Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial / Eficácia da melatonina na redução da incidência de delirium em pacientes adultos graves: um ensaio clínico randomizado

ABSTRACT Objective: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. Methods: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). Results: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. Conclusion: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

RESUMO Objetivo: Determinar se a melatonina enteral diminui a incidência de delirium em adultos em estado grave. Métodos: Neste estudo controlado e randomizado, os adultos foram admitidos à unidade de terapia intensiva e/ou receberam apenas o padrão de cuidado habitual (Grupo Controle) ou o tratamento combinado com 3mg de melatonina enteral uma vez ao dia às 21h (Grupo Melatonina). A ocultação da alocação foi feita por meio de envelopes selados opacos e numerados sequencialmente. O intensivista que avaliou o delirium e o pesquisador que realizou a análise dos dados foram cegados quanto à alocação do grupo. O desfecho primário foi a incidência de delirium dentro de 24 horas de internação na unidade de terapia intensiva. Os desfechos secundários foram a incidência de delirium nos dias 3 e 7, a mortalidade na unidade de terapia intensiva, a duração da internação na unidade de terapia intensiva, a duração da ventilação mecânica e o escore da escala de desfecho de Glasgow (na alta). Resultados: Foram incluídos 108 pacientes na análise final, com 54 sujeitos em cada grupo. Em 24 horas de internação na unidade de terapia intensiva, a incidência de delirium não foi diferente entre os Grupos Melatonina e Controle (29,6% versus 46,2%; RR = 0,6; IC95% 0,38 - 1,05; p = 0,11). Nenhum desfecho secundário apresentou diferenças estatisticamente significativas. Conclusão: Em adultos em estado grave, 3mg de melatonina enteral não foi mais eficaz que os cuidados padrão na redução da incidência de delirium.

Estimated continuous cardiac output based on pulse wave transit time in critically ill children: a report of two cases / Débito cardíaco contínuo estimado baseado no tempo de trânsito da onda de pulso em crianças em estado crítico: relato de dois casos

ABSTRACT Cardiac output is an essential determinant of oxygen delivery, although unreliably measured on clinical examination and routine monitoring. Unfortunately, cardiac output monitoring is rarely performed in pediatric critical care medicine, with a limited availability of accurate methods for children. Herein, we report two pediatric cases in which noninvasive pulse-wave transit time-based cardiac output monitoring (esCCO, Nihon Kohden, Tokyo, Japan) was used. The esCCO system calculates cardiac output continuously by using the negative correlation between stroke volume and pulse wave transit time and requires only electrocardiogram monitoring, noninvasive blood pressure, and pulse oximetry signals. Before starting its use, esCCO should be calibrated, which can be done using patient information (gender, age, height, and body weight) or entering cardiac output values obtained by other methods. In both cases, when calibrations were performed using patient information, the agreement between esCCO and echocardiographic measurements was poor. However, after calibration with transthoracic echocardiography, the cardiac output values obtained by both methods remained similar after 2 hours and 18 hours. The results indicate that the esCCO system is suitable for use in children; however, further studies are needed to optimize its algorithm and determine its accuracy, precision, and trend in children.

RESUMO O débito cardíaco é um determinante importante do fornecimento de oxigênio, embora a sua mensuração seja realizada de forma pouco confiável no exame clínico e no monitoramento de rotina. Infelizmente, o monitoramento do débito cardíaco raramente é realizado na medicina intensiva pediátrica, com disponibilidade limitada de métodos precisos para crianças. Relatamos aqui dois casos pediátricos nos quais utilizouse o monitoramento não invasivo do débito cardíaco por meio da análise do tempo de trânsito de ondas de pulso (esCCO, Nihon Kohden, Tóquio, Japão). O sistema esCCO calcula o débito cardíaco continuamente pela correlação negativa entre o volume sistólico e o tempo de trânsito de ondas de pulso e requer apenas o monitoramento por eletrocardiograma, pressão arterial não invasiva e sinais de oximetria de pulso. Antes de iniciar seu uso, o esCCO deve ser calibrado, o que pode ser feito com informações do paciente (sexo, idade, altura e peso corporal) ou informando os valores do débito cardíaco obtidos mediante outros métodos. Em ambos os casos, quando as calibragens foram realizadas com informações do paciente, a concordância entre o débito cardíaco contínuo estimado e as medidas ecocardiográficas foi insatisfatória. Entretanto, após a calibragem com ecocardiografia transtorácica, os valores do débito cardíaco obtidos pelos dois métodos permaneceram semelhantes após 2 horas e 18 horas. Os resultados indicam que o sistema esCCO pode ser útil em crianças; entretanto, são necessários mais estudos para otimizar seu algoritmo e determinar sua exatidão, precisão e tendência em crianças.

Factors affecting vancomycin pharmacokinetics in severe children / 中国小儿急救医学

Vancomycin plays an increasingly important role in the treatment of complex infections in severe patients, and it is currently the first choice for the treatment of methicillin-resistant S. aureus infection.The incidence of infectious diseases in children is extremely high, and the disease changes quickly, easy to become severe.With the increase of drug-resistant bacteria, vancomycin is becoming widely used.As a special group, children with severe illness have great individual difference, and the conventional dose application of vancomycin often cannot achieve the ideal treatment effect.Therefore, we need to realize the different circumstances of vancomycin pharmacokinetic changes and routine drug therapy monitoring, namely by measuring the patient with drug exposure, pharmacological markers or pharmacodynamic index design, to timely adjust physical treatment regimen, improve drug efficacy, reduce drug resistance and adverse reactions.

