A nomogram prognostic model for diffuse large B-cell lymphoma based on SUVmax and GNRI in elderly patients.

To establish a nomogram for elderly patients with diffuse large B-cell lymphoma (DLBCL) based on nutritional and imaging features. The data of 221 elderly pretreatment DLBCL patients were retrospectively analyzed. All cases were randomly separated into the training group and validation group. A nomogram was built based on the results of multivariate analysis. A nomogram was established based on maximum standardized uptake value (SUVmax), geriatric nutritional risk index (GNRI), and lactate dehydrogenase. The concordance index (C-index) of the nomogram was 0.772 for the training group and 0.729 for the validation group, and similar results were found in the area under the curve (AUC). The calibration curve showed favorable consistency between prediction and real survival. The decision curve analysis (DCA) also showed that the nomogram had favorable clinical effectiveness. The new risk-stratification model divided patients into three groups with obvious survival. The C-index and AUCs for the new model were greater than those of IPI and NCCN-IPI. The DCA curve suggested that the new model had better clinical effectiveness than the IPI and NCCN-IPI. The nomogram prognostic model based on SUVmax and GNRI performed superior to NCCN-IPI and equal to IPI for risk stratification of elderly DLBCL patients.

Effects of Shen-Fu injection on mitochondrial function in the intestinal epithelial cells of rats with endotoxemia.

Recently, several studies have demonstrated that reactive oxygen species are responsible for inducing multiple organ failure and septic shock. Particularly, mitochondrial dysfunction has been demonstrated in the pathogenesis of multiple organ dysfunction syndrome (MODS). In cytopathic hypoxia, impairment of mitochondrial oxidative phosphorylation decreases aerobic adenosine triphosphate (ATP) production and potentially induces MODS. Shen-Fu (SF) injections are widely used in the treatment of various diseases. SF exhibits cardiovascular protective effects. For example, it can stretch the coronary artery, stabilize blood pressure, regulate IRI, and improve the overall heart function. Clinical studies have demonstrated that SF injections have notable therapeutic effects on septic and hemorrhagic shocks. In the present study, the effects of SF injection on mitochondrial function in the intestinal epithelial cells of rats with endotoxemia were analyzed.

Economic variations in patterns of care and outcomes of patients receiving invasive mechanical ventilation in China: a national cross-sectional survey.

BACKGROUND: Ventilation practice may be affected by economic variations, which might result in different outcomes to mechanically ventilated patients. We aimed to investigate the important effect of economic variations in patients with mechanical ventilation (MV) in China. METHODS: We carried out a national prospective multicentre cross-sectional observational study over 1 month of all patients receiving invasive MV for more than 24 hours in 20 intensive care units (ICUs), including patient characteristics, practice of MV, weaning modalities and outcomes, including probability of weaning and survival. Based on the 2012 World Bank classification of counties, patients were divided into high-income and middle-income groups according to gross domestic product per capita in their province of origin. RESULTS: Of the 483 patients enrolled, 291 (60.2%) were from high-income provinces and 192 (39.8%) were from middle-income provinces. Tidal volume, peak pressure, plateau and driving pressure were significantly lower, and the proportion of patients receiving protective ventilation (71.1% vs. 59.9%, P=0.014) was significantly higher in the high-income group than in the middle-income group. The probability of weaning within 28 days was significantly greater in the high-income group than in the middle-income group (P=0.046). Patients in the high-income group had significantly higher median numbers of ventilator-free days within 14 and 28 days than those in the middle-income group (P<0.05). Although the patients did not differ in terms of their demographics, survival within 28 days was significantly higher in the high-income group than in the middle-income group (P=0.025). Driving pressure, positive end-expiratory pressure and spontaneous breathing trial were independently associated with hospital mortality. CONCLUSIONS: Important economic differences exist in the management of MV and patient outcomes. Higher income is associated with a higher proportion of protective ventilation, lower driving pressure, shorter weaning and better survival in mechanically ventilated patients in China.

Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial.

