Summary of the best evidence for the energy and protein intake targets and calculation in critically ill patients / 中华危重病急救医学

Objective:To evaluate and summarize the best evidence of energy and protein intake targets and calculation in adult critically ill patients, and to provide evidence-based basis for critical nutrition management.Methods:Evidence related to energy and protein intake targets and calculation of adult critically ill patients, including guideline, expert consensus, systematic review and evidence summary, were systematically searched in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Library, UpToDate, BMJ Best Practice, Joanna Briggs Institute (JBI), Web of Science, SinoMed, Medive, China National Knowledge Infrastructure, Wanfang database, VIP database, Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), Registered Nurses Association of Ontario (RNAO), and Society of Critical Care Medicine (SCCM) from January 2012 to June 2022. Two researchers independently evaluated the quality of the included literatures using the JBI Evidence-based Health Care Center evaluation tool and the Appraisal of Clinical Practice Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ), extracted and summarized the best evidence for the nutritional intake goal and calculation of adult critically ill patients, and described the evidence.Results:A total of 18 literatures were included, including 5 clinical guidelines, 8 expert consensus, 3 systematic reviews and 2 evidence summaries. After literature quality evaluation, 18 articles were all enrolled. The evidence was summarized from the four aspects, including energy target calculation method, dose body weight, energy and protein intake target, and calculation method, 24 pieces of the best evidence were finally formed.Conclusions:The best evidence of energy and protein intake targets and calculation for critically ill patients was summarized based on evidence-based. Clinical medical staff can choose indirect calorimetry to calculate energy goals when equipment is available. Patient's height, body weight should be recorded accurately, dose body weight can be determined by body mass index (BMI). Meanwhile, blood urea nitrogen (BUN) loss, fat-free body weight, simple formulas and other methods should be used to continuously evaluate and adjust protein intake targets, to achieve the purpose of optimizing intensive nutrition support.

Neumotórax a tensión secundario a colocación de sonda enteral: reporte de caso / Tension pneumothorax secondary to enteral tube: a case report / Pneumotórax hipertensivo secundário à colocação de sonda enteral: relato de caso

Resumen: La colocación de una sonda enteral es un procedimiento invasivo rutinario que puede presentar complicaciones graves. Presentamos el caso de un hombre de 54 años de edad que presentó paro cardiorrespiratorio secundario a infarto de miocardio y que, después de la colocación de una sonda nasoyeyunal, desarrolló neumotórax, por lo que ameritó su retiro, la colocación de una sonda endopleural y la administración de antibióticos. El paciente mostró adecuada expansión pulmonar, lo cual permitió el retiro de la sonda endopleural a los seis días de su instalación, la extubación del enfermo y finalmente su egreso por mejoría. El neumotórax asociado a la colocación de la sonda enteral se presenta en 1.2% de los pacientes. Los factores de riesgo son: déficit neurológico, alteración de la deglución y del reflejo tusígeno. El tratamiento descrito en la literatura es el retiro de la sonda, el uso de antibióticos y el drenaje torácico.

Abstract: Enteral tube placement is a routine invasive procedure that can present serious complications. We present the case of a 54-year-old man who presented with cardiorespiratory arrest secondary to myocardial infarction and who, after placement of a nasojejunal tube, developed pneumothorax that required removal of the tube, placement of a chest tube and administration of antibiotics. The patient presented adequate lung expansion, which allowed removal of the chest tube six days after its installation, extubation and finally discharge due to improvement. Pneumothorax associated with enteral tube placement occurs in 1.2% of patients. Risk factors are neurological deficit, impaired swallowing and cough reflex. Treatment described in the literature is removal of the tube, use of antibiotics and chest drainage.

Resumo: A colocação de sonda enteral é um procedimento invasivo de rotina que pode apresentar complicações graves. Apresentamos o caso de um homem de 54 anos que apresentou parada cardiorrespiratória secundária a infarto do miocárdio e que, após colocação de sonda nasojejunal, desenvolveu pneumotórax que exigiu sua retirada, colocação de sonda endopleural e administração de antibióticos.O paciente apresentou expansão pulmonar adequada, o que permitiu a retirada do tubo endopleural 6 dias após sua instalação, a extubação do paciente e por fim sua alta por melhora. O pneumotórax associado à colocação de sonda enteral ocorre em 1.2% dos pacientes. Os fatores de risco são: déficit neurológico, deglutição prejudicada e reflexo da tosse. O tratamento descrito na literatura é a retirada da sonda, uso de antibióticos e drenagem torácica.

Effect of hypophosphatemia on the prognosis of critically ill patients / 中华危重病急救医学

Objective:To explore the impact of hypophosphatemia on the occurrence and prognosis of critically ill patient.Methods:The clinical data of critically ill patients admitted to the intensive care unit (ICU) of Tianjin First Central Hospital from October 2021 to April 2022 were retrospectively analyzed. Patients were divided into hypophosphatemia group (serum phosphorus level < 0.80 mmol/L) and non-hypophosphatemia group (serum phosphorus level ≥ 0.80 mmol/L) when they were admitted to the ICU. The following variables were also collected, including gender, age, acute physiology and chronic health evaluationⅡ(APACHE Ⅱ), sequential organ failure assessment (SOFA), serum phosphorus level, serum calcium level, serum magnesium level, white blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LYM), neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP), presence of infection and infection site, length of hospital stay, ICU stay, 28-day mortality, and mechanical ventilation time. Multivariate Logistic regression analysis was used to evaluate the relationship between each variable and the 28-day mortality. The receiver operator characteristic curve (ROC curve) was drawn, and the area under the ROC curve (AUC) and 95% confidence interval (95% CI) were calculated to evaluate the predictive value of serum phosphorus levels for the prognosis of ICU patients. Results:A total of 263 patients were enrolled, including 54 patients with hypophosphatemia and 209 patients without. The SOFA score, LYM level and the infection rate of patients in the hypophosphatemia group were significantly higher than those in the non-hypophosphatemia group [SOFA score: 6.70±3.17 vs. 5.64±3.59, LYM (×10 9/L): 0.99±0.54 vs. 0.77±0.54, infection rate: 77.78% (42/54) vs. 59.33% (124/209), all P < 0.05], the NLR was significantly lower than that of the non-hypophosphatemia group [10.67 (7.08, 18.02) vs. 12.25 (7.25, 21.68), P < 0.05]. The length of hospital stay, ICU stay, and mechanical ventilation duration in the hypophosphatemia group were significantly longer than those in the non-hypophosphatemia group [length of hospital stay (days): 15 (11, 28) vs. 12 (6, 21), length of ICU stay (days): 10.35±7.80 vs 7.15±6.61, mechanical ventilation duration (days): 3 (0, 12) vs. 2 (0, 5), all P < 0.05]. There was no significant difference in the 28-day mortality between the hypophosphatemia group and the non-hypophosphatemia group [9.26% (5/54) vs. 11.00% (23/209), P > 0.05]. Multivariate Logistic regression analysis showed that APACHE Ⅱ score [odds ratio ( OR) = 1.188, 95% CI was 1.110-1.271], CRP ( OR = 1.016, 95% CI was 1.007-1.026), and NLR ( OR = 1.002, 95% CI was 0.996-1.008) were independent risk factors affecting the 28-day mortality of critically ill patients in ICU (all P < 0.05). ROC curve analysis showed that the AUC of serum phosphorus levels for predicting the length of hospital stay of critically ill patients in ICU > 10 days, ICU stay > 5 days, and mechanical ventilation duration > 5 days were 0.701 (95% CI was 0.632-0.770), 0.771 (95% CI was 0.691-0.852), 0.617 (95% CI was 0.541-0.692), respectively, all P < 0.01. Conclusion:Hypophosphatemia has some predictive value for the length of hospital and ICU stay and mechanical ventilation time in critically ill patients, but it cannot predict the 28-day mortality.