Development and validation of a nomogram to predict in-hospital cardiac arrest in critically ill patients / 中华急诊医学杂志

Objective:To explore the independent risk factors of in-hospital cardiac arrest (IHCA) in critically ill patients and construct a nomogram model to predict the risk of IHCA based on the identified risk factors.Methods:Patients who were admitted to the intensive care units (ICUs) from 2008 to 2019 were retrospectively enrolled from the Medical Information Mart for Intensive Care -Ⅳ database. The patients were excluded if they (1) were younger than 18 years old, (2) had repeated ICU admission records, or (3) had an ICU stay shorter than 24 h. The patients were randomly divided into the training and internal validation cohorts (7 : 3). Univariate and multivariate logistic regression models were used to identify independent risk factors of IHCA, and a nomogram was constructed based on these independent risk factors. Calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used to evaluate the nomogram model. Finally, the nomogram was externally validated using the emergency ICU collaborative research database.Results:A total of 41,951 critically ill patients were enrolled (training cohort, n=29 366; internal validation cohort, n=12 585). Multivariate analysis showed that myocardial infarction, pulmonary heart disease, cardiogenic shock, respiratory failure, acute kidney injury, respiratory rate, glucose, hematocrit, sodium, anion gap, vasoactive drug use, and invasive mechanical ventilation were independent risk factors of IHCA. Based on the above risk factors, a nomogram for predicting IHCA was constructed. The area under the ROC curve (AUC) of the nomogram was 0.817 (95% CI: 0.785–0.847). The calibration curve showed that the predicted and actual probabilities of the nomogram were consistent. Moreover, DCA showed that the nomogram had clinical benefits for predicting IHCA. In the internal validation cohort, the nomogram had a similar predictive value of IHCA (AUC=0.807, 95% CI: 0.760–0.862). In an external validation cohort of 87,626 critically ill patients, the nomogram had stable ability for predicting IHCA (AUC=0.804, 95% CI: 0.786–0.822). In addition, the nomogram also had predictive value for in-hospital mortality (AUC=0.818, 95% CI: 0.802-0.834). Conclusions:The nomogram is constructed based on identified independent risk factors, which has good predictive value for IHCA. Moreover, the performance of the nomogram in the external validation cohort is robust. The study findings may help clinicians to assess the risk of IHCA in critically ill patients.

The value of systemic immune inflammation index in predicting the risk of hospital death in critically ill patients / 中华急诊医学杂志

Objective:To explore the predictive value of systemic immune inflammation index (SII) for the risk of hospital death in critically ill patients.Methods:The basic information and clinical data of critically ill patients were extracted from the Medical Information Mart for Intensive Care database-Ⅳ (MIMIC-IV) database, including demographic data, vital signs, blood routine, Logistic organ dysfunction score (Lods), Oxford acute severity of illness score (Oasis), simplified acute physiology score (Saps-Ⅱ), acute physiology score Ⅲ (APS-Ⅲ), sequential organ failure score (SOFA) and outcome. The main outcome was hospital death, and the secondary outcomes were length of hospital stay, continuous renal replacement therapy (CRRT), invasive ventilation and 1-year mortality. Patients were divided into two groups according to in-hospital death, and the differences between the groups were compared. According to the SII tripartite for inter-group comparison, the patients were further divided into three groups for comparison, and Logistic regression model was used to analyze the odd ratio ( OR) of the three groups. Results:A total of 32 450 critically ill patients were included in the study, of which 3765 died in hospital, with a mortality rate of 11.6%. ① Compared with the survival group, the SII in the death group were significantly higher ( P < 0.05). ② The mortality for the SII tripartite grouping (<817; 817~2 151; >2 151) were 8.4%, 10.2% and 16.3%, respectively, and the differences between groups were statistically significant. ③ Further, Logistic regression model analysis showed that the risk of death increased gradually with the increase of groups (the first group was the reference group, OR of the second group was 1.38, 95% CI 1.24-1.54, and OR of the third group was 2.03, 95% CI 1.83-2.24 ( P < 0.05). Conclusions:SII has a certain value in predicting hospital death in critically ill patients. It is easy to obtain and can be used for risk stratification of critically ill patients.

