Epidemiology of Sepsis-3 in a sub-district of Beijing: secondary analysis of a population-based database / 中华医学杂志(英文版)

Background@#With the publication of Sepsis-3 definition, epidemiological data based on Sepsis-3 definition from middle-income countries including China are scarce, which prohibits understanding of the disease burden of this newly defined syndrome in these settings. The purpose of this study was to describe incidence and outcome of Sepsis-3 in Yuetan sub-district of Beijing and to estimate the incidence rate of Sepsis-3 in China.@*Methods@#The medical records of all adult residents hospitalized from July 1, 2012 to June 30, 2014 in Yuetan sub-district of Beijing were reviewed. Patients with sepsis-3 and severe sepsis/septic shock were identified. The incidence rates and mortality rate of sepsis-3 and sepsis/septic shock were calculated, incidence rates and in-hospital mortality rates were normalized to the population distribution in the 2010 National Census. Population incidence rate and case fatality rate between sexes were compared with the Z test, as the data conformed to Poisson distribution.@*Results@#Of the 21,191 hospitalized patients, 935 patients were diagnosed with Sepsis-3, and 498 cases met severe sepsis/septic shock criteria. The crude annual incidence rate of Sepsis-3 in Yuetan sub-district was 363 cases per 100,000 population, corresponding to standardized incidence rates of 236 cases per 100,000 population per year, respectively. The overall case fatality rate of Sepsis-3 was 32.0%, the crude population mortality rates of Sepsis-3 was 116 cases per 100,000 population per year, the standardized mortality rate was 67 cases per 100,000 population per year, corresponding to a speculative extrapolation of 700,437 deaths in China. The incidence rate and mortality rate of Sepsis-3 were significantly higher in males, elderly people, and patients with more comorbidities. The 62.1% of patients with Sepsis-3 had community-acquired infections, compared with 75.3% of infected patients without Sepsis-3 (P < 0.001). The most common infection in patients with Sepsis-3 was lower respiratory tract infection. When compared with patients with Sepsis-3, patients diagnosed as severe sepsis/septic shock were more likely to have higher case fatality rate (53.4% vs. 32.0%, P < 0.001)@*Conclusions@#This study found the standardized incidence rate of 236 cases per 100,000 person-year for Sepsis-3, which was more common in males and elderly population. This corresponded to about 2.5 million new cases of Sepsis-3 per year, resulting in more than 700,000 deaths in China.@*Clinical trial registration@#NCT02285257, https://clinicaltrials.gov/ct2/show/record/NCT02285257.

Epidemiology of Sepsis-3 in a sub-district of Beijing: secondary analysis of a population-based database / 中华医学杂志(英文版)

BACKGROUND@#With the publication of Sepsis-3 definition, epidemiological data based on Sepsis-3 definition from middle-income countries including China are scarce, which prohibits understanding of the disease burden of this newly defined syndrome in these settings. The purpose of this study was to describe incidence and outcome of Sepsis-3 in Yuetan sub-district of Beijing and to estimate the incidence rate of Sepsis-3 in China.@*METHODS@#The medical records of all adult residents hospitalized from July 1, 2012 to June 30, 2014 in Yuetan sub-district of Beijing were reviewed. Patients with sepsis-3 and severe sepsis/septic shock were identified. The incidence rates and mortality rate of sepsis-3 and sepsis/septic shock were calculated, incidence rates and in-hospital mortality rates were normalized to the population distribution in the 2010 National Census. Population incidence rate and case fatality rate between sexes were compared with the Z test, as the data conformed to Poisson distribution.@*RESULTS@#Of the 21,191 hospitalized patients, 935 patients were diagnosed with Sepsis-3, and 498 cases met severe sepsis/septic shock criteria. The crude annual incidence rate of Sepsis-3 in Yuetan sub-district was 363 cases per 100,000 population, corresponding to standardized incidence rates of 236 cases per 100,000 population per year, respectively. The overall case fatality rate of Sepsis-3 was 32.0%, the crude population mortality rates of Sepsis-3 was 116 cases per 100,000 population per year, the standardized mortality rate was 67 cases per 100,000 population per year, corresponding to a speculative extrapolation of 700,437 deaths in China. The incidence rate and mortality rate of Sepsis-3 were significantly higher in males, elderly people, and patients with more comorbidities. The 62.1% of patients with Sepsis-3 had community-acquired infections, compared with 75.3% of infected patients without Sepsis-3 (P < 0.001). The most common infection in patients with Sepsis-3 was lower respiratory tract infection. When compared with patients with Sepsis-3, patients diagnosed as severe sepsis/septic shock were more likely to have higher case fatality rate (53.4% vs. 32.0%, P < 0.001) CONCLUSIONS:: This study found the standardized incidence rate of 236 cases per 100,000 person-year for Sepsis-3, which was more common in males and elderly population. This corresponded to about 2.5 million new cases of Sepsis-3 per year, resulting in more than 700,000 deaths in China.@*CLINICAL TRIAL REGISTRATION@#NCT02285257, https://clinicaltrials.gov/ct2/show/record/NCT02285257.

