Effects on extravascular lung water of lung protective ventilation strategy applied on piglets with acute respiratory distress syndrome induced by paraquat / 中华劳动卫生职业病杂志

Objective: To study the effects on extravascular lung water of lung protective ventilation strategy applying on piglets with acute respiratory distress syndrome (ARDS) induced by paraquat (PQ) under pulse indicating continuous cardiac output (PiCCO) monitoring. Methods: The piglets models with ARDS induced by PQ were established in June 2020 and all of them were received mechanical ventilation and divided into three groups according to tidal volume (V(T)) : small V(T) group (6 ml/kg) , middle V(T) group (10 ml/kg) and large V(T) group (15 ml/kg) , there were 5 piglets in each group. The positive end expiratory pressure (PEEP) were all setup on 10 cmH(2)O. The indexes such as arterial blood gas analysis, oxygenation index (OI) , extravascular lung water index (ELWI) and pulmonary vascular permeability index (PVPI) were monitored at time of before the model was established (baseline) , time of the model was established (t(0)) and 2 h (t(2)) , 4 h (t(4)) , 6 h (t(6)) after mechanical ventilation. Lung tissue were punctured at time of baseline, t(0) and t(6) to be stained by Hematoxylin-eosin (HE) staining and pulmonary pathology were observed under light microscopy. Results: The heart rate (HR) , mean arterial pressure (MAP) and partial pressure of carbon dioxide (PaCO(2)) of all groups were higher than the base value while the pH values, partial pressure of oxygen (PaO(2)) and OI were lower than the base value when the models were established (P<0.05) . After mechanical ventilation, the HR and MAP values of all groups at t(2), t(4) and t(6) were lower than t(0) while the PaCO(2) of t(4) and t(6) were all higher than t(0), the differences were statistically significant (P<0.05) . The PaO(2) and OI of all groups showed a trend of rising at first and then decreasing after mechanical ventilation. The MAP, PaO(2), PaCO(2) and OI of the middle V(T) group and large V(T) group were apparently lower than that of the small V(T) group at t(2), t(4) and t(6) (P<0.05) . The ELWI and PVPI at t(0) of all groups were higher than that of baseline (P<0.05) . The ELWI of the small V(T) group at t(6) were lower than t(0) of the same group and t(6) of the middle V(T) group and large V(T) group (P<0.05) . HE staining showed congestion and edema of alveolar tissue, swelling of capillaries, exudation of red blood cells and widening of alveolar septum in piglets after successful modeling. And further widening of alveolar septum and rupture of alveolar septum could be seen in the lung tissues of each group at t(6), and the injury was the slightest in the small V(T) group. Conclusion: The lung protective ventilation strategy can alleviate the extravascular lung water and ARDS induced by PQ and improve oxygenation.

Clinical value of point of care ultrasound on cardiac output and volume responsiveness in patients with septic shock / 中华危重病急救医学

