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Objective:To investigate the effect of deescalation noninvasive positive pressure ventilation in the removal of endotracheal intubation in patients with Stanford type A aortic dissection (AAD) complicated with obesity.Methods:A total of 80 obese patients with AAD from March 2018 to January 2020 in the First Affiliated Hospital of Xi′an Jiaotong University were divided into experimental group and control group with 40 cases in each group by random number table method. The control group received traditional oxygen treatment with mask, while the experimental group received de-escalation noninvasive positive pressure ventilation. The blood gas index, respiratory rate and respiratory comfort score was recorded at different times before and after intervention, make a comparison with the two groups in the incidence of hypoxemia, secondary intubation and other complications.Results:Finally, 36 cases were included in the experimental group and 38 cases in the control group. After 2, 8, 24, 48, 72 h of extubation, the oxygenation index, PaO 2, SaO 2 were higher and PaCO 2, respiratory rate were lower in the experimental group compared to the control group, the differences were statistically significant ( t values were 2.02-9.00, all P<0.05). At 72 h after extubation, the pH value of the experimental group was 7.43 ± 0.08, which was higher than 7.38 ± 0.09 of the control group, and the difference was statistically significant ( t=2.44, P<0.05). At 24, 48, 72 h after extubation, the throat pain scores and oral nasal dryness symptom and sore throat symptom scores were (3.11 ± 1.53), (2.25 ± 0.57), (0.94 ± 0.14) points and (4.33 ± 1.08), (3.33 ± 0.68), (2.81 ± 0.43) points in the experimental group, lower than in the control group (5.24 ± 1.96), (3.58 ± 0.73), (2.18 ± 0.91) points and (6.00 ± 1.92), (5.39 ± 1.13), (4.79 ± 0.54) points, the differences were statistically significant ( t values were 3.46-5.21, all P<0.05). The incidence of hypoxemia, secondary intubation and intolerance were 2.8% (1/36), 2.8% (1/36) and 0 in the experimental group, lower than in the control group 26.3% (10/38), 21.1% (8/38) and 10.5% (4/38), the differences were statistically significant ( χ2=8.09, 5.78, 4.01, all P<0.05). Conclusions:De-escalation noninvasive positive pressure ventilation for obese patients with AAD can effectively improve oxygenation, reduce the incidence of hypoxemia and secondary intubation, and alleviate respiratory symptoms.
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After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.
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Background: Although rare, infection is considered to be most dreadful of the prosthetic related complications resulting in repeated surgical intervention, extended hospitalization or sometimes in loss of implant or permanent disability if not treated promptly. Poor treatment outcome associated with prosthetic joint infections (PJIs) could be partly attributed to rise in anti-microbial resistance among the causative agents. Case Presentation: This is a first reported case of ceftriaxone + sulbactam + ethylenediaminetetraacetic acid (CSE 1034) being used as an de-escalation therapy for more than 24 days with good safety and efficacy outcome in a 78 year male patient with PJI associated with hip replacement surgery, treated initially with meropenem and colistin followed by prolonged de-escalation therapy (24 days).Conclusions: In clinically complicated cases of deep infections where prolonged use of last resort antibiotics is used, CSE-1034 can be considered as a safe, efficacious and economical de-escalating antibiotic to complete the treatment course and prevent recurrence of infection, especially in PJI
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The application of immunological checkpoint inhibitors (ICIs) has modified many treatment strategies of malignant tumors, which has become a milestone in cancer therapy. The principle of action can be explained as "brake theory". After releasing the brakes by ICIs, unprecedented systemic toxicities, even some refractory and fatal immune-related adverse effects (irAEs) may develop. In this article, we summarized the recommended treatments of grade 3-4 severe irAEs in the latest European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN)/American Society of Clinical Oncology (ASCO), Society for Immunotherapy of Cancer (SITC) and Chinese Society of Clinical Oncology (CSCO) guidelines and consensus. We also performed a systemic review of case reports and reviews of irAEs up to May 20, 2019 in PubMed and Chinese journals. Successful applications of specific immunosuppressive drugs and stimulating factors beyond the above guidelines and consensus were supplemented and highlighted, including agents blocking interleukin 6 (IL-6), rituximab, anti-tumor necrosis factor-α (TNFα) monoclonal antibody (mAb), anti-integrin 4 mAb, Janus kinase inhibitors, thrombopoietin receptor agonists and antithymocyte globulin (ATG) etc. We put some concerns of using high-dose steroids for long-term, and emphasize the secondary infections, tumor progression, and unavailability of ICI re-challenge during steroid treatment. We propose the "De-escalation Therapy" principle for severe and refractory irAEs, and suggest that immunosuppressive drugs specifically targeting cytokines should be used as early as possible. Many irAEs in the era of immunotherapy are unprecedented compared with traditional chemotherapy and small-molecule targeted therapy, which is a big challenge to oncologists. Therefore, the establishment of multidisciplinary system is very important for the management of cancer patients.