Development of acute kidney injury prognostic model for critically ill patients based on MIMIC-Ⅲ database / 中华危重病急救医学

Objective:To investigate the risk factors affecting the prognosis of patients with acute kidney injury (AKI) in the intensive care unit (ICU) based on the Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) database, and to establish a prognostic model for AKI.Methods:Patients (aged ≥ 18 years) with acute renal failure, admitted to the ICU for the first time, and had complete hospital records (the RIFLE diagnostic criteria were used in the database, and the diagnosis was expressed as AKI in this article) were screened from MIMIC-Ⅲ database according to diagnostic codes. Patients were divided into two groups based on survival state at discharge, and the general information, underlying diseases, injury factors, vital signs and laboratory indicators within 24 hours after AKI, related intervention and prognostic indicators were analyzed. Univariate and multivariate Logistic regression analysis were used to determine the risk factors affecting mortality in patients with AKI and established a prediction model. The receiver operator characteristic curve (ROC curve) was used to analyze the predictive value of the prediction model for the prognosis of AKI patients.Results:There were 4 554 patients with AKI included and 862 died, with mortality of 18.93%. Univariate Logistic regression analysis was performed for factors that might be associated with death in AKI patients, and the results showed that age, hypertension, lymphoma, metastatic carcinoma, vancomycin, aspirin, coagulation abnormalities, cardiac arrest, sepsis or septic shock, invasive mechanical ventilation, white blood cell count (WBC), platelet count (PLT), K +, blood urea nitrogen (BUN), total bilirubin (TBil), renal replacement therapy (RRT) and length of stay (LOS) were independent risk factors [odds ratio ( OR) and 95% confidence interval (95% CI) were 1.002 (1.001-1.003), 0.764 (0.618-0.819), 1.749 (1.112-2.752), 2.606 (1.968-3.451), 1.779 (1.529-2.071), 0.689 (0.563-0.842), 1.871 (1.590-2.201), 2.468 (1.209-5.036), 2.610 (2.226-3.060), 2.154 (1.853-2.505), 1.105 (1.009-1.021), 0.998 (0.997-0.998), 1.132 (1.057-1.212), 1.008 (1.006-1.011), 1.061 (1.049-1.073), 2.142 (1.793-2.997), 0.805 (0.778-1.113), all P < 0.05]. Further binary Logistic regression analysis showed that lymphoma, metastatic cancer, vancomycin, cardiac arrest, sepsis or septic shock, coagulation dysfunction, invasive mechanical ventilation, increased BUN, increased TBil, increased or decreased blood K + and increased WBC were independent risk factors for death [β values were 0.636, 1.005, 0.207, 0.894, 0.787, 0.346, 0.686, 0.006, 0.051, 0.085, and 0.009; OR and 95% CI were 1.889 (1.177-3.031), 2.733 (2.027-3.683), 1.229 (1.040-1.453), 2.445 (1.165-5.133), 2.197 (1.850-2.610), 1.413 (1.183-1.689), 1.987 (1.688-2.338), 1.006 (1.003-1.009), 1.052 (1.039-1.065), 1.089 (1.008-1.176), and 1.009 (1.004-1.015), respectively, all P < 0.05]. The Hosmer-Lemeshow test showed that the AKI prognostic model was able to fit the observed data well ( P = 0.604). ROC curve analysis showed that the area under ROC curve (AUC) of the AKI prognostic model was 0.716 (95% CI was 0.697-0.735), when the cut-off value was 0.320, the sensitivity was 71.9%, the specificity was 60.1%, the positive likelihood ratio was 1.80, and the negative likelihood ratio was 0.47. Conclusion:The prognostic prediction model of AKI in critically ill patients established and based on the MIMIC-Ⅲ database may have practical significance for prognostic risk assessment of AKI and later intervention.

Monocyte/lymphocyte ratio as a predictor of 30-day mortality and adverse events in critically ill patients: analysis of the MIMIC-Ⅲ database / 中华危重病急救医学