Objective:To assess the value of point of care ultrasound on cardiac output (CO) and volume responsiveness in patients with septic shock.Methods:A prospective investigation study was conducted. Twenty-four mechanical ventilation patients with septic shock who needed pulse-indicated continuous cardiac output (PiCCO) monitoring in the department of critical care medicine of Zhengzhou University People's Hospital, Henan Provincial People's Hospital from November 25, 2020 to April 30, 2021 were selected as the subjects, the patient's basic information and laboratory test results were recorded. PiCCO was used as standard to monitor CO and stroke volume variability (SVV) at 0, 2, 6, 12, 24 and 48 hours. At the same time, point of care transthoracic echocardiography (TTE) was used to measure velocity time integral (VTI) and inferior vena cava diameter (dIVC), the CO, VTI variation rate (△VTI) and dIVC variation rate (△dIVC) were calculated. Then, using the value monitored by PiCCO as the standard, the consistency and correlation analysis were carried out between point of care ultrasound with PiCCO.Results:Twenty-two out of 24 patients obtained satisfactory ultrasound Doppler images, the heart rate (HR), mean arterial pressure (MAP) and body temperature of the enrolled patients were consistent with the pathophysiological characteristics of septic shock. With the extension of treatment time, HR and CO both gradually decreased, and MAP gradually increased, reaching a peak or trough at 48 hours after admission. The difference were statistically significant compared with the time of admission [HR (bpm): 90.36±15.35 vs. 116.82±19.82, MAP (mmHg, 1 mmHg = 0.133 kPa): 87.82±11.06 vs. 58.82±9.85, CO (L/min): 4.80±0.56 vs. 6.78±1.31, all P < 0.05]. The CO obtained by PiCCO and point of care ultrasound had good agreement [5.36 (4.78, 6.33) L/min and 5.21 (4.88, 6.35) L/min, respectively], the average difference value at each time point was (-0.02±0.69) L/min, the 95% agreement limit range was -1.35-1.34, and there was a high degree of correlation ( rs = 0.800, P < 0.001); The SVV by PiCCO and the △dIVC by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 21.00% (14.00%, 25.75%), respectively], the average difference value at the time point was (-3.16±6.89)%, the 95% agreement limit range was -16.89-10.54, and there was a moderate correlation ( rs = 0.702, P < 0.001); The SVV by PiCCO and the △VTI by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 16.00% (11.25%, 20.75%), respectively], the average difference value at each time point was (13.03±14.75)%, and the 95% agreement limit range was 1.72-27.78, and there was a high correlation ( rs = 0.918, P < 0.001). Conclusion:Point of care ultrasound can accurately assess CO and volume responsiveness of patients with septic shock, and the △VTI is better than the △dIVC in assessing volume responsiveness.

A clinical study of the evaluation of hemodynamic status in mechanically ventilated critically ill patients by continuous non-invasive arterial pressure monitor / 中华危重病急救医学

Objective To evaluate the difference and correlation between continuous non-invasive arterial pressure (CNAP) monitor and pulse indicated continuous cardiac output (PiCCO) monitor on determination of hemodynamic parameters in mechanically ventilated critically ill patients, and to assess the feasibility of non-invasive monitoring of hemodynamics with CNAP. Methods A prospective observation self-control study was conducted. The critically ill patients with mechanical ventilation who needed hemodynamics monitoring, and admitted to the fourth department of intensive care unit (ICU) of Fujian Provincial Hospital from June 2018 to March 2019 were enrolled. PiCCO catheter were inserted immediately after admission, the hemodynamic indexes were measured by thermodilution method, and mean arterial pressure (MAPPiCCO), cardiac index (CIPiCCO), pulse pressure variation rate (PPVPiCCO) and systemic vascular resistance index (SVRIPiCCO) were obtained at 0 hour and 24 hours respectively. Meanwhile, the above indexes (MAPCNAP, CICNAP, PPVCNAP and SVRICNAP) were measured with CNAP. All measurements were repeated thrice and average values were reported. The differences in above parameters between the two methods were evaluated. Pearson test was used for the correlation analysis and Bland-Altman analysis method was used for consistency test. Results Thirty-eight patients were enrolled into this study. One patient died within 24 hours was excluded, 2 patients were excluded due to withdrawing treatment within 24 hours, 2 patients were excluded because of atrial fibrillation, and 1 patient's data was lost due to technical problems. Thus, data from 32 patients were available for final analysis. There were 12 females and 20 males, aging 26-84 years old with the mean of (66.8±19.1) years old, body mass index (BMI) of (23.7±3.9) kg/m2, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score of 19.5±5.3, sepsis-related organ failure assessment (SOFA) score of 9.7±4.1. There were no significant differences in CI or PPV between CNAP and PiCCO groups [CI (mL·s-1·m-2): 59.8±12.6 vs. 58.5±14.2, PPV: (14.7±6.8)% vs. (14.0±6.8)%, both P > 0.05]. MAP and SVRI measured by CNAP were significantly higher than those measured by PiCCO [MAP (mmHg, 1 mmHg = 0.133 kPa):65.6±9.4 vs. 60.1±9.2, SVRI (kPa·s·L-1·m-2): 206.2±53.9 vs. 179.5±57.8, both P < 0.01]. The correlation analysis showed that MAP, CI, PPV and SVRI measured by the two methods were significantly positively correlated (r value was 0.624, 0.864, 0.835 and 0.655 respectively, all P < 0.05). Bland-Altman analysis showed that CNAP and PiCCO had a good consistency for the measurement of CI and PPV, the average differences were 1.2 mL·s-1·m-2 and 0.5% respectively, while the 95% confidence interval (95%CI) were -12.8-15.3 mL·s-1·m-2 and -7.1%-8.2% respectively. However, the consistency of MAP and SVRI measured by those two methods was poor, the average differences were 5.5 mmHg and 26.8 kPa·s·L-1·m-2 respectively, while the 95%CI was -10.4-21.3 mmHg and -64.5-118.0 kPa·s·L-1·m-2 respectively. Conclusion CNAP was comparable with PiCCO when monitoring CI and PPV in mechanically ventilated critically ill patients; while the results of MAP and SVRI might be inaccurate, which should be interpreted correctly and carefully.