Updates in timing of initiation of renal replacement therapy in patients with acute kidney injury / 解放军医学杂志

Acute kidney injury (AKI) is one of the most common serious complications in Intensive Care Unit (ICU),and also an independent risk factor for death.It is associated with a substantial increase in morbidity and mortality.AKI occurs in about 13 million people per year,and the mortality of AKI was 13.1％.A meta analysis showed that the incidence of AK1 was 0.99％-11.6％ in China.Renal replacement therapy (RRT) has become one of the conventional treatments for AKI patients,however the timing of RRT initiation in patients with AKI has not yet been defined.In this article,based on the two recent large randomized controlled trials (RCT),the timing to start or terminate the treatment are reviewed.

Prognostic Value of Initial Troponin Ⅰ Level in Non-cardiac Surgery Critically Ill Patients at Intensive Care Unit / 中国循环杂志

Objective: To evaluate the prognostic value of initial troponin Ⅰ (TnI) level in non-cardiac surgery critically ill patients at surgical intensive care unit (ICU). Methods: We consecutively observed non-cardiac surgery critically ill patients admitted in surgical ICU of our hospital from 2015-01-01 to 2015-12-31. TnI level was measured at the early ICU admission, general clinical data, previous history, acute physiology and chronic health evaluation (APACHE) Ⅱ score and mortality were compared between the patients with elevated TnI and normal TnI; TnI level at the early ICU admission, general clinical data, previous history and APACHE Ⅱ score were compared between survival patients and deceased patients. Risk factors for ICU mortality were studied by multivariable regression analysis;predictive values for initial TnI level and APACHE Ⅱ score in mortality were assessed by receiver operating curve (ROC). Results: A total of 1 193 patients were enrolled and 159 (13.3%) of them had TnI elevation upon ICU admission. Compared with normal TnI patients, TnI elevated patients had the higher APACHE Ⅱ score [17.0 (14.0-21.0) vs 15.0 (13.0-18.0)] and ICU mortality (18.2% vs 2.6%), both P=0.000. There were 56 patients died and 1 137 survived, single and multivariable regression analysis indicated that age (OR=1.041), APACHE Ⅱ score (OR=1.218) and initial TnI level (OR=6.366) were the independent risk factors for ICU mortality, all P<0.05. AUC of ROC for predictive value of ICU mortality in APACHE Ⅱ score was 0.763, in initial TnI level was 0.778; their combination AUC was 0.803. Conclusion: Increased TnI level at the early ICU admission was an independent risk factor for ICU mortality in non-cardiac surgery critically ill patients which had predictive value for death.

Reaching the standard does not mean achieving the aim-the most important role of analgesia and sedation in organs / 天津医药

