RESUMEN
Hospital culture plays an important role in the orderly operation of large shelter hospitals as well as epidemic prevention and control.From April to May 2022, the shelter hospital of the National Convention and Exhibition Center(Shanghai) had created the large shelter hospital culture co-built by doctors and patients with a greater sense of belonging by taking measures such as joint party building between doctors and patients, giving play to the vanguard force of party members, carrying out various forms of cultural, sports and science popularization activities, encouraging enthusiastic patients to participate in activity planning, focusing on key groups, formulating shelter " residents convention", and so on. These measures ultimately formed cultural adaptation, cultural synchronization and cultural shaping, which were conducive to enhancing the empathy of doctors and patients, improving the effectiveness of medical implementation, and promoting the standardization of shelter management system. This harmonious, warm and autonomous culture co-built by doctors and patients effectively ensures the safe and orderly operation of the shelter hospital, and provides reference for the construction of the cultural system of large shelter hospitals in China.
RESUMEN
Objective:To explore the protective effect and its mechanism of vitamin C on septic renal injury induced by lipopolysaccharide (LPS).Methods:Renal tubular epithelial cells HK-2 were induced with 10 mg/L LPS for 8 hours and 12 hours, respectively, and then 0.5 mmol/L and 1 mmol/L vitamin C were added, respectively. Cell viability was measured using cell proliferation and toxicity assay cell counting kit-8 (CCK-8) to determine suitable condition for subsequent experiments. HK-2 cells were divided into control group, LPS group and LPS+vitamin C group (LPS+VC group). The contents of necrosis factors phosphorylated mixed lineage kinase domain-like protein (p-MLKL) and phosphorylated receptor-interacting protein kinase 3 (p-RIPK3) were measured by Western blotting. The contents of inflammatory factors interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were determined by enzyme linked immunosorbent assay (ELISA) in each group. Differences among the groups were compared.Results:CCK-8 showed that 1 mmol/L vitamin C improved the survival rate of HK-2 cells to 86% after 12 hours of LPS induction, so this condition was selected for subsequent experiments. After 12 hours LPS induction in HK-2 cells, the expressions of p-MLKL and p-RIPK3 were significantly higher than those of the control group, and the levels of IL-1β and TNF-α were also significantly higher than those of the control group [IL-1β (ng/L): 23.2±1.4 vs. 12.8±3.9, TNF-α (ng/L): 36.4±3.9 vs. 11.6±1.8, both P < 0.05], indicating the co-existence of cell necrosis and inflammation. Compared with LPS group, 1 mmol/L vitamin C significantly decreased the protein expression of p-MLKL and p-RIPK3, and also significantly decreased the levels of IL-1β and TNF-α [IL-1β (ng/L): 19.8±0.7 vs. 23.2±1.4, TNF-α (ng/L): 17.4±5.8 vs. 36.4±3.9, both P < 0.05]. Conclusion:Vitamin C can alleviate LPS-induced HK-2 cell damage, and reduce the expressions of necrotic factors and inflammatory factors.
RESUMEN
Sepsis associated-acute kidney injury (SA-AKI) is a common complication of sepsis, which has a high incidence and is closely related to a poor prognosis. However, delayed diagnosis and non-specific treatments make it difficult to systematically manage SA-AKI. Based on massive clinical data, machine learning could build prediction models, which provide alarms and suggestions for the clinical decision support system. Although there are still many challenges such as poor interpretability, it has shown clinical application value in SA-SKI risk prediction, imaging diagnosis, subtype identification, prognosis assessment, and so on. Based on a brief introduction of machine learning, this article reviews the application, limitations, and future directions of machine learning in the diagnosis and treatment of SA-AKI, and explores the possibility of machine learning in the medical field, in order to promote the development of precision medicine and intelligent medicine.
RESUMEN
Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection, and is one of the main causes of death in intensive care unit (ICU) patients. Coagulation dysfunction runs through the pathophysiological progress of sepsis whose severity should be closely related to the prognosis of sepsis. Neutrophil extracellular traps (NETs) is a three-dimensional network structure with DNA as the skeleton and inlaid with various protein components. The excessive production of NETs can lead to sepsis-induced coagulopathy (SIC) by activating the coagulation system, inhibiting the anticoagulation system, resisting fibrinolysis, damaging vascular endothelial cells and the interaction of platelets. At present, the treatment of SIC is mainly symptomatic treatment, and there is no recognized effective anticoagulation strategy. Interventions for NETs and their components, and drugs for antiplatelets are expected to become new directions for disease treatment.
RESUMEN
Trauma center is an important link of trauma treatment, which is beneficial for professional integrated treatment of trauma patients and reduction of disability and death rate. The establishment of trauma rescue and treatment system is conducive to improving the regional trauma treatment capacity, rationalizing the layout of medical resources and standardizing the trauma treatment. Making full use of geographic information system (GIS) to analyze the big data such as the number of trauma patients, population, ground traffic situation and geographic information in the region and scientifically plan the number and location of trauma centers in the region is crucial to further optimize the geographic layout of trauma treatment centers, coordinate regional trauma treatment resources and improve the overall treatment capacity and is conducive to optimizing trauma treatment resources, improving regional trauma treatment capacity and reducing the disability and death rate of trauma patients. Based on domestic and foreign literature researches, the authors discuss how to use GIS to optimize the trauma rescue and treatment system in China in order to provide a useful reference for construction of regional trauma rescue and treatment system.