A clinical study of the evaluation of hemodynamic status in mechanically ventilated critically ill patients by continuous non-invasive arterial pressure monitor / 中华危重病急救医学

Objective To evaluate the difference and correlation between continuous non-invasive arterial pressure (CNAP) monitor and pulse indicated continuous cardiac output (PiCCO) monitor on determination of hemodynamic parameters in mechanically ventilated critically ill patients, and to assess the feasibility of non-invasive monitoring of hemodynamics with CNAP. Methods A prospective observation self-control study was conducted. The critically ill patients with mechanical ventilation who needed hemodynamics monitoring, and admitted to the fourth department of intensive care unit (ICU) of Fujian Provincial Hospital from June 2018 to March 2019 were enrolled. PiCCO catheter were inserted immediately after admission, the hemodynamic indexes were measured by thermodilution method, and mean arterial pressure (MAPPiCCO), cardiac index (CIPiCCO), pulse pressure variation rate (PPVPiCCO) and systemic vascular resistance index (SVRIPiCCO) were obtained at 0 hour and 24 hours respectively. Meanwhile, the above indexes (MAPCNAP, CICNAP, PPVCNAP and SVRICNAP) were measured with CNAP. All measurements were repeated thrice and average values were reported. The differences in above parameters between the two methods were evaluated. Pearson test was used for the correlation analysis and Bland-Altman analysis method was used for consistency test. Results Thirty-eight patients were enrolled into this study. One patient died within 24 hours was excluded, 2 patients were excluded due to withdrawing treatment within 24 hours, 2 patients were excluded because of atrial fibrillation, and 1 patient's data was lost due to technical problems. Thus, data from 32 patients were available for final analysis. There were 12 females and 20 males, aging 26-84 years old with the mean of (66.8±19.1) years old, body mass index (BMI) of (23.7±3.9) kg/m2, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score of 19.5±5.3, sepsis-related organ failure assessment (SOFA) score of 9.7±4.1. There were no significant differences in CI or PPV between CNAP and PiCCO groups [CI (mL·s-1·m-2): 59.8±12.6 vs. 58.5±14.2, PPV: (14.7±6.8)% vs. (14.0±6.8)%, both P > 0.05]. MAP and SVRI measured by CNAP were significantly higher than those measured by PiCCO [MAP (mmHg, 1 mmHg = 0.133 kPa):65.6±9.4 vs. 60.1±9.2, SVRI (kPa·s·L-1·m-2): 206.2±53.9 vs. 179.5±57.8, both P < 0.01]. The correlation analysis showed that MAP, CI, PPV and SVRI measured by the two methods were significantly positively correlated (r value was 0.624, 0.864, 0.835 and 0.655 respectively, all P < 0.05). Bland-Altman analysis showed that CNAP and PiCCO had a good consistency for the measurement of CI and PPV, the average differences were 1.2 mL·s-1·m-2 and 0.5% respectively, while the 95% confidence interval (95%CI) were -12.8-15.3 mL·s-1·m-2 and -7.1%-8.2% respectively. However, the consistency of MAP and SVRI measured by those two methods was poor, the average differences were 5.5 mmHg and 26.8 kPa·s·L-1·m-2 respectively, while the 95%CI was -10.4-21.3 mmHg and -64.5-118.0 kPa·s·L-1·m-2 respectively. Conclusion CNAP was comparable with PiCCO when monitoring CI and PPV in mechanically ventilated critically ill patients; while the results of MAP and SVRI might be inaccurate, which should be interpreted correctly and carefully.