The aim of analgesia and sedation treatment is to protect the morphology and functional reserve of organs. On the basis of circulatory perfusion and oxygenation, which can meet the minimum requirement of body and organ metabolism in the whole body, the organs can be rest and function harmoniously, so as to save and protect the organ's reserve function to the maximum extent, so that the critically ill patients can maintain good living quality as much as possible after the rehabilitation. It will be very important for the sustainable development of critical care medicine. In the process of achieving the purpose of analgesic and sedative therapy, it is necessary to set up different analgesic sedative targets according to the patient's condition, basic state and organ function. It is not suitable to simply and mechanically emphasize "deep sedation"or "light sedation". Analgesic and sedative treatment is a double-edged sword. No monitoring, no analgesia and sedation. To give the optimal analgesia and sedation therapy, it requires continuous monitoring and evaluation of whether the treatment is in order to achieve analgesic and sedative targets and to reach the purpose of protecting organ function. However, the monitoring and evaluation should not only be limited to the understanding of pain and consciousness and cognition, but also the dynamic changes in the basic vital signs of patients. By means of monitoring and evaluation, we can achieve the goal of keeping all organs of the body alive, preserving function as much as possible, reducing chronic and critical illness and improving the quality of life in patients.

Pharmacokinetic and Pharmacodynamic Efficacies of Continuous versus Intermittent Administration of Meropenem in Patients with Severe Sepsis and Septic Shock: A Prospective Randomized Pilot Study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The antibiotic meropenem is commonly administered in patients with severe sepsis and septic shock. We compared the pharmacokinetic, clinical, and bacteriological efficacies of continuous infusion of meropenem versus intermittent administration in such patients.</p><p><b>METHODS</b>Patients admitted to the Intensive Care Unit (ICU) with severe sepsis or septic shock who received meropenem were randomly assigned to either the continuous (n = 25) or intermittent groups (n = 25). The continuous group received a loading dose of 0.5 g of meropenem followed by a continuous infusion of 3 g/day; the intermittent group received an initial dose of 1.5 g followed by 1 g for every 8 h. Clinical success, microbiological eradication, superinfection, ICU mortality, length of ICU stay, and duration of meropenem treatment were assessed. Serial plasma meropenem concentrations for the first and third dosing periods (steady state) were also measured.</p><p><b>RESULTS</b>Clinical success was similar in both the continuous (64%) and intermittent (56%) groups (P = 0.564); the rates of microbiological eradication and superinfection (81.8% vs. 66.7% [ P = 0.255] and 4% vs. 16% [ P = 0.157], respectively) showed improvement in the continuous group. The duration of meropenem treatment was significantly shorter in the continuous group (7.6 vs. 9.4 days; P= 0.035), where a better steady-state concentration was also achieved. Peak and trough concentrations were significantly different between the continuous and intermittent groups both in the first (Cmax: 19.8 mg/L vs. 51.8 mg/L, P= 0.000; Cmin: 11.2 mg/L vs. 0.5 mg/L, P= 0.000) and third dosing periods (Cmax: 12.5 mg/L vs. 46.4 mg/L, P= 0.000; Cmin: 11.4 mg/L vs. 0.6 mg/L, P= 0.000). For medium-susceptibility pathogens, continuous infusion concentrations above the minimal inhibitory concentration were 100%, which was better than that in the intermittent group.</p><p><b>CONCLUSIONS</b>Continuous infusion of meropenem provides significantly shorter treatment duration and a tendency for superior bacteriological efficacy than intermittent administration. Continuous infusion may be more optimal against intermediate-susceptibility pathogens.</p>

Value of Kidney Disease Improving Global Outcomes Urine Output Criteria in Critically Ill Patients: A Secondary Analysis of a Multicenter Prospective Cohort Study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGOUO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGOSCr).</p><p><b>METHODS</b>We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGOUOand KDIGOSCr. Hospital mortality of patients with more severe AKI classification based on KDIGOUOwas compared with other patients by univariate and multivariate regression analyses.</p><p><b>RESULTS</b>The prevalence of AKI increased from 52.4% based on KDIGOSCrto 55.4% based on KDIGOSCrcombined with KDIGOUO. KDIGOUOalso resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGOUO. Compared with non-AKI patients or those with maximum AKI classification by KDIGOSCr, those with maximum AKI classification by KDIGOUOhad a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141-13.873, P< 0.001). In a multivariate logistic regression analysis, AKI based on KDIGOUO (OR: 2.891, 95% CI: 1.964-4.254, P< 0.001), but not based on KDIGOSCr (OR: 1.322, 95% CI: 0.902-1.939, P = 0.152), was an independent risk factor for hospital mortality.</p><p><b>CONCLUSION</b>UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.</p>

