[A preliminary study on the classification and prognosis of microcirculation alterations in patients with septic shock].

Objective: To explore the correlation between different types of microcirculation alterations and the prognosis in patients with septic shock. Methods: This research employed a prospective observational study methodology for selecting subjects with septic shock. Side-stream dark field(SDF) was used to monitor the sublingual microcirculation to determine the total vascular density (TVD), perfused vessel density (PVD), the proportion of perfused vessels (PPV), and the microvascular flow index (MFI), heterogeneity index (HI) indicators. At the bedside, patients with microcirculation disorders were divided into four types: stasis, dilution, heterogeneity, and hyperdynamic. The 30-day survival status after enrollment and hemodynamics parameters were recorded. Results: A total of 64 patients with septic shock were selected in the study, including 18 cases of stasis type, 11 of dilution type, 18 of heterogeneous type, and 17 of hyperdynamic type. There were statistical differences in the mean arterial pressure (MAP) [stasis:(77±9) mmHg (1 mmHg=0.133 kPa), dilution:(80±11) mmHg, heterogeneity: (78±12) mmHg, hyperdynamic:(88±12) mmHg], TVD [ stasis:(10.84±3.01) mm/mm2, dilution:(9.64±1.72) mm/mm2, heterogeneity:(11.39±2.18) mm/mm2, hyperdynamic: (11.87±2.67) mm/mm2 ], PVD [stasis:(5.93±1.94) mm/mm2, dilution:(6.86±1.48) mm/mm2, heterogeneity: (8.31±1.78) mm/mm2, hyperdynamic:(9.68±2.46) mm/mm2], PPV [stasis:52.45 (46.25, 63.33)%, dilution:73.70 (61.50, 75.20)%, heterogeneity: 71.25 (67.95, 77.00)%, hyperdynamic:80.70 (77.25, 86.45)%], MFI(stasis:1.34±0.45, dilution: 1.70±0.38, heterogeneity:1.82±0.28, hyperdynamic:2.25±0.33), and HI [stasis:0.68 (0.51, 1.87), dilution: 0.57 (0.49, 0.64), heterogeneity:0.70 (0.59, 0.91), hyperdynamic: 0.40 (0.37, 0.52)] of the four types of microcirculation alterations. The cumulative survival rates in stasis, dilution, heterogeneity and hyperdynamic types at 30 day were 7/18, 4/11, 10/18 and 14/17, respectively, which in stasis and dilution types was significantly lower than that of hyperdynamic type (χ²=7.221, P=0.007;χ2=6.764, P=0.009). Multivariate Cox regression analysis showed the type of microcirculation alterations (stasis:RR=4.551, 95%CI 1.228-16.864, P=0.023; dilution:RR=4.086, 95%CI 1.011-16.503, P=0.048), acute physiology and chronic health evaluation Ⅱ (RR=1.077, 95%CI 1.006-1.153, P=0.032) were independent prognostic risk factors. Conclusions: Microcirculation alterations are common in patients with septic shock, and it is hard to predict the types of microcirculation alterations with hemodynamics parameters. The prognosis of patients with septic shock is related to the types of microcirculation alterations, suggesting that routine monitoring of microcirculation might be helpful to guide hemodynamic therapy.

[A preliminary study on the evaluation of diaphragm function by ultrasound in patients with invasive mechanical ventilation].

Objectives: To study the feasibility of using ultrasound to evaluate diaphragm function in patients with invasive mechanical ventilation. Methods: From March to December 2017, 40 adult patients with acute respiratory distress syndrome who were admitted to the Department of Critical Care Medicine, Xiangya Hospital, Central South University for more than 48 hours were included. Diaphragmatic excursion and thickness of bilateral anterior, middle and posterior parts were measured by ultrasound for 5 consecutive days. Results: (1) Compared with the diaphragmatic excursion of the right [anterior: (11.05±3.04) mm; middle: (12.08±2.71) mm; posterior: (11.51±3.33) mm] and left [anterior: (13.63±7.52) mm; middle: (15.44±7.52) mm; posterior: (14.76±6.93) mm] sides on day 1, the diaphragmatic excursion of the right [anterior: (8.90±3.65) mm; middle: (10.02±4.24) mm; posterior: (10.25±4.38) mm] and left [anterior: (9.82±1.96) mm; middle: (11.60±1.13) mm; posterior: (11.52±1.98) mm] sides decreased significantly on day 3 (P<0.05). Bilateral anterior, middle and posterior diaphragmatic excursion recovered on day 5, and was higher than the baseline levels on day 1, with the left middle and posterior diaphragmatic excursion changing most significantly. (2) Compared with day 1, 2, 3, the thickening fraction of bilateral anterior, middle and posterior diaphragm were significantly decreased on day 4, with the left middle part [day 1: (33.87±14.34)%; day 2: (37.26±13.91)%; day 3: (30.56±14.27)%; day 4: (15.53±5.68)%] and the left posterior part [day 1: (35.50±15.69)%; day 2: (39.84±15.32)%; day 3: (29.06±14.96)%; day 4: (13.30±5.79)%] changing most significantly (P<0.05). The thickening fractions of left anterior, middle and posterior diaphragm recovered on day 5 compared with that on day 4, but still lower than those on day 1 (P<0.05). Conclusions: It is feasible to evaluate the diaphragm function in patients with invasive mechanical ventilation by ultrasound, which can provide guidance for preventing diaphragmatic atrophy and withdrawing from mechanical ventilation.

