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Objective To investigate the effect of midazolam on inflammatory response in patients with moderate and severe craniocerebral injury and its protective effect on the brain and mechanism.Methods A prospective study was conducted.One hundred and twenty patients with moderate and severe craniocerebral injury admitted to the Intensive Care Unit (ICU) of Jiangsu Subei Peoples' Hospital from April 2013 to July 2016 were enrolled,and they were divided into a conventional treatment group (58 cases) and a midazolam group (62 cases) according to the random number table method.Both groups were given conventional western medicine treatment,and in cases with surgical indications,operations were performed;in midazolam group,additionally intravenous injection of midazolam 2-3 mg was given firstly,and then continuous intravenous infusion of the drug 0.05-0.10 mg· kg-1· h-1 was applied by a pump,and in operative patients,the above management was given 3 hours after operation.The mean arterial pressure (MAP),heart rate (HR),Riker sedation agitation score (SAS) and electroencephalogram bispectral index (BIS) were measured before and after treatment for 24,48 and 72 hours,respectively.The levels of interleukin-6 (IL-6) and soluble nerve chemotactic protein (sFkn) in plasm and cerebrospinal fluid (CSF) were measured by double antibody sandwich enzyme linked immunosorbent assay (ELISA) at each time point;the incidence of epilepsy and 28-day mortality were recorded.Results Before and after treatment,the MAP and HR in the two groups of patients were stable,the difference being not statistically significant (both P ＞ 0.05).Compared with those before treatment,after treatment the SAS score and BIS in two groups of patients were gradually decreased,and at 72 hours reached the lowest levels (SAS score:conventional treatment group was 3.8 ± 1.0 vs.5.7 ± 2.0,midazolam group was 3.6 ± 0.9 vs.5.8 ± 1.7;BIS:conventional treatment group was 69± 12 vs.82± 12,midazolam group was 72± 15 vs.82± 12,all P ＜ 0.05),but there were no significant differences between the two groups (all P ＞ 0.05),suggesting that the two groups had achieved the desired goal of sedation.ELISA results showed:compared with those before treatment,after treatment for 24 hours,the CSF IL-6,sFkn and plasm sFkn levels were temporarily increased in short term,and then showed a tendency of gradually decreasing,and the plasm IL-6 presented persistently descending in the conventional treatment group,while in the midazolam group,since 24 hours after treatment,each index showed a trend of decrease and continued to 72 hours.After treatment at each time point,the CSF and plasm levels of IL-6 and sFkn were significantly lower in midazolam group than those of the conventional treatment group,and reached to the minimal levels at 72 hours [CSF:IL-6 (ng/L) was 251.6 ± 145.7 vs.347.3 ± 146.4,sFkn (ng/L):289.7 ± 79.3 vs.423.6 ± 132.8;plasm:IL-6 (ng/L) was 54.4± 27.3 vs.85.6 ± 41.8,SFkn (ng/L):919.9±426.3 vs.1 199.4 ± 414.8,all P ＜ 0.05].The incidence of epilepsy in the midazolam group was obviously lower than that in the conventional treatment group [1.61％ (1/62) vs.10.34％ (6/58),P ＜ 0.05],but there was no significant difference between midazolam group and the conventional treatment group in the 28-day mortality [11.29％ (7/62) vs.10.34％ (6/58),P ＞ 0.05].Conclusion Midazolam can reduce the incidence of epilepsy in patients with moderate and severe traumatic brain injury,and its brain protective effect may be related to the decrease of CSF and plasm IL-6 and sFkn levels.
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Objective To evaluate the value of transpulmonary pressure (Ptp) guided optimal positive end-expiratory pressure (PEEP) selection in patients with early acute respiratory distress syndrome (ARDS).Methods A prospective randomized self-control study was conducted.ARDS patients in the early stage (onset ≤3 days) undergoing intubation and mechanical ventilation admitted to intensive care unit (ICU) of Jiangsu Provincial Subei People's Hospital from December 2013 to December 2015 were enrolled.The PEEP level was regulated to 30 cmH2O (1 cmH2O =0.098 kPa) after recruitment maneuver,and then it was gradually decreased to 0 with lowering by 3 cmH2O every 5 minutes.The optimal PEEP was titrated by Ptp,lowest dead space fraction (VD/VT),highest static lung compliance (Cst),and optimal oxygenation,respectively.Parameters of respiratory mechanics and gas exchange were observed.Results Totally 28 patients with ARDS (including 17 male and 11 female) were included with the average age of (45 ± 12) years old,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score was 21 ± 9,oxygenation index (PaO2/FiO2) was (165 ± 76) mmHg (1 mmHg =0.133 kPa).