PURPOSE: Noninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure. METHODS: Highly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early or standard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality. RESULTS: We enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0-7.0) vs. 5.5 (4.0-9.0) days, respectively, p = 0.004], while ICU LOS was not significantly different [8.0 (6.0-12.0) vs. 9.0 (6.5-12.5) days, respectively (p = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p = 0.001), and hospital LOS, 20 (13-32) vs. 27(18-39) days (p = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies. CONCLUSIONS: In highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.

A modified acute respiratory distress syndrome prediction score: a multicenter cohort study in China.

BACKGROUND: Early recognition of the risks of acute respiratory distress syndrome (ARDS) and prevention of the development of ARDS may be more effective in improving patient outcomes. We performed the present study to determine the ARDS risk factors in a Chinese population and validate a score to predict the development of ARDS. METHODS: This was an observational multicenter cohort study performed in 13 tertiary hospitals in China. Patients admitted into participating intensive care units (ICUs) from January 1 to January 31, 2012, and from January 1 to January 10, 2013, were enrolled in a retrospective derivation cohort and a prospective validation cohort, respectively. In the derivation cohort, the potential risk factors of ARDS were collected. The confirmed risk factors were determined with univariate and multivariate logistic regression analyses, and then the modified ARDS prediction score (MAPS) was established. We prospectively enrolled patients to verify the accuracy of MAPS. RESULTS: A total of 479 and 198 patients were enrolled into the retrospective derivation cohort and the prospective validation cohort, respectively. A total of 93 (19.4%) patients developed ARDS in the derivation cohort. Acute pancreatitis, pneumonia, hypoalbuminemia, acidosis, and high respiratory rate were the risk factors for ARDS. The MAPS discriminated patients who developed ARDS from those who did not, with an area under the curve (AUC) of 0.809 [95% confidence interval (CI), 0.758-0.859, P<0.001]. In the prospective validation cohort, performance of the MAPS was similar to the retrospective derivation cohort, with an AUC of 0.792 (95% CI, 0.717-0.867, P<0.001). The lung injury prediction score (LIPS) showed a predicted value of an AUC of 0.770 (95% CI, 0.728-0.812, P<0.001) in our patients, which was significantly lower than our score (P<0.046). CONCLUSIONS: The MAPS based on risk factors could help the clinician to predict patients who will develop ARDS. TRIAL REGISTRATION: ClinicalTrials.gov NCT01666834.

Practice of diagnosis and management of acute respiratory distress syndrome in mainland China: a cross-sectional study.

BACKGROUND: Although acute respiratory distress syndrome (ARDS) has been recognized for more than 50 years, limited information exists about the incidence and management of ARDS in mainland China. To evaluate the potential for improvement in management of patients with ARDS, this study was designed to describe the incidence and management of ARDS in mainland China. METHODS: National prospective multicenter observational study over one month (August 31st to September 30th, 2012) of all patients who fulfilled the Berlin or American European Consensus Conference (AECC) definition of ARDS in 20 intensive care units, with data collection related to the management of ARDS, patient characteristics and outcomes. RESULTS: Of the 1,814 patients admitted during the enrollment period, 149 (8.2%) and 147 (8.1%) patients were diagnosed by AECC and Berlin definition, respectively. Lung protective strategy with low tidal volume (Vt) (≤8 mL/kg) and limitation of the plateau pressure (Pplat) (≤30 cmH2O) was performed in 75.2% patients. And, 36%, 21.1% and 4.1% patients with severe, moderate and mild ARDS had the driving pressure more than 14 cmH2O (P<0.05). Pplat and driving pressure increased significantly in patients with a higher degree of ARDS severity (P=0.002 and P<0.001, respectively), but Vt were comparable in the three groups (P>0.05). In severe ARDS, patient median positive end expiratory pressure (PEEP) was 10.0 (8.0-11.3) cmH2O and median FiO2 was 90%. A recruitment maneuver was performed in 35.5% of the patients, and 8.7% of patients with severe ARDS received prone position. Overall hospital mortality was 34.0%. Hospital mortality was 21.8% for mild, 31.1% for moderate, and 60.0% for patients with severe ARDS (P=0.004). CONCLUSIONS: Despite general acceptance of low Vt and limited Pplat, high driving pressure, low PEEP and low use of adjunctive measures may still be a concern in mainland China, especially in patients with severe ARDS. TRIAL REGISTRATION: ClinicalTrials.gov NCT01666834; date of registration release: August 14th 2012.