Incidência e fatores de risco associados à síndrome pós-cuidados intensivos em uma coorte de pacientes em estado crítico / Incidence and risk factors for postintensive care syndrome in a cohort of critically ill patients

RESUMO Objetivo: Determinar a incidência da síndrome pós-cuidados intensivos em uma coorte de pacientes em estado crítico admitidos à unidade de terapia intensiva e identificar fatores de risco relacionados ao seu desenvolvimento nas áreas de saúde física, cognitiva e mental. Métodos: Este foi um estudo de coorte observacional prospectivo desenvolvido na unidade de terapia intensiva de um hospital universitário. Foram incluídos no estudo pacientes internados em unidade de terapia intensiva a partir de 1 semana e com necessidade de ventilação mecânica por mais de 3 dias, choque ou delirium. Foram registradas variáveis demográficas, motivo da admissão, diagnósticos, sedação, tipo de ventilação mecânica, complicações e tempo de internação. Realizou-se análise univariada para identificar os fatores de risco relacionados à síndrome pós-cuidados intensivos. As escalas utilizadas para a avaliação das diferentes esferas foram Barthel, Pfeiffer, Hospital Anxiety and Depression Scale e Impact of Event Scale-6. As principais variáveis de interesse foram incidência da síndrome pós-cuidados intensivos de modo geral e por domínios. Os fatores de risco foram examinados em cada um dos domínios da saúde (saúde física, cognitiva e mental). Resultados: Participaram 87 pacientes. A Acute Physiology and Chronic Health Evaluation II média foi de 16,5. O número médio de dias na unidade de terapia intensiva foi 17. A incidência geral da síndrome pós-cuidados intensivos foi de 56,3% (n = 49; IC95% 45,8 - 66,2). A incidência da síndrome pós-cuidados intensivos em cada uma das esferas foi de 32,1% (física), 11,5% (cognitiva) e 36,6% (saúde mental). Conclusão: A incidência da síndrome pós-cuidados intensivos foi de 56,3%. A esfera da saúde mental foi a mais frequentemente envolvida. Os fatores de risco diferem, dependendo da área considerada.

ABSTRACT Objective: To determine the incidence of postintensive care syndrome in a cohort of critically ill patients admitted to the intensive care unit and to identify risk factors related to its development in the physical, cognitive and mental health areas. Methods: This was a prospective observational cohort study developed in the intensive care unit of a university hospital. Patients with intensive care unit stays equal to or longer than one week and the need for mechanical ventilation for more than 3 days, shock or delirium were included in the study. Demographic variables, reasons for admission, diagnoses, sedation, type of mechanical ventilation used, complications and length of stay were recorded. A univariate analysis was performed to identify risk factors related to postintensive care syndrome. The scales used for the assessment of the different spheres were Barthel, Pfeiffer, Hospital Anxiety and Depression Scale and Impact of Event Scale-6. The main variables of interest were postintensive care syndrome incidence overall and by domains. Risk factors were examined in each of the health domains (physical, cognitive and mental health). Results: Eighty-seven patients were included. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. The mean number of intensive care unit days was 17. The incidence of global postintensive care syndrome was 56.3% (n = 49, 95%CI 45.8 - 66.2%). The incidence of postintensive care syndrome in each of the spheres was 32.1% (physical), 11.5% (cognitive), and 36.6% (mental health). Conclusions: The incidence of postintensive care syndrome is 56.3%. The mental health sphere is the most frequently involved. The risk factors are different depending on the area considered.

É possível estimar a saturação venosa de oxigênio central a partir da saturação tecidual de oxigênio durante o teste de oclusão venosa? / Can central-venous oxygen saturation be estimated from tissue oxygen saturation during a venous occlusion test?

RESUMO Objetivo: Testar se, após um teste de oclusão venosa, a taxa de saturação tecidual de oxigênio é capaz de estimar a taxa de saturação venosa de oxigênio central. Métodos: Realizou-se estudo observacional em pacientes de unidade de terapia intensiva. A taxa de saturação tecidual de oxigênio foi monitorada a partir de um espectrômetro tecidual (InSpectra modelo 650, Hutchinson Technology Inc., MN, Estados Unidos) com uma sonda múltipla de 15mm e 25mm na posição tenar. Aplicou-se um teste de oclusão venosa no braço superior de voluntários para testar a tolerabilidade e o padrão de mudanças na taxa de saturação tecidual de oxigênio durante a realização do teste de oclusão venosa. Inflou-se um manguito de esfigmomanômetro a uma pressão 30mmHg maior que a pressão diastólica até que a taxa de saturação tecidual de oxigênio alcançasse um platô e o manguito fosse desinflado a 0mmHg. Os parâmetros da taxa de saturação tecidual de oxigênio foram classificados como em repouso e mínima ao final do teste de oclusão venosa. Nos pacientes, o manguito foi inflado a uma pressão 30mmHg maior que a pressão diastólica durante 5 minutos, que foi o tempo derivado dos voluntários, ou até que a taxa de saturação tecidual de oxigênio atingisse um platô. Os parâmetros da taxa de saturação tecidual de oxigênio foram classificados como em repouso e mínima, e o tempo médio que a taxa de saturação tecidual de oxigênio se igualou à de saturação venosa de oxigênio central. A taxa de saturação tecidual de oxigênio no tempo médio foi comparada à de saturação venosa de oxigênio central. Resultados: Todos os nove voluntários toleraram bem o teste de oclusão venosa. O tempo de tolerabilidade ou o platô da taxa de saturação tecidual de oxigênio foi de 7 ± 1 minutos. Estudamos 22 pacientes. O tempo médio para a equalização da taxa de saturação tecidual de oxigênio à de saturação venosa de oxigênio central foi de 100 segundos e 95 segundos, utilizando sondas de 15 e 25mm, respectivamente. A taxa de saturação tecidual de oxigênio em 100 segundos foi de 74% ± 7%, utilizando sonda de 15mm, e de 74% ± 6%, utilizando sonda de 25mm. Então, as taxas foram comparadas à taxa de saturação venosa de oxigênio central, que apresentou 75% ± 6%. A taxa de saturação tecidual de oxigênio em 100 segundos correlacionou-se com a de saturação venosa de oxigênio central (15mm: R2 = 0,63; 25mm: R2 = 0,67; p < 0,01) sem discrepância (Bland-Altman). Conclusão: A taxa de saturação venosa de oxigênio central pode ser estimada a partir da taxa de saturação tecidual de oxigênio, a partir de um teste de oclusão venosa.