① During decremental PEEP titration,Ptp was gradually decreased,and expiratory Ptp (Ptp-e) was more than zero [(1.3±0.3) cmH2O] when PEEP was (9.6 ± 2.3) cmH2O.Cst was initially improved until reaching a peak,and then deteriorated.Cst was highest [(50 ± 8) mL/cmH2O] when PEEP was (11.5 ± 2.4) cmH2O.PaO2/FiO2 reached the maximum [(312 ± 99) mmHg] at PEEP level of (18.0 ± 2.5) cmH2O.Compared with Ptp-e 3.00-5.99 cmH2O,PaO2/FiO2 was significantly decreased when Ptp-e became negative (all P ＜ 0.05).VD/VT was lowest (0.52 ±0.05) when PEEP was (10.1 ± 2.2) cmH2O.When compared with ventilation [inspiratory Ptp (Ptp-i) 0-2.99 cmH2O],it was significantly higher during high (Ptp-i ≥ 15 cmH2O,all P ＜ 0.05).② There were no statistically significant differences in the levels of optimal PEEP,Ptp-i and Ptp-e among Ptp,lowest VD/VT and highest Cst methods (all P ＞ 0.05),but they were significantly less than optimal oxygenation method (all P ＜ 0.05).Compared with baseline and the method of optimal oxygenation,Cst in other three PEEP titration methods including Ptp,lowest VD/VT and highest Cst was improved obviously (mL/cmH2O:46± 7,47±9,50± 8 vs.30± 8,35 ± 10,all P ＜ 0.05).PaO2/FiO2 (mmHg) in the method of Ptp and lowest VD/VT were higher than the baseline (252 ± 86,258 ± 72 vs.165 ± 76,both P ＜ 0.05),but significantly lower than that of optimal oxygenation method (312 ± 99,both P ＜ 0.05),and did not significantly differ from that of highest Cst (268± 85,both P ＞ 0.05).Compared with baseline and the method of optimal oxygenation,VD/Vr improved significantly in ventilated patients on PEEP targeting with Ptp and lowest VD/VT (0.53±0.05,0.52±0.05 vs.0.59±0.05,0.58±0.04,all P ＜ 0.05).Conclusion Titration the optimal PEEP level with the method of Ptp could promote collapse alveolar recruitment,improve oxygenation and lung compliance,decrease dead space ventilation,and will not cause alveolar excessive inflation in patients who undergoing mechanical ventilation with early ARDS.
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Objective To explore the prognostic value of arterial blood lactate (Lac) levels and lactate clearance rate (LCR) in the patients with septic shock.Methods A retrospective study was conducted.Clinical data of 94 septic patients admitted in the Department of Critical Care Medicine in Subei People's Hospital from January 2011 to June 2014 were analyzed.The arterial blood Lac levels at the moment of diagnosis of septic shock (incipient value,0 hour) and early-stage after treatment (3,6 and 24 hours) were reviewed,and individual LCR was calculated at 3,6,24 hours for each patient.According to the outcome in intensive care unit (ICU),patients were divided into survival group (n =48) and death group (n =46).The Lac and LCR at different time points in two groups were analyzed,and the relationships between them and outcome were analyzed.The receiver-operating characteristic (ROC) curve was plotted to assess the value of Lac and LCR at different time points for predicting the outcome.Results Lac level after treatment in survival group was significantly lower than incipient value,but there was no obvious change in death group.Compared with death group,early Lac levels (mmol/L) in survival group were significantly reduced (0 hour:3.80 ± 2.14 vs.5.75±3.21,3 hours:2.05± 1.04 vs.5.03±2.53,6 hours:1.80±0.77 vs.4.40±2.02,24 hours:1.35±0.43 vs.4.90 ± 2.72,P ＜ 0.05 or P ＜ 0.01),the LCR was significantly increased [3 hours:50.00 (72.35)％ vs.13.51 (20.67)％,6 hours:41.43 (58.42)％ vs.22.00 (22.31)％,24 hours:58.73 (29.94)％ vs.18.92 (47.28)％,P ＜ 0.05 or P ＜ 0.01].The Lac levels at all time points were positively correlated with the outcome,and 6-hour and 24-hour LCR were negatively correlated with the outcome.According to the incipient Lac level,patients were divided into low Lac group (Lac ＜ 2 mmol/L),mild Lac group (Lac 2-3 mmol/L) and high Lac group (Lac ≥ 4 mmol/L).The mortality in low Lac group,mild Lac group,high Lac group was gradually increased [23.07％ (6/26),50.00％ (8/16),61.54％ (32/52),x2=10.270,P =0.006].ROC curves demonstrated that the area under ROC curve (AUC) of 24-hour Lac was the largest,0.944,and it was more sensitive and specific in the prognosis evaluation (100％ and 78.3％,respectively).According to the cut-off value of 24-hour Lac as 2.35 mmol/L,patients were divided into high Lac and low Lac groups,and mortality rate in high Lac group was significantly higher than that in low Lac group [100.0％ (36/36) vs.17.24％ (10/58),x2=30.441,P =0.000].The AUC of 24-hour LCR was the largest,0.865,and it was more sensitive and specific for the prognosis evaluation (83.3％ and 91.3％,respectively).According to the cut-off value of 24-hour LCR as 36.8％,patients were divided into high LCR group and low LCR group,and mortality rate in low LCR group was significantly higher than that in high LCR group [84.00％ (42/50) vs.9.09％ (4/44),x2=26.278,P =0.000].Conclusion Early high Lac in patients with septic shock prompts a poor prognosis,and 24-hour Lac levels and LCR are indicators of assessment of clinical therapeutic effect and prognosis of patients with septic shock.