Correlation Between Central Vein Smoke Ultrasonography and Thrombus Elasticity Graphy in Severe Patients.

Objective: The objective of this study was to analyze the correlation between central vein smoke ultrasonography (CVSU) and thrombus elasticity graphy (TEG). Methods: A retrospective analysis was made on 300 severe patients with smoky echo changes (SECs) in the internal jugular and femoral veins who were admitted to the hospital from January 2021 to March 2022. According to the ultrasound results, all patients were divided into Group A (n = 75), Group B (n = 75), Group C (n = 75), and Group D (n = 75). TEG examination, ultrasound examination, routine coagulation test were received. The coagulation function and TEG index were compared and analyzed in each group, and their correlation was analyzed. Results: The trends of R value and K value of TEG index of patients in different groups were the same. The R value and K value in group D were the highest, followed by group C, and the lowest in group A; while those in groups C and D exhibited great differences with P < .05 to those in groups A and B. The PT, TT, APTT, and FIB of patients in groups C and D were much higher based on the values in groups A and B. R-value was positively correlated with APACHEII (0.678), TT (0.198), and APTT (0.187), and negatively associated with PT (-0.008), D-D (-0.315), and FDP (-0.298). K value presented a positive correlation with APACHEII (0.692) and TT (0.342) but a negative correlation with PT (-0.187), APTT (-0.053), D-D (-0.497), and FDP (-0.453). Positive correlations were observed between α and PT (0.198), APTT (0.046), D-D (0.602), and FDP (0.532), while negative correlations were found between α and APACHEII (-0.398) and TT (-0.315). MA was positively correlated with PT, D-D, and FDP but negatively with APACHEII, TT, and APTT. Conclusion: TEG parameters had an obvious correlation with the coagulation function test, which can effectively evaluate the CVSU in severe patients. The ultrasonic signs can be undertaken as clinical hypercoagulability detection indicators in severe patients and intervention indicators for early thrombosis prevention in the future, they can guide clinicians to make the best treatment plan for severe patients.

Bedside Ultrasound-guided Nasointestinal Tube Placement in Critically Ill Patients in Intensive Care Unit.

Objective: To verify the efficacy and safety of bedside ultrasound-guided nasointestinal tube (NIT) placement techniques in critically ill patients in the ICU. Methods: 100 Critically ill patients were selected and were randomly enrolled into a bedside ultrasound guidance (BUG) group (BUG guiding the NIT placement) and a traditional blind insertion (TBI) group, with 50 cases in both. The efficacy and safety of these tube placements were compared. Results: The success rate of intubation in the BUG group (74%) was higher than that in the TBI group (44%). The proportion of patients in the BUG group who had catheterization sites in the intestine (72%) was higher than that in the TBI group (46%) (P < .05). The average number of tube insertions and mean time of successful intubation time in the BUG group was slightly higher than those in the TBI group [(1.22 ± 0.00) times vs. (1.20 ± 1.00) times and (24.40 ± 0.50) min vs. (20.72 ± 0.50) min) (P > .05) respectively]. Conclusions: Bedside ultrasound-guided nasojejunal tube has a good outcome in ICU patients with critical conditions, can improve the success rate of intubation, and has a certain safety.

Daily point-of-care ultrasound-assessment of central venous catheter-related thrombosis in critically ill patients: a prospective multicenter study.

PURPOSE: Central venous catheter (CVC)-related thrombosis (CRT) is a known complication in critically ill patients. However, its clinical significance remains unclear. The objective of the study was to evaluate the occurrence and evolution of CRT from CVC insertion to removal. METHODS: A prospective multicenter study was conducted in 28 intensive care units (ICUs). Duplex ultrasound was performed daily from CVC insertion until at least 3 days after CVC removal or before patient discharge from the ICU to detect CRT and to follow its progression. CRT diameter and length were measured and diameter > 7 mm was considered extensive. RESULTS: The study included 1262 patients. The incidence of CRT was 16.9% (95% confidence interval 14.8-18.9%). CRT was most commonly found in the internal jugular vein. The median time from CVC insertion to CRT onset was 4 (2-7) days, and 12% of CRTs occurred on the first day and 82% within 7 days of CVC insertion. CRT diameters > 5 mm and > 7 mm were found in 48% and 30% of thromboses. Over a 7-day follow-up, CRT diameter remained stable when the CVC was in place, whereas it gradually decreased after CVC removal. The ICU length of stay was longer in patients with CRT than in those without CRT, and the mortality was not different. CONCLUSION: CRT is a frequent complication. It can occur as soon as the CVC is placed and mostly during the first week following catheterization. Half of the thromboses are small but one-third are extensive. They are often non-progressive and may be resolved after CVC removal.

Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study.

BACKGROUND: Subclavian vein puncture is commonly used in the intensive care unit (ICU) but is associated with complications. OBJECTIVE: Our aim was to compare the efficacy and safety of static ultrasound-guided subclavian vein puncture with traditional anatomical landmark-guided subclavian vein puncture in critically ill patients in the ICU. METHODS: This pilot randomized controlled trial enrolled patients admitted to the ICU and requiring subclavian vein puncture between November 2017 and September 2018. The patients were randomized to ultrasound-guided puncture or anatomical landmark-guided puncture. The primary outcome measure was the puncture success rate. The secondary outcome measures included the number of punctures, rate of success at the first attempt, puncture time (i.e., procedure duration) and incidence of complications. RESULTS: A total of 194 patients were included in the analyses. Compared with the anatomical landmarks group, the ultrasound group had a higher puncture success rate (91.7% vs. 77.6%; p = 0.007), lower rate of complications (7.3% vs. 20.4%; p = 0.008), and lower incidence of mispuncture of an artery (2.1% vs. 14.3%; p = 0.002). There were no significant differences in the number of punctures and puncture time between the two groups (both, p > 0.05). CONCLUSIONS: Static ultrasound-guided subclavian vein puncture is superior to the traditional landmark-guided approach for critically ill patients in the ICU. It is suggested that static ultrasound-guided puncture techniques should be considered for subclavian vein puncture in the ICU. TRIAL REGISTRATION: ChiCTR1900024051.

A radiopharmaceutical [89Zr]Zr-DFO-nimotuzumab for immunoPET with epidermal growth factor receptor expression in vivo.

INTRODUCTION: The potential of the positron-emitting zirconium-89 (89Zr) (t1/2 = 78.4 h) has been recently reported for immune positron emission tomography (immunoPET) radioimmunoconjugates design. In our work, we explored the optimized preparation of [89Zr]Zr-DFO-nimotuzumab, and evaluated 89Zr-labeled monoclonal antibody (mAb) construct for targeted imaging of epidermal growth factor receptor (EGFR) overexpressed in glioma. METHODS: To optimize the radiolabeling efficiency of 89Zr with DFO-nimotuzumab, multiple immunoconjugates and radiolabeling were performed. Radiolabeling yield, radiochemical purity, stability, and activity assay were investigated to characterize [89Zr]Zr-DFO-nimotuzumab for chemical and biological integrity. The in vivo behavior of this tracer was studied in mice bearing subcutaneous U87MG (EGFR-positive) tumors received a 3.5 ±â€¯0.2 MBq/dose using PET/CT imaging. One group mice bearing subcutaneous U87MG (EGFR-positive) tumors received [89Zr]Zr-DFO-nimotuzumab (3.5 ±â€¯0.2 MBq, ~3 µg) (nonblocking) for immunoPET; the other group had 30 µg predose (blocking) of cold nimotuzumab 24 h prior to [89Zr]Zr-DFO-nimotuzumab. RESULTS: [89Zr]Zr-DFO-nimotuzumab was prepared with high radiochemical yield (>90%), radiochemical purity (>99%), and specific activity (115 ±â€¯0.8 MBq/mg). In vitro validation showed that [89Zr]Zr-DFO-nimotuzumab had an initial immunoreactive fraction of 0.99 ±â€¯0.05 and remained active for up to 5 days. A biodistribution study revealed excellent stability of [89Zr]Zr-DFO-nimotuzumab in vivo compared with 89Zr as a bone seeker. High uptake in the liver and heart and modest penetration in the brain were observed, with no significant accumulation of activity in other organs. ImmunoPET studies also indicated prominent image contrast that remarkably high uptake up to ~20%ID/g for nonblocking and ~2%ID/g for blocking in tumor between 12 and 120 h after administration. CONCLUSION: These studies developed a radiopharmaceutical [89Zr]Zr-DFO-nimotuzumab with optimized synthesis. The potential utility of [89Zr]Zr-DFO-nimotuzumab in assessing EGFR status in glioma was demonstrated in this study.