Experimental study of airway pressure release ventilation in the treatment of acute respiratory distress syndrome.

Airway pressure release ventilation (APRV) is a ventilator mode which has demonstrated potential benefits in acute respiratory distress syndrome (ARDS) patients. We therefore sought to compare relevant pulmonary data and safety outcomes of this mode to the conventional ventilation and sustained inflation. Canines admitted after intravenous injection of oleic acid requiring mechanical ventilation were randomly divided into 3 groups (n=6), namely conventional ventilation group, low tidal volume ventilation with recruitment group (LTV+SI) and APRV group. The changes of oxygenation, ventilation, airway pressure, inflammatory reaction and hemodynamics at the basic state were observed at 0, 1, 2 and 4 h during the experiment. The levels of PaO2/FiO2 in APRV group were higher than LTV+SI group at 2 and 4 h (P<0.05). In APRV group, the PCO2 levels at 1, 2 and 4 h is much lower than LTV+SI group (P<0.05). Outcome variables showed no differences between APRV, LVT+SI and conventional mechanical ventilation for plateau airway pressure (24±1 vs. 29±3 vs. 25±4), mean arterial pressure (92.9±16.5 vs. 85.8±21.4 vs. 88.7±24.4), cardiac index (4.3±1.7 vs. 3.5±1.9 vs. 3.4±2.1), ERO2 (13.4±10.3 vs. 16.1±6.8 vs. 17.6±9.1), lac (2.5±1.7 vs. 3.1±1.6 vs. 3.9±1.9), tumor necrosis factor (TNF)-α (132±11 vs. 140±6 vs. 195±13) and matrix metalloproteinase (MMP)-9. For canines sustaining acute respiratory distress syndrome requiring mechanical ventilation, APRV can significantly improve oxygenation and keep hemodynamic stability compared with LTV+SI. The results of TNF-α and MMP-9 suggest that APRV could be as protective for ARDS as LTV with recruitment group.

Part of plasmapheresis with plasma filtration adsorption combined with continuous hemodiafiltration in the treatment of severe acute liver failure.

The present study is a retrospective analysis of 11 cases with severe acute liver failure combined with multiple organ dysfunction syndrome (MODS) performed during the period June, 2012 to December, 2014. After part of plasmapheresis with plasma filtration adsorption combined with continuous hemodiafiltration treatment, good curative effects were obtained and the main clinical symptoms and biochemical index were significantly improved. Following treatment, 8 of the 11 patients survived at a survival rate of 72.7%, and 3 patients succumbed with a mortality of 27.3%. The results suggested that part of plasmapheresis with plasma filtration adsorption combined with continuous venovenous hemodiafiltration (CVVHDF) treatment is beneficial in the removal of metabolites and toxins. Additonally, it can effectively improve liver function and clinical symptoms, improve hepatic encephalopathy, correct the disorder of internal environment, and improve the prognosis of patients.

Effect of setting high APRV guided by expiratory inflection point of pressure-volume curve on oxygen delivery in canine models of severe acute respiratory distress syndrome.