A clinical study of the evaluation of hemodynamic status in mechanically ventilated critically ill patients by continuous non-invasive arterial pressure monitor / 中华危重病急救医学

Objective@#To evaluate the difference and correlation between continuous non-invasive arterial pressure (CNAP) monitor and pulse indicated continuous cardiac output (PiCCO) monitor on determination of hemodynamic parameters in mechanically ventilated critically ill patients, and to assess the feasibility of non-invasive monitoring of hemodynamics with CNAP.@*Methods@#A prospective observation self-control study was conducted.The critically ill patients with mechanical ventilation who needed hemodynamics monitoring, and admitted to the fourth department of intensive care unit (ICU) of Fujian Provincial Hospital from June 2018 to March 2019 were enrolled. PiCCO catheter were inserted immediately after admission, the hemodynamic indexes were measured by thermodilution method, and mean arterial pressure (MAPPiCCO), cardiac index (CIPiCCO), pulse pressure variation rate (PPVPiCCO) and systemic vascular resistance index (SVRIPiCCO) were obtained at 0 hour and 24 hours respectively. Meanwhile, the above indexes (MAPCNAP, CICNAP, PPVCNAP and SVRICNAP) were measured with CNAP. All measurements were repeated thrice and average values were reported. The differences in above parameters between the two methods were evaluated. Pearson test was used for the correlation analysis and Bland-Altman analysis method was used for consistency test.@*Results@#Thirty-eight patients were enrolled into this study. One patient died within 24 hours was excluded, 2 patients were excluded due to withdrawing treatment within 24 hours, 2 patients were excluded because of atrial fibrillation, and 1 patient's data was lost due to technical problems. Thus, data from 32 patients were available for final analysis. There were 12 females and 20 males, aging 26-84 years old with the mean of (66.8±19.1) years old, body mass index (BMI) of (23.7±3.9) kg/m2, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score of 19.5±5.3, sepsis-related organ failure assessment (SOFA) score of 9.7±4.1. There were no significant differences in CI or PPV between CNAP and PiCCO groups [CI (mL·s-1·m-2): 59.8±12.6 vs. 58.5±14.2, PPV: (14.7±6.8)% vs. (14.0±6.8)%, both P > 0.05]. MAP and SVRI measured by CNAP were significantly higher than those measured by PiCCO [MAP (mmHg, 1 mmHg = 0.133 kPa): 65.6±9.4 vs. 60.1±9.2, SVRI (kPa·s·L-1·m-2): 206.2±53.9 vs. 179.5±57.8, both P < 0.01]. The correlation analysis showed that MAP, CI, PPV and SVRI measured by the two methods were significantly positively correlated (r value was 0.624, 0.864, 0.835 and 0.655 respectively, all P < 0.05). Bland-Altman analysis showed that CNAP and PiCCO had a good consistency for the measurement of CI and PPV, the average differences were 1.2 mL·s-1·m-2 and 0.5% respectively, while the 95% confidence interval (95%CI) were -12.8-15.3 mL·s-1·m-2 and -7.1%-8.2% respectively. However, the consistency of MAP and SVRI measured by those two methods was poor, the average differences were 5.5 mmHg and 26.8 kPa·s·L-1·m-2 respectively, while the 95%CI was -10.4-21.3 mmHg and -64.5-118.0 kPa·s·L-1·m-2 respectively.@*Conclusion@#CNAP was comparable with PiCCO when monitoring CI and PPV in mechanically ventilated critically ill patients; while the results of MAP and SVRI might be inaccurate, which should be interpreted correctly and carefully.

