Correlation between four limbs perfusion index and lactic acid in patients with severe neurological diseases / 中华危重病急救医学

OBJECTIVE@#To observe the correlation between the four limbs perfusion index (PI) and blood lactic acid in patients with neurosis, and evaluate the predictive value of PI on microcirculation perfusion metabolic disorder in patients with neurosis.@*METHODS@#A prospective observational study was conducted. Adult patients admitted to the department of neurological intensive care unit (NICU) of the First Affiliated Hospital of Xinjiang Medical University from July 1 to August 20 in 2020 were enrolled. Under the condition of indoor temperature controlled at 25 centigrade, all patients were placed in the supine position, and the blood pressure, heart rate, PI of both fingers and thumb toes and arterial blood lactic acid were measured within 24 hours and 24-48 hours after NICU. The difference of four limbs PI at different time periods and its correlation with lactic acid were compared. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive value of four limbs PI on patients with microcirculatory perfusion metabolic disorder.@*RESULTS@#A total of 44 patients with neurosis were enrolled, including 28 males and 16 females; average age (61.2±16.5) years old. There were no significant differences in PI of the left index finger and the right index finger [2.57 (1.44, 4.79) vs. 2.70 (1.25, 5.33)], PI of the left toe and the right toe [2.09 (0.85, 4.76) vs. 1.88 (0.74, 4.32)] within 24 hours after entering the NICU, and the PI of the left index finger and the right index finger [3.17 (1.49, 5.07) vs. 3.14 (1.33, 5.36)], PI of the left toe and the right toe [2.07 (0.75, 5.20) vs. 2.07 (0.68, 4.67)] at 24-48 hours after NICU admission (all P > 0.05). However, compared to the PI of the upper and lower limbs on the same side, except for the 24-48 hours after ICU of the PI difference between the left index finger and the left toe (P > 0.05), the PI of the toe was lower than that of the index finger at the other time periods (all P < 0.05). The correlation analysis showed that the PI value of four limbs of patients in both time periods were significantly negatively correlated with arterial blood lactic acid (the r values of the left index finger, the right index finger, the left toe and the right toe were -0.549, -0.482, -0.392 and -0.343 respectively within 24 hours after entering the NICU; the r values of the left index finger, the right index finger, the left toe and the right toe were -0.331, -0.292, -0.402 and -0.442 respectively after entering the NICU 24-48 hours, all P < 0.05). Taking lactic acid ≥ 2 mmol/L as the diagnostic standard for metabolic disorder of microcirculation perfusion (total 27 times, accounting for 30.7%). The efficacy of four limbs PI in predicting microcirculation perfusion metabolic disorder were compared. ROC curve analysis showed that the area under the curve (AUC) and 95% confidence interval (95%CI) of left index finger, right index finger, left toe and right toe predicting microcirculation perfusion metabolic disorder were 0.729 (0.609-0.850), 0.767 (0.662-0.871), 0.722 (0.609-0.835), 0.718 (0.593-0.842), respectively. There was no significant difference in AUC compare with each other (all P > 0.05). The cut-off value of PI of right index finger for predicting microcirculation perfusion metabolic disorder was 2.46, the sensitivity was 70.4%, the specificity was 75.4%, the positive likelihood ratio was 2.86, and the negative likelihood ratio was 0.30.@*CONCLUSIONS@#There are no significant differences in PI of bilateral index fingers, bilateral toes in patients with neurosis. However, unilateral upper and lower limbs showed lower PI in the toe than in the index finger. There is a significantly negatively correlation between PI and arterial blood lactic acid in all four limbs. PI can predict the metabolic disorder of microcirculation perfusion, and its cut-off value is 2.46.

Path on the management of surgical graded and refined management based on information technology / 中华医院管理杂志

The authors attempted to use information technology in hierarchical management on clinician′s surgical authority. By means of a hierarchical surgery catalogue database, clinicians′ surgical authority is subject to by-level IT-based approval, and such authorities as clinician′s surgical medical advice, application for surgery, and approval of special surgeries are regulated. Thanks to multi-dimensional objective data, clinicians′surgical competence is subject to a dynamic evaluation, hierarchical authorization and reauthorization. These measures further standardize the behavior of the surgeons, and rule out unauthorized operations, thus improving fine management of surgeries and ensuring patient safety.