In the present study, the effect of setting high airway pressure release ventilation (APRV) pressure guided by an expiratory inflection point of pressure-volume (PV) curve following lung recruitment maneuver (RM) on oxygen delivery (DO2) in canine models of severe acute respiratory distress syndrome (ARDS) was examined. Canine models of severe ARDS were established by intravenous injection of oleic acid. After injection of sedative muscle relaxants, a PV curve plotted using the super-syringe technique, and the pressure at lower inflection point (LIP) at the inhale branch and the pressure at the point of maximum curvature (PMC) at the exhale branch were measured. The ventilation mode was biphasic positive airway pressure (BiPAP), an inspiration to expiration ratio of 1:2, and Phigh 40 cm H2O, Plow 25 cm H2O. Phigh was decreased to 30 cm H2O after 90 sec. The dogs were randomized into 3 groups after RM, i.e., Blip group, BiPAP Plow = LIP+2 cm H2O; Bpmc group, BiPAP Plow = PMC; and Apmc group. In the APRV group, Phigh was set as PMC, with an inspiratory duration of 4 sec and expiratory duration of 0.4 sec. PMC was 18±1.4 cm H2O, and LIP was 11±1.3 cm H2O. Thirty seconds after RM was stabilized, it was set as 0 h. Hemodynamics, oxygenation and DO2 were measured at 0, 1, 2 and 4 h after RM in ARDS dogs. The results demonstrated: i) cardiac index (CI) in the 3 groups, where CI was significantly decreased in the Bpmc group at 0, 1, 2 and 4 h after RM compared to prior to RM (P<0.05) as well as in the Blip and Apmc groups (P<0.05). CI in the Blip and Apmc groups was not significantly altered prior to and after RM. ii) Oxygenation at 0, 1, 2 and 4 h in the 3 groups was improved after RM and the oxygenation indices for the 3 groups at 1 and 2 h were not significantly different (P>0.05). However, the oxygenation index in the Blip group at 4 h was significantly lower than those at 0 h for the Apmc and Bpmc groups (P<0.05). Oxygenation for the Apmc group at 4 h was higher than that for the Blip and Bpmc groups (P<0.05). Oxygenation for the Bpmc group was lower than that at 0 h, although the difference was not significant (P>0.05). iii) DO2 in at 0, 1, 2 and 4 h in the Bpmc group was significantly lower than that in the Blip and Apmc groups, and not significantly improved after RM. DO2 in the Blip and Apmc groups after RM was improved as compard to that before RM and that in the Bpmc group. However, DO2 at 4 h in the Blip group was significantly lower than that at 0 h and in the Apmc group (P<0.05). DO2 at 4 h in the Apmc group was higher than that at 0 h and that in the remaining 2 groups (P<0.05). In conclusion, high APRV pressure guided at PMC of PV curve after RM significantly improved DO2 in ARDS dogs.

Clinical observation on the treatment of acute liver failure by combined non-biological artificial liver.

The clinical efficacy and safety of different combinations of non-bio artificial liver in the treatment of acute liver failure was examined. A total of 61 cases were selected under blood purification treatment from the patients with severe acute liver failure admitted to the severe disease department of the hospital from December, 2010 to December, 2015. Three types of artificial liver combinations were observed, i.e., plasma exchange plus hemoperfusion plus continuous venovenous hemodiafiltration (PE+HP+CVVHDF), PE+CVVHDF and HP+CVVHDF. The heart rate (HR), mean arterial pressure (MAP), respiratory index (PaO2/FiO2), liver and kidney function indicator, as well as platelet and coagulation function were compared. A comparison before and after the treatment using the three methods, showed improvement in the HRs, MAPs, PaO2/FiO2, total bilirubins (TBIL) and alanine aminotransferases (ALT) (P<0.05), of which TBIL and ALT were decreased more significantly (P<0.01) in the PE+CVVHDF and PE+HP+CVVHDF groups. Only changes in the PE+HP+CVVHDF and PE+CVVHDF groups were statistically significant after prothrombin time and albumin treatment (P<0.05). The difference between the decrease in TBIL in the PE+HP+CVVHDF group and that in the HP+CVVHDF group was statistically significant (P<0.05). Treatment of the 61 patients using the artificial liver support system yielded a survival rate of 62.3% (38/61), and a viral survival rate of 35.0% (7/20); with the non-viral survival rate being 75.6% (31/41). In conclusion, following the treatment of three types of artificial livers, the function was improved to varying degrees, with the PE+HP+CVVHDF and the PE+CVVHDF method being better. By contrast, after the treatment of non-viral liver failure, the survival rate was significantly higher than the patients with viral liver failure.

