Changes of peripheral perfusion index in very low birth weight infants with late-onset sepsis / 中国小儿急救医学

Objective:To analyze the changes of peripheral perfusion index (PPI) with late-onset sepsis (LOS) in very low birth weight infants during hospitalization.Methods:Very low birth weight infants admitted to the neonatal intensive care unit of Children′s Hospital of Fudan University from August 1, 2021 to August 31, 2022 were consecutively included.Infants with admission age ≥three days and unstable circulation, or positive blood culture within three days after birth were excluded.From the day of admission, the PPI values of the right hand and either foot of the infants were measured with Masimo SET Radical-7 everyday while whether LOS occurred during hospitalization was observed.The mean PPI curve of very and extremely low birth weight infants without LOS was plotted.For those with LOS confirmed by blood culture, the PPI change trajectory three days before and after the occurrence of LOS was drawn, and the change trend of PPI before the occurrence of LOS was analyzed by trend chi-square test.Non-parametric test was used to analyze the effect of LOS on pre- and post-ductal PPI values.Results:A total of 107 very low birth weight infants were included in the final analysis.Among them, there were 11 infants confirmed as LOS by blood culture, 37 infants diagnosed as clinical LOS, and 59 infants without LOS.Pre-and post-ductal PPI values of very low birth weight infants without LOS were 2.06±1.30 and 1.72±0.92, respectively; those with clinical LOS were 1.90±0.94 and 1.58±0.83, respectively; those with LOS confirmed by blood culture were 1.92±1.11 and 1.62±0.82, respectively.For infants with LOS confirmed by blood culture, the pre-and post-ductal PPI values showed a continuous downward trend during three days before the onset of disease, with the lowest PPI values on the first day before the diagnosis of blood culture.The downtrend of pre-ductal PPI was statistically significant ( χtrend2=5.57, P<0.05). Conclusion:The PPI value of very low birth weight infants show a downward trend when LOS occurs.It should be observed dynamically in clinical practice, which is helpful to suspect or identify LOS as early as possible.

Application of peripheral perfusion index in the screening of congenital heart disease in neonates / 中国小儿急救医学

Congenital heart disease (CHD) is the most common congenital malformations, and critical CHD is one of the main causes of neonatal death and poor prognosis.Early screening and detection of congenital heart disease in newborns is helpful to early intervention and improve prognosis.At present, pulse oximetry alone, pulse oximetry combined with physical examination or pulse oximetry combined with cardiac murmur auscultation in early postnatal screening can detect most of critical CHD, but there are still some false negative results.Peripheral perfusion index (PPI) may have a certain value in finding left ventricular obstructive CHD that can not be found in the current screening methods.Therefore, this review summarized the technical principle and influence factors of PPI, its feasibility and effectiveness in neonatal CHD screening, and the possible threshold of screening, in order to provide a certain basis for PPI screening of neonatal CHD in the future.

Clinical study of fluid resuscitation guided by peripheral perfusion index in patients with septic shock / 中华危重病急救医学