[The clinical significance of transcranial Doppler in early diagnosis of sepsis-associated encephalopathy].

Objective: To investigate the clinical significance of transcranial Doppler (TCD) in early diagnosis of sepsis-associated encephalopathy(SAE). Methods: Septic patients admitted to the intensive care unit(ICU) were recruited at Xiangya Hospital, Central South University from July 2015 to March 2016. Clinical data and TCD parameters during 24 hours after admission were collected. All patients were screened for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) twice a day. The gold standard of the diagnosis of SAE was positive CAM-ICU evaluation. Patients were divided into SAE group and the non-SAE group. TCD data including systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), pulsatility index (PI) and resistant index (RI) were analyzed to determine the optimal diagnostic cut-off value. Results: A total of 43 patients were enrolled including 12 in SAE group and 31 in non-SAE group. Vm and Vd were lower in SAE group [Vm: (53.50±12.22) cm/s vs. (61.68±9.63) cm/s, P<0.05; Vd: (33.42±10.87) cm/s vs. (43.16±7.84) cm/s, P<0.01] but PI and RI were significant higher in SAE group[PI:(1.16±0.2) vs. (0.90±0.15), P<0.01;RI:(0.65±0.08) vs. (0.56±0.06), P<0.01] than in non-SAE group. The cut-off values of Vs, Vm, Vd, PI and RI for the diagnosis of SAE were 112cm/s, 55.50cm/s, 34.50cm/s, 1.16, 0.65, respectively, with the relevant sensitivities of 19.4%, 83.9%, 93.5%, 58.3%, 58.3% and the specificities of 100.0%, 50.0%, 58.3%, 96.8%, 96.8%, respectively. The diagnostic AUC of Vd, PI and RI were 0.741, 0.808 and 0.808 respectively. Conclusions: The parameter changes of TCD suggest that the pathogenesis of SAE is related to cerebral hypoperfusion, TCD is a helpful method for the early diagnosis of SAE.

[Combining relative alpha variability and electroencephalogram reactivity to predict the prognosis of hypoxic-ischemic encephalopathy in adult patients].

Objective: To evaluate the role of combining relative alpha variability and electroencephalogram (EEG) reactivity to predict the prognosis of hypoxic-ischemic encephalopathy(HIE) in adult patients. Methods: A total of 28 adult patients with HIE admitted to general intensive care unit at Xiangya Hospital in Central South University were enrolled in this observational study from January2016 to April 2017. These patients with body temperature over 35℃ after 72-hour admission could be continuously monitored at least 12 hours byEEG.At the same time,each patient was assessed for EEG reactivity.Then we analyzed the correlation between EEG reactivity, relative alpha variability and clinical prognosis. Results: EEG reactivity was elicited in 15/28 patients, among whom 12 patients had a good outcome. While in the other 13 patients, EEG reactivity was not elicited, among whom only 3 patients had a good outcome. As to the results ofrelative alpha variability,11/13 patients with degree 3-4were of good prognosis; while only 3/15 patients with degree 1-2 were of good prognosis. Glasgow coma scale(GCS), EEG reactivity, and relative alpha variability were correlated with clinical outcome(χ(2)=5.073,9.073,-3.626, respectively,all P<0.05). The sensitivity of GCS, EEG reactivity, and relative alpha variability to predict the poor prognosis were 69.2%, 76.9%, 84.6%, respectively. The specificity were 73.3%, 80.0%, 73.3%, respectively. The consistency rates were 71.4%, 78.6%, 78.6%, respectively. The positive predictive values were 69.2%, 76.9%, 73.3%, respectively. The negative predictive values were 73.3%, 80.0%, 84.6%, respectively. More importantly, the accuracy of the relative alpha variability combined with EEG reactivity for the prediction of poor prognosis was much higher with the positive predictive value of 90.0%,the specificity of 93.3%, the sensitivity of 69.2%, the consistency rate of 82.1%,and the negative predictive values of 77.8%. Conclusions: The combination of relative alpha variability and EEG reactivityis reliable to predict clinical outcome of patients with HIE.

[A survey of fluid therapy in 2 intensive care units].

To explore the present status of fluid therapy and clinical outcome in critically ill patients in intensive care units (ICU). ICU patients consecutively admitted to our ICU were prospectively enrolled. Patients' demographics, laboratory data, fluid record and clinical outcome were collected. Fluid intake quantity of all patients was at peak on the fifth day which was 2 806 (1 997, 3 582) ml. From the fourth day in ICU, fluid balance started to benegative as -84 (-1 127, 612) ml and gradually increased. Crystalloid solution was the main components. For treatment purposes, medication injections and nutrients were major fluids. Positive correlations were found between total fluid intake quantity, total crystalloid volume, total colloidal volume and hospital stay, ICU stay, duration of intubation (r values as 0.211, 0.686, 0.282, 0.155, 0.506, 0.174, 0.209, 0.072, 0.292, respectively P<0.05). Moreover, positive correlations were also demonstrated between total colloidal volume and total bilirubin, direct bilirubin, alanine transaminase, aspartate transaminase, blood urea nitrogen, serum creatinine (r values as 0.196, 0.242, 0.190, 0.335, 0.284, 0.223, respectively P<0.05).