ABSTRACT Objective: To test whether tissue oxygen saturation (StO2) after a venous occlusion test estimates central venous oxygen saturation (ScvO2). Methods: Observational study in intensive care unit patients. Tissue oxygen saturation was monitored (InSpectra Tissue Spectrometer Model 650, Hutchinson Technology Inc., MN, USA) with a multiprobe (15/25mm) in the thenar position. A venous occlusion test in volunteers was applied in the upper arm to test the tolerability and pattern of StO2 changes during the venous occlusion test. A sphygmomanometer cuff was inflated to a pressure 30mmHg above diastolic pressure until StO2 reached a plateau and deflated to 0mmHg. Tissue oxygen saturation parameters were divided into resting StO2 (r-StO2) and minimal StO2 (m-StO2) at the end of the venous occlusion test. In patients, the cuff was inflated to a pressure 30mmHg above diastolic pressure for 5 min (volunteers' time derived) or until a StO2 plateau was reached. Tissue oxygen saturation parameters were divided into r-StO2, m-StO2, and the mean time that StO2 reached ScvO2. The StO2 value at the mean time was compared to ScvO2. Results: All 9 volunteers tolerated the venous occlusion test. The time for tolerability or the StO2 plateau was 7 ± 1 minutes. We studied 22 patients. The mean time for StO2 equalized ScvO2 was 100 sec and 95 sec (15/25mm probes). The StO2 value at 100 sec ([100-StO2] 15mm: 74 ± 7%; 25mm: 74 ± 6%) was then compared with ScvO2 (75 ± 6%). The StO2 value at 100 sec correlated with ScvO2 (15 mm: R2 = 0.63, 25mm: R2 = 0.67, p < 0.01) without discrepancy (Bland Altman). Conclusion: Central venous oxygen saturation can be estimated from StO2 during a venous occlusion test.

Rehabilitation of Mobility for Critically Ill Patients Based on World Health Organization Family International Classifications: A Scoping Review / 中国康复理论与实践

Objective:To analyze rehabilitation of functioning of mobility for critically ill patients based on the framework of the World Health Organization Family International Classifications (WHO-FICs). Methods:A scoping review of rehabilitation of functioning of mobility for critically ill patients had been conducted. Literatures on early mobilization or rehabilitation in the field of critical illness from databases of Web of Science, PubMed, CNKI, and Wanfang up to February 28, 2021 were retrieved. The diseases, functioning, rehabilitation intervention, functioning evaluation and environment of patients in critical ward had been reviewed. Results:Based on WHO-FICs framework, this paper reviewed literatures in five dimensions: the type of diseases, functioning, rehabilitation intervention, functioning evaluation and environment factors. The diseases included respiratory system diseases (MD10-MD6Y), neurological system diseases (MB40-MB9Y), cardiovascular system diseases (MC80-MC9Y), post-surgical (MD80-ME4Y, ME60-ME6Y, ME80-MF1Y), and others (NA00-NF2Z, MA00-MA3Y, 1G40-1G41). The functioning included movement-related structures (s720-s760), neuromusculoskeletal and movement-related functions (b710-b740), mobility (d4), self-care (d5), and remunerative employment (d850). The rehabilitation interventions were divided into three categories based on the International Classification of Health Interventions (ICHI) β-3: therapeutic, preventive, and health promotion interventions. The evaluation of functioning mainly involved joint mobility, muscle strength, muscle tone, de Morton Mobility Index, Functional Status Score for Intensive Care Unit (FSS-ICU), 6-Minute Walking Test (6WMT), intensive care unit (ICU) length of stay and so on. The intensive care environment was also discussed using ICF environment factors. Conclusion:This paper proposed a framework of rehabilitation of mobility for critically ill patients based on the WHO-FICs. It focused on respiratory system disease, neurological system diseases, cardiovascular system diseases, post-surgical with mobility dysfunction. To implement interventions in therapeutic, preventive, and health promotion to optimize patients' function, and to prevent complications and secondary dysfunction, and improve their well-being.

