation cardiac index (CI) was significantly lower in group B (mL·s-1·m-2: 40.67±4.00 vs. 49.84±7.50, P < 0.01). Both the duration of mechanical ventilation and the length of stay in the ICU in group B were significant longer than those in group A (days: 3.2±2.1 vs. 1.8±1.3, 5.0±1.7 vs. 3.6±1.2, both P < 0.01). The post-operation complications, 7-day and 28-day mortality in group B were all significantly higher than those in group A (65.4% vs 30.2%, 19.2% vs. 1.7%, 26.9% vs. 3.5%, all P < 0.01). Logistic regressive analysis showed that after controlling the influence of postoperative AKI and CI on mortality, the intraoperative fluid accumulation ratio at ICU admission was still an independent risk factor [odds ratio (OR) of 7-day mortality = 1.380, 95% confidence interval (95%CI) = 1.019-1.869, P = 0.037; OR of 28-day mortality = 1.302, 95%CI = 1.026-1.654, P = 0.030]. The area under the curve of ROC (AUC) in predicting the 28-day mortality of patients after operation using intraoperative fluid accumulation ratio was 0.874 (P = 0.000), with a sensitivity of 95.0 % and a specificity of 78.4% at the optimal threshold value of 7.5%. Conclusions Intraoperative fluid overload in patients admitted to the ICU would aggravate their condition, prolong the duration of mechanical ventilation and the length of ICU stay, and increase post-operative complications morbidity and mortality. After controlling the influence of AKI and cardiac insufficiency on mortality, the fluid overload was still an independent risk factor for the death of patients after cardiopulmonary bypass cardiac operation.
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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.
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Objective To explore the clinic values of early goal directed treatment (EGDT)with the target of mixed venous oxygen saturation (SvO2)and difference of mixed venous-arterial partial pressure of carbon dioxide (Pv-aCO2) in monitoring of oxygen metabolism and treatment for patients post open-heart operation. Methods A prospective study was conducted. The adult patients admitted to Third People's Hospital of Chengdu from December 2011 to March 2014 with SvO22 mmol/L when admitted in intensive care unit(ICU)were selected on whom elective open-heart operation and pulmonary artery catheter examination were done. All patients received EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg (1 mmHg=0.133 kPa)and were divided into three groups by the values of SvO2 and Pv-aCO2 at 6-hour after ICU admission:A group with SvO2≥0.65 and Pv-aCO2<6 mmHg,B group with SvO2≥0.65 and Pv-aCO2≥6 mmHg,and C group with SvO2<0.65. Then the changes and prognosis of the patients in different groups were observed. Results 103 cases were included,44 in A group,31 in B group and 28 in C group. The acute physiology and chronic health evaluationⅡ (APACHEⅡ)score in group A were significantly lower than that in group B or C at 6,24,48 and 72 hours (T6,T24,T48,T72)of ICU admission (T6:11.4±5.8 vs. 13.9±5.4,13.7±6.4;T24:8.8±3.7 vs. 10.8±4.8,11.8±5.4;T48:8.7±4.1 vs. 9.6 ±4.2,10.2 ±5.1;T72:7.5 ±3.4 vs. 8.6 ±2.9,9.2 ±4.2,all P<0.05),and the sequential organ failure assessment (SOFA)showed the same tendency (T6:6.5±4.3 vs. 8.0±3.8,9.1±4.5;T24:6.6±3.6 vs. 8.6±3.9, 8.5±3.3;T48:5.2±3.4 vs. 7.0±3.6,7.6±5.1;T72:4.6±2.4 vs. 5.8±2.5,6.8±3.5,all P<0.05). The values of blood lactic acid (mmol/L)in group A and B were significant lower than that in group C at T6,T24,T48 and T72 (T6:1.60 ±0.95,2.20 ±1.02 vs. 2.55 ±1.39;T24:2.26 ±1.26,2.70 ±1.36 vs. 3.34 ±2.36;T48:2.01 ±1.15, 2.17 ±1.51 vs. 2.42 ±1.63;T72:1.62 ±1.14,1.64 ±0.75 vs. 2.11 ±1.29,all P<0.05). The time of machine ventilation(days)in group A or B was significantly shorter than that in group C(2.8±2.0,3.6±2.3 vs. 5.0±3.1,both P<0.05). ICU day (days)in group A was significant shorter than that in group C (4.6±2.5 vs. 6.5±3.7,P<0.05). The 7-day mortalities after operation in three groups were significantly different. Compared with group A (2.3%),the odds ratio (OR)in group B (22.6%)was 12.5 (P<0.05),group C (25.0%)14.3 (P<0.05). The morbidity and 28-day mortality in three groups were not significantly different. Pv-aCO2 negatively correlated with cardiac index(CI, r=-0.685,P=0.000),but not correlated with blood lactic acid(r=0.187,P=0.080). Conclusions EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg improved the general condition and tissue hypoxia,shortened the time of machine ventilation and duration of hospitalization in ICU,and decrease the 7-day mortality.