RESUMEN
Objective:To investigate the clinical features, risk factors and prognosis of Clostridium difficile infection/colonization (CDI/CDC) in emergency intensive care unit (EICU) of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, then provides theoretical basis for clinical treatment. Methods:A retrospective case-control study was conducted. The data of EICU patients admitted to Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2016 to June 2020 were collected. Taking the CDI/CDC patients as research objects [ Clostridium difficile (CD) positive group] and the CD negative patients with the same gender and age difference less than 5 years who were admitted to the hospital during the same period as the control (CD negative group). Demographic information, risk factors, prognosis and stool samples were collected. Single factor analysis and binary Logistic regression were used to analyze the CD positive infection rate, risk factors, and hospital death of patients with different clinical characteristics. Results:About 487 patients in EICU were included, 76 cases were taken into CD positive group, CD positive rate was 15.6%, including CDI 11 cases, CDC 65 cases. Among the CD positive group, all of the cases used proton pump inhibitor (PPI), and 75 cases used at least one antibiotic. Seventy-six CD negative patients with or without diarrhea (CD negative group) were included in this study. Among them, 75 patients used PPI and 74 patients used at least one antibiotic. Univariate analysis showed that acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), duration of hospitalization, and carbapenem use were the risk factors for CDI/CDC. There were significant differences in the above indicators between CD positive group and CD negative group [APACHEⅡ: 18.0 (12.2, 25.8) vs. 10.0 (7.0, 14.0), duration of hospitalization (days): 46.0 (30.5, 72.5) vs. 18.5 (9.2, 37.0), proportion of carbapenems: 81.6% (62/76) vs. 64.5% (49/76), all P < 0.05]. Binary Logistic analysis regression analysis showed that APACHEⅡ score [odds ratio ( OR) = 0.802, 95% confidence interval (95% CI) was 0.730-0.882, P < 0.01] and duration of hospitalization ( OR = 0.960, 95% CI was 0.942-0.978, P < 0.01) were independent risk factors for CDI/CDC. There was no difference in overall mortality between the CD positive group and CD negative group [27.6% (21/76) vs. 38.2% (29/76), P = 0.167]. Conclusions:Critically ill patients in EICU routinely use PPI and antibiotics, and the use of antibiotics does not affect the CD positive rate. The independent risk factors of CDI/CDC are the APACHEⅡ score and the duration of hospitalization, but fecal CD positive has no obvious influence on death.
RESUMEN
Objective:To observe the changes of renal function in critically ill patients after using vancomycin and analyze the renal protective effect of reduced glutathione (GSH) on vancomycin nephrotoxicity.Methods:The clinical data of patients with severe infection who were administered with vancomycin or plus infusion of GSH admitted to intensive care unit (ICU) of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2012 to October 2019 were collected during the study period, and the patients were divided into only vancomycin group and vancomycin combined with GSH group. The gender, age, body weight, underlying diseases, clinical diagnosis, severity score, renal function before and after taking the medicine, average daily dose and treatment duration of vancomycin and GSH, length of ICU stay and clinical outcomes were recorded and analyzed.Results:A total of 217 patients were enrolled, with 127 patients in the only vancomycin group, and 90 in the combination with GSH group. There was no statistically significant difference between the two groups in terms of gender, body weight, duration of vancomycin treatment, history of chronic kidney disease, and ICU mortality. The main causes of 217 patients admitted to the ICU were lung infection, sepsis/septic shock, and severe acute pancreatitis (SAP) and so on. The majority of patients in only vancomycin group had lung infections (63.0%), while the main etiology in combination with GSH group was SAP (46.7%). Compared with the only vancomycin group, the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score in the combination with GSH group significantly decreased [15.0 (10.5, 21.0) vs. 27.0 (20.0, 31.0), P < 0.01], but the quick sequential organ failure assessment (qSOFA) score was significantly higher [1.0 (0, 1.0) vs. 0 (0, 0.2), P < 0.01], the basic renal function was poorer [serum creatinine (SCr, μmol/L): 102.0 (64.7, 178.0) vs. 56.0 (42.0, 71.0), blood urea nitrogen (BUN, mmol/L): 11.5 (6.7, 18.4) vs. 4.70 (3.5, 8.1), both P < 0.05], and the average daily dose of vancomycin was lower (mg·kg -1·d -1: 22.22±10.09 vs. 25.51±9.56, P < 0.05). The renal function of patients was getting worse significantly after vancomycin usage as compared with before [SCr (μmol/L): 68.0 (50.3, 103.4) vs. 56.0 (42.0, 71.0), BUN (mmol/L): 5.4 (3.6, 9.6) vs. 4.7 (3.5, 8.1), both P < 0.05]. However, the renal function indexes of the combination with GSH group were better than those before treatment [SCr (μmol/L): 81.0 (61.0, 129.0) vs. 102.0 (64.7, 178.0), P < 0.05; BUN (mmol/L): 8.4 (6.2, 17.8) vs. 11.5 (6.7, 18.4), P > 0.05], and the length of ICU stay was significantly shorter than that in the only vancomycin group [days: 29.0 (14.0, 54.2) vs. 37.0 (25.0, 55.0), P < 0.05]. Conclusions:The incidence of drug-induced renal injury caused by vancomycin is high. The GSH can significantly reduce their renal toxicity and shorten the length of hospital stay.