Effect of goal-directed therapy bundle based on PiCCO parameters to the prevention and treatment of acute kidney injury in patients after cardiopulmonary bypass cardiac operation: a prospective observational study / 中华危重病急救医学

Objective To explore the effect of goal-directed therapy bundle based on pulse-indicated continuous cardiac output (PiCCO) parameters to the prevention and treatment of acute kidney injury (AKI) in patients after cardiopulmonary bypass cardiac operation. Methods A prospective observational study was conducted. The adult patients with selective cardiopulmonary bypass cardiac operation admitted to the Third People's Hospital of Chengdu from December 2015 to January 2018 were enrolled. All patients were divided into two groups based on informed consent for PiCCO monitor at the time of admission to the intensive care unit (ICU): regular monitoring and treatment group (group A) and goal-directed therapy group based on PiCCO parameters (group B). In group A, the restrictive capacity management strategy was implemented to maintain the mean arterial pressure (MAP) > 65 mmHg (1 mmHg = 0.133 kPa) and the central venous pressure (CVP) between 8 mmHg and 10 mmHg. In group B, volume and hemodynamic status were optimized depending on PiCCO parameters to a goal of cardiac index (CI) > 41.68 mL·s-1·m-2, global end diastolic volume index (GEDVI) > 700 mL/m2 or intrathoracic blood volume index (ITBVI) > 850 mL/m2, extravascular lung water index (EVLWI) < 10 mL/kg, and MAP > 65 mmHg. Then the changes in hemodynamics and different prognosis of the patients in two groups were observed. Risk factors affecting the AKI were analyzed by Logistic regression. Results 171 cases were included, with 68 in group A and 103 in group B. There were no significant differences in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), operation ways, operation time, cardiopulmonary bypass time, intraoperative dominant liquid equilibrium quantity, the use of intra-aortic balloon counterpulsation (IABP) during operation, and serum creatinine (SCr) level at the time of admission to ICU between the two groups. There were no significant differences in CVP within 24 hours after admission to ICU between the two groups. MAP in group B was significantly higher than that in group A at 8 hours and 16 hours after ICU admission (mmHg: 68.9±6.3 vs. 66.7±5.1, 69.0±4.9 vs. 67.0±5.3, both P < 0.05). Sequential organ failure assessment (SOFA) score in group B was significantly lower than that in group A at 24 hours after ICU admission (5.7±2.2 vs. 6.9±2.8, P < 0.05). Dominant liquid equilibrium quantity in group B was significant higher than that in group A at 24 hours after ICU admission (mL/kg: 7.1±6.2 vs. -0.1±8.2, P < 0.01), but there was no significant difference of that between groups at 48 hours and 72 hours after ICU admission. Compared with group A, incidence of combination with AKI during 72 hours after ICU admission was significantly decreased in group B [48.5% vs. 69.1%; odds ratio (OR) =0.422, 95% confidence interval (95%CI) = 0.222-0.802, P < 0.05], and incidence of moderate to severe AKI was also significantly decreased in group B (19.4% vs. 35.3%; OR = 0.442, 95%CI = 0.220-0.887, P < 0.05). There was no significant difference in usage of continuous renal replacement therapy (CRRT) after ICU admission between both groups (group A was 4.4%, group B was 4.9%, P > 0.05). It was shown by correlation analysis that only MAP and CI at 8 hours after ICU admission were significantly negatively correlated with AKI (MAP and AKI: r = -0.697, P = 0.000;CI and AKI: r = -0.664, P = 0.000). It was shown by Logistic regressive analysis that the MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI at 72 hours after ICU admission (MAP:OR = 0.736, 95%CI = 0.636-0.851, P = 0.000; CI: OR = 0.006, 95%CI = 0.001-0.063, P = 0.000). There were no significant differences in the duration of mechanical ventilation, the length of ICU stay, the post-operation complications (except AKI), 7-day and 28-day mortality between the two groups. Conclusions Goal-directed therapy bundle based on PiCCO parameters reduced the incidence of AKI in patients after cardiopulmonary bypass cardiac operation and improved the severity of systemic disease. However, it did not reduce the duration of mechanical ventilation, length of ICU stay, the incidence of complications (except AKI), short-term mortality. The MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI in patients after cardiopulmonary bypass cardiac operation.