Evaluation of the timing of application of nasal continuous positive airway pressure in critically ill children / 中国小儿急救医学

Objective To study the clinical data of patients treated with nasal continuous positive airway pressure (NCPAP) in PICU,and to explore the application time and range of NCPAP in critically ill children. Methods A prospective study was conducted to collect clinical data of 192 severe patients admitted to PICU from January 2016 to June 2017 who had shortness of breath after giving oxygen through nasal cath-eter for 1 hour and then switched to NCPAP. According to using NCPAP oxygen partial pressure,children were divided into three groups:group A[ shortness of breath ( PaO2≥70 mmHg,1 mmHg＝0. 133 kPa) ], group B[shortness of breath combined,reduced oxygen partial pressure(50mmHg<PaO2<70 mmHg)],and group C[shortness of breath combined respiratory failure(PaO2≤50 mmHg)]. The indicators of three groups of children at different time points of NCPAP were compared. Results Among 192 children,161 (83. 85%) had respiratory diseases,14 (7. 29%) had severe hand-foot-mouth disease,10 (5. 21%) had severe sepsis, and 7 (3. 65%) had other multiple organ disorders. PaO2/FiO2gradually increased after using NCPAP for 1 hour and 4 hours,and the improvement of oxygenation in group A was most obvious,there was significant difference among the three groups (P<0. 05). There were significant differences in heart rate,shortness of breath after using NCPAP for 1 hour and 4 hours among the three groups (P<0. 05). There were 2 cases of ventilation failure in group A (failure rate 3. 57%),9 cases (11. 11%) of ventilation failure in group C,30 cases (54. 55%) of ventilation failure in group C,and there was significant difference in the failure rate of noninvasive ventilation among the three groups (χ2＝51. 684,P<0. 001). There were significant differences in the discharge rate among the three groups (P<0. 05). Conclusion NCPAP has obvious effect on the critical-ly ill children with conventional oxygen remaining respiratory abnormalities;Children with respiratory failure under nasal catheter are prone to suffer from the failure of noninvasive assisted ventilation when using NCPAP assisted ventilation,closely monitor of the disease condition is needed.

Current Trend of Nutritional Support Treatment Guidelines for Critically Ill Patients

Critically ill and injured patients admitted in the intensive care unit have a range of diseases with various severities. Their conditions should be assessed and the patients should receive specialized nutrition therapy depending on their condition. Like general intensive care, nutrition therapy is upgraded every few years with revised information to provide more idealized nutrition support. The main guidelines in this review are from the Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Their previous 2009 guidelines were revised and published in 2016. This review summarizes the 2016 SCCM/ASPEN guidelines focusing on the changes from the previous 2009 guidelines.

Clinical significance of early immunological paralysis in patients with severe H1N1 influenza A / 中华危重病急救医学

Objective To analysis the immunological characteristics of patients with severe H1N1 influenza A, and to provide theoretical basis for predicting the prognosis of the disease. Methods A retrospective analysis was conducted. The clinical data of 15 patients diagnosed with severe H1N1 influenza A and admitted to Shanghai General Hospital of Nanjing Medical University from October 2015 to December 2016 were collected. All the patients were divided into survival and death groups according to 28-day survival. Clinical characteristics, treatment algorithm, organ function, inflammatory reaction and immune cell status were compared, and Cox regression was used to decide the risk factors of 28-day death in patients with severe H1N1 infection A. Results All 15 patients with severe H1N1 infection A were enrolled, most of who presented with cough (93.3%), fever (86.7%), sputum production (80.0%), shortness of breath (73.3%), myalgia (40.0%) and fatigue (40.0%). All had been received anti-virus, antibiotics, mechanical ventilation and anti-coagulation therapy; some were treated with prone position, neuromuscular blocker and extracorporeal membrane oxygenation (ECMO). The incidences of acute myocardial and kidney injury were high, and the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score (14.1±6.1) and sequential organ failure assessment (SOFA) score (9.6±4.1) implicated the critical condition. Of 15 patients, 4 patients died in 28 days, while 11 were cured and discharged. Compared with survival group, the patients in death group had higher levels of APACHE Ⅱscore (22.7±3.8 vs. 11.8±3.8), troponin [cTn (μg/L): 0.52 (0.07, 2.02) vs. 0.15 (0.10, 0.45)] and blood urea nitrogen [BUN (mmol/L): 11.9 (6.7, 29.1) vs. 3.9 (2.7, 6.8)] and a lower level of blood platelets count [PLT (×109/L): 76±33 vs. 146±49, all P 0.05). B lymphocyte in death group was significantly higher than that of survival group (0.477±0.136 vs. 0.229±0.121, P < 0.01). Cox regression analysis revealed that APACHE Ⅱ score [risk ratio (RR) = 20.4, 95% confidence interval (95%CI) = 5.3-31.2, P = 0.017], CD4+ T cell (RR = 11.1, 95%CI = 5.1-20.0, P = 0.048) and CD8+ T cell (RR = 9.1, 95%CI = 4.3-16.7, P = 0.049) were independently risk factors of 28-day survival of patients with severe H1N1 influenza A. Conclusion Immunological paralysis and severe inflammatory response were early complicated with severe H1N1 influenza A, and these were significantly associated with prognosis.