RESUMEN
Objective:To observe the changes of renal function in critically ill patients using vancomycin and analyze the renal protective effect of high dose vitamin C (VC) on vancomycin nephrotoxicity.Methods:Retrospective analysis was carried out to enroll the patients who were hospitalized in emergency intensive care unit (ICU) of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2012 to October 2019. All patients were administered with vancomycin or VC infusion in addition. According to the infusion of vancomycin alone or in combination with VC, the patients were divided into vancomycin group and vancomycin in combination with VC group; vancomycin group was further divided into two groups according to before vancomycin or after vancomycin usage; combination group were further divided into two groups according to before VC use or after VC. The initial dosage of vancomycin was calculated according to the actual weight of the patient and adjusted according to the renal function. The dosage of VC was determined according to the disease severity of the patient, and the dosage range was 50-200 mg·kg -1·d -1, continuously infused into the body. The age, gender, weight and renal function etc. were recorded and analyzed. Results:A total of 245 patients who met the requirements were included in the analysis. There were 127 patients in the vancomycin group and 118 patients in the combination group. The causes of patients admitted to ICU were pulmonary infection, sepsis, severe acute pancreatitis, etc. Among them, pulmonary infection accounted for 63.0% in vancomycin group, while severe acute pancreatitis accounted for 61.9% in combination group. The quick sequential organ failure assessment (qSOFA) score of combination group was significantly higher than that of vancomycin group [1.0 (0, 1.0) vs. 0 (0, 0.2), P < 0.01], its basic renal function was also significantly worse [serum creatinine (SCr, μmol/L): 98.0 (65.0, 178.2) vs. 56.0 (42.2, 71.0), blood urea nitrogen (BUN, mmol/L): 11.30 (6.48, 18.38) vs. 4.70 (3.45, 8.10), both P < 0.05], and the average daily dose of vancomycin was also significantly lower than that of vancomycin group (mg·kg -1·d -1: 23.0±9.4 vs. 26.6±8.5, P < 0.01). Compared with vancomycin before administration, the renal function was getting worse significantly after vancomycin administration [SCr (μmol/L): 68.0 (50.2, 104.5) vs. 56.0 (42.2, 71.0), BUN (mmol/L): 5.35 (3.75, 9.83) vs. 4.70 (3.45, 8.10), both P < 0.05]. Combination with VC significantly improved renal function compared with that before VC treatment [SCr (μmol/L): 79.0 (58.0, 129.0) vs. 98.0 (65.0, 178.2), P < 0.05; BUN (mmol/L): 9.60 (6.10, 18.30) vs. 11.30 (6.48, 18.38), P > 0.05] and shortened the length of ICU stay [days: 28.5 (14.8, 54.2) vs. 37.0 (25.0, 55.0), P < 0.01]. Conclusions:The incidence of drug-induced renal injury caused by vancomycin is high. Intravenous high dose VC can significantly reduce the nephrotoxicity of vancomycin and shorten the length of hospital stay. When vancomycin is used in critically ill patients, VC can be used in combination to reduce or avoid drug-induced renal injury, improve curative effect and reduce toxic effects.