Integrated production and distribution scheduling problems related to fixed delivery departure dates and weights of late orders.

We consider an integrated production and distribution scheduling problem faced by a typical make-to-order manufacturer which relies on a third-party logistics (3PL) provider for finished product delivery to customers. In the beginning of a planning horizon, the manufacturer has received a set of orders to be processed on a single production line. Completed orders are delivered to customers by a finite number of vehicles provided by the 3PL company which follows a fixed daily or weekly shipping schedule such that the vehicles have fixed departure dates which are not part of the decisions. The problem is to find a feasible schedule that minimizes one of the following objective functions when processing times and weights are oppositely ordered: (1) the total weight of late orders and (2) the number of vehicles used subject to the condition that the total weight of late orders is minimum. We show that both problems are solvable in polynomial time.

Effect of the Shenfu Injection Combined with Early Goal-Directed Therapy on Organ Functions and Outcomes of Septic Shock Patients.

Shenfu injection (SFI) derived from traditional Chinese medicine has been widely used in cardiovascular diseases. The objective of this study was to determine the effect of SFI and conventional early goal-directed therapy (EGDT) on organ functions and outcomes of septic shock patients. For this purpose, a total of 45 septic shock patients were randomly divided into control group A (24 patients on EGDT) and experimental group B (21 patients on SFI + EGDT). SFI was administered (100@20 mL/h) twice daily. Hemodynamic status, lactic acid, and vasoactive drug use were observed before and after treatment. Other indicators included ventilator weaning time, ICU stay time, free of organ failure time, and 28-day hospital mortality. Regarding experimental group, compared with controls, BUN/creatinine decreased significantly at 3, 5, and 7 days while PaO2/FiO2 increased at 1 and 3 days (P < 0.05). APACHE-II and SOFA scores decreased in both groups at 3, 5, and 7 days (P < 0.05), whereas SOFA scores improved more in experimental group as compared with controls. Ventilator weaning time and ICU stay were significantly shorter in experimental group as compared with controls. In both groups, mean arterial pressure/systemic vascular resistance index post-treatment levels increased and lactic acid decreased at 6, 12, 24, 48, and 72 h (P < 0.05). Heart rate decreased at 24, 48, and 72 h (P < 0.05); while gamma-glutamyl transpeptidase and glutamate oxaloacetate transaminase levels increased at 1 day and 1 and 3 days, respectively (P < 0.05). Combined use of SFI and EGDT can improve hemodynamics, reduce the damage to vital organs, and shorten ventilation and ICU stay times in septic shock patients.

The Use of Limited Fluid Resuscitation and Blood Pressure-Controlling Drugs in the Treatment of Acute Upper Gastrointestinal Hemorrhage Concomitant with Hemorrhagic Shock.

The aim of this study was to evaluate the usefulness of the limited fluid resuscitation regimen combined with blood pressure-controlling drugs in treating acute upper gastrointestinal hemorrhage concomitant with hemorrhagic shock. A total of 51 patients were enrolled and divided into a group that received traditional fluid resuscitation group (conventional group, 24 patients) and a limited fluid resuscitation group (study group, 27 patients). Before and after resuscitation, the blood lactate, base excess, and hemoglobin values, as well as the volume of fluid resuscitation and resuscitation time were examined. Compared with conventional group, study group had significantly better values of blood lactate, base excess, and hemoglobin (all p < 0.05). In addition, both volume of fluid resuscitation and resuscitation time were significantly (p < 0.05) lower in these patients. Limited fluid resuscitation combined with blood pressure-controlling drugs effectivelyxxx maintains blood perfusion of vital organs, improves whole body perfusion indicators, reduces the volume of fluid resuscitation, and achieves better bleeding control and resuscitation effectiveness.

Combined use of non-biological artificial liver treatments for patients with acute liver failure complicated by multiple organ dysfunction syndrome.