Effects of Compliance with the Nutrition Support Team in Critically Ill Pediatric Patients

PURPOSE: This study performed a comparative evaluation of nutritional condition's improvement and clinical effects in accordance with the Nutrition Support Team (NST) consultation compliance of critically ill pediatric patients. METHODS: The medical records of 64 critically ill pediatric patients (2 to 18 years old), who were officially referred to a NST consultant in pediatric intensive care unit from January to August 2015, were reviewed. The patients were divided into 2 groups according to the compliance of NST consultation answers. The total delivered/required caloric and protein ratio, weight, serum total protein, serum albumin, hemoglobin, and hematocrit were compared. RESULTS: According to the NST consultation answer, 'nutrition support increase' occupied the largest proportion at 38.5%; 'maintenance' and 'decrease' accounted for 35.7% and 18.2% respectively. The NST compliance group and non-compliance group were 20 and 14 patients, respectively. Although total delivered/required caloric ratio was significantly increased in the NST compliance group (19.7%, P=0.036), there was no significant difference in the NST non-compliance group (5.1%, P=0.692). The total delivered/required protein ratio was increased (15.1%, P=0.163) in the NST compliance group and decreased (-4.7%, P=0.774) in the NST non-compliance group. The NST non-compliance group (-8.6%, P=0.219) was further reduced weight than the NST compliance group (-1.0%, P=0.820). The serum albumin was significantly increased in the NST compliance group (13.1%, P=0.003), but there was no difference in the NST non-compliance group (7.1%, P=0.433). CONCLUSION: Although 56.7% of NST consultations were needed for nutritional interventions, a lower NST compliance (53.8%) is the limit of nutritional support. The NST compliance group was supplied adequately with more calories and protein than before consultation and a more improved nutritional status. Therefore, aggressive NST consultation can help increase the therapeutic effect by improving the nutritional status. This study will form the basis to seek ways to further enhance NST compliance.

The effect of nutritional risk and Acute Physiology and Chronic Health EvaluationⅡ on the prognosis of critically ill patients / 中国实用护理杂志

Objective To explore the effect of nutritional risk and Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ) on the prognosis of critically ill patients. Methods From January 2014 to November 2015, 138 critically ill patients were screened using Nutritional Risk Screening 2002 (NRS-2002) in intensive care unit (ICU) of our hospital. APACHEⅡand nutritional status of the patients were measured at the same time. Patients were divided into the survival group and death group according to the prognosis,the NRS-2002, nutritional status and APACHEⅡscores were compared between the two groups.The effect of NRS-2002 and APACHEⅡon the prognosis of critically ill patients was analyzed. Results Of 138 critically ill patients, 131 cases were found nutritional risk and 82 patients survived (62.60%) ,7 cases were found without nutritional risk and 5 patients survived,There were no significant differences in survival rate of both groups(P=0.714). The APACHEⅡscores in the nutritional risk group were (22.14 ± 6.86) points, which were obviously higher than those of non-nutritional risk group(5.80 ± 1.90)points. There were significant differences(t′=17.47,P0.05).Logistic regression analysis showed APACHEⅡ, nutritional risks, RBC,HGB,ALB and CRP were all the risk factors for the prognosis of critically ill patients(P<0.01), while APACHEⅡ, RBC, nutritional risks and ALB were the leading influencing factors. Conclusions There exists higher nutritional risks among the critically ill patients. APACHEⅡ, RBC, nutritional risks and ALB should be given more attention when they are admitted in the ICU. Patients′nutritional status should be comprehensively evaluated and the prognosis of the patients should be predicted.

Avaliação do risco nutricional em pacientes oncológicos graves: revisão sistemática / Nutritional risk assessment in critically ill cancer patients: systematic review

RESUMOObjetivo:Revisar sistematicamente os principais métodos para avaliação do risco nutricional utilizados em pacientes oncológicos graves e apresentar aqueles que melhor avaliam os riscos e preveem desfechos clínicos relevantes neste grupo de pacientes, além de discutir as vantagens e as desvantagens destes métodos, segundo a literatura atual.Métodos:O estudo consistiu de uma revisão sistemática com base na análise de artigos obtidos nas bases de dados PubMed, LILACS e SciELO, realizando as buscas com os termos em inglês: “nutritional risk assessment”, “critically ill” e “cancer”.Resultados:Apenas 6 (17,7%) dos 34 artigos inicialmente obtidos cumpriam os critérios para inclusão e foram selecionados para revisão. Os principais desfechos destes estudos foram que o gasto de energia em repouso se associou com subnutrição e superalimentação. O escore elevado da Avaliação Subjetiva Global - Produzida pelo Paciente associou- se de forma significante com baixa ingestão de alimentos, perda de peso e desnutrição. Em termos de marcadores bioquímicos, níveis mais elevados de creatinina, albumina e ureia se associaram de forma significante com mortalidade mais baixa. Os piores índices de sobrevivência foram encontrados para pacientes com condições de desempenho piores, conforme avaliação usando o Eastern Cooperative Oncologic Group performance status, escore prognóstico de Glasgow elevado, baixa albumina/hipoalbuminemia, elevado escore da Avaliação Subjetiva Global - Produzida Pelo Paciente e para níveis elevados de fosfatase alcalina. Valores de avaliação do Índice de Risco Nutricional Geriátrico inferiores a 87 se associaram de forma significante com mortalidade. O escore pelo índice prognóstico inflamatório nutricional se associou com condição nutricional anormal em pacientes oncológicos graves. Dentre os estudos revisados que avaliaram apenas peso e índice de massa corporal, não se encontrou qualquer desfecho clínico significante.Conclusão:Nenhum dos métodos revisados ajudou a definir o risco entre esses pacientes. Portanto, sugere-se a avaliação por meio da quantificação da perda de peso e dos níveis séricos, preferivelmente em combinação com outros métodos utilizando escores como o Eastern Cooperative Oncologic Group performance status, o escore prognóstico de Glasgow e a Avaliação Subjetiva Global - Produzida Pelo Paciente, já que seu uso é simples, factível e útil em tais casos.