RESUMEN
Objective:To investigate the different outcomes of two types of acute kidney injury (AKI) according to standard of Kidney Disease: Improving Global Outcomes-AKI (KDIGO-AKI), and to analyze the risk factors that affect the prognosis of intensive care unit (ICU) patients in China.Methods:A secondary analysis was performed on the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a multicenter prospective study involving 3 063 patients in 22 tertiary ICUs in 19 provinces and autonomous regions of China. The demographic data, scores reflecting severity of illness, laboratory findings, intervention during ICU stay were extracted. All patients were divided into pure AKI (PAKI) and acute on chronic kidney disease (AoCKD). PAKI was defined as meeting the serum creatinine (SCr) standard of KDIGO-AKI (KDIGO-AKI SCr) and the estimated glomerular filtration rate (eGFR) at baseline was ≥ 60 mL·min -1·1.73 m -2, and AoCKD was defined as meeting the KDIGO-AKI SCr standard and baseline eGFR was 15-59 mL·min -1·1.73 m -2. All-cause mortality in ICU within 28 days was the primary outcome, while the length of ICU stay and renal replacement therapy (RRT) were the secondary outcome. The differences in baseline data and outcomes between the two groups were compared. The cumulative survival rate of ICU within 28 days was analyzed by Kaplan-Meier survival curve, and the risk factors of ICU death within 28 days were screened by Cox multivariate analysis. Results:Of the 3 063 patients, 1 042 were enrolled, 345 with AKI, 697 without AKI. The AKI incidence was 33.11%, while ICU mortality within 28 days of AKI patients was 13.91% (48/345). Compared with PAKI patients ( n = 322), AoCKD patients ( n = 23) were older [years old: 74 (59, 77) vs. 58 (41, 72)] and more critical when entering ICU [acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score: 23 (19, 27) vs. 15 (11, 22)], had worse basic renal function [eGFR (mL·min -1·1.73 m -2): 49 (38, 54) vs. 115 (94, 136)], more basic complications [Charlson comorbidity index (CCI): 3 (2, 4) vs. 0 (0, 1)] and higher SCr during ICU stay [peak SCr for diagnosis of AKI (μmol/L): 412 (280, 515) vs. 176 (124, 340), all P < 0.01]. The mortality and RRT incidence within 28 days in ICU of AoCKD patients were significantly higher than those of PAKI patients [39.13% (9/23) vs. 12.11% (39/322), 26.09% (6/23) vs. 4.04% (13/322), both P < 0.01], while no significant difference was found in the length of ICU stay. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate in ICU in AoCKD patients was significantly lower than PAKI patients (Log-Rank: χ2 = 5.939, P = 0.015). Multivariate Cox regression analysis showed that admission to ICU due to respiratory failure [hazard ratio ( HR) = 4.458, 95% confidence interval (95% CI) was 1.141-17.413, P = 0.032], vasoactive agents treatment in ICU ( HR = 5.181, 95% CI was 2.033-13.199, P = 0.001), and AoCKD ( HR = 5.377, 95% CI was 1.303-22.186, P = 0.020) were independent risk factors for ICU death within 28 days. Conclusion:Further detailed classification (PAKI, AoCKD) based on KDIGO-AKI SCr standard combined with eGFR is related to ICU mortality in critical patients within 28 days.
RESUMEN
Objective:To observe the changing characteristics of pharmacokinetic and pharmacodynamic (PK-PD) parameters of vancomycin in critical patients under different drug regimens and to further explore the influencing factors.Methods:The clinical data of patients who treated with vancomycin and recorded by steady-state through concentration (C min) admitted to intensive care unit (ICU) of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2011 to December 2018 were analyzed retrospectively. The patients were divided into three groups according to the dosing interval (groups of q12 h, q8 h and q6 h respectively) and C min was collected. The serum concentration of vancomycin before (0 hour) and 1, 2, 4, 6, 8, 12 and 24 hours after administration were estimated by JPKD Ver 3.1. Area under the curve (AUC 0-24 h) was estimated by trapezoidal area method. Minimum inhibitory concentration (MIC) of pathogenic microorganisms in the same period was retrieved, thus AUC 0-24 h/MIC was calculated. Results:285 patients with 529 records of C min were enrolled in the study, including 375 data in q12 h group, 121 data in q8 h group and 33 data in q6 h group. After unifying daily dose by JPKD Ver 3.1, the C min (10-20 mg/L) reaching rate of q12 h group, q8 h group, q6 h group were 35.7%, 43.8% and 60.6%, respectively, while only q12 h group was statistically significant compared with q6 h group ( P < 0.01). q6 h group and q8 h group showed higher C min than q12 h group (mg/L: 13.8±5.2, 13.5±7.3 vs. 11.4±7.9, both P < 0.05) and lower peak concentration (C max) than q12 h group (mg/L: 19.4±5.3, 21.5±7.3 vs. 23.9±8.1, both P < 0.05). However, there was no significant difference in terms of percentage of PD target (AUC 0-24 h/MIC≥400) among the three groups (q12 h group, q8 h group, q6 h group were 38.1%, 41.3%, 45.5%, P > 0.05). Multiple linear regression analysis showed that creatinine clearance (CCr) and vancomycin clearance (CLvancomycin) were the main influencing factors of vancomycin PD parameters such as C min and AUC 0-24 h/MIC ( r values of CCr were -0.391, -0.424, and rvalues of CLvancomycin were -0.673, -0.663, all P < 0.01), and were negatively correlated with age ( r values were -0.432 and -0.488, respectively, both P < 0.01). Conclusions:At the same daily dose, C min can be increased and C max can be decreased by increasing the frequency of vancomycin administration, thus minimize the fluctuation of vancomycin serum concentration, but AUC 0-24 h/MIC is not affected. Vancomycin administration regimen in severe patients should be optimized according to CCr, CLvancomycin and age.