The influence of continuous veno-venous hemofiltration on cardiac output value monitored by transpulmonary thermodilution technique in critical patients / 中华危重病急救医学

Objective To investigate the influence of continuous veno-venous hemofiltration (CVVH) on cardiac output (CO) value and parameters of hemodynamics monitored by transpulmonary thermodilution technique in critical patients. Methods A prospective cohort study was conduced. Sixty-two critical patients admitted to intensive care unit (ICU) of Zunyi Medical College Affiliated Hospital from January 2011 to October 2015 were enrolled. All of the patients received CVVH through femoral vein puncture catheter. The CO value was monitored before CVVH operation, immediately after CVVH operation (8 ℃ normal saline was injected immediately after the output of blood from the arterial end), 5 minutes after operation, the time at the sudden interruption (press pause key after 10 minutes of operation) and resumed immediately, 15 minutes and 30 minutes after operation by pulse-indicated continuous cardiac output (PiCCO) with transpulmonary thermodilution method. The changes in heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), and blood temperature were observed at all time points. Results From CVVH before start to 5 minutes thereafter, CO values were not significantly changed in patients, fluctuating in 6.96 (7.33, 8.67)-6.98 (6.43, 7.45) L/min. When CVVH was suddenly interrupted, CO value was immediately increased to the peak 8.04 (7.36, 8.77) L/min, which showed statistically significant difference as compared with other time points (all P < 0.01). Immediately after the CVVH recovery from interruption, the CO value dropped to 4.71 (4.14, 7.26) L/min, and it was significantly lower than those at other time points (all P < 0.01). With the CVVH recovery, the patients' CO value was gradually restored to the stable operation ahead of interruption [4.71 (4.14, 7.26)-6.85 (6.08, 7.26) L/min]. During CO monitoring, HR, MAP, CVP and blood temperature of the patients were at the same level, and no significant changes were founded. Conclusions CVVH interruption of immediate PiCCO monitoring CO value were significantly increased, immediately after the CVVH recovery the CO value were significantly reduced, and the normal operation of CVVH did not affect the CO value monitoring. Hemodynamics and blood temperature of all patients were stable during CVVH.

Comparison of ultrasonic cardiac output monitor and pulse indicated continuous cardiac output monitor on determination of hemodynamic parameters in critical patients / 中华危重病急救医学

Objective To evaluate the difference and correlation between ultrasonic cardiac output monitor (USCOM) and pulse indicated continuous cardiac output (PiCCO) monitor on determination of hemodynamic parameters in critical patients.Methods A prospective observation self-control study was conducted.The critical patients who need hemodynamics monitoring,and admitted to Department of Critical Care Medicine of Peking University People's Hospital from March 2013 to December 2015 were enrolled.Cardiac output (CO),cardiac index (CI),stroke volume (SV),and stroke index (SI) were determined by PiCCO using thermodilution method at immediately (0 hour) and 24 hours after successful location of PiCCO catheter for 3 times then the above indexes were measured with USCOM,and the average values were chosen for statistical analysis.The differences in above parameters between the two methods,and the correlation of the parameters monitored by two methods were evaluated by Pearson linear correlation method,the consistency test was conducted by Bland-Altman method.Results In 31 critical patients enrolled,there were 18 males and 13 females,aging 29-89 years old with the mean of (48.1 ± 36.3) years,body mass of (68.7 ± 17.5) kg,and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score of 21.2 ± 3.1.CO,CI,SV,and SI detected by USCOM were significantly higher than those detected by PiCCO [CO (L/min):6.32 ± 1.98 vs.5.86 ± 1.72,t =4.887,P =0.000;CI (mL· s-1· m-2):61.68 ± 20.17 vs.56.84± 17.34,t =5.189,P =0.000;SV (mL):61.9 ± 19.7 vs.57.0± 16.9,t =3.977,P =0.000;SI (mL/m2):36.84 ± 12.67 vs.33.33 ± 10.79,t =4.278,P =0.000].It was shown by correlation analysis that CO,CI,SV,and SI monitored by USCOM and PiCCO was positively correlated (R2 value was 0.795,0.798,0.837,and 0.827,respectively,all P =0.000).It was shown by Bland-Altman analysis that the mean CO change (ΔCO) from 0 hour to 24 hours was 0.1 L/min,and the 95％ confidence interval was-0.62 to 0.80.Conclusion There was significant difference in the comparison of hemodynamics parameters monitored by USCOM and PiCCO respectively in critical patients,the overall values monitored by USCOM were higher than those monitored by PiCCO monitoring,but the correlations were good.

