Predictive value of von Willebrand factor for venous thromboembolism in critically ill patients based on propensity score matching / 中华危重病急救医学

Objective:To analyze the predictive value of von Willebrand factor (vWF) for venous thromboembolism (VTE) of patients in intensive care unit (ICU) by using propensity score matching (PSM).Methods:Patients admitted to ICU of the Second Affiliated Hospital of Kunming Medical University from December 2020 to June 2022 who stayed in ICU for ≥72 hours and underwent daily bedside vascular ultrasound screening were included. Baseline data such as age, gender, primary disease, and chronic comorbidities were collected. Coagulation indexes before admission to ICU and 24 hours and 48 hours after ICU admission were collected, including prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), international normalized ratio (INR), fibrinogen (Fib), fibrin monomer (FM), vWF, D-dimer, antithrombin Ⅲ (ATⅢ), etc. Patients were divided into VTE group and non-VTE group according to whether they had VTE or not [diagnosis of VTE: patients underwent daily ultrasound screening of bedside blood vessels (both upper and lower limbs, visceral veins), and those suspected of having thrombosis were confirmed by ultrasonographer or pulmonary angiography]. Using PSM analysis method, the VTE group was used as the benchmark to conduct 1 : 1 matching of age, whether there was malignant tumor, whether there was infection, whether there was diabetes, and coagulation indicators before admission to ICU. Finally, the cases with balanced covariates between the two groups were obtained. The risk factors of VTE were analyzed by multivariate Logistic regression analysis. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of vWF in the occurrence of VTE in critically ill patients.Results:A total of 120 patients were enrolled, of which 18 (15.0%) were diagnosed with VTE within 72 hours after admission to ICU, and 102 (85.0%) were not found to have thrombus in ICU. Before PSM, there were significant differences in age, gender, proportion of malignant tumor and infection, and coagulation indexes between VTE group and non-VTE group. After PSM, 14 pairs were successfully matched, and the unbalanced covariables between the two groups reached equilibrium. Multivariate Logistic regression analysis showed that vWF was an independent risk factor for VTE at 48 hours after ICU admission in critically ill patients [odds ratio ( OR) = 1.165, 95% confidence interval (95% CI) was 1.000-1.025, P = 0.004]. ROC curve analysis showed that the area under the ROC curve (AUC) of vWF at 48 hours after ICU admission for predicting VTE was 0.782, 95% CI was 0.618-0.945, P = 0.007. When the optimal cut-off value was 312.12%, the sensitivity was 67.7% and the specificity was 93.0%. Conclusion:Dynamic monitoring of vWF is helpful to predict the occurrence of VTE in ICU patients, and vWF at 48 hours after ICU admission has certain value in predicting the occurrence of VTE.

Analysis of treatment for 360 critically ill pregnant and parturient women in intensive care unit / 中华危重病急救医学

Objective:To analyze the clinical characteristics and outcomes of critically ill pregnant and parturient women in intensive care unit (ICU), and to provide clinical experience for the subspecialty construction of critical obstetrics.Methods:The clinical data of critically ill pregnant and parturient women admitted to the department of critical care medicine, the Second Affiliated Hospital of Kunming Medical University from January 2011 to December 2019 were collected. The main reasons for maternal transfer to ICU, the causes of maternal death, and organ support measures, etc. were summarized.Results:A total of 39 567 critically ill pregnant and parturient women were admitted to the department of obstetrics in our hospital, and 360 were transferred to ICU, with an average ICU transfer rate of 0.91%. Since 2016, the number of obstetric admissions, the number of ICU transfers and the ICU transfer rate had increased significantly. The average age of severe maternals admitted to ICU was (30.9±5.7) years old. The average acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score was 7 (4, 10). The average length of ICU stay was 1 (1, 2) day. The average ventilator duration was 9.0 (3.0, 17.5) hours. The main delivery mode of pregnant women in ICU was cesarean section (84.72%). Forty-eight patients (13.33%) underwent hysterectomy, of which 42 (87.5%) due to postpartum hemorrhage. The top 3 causes of ICU admission were severe postpartum hemorrhage [36.94% (133/360)], hypertensive disorders of pregnancy [21.67% (78/360)], pregnancy with cardiac disease [15.00% (54/360)]. The leading cause of postpartum hemorrhage in women transferred to ICU was placental abnormality [63.98% (103/161)], followed by uterine atony [28.57% (46/161)]. The average blood loss was (4 019±2 327) mL within 24 hours after delivery, and the number of women who underwent hysterectomy due to postpartum hemorrhage decreased year by year. During the study period, there were 2 maternal deaths, which were indirect obstetric deaths, 3 cases were discharged against-advice (expected death), including 1 indirect death and 2 direct obstetric death; the mortality in ICU was 1.39% (5/360).Conclusions:The most common reasons for pregnant and parturient women to be admitted to ICU were severe postpartum hemorrhage and hypertensive disorders of pregnancy. The leading cause of postpartum hemorrhage was placental problem. Indirect obstetric deaths exceeded direct obstetric deaths, mainly due to pregnancy complicated with cardiac disease and severe pneumonia. ICU has become an important battlefield for rescuing critically ill maternal and an important guarantee for reducing the maternal mortality.

Severe influenza A (H1N1) in late pregnancy: a case report / 中华危重病急救医学

Pregnancy has increased susceptibility to H1N1 influenza virus infection. Maternal influenza infection is associated with increased risk of morbidity and mortality. A case of influenza A (H1N1) during late pregnancy (pregnancy 1, birth 0, pregnancy 30+2 weeks) was admitted to the Second Affiliated Hospital of Kunming Medical University on December 16th, 2018. The patient was set on mechanical ventilation with a FiO2 of 1.0, a positive end-expiratory pressure (PEEP) of 15 cmH2O (1 cmH2O = 0.098 kPa), and a tidal volume of 4-6 mL/kg (ideal body weight). However the pulse oxygen saturation (SpO2) could only be maintained at about 0.85. The disease was controlled by the treatments of anti-infection, mechanical ventilation, immune therapy, nutritional support, preventive anticoagulant treatment by heparin sodium, adequate negative fluid balance, and other organ support therapy. This article introduced the treatment process of the patient in detail, and provided experience for clinical treatment.