RESUMEN
Objective:To explore the clinical value of procalcitonin (PCT) in predicting mortality of patients with acute biliary pancreatitis (ABP).Methods:The clinical data of 196 ABP patients admitted in the emergency department of Ruijin Hospital Affiliated to Shanghai Jiaotong University Medical College from January 2013 to June 2017 were analyzed retrospectively. The enrolled patients were divided into survival group ( n=176) and death group ( n=20) according to clinical outcome, and their clinical characteristics, laboratory results(including WBC, CRP, PCT), APACHEⅡ score, BISAP score, modified Marshall score, SOFA score and CTSI at admission were compared between two groups. The ROC curve and AUC were used to evaluate the effectiveness of PCT and multiple scoring systems in predicting mortality in ABP patients, and the Delong test was used to compare the predictive efficacy of various methods at 1-2 d, 3-4 d, and 5-7 d days after onset. Results:The PCT level, APACHEⅡ score, BISAP score, modified Marshall score, SOFA score, and CTSI of patients in the death group were significantly higher than those in the survival group [6.98(3.12, 13.64) μg/L vs 0.55(0.17, 1.74) μg/L, 12.00(6.00, 18.75) vs 6.00(3.00, 9.00), 3.20±1.47 vs 1.59±1.05, 2.85±0.37 vs 1.96±0.64, 5.50(4.00, 9.50) vs 2.00(1.00, 4.25), 5.05±2.33 vs 3.39±1.74], and all the differences were statistically significant (all P values <0.05). The AUC of PCT for predicting death was 0.881 (95% CI 0.820-0.938)and the cut-off value was 2.44. The predictive value of PCT was similar to that of the modified Marshall score, BISAP score and SOFA score, but higher than that of APACHEⅡ score and CTSI (all P values <0.05). The predictive AUC of PCT at 3-4 days after onset was higher than that of modified Marshall score, BISAP score and SOFA score, and were significantly higher than those at 1-2 days after onset. Conclusions:PCT can be used to predict the mortality of ABP within 7 days of onset. The predictive value of PCT was comparable to the modified Marshall score, BISAP score and SOFA score, and the best predictive time was 3-4 days after onset.
RESUMEN
OBJECTIVE@#To investigate the effectiveness and safety of clinical pharmacists-directed vancomycin dosing and therapeutic drug monitoring (TDM), and to promote the individualized medication of vancomycin.@*METHODS@#Information of hospitalized patients treated by vancomycin admitted to Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2011 to October 2017 was collected retrospectively during study period, the patients were divided into pharmacists intervention and non-pharmacists intervention groups according to pharmacist-directed vancomycin dosing guideline or not. The individualized dosing regimen of vancomycin for the patients in pharmacists intervention group was guided by clinical pharmacists, this guideline was that pharmacists offered the TDM guidance, made the individualized dosage regimen of vancomycin, etc., which based on the patients' pathophysiology, condition, and the adjustments of increased dose or 24-hour continuous infusion vancomycin were made for patients if the steady-state trough concentrations fell below the target level. Vancomycin dosage was made for patients in the non-pharmacists intervention group by physicians only based on vancomycin instructions or clinical experience. The vancomycin dosing, TDM, microorganism culture, renal function, 30-day mortality rate, and length of hospital stay were recorded. The appropriateness of TDM for vancomycin was defined as a blood collection within 1 hour of the next scheduled dose after steady state achieved. The rationality of the initial dosing regimen was determined based on the vancomycin application guidelines issued by Infectious Diseases Society of America (IDSA) in 2009.@*RESULTS@#A total of 258 patients were enrolled, and there were 158 patients in the non-pharmacists intervention group and 100 in pharmacists intervention group. The appropriateness of TDM for vancomycin in pharmacists intervention group was significantly improved as compared with that in non-pharmacists intervention group [87.0% (87/100) vs. 69.6% (110/158), P < 0.01], the percentage of first trough serum concentrations drawn on day 3 after steady state achieved was significantly increased [51.0% (51/100) vs. 37.3% (53/142), P < 0.05]. Compared with the non-pharmacists intervention group, the percentages of patients who received appropriate initial dosing and attained the initial target therapeutic range in pharmacists intervention group were significantly increased [87.4% (76/87) vs. 68.2% (75/110), 51.7% (45/87) vs. 30.9% (34/110), both P < 0.01], the percentage of patients whose vancomycin dosing regimen was adjusted based on TDM results was also significantly increased [54.0% (47/87) vs. 15.5% (17/110), P < 0.01], the rate of vancomycin serum concentrations reaching the standard was increased [70.1% (61/87) vs. 32.7% (36/110), P < 0.01], and a lower number of patients in sub- or supra-therapeutic range was observed in pharmacists intervention group [27.6% (24/87) vs. 46.4% (51/110), 2.3% (2/87) vs. 20.9% (23/110), both P < 0.01]. In addition, a lower incidence of vancomycin-induced acute kidney injury (AKI) was observed in pharmacists intervention group as compared with that in non-pharmacists intervention group [0 (0/87) vs. 6.4% (7/110), P < 0.01]. No significant difference was observed in the microorganism culture, 30-day mortality rate or length of hospital stay between the two groups. Among the 87 patients in pharmacists intervention group, the vancomycin dosing was adjusted for 42 patients who did not attain the target therapeutic range, increasing the dose of vancomycin was made for 22 patients, 24-hour continuous infusion was made for 20 patients. Compared with the only increasing vancomycin dose group, vancomycin continuous infusion for 24 hours could significantly increase the serum trough concentration (mg/L: 18.0±6.7 vs. 12.5±5.8, P < 0.05), and reduce daily dosage (mg/kg: 27.1±7.1 vs. 36.6±9.2, P < 0.01).@*CONCLUSIONS@#The implementation of a pharmacist-directed vancomycin dosing guideline based on TDM optimized vancomycin dosing regimen, improved the accuracy and timeliness of TDM for vancomycin, achieved a higher percentage of levels within the therapeutic range, and a lower incidence of vancomycin-induced AKI.