Combining regional oxygen saturation and lactate to predict early postoperative outcome in children undergoing congenital cardiac surgery / 中国胸心血管外科临床杂志

@#Objective    To assess the predictive abilities of postoperative regional oxygen saturation (rSO2) measured by near-infrared spectroscopy (NIRS) and lactate level for early postoperative outcome in children undergoing congenital heart disease surgery. Methods    A total of 73 children (43 males, 30 females, mean age of 91±18 days) undergoing cardiovascular surgery were enrolled from December 2016 to September 2017. The 73 children were divided into an early poor outcome group and a without poor outcome group. Binary logistic regression method was used to determine the independent factors of predicting early poor outcome. Receiver operating characteristic curve was used to identify the optimal cutoff values. Results    The early poor outcome rate was 47%. By regression analyses, nadir splanchnic rSO2 values, peak lactate level were 2 independent factors of predicting poor outcome. For nadir splanchnic rSO2 alone, the area under the ROC curve for poor outcome were 0.897. For peak lactate alone, the area under the ROC curve for poor outcome was 0.867. After combination of nadir splanchnic rSO2 and peak lactate, the area under the ROC curve for poor outcome increased to 0.944 (P<0.05). Conclusion    Combining the parameter of nadir splanchnic rSO2 and peak lactate during the first postoperatively 24 hours yielded to a more accurate predictive ability for early outcome in children undergoing congenital cardiac surgery.

Beneficial effect of exogenous surfactant in infants suffering acute respiratory distress syndrome after cardiac surgery.

OBJECTIVES: The efficiency of exogenous pulmonary surfactant for pediatric patients suffering acute respiratory distress syndrome after cardiac surgery remains indeterminate. This study explored (1) whether use of exogenous surfactant improved recovery for patients suffering postoperative acute respiratory distress syndrome and (2) whether kinetic analysis of pulmonary functional change was helpful to indicate an appropriate dosing scheme. METHODS: Pediatric patients receiving an exogenous surfactant due to acute respiratory distress syndrome after cardiac surgery for congenital heart defects were reviewed from chart records. They were compared with patients without its use despite the same postoperative complication. Oxygenation index and ventilation index were calculated and fitted with a monoexponential function before and after its use. Other outcomes including chest radiography, duration of mechanical ventilation, and intensive care unit and hospital stay were also analyzed. RESULTS: All patients developing postoperative acute respiratory distress syndrome were infants. Among them, 19 infants received surfactant administration (Curosurf, 100 mg kg⁻¹, treatment group). Twenty-four infants without its administration served as control, though also suffering from the same complication. All infants receiving surfactant survived, whereas three infants in the control group died. The duration of mechanical ventilation or hospital stay was significantly shorter after surfactant administration. The infants received either one (n = 13, one-dose subgroup) or two doses (n = 6, two-dose subgroup) before successful weaning from the ventilator. After the first dose was administered, the maximal rates of oxygen index and ventilation index change were significantly higher for infants in the one-dose subgroup (oxygen index: 2.3 ± 0.9 vs 0.8 ± 0.7, p = 0.009, ventilation index: 12.9 ± 3.8 vs 3.9 ± 2.5, p = 0.007). Shortly thereafter (< 12 h), both parameters in the two-dose subgroup deteriorated and a second dose was administered 24h later. CONCLUSIONS: Exogenous pulmonary surfactant is an efficient medication for infants suffering acute respiratory distress syndrome after cardiac surgery. Kinetics analysis of functional change after initial surfactant use may be referred for early determination of an optimal dosing scheme.