Severe influenza A (H1N1) in late pregnancy: a case report / 中华危重病急救医学

Pregnancy has increased susceptibility to H1N1 influenza virus infection. Maternal influenza infection is associated with increased risk of morbidity and mortality. A case of influenza A (H1N1) during late pregnancy (pregnancy 1, birth 0, pregnancy 30+2 weeks) was admitted to the Second Affiliated Hospital of Kunming Medical University on December 16th, 2018. The patient was set on mechanical ventilation with a FiO2 of 1.0, a positive end-expiratory pressure (PEEP) of 15 cmH2O (1 cmH2O = 0.098 kPa), and a tidal volume of 4-6 mL/kg (ideal body weight). However the pulse oxygen saturation (SpO2) could only be maintained at about 0.85. The disease was controlled by the treatments of anti-infection, mechanical ventilation, immune therapy, nutritional support, preventive anticoagulant treatment by heparin sodium, adequate negative fluid balance, and other organ support therapy. This article introduced the treatment process of the patient in detail, and provided experience for clinical treatment.

Effect of sufentanil on analgesia and sedation for ventilated critically ill patients / 中华危重病急救医学

Objective To compared analgesic effect of sufentanil and fentanyl in surgery patients during mechanical ventilation, and to explore the rational dosage of analgesic and sedative drugs. Methods A prospective randomized controlled trial was conducted. 600 postoperative critically ill patients underwent mechanical ventilation for 12-72 hours admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from April 2013 to March 2015 were enrolled. They were randomly divided into two groups, sufentanil and fentanyl was used for analgesia respectively, and 300 patients in each group. The initiate dosage of sufentanil and fentanil was 5 μg/h and 50 μg/h, and the dosage was adjusted. A postoperative pain score (Prince-Henry score) of 0-1, and Richmond agitation-sedation scale (RASS) score -1-0 were targeted. 1 mg/kg of propofol was used if patient could not fall in sleep or felt anxious after loading dose of sufentanil (5 μg) or fentanil (50 μg) for 5 minutes. The use of analgesic drugs, the proportion and dosage of propofol was observed in the two groups, and adverse reactions were recorded. Results The mean dose of sufentanil for analgesia was (0.07±0.02) μg·kg-1·h-1, and the mean dose of fentanyl was (0.67±0.12) μg·kg-1·h-1. The patients in the two groups received propofol 40 to 60 mg/h in night, and the use proportion of propofol in sufentanil group was slightly less than that in fentanyl group (25.7% vs. 28.3%), but the difference was not statistically significant (P > 0.05). It was found by subgroup age analysis that, the mean analgesic dose of sufentanil or fentanyl in patients over 80 years old was lower than that in 70-79 years, 60-69 years and < 60 years groups but without statistical significance. There were 11 cases (3.7%) and 21 cases (7.0%) patients suffered from respiratory depression in sufentanil group and fentanyl group, respectively, without statistical significance (P = 0.069). The hemodynamics of patients in two groups was stable during analgesia, and no accidental extubation due to restlessness was found. Conclusions A smaller dose of sufentanil for postoperative patients underwent mechanical ventilation with satisfactory analgesia was (0.07±0.02) μg·kg-1·h-1, but need to be added with 40-60 mg/h and a small dose of propofol to improve anxiety and sleep. The proportion of patients needing propofol addition was slightly lower than that of fentanyl.

Early diagnosis value of plasma NGAL,CysC on detection of surgical critical illness patients with AKI / 重庆医学

Objective To assess and compare the roles of plasma concentrations of neutrophil gelatinase associated lipocalin (NGAL) and Cystatin C for early diagnosis and treatment of septic acute kidney injury (AKI) in adult Surgical critically ill patient . Methods One hundred patients were divided into two groups ,the group of 63 cases of AKI and AKI group of 37 cases ,plasma NGAL and Cystatin C level of the 2 groups were determined by the method of enzyme‐linked immunosorbent (ELISA) ,latex en‐hanced immune turbidimetry (PETIA) respectively on arrival in the surgical intensive care unit(SICU) (T0 ) and 24 h after arrival in SICU(T1 ) .Results Compared with patients in non AKI group ,both plasma NGAL and Cystatin C level of patients in AKI group on T0 and T1 increased significantly ,the difference between the two groups had significant statistical difference (P<0 .01);Although ,plasma NGAL on T1 performed less well (AUC=0 .69) ,with a threshold value of 92 ng/mL(70 .3% sensitivity ,57%specificity) .Plasma NGAL showed significant discrimination for AKI diagnosis (AUC=0 .85) with a threshold value of 65 .95 ng/mL(81 .8% sensitivity ,76 .2% specificity) on T0 .Both plasma Cystatin C on T0 and T1 worked well for the diagnosis of AKI (AUC=0 .90 ,0 .88 ,thresholds 1 .49 and 1 .47 mg/L ,respectively) ,with diagnostic sensitivity of 89 .2% ,82 .5% respectively ,speci‐ficity of 83 .8% ,76 .2% respectively .Conclusion Plasma NGAL and Cystatin C are useful markers in predicting AKI in surgical critically ill patients ,the early diagnosis value of plasma Cystatin C for AKI is better than plasma NGAL on arrival in the surgical intensive care unit .