Asunto(s)
Humanos , Antibacterianos , China , Monitoreo de Drogas , Farmacéuticos , Estudios Retrospectivos , Vancomicina/administración & dosificaciónRESUMEN
Objective To assess the predictive effect of myocardial injury biomarkers (proBNP, CK-MB, and cTnI) on the severity of acute pancreatitis (AP). Methods The records of 246 patients diagnosed with acute pancreatitis who were treated at Ruijin Hospital Emergency Department from January 2015 to December 2016 were retrospectively analyzed. According to the revised 2012 Atlanta guidelines, these patients were divided into the mild acute pancreatitis (MAP, n=47), moderately severe acute pancreatitis (MSAP, n=151) and severe acute pancreatitis (SAP, n=48) groups. The highest plasma levels of troponin I (cTnI), creatine kinase (CK)-MB, N-terminal B-type brain natriuretic peptide (NT-proBNP), C-reactive protein (CRP), and procalcitonin (PCT) were recorded for comparison within 72 h after admission. The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score, sequential organ failure assessment (SOFA), bedside index for severity in acute pancreatitis (BISAP) and Balthazar computed tomography severity index (CTSI) were calculated at admission within 72 h. Whether there is an occurrence of organ dysfunction, and the organ types and persist time of organ dysfunction were recorded. The analysis of variance, SNK-q test and paired samples t test were used for the statistical analysis. Results The levels of proBNP, CK-MB, and cTnI were significantly higher in the SAP group than in the non-SAP group. The receiver operating characteristic (ROC) curve demonstrated cTnI had the maximum predictive power (AUC=0.872), while proBNP had the least predictive ability (AUC=0.763). The established model, which is to explore whether the myocardial injury markers had the predictive value, showed that the combination of myocardial injury indicators (CK-MB, cTnI) and traditional indicators had higher predictive value for SAP than traditional indicators alone (AUC=0.966 vs. AUC=0.945, P=0.04). Conclusions The elevated markers of myocardial injury had certain predictive value for severe acute pancreatitis.
RESUMEN
Objective@#To investigate the effectiveness and safety of clinical pharmacists-directed vancomycin dosing and therapeutic drug monitoring (TDM), and to promote the individualized medication of vancomycin.@*Methods@#Information of hospitalized patients treated by vancomycin admitted to Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2011 to October 2017 was collected retrospectively during study period, the patients were divided into pharmacists intervention and non-pharmacists intervention groups according to pharmacist-directed vancomycin dosing guideline or not. The individualized dosing regimen of vancomycin for the patients in pharmacists intervention group was guided by clinical pharmacists, this guideline was that pharmacists offered the TDM guidance, made the individualized dosage regimen of vancomycin, etc., which based on the patients' pathophysiology, condition, and the adjustments of increased dose or 24-hour continuous infusion vancomycin were made for patients if the steady-state trough concentrations fell below the target level. Vancomycin dosage was made for patients in the non-pharmacists intervention group by physicians only based on vancomycin instructions or clinical experience. The vancomycin dosing, TDM, microorganism culture, renal function, 30-day mortality rate, and length of hospital stay were recorded. The appropriateness of TDM for vancomycin was defined as a blood collection within 1 hour of the next scheduled dose after steady state achieved. The rationality of the initial dosing regimen was determined based on the vancomycin application guidelines issued by Infectious Diseases Society of America (IDSA) in 2009.@*Results@#A total of 258 patients were enrolled, and there were 158 patients in the non-pharmacists intervention group and 100 in pharmacists intervention group. The appropriateness of TDM for vancomycin in pharmacists intervention group was significantly improved as compared with that in non-pharmacists intervention group [87.0% (87/100) vs. 69.6% (110/158), P < 0.01], the percentage of first trough serum concentrations drawn on day 3 after steady state achieved was significantly increased [51.0% (51/100) vs. 37.3% (53/142), P < 0.05]. Compared with the non-pharmacists intervention group, the percentages of patients who received appropriate initial dosing and attained the initial target therapeutic range in pharmacists intervention group were significantly increased [87.4% (76/87) vs. 68.2% (75/110), 51.7% (45/87) vs. 30.9% (34/110), both P < 0.01], the percentage of patients whose vancomycin dosing regimen was adjusted based on TDM results was also significantly increased [54.0% (47/87) vs. 15.5% (17/110), P < 0.01], the rate of vancomycin serum concentrations reaching the standard was increased [70.1% (61/87) vs. 32.7% (36/110), P < 0.01], and a lower number of patients in sub- or supra-therapeutic range was observed in pharmacists intervention group [27.6% (24/87) vs. 46.4% (51/110), 2.3% (2/87) vs. 20.9% (23/110), both P < 0.01]. In addition, a lower incidence of vancomycin-induced acute kidney injury (AKI) was observed in pharmacists intervention group as compared with that in non-pharmacists intervention group [0 (0/87) vs. 6.4% (7/110), P < 0.01]. No significant difference was observed in the microorganism culture, 30-day mortality rate or length of hospital stay between the two groups. Among the 87 patients in pharmacists intervention group, the vancomycin dosing was adjusted for 42 patients who did not attain the target therapeutic range, increasing the dose of vancomycin was made for 22 patients, 24-hour continuous infusion was made for 20 patients. Compared with the only increasing vancomycin dose group, vancomycin continuous infusion for 24 hours could significantly increase the serum trough concentration (mg/L: 18.0±6.7 vs. 12.5±5.8, P < 0.05), and reduce daily dosage (mg/kg: 27.1±7.1 vs. 36.6±9.2, P < 0.01).@*Conclusions@#The implementation of a pharmacist-directed vancomycin dosing guideline based on TDM optimized vancomycin dosing regimen, improved the accuracy and timeliness of TDM for vancomycin, achieved a higher percentage of levels within the therapeutic range, and a lower incidence of vancomycin-induced AKI.