Clinical feature of severe hand, foot and mouth disease with acute pulmonary edema in pediatric patients / 中华危重病急救医学

ObjectiveTo explore the clinical feature of severe hand, foot and mouth disease (HFMD) in pediatric patients, and to observe the hemodynamic changes in those with acute pulmonary edema.Methods A prospective observation study was conducted. Thirty-five severe HFMD pediatric patients with acute pulmonary edema admitted to the intensive care unit (ICU) and Department of Pediatric of First People's Hospital of Foshan from May 2008 to September 2014 were enrolled. The clinical features were thoroughly investigated. Hemodynamic data were monitored by pulse-indicated continuous cardiac output (PiCCO) in 5 cases, and the changes in PiCCO parameters were observed at ICU admission (0 hour), and 24, 48, 96 hours after treatment.Results Thirty-five patients who met the diagnostic standard of severe HFMD were enrolled, including 22 male and 13 female, aged from 7 months to 4 years. Six patients were younger than 1 year, 13 1-2 years, 12 2-3 years, and 4 patients 3-4 years old. The most common time of occurrence of pulmonary edema was 3-4 days after the onset of the disease. Fever and central nervous system symptoms were found in all the patients, and examination of the cerebral spinal fluid (CSF) revealed non-bacterial inflammatory changes. PiCCO results showed a tendency of lowering of heart rate (HR), systemic vascular resistance index (SVRI), and extravascular lung water index (EVLWI) after the treatment, and the values obtained at 96 hours were significantly lower than those at 0 hour [HR (bpm): 119.0±14.7 vs. 200.8±19.7, SVRI (kPa·s·L-1·m-2):148.9±14.6 vs. 209.6±58.7, EVLWI (mL/kg): 10.5±1.9 vs. 34.8±10.8,P< 0.05 orP< 0.01], global end-diastolic volume index (GEDVI) was also gradually decreased without significant differences among all the time points, together with a tendency of increase in stroke volume index (SI) and cardiac index (CI). The values of the parameters at 96 hours were significantly higher than those at 0 hour [SI (mL/m2): 38.5±6.5 vs. 17.4±2.8, CI (mL·s-1·m-2): 75.0±8.0 vs. 55.5±8.5, bothP< 0.01]. Left atrium was found to be enlarged, and left ventricular systolic function decreased in two patients by cardiac ultrasonic. Four out of 35 patients died, and functional disability of extremities was found in 1 patient. Other patients were cured and discharged without any sequelae.Conclusions Severe HFMD complicated by acute pulmonary edema is a perilous condition in children, accompanied commonly by pathologic changes in central nervous system and systolic dysfunction of left ventricle. According to the results with PiCCO monitoring, HFMD patients suffering from acute pulmonary edema may be of cardiac origin in addition to neurogenic origin.

Clinical studies of surviving sepsis bundles according to PiCCO on septic shock patients / 中华危重病急救医学