Objective:To investigate the correlation of monocyte/lymphocyte ratio (MLR) with the prognosis and adverse event in critically ill patients.Methods:Basic information of patients were extracted from Medical Information Mart for Intensive Care-Ⅲ (MIMIC-Ⅲ), including demographics, blood routine, biochemical indexes, systemic inflammatory response syndrome score (SIRS), sequential organ failure assessment (SOFA) score, and outcome, etc. MLR on the first day of intensive care unit (ICU) admission was calculated. The receiver operating characteristic curve (ROC curve) was applied to evaluate the prognostic value of MLR on the 30-day mortality and its cut-off value. According to the cut-off value, the patients were divided into two groups, and the differences between the groups were compared. Logistic regression model was used to analyze the relationship of MLR with 30-day mortality, continuous renal replacement therapy (CRRT), mechanical ventilation, the length of ICU stay, and total hospitalization time.Results:① A total of 43 174 critically ill patients were included. ROC curve showed that area under ROC curve (AUC) of MLR in predicting 30-day mortality was 0.655 [95% confidence interval (95% CI) was 0.632-0.687]. The cut-off value of MLR calculated according to the maximum Yoden index was 0.5. There were 16 948 patients with MLR ≥ 0.5 (high MLR group) and 26 226 patients with MLR < 0.5 (low MLR group). ② Compared with the low MLR group, the high MLR group had higher age, proportion of male, body mass index (BMI) [age (years old): 66.0 (51.7, 78.4) vs. 57.6 (27.1, 74.6), proportion of male: 57.2% vs. 52.5%, BMI (kg/m 2): 26.5 (22.5, 31.1) vs. 24.7 (14.3, 29.7)]. The high MLR group also had higher incidence of complications (hypertension: 49.2% vs. 44.6%, chronic heart failure: 32.6% vs. 21.7%, diabetes mellitus: 27.0% vs. 23.4%, chronic obstructive pulmonary disease: 21.5% vs. 16.1%, renal insufficiency: 19.3% vs. 13.1%), and higher white blood cell count (WBC), blood glucose, lactate (Lac), serum creatinine (SCr), SIRS score and SOFA score [WBC (×10 9/L): 13.8 (9.6, 19.2) vs. 11.5 (8.4, 15.6), blood glucose (mmol/L): 8.66 (6.88, 11.49) vs. 8.27 (6.55, 10.88), Lac (mmol/L): 2.2 (1.5, 3.7) vs. 2.1 (1.4, 3.3), SCr (μmol/L): 106.1 (70.7, 176.8) vs. 88.4 (70.7, 132.6), SIRS score: 3 (2, 4) vs. 2 (2, 3), SOFA score: 4 (2, 7) vs. 3 (1, 5)]. The 30-day mortality, and the proportion of patients with length of ICU stay > 5 days, total hospitalization time > 14 days, CRRT and mechanical ventilation > 5 days were significantly higher in high MLR group (30-day mortality: 20.0% vs. 8.3%, length of ICU stay > 5 days: 33.2% vs. 20.4%, total hospitalization time > 14 days: 33.7% vs. 16.2%, CRRT: 3.6% vs. 0.7%, mechanical ventilation > 5 days: 18.4% vs. 5.7%), with statistically significant differences (all P < 0.05). ③ After adjusted with the related factors, multivariate Logistic regression analysis showed that elevated MLR was an independent risk factor for increased 30-day mortality [odd ratio ( OR) = 1.54, 95% CI was 1.37-1.72, P < 0.001]. Moreover, the increased MLR was independently associated with the increased risk of usage of CRRT ( OR = 2.77, 95% CI was 2.18-3.51), mechanical ventilation > 5 days ( OR = 2.45, 95% CI was 2.21-2.72), the length of ICU stay > 5 days ( OR = 2.29, 95% CI was 2.10-2.49), and total hospitalization time > 14 days ( OR = 2.28, 95% CI was 2.08-2.49), all P < 0.001. Conclusions:Retrospective analysis of large sample shows that MLR elevation is an independent risk factor for 30-day mortality, usage of CRRT, prolonged mechanical ventilation time, prolonged hospitalization, prolonged length of ICU stay. MLR can be used for risk stratification of severe patients.

Estado nutricional de pacientes geriátricos con ventilación mecánica en cuidados intensivos / Nutritional status of geriatric patients with mechanical ventilation under intensive care

Introducción: La desnutrición en pacientes ingresados en una sala de terapia intensiva es elevada, pero en el anciano crítico es aún mayor, con repercusión sobre el aparato respiratorio, prolongación de la ventilación y otras complicaciones. Objetivo: Caracterizar el estado nutricional en pacientes geriátricos con ventilación mecánica en una unidad de cuidados intensivos. Métodos: Se realizó un estudio descriptivo, prospectivo y de corte transversal durante el periodo de enero de 2017 a marzo de 2019 en la unidad de cuidados intensivos del Hospital General Docente "Orlando Pantoja Tamayo". Se estudiaron 83 pacientes con edades mayor o igual a 60 años, los cuales requirieron del uso de ventilación mecánica más de 24 h. El estado nutricional fue evaluado con el empleo del índice de control nutricional. Resultados: Predominó el sexo masculino, el grupo de edades de 60 a 74 años, y las enfermedades tipo quirúrgicas. Solo 9,1 % de los que recibieron ventilación mecánica invasiva no estaban desnutrido. Los que fallecieron tenían desnutrición moderada o severa. Conclusiones: En los pacientes geriátricos ventilados, ingresados en la unidad de cuidados intensivos, se encontró un alto grado de malnutrición. La desnutrición moderada o severa predominó en la mayoría de los que recibieron ventilación mecánica invasiva y en el grupo de fallecidos(AU)

Introduction: Malnutrition in patients hospitalized in an intensive care room is high, but it is even higher in the critically-ill elderly patient, with repercussions on the respiratory system, prolonged ventilation, and other complications. Objective: To characterize the nutritional status of geriatric patients under mechanical ventilation in an intensive care unit. Methods: A descriptive, prospective and cross-sectional study was carried out during the period from January 2017 to March 2019, in the intensive care unit of Orlando Pantoja Tamayo General Teaching Hospital. 83 patients aged 60 or older were studied; they required mechanical ventilation for more than 24 hours. The nutritional status was evaluated with the use of the nutritional control score. Results: There was a predominance of the male sex, the age group 60-74 years, and of surgical diseases. Only 9.1% of those who received invasive mechanical ventilation were not undernourished. Those who died had moderate or severe undernutrition. Conclusions: In ventilated geriatric patients hospitalized in the intensive care unit, a high degree of malnutrition was found. Moderate or severe malnutrition predominated in the majority of those who received invasive mechanical ventilation and in the group of the deceased(AU)

Cross Sectional Survey on Therapeutic Drug Monitoring of Imipenem in Critically Ill Patients of the Real World / 中国药学杂志

OBJECTIVE: To explore the application of therapy drug monitoring of imipenem in ICU, and to provide evidence for the use of imipenem in critically ill patients. METHODS: A cross-sectional survey was conducted to collect clinical data of 67 patients receiving therapeutic drug monitoring of imipenem in ICU from January 1, 2016 to December 31, 2018. Using SPSS21.0 statistical software, 71 cases of therapeutic drug monitoring data (blood drug concentration, f%T>MIC) and related clinical data were analyzed. RESULTS: Of all 71 cases of therapeutic drug monitoring, there are 37 cases (52.11%) f%TMIC≥40%,26 cases(36.62%)f%TMIC70%,and 10 cases(14.08%) f%TMIC=100%. f%TMIC of all cases with 0.25 g q6h were 70%. Among other dosage regimens, the highest proportion of f%T>MIC>40% was 1 g q12h (66.67%) and the highest proportion of f%T>MIC>70% was 0.5 g q8h(43.59%). According to different f%T>MIC, those patients were divided into ≤40% group, >40%-70% group and>70%group. Only group>70% showed a downward trend in the infection index of patients before and after medication. The body temperature decreased significantly (P=0.004), while the average PCT level of group MIC>70% group showed a downward trend in serum creatinine after treatment, but there was no significant difference (P=0.285). The serum drug concentration in CRRT group was slightly higher than that in non-CRRT group, and there was no significant difference in f%T>MIC (P=0.376, P=0.209, P=0.988). CONCLUSION: The level of f%T>MIC of imipenem in ICU is unsatisfactory. For critically ill patients, when imipenem f%T>MIC>70%, the antimicrobial effect is better.