RESUMEN
The latest definition of sepsis (Sepsis-3) is the life-threatening organ dysfunction due to overreaction of immune system caused by infection. The situation can develop into multiple organ dysfunction syndromes (MODS). In the pathological process of pathogen invasion, a large number of inflammatory factors directly damage organ function, while dysfunction of coagulation system is also involved in this process. With the overreaction of inflammation, disseminated intravascular coagulation (DIC) occurred, which further exacerbated organ damage. As excessive inflammation and coagulation disorders are mutually reinforced, the clearance of pathogenic microorganisms and the control of inflammatory reactions cannot effectively improve the sepsis caused by MODS. As a clinically readily available anticoagulant, heparin is widely used in a variety of severe situations caused by DIC, thromboembolic disease and some invasive procedure for anticoagulant treatment. In recent years, domestic and foreign studies have found that heparin has a certain anti-inflammatory effect, which can reduce the incidence of DIC, improve sepsis patients with microcirculation and MODS, reduce 28-day mortality. However, there is controversy in its effectiveness and safety. Therefore, the application of heparin in the treatment of sepsis need to be further defined and discussed.
RESUMEN
Objective To evaluate the serum trough concentration and the pharmacokinetics/pharmacodynamics (PK/PD)of vancomycin in patients with severe acute pancreatitis (SAP), and analyze the effect of vancomycin continuous infusion for optimizing the characteristics of its PK/PD.Methods The inhospital patients with SAP received vancomycin treatment and admitted to emergency intensive care unit (EICU) of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2011 to December 2016 were enrolled. Steady-state trough concentrations of vancomycin from patients were collected retrospectively. The SAP patients were divided into augmented renal clearance (ARC) and non-ARC groups, as well as systemic inflammatory response syndrome (SIRS) and non-SIRS groups according to the patients with or without symptom above. Adjustments of increased dosage or 24-hour continuous infusion or increase vancomycin dose were made for patients if the steady-state trough concentrations fell below the target level. Steady state trough concentration for vancomycin intermittent infusion or steady state concentration for vancomycin continuous infusion was determined by the fluorescence polarization immunoassay method. PK parameters of vancomycin were calculated using the Bayesian estimator and the area under the serum drug concentration-time curve (AUCc-t), the minimum inhibitory concentration (MIC) and AUCc-t/MIC was recorded and calculated.Results The steady state trough concentration or steady state concentration from 61 patients with SAP were collected with mean steady state trough concentration of vancomycin of (7.7±4.4) mg/L, which was significantly lower than standard concentration (15 mg/L,P < 0.001). Apparent volume of distribution (Vd) and clearance of vancomycin was (1.06±0.26) L/kg and (8.9±2.8) L/h. The serum steady state trough concentration of vancomycin in ARC group (n = 33) was significantly lower than that in non-ARC group (n = 28; mg/L: 6.7±3.5 vs. 8.2±4.1, P < 0.01), clearance was significantly increased (L/h: 9.8±2.9 vs. 7.7±2.2,P < 0.01). Compared with non-SIRS group (n = 31), the serum steady state trough concentration of vancomycin in SIRS group (n= 30) was significantly lowered (mg/L: 6.1±3.2 vs. 13.0±4.2,P < 0.01), and clearance was significantly increased (L/h: 9.4±2.0 vs. 7.1±2.1,P < 0.05). Compared with the only increasing vancomycin dose group (n = 29), vancomycin continuous infusion for 24 hours (n = 21) could significantly reduce daily dosage (mg/kg: 13.6±3.9 vs. 19.1±3.5,P < 0.01), increase the serum trough concentration (mg/L: 18.1±7.0 vs. 12.6±5.3,P < 0.01), and improve the AUCc-t/MIC.Conclusions The serum trough concentration of vancomycin was significantly reduced in SAP patients with ARC. The more serious of the SIRS is, the lower the vancomycin trough concentration is. Vancomycin 24-hour continuous infusion could optimize the PK/PD parameters, decrease the daily dose, increase the clinical effect, and reduce the bacterial resistance.