BACKGROUND: Acute liver failure (ALF) caused by viral and non-viral hepatitis is often accompanied with severe metabolic disorders, the accumulation of toxic substances and continuous release and accumulation of a large number of endogenous toxins and inflammatory mediators. The present study aimed to investigate the effects of various combined non-biological artificial liver treatments for patients with acute liver failure (ALF) complicated by multiple organ dysfunction syndrome (MODS). METHODS: Thirty-one patients with mid- or late-stage liver failure complicated by MODS (score 4) were randomly divided into three treatment groups: plasmapheresis (PE) combined with hemoperfusion (HP) and continuous venovenous hemodiafiltration (CVVHDF), PE+CVVHDF, and HP+CVVHDF, respectively. Heart rate (HR) before and after treatment, mean arterial pressure (MAP), respiratory index (PaO2/FiO2), hepatic function, platelet count, and blood coagulation were determined. RESULTS: Significant improvement was observed in HR, MAP, PaO2/FiO2, total bilirubin (TBIL) and alanine aminotransferase (ALT) levels after treatment (P<0.05). TBIL and ALT decreased more significantly after treatment in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.01). Prothrombin time (PT) and albumin were significantly improved only in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.05). TBIL decreased more significantly in the PE+HP+CVVHDF group than in the HP+CVVHDF and PE+CVVHDF groups (P<0.05). The survival rate of the patients was 58.1% (18/31), viral survival rate 36.4% (4/11), and non-viral survival rate 70% (14/20). CONCLUSION: Liver function was relatively improved after treatment, but PE+HP+CVVHDF was more efficient for the removal of toxic metabolites, especially bilirubin. The survival rate was significantly higher in the patients with non-viral liver failure than in those with viral liver failure.

Hemodiafiltration combined with resin-mediated absorption as a therapy for hyperlipidemic acute pancreatitis.

The aim of this study is to investigate whether hemodiafiltration combined with resin-mediated absorption is a better therapy for hyperlipidemic acute pancreatitis. Patients (n = 67) with acute pancreatitis treated in ICU from January 2009 to December 2012 were included in this study. Seven of these 67 cases were diagnosed hyperlipidemic acute pancreatitis (HLAP). All the 7 HLAP patients went through fast, gastrointestinal decompression, anti-shock treatment, inhibition of pancreatic secretion, antiseptic treatments, and hemoperfusion (HP) combined with continuous veno venous hemodiafiltration (CVVHDF). After one round of treatment by resin adsorption, there was a significant decrease in serum triglycerides (TG) (29.78 %) and total cholesterol (TC) (24.02 %) levels (p < 0.01). TG and TC levels dropped by 49.02 and 37.66 %, respectively, after 1-day treatment of HP + CVVHDF; by 62.81 and 47.37 % on day 2 post-treatment; and by 69.57 and 49.47 % on day 3 post-treatment. All the 7 patients survived. The average time spent in the ICU was 7 ± 3.8 days, and the average duration of hospitalization was 19 ± 15.1 days. Our results show that hemoperfusion combined with hemodiafiltration is an efficient treatment as this approach can reduce plasma lipid levels effectively and reduce the risk of acute pancreatitis due to hyperlipidemia.

Efficacy of various combined blood purification techniques for treating patients with non-viral acute liver failure.