Deuda calórica en una cohorte de pacientes hospitalizados en unidades de cuidado intensivo / Caloric debt in a cohort of intensive care unit patients

El soporte nutricional que se brinda a los pacientes críticos, constituye para la mayoría la única vía de acceso a través de la cual es posible cubrir sus requerimientos nutricionales diarios. Sin embargo, se ha identificado que la presencia de deuda calórica impide cubrir dichos requerimientos. Este estudio determinó la deuda calórica y su potencial efecto clínico a través de una cohorte prospectiva que incluyó 191 pacientes que recibieron soporte nutricional en unidades de cuidado intensivo (UCI). Se evaluó la magnitud de la deuda calórica, los principales factores que la favorecen y se exploraron diferencias en desenlaces clínicos relacionados con mortalidad, complicaciones infecciosas y tiempo de estancia en UCI. Los resultados evidenciaron que la deuda calórica estuvo presente en el 73,8%(IC 95% = 67%-80%) de los pacientes evaluados; la principal causa estuvo relacionada con la interrupción de la nutrición enteral y no se encontró asociación entre el porcentaje de adecuación calórico y los desenlaces evaluados. Esta evaluación permitió establecer que la mayoría de los pacientes, a pesar de recibir soporte nutricional, se encuentran expuestos a deuda calórica siendo necesario generar estrategias de atención que permitan disminuir la exposición de esta población a dicha condición.

The nutritional support offered to critically ill patients is, for most of them, the only means to fulfill their daily nutritional requirements. However, it has been documented that nutritional support is not enough to cover such needs, due to the presence of caloric debt. We seek to determine the caloric debt and its potential to clinical affect critically ill patients that receive nutritional support in the Intensive Care Unit (ICU). We conducted a prospective cohort study with 191 patients. We assessed the magnitude of caloric debt and its related factors. We also explored variations in clinical outcomes related to mortality, infectious complications and ICU stay length. Caloric debt was found in 73.8% (95% CI = 67-80%) of patients who received less than 80% of their daily caloric requirements. Main causes were related to enteral nutrition interruption. We found no association between caloric debt and the evaluated outcomes. This evaluation made it possible to establish that the majority of patients, despite receiving nutritional support, were exposed to caloric debt, and it is necessary to generate care strategies to reduce the patients' exposure to this condition.

Caracterización del estado nutricional de pacientes posoperados con complicaciones en una unidad de cuidados intensivos / Characterization of the status of postoperative patients with complications in an intensive care unite

Introducción: Las unidades de atención al paciente gravemente enfermo informan numerosos casos con desnutrición. Para poder estimarlo es necesario utilizar indicadores dietéticos, antropométricos, bioquímicos e inmunológicos. Objetivo: Caracterizar el estado nutricional de los pacientes posoperados ingresados en una unidad de cuidados intensivos. Métodos: Se realizó un estudio descriptivo, prospectivo de corte transversal. Los valores se obtuvieron de los indicadores antropométricos (circunferencia media del brazo y circunferencia de la pantorrilla), bioquímicos (albúmina, colesterol, triglicéridos y creatinina) e inmunológicos (conteo total de linfocitos) de 98 pacientes ingresados en dicha unidad. El estado nutricional fue evaluado mediante variables independientes. Resultados: Predominaron los pacientes con estadía entre 1-7 días (71,4 por ciento), la ventilación mecánica se utilizó en 33,6 por ciento, fallecieron 19,3 por ciento de los pacientes, y predominó el grupo de afecciones intraabdominales 38,8 por ciento. La linfopenia (68,3 por ciento) y la hipoalbuminemia (62,2 por ciento) fueron más significativas, seguida de la circunferencia media del brazo (CMB) en rango de desnutrición (47,9 por ciento). No se demostró asociación de las variables nutricionales con la estadía, ni la necesidad de ventilación mecánica. Todas las variables se asociaron con el estado al egreso. Conclusiones: Predominó la estadía alrededor de una semana, la tercera parte de la muestra requirió apoyo ventilatorio, y la mortalidad fue baja. De las variables nutricionales estudiadas no se encontró asociación de estas con la estadía ni el uso de ventilación mecánica pero sí con el estado al egreso(AU)

Introduction: Critically ill care units report numerous cases of malnutrition. In order to estimate such statistics, it is necessary to use dietary, anthropometric, biochemical and immunological indicators. Objective: To characterize the nutritional status of postoperative patients admitted to an intensive care unit. Methods: A descriptive, prospective, cross-sectional study was carried out. The values ;were obtained from the indicators of the type anthropometric (average arm and calf circumference), biochemical (albumin, cholesterol, triglycerides and creatinine) and immunological (total lymphocyte count) of 98 patients admitted to the unit. The nutritional status was evaluated by independent variables. Results: Patients with 1-7 days of stay predominated (71.4 percent), mechanical ventilation was used in 33.6 percent, 19.3 percent of patients died, and the group of intra-abdominal conditions predominated (38.8 percent). Lymphopenia (68.3 percent) and hypoalbuminemia (62.2 percent) were more significant, followed by average arm circumference (AAC) in the malnutrition range (47.9 percent). There was no association of nutritional variables with the stay, nor the need for mechanical ventilation. All the variables were associated with the state at the time of discharge. Conclusions: A stay of about one week predominated, one third of the sample required ventilatory support, and mortality was low. Among all the nutritional variables studied, no association was found with the stay or the use of mechanical ventilation, but instead with the state at discharge(AU)

Angina renal: «El principio del fin¼ / Renal angina: «The beginning of the end¼ / Angina renal: «O começo do fim¼