Objective:To explore the guiding effect of peripheral perfusion index (PI) on fluid resuscitation in patients with septic shock.Methods:Sixty-five patients with septic shock who were diagnosed according to relevant criteria of septic shock and admitted to the department of critical care medicine of the Affiliated Hospital of Hangzhou Normal University from September 2017 to December 2020 were included. Patients were divided into the conventional treatment group (30 cases) and PI guidance group (35 cases) by random number method. Both groups of patients were treated with the bundle according to clinical guidelines. Sputum, urine and blood were collected for pathogenic microorganism culture before the application of antibiotics, and vasoactive drugs were given. Both groups need to achieve all the following resuscitation goals within 6 hours: urine output > 0.5 mL·kg -1·h -1, mean arterial pressure (MAP) ≥ 65 mmHg (1 mmHg ≈ 0.133 kPa), central venous pressure (CVP) was 8-12 mmHg, and central venous oxygen saturation (ScvO 2) ≥ 0.70. There was no further resuscitation in the conventional treatment group after the goals were achieved. In addition to these four goals, the PI guidance group was expected to achieve PI≥ 1.4. Heart rate (HR), CVP, MAP, ScvO 2, blood lactic acid (Lac), the time of fluid negative balance, intensive care unit (ICU) mortality and 28-day mortality between the two groups were compared before and after 6 hours of fluid resuscitation. Results:Before fluid resuscitation, there were no statistically significant differences in all indicators between two groups. After 6 hours fluid resuscitation, the four treatment goals in PI guidance group were slightly lower than those of the conventional treatment group [HR (times/min): 96.5±12.1 vs. 97.7±7.9, MAP (mmHg): 83.2±6.2 vs. 82.1±7.5, ScvO 2: 0.661±0.077 vs. 0.649±0.051, CVP (mmHg): 10.8±2.7 vs. 10.4±2.1], there were no statistically significant differences between the two groups (all P > 0.05); the Lac level of the PI guidance group after resuscitation was lower than that of the conventional treatment group, and the difference was statistically significant (mmol/L: 4.8±1.3 vs. 5.9±1.4, P < 0.05); the duration of fluid negative balance in the PI guidance group was earlier than that in the conventional treatment group [days: 3.0 (2.0, 3.0) vs. 3.5 (3.0, 4.0), P < 0.05]. The ICU mortality and 28-day mortality in the PI guidance group were lower than those in the conventional treatment group [ICU mortality rate: 37.1% (13/35) vs. 50.0% (15/30), 28-day mortality rate: 57.1% (20/35) vs. 60.0% (18/30)], but the differences were not statistically significant (both P > 0.05). Conclusions:The peripheral PI can be used as an important indicator of fluid resuscitation in patients with septic shock. PI guiding fluid resuscitation in patients with septic shock can reduce Lac levels, shorten the duration of fluid negative balance and reduce the risk of fluid overload.

The prognostic value of PI combined with Pv-aCO 2 /Ca-vO 2 in patients with septic shock / 中华急诊医学杂志

Objective:To explore the predictive value of peripheral perfusion index (PI) combined with central venous-arterial carbon dioxide tension to arterial-venous oxygen content ratio(Pv-aCO 2/Ca-vO 2)for prognosis after initial resuscitation of septic shock. Methods:A total of 76 cases of patients with septic shock from January 2019 to January 2021 in emergency intensive care unit (EICU) of Harrson international peace hospital affiliated to Hebei Medical University were enrolled. All recovered according to 2016 Severe Sepsis and Septic Shock Treatment International Guidelines 2016 (SSC 2016) , and PI was monitored, central vein and arterial blood gas analysis was performed, and the ratio of Pv-aCO 2/Ca-vO 2 was calculated.The PI and Pv-aCO 2/Ca-vO 2 at 3 h,hemodynamic variables,oxygen metabolism indexes,APACHEⅡ and SOFA score were recorded.Patients were divided into survival group and death group according to 28 d survival condition, the dfferences in demographics and clinical data were compared between two groups.The Kaplan-Meier urviving curve was created and the survival of the patients was analyzed by the Log-rank test. Risk factors associated with the prognosis were analyzed using the Cox regression analysis. The role of PI and Pv-aCO 2/Ca-vO 2 in prediting death was evaluated by receiver operating characteristic curves(ROC). Results:There were 37 cases in survival group and 39 cases in death group.Compared with death group, PI in survival group [(1.77±0.63) vs. (0.89±0.69)]was significantly higher,and Pv-aCO 2/Ca-vO 2[(1.52±0.52) vs. (2.57±0.86)] was significantly lower ( P<0.05). Kaplan-Meier survival curve showed that the median survival time in the high PI group [20.09 d (95% CI:16.95-23.24) vs.11.00d (95% CI:7.14-14.86)] was longer than that in the low PI group(χ 2=12.424, P=0.000),and that in low Pv-aCO 2/Ca-vO 2 group [23.74 d (95% CI:20.35-27.13) vs.12.85d (95% CI:9.75-15.95)] was longer than that in the high Pv-aCO 2/Ca-vO 2 group (χ 2=12.200, P=0.000) .Cox regression analysis showed that both PI ( RR=0.397, 95% CI: 0.230-0.687, P =0.001) and Pv-aCO 2/Ca-vO 2 ( RR=1.878, 95% CI: 1.169-3.019, P =0.009) were predictors of 28 d mortality.The area under the ROC curve of PI and Pv-aCO 2/Ca-vO 2 for predicting 28 d death in patients with septic shock were 0.828 (95% CI: 0.732-0.923) and 0.785 (95% CI: 0.6777-0.893)respectively. The optimal cutoff values were 0.52 (sensitivity 58.3% and specificity 94.4%) and 0.35 (sensitivity 88.9% and specificity 63.9%)respectively, and the AUC of the combined prediction of the two indicators was 0.903 (95% CI: 0.835-0.971). Conclusions:Combination of PI and Pv-aCO 2/Ca-vO 2 is better to predict the risk of adverse outcomes of septie shock patients,and may provide useful information for the resuscitation at early stage.