We sought to study the clinical efficacy of various combined blood purification techniques in patients with non-viral acute liver failure complicated by multiple organ dysfunction syndrome (MODS). For this purpose, 19 patients diagnosed of mid- or late-stage liver failure with MODS score-4 were randomly divided into 3 treatment groups of PE+HP+CVVHDF, PE+CVVHDF, and HP+CVVHDF, respectively. Pre- and post-treatment heart rate (HR), mean arterial pressure (MAP), arterial blood gases (pH, PaO2, and PaCO2), hepatic function, platelet count, and blood coagulation were determined. The data show significant improvement in HR, MAP, PaO2/FiO2, total bilirubin (TBIL), and alanine aminotransferase (ALT) levels after treatment (P < 0.05). TBIL decreased more significantly after treatment in PE+CVVHDF and PE+HP+CVVHDF groups (P < 0.01). Significant improvement in prothrombin time and albumin was observed only in PE+CVVHDF and PE+HP+CVVHDF groups (P < 0.05). The decrease of TBIL and improvement of PaO2/FiO2 ratio were more pronounced in PE+HP+CVVHDF than in HP+CVVHDF group (P < 0.05). To conclude, liver function was relatively improved by all the three combined blood purification techniques used; however, PE+HP+CVVHDF approach was found more efficient in the removal of toxic metabolites, especially bilirubin. The data suggest that the combined blood purification techniques used were effective and involved minor side effects.

[Effect of Xuebijing injection treatment on acute respiratory distress syndrome: a multicenter prospective randomized control clinical trial].

OBJECTIVE: To assess the therapeutic effect of Xuebijing injection on adult patients with acute respiratory distress syndrome (ARDS). METHODS: A multicenter prospective randomized control study was conducted at 10 intensive care units in Jiangsu province. A total of 172 early ARDS patients were randomly divided into Xuebijing treatment and control groups. All patients received routine therapy of ARDS while additional Xuebijing injection 100 ml was administered in the treatment group intravenously for 7 days. Lung injury score, acute physiology and chronic health evaluation II (APACHE II) score, multiple organ dysfunction score (MODS) and PaO2/FiO2 of the patients was recorded before and after treatment. Mortality at 28 days and the duration of mechanical ventilation were compared between two groups. RESULTS: Ninety-one patients were assigned to receive Xuebijing injection and 81 patients as control; Mortality at Days 28 and 90, the duration of mechanical ventilation and ventilation free days showed no difference between two groups (P > 0.05). PaO2/FiO2 improved after randomization versus pre-treatment in all patients. There was no significant difference between two groups. Murray scores were not significantly different between two groups. In a subgroup analysis of patients with pulmonary infection, pulmonary contusion and extra-pulmonary cause, two groups had no difference in mortality at Day 28, mortality at Day 90, the duration of mechanical ventilation, ventilation free days and days of ICU stay (P > 0.05). CONCLUSION: The treatment of Xuebijing injection early in course of ARDS does not improve the mortality of ARDS patients. But it may improve lung function and oxygenation. Further studies are warranted.

[Effects of combination of midazolam and propofol on anterograde amnesia in critical patients].

OBJECTIVE: To observe the effects of sedation with midazolam and propofol on anterograde amnesia in critical patients. METHODS: Sixty selected patients on mechanical ventilation in intensive care unit (ICU) were randomly divided into three subgroups (propofol, midazolam, and midazolam and propofol combination group), with 20 cases in each group. Patients who were awakened from sedation were showed with a card depicted with different colors, figures and numbers. When patients were totally conscious after weaning from mechanical ventilation,the influence of the different methods of sedation on anterograde amnesia of these critically ill patients was assessed. RESULTS: (1) 70%, 95% and 90% of patients manifested amnesia in propofol, midazolam and the combination group, respectively. All the patients recovered their memory immediately in 30 minutes after withdrawal of the sedatives. (2) When midazolam was compared with propofol and combination group, time of onset was obviously prolonged after an intravenous injection of a load dose in midazolam group [(2.7+/-1.1) minutes and (3.1+/-1.3) minutes vs. (5.1+/-2.8) minutes], also was time of extubation after regaining of consciousness [(0.7+/-0.2) hour and (1.2+/-0.6) hours vs. (2.7+/-0.3) hours, all P<0.01]. There was no significant difference between propofol group and the combination group in time of onset and extubation (both P>0.05). (3) Cost of propofol [(2,100+/-125) yuan] was 75% higher than that of midazolam [(1,200+/-112) yuan, P<0.01], but cost of sedatives in the combination group [(1,300+/-132) yuan] was similar to that in midazolam group (P>0.05). CONCLUSION: Combination of midazolam and propofol can not only ensure anterograde amnesia in critical patients, reduce drug dosage and adverse reactions, but also can help reduce the hospital expenses. This method may be a better sedation program in ICU.