Preliminary study of the arm equilibrium pressure to predict the effect of fluid challenge on urine output in oliguric intensive care unit patients / 中华内科杂志

Objective To evaluate whether arm equilibrium pressure (Parm) is helpful to predict the effect of fluid load in improving oliguria in intensive care unit(ICU) patients.Methods Hemodynamically stable patients [mean artery pressure (MAP)＞65 mmHg (1 mmHg=0.133 kPa),heart rate (HR)＜120 beats/min,lactic acid＜2 mmol/L] with urine output (UO)＜0.5 ml· kg-1· h-1 for 3 consecutive hours were enrolled.The fluid loading was performed by infusion of ringer's lactate 500 ml within 30 minute after baseline hemodynamic data were recorded.The positive renal response was defined as UO increased more than 0.5 ml· kg-1 · h-1 1 hour after fluid challenge,otherwise was negative.Results A total of 30 oliguric ICU patients were enrolled including 17 males and 13 females with median age (54.2±16.3) years.After fluid load,patients' HR decreased[(84± 13)beat/min vs.(80± 10) beat/min,P＜0.01],central venous pressure (CVP) increased[(7.0±2.4)mmHg vs.(8.8±2.6) mmHg,P＜0.01],30s Parm [(33.4±5.3) mmHg vs.(35.4±5.8) mmHg,P＜0.01] and 60s Parm [(26.9±4.5) mmHg vs.(28.7±5.0) mmHg,P＜0.01] increased,and UO [(18.5±8.8)ml/h vs.(64.1±38.3)ml/h,P＜0.01] increased significantly,while MAP and lactic acid did not change (P＞0.05).There were eighteen renal responders and 12 patients did not response.In responding group,MAP[(78.1 ±10.7) mmHg vs.(91.2±11.7) mmHg,P＜0.01],30s Parm[(30.4±3.8) mmHg vs.(38.0±3.7) mmHg,P＜0.01]and 60s Parm [(24.3±2.5) mmHg vs.(30.8±4.0) mmHg,P＜0.01] before fluid load were lower than those in negative group.HR,CVP,lactic acid,age and body weight were comparable between two groups (P＞0.05).After volume loading,MAP,30s and 60s Parrn in positive group were still lower than those in negative group (P＜0.05),while HR,CVP and lactic acid were similar (P＞0.05).Correlation analysis showed that baseline 30s Parm (r=-0.75,P＜0.01),60s Parm (r=-0.69,P＜0.01),and MAP (r=-0.46,P＜0.05) were negatively correlated with 1 h UO after fluid load,but HR and CVP were not (P＞0.05).The receiver operating curve (ROC) showed that 30s Parm had the largest area under curve (AUC) of 0.94 (95％ CI 0.84-1.05,P＜0.01),which 35.5 mmHg was the best threshold with sensitivity 94.4％ and specificity 91.7％(likelihood ratio 11.37).Conclusion In hemodynamically stable oliguric ICU patients,if Parm is lower than normal reference value,volume expansion is more likely to increase UO.Thus Parm can be used to predict the effect of fluid loadon UO.

The impact of different occlusion time on forearm equilibrium pressure and the correlation with systemic hemodynamics / 中华内科杂志