Nitric oxide in conjunction with milrinone better stabilized pulmonary hemodynamics after Fontan procedure.

Inhaled nitric oxide (iNO) has been used for patients with increased pulmonary vascular resistance (PVR) shortly after Fontan operation, but repeat deterioration of PVR during or shortly after its withdrawal remains a major concern. Milrinone, a phosphodiesterase type 3 (PDE3) inhibitor, can also reduce PVR for postoperative patients with pulmonary hypertension. We hypothesized that iNO, in conjunction with milrinone, can provide additive benefits for pulmonary hemodynamics and reduce the occurrence of iNO withdrawal failure/rebound. Thirty-one patients with marked elevation of transpulmonary pressure gradient (TPG, >10 mm Hg) or central venous pressure (CVP, >15 mm Hg) after modified fenestrated Fontan operation were prospectively randomized into two groups, that is, group iNO (iNO at approximately 10 ppm, n = 15) and group iNO + Mil (iNO at approximately 10 ppm and milrinone at 0.5 microg/kg/min, n = 16). Hemodynamics, arterial blood oxygenation, and occurrence of withdrawal failure/rebound were compared between the two groups. Combined application of iNO and milrinone resulted in (i) more significant decrement of CVP (19.6 +/- 3.5% in group iNO + Mil vs. 15.2 +/- 4.6% in group iNO, P < 0.05) and TPG (18.2 +/- 4.8% in group iNO + Mil vs. 15.3 +/- 2.6% in group iNO, P < 0.05), (ii) more significant increment of systolic systemic arterial pressure (8.7 +/- 2.7% in group iNO + Mil vs. 5.2 +/- 3.1% in group iNO, P < 0.05), and (iii) more significant improvement of arterial oxygen saturation (9.3 +/- 3.2% in group iNO + Mil vs. 6.8 +/- 2.8% in group iNO, P < 0.01). Occurrence of iNO withdrawal failure during its weaning or rebound after its discontinuation was significantly lower in group iNO + Mil. The combined use of iNO and milrinone provided additive benefits as compared with exclusive use of iNO for patients with elevated PVR after Fontan procedure.

Nitric oxide and milrinone: combined effect on pulmonary circulation after Fontan-type procedure: a prospective, randomized study.

BACKGROUND: Early morbidity and mortality after Fontan operations are related to the elevation of postoperative pulmonary vascular resistance. Inhalation of nitric oxide (iNO) and intravenous milrinone are two options capable of reducing pulmonary vascular resistance. We hypothesized that their combined use could maximally stabilize the pulmonary circulation after Fontan operation. METHODS: Forty-six patients with high pulmonary vascular resistance (transpulmonary pressure gradient >10 mm Hg or central venous pressure >15 mm Hg) and impaired oxygenation after Fontan operation were prospectively randomized into three groups: group Mil (n = 15, milrinone at 0.5 microg x kg(-1) x min(-1)), group iNO (n = 15, iNO at <20 ppm), and group iNO + Mil (n = 16, iNO plus Mil). Pulmonary hemodynamic and oxygenation changes were compared among the three groups. RESULTS: Inhalation of nitric oxide with milrinone led to (1) the most significant reduction of pulmonary vascular resistance (transpulmonary pressure gradient from 11.26 +/- 1.40 mm Hg [baseline] to 7.93 +/- 0.90 mm Hg [24-hour use] in group iNO + Mil versus from 11.10 +/- 1.38 to 8.69 +/- 0.86 mm Hg; p = 0.048 in group iNO and from 11.17 +/- 1.41 mm Hg to 9.72 +/- 1.32 mm Hg; p < 0.001 in group Mil); (2) the most significant improvement of arterial blood oxygenation (ratio of arterial oxygen partial pressure to inspired fraction of oxygen from 68.88 +/- 14.09 to 131.25 +/- 15.92 in group iNO + Mil versus from 70.07 +/-14.24 to 120.20 +/- 15.92; p = 0.047 in group iNO and from 72.60 +/- 12.92 to 95.20 +/- 13.49; p < 0.001 in group Mil). Time on mechanical ventilation was shortest in group iNO + Mil (p = 0.043). CONCLUSIONS: Combined use of iNO and milrinone optimally stabilized pulmonary hemodynamics after Fontan operation.