Relationship between adrenal function and prognosis in patients with severe sepsis.

BACKGROUND: It is known that the hypothalamic-pituitary-adrenal (HPA) axis is highlighted by stimulation, such as sepsis, trauma, etc, when corticortropin increases and plasma cortisol levels enhance. Relative adrenal insufficiency is not uncommon in critically ill patients and may occur in severe sepsis patients with high plasma cortisol levels. It has been demonstrated that a short corticotropin test has a good prognostic value and is helpful in identifying patients with septic shock at high risk for death, but it has not been established for all severe sepsis patients, especially in China. The aim of this study is to explore the relationship between adrenal function and prognosis in patients with severe sepsis. METHODS: This prospective study was conducted between July and December 2004 in 6 teaching hospitals. Two hundred and forty patients with severe sepsis were enrolled in this study. A short corticotropin stimulation test was performed in all patients by intravenous injection of 250 microg of corticotropin. Blood samples were taken immediately before the test (T0), 30 (T30) and 60 (T60) minutes afterward, and the plasma cortisol concentration was measured by radio-immunoassay. At the onset of severe sepsis, the following parameters were recorded: age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) II, heart rate, mean arterial pressure (MAP), arterial partial pressure of oxygen (PaO(2))/fraction of inspired oxygen (FiO(2)), peripheral blood of hemoglobin, platelets and leukocyte concentration and the number of organ failure. Patients were designated into two groups (survival and non-survival groups) according to the 28-day mortality. Relative adrenal insufficiency was defined as the difference between T0 and the highest value of T30 or T60 (DeltaTmax) < or = 9 microg/dl. RESULTS: (1) Two hundred and forty patients with severe sepsis were included in this study, with 134 patients in the survival group and 106 in the non-survival group. The 28-day mortality was 44.2%. (2) Between the survival group and non-survival group age, APACHE II, peripheral blood of platelets, the number of organ failures, T0 and DeltaTmax showed significant differences. T0 was (23 +/- 10) microg/dl and (36 +/- 18) microg/dl in the survival group and nonsurvival group respectively. DeltaTmax was (18 +/- 9) and (10 +/- 8) microg/dl in the survival group and non-survival group respectively. The areas under the ROC curve for T0 and DeltaTmax were both 0.72, and the area under the ROC curve for APACHE II was 0.70. By multivariate analysis age, T0, the number of organ failures and relative adrenal insufficiency (DeltaTmax < or = 9 microg/dl) were independent predictors of death. (3) The incidence of relative adrenal insufficiency was 38.3% in total, 19.4% in the survival group and 62.3% in the non-survival group (P < 0.001). The 28-day mortality was 71.7% among the relative adrenal insufficiency patients but 27.0% among normal adrenal function patients. CONCLUSIONS: The prevalence of relative adrenal insufficiency is high in severe sepsis. Relative adrenal insufficiency has a good prognostic value for severe sepsis.

[Relationship between the adrenal function and the prognosis of acute respiratory distress syndrome].

OBJECTIVE: To explore the relationship between the adrenal function and the prognosis of acute respiratory distress syndrome (ARDS). METHODS: One hundred and fifty-eight patients with ARDS were enrolled in this study and were divided into two groups based on the prognosis: survival group and death group. Every patient was given one shot of corticotrophin 250 microg intravenously, plasma cortisol level was detected by radio-immunoassay before the shot (T0) and 30 minutes (T30) and 60 minutes (T60) after. And meanwhile the following parameters in the patients were recorded: age, APACH II, heart rate, mean arterial pressure, PaO(2)/FiO(2), arterial pH, hemoglobin, platelets and WBC, the number of failed organ and 28-day mortality. Relative adrenal insufficiency was defined as the difference between T0 and the highest value of T30 or T60 (DeltaTmax)