Objective To observe the changes of arm equilibrium pressure (Parm) in different occlusion time,the reference range of Parm in hemodynamic stable patients,and to explore the relationship between Parm and systemic hemodynamic parameters.Methods Mechanically ventilated postoperative abdominal surgery patients who admitted to ICU with stable hemodynamic status were enrolled.After hemodynamic data were recorded,arm stop-flow maneuvers were performed to measure Parm.At 10,20,30,40,50,60 seconds after occlusion,arterial pressure were measured twice within 5 minutes and recorded as the average value.Results Thirty patients were included.The Parm decreased gradually with the prolongation of the occlusion time.The value was not stable within 60 s,but the reducing extent was not obvious after 40s.The 95％ reference range of Parm 30 S was 23-44 mmHg(1 mmHg =0.133 kPa) and Parm 60 S was 19--35 mmHg.Parm at 30 s and 60 s were positively correlated with systolic arterial pressure,diastolic arterial pressure,mean arterial pressure,central venous pressure (all P ＜ 0.001),but not heart rate and pulse pressure.Linear regression analysis showed that Parm at 10 s,20 s,30 s only had linear correlation with diastolic arterial pressure (10 s,β =0.504,P =0.001;20 s,β =0.297,P =0.005;30 s,β =0.231,P =0.015),and Parm at 40 s,50 s,60 s were linear correlation with diastolic arterial pressure (40 s,β =0.220,P =0.004;50 s,β =0.210,P =0.004;60 s,β =0.213,P =0.004) and central venous pressure (40 s,β =0.516,P =0.018;50 s,β =0.513,P =0.01;60 s,β =0.472,P =0.023).Conclusion In mechanically ventilated postoperative abdominal surgery patients with stable hemodynamic status,Parm decreases when occlusion time is prolonged,which is not stable within 60 s occlusion.Arterial blood pressure and central venous pressure are positively correlated with Parm.

“Diffusion index”used to evaluate the prognosis of ARDS / 中华急诊医学杂志

Objective To propose the concept of “Diffusion Index”to replace Oxygenation Index as independent indicators to evaluate prognosis on ARDS patients under mechanical ventilation treatments,and comparison carried out between them preliminarily.Methods Calculation of “1 000 × (PaO2 /FiO2 /PEEP)”was taken as “Diffusion Index”.A total of 130 ARDS patients under mechanical ventilation support (MVS)were admitted to Peking Union Medical College Hospital ICU from July 2013 to July 2014.The data of these patients were retrospectively analyzed.Of them,15 patients were excluded because these patients refused invasive ventilation support.Respirator parameter setting and haemogas figures were recorded accordingly. Both Diffusion Index and Oxygenation Index were used separately to predict detachment of MVS from patients in 28 days,and the correlation between these two indexes and ARDS prognosis were determined.Results According to the outcomes of patients in 28 days,patients were divided into 3 groups:detached group (n =44),failed to detach group (n =14)and death group (n =57).There was obvious difference in trend diagrams observed among three groups between diffusion index and oxygenation index.COX regression analysis of survival curve demonstrated that if Diffusion Index kept greater than 405.8,probability of detachment of MVS from patients was higher and the correlation was significant (P =0.009 ).Conclusions Compared with Oxygenation Index,“Diffusion Index” is a comprehensive indicator for ARDS prognosis with better reliability and validity.

Effects of oral pyruvate-glucose-electrolyte solution on organ function and survival in resuscitation of lethal hemorrhagic shock rats / 中华急诊医学杂志