Temperature gradients in domestic cats over seven-years-old: descriptive analysis / Avaliação descritiva dos gradientes de temperatura em felinos domésticos com mais de sete anos

The temperature gradients are dynamic and noninvasive monitoring techniques that provide information on peripheral blood flow and have been related to the prognosis of patients with circulatory shock. This study evaluated 47 elderly domestic cats' temperature gradients, and we measured central (rectal) and peripheral (palmar, plantar and medial region of the radio) temperatures. Values found in this study are compatible with studies in young felines and differ from dogs and humans. The mean gradients found were 7.5°C for the central-peripheral; 5.6°C for the peripheral-environmental; 2.7°C for the skin-diff; and 0°C for the member-diff and the variables age and gender do not seem to influence these measurements. To the authors' knowledge, there is no description of temperature gradients in elderly domestic cats, so this study pretends to clarify the vasoconstriction response in this group of animals.(AU)

Os gradientes de temperatura são técnicas de monitoração dinâmicas e não-invasivas que fornecem informações sobre o fluxo sanguíneo periférico, e têm sido relacionados ao prognóstico de paciente com choque circulatório. O presente estudo avaliou os gradientes de temperatura em 47 felinos domésticos idosos aferindo as temperaturas central (retal) e periférica (palmar, plantar e região medial do rádio). Os gradientes encontrados foram 7,5°C para o centro-periférico; 5,6°C para o periférico-ambiental; 2,7°C para o skin-diff; e 0°C para o member-diff. As variáveis idade e sexo não pareceram influenciar as mensurações. Não há, em conhecimento dos autores, descrição prévia dos gradientes de temperatura em felinos domésticos idosos, e por isso esse estudo pretende contribuir com o entendimento sobre a capacidade de resposta de vasoconstrição nesse grupo de animais.(AU)

Plano de análise estatística para o estudo do tratamento precoce baseado em metas com utilização de uma visão fisiológica holística - estudo ANDROMEDA-SHOCK: um estudo randomizado e controlado / Statistical analysis plan for early goal-directed therapy using a physiological holistic view - the ANDROMEDA-SHOCK: a randomized controlled trial

RESUMO Fundamentação: O estudo ANDROMEDA-SHOCK é um estudo internacional, multicêntrico, randomizado e controlado comparando ressuscitação guiada pela perfusão periférica com ressuscitação guiada pelo lactato em pacientes com choque séptico, com a finalidade de testar a hipótese de que a ressuscitação guiada pela perfusão periférica associa-se a menor morbidade e mortalidade. Objetivo: Relatar o plano de análise estatística para o estudo ANDROMEDA-SHOCK. Métodos: Descrevemos o delineamento do estudo, os objetivos primário e secundários, pacientes, métodos de randomização, intervenções, desfechos e tamanho da amostra. Descrevemos nossos planos de análise estatística para os desfechos primários, secundários e terciários. Também descrevemos as análises de subgrupos e sensibilidade. Finalmente, fornecemos detalhes para a apresentação dos resultados, inclusive modelos de tabelas para apresentar as características basais, a evolução das variáveis de hemodinâmica e perfusão, e os efeitos dos tratamentos nos desfechos. Conclusão: Segundo as melhores práticas de pesquisa, relatamos nosso plano de análise estatística e plano de gestão de dados antes do fechamento da base de dados e do início da análise dos dados. Nossa expectativa é que este procedimento previna a ocorrência de vieses na análise e incremente a utilidade dos resultados relatados.