Resumen: La lesión renal aguda es una de las entidades más comunes en el Área de Terapia Intensiva, llega a presentarse hasta en 50% de los enfermos que ingresan a la Unidad de Terapia Intensiva. Se han desarrollado herramientas de detección de riesgo de lesión renal aguda, las cuales utilizan información de rutina altamente accesible (AKI predictor). El objetivo es determinar el desempeño de AKI predictor en la detección de daño renal y requerimiento de terapia sustitutiva renal (TSR) en pacientes adultos admitidos a la Unidad de Terapia Intensiva. Material y métodos: Se recolectaron de manera retrospectiva variables demográficas, bioquímicas, clínicas y el valor de AKI predictor al ingreso y 24 horas de cada paciente admitido en un periodo de ocho meses; asimismo, se determinó el concepto de daño renal definido como requerimiento de TSR y/o progresión de daño renal definida como un incremento de la creatinina ≥ 0.3 mg/dL en 24 horas y/o presencia de diuresis < 0.5 mL/kg/hora a las 48 horas. Se construyeron curvas receiver operating characteristics con el fin de determinar el desempeño del AKI predictor en la detección de daño renal o requerimiento de TSR por separado. Resultados: Se incluyó un total de 95 pacientes, donde aquéllos con daño renal mostraron mayor gravedad de la enfermedad por Sequential Organ Failure Assessment score, mayor proporción de pacientes con sepsis, uso de vasopresores, mortalidad y estancia en la Unidad de Terapia Intensiva. La herramienta AKI predictor calculada al ingreso mostró un área bajo la curva significativa de 0.76 para le detección de daño renal, 0.85 para requerimiento de TSR y calculada a las 24 horas un área bajo la curva significativa de 0.91 para detección de TSR. Conclusiones: La herramienta AKI predictor se muestra como una opción viable en la práctica diaria para la evaluación dinámica de aquellos pacientes que muestren progresión del daño renal, dejando como última consecuencia el uso de TSR.

Abstract: Acute kidney injury (AKI) is one of the most common entities in the intensive care area. It occurs in up to 50% of patients admitted to the intensive care unit (ICU). New tools to detect AKI risk using highly accessible routine information have been developed (AKI predictor). The goal is to determine the performance of the AKI predictor tool to detect renal damage and renal replacement therapy (RRT) requirement in adult patients admitted to the ICU. Material and methods: Demographic, biochemical, clinical variables and AKI predictor percentages at admission and at 24 hours were retrospectively collected of every patient admitted in an 8 months period, likewise the concept of renal damage was determined, defined as requirement of RRT and/or an increment of creatinine ≥ 0.3 mg/dL in 24 hours and/or urine output < 0.5 mL/kg/h at 48 hours. Receiver operating characteristics curves were developed in order to determine the performance of the AKI predictor to detect renal damage or RRT requirement by separate. Results: 95 patients were included in the analysis, those with renal damage showed higher illness severity by Sequential Organ Failure Assessment score, higher proportion of these patients presented sepsis, need for vasopressors, mortality and longer UCI stay. AKI predictor tool showed a significant area under the curve (AUC) of 0.76 for renal damage detection, 0.85 for requirement of RRT and calculated at 24 hours an AUC of 0.91 for RRT requirement. Conclusions: The AKI predictor tool it is shown as a viable option in daily practice for the dynamic evaluation of those patients who will show renal damage progression until its final consequence RRT.

Resumo: Introdução: A lesão renal aguda (LRA) é uma das entidades mais comuns na área de terapia intensiva, podendo ocorrer em até 50% dos pacientes internados em unidade de terapia intensiva (UTI). Foram desenvolvidas ferramentas de detecção de risco para o LRA, que usam informações de rotina altamente acessíveis (preditor de AKI). Objetivo: Determinar o desempenho do preditor de LRA na detecção de dano renal e a necessidade de terapia renal substitutiva (TRS) em pacientes adultos admitidos na UTI. Métodos: Variáveis clínicas, demográficas, bioquímicas e o valor do preditor de IRA foram coletados retrospectivamente na admissão e 24 horas de cada paciente em um período de 8 meses, bem como o conceito de dano renal definido como requisito de TRS e/ou progressão do dano renal definido como aumento da creatinina ≥ 0.3 mg/dL em 24 horas e/ou presença de diurese < 0.5 mL/kg/hora às 48 horas. As curvas Receiver Operating Characteristics foram construídas com o objetivo de determinar o desempenho do preditor de AKI na detecção de dano renal ou exigência de TSR separadamente. Resultados: Foram incluídos 95 pacientes, sendo que aqueles com lesão renal apresentaram maior gravidade da doença devido ao escore Sequential Organ Failure Assessment, maior proporção de pacientes com sepse, uso de vasopressores, mortalidade e permanência na UTI. O instrumento preditor AKI calculado na admissão, mostrou uma área significativa sob a curva (ABC) de 0.76 para a detecção de dano renal, 0.85 para a necessidade de TSR e calculada às 24 horas um ABC significativa de 0.91 para a detecção de TSR. Conclusão: O instrumento preditor de AKI é apresentado como uma opção viável na prática diária para a avaliação dinâmica daqueles pacientes que apresentarão progressão da lesão renal até a última consequência do uso da TRS.

Análise do estado funcional de pacientes crí­ticos internados em unidade de terapia intensiva / Functional status analysis of critically ill patients in the intensive care unit

O comprometimento fí­sico funcional é um aspecto significativo em pacientes crí­ticos e para que seja possí­vel intervir de forma precoce, torna-se importante analisar o estado funcional destes indiví­duos. Este é um estudo longitudinal e prospectivo, do qual participaram 40 indiví­duos internados na UTI do HU/UFSC em Ventilação Mecânica (VM) por pelo menos 48h. Na inclusão ao estudo (AV1) foram coletados dados referentes ao estado funcional e fragilidade prévios; na segunda etapa (AV2) - avaliação da força muscular e do estado funcional; e na alta clí­nica (AV3) ­ reavaliação da força muscular, estado funcional e check list dos marcos funcionais. De forma geral, os pacientes apresentaram prejuí­zo significativo na funcionalidade no despertar, com Índice de Barthel médio de 3,33 ± 6 e Escore Perme de 8,18 ± 3,99 e também na alta da UTI, com Índice de Barthel médio de 12,7 ± 13,99 e Escore Perme de 13,68 ± 6. O estado funcional e a fragilidade prévios se relacionaram com os desfechos clí­nicos (p = 0,022 e p = 0.019, respectivamente). O estado funcional no despertar teve correlação com o desfecho funcional (p < 0,001). A força muscular periférica se alterou juntamente com o estado funcional tanto no despertar (p = 0,005 e p < 0,001) quanto na alta da UTI (p = 0,002). Sendo assim, pode-se dizer que o estado funcional dos pacientes reduziu significativamente durante a internação na UTI, comparada há um mês antes da admissão, e manteve-se baixa após a alta dessa unidade. Verificou-se ainda que o estado funcional e a fragilidade prévios se relacionam com o desfecho clí­nico e que o estado funcional no despertar se relaciona com o desfecho funcional. A força muscular periférica também se alterou juntamente com o estado funcional. (AU)