Continuous pulmonary infusion of L-arginine during deep hypothermia and circulatory arrest improves pulmonary surfactant integrity in piglets.

BACKGROUND: The integrity of pulmonary surfactant (PS) is impaired during deep hypothermia and circulatory arrest (DHCA), a preferred bypass strategy for infants undergoing complex cardiac operations, due mainly to bypass-induced systemic inflammation. The requirement of L-arginine, a precursor of nitric oxide, is elevated during acute pulmonary inflammation. We hypothesized that continuous intrapulmonary supplementation of L-arginine during DHCA can maintain the integrity of PS metabolism and thus protect the pulmonary function. METHODS: Sixteen piglets underwent 90-minute circulatory arrest at 18 degrees C before rewarming. During circulatory arrest, antegrade infusion of Ringer's lactate solution alone (n = 8) or containing L-arginine (1 mg/kg/min, n = 8) was initiated into the pulmonary circulation. Disaturated phosphatidylcholine, total phospholipids, and total proteins from tracheal aspirates were measured serially until the experiment ended (4 hours after rewarming). Various variables of pulmonary function were also monitored. RESULTS: L-arginine led to less decrement of disaturated phosphatidylcholine/total phospholipids and disaturated phosphatidylcholine/total proteins after DHCA. At 4 hours after rewarming, L-arginine had significantly mitigated the deterioration of pulmonary static compliance (3.6 +/- 0.5 vs 3.3 +/- 0.3 mL/cm H2O) and partial pressure of arterial oxygen/fraction of inspired oxygen (330 +/- 48 vs 296 +/- 32 mm Hg). Pulmonary retention of water (6.2 +/- 1.0 vs 5.5 +/- 1.2) was significantly reduced. The L-arginine-treated group showed an increase in NO metabolites (NO2-/NO3-) from the pulmonary circulation, the extent of which is correlated to PS content. CONCLUSIONS: Continuous L-arginine supplementation during DHCA attenuated PS depletion and, therefore, ameliorated postoperative pulmonary dysfunction.

Better protection of pulmonary surfactant integrity with deep hypothermia and circulatory arrest.

BACKGROUND: The influence of deep hypothermia with either circulatory arrest (DHCA) or low-flow (DHLF) perfusion on pulmonary surfactant metabolism in neonates undergoing cardiac surgery remains unknown. This study was conducted to determine the influence of either strategy on surfactant metabolism and pulmonary function with neonatal piglet model. METHODS: Sixteen piglets underwent 90-minute deep hypothermia, either with circulatory arrest or low-flow perfusion (30 mL.kg(-1).min(-1)) at 18 degrees C. Disaturated phosphatidylcholine, total phospholipids, and total proteins from tracheal aspirates were measured serially until the end of cardiopulmonary bypass. Lung static compliance, airway resistance, and arterial blood oxygen partial pressure to inspired oxygen fraction were also measured. RESULTS: The DHLF caused more significant decrement of pulmonary static compliance than DHCA (3 +/- 0.4 mL.cmH2O(-1) vs 3.5 +/- 0.3 mL.cmH2O(-1) at 90 minutes of deep hypothermia). Arterial blood oxygen partial pressure to inspired oxygen fraction decreased more significantly after cardiopulmonary bypass in the DHLF group than the DHCA group (205 +/- 84 mm Hg vs 302 +/- 96 mm Hg). The DHLF caused more severe decrement of disaturated phosphatidylcholine total phospholipids (50% +/- 21% vs 67% +/- 23% of baseline at 90 minutes of deep hypothermia) and disaturated phosphatidylcholine total proteins (58% +/- 23% vs 73% +/- 23% of baseline at 90 minutes of deep hypothermia) than DHCA. More significant water retention developed in the lung in the DHLF group than in the DHCA group. The extent of surfactant depletion was statistically correlated with the extent of pulmonary functional deterioration in either group. CONCLUSIONS: The DHCA induces less injury on pulmonary surfactant metabolism and pulmonary function than DHLF.