Objective To study the effects of oral rehydration with the solution of pyruvate-glucoseelectrolyte (PGES) by comparison with the bicarbonate-glucose-electrolyte solution (BGES) on resuscitation in rats with lethal hemorrhagic shock.Methods Sixty adult male SD rats with intra-gastric tube,and cannulation of femoral artery and vein were subjected to 45％ total blood volume loss from the femoral artery,and then randomly divided into three groups (n =20 in each group):no fluid resuscitation group (NR),oral fluid resuscitation with the PGES group (PGES) and oral fluid resuscitation with the BGES group (BGES).In NR group,the animals received no fluid replacement or any other treatment.Rats in PGES and BGES groups were infused intra-gastrically with pre-warmed PGES or BGES in volume of 2 times shed blood given at 30 min after hemorrhage and completed within 6 hours.Blood samples in each group were collected from the abdominal aorta before or at 0,1,2,4 h post hemorrhage to detect serum alanine aminotransferase (ALT),creatinine (Cr),creatine phosphate kinase isoenzyme (CK-MB) and intestinal fatty acid binding protein (iFABP).Another 84 rats randomly divided into four groups:NR group (n =24),PGES group (n =24),BGES group (n =24),and no hemorrhage group (NH group,n =12).Rats in the three hemorrhage groups were treated the same as described above,and the rats in NH group underwent the same surgical procedure without hemorrhage were served as the sham group.All these rats were observed for their 24-hour survival rates.Results The 24-hour survival rates of PGES and BGES groups were both significantly higher than the rate of NR group (11/24 vs.1/24,x2 =18.087,P ＜0.01 ; 5/24 vs.1/24,x2 =6.445,P ＜ 0.05) ; the survival rate of PGES group was also significantly higher than that of BGES group (11/24 vs.5/24,x2 =4.02,P ＜ 0.05).All levels of ALT,CK-MB,Cr and iFABP in both the NR group and two oral resuscitation groups at 1 h,2 h and 4 h post hemorrhage were significantly higher than those before the blood loss,respectively (P ＜ 0.01).These biomarkers at 2 h,4 h post hemorrhage were significantly lower in the PGES and BGES groups than those in NR group (P ＜ 0.01) ; the serum levels of ALT,CK-MB,Cr and iFABP were significantly lower in the PGES group than those in the BGES group at 2 h and 4 h post hemorrhage,respectively (P ＜ 0.05).Conclusions Present results demonstrated that the pyruvate-enriched oral re-hydration solution (ORS =PGES) was more effective in preserving the organ function and prolonging the animal survival after resuscitation of lethal hemorrhagic shock in comparison with the bicarbonate-containing ORS (BGES).The oral re-hydration solution (PGES) recommended by the World Hygiene Organization (WHO ORS) may require further improvement in oral resuscitation of shock and the PGES may be recommended as a choice of oral re-hydration salts in the treatment of lethal hemorrhagic shock when intravenous administration is not available.

Titrating positive end-expiratory pressure after recruitment maneuver according to end-tidal carbon dioxide and its related indicators in acute respiratory distress syndrome dog model / 中华内科杂志

Objective To investigate the relationship between end-tidal carbon dioxide with its related indicators and ventilation/perfusion of the acute respiratory distress syndrome (ARDS) lung,and to explore a feasible way to titrate positive end-expiratory pressure (PEEP) in clinical practice.Methods Five mixed-breed dogs with oleic acid lung injury model were mechanically ventilated at a serial PEEP trial including a recruitment maneuver (RM) before each PEEP level changed.The value of blood dynamics,end-tidal carbon dioxide partial pressure ( PetCO2 ) and arterial carbon dioxide pressure under different PEEP levels were recorded.Arterial end-tidal carbon dioxide gradient (Pa-etCO2) and dead space fraction (Vd/Vt％) were calculated.All dogs received CT scan.Lung volume under different pressure levels,and ratio and volume of alveolar closing pressure,collapsed alveoli,sufficiently and insufficiently ventilated alveoli were obtained.Alveolar opening and closing analysis were performed by non-liner regression equation.Results The mean pressure when Vd/Vt％ obtained lowest level were ( 11.2 ± 4.4 ) cm H2O(1 em H2 O =0.098 kPa),which had no significant difference when compared to alveolar closing pressure[ ( 11.5 ± 3.2 ) cm H2O ]( P ＞ 0.05 ).The fraction of insufficiently ventilated and collapsed alveoli showed a significant linear correlation with the Vd/Vt％ when PEEP was lower than Pmin ( r =0.632,P =0.004 ).There was a linear correlation between the Vd/Vt％ and the fraction of over-distended alveoli when PEEP was higher than Pmin ( r =0.770,P =0.001 ).Conclusions Closing pressure is in accordance with PEEP level after RM having reached the best ventilation/circulation ratio.The characteristics of lung collapse can be revealed by Vd/Vt％ changes after RM.To titrate PEEP for the lowest Vd/Vt％ after RM may be a feasible way to match the best ventilation and circulation effects of PEEP.

Relationship between hyperlactatemia of patients with refractory septic shock and hemodynamics oriented therapy / 解放军医学杂志

10% at 24-hour later than the initial value.Conclusion In patients with refractory septic shock who achieved the goal of combiming CVP ≥ 8mmHg,MAP ≥ 65mmHg,SmVO2 ≥ 65% hyperlactemia was ameliorated.Lactate clearance rate can be used as a good marker to predict outcome of septic shock patients.