Objective To explore the effect of early goal-directed therapy (EGDT) according to pulse indicated continuous cardiac output (PiCCO) on septic shock patients.Methods Eighty-two septic shock patients in Subei People's Hospital of Jiangsu Province from January 2009 to December 2012 were enrolled and randomly divided into two groups using a random number table,standard surviving sepsis bundle group (n=40) and modified surviving sepsis bundles group (n =42).The patients received the standard EGDT bundles in standard surviving sepsis bundle group.PiCCO catheter was placed in modified surviving sepsis bundles group.Fluid resuscitation was guided by intrathoracic blood volume index (ITBVI) with the aim of 850-1 000 mL/m2.Dobutamine was used to improve the heart function according to left ventricular contractile index (dPmax) and stroke volume index (SVI).The mean arterial blood pressure (MAP) was maintained 65 mmHg (1 mmHg=0.133 kPa) or above with norepinephrine.Extra-vascular lung water was monitored for the titration of liquid and diuretics.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,the number of patients needed vasopressor,serum procalcitonin (PCT),lactic acid and lactate extraction ratio,the amount of fluid resuscitation,duration of mechanical ventilation,duration of intensive care unit (ICU) stay,hospital mortality were recorded in both groups.Results After treatment,the APACHE Ⅱ score,SOFA score and the number of patients needed vasopressor were gradually reduced in both groups,and those in modified surviving sepsis bundle group were significantly lower than those of standard sepsis bundle group at 72 hours (APACHE Ⅱ score:13.1 ± 6.5 vs.20.9 ± 7.5,SOFA score:8.8 ± 4.3 vs.14.6 ± 4.9,the number of patients needed vasopressor:8 vs.17,all P＜0.05).Arterial blood lactate clearance rate was gradually increased after treatment in both groups.Lactate clearance rate in modified surviving sepsis bundle group was significantly higher than that of standard surviving sepsis bundle group [6 hours:(18.2 ± 8.3)％ vs.(10.8 ± 7.5)％,t=-6.036,P=0.001 ; 12 hours:(22.6 ± 7.3)％ vs.(12.4 ± 8.1)％,t=-4.536,P=0.001 ; 24 hours:(27.8 ± 5.6)％ vs.(16.4 ± 9.5)％,t=-5.882,P=0.000].The amount of fluid resuscitation within 6 hours in modified surviving sepsis bundle group increased significantly compared with standard surviving sepsis bundle group (mL:3 608 ± 715 vs.2 809 ± 795,t=-3.865,P=0.033).The amount of fluid resuscitation within 24,48 and 72 hours in modified surviving sepsis bundle group was significantly less than that of standard modified surviving sepsis bundle group with the nadir at 72 hours (mL:918 ± 351 vs.1 805 ± 420,t=5.907,P=0.037).Duration of mechanical ventilation (hours:98.4 ± 20.3 vs.143.3 ± 29.6,t=9.766,P=0.001) and ICU stay (days:7.1 ± 3.1 vs.9.5 ± 2.5,t=2.993,P=0.004) were significantly reduced in modified surviving sepsis bundle group compared with standard surviving sepsis bundle group.The hospital mortality in modified surviving sepsis bundle group was slightly lower than that in standard surviving sepsis bundle group [16.7％(7/42)比 17.5％(7/40),x2=0.010,P=0.920].Conclusions Modified surviving sepsis bundle treatment according PiCCO can reduce the severity of disease in patients with septic shock,can make more accurately guide fluid resuscitation,and can reduce lung water and duration of mechanical ventilation and ICU stay.It has great clinical significance.

The significance of non invasive cardiac output monitoring system on evaluating circulatory and respiratory function in pig with acute respiratory distress syndrome / 中华危重病急救医学

Objective To investigate the effect of non invasive cardiac output monitoring(NICO)system in pig model with acute respiratory distress syndrome(ARDS),and to provide experimental basis for clinical application. Methods Eleven anaesthetized and ventilated ARDS male pig models were induced by intravenously infusing 0.2 mL/kg oleic acid. Lung recruitment was condocted by pressure control ventilation on pigs with ARDS. The optimal positive end-expiratory pressure(PEEP)was determined by optimal dead space fraction〔the ratio of dead space to tidal volume(VD/VT)〕. Cardiac output(CO)was determined by NICO,the respiratory function was monitored, and the VD/VT,dynamic compliance(Cdyn),oxygenation index(PaO2/FiO2),the volume of alveolar ventilation(Valv) and arterial blood oxygen saturation(SaO2)were recorded before infusing oleic acid,after stabilization of ARDS model and at optimal PEEP level,and the intrapulmonary shunt fraction(Qs/Qt)was calculated. CO was also determined by application of pulse indicated continuous cardiac output(PiCCO),and the linear regression analysis between CO determined by NICO and CO determined by PiCCO was conducted. Results Seven experimental ARDS pigs model were successfully established. The optimal PEEP identified by the lowest VD/VT method was(15.71±1.80)cmH2O (1 cmH2O=0.098 kPa). Compared with before infusing oleic acid,VD/VT and Qs/Qt after stabilization of ARDS model were significantly increased〔VD/VT:(72.29±8.58)% vs.(56.00±11.06)%,Qs/Qt:(21.04±15.05)%vs.(2.00±1.32)%,both P0.05). There was linear correlation between CO determined by NICO and CO determined by PiCCO(r2=0.925,P<0.001). Conclusions NICO technique provides a useful and accurate non invasive estimation of CO and respiratory function.VD/VT provided by NICO can titrate the optimal PEEP in patients with ARDS.