ABSTRACTObjective:To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature.Methods:The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”.Results:Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found.Conclusion:None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic Score and Patient-Generated Subjective Global Assessment, is suggested given that their use is simple, feasible and useful in such cases.

Critically ill children with hyponatremia and hypernatremia / 中国小儿急救医学

Hyponatremia and hyponatremia are the most common diseases in the PICU,which are easily lead to serious complications.If severe hyponatremia,hypernatremia or high sodium crisis happened,it can be expressed as repeated convulsions,coma and other serious neurological symptoms,even life-threaten-ing.The most causes are diarrhea disease,intracranial disease,the heat syndrome and so on.We can formulate the best management method of these disease based on they different causes,pathogenesis,clinical manifesta-tions and clinical manifestations.

Glucocorticoids for pediatric critical illness:new insights into old ideas / 中华实用儿科临床杂志

Glucocorticoids have been widely prescribed for various indications of critically illness. The clinical efficacy is persistently investigated but controversy still remains. Recent advances in pharmacological mechanisms of corticosteroid action has attracted much attention. This review focuses on the role of corticosteroids therapy in critically ill children with severe sepsis and septic shock,severe hand-foot-mouth disease,severe asthma,acute respiratory dis-tress syndrome,severe pneumonia,or increased intracranial pressure. Although the debate has been on,recommend that use of glucocorticoid therapy in critically ill children should be tailored for the individual based on clinical guidelines.

Ventilação mecânica domiciliar: uma realidade cada vez mais frequente / Mechanical ventilation home: an increasingly frequent reality

Desde que a ventilação mecânica foi difundida após a epidemia de poliomielite até os dias atuais com o avanço das estratégias diagnósticas e terapêuticas, houve significativo aumento na sobrevida dos pacientes criticamente enfermos. Este subgrupo de sobreviventes encontra-se em um estado cronicamente crítico e dentre outras disfunções e terapias de suporte, caracteriza-se pela necessidade de ventilação mecânica prolongada. Paralelo a este fato, o envelhecimento populacional eleva a chance de internações hospitalares com necessidade de assistência ventilatória invasiva. Nos dias de hoje, a ventilação mecânica domiciliar é uma realidade e tornou-se uma opção viável para pacientes com insuficiência respiratória crônica, também estimulada pelo crescimento da utilização de ventilação não invasiva com pressão positiva, o reconhecimento de diferentes tipos de pacientes que podem se beneficiar desta técnica e redução dos custos hospitalares através da desospitalização.Atualmente possuímos diversos tipos e modelos de ventiladores exclusivos para ventilação mecânica domiciliar, assim como interfaces e a escolha do dispositivo ideal para cada paciente pode ser uma tarefa árdua. Porém não pode ser esquecido que o objetivo principal da utilização da ventilação domiciliar deve ser o controle dos sintomas decorrentes da doença do paciente e consequente melhora da qualidade de vida...

Since mechanical ventilation was widespread after the polio epidemic to the present day with the advancement of diagnostic and therapeutic strategies, a significant increase in survival of critically ill patients. This subgroup of survivors is in a critical state and chronically various etiologies and therapies support, characterized by the need for prolonged mechanical ventilation. Parallel to this fact, population aging increases the chance of hospitalizations requiring invasive mechanical ventilation. Today, home mechanical ventilation is a reality and has become a viable option for patients with chronic respiratory insufficiency, also encouraged by the increasing use of noninvasive positive pressure ventilation, recognition of different types of patients who may benefit from this technique and reduced hospital costs through deinstitutionalization.We currently have various types and models of home mechanical ventilatiors, as well as interfaces and choosing the right device for each patient can be a chore. But it can not be forgotten that the main purpose of using home ventilation is to control the symptoms of the patient’s illness and consequent improvement in quality of life...

Fração de excreção de potássio na evolução da lesão renal aguda em pacientes graves: um potencial marcador a ser monitorizado? / Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool?