Functional physical impairment is a significant aspect in critically ill patients and in order to be able to intervene at an early stage, it is important to analyze the functional status of these individuals. This is a longitudinal and prospective study, in which participated 40 patients hospitalized at ICU of the HU/UFSC in mechanical ventilation for at least 48 hours. At inclusion in the study (AV1) data was collected regarding the previous functional status and frailty, at second stage (AV2) - evaluation of muscle strength and functional status and clinical discharge (AV3) ­ revaluation of muscle strength, functional status and a check list of functional milestones. In general, the patients presented significant impairment of functionality at awakening, with a Barthel Index mean of 3.33 ± 6 and Perme Score of 8.18 ± 3.99, and at ICU discharge, with a Barthel Index with mean of 12.7 ± 13.99 and a Perme Score of 13.68 ± 6. The previous functional and frailty status was related to the clinical outcome (p = 0.022 and p=0.019, respectively). The functional status at awakening had a correlation with the functional outcome (p<0.001). The peripheral muscle strength modifies with functional status in both the awakening (p=0,005 e p<0,001) and discharge of the ICU (p=0,002). Therefore, the functional status of patients has significantly reduced during ICU stay, compared with the status one month prior, and remains low after discharge. It was also find that the functional status and previous frailty relate with the clinical outcome and that the functional status at awakening correlated to functional outcome. The peripheral muscle strength also modifies with functional status. (AU)

Exploration of design and practice of disaster medical rescue monitoring system with privacy protection mechanism / 中华危重病急救医学

Chronic?obstructive?pulmonary?disease?(COPD)?is?a?severe?respiratory?disease?characterized?by?airway?obstruction?with?high?mortality?and?rate?of?recurrence.?Rehabilitation?exercise?can?lessen?the?possibility?of?the?progressive?exacerbation?of?the?patient's?condition,?exerting?an?active?role?in?improving?their?lung?function?and?the?quality?of?the?patients'?life.?Therefore,?we?have?designed?a?lung?function?exercise?bottle,?which?is?capable?of?adjusting?the?pressure?according?to?the?patient's?needs.?It?is?easy?to?operate?and?apply?in?practice.?The?exercise?bottle?is?composed?of?three?components,?including?bottle?body,?threaded?round?cap?and?air?blow?pipe.?The?bottle?body?is?formed?in?rectangle?shape,?and?utilized?to?contain?liquid.?The?filling?opening?is?designed?on?the?top?of?the?bottle.?Outside?of?the?filling?opening,?there?is?a?screw?thread?round?cap,?which?can?adjust?the?pressure?according?to?the?patient's?tolerance,?gradually?increasing?the?training?intensity,and?improving?the?training?effect?thereby.?The?blowpipe?can?be?inserted?into?the?bottle?body?and?the?patient?can?blow?the?air?through?the?tube.?Compared?with?the?traditional?rehabilitation?training,?when?the?newly?invented?lung?function?exercise?bottle?has?been?used?for?rehabilitation?exercise,?the?air?pressure?in?the?bottle?can?be?adjusted,?with?the?advantage?of?wider?range?of?application,?lower?cost?and?more?convenient.?It?provides?a?good?solution?for?clinical?and?home-based?rehabilitation?and?is?worth?of?popularizing.

Effect of conservative and conventional oxygen therapy on the prognosis of critically ill patients: a Meta-analysis / 中华危重病急救医学

Objective? To?compare?the?efficacy?and?safety?of?conservative?and?conventional?oxygen?therapy?in?critically?ill?patients.? Methods? Relevant?literature?and?randomized?controlled?trials?(RCTs)?about?the?effect?of?conservative?oxygen?therapy?and?conventional?oxygen?therapy?on?the?prognosis?of?intensive?care?unit?(ICU)?critically?ill?patients?was?searched?from?CNKI,?VIP,?Wanfang?Data,?Chinese?Clinical?Trial?Registry,?PubMed,?Embase,?the?Cochrane?Library,?and?ClinicalTrials.gov?by?using?the?keywords?"critically?ill?patients,?conservative?oxygen?therapy,?liberal?oxygen?therapy,?conventional?oxygen?therapy,?mortality"?until?October?30th?in?2018.?The?main?outcome?indicators?were?short-term?mortality?(28-day?mortality?or?ICU?mortality);?secondary?indicators?were?90-day?mortality,?duration?of?mechanical?ventilation,?the?length?of?ICU?stay,?total?hospitalization?time,?new?infection?rate?in?ICU?and?incidence?of?new?organ?dysfunction?in?ICU.?In?the?conservative?oxygen?therapy?group,?the?aim?of?pulse?oxygen?saturation?(SpO2)?was?0.90-0.92?or?the?arterial?partial?oxygen?pressure?(PaO2)?was?70-100?mmHg?(1?mmHg?=?0.133?kPa),?while?in?conventional?oxygen?therapy?group?SpO2?>?0.96?or?PaO2?>?150?mmHg.?Literature?search,?quality?evaluation?and?data?extraction?was?conducted?independently?by?the?two?authors.?The?quality?of?these?study?was?evaluated?using?Cochrane?risk?deviation?assessment?tool,?and?the?relevant?data?were?analyzed?using?RevMan?5.3?software.? Results? Four?studies?were?included?in?the?analysis,?these?studies?were?assessed?as?moderate?to?high?quality?studies.?A?total?of?1?076?patients?were?enrolled,?with?539?in??the?conservative?oxygen?therapy?group?and?537?in?the?conventional?oxygen?therapy?group.?Compared?with?conventional? oxygen?therapy?group,?short-term?mortality?[odds?ratio?(OR)?=?0.66,?95%?confidence?interval?(95%CI)?=?0.50-0.87,?P?=?0.003]?and?the?incidence?of?new?organ?dysfunction?in?ICU?(OR?=?0.64,?95%CI?=?0.41-0.99,?P?=?0.04)?were?significantly?decreased?in?conservative?oxygen?therapy?group,?duration?of?mechanical?ventilation?was?significantly?prolonged?[standardized?mean?difference?(SMD)?=?17.17,?95%CI?=?7.14-27.21, P?=?0.000?8].?But?there?was?no?significantly?difference?in?90-day?mortality?(OR?=?0.83,?95%CI?=?0.59-1.17,?P?=?0.28),?new?infection?rate?in?ICU?(OR?=?0.90,??95%CI?=?0.66-1.21,?P?=?0.47),?the?length?of?ICU?stay?(SMD?=?-0.22,?95%CI?=?-1.02-0.59,?P?=?0.60)?and?total?hospitalization?time?(SMD?=?1.44,?95%CI?=?-1.43-4.31,?P?=?0.32)?between?the?two?groups.? Conclusion? Compared?with?conventional?oxygen?therapy,?conservative?oxygen?therapy?can?reduce?short-term?mortality?and?the?incidence?of?organ?dysfunction?in?critically?ill?patients,?but?cannot?decrease?the?length?of?ICU?stay?and?total?hospitalization?time.

Safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit: a systematic review / 中华危重病急救医学

Objective To determine the safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit (ICU) by systematic review.Methods Randomized controlled trails (RCTs) and cohort studies about early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in ICU were retrieved in CBM,CNKI,Wanfang Data,PubMed,Cochrane Library and Web of Science from their foundation to March 2018,and other sources as supplement was also retrieved.The intervention program of RCT study was ICU routine nursing in control group,early activity in observation group,and early activity in cohort study without control group.Early activities included active and passive activities on the bed,sitting upright,bed-chair transfer,standing and walking.Literature screening and data extraction were performed independently by two researchers.Variables or parameters.related to cardiovascular,respiratory,nervous,orthopedic and other systems were collected for safety criteria.Variables or parameters used in at least three literatures were collected for each system.Cochrane 5.1.0 was used to evaluate the quality of RCT study,and Newcastle-Ottawa scale (NOS) was used to evaluate the quality of cohort study.Results A total of 24 articles about early activity of patients undergoing mechanical ventilation in ICU were enrolled,involving 4647 patients,including 11 RCT studies involving 1 031 patients,509 in control group and 522 in observation group;13 cohort studies including 3616 patients.It was shown by systematic review that safety criteria for early activity in patients undergoing mechanical ventilation in ICU involved five systems,20 variables or parameters.The cardiovascular system included 8 variables or parameters,such as 40 bpm ＜ heart rate (HR) ＜ 130 bpm (n =4),hemodynamic stability (n =5),no myocardial infarction (n =3),no arrhythmia (n =4),no vascular active drugs (n =4),90 mmHg ＜ systolic blood pressure (SBP) ＜ 200 mmHg (1 mmHg =0.133 kPa,n =4),65 mmHg ≤ mean arterial pressure (MAP) ≤ 110 mmHg (n =3),no history of cardiopulmonary resuscitation (CPR,n =5).The respiratory system included 4 variables or parameters,involving 5 times/min ＜ respiratory rate (RR) ＜ 40 times/min (n =5),fraction of inspired oxygen (FiO2) ≤ 0.60 and positive end-expiratory pressure (PEEP) ≤ 10 cmH2O (1 cmH2O =0.098 kPa,n =4),FiO2 ＜ 0.60 or PEEP ＜ 10 cmH2O (n =3),pulse blood oxygenation (SpO2) ＞ 0.88 (n =5).The nervous system included 4 variables,including no neuromuscular disease (n =7),no increase in intracranial pressure (n =7),no coma (n =4),understand and do the right thing (n =4).The orthopedic system included 2 variables,including no fracture (n =3),no unstable fracture (n =8).Other factors included 2 variables,including no open abdomen wound (n =4),and no palliative care (n =3).Conclusions This study identified safety criteria for early goal-directed rehabilition exercise in patients undergoing mechanical ventilation in ICU included five systems of cardiovascular,respiratory,neurological,orthopedic,and other systems,in which cardiovascular and respiratory systems were the most frequently cited variables or parameters.The consistency of each system security criteria or variables reported by different literatures was high,but the parameters need to be further verified by high-quality study.

Study of Cystatin C in the prognosis of critically ill patients / 中国实用内科杂志

OBJECTIVE: To evaluate the association between Cystatin C levels change and the clinical outcomes of critically ill patients.METHODS: There were altogether 4642 patients in intensive care unit(ICU)of West China Hospital of Sichuan university from 28 th August 2009 to 16 th April 2010,and their general conditions were recorded,including sex,age,and being with or without diabetes mellitus;then the database was established accordingly.The patients were divided into four groups according to the change of Cys C values in ICU:high increase(>1 mg/L),slight increase(≤1 mg/L),high decrease(>1 mg/L)and slight decrease(≤1 mg/L).The difference in 30-day mortality in patients were compared.The patients were followed up for 8 years.RESULTS: One thousand and thirty-six patients were included in this study,272 cases died within 30 days,with the highest in patients of the group with high increase of Cystatin C(77.9%),followed the high-decrease group(33.3%);the mortality rate of group with slight decrease was the lowest among the four groups(16.5%).The 8-year survival of 764 patients who did not die within 30 days was 54.58%.CONCLUSION: The change of Cystatin C value is closely related to the 30-day mortality of critically ill patients.The lowest 30-day mortality of critically ill patients is the group with slight decrease of Cystatin C.

Attaching importance to the study of referral and transport of critically ill patients: my humble opinion on non-emergency medical referral and transporting service / 中华危重病急救医学

The transfer of critically ill patients is related to the treatment and prognosis of patients. It is not only the work of saving lives and injuries in the medical and health system, but also a measure of the ability and level of public health services in a region. "Non-emergency medical transshipment service" is a new form of business which is emerging at present. The phenomenon of "illegal ambulance" derived from it has attracted the attention of relevant government departments and has become the focus of media. The solution of this problem involves many aspects. The perspectives of defining the orientation of transfer work, constructing transfer service system, formulating transfer process norms and improving the quality of transfer efficiency are discussed in this paper, and it clearly puts forward that the development of "non-emergency medical transfer service" should adhere to the development path of marketization, diversification, standardization and specialization.

Effect of probiotics combined with early enteral nutrition on infection and gastrointestinal dysfunction in patients undergoing mechanical ventilation in intensive care unit / 中国感染控制杂志

Objective To analyze the effect of probiotics combined with early enteral nutrition on infection and gastrointestinal dysfunction in patients undergoing mechanical ventilation in intensive care unit (ICU).Methods Prospective cohort study was adopted to select patients who admitted to ICU in a hospital from February 2016 to October 2017, they were randomly divided into three groups:A, B, and C.Group A received early enteral nutrition combined with probiotics, group B received early enteral nutrition, and group C received early parenteral nutrition.Infection condition, level of infection indicators (on the 3 rd, 7 th and 14 th day after treatment), occurrence of gastrointestinal dysfunction, acute physiology and chronic health evaluation II (APACHE II) on the 14 th day after treatment were compared among three groups.Results Incidences of infection in group A, B, and C were 6.00％, 20.00％, and 22.00％ respectively, difference among three groups was significant (χ2=8.57, P=0.01).C-reactive protein (CRP) and white blood cell count (WBC) in group A on the 7 th and 14 th day were both lower than those in group B and C;procalcitonin (PCT) in group A and B on the 3 rd day were both lower than that in group C;PCT in group A on the 7 th and 14 th day were both lower than those in group B and C;difference were all statistically significant (all P＜ 0.05).Incidence of abdominal distension (8.00％), diarrhea (4.00％) and gastric retention (4.00％) in group A were the lowest among three groups.APACHE II score in group A on the 14 th day after treatment was lowest.Conclusion Early enteral nutrition combined with probiotics for treatment of ICU patients with mechanical ventilation can effectively reduce the incidence of infection and gastrointestinal dysfunction, promote rehabilitation, which is worth promoting the application.