Prevalence, risk factors, clinical course, and outcome of acute kidney injury in Chinese intensive care units: a prospective cohort study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Acute kidney injury (AKI) has been recognized as a major healthcare problem affecting millions of patients worldwide. However, epidemiologic data concerning AKI in China are still lacking. The objectives of this study were to characterize AKI defined by RIFLE criteria, assess the association with hospital mortality, and evaluate the impact of AKI in the context of other risk factors.</p><p><b>METHODS</b>This prospective multicenter observational study enrolled 3,063 consecutive patients from 1 July 2009 to 31 August 2009 in 22 ICUs across mainland China. We excluded patients who were admitted for less than 24 hours (n = 1623), younger than 18 years (n = 127), receiving chronic hemodialysis (n = 29), receiving renal transplantation (n = 1) and unknown reasons (n = 28). There were 1255 patients in the final analysis. AKI was diagnosed and classified according to RIFLE criteria.</p><p><b>RESULTS</b>There were 396 patients (31.6%) who had AKI, with RIFLE maximum class R, I, and F in 126 (10.0%), 91 (7.3%), and 179 (14.3%) patients, respectively. Renal function deteriorated in 206 patients (16.4%). In comparison with non AKI patients, patients in the risk class on ICU admission were more likely to progress to the injury class (odds ratio (OR) 3.564, 95% confidence interval (CI) 1.706 - 7.443, P = 0.001], while patients in the risk class (OR 5.215, 95% CI 2.798-9.719, P < 0.001) and injury class (OR 13.316, 95% CI 7.507-23.622, P < 0.001) had a significantly higher probability of deteriorating into failure class. The adjusted hazard ratios for 90-day mortality were 1.884 for the risk group, 3.401 for the injury group, and 5.306 for the failure group.</p><p><b>CONCLUSIONS</b>The prevalence of AKI was high among critically ill patients in Chinese ICUs. In comparison with non-AKI patients, patients with RIFLE class R or class I on ICU admission were more susceptibility to progression to class I or class F. The RIFLE criteria were robust and correlated well with clinical deterioration and mortality.</p>

Pretreatment with interleukin-33 reduces warm hepatic ischemia/reperfusion injury in mice / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Interleukin (IL)-33 is a recently identified member of the IL-1 family that binds to the receptor, ST2L. This study examined IL-33 production in mouse liver and investigated its role in hepatic ischemia/reperfusion (I/R) injury.</p><p><b>METHODS</b>Male BALB/c mice ((22 ± 3) g) were subjected to 90 minutes partial hepatic ischemia, followed by 6 hours reperfusion. First, mice were randomized into two groups: control group (laparotomy only, without blocking blood supply) and ischemia model group. IL-33 mRNA and serum protein levels were measured at 30, 60, 90 minutes after ischemia and 2 and 6 hours after reperfusion. Second, mice were randomized into four groups: control, model (injection of rabbit IgG polyclonal antibody), recombinant IL-33 intervention and anti-ST2L antibody intervention group. Mice were sacrificed 6 hours after reperfusion. Liver pathology was observed via transmission electron microscopy. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), IL-4, IL-5, IL-13, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) levels were measured.</p><p><b>RESULTS</b>Levels of IL-33 mRNA and protein did not change during ischemia (P > 0.05) but increased significantly during reperfusion (P < 0.05). After reperfusion for 6 hours, serum levels of ALT, AST, IL-4, IL-5, IL-13, IFN-γ and TNF-α were significantly increased (P < 0.05), and hepatocellular ultrastructure was damaged. Pretreatment with IL-33 attenuated severity of liver damage compared with controls, but pretreatment with anti-ST2L antibody increased severity. Serum levels of IL-4, IL-5 and IL-13 protein increased whereas IFN-γ decreased following IL-33 pretreatment. Pretreatment with anti-ST2L antibody significantly decreased serum IL-4, IL-5, IL-13 levels and increased serum IFN-γ levels compared with controls (P < 0.05). There was no change in the level of TNF-α.</p><p><b>CONCLUSION</b>IL-33 is produced systematically and locally in liver during I/R injury. Pretreatment with IL-33 is therapeutic for hepatic I/R injury, possibly via inducing a Th1 to Th2 shift.</p>