[The diagnostic value of neuron-specific enolase, central nervous system specific protein and interleukin-6 in sepsis-associated encephalopathy].

Objective: To investigate the diagnostic value of neuron-specific enolase(NSE), central nervous system specific protein(S100ß), interleukin-6(IL-6) in sepsis-associated encephalopathy(SAE). Methods: Clinical data of patients admitted to ICU and diagnosed with sepsis were collected from January 2015 to June 2016 in Xiangya Hospital, Central South University. SAE was defined as cerebral dysfunction in the presence of sepsis that also fulfilled the exclusion criteria. The acute physiology and chronic health score (APACHE Ⅱ), sequential organ failure assessment (SOFA), NSE, S100ß, IL-6, ICU stay time and 28-day mortality were compared between the two groups. NSE, S100ß and IL-6 were measured on the 1st and 3rd day in ICU to determine the optimal cut-off value of SAE. Results: Among 59 enrolled patients, 36 were assigned to SAE group while 23 were non-SAE group. The SAE group had a significantly higher APACHE Ⅱ and SOFA scores, as well as the length of ICU stay (P<0.01). The levels of NSE, S100ß and IL-6 in the two groups both increased on the 1st day, and decreased on the 3rd day. The level of NSE on the 1st day[19.28(13.00, 30.52) µg/L vs 16.61(7.58, 22.01 µg/L)] and the 3rd day[16.03(9.40, 21.29) µg/L vs 11.39(8.49, 15.00) µg/L, P=0.029], IL-6 on the 1st day[676.25(81.34, 5 000.00) mg/L vs [209.10(42.27, 648.20) mg/L, P=0.005] and the 3rd day[157.10(72.85, 687.63) mg/L vs 55.92(31.62, 177.00) mg/L, P=0.026] of SAE group was significantly higher than those of non-SAE group. However S100ß between groups on the 1st day [0.33(0.15, 0.54) µg/L vs 0.23(0.16, 0.53) µg/L] and the 3rd day[0.19(0.10, 0.29) µg/L vs 0.10(0.05, 0.17) µg/L] was neither significant (P>0.05). The diagnostic values for SAE of NSE, S100ß and IL-6 were 14.36 µg/L, 0.14 µg/L and 91.305 mg/L with sensitivity 61.1%, 61.1%, 72.2% and specificity 73.9%, 69.6%, 69.6%, respectively. The diagnostic AUC of NSE and IL-6 combination was 0.774, 95%CI 0.651-0.896. Conclusion: All sepsis patients have different degrees of brain injury. NSE combined with IL-6 on the 3rd day in ICU demonstrates the diagnostic significance of SAE.

[The application of Critical Care Chest Ultrasonic Evaluation-plus Protocol in the etiological diagnosis of dyspnea and/or hemodynamic instability caused by abdominal abnormality].

Objective: To investigate the application of Critical Care Chest Ultrasonic Examination (CCUE)-plus (CCUE-plus) in the etiological diagnosis in patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities. Methods: Patients who suffered from dyspnea and/or hemodynamic instability in the Department of Critical Care Medicine, Xiangya Hospital, Central South University from September 2013 to September 2016 were recruited in this study. A total of 255 consecutive patients completed CCUE within 2hrs of admission. If the diaphragm could not be seen in the routine phrenic points according to Bedside Lung Ultrasound Evaluation (BLUE) protocol, it would be found along midaxillary line and defined m-point. The 59 patients with altered diaphragmatic position (m-point was more than 2 cm higher than phrenic point) received sequential abdominal ultrasonography. The latter ultrasonographic findings were compared with CT results. Results: There were 42(71.19%) cases with positive findings of abdominal ultrasonography, including 18 cases of seroperitoneum, 16 cases of intestinal obstruction and 8 cases combined. Compared with 56 patients who applied with CT exam, the abdominal ultrasonography revealed a sensitivity of 76.7% and a specificity of 100.0% to diagnose seroperitoneum (AUC(ROC) 0.917); whereas the sensitivity was 75.0% and the specificity was 90.9% (AUC(ROC) 0.778) to diagnose intestinal obstruction. Moreover, there were 44(74.58%) patients with normal left ventricular systolic function; more than three quarters (46/59, 77.97%) patients had pulmonary consolidation. Conclusion: In patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities and altered diaphragmatic position in BLUE protocol, CCUE-plus protocol has a high positive predictive value of more than 90% in abdominal abnormality. The findings of abdominal ultrasonography may change therapeutic target from cardio-pulmonary optimization to relief of intestinal obstruction or drainage of seroperitoneum.