Mortalidad en pacientes con ventilación mecánica ingresados en una Unidad de Cuidados Intensivos / Mortality in mechanically ventilated patients admitted to an Intensive Care Unit

Introducción: La ventilación mecánica es un proceder para la sustitución de la ventilación, que salva la vida de pacientes con insuficiencia respiratoria aguda, al mismo tiempo es una de las primeras causas de complicaciones y de mortalidad. Objetivo: Identificar las características clínico-epidemiológicas en pacientes fallecidos con ventilación mecánica, ingresados en la UCI del hospital Joaquín Albarrán Domínguez en el trienio 2013-2015. Material y Métodos: Se realizó un estudio descriptivo, transversal, con las historias clínicas de dichos pacientes, recopilando la información en una matriz de datos y posteriormente fue analizada con el software SPSS 21.0, a través de frecuencias absolutas y relativas y con la utilización de la prueba de chi2 para las correlaciones bi-variadas, tomando como valor de significación estadística p< 0,05. Resultados: De los 166 pacientes, el 49,4 por ciento superaba los 70 años. La EPOC fue el motivo de ventilación más frecuente. Las mayores complicaciones de la ventilación fueron: fallo multiorgánico 25,3 por ciento, fallo al destete 21,6 por ciento, y distrés respiratorio 20,4 por ciento. Conclusiones: El fallo multiorgánico, las bronconeumonías bacterianas bilaterales y la neumonía asociada a la ventilación mecánica, fueron las principales complicaciones y causas de muerte más frecuentes en los pacientes ventilados(AU)

Introduction: Mechanical ventilation is a procedure used for the replacement of ventilation, which saves the life of patients with acute respiratory failure; but at the same time, it is one of the first causes of complications and mortality. Objective: To identify the clinical and epidemiological characteristics of patients who died while receiving mechanical ventilation, admitted to the Intensive Care Unit (ICU) of the Joaquín Albarrán Dominguez Clinical Surgical Hospital during the triennium 2013-2015. Material and methods: A descriptive, cross-sectional study was carried out with the clinical histories of these patients. The information was collected in a data matrix that was subsequently analyzed with the SPSS 21.0 software, on the basis of absolute and relative frequencies and the use of the chi2 test for the bi-varied correlations; the statistical significance value was p <0.05. Results: Of the 166 patients selected for the study, the 49.4 percent were over 70 years of age. COPD was the most frequent reason for ventilation. The main complications of ventilation were: multiple organ failure (25.3 percent), weaning failure (21.6 percent), and respiratory distress (20.4 percent). Conclusions: Multiple organ failure, bilateral bacterial bronchopneumonia, and pneumonia associated with mechanical ventilation were the most frequent complications and causes of death in ventilated patients(AU)

Analysis on syndrome differentiation and treatment of "heat fecaloma with watery discharge" in critically ill elderly patients / 中国中西医结合急救杂志

Objective In critically ill elderly patients with "heat fecaloma with watery discharge", deficiency syndrome occupies its eighty to ninety percent, while "heat accumulation" occupies its ten to twenty percent; in fact, it is "dry feces accumulation stagnation and manure water side stream". Factors of Qi deficiency, blood deficiency, Yin deficiency, Yang deficiency, etc. are the main causes of dry stool accumulating in the intestine and manure water flows to side stream. The therapeutic principles of this disease should be removing stasis by purgation, in the mean time supplementing Qi and moistening intestine, or moisturizing dryness by nourishing blood, or supplementing Yin and increasing fluids, or warming yang for relaxing bowels in order to solve the root causes of the disease. The mechanism of heat fecaloma with watery discharge in critically ill elderly patients is different from that of general patients; clinically it is necessary to interrogate the disease history in detail, synthesize the four diagnostic methods, and differentiate manifestations from root cause, deficiency from sthenia, mildness from severity and amelioration from urgency. Casually using attack should be avoided, and aiming to treat its root cause is the proper therapeutic method.

Effect of enteral nutrition time on pH value of gastric juice and ventilator-associated pneumonia in critically ill patient / 中华危重病急救医学

Objective To investigate the effect of enteral nutrition (EN) start time on pH value of gastric juice and ventilator-associated pneumonia (VAP) in critically ill patients with invasive mechanical ventilation, so as to provide reference for the rational selection of EN timing.Methods Patients with mechanical ventilation who underwent EN treatment admitted to the intensive care unit (ICU) of the First Affiliated Hospital of Zhengzhou University from January 1st, 2016 to November 30th, 2017 were enrolled, and the inclusion criteria were age ≥ 18 years, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) ≤ 15, and nutritional risk screening (NRS 2002) ≥ 3. Patients were divided into two groups according to the start time of EN: early EN group (implementation of EN within 48 hours after mechanical ventilation) and late EN group (implementation of EN after 48 hours after mechanical ventilation). The pH value of gastric juice, VAP incidence, mechanical ventilation time, and the length of ICU stay were compared between the two groups.Results A total of 108 patients were included, 54 in the early EN group and 54 in the late EN group respectively. The pH value of gastric juice in early EN group was lower than that in late EN group [4.8 (3.8, 5.8) vs. 5.6 (4.6, 6.6),P < 0.01]. There were 8 patients with VAP in the early EN group, 3 of whom were early onset VAP. There were 17 patients with VAP in the late EN group, 10 of whom were early onset VAP. The incidence of VAP and the incidence of premature VAP in the early EN group were significantly lower than those in the late EN group (14.8％ vs. 31.5％, 5.6％ vs. 18.5％, bothP < 0.05). The mechanical ventilation time [days: 7.5 (5.7, 9.0) vs. 8.6 (6.8, 10.7) and the length of ICU stay [days: 10.0 (8.5, 11.7) vs. 11.0 (9.5, 12.6)] in the early EN group were significantly shorter than those in the late EN group (allP < 0.05).Conclusion At the same time of protecting gastric mucosa, early EN is helpful to reduce the incidence of VAP, reduce the duration of mechanical ventilation and the length of ICU stay, and improve the prognosis.