ABSTRACT Background: ANDROMEDA-SHOCK is an international, multicenter, randomized controlled trial comparing peripheral perfusion-targeted resuscitation to lactate-targeted resuscitation in patients with septic shock in order to test the hypothesis that resuscitation targeting peripheral perfusion will be associated with lower morbidity and mortality. Objective: To report the statistical analysis plan for the ANDROMEDA-SHOCK trial. Methods: We describe the trial design, primary and secondary objectives, patients, methods of randomization, interventions, outcomes, and sample size. We describe our planned statistical analysis for the primary, secondary and tertiary outcomes. We also describe the subgroup and sensitivity analyses. Finally, we provide details for presenting our results, including mock tables showing baseline characteristics, the evolution of hemodynamic and perfusion variables, and the effects of treatments on outcomes. Conclusion: According to the best trial practice, we report our statistical analysis plan and data management plan prior to locking the database and initiating the analyses. We anticipate that this procedure will prevent analysis bias and enhance the utility of the reported results.

Significance of peripheral perfusion index in early diagnosis and goal-directed therapy of septic shock patients: a prospective single-blind randomized controlled trial / 中华危重病急救医学

Objective To investigate the application of peripheral perfusion index (PPI) in early diagnosis and goal-directed therapy of septic shock, and to provide reference for the early clinical diagnosis and treatment of septic shock. Methods A prospective single-blind randomized controlled trial (RCT) was conducted. Adult patients with sepsis admitted to emergency medical department and intensive care unit (ICU) of the First People's Hospital of Lianyungang City in Jiangsu Province from January 2013 to December 2016 were enrolled. The patients were randomly divided into two groups (n = 46). The PPI group was defined using PPI < 1.4 as diagnosis of septic shock standard, and PPI > 2 as treatment guide target. Control group was defined according to the traditional diagnostic criteria of shock which systolic blood pressure was less than 90 mmHg (1 mmHg = 0.133 kPa) or systolic blood pressure value decrease> 40 mmHg baseline and bundle treatment was performed. The volume of fluid resuscitation, organ dysfunction, the sequential organ failure score (SOFA), acute physiology and chronic health evaluationⅡ (APACHE Ⅱ) score,continuous renal replacement therapy (CRRT) time, mechanical ventilation (MV) time, the length of ICU stay and 28-day mortality were observed. Results There were 39 and 27 septic shock patients in PPI group and control group respectively. The diagnostic criteria of traditional septic shock with blood pressure as "gold standard", the sensitivity of PPI < 1.4 for septic shock was 94.3%, the specificity was 28.2%, the authenticity was 66.3%, the positive predictive value was 64.1%, the negative predictive value was 78.6%, the positive likelihood ratio was 1.31, the negative likelihood ratio was 0.18. The per capita fluid replacement within 24 hours in the PPI group was significantly higher than that in the control group (mL: 4 601±1 250 vs. 3 458±1 006, P < 0.01), but there was no significant difference in the per capita volume of the patients diagnosed as septic shock (mL: 4 596±1 320 vs. 4 205±1 058, P > 0.05). Compared with the control group, the PPI group treated patients within 48 hours with less vascular active drugs (cases: 6 vs. 15), APACHE Ⅱand SOFA score were lower (48 hours: APACHE Ⅱ was 10.2±2.1 vs. 12.0±3.2; 72 hours: SOFA was 5.1±1.8 vs. 6.0±2.1, APACHE Ⅱ was 8.9±1.8 vs. 9.8±2.2), the period of CRRT and the length of ICU stay were shorter [the period of CRRT (days): 3.0±0.9 vs. 3.6±1.4, the length of ICU stay (days): 5.2±2.1 vs. 6.3±2.9), the difference was statistically significant (all P < 0.05). There was no significant difference in the liver and kidney function index, arterial blood lactic acid (Lac), MV time (days: 3.3±1.4 vs. 3.5±1.2) and 28-day mortality (15.22% vs. 19.57%) between two groups (all P > 0.05). Conclusions The inadequacy of microcirculatory perfusion by oximetry-derived PPI is more sensitive to the diagnosis of septic shock than hypotension of systemic circulation. With PPI guiding the fluid resuscitation of septic shock patients, vasopressors can be withdrawn earlier and the duration of the CRRT and ICU can be decreased.