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The widespread use of antibiotics has been effectively controlled serious life-threatening infections.The trituration,exploitation and use of antibiotics has been rapidly developed and applied to many fields.Due to the extensive use of various antibiotics,the emergences of drug-resistant bacteria and the rates of bacterial resistance have increased unceasingly which has been a common focus in the world.Resistant pathogen can reduce the effectiveness of antibiotics,and which is a serious threat to human health.De-escalation therapy of antibiotics can quickly and effectively control serious infections,and avoid bacterial resistance,and induce fungal infections.The rational use of antibiotics in pediatrics is very imperative,which includes strengthening management of antibiotics,and improving awareness and vigilance of the adverse reactions of antibiotics,and consummating specification of medication.Then,realize the correct,safe,rational medication of antibiotics.
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Objeetive To evaluate the efficacy of loratadine combined with de-escalation therapy for infant wheeze.Methods One hundred out-patients from Dec.2011 to Apr.2012 were randomly divided into 2 groups:Loratadine combined with de-escalation therapy was adopted in Loratadine group,while no Loratadine was taken in control group.The dose of Loratadine was 0.3 mL/(kg · d),14 days ; oral Prednisone 0.5 mg/(kg · d),3 days; Azithromycin 10 mg/(kg · d),3 days; Tulobuterol patch 0.5 mg/d,7 days; Montelukast 4 mg/d,14 days.Control group abolished Loratadine,but the rest of drugs were same as Loratadine group.Results The respiratory symptoms (gasp,wheeze sound,phlegm removal difficulty) and the nasal symptoms (including nasal congestion,sneeze,runny nose)in the acute phase of infant wheeze all had therapeutic effect,and there were significant differences in scoring symptoms (all P ＜ 0.05).The Loratadine group had certain treatment effect on eczema.The cough symptoms in 3 days,7days,14 days of the treatment had statistically significant differences between the both groups (all P ＜ 0.05).And there were statistical differences in eczema symptom of the Loratadine group in 7 days and 14 days of treatment (all P ＜ 0.05).Control group still had no statistical differences (all P ＞ 0.05).Days of improvement in symptoms,wheeze recurrence rate and frequency of respiratory infections in I month between 2 groups had no significant differences.Conclusions Loratadine can obviously improve the patients' breathing cough symptoms,and play a certain role in the treatment combined with de-escalation therapy in infant wheezing,and has high safety and eczema therapy effect.Loratadine can be used in clinic personally according to the patient's condition.
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Objective To evaluate the effect of the de-escalation therapy of antimicrobial agents combined bronchoalveolar lavage on the treatment of acute stroke complicate pulmonary infection.Methods 80 patients of acute stroke complicated pulmonary infection were randomized into two groups.The method of the de-escalation therapy of antimicrobial agents combined bronchoalveolar lavage was used in therapeutic group(n=40)while the patients in control group(n=42)received routine therapy of antimicrobial agents.The effective rate,the bacteria1 eradication rat,the average time of pneumonia absorption and the average time NICU stay between two groups were compared and analyzed.Results The effective rate and the bacteria1 eradication rat in therapeutic group were significantly higher than those in control group(P