Objetivo: Avaliar o comportamento da fração de excreção de potássio durante a evolução da lesão renal aguda em pacientes graves. Métodos: Foram incluídos 168 pacientes como parte de um estudo maior, no qual avaliamos parâmetros sanguíneos e urinários durante a evolução da lesão renal aguda. Foram coletadas diariamente amostras de sangue e urina até a remoção da sonda vesical ou a necessidade de terapia de substituição renal. Descrevemos a evolução da fração de excreção de potássio conforme a presença ou não de lesão renal aguda, sua duração - transitória ou persistente - e gravidade (com base no estágio Acute Kidney Injury Network - AKIN). Foi também avaliado o desempenho diagnóstico da fração de excreção de potássio no dia do diagnóstico da lesão renal aguda, para prever a sua duração e a necessidade de terapia de substituição renal. Resultados: A fração de excreção de potássio foi significativamente maior na lesão renal aguda persistente do que na transitória no dia do diagnóstico da lesão renal aguda (24,8 versus 13,8%; p<0,001). Ambos os grupos tiveram aumento de sua fração de excreção de potássio mediana nos 2 dias que precederam o diagnóstico de lesão renal aguda. Pacientes que não desenvolveram mantiveram níveis baixos e estáveis de fração de excreção de potássio. A fração de excreção de potássio, no dia do diagnóstico de lesão renal aguda, demonstrou razoável precisão em prever lesão renal aguda persistente (área sob a curva: 0,712; intervalo de confiança de 95%: 0,614-0,811; p<0,001). A área sob ...

Objective: To evaluate the behavior of fractional excretion of potassium in the course of acute kidney injury in critically ill patients. Methods: As part of a larger study in which we have evaluated blood and urinary parameters in the course of acute kidney injury, 168 patients were included. Blood and urine samples were collected daily until the removal of the urinary catheter or the initiation of renal replacement therapy. We describe the evolution of fractional excretion of potassium based on whether acute kidney injury was diagnosed, its duration (transient or persistent) and its severity (creatinine-based Acute Kidney Injury Network - AKIN stage). The diagnostic performance of fractional excretion of potassium in predicting the duration of acute kidney injury and the need for renal replacement therapy on the day of acute kidney injury diagnosis was also evaluated. Results: Fractional excretion of potassium was significantly higher in persistent acute kidney injury compared to transient acute kidney injury on the day of acute kidney injury diagnosis (24.8 vs. 13.8%, p<0.001). Both groups had the median fractional excretion of potassium increasing in the two days preceding the acute kidney injury diagnosis. Patients without acute kidney injury had stable low fractional excretion of potassium values. The fractional excretion of potassium was fairly accurate in predicting persistent acute kidney injury (area under the curve: 0.712; 95% confidence interval: 0.614-0.811; p<0.001) on the day of acute kidney injury diagnosis. The area under the curve was 0.663 (95% confidence interval: 0.523-0.803; p=0.03) for renal replacement therapy. The fractional excretion of potassium increased with maximum AKIN stage reached, in both transient and persistent acute kidney injury. Conclusion: Sequential fractional excretion of potassium assessment appears to be useful in critically ill patients at risk for acute kidney injury. .

A clinical analysis of 188 cases of pregnancy complicated with critically heart disease / 中南大学学报(医学版)

Objective: To investigate the factors that affect the outcome of pregnancies complicated with critically heart disease admitted to obstetric Intensive Care Unit (ICU). Methods: A retrospective study was conducted for 188 pregnant and postpartum patientscomplicated with heart disease who were admitted to the ICU in West China Second University Hospital from July 2009 to March 2013. Results: During the 4 years, there were 619 cases of pregnancy complicated with heart disease hospitalization. Among them, 188 (30.37%) patients complicated with severe heart disease were admitted to the ICU, accounting for 39.17% of the total ICU admission (480); the mean maternal age was (28.45±6.08) years old and the mean gestational time was (36.03±4.19) weeks. 23 (12.23%) patients received regular antenatal care in our hospital. 61 (32.45%) patients never received antenatal care before hospitalization. Among them, 5 patients were dead. hTe ratio for diagnosis of heart disease before pregnancy, during pregnancy and atfer admission were 39.89%, 25.54% and 34.57%, respectively; the most common heart diseases during pregnancy were congenital cardiac disease (80, 42.55%) and rheumatic heart disease (45, 23.94%) followed by arrhythmias (20, 10.64%). The most common complication were pulmonary arterial hypertension (51, 27.13%), arrhythmias (47, 25.00%) and severe heart failure (30, 15.96%); the cardiac function of 164 (87.23%) patients was at stage I–II and 5 (2.66% ) patients died when discharged from hospital. 151 (80.32%) patients received multidisciplinary consultation and 34 (18.09%) used central venous catheterization to control central venous pressure (CVP). 21 (11.17%) patients required mechanical ventilation. 11 (5.85%) patients required emergency life support (cardiopulmonary resuscitation 9 + electric deifbrillation 3). Conclusion: Pregnancy complicated with heart disease is the leading reason for admission to ICU. hTe congenital cardiac disease, rheumatic heart disease and arrhythmias are the main heart diseases during pregnancy. Multidisciplinary cooperation and intensive care are the key measures to improve the outcomes of patients with critically illness. It is very important for reduction of the maternal mortality rate through strengthening preconception care and antenatal care.

Percutaneous Dilatational Tracheostomy / 결핵및호흡기질환

For decades, the standard technique for tracheostomy was the open, surgical technique. However, during the past 20 years, the use of percutaneous dilatational tracheostomy has been increased and shown to be a feasible and safe procedure in critically ill patients. The purpose of this report is to review the percutaneous dilatational tracheostomy technique, describe the role of bronchoscopy as guidance for the procedure, and identify the available evidences comparing percutaneous dilatational tracheostomy to surgical tracheostomy.