Résumé
Objective To analyze the clinical characteristics of bloodstream infection in patients with immune function inhibition. Methods A retrospective analysis was conducted. 234 patients with bloodstream infection admitted to intensive care unit (ICU) of the Affiliated Drum Tower Hospital of Nanjing University Medical School from August 1st in 2015 to December 31st in 2017 were enrolled. According to the immune function on the day of bloodstream infection, they were divided into normal immune function group [human leukocyte antigen DR (HLA-DR) > 30%, n = 144] and immunosuppression group (HLA-DR ≤30%, n = 90). The gender, age, primary disease, complication, acute physiology and chronic health evaluationⅡ (APACHEⅡ) with 24 hours after ICU admission, sequential organ failure assessment (SOFA) score, etiology, infection parameters on the day of bloodstream infection [peak temperature, white blood count (WBC), neutrophils ratio, procalcitonin (PCT), and C-reactive protein (CRP)] and prognosis parameters (bacterial clearance time, the length of ICU and hospital stay, 28-day mortality) between the two groups were analyzed. Results 234 patients were enrolled in the final analysis, including 132 males and 102 females, with an average age of (60.5±18.4) years old. Severe pneumonia and abdominal infection were the main causes of primary diseases. There was no significant difference in gender composition, age, APACHEⅡ, SOFA score, other complications and primary morbidity between the two groups except that the proportion of malignant tumors in the immunosuppressive group was higher than that in the normal immune function group [43.3% (39/90) vs. 41.7% (60/144), P < 0.05]. Compared with the normal immune function group, the Gram-positive cocci infection rate in the immunosuppressive group was significantly lowered [40.0% (36/90) vs. 56.2% (81/144)], Gram-negative bacilli infection rate [50.0% (45/90) vs. 39.6% (57/144)] and fungus infection rate [10.0% (9/90) vs. 4.2% (6/144)] were significantly increased (both P < 0.05). The levels of WBC, neutrophils ratio, and PCT on the day of bloodstream infection in the immunosuppressive group were significantly lower than those of normal immune function group [WBC (×109/L): 10.2±2.1 vs. 13.5±3.6, neutrophils ratio: 0.87±0.17 vs. 0.96±0.22, PCT (μg/L): 1.3±1.1 vs. 4.7±2.1, all P < 0.05], but no significant difference in the peak temperature (℃: 38.5±1.7 vs. 38.9±1.3) or CRP (mg/L: 134.0±42.6 vs. 164.0±55.8) was found as compared with normal immune function group (both P > 0.05). Compared with the normal immune function group, the bacterial clearance time in the immunosuppressive group was significantly prolonged (days: 16.0±10.1 vs. 12.3±4.7), 28-day mortality was significantly increased [61.1% (55/90) vs. 44.4% (64/144)] with statistical significances (both P < 0.05), but no significance was found in the length of ICU stay (days: 21.0±17.1 vs. 18.7±10.4) or the length of hospital stay (days: 36.0±28.1 vs. 33.8±16.8, both P > 0.05). Conclusion Gram-negative bacilli was the main pathogen of bloodstream infection in immunosuppressive patients, and the fungal infection rate was high, inflammation reaction was not obvious, bacterial clearance time was long, and prognosis was poor.
Résumé
Objective To examine the clinical characteristics and risk factors for acute kidney injury (AKI) in patients receiving donation after cardiac death liver transplantation during the immediate postoperative period.Methods Patients who underwent liver transplantation between July 2013 and January 2017 were study retrospectively.AKI was defined according to the criteria of Kidney Disease Improving Global Outcomes (KDIGO) guideline in the first 7 days following liver transplantation.Donor and graft variables,and recipient characteristics in the perioperative period were analyzed to identify the risk factors for development of AKI.Results Thirty-five (67.3％) of the 52 included patients developed AKI 7 days post-liver transplantation,including 16 (30.8％) in stage 1,5 (9.6％) in stage-2 and 14 (26.9％) in stage-3 with KDIGO guideline criteria.85.7％ (30/35) of AKI occurred within postoperative day 0 to day 2,and the renal function of 60.0％ (21/35) patients who developed AKI recovered within 3 days.Patients with AKI had a prolonged ICU stay (for AKI,7.4±6.5 days;for non-AKI,4.0 ± 2.1 days,P =0.037) and an increased likelihood of 28-day mortality after transplantation (for AKI,17.1％;for non-AKI,0).Significant risk factors for development of AKI were detected including donors' ICU stay＞7 days,recipients' preoperative model for end-stage liver disease (MELD) score ＞12,preoperative serum urea nitrogen＞4.9 mmol/L,intraoperative blood loss＞ 5 000 mL,intraoperative total fluid infusion＞ 11 000 mE and peak postoperative glutamic-oxaloacetic transaminase (AST)＞ 1 240 U/L.Logistic regression analysis showed that recipients' preoperative MELD score ＞ 12 (odds ratio 25.3,P =0.027) and peak postoperative AST ＞ 1 240 U/L (odds ratio 37.1,P =0.012) were independent risk factors for development of AKI after liver transplantation.Conclusion Liver transplantation is associated with a high frequency of AKI.Increased recipients' preoperative MELD score and peak postoperative AST are independent risk factors for development of early AKI after liver transplantation.
Résumé
Objective To analyze the main clinical features of human infection with H7N9 avian influenza complicated by acute respiratory distress syndrome (ARDS).Methods A retrospective analysis of complete clinical data of 9 cases of human infection with H7N9 avian influenza complicated by ARDS admitted from March 2013 to December 2014 admitted to Department of Critical Care Medicine of the Affiliated Drum Tower Hospital of Nanjing University Medical School was conducted.Results Nine patients' mean age was (46.3±12.3) years, male accounting for 66.7% (6/9). The main clinical features: ① In the duration of acute phase, high fever, cough, hemoptysis sputum, reduction of white blood cell count (WBC) and platelet count (PLT), and myocardial enzyme elevation were the features of the disease. Chest CT showed pulmonary consolidation and ground-glass like shadows. ② On admission, all their oxygenation indexes (PaO2/FiO2) were less than 200 mmHg (1 mmHg = 0.133 kPa) of which 66.7% (6/9) was less than 100 mmHg, mean (98.9±62.8) mmHg; 55.6% (5/9) required invasive mechanical ventilatory support; 77.8% (7/9) combined with shock, and hemodynamic monitoring showed peripheral vascular resistance was decreased. ③ There were secondary bloodstream infection in 5 cases and lung infection in 4 cases, accounting for 77.8% (7/9). ④ In 22.2% (2/9) patients, the virus relapsed after the anti-virus therapy was stopped for 7 days, then immediately antiviral treatment was used again, it was still effective.Conclusion Human infection with H7N9 avian influenza complicated by ARDS has typical clinical symptoms, laboratory tests and imaging features, often associated with distributive shock, and at the late stage, secondary pulmonary or blood infection and the virus resurgence may occur.