RESUMEN
Objective To investigate the expression variation of aquaporin in colon tissues in acute necrotizing pancreatitis (ANP).Methods ANP rat model was induced by the retrograde injection of sodium taurocholate into the biliopancreatic duct.The rats were killed at 4 h, 8 h, 12 h and 24 h after modeling with 6 rats for each time point.The pancreas and colon tissues were harvested for pathological examination.The levels of IL-6, TNF-α mRNA expression and AQR (aquaporin-3, aquaporin-4, aquaporin-8) mRNA expression in proximal and distant colon were detected by RT-PCR.The levels of aquaporin protein in colon were examined by immunohistochemistry.Results After the establishment of ANP SD rat model, the integrity of colonic mucosa was continuously damaged, the structure of epithelial cells was unclear and the colonic villus were broken and destroyed, and inflammatory cell infiltration in submucosa was observed.The pathological score increased with the time of modeling.In 4 h, except that the mRNA levels of AQP-4 in distal colon was not obviously changed, mRNA levels of IL-6 and TNF-α, mRNA and protein expression of AQP-3 and AQP-8 in the proximal and distal colon of ANP rats were significantly elevated compared with shame group (P<0.05).AQP-3 and AQP-8 mRNA in proximal colon of ANP rats reached its peak in 8 h after the establishment and AQP-4 mRNA peaked at 24 h.AQP-3 and AQP-4 mRNA in distant colon of ANP rats reached its peak in 8 h after the establishment and AQP-8 mRNA peaked at 24 h.Protein expression of AQP-3, AQP-4 and AQP-8 in proximal and distant colon was strongest in 12 h and 24 h after the establishment.Conclusions With the progression of the ANP, the expression levels of AQP-3, AQP-4 and AQP-8 in both proximal and distal colons were elevated in various degrees, indicating that the aquaporins may participate in water metabolism of colon during ANP.
RESUMEN
Objective To observe the change of the serum trough concentration and its pharmacokinetics of vancomycin in patients with severe acute pancreatitis (SAP), and to analyze the factors influencing vancomycin concentration. Methods A retrospective analysis was conducted. Steady-state trough concentrations of vancomycin from patients (18-80 years old) with SAP concomitantly with G+ infection admitted to Intensive Care Unit (ICU) of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2010 to December 2016 were enrolled. According to the usage time of vancomycin, the patients with SAP were divided into early group (onset within 21 days), middle group (onset between 21-28 days) and late group (onset over 28 days). The gender, age, body weight, clinical diagnosis, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score, renal function, and the pharmacokinetic parameters were recorded. Influencing factors of vancomycin was analyzed by multiple linear regression and stepwise regression. Results Fifty-eight patients were enrolled who contained 134 times trough concentrations of vancomycin. There were 41 patients enrolled and 61 times of trough concentrations in the early group, 24 patients enrolled and 33 times of trough concentrations in the middle group, and 28 patients enrolled and 40 times of trough concentrations in the late group. There was no significant difference in gender, age, body weight, serum creatinine, creatinine clearance (CCr), albumin, APACHE Ⅱ score among the three groups. There was significantly difference in the duration from the onset time to vancomycin administration between early, middle groups and late group (days:15.9±3.2, 23.3±2.2 vs. 35.0±6.7, both P 0.05). Compared with the standard concentration (15 mg/L) of vancomycin, the serum trough concentration of vancomycin was significantly reduced in SAP patients [(7.5±4.3) mg/L, P < 0.01]. Apparent volume of distribution (Vd) was (72.4±15.4) L, and clearance rate (CL) was (9.0±2.8) L/h. According to the Bayesian, the serum trough concentration of vancomycin was significantly reduced in early group and middle group compared with late group (mg/L: 5.0±2.1, 7.3±2.5 vs. 11.5±5.1, both P < 0.01), CL was significantly increased (L/h: 10.5±3.0, 8.1±1.9 vs. 7.4±1.9, both P < 0.05), and Vd was significantly increased in early group compared with late group (L: 73.7±15.5 vs. 71.0±12.6, P < 0.05). It was shown by multiple linear regression analysis that there was strong relationship between serum trough concentration and the serum creatinine, CCr, average daily dose and the starting time of vancomycin treatment (r value were 0.449, -0.318, 0.373, 0.763, respectively, all P < 0.05). Conclusions The serum trough concentration of vancomycin was significantly reduced in SAP patients. And the earlier usage of vancomycin, the lower of the trough concentration is. Therefore, higher dosage regimen was needed to ensure the clinical effect, and reduce the bacterial resistance.
RESUMEN
The medical records of 197 patients on linezolid therapy were collected retrospectively.The prevalence and risk factors for linezolid-induced reduction of hemoglobin were identified.The incidence of linezolid-induced reduction of hemoglobin was 31.98％.The patients with reduction of hemoglobin had older age [(68 ± 14) vs.(59 ± 18) years,P =0.000] and lower creatinine clearance (CCr) [(72 ±42)vs.(98 ± 52) ml/min,P =0.000].Multivariate logistic regression analysis showed that age ≥65 years,treatment duration ≥ 15 days,CCr ＜ 65 ml/min and pre-treatment hemoglobin value ＜ 95 g/L were significant risk factors for linezolid-induced reduction of hemoglobin.
RESUMEN
10.3969/j.issn.1008-9691.2013.03.015