Recurrent hypertriglyceridemic acute pancreatitis in an adult patient caused by the de novo mutation of p.K327N in the GPD1 gene： A case report / 临床肝胆病杂志

Hypertriglyceridemia （HTG） is the second leading cause of acute pancreatitis in China and can be caused by primary factors， namely gene mutations， which may lead to recurrent hypertriglyceridemic acute pancreatitis （HTG-AP） and difficulties in effective control of triglyceride. This article reports an adult Chinese male patient who experienced eight attacks of HTG-AP and was found to carry a de novo heterozygous mutation， p.K327N， of the GPD1 gene， which may cause the persistent high level of triglyceride and recurrent attacks of HTG-AP.

Experimental study on high-frequency subharmonic scattering characteristics of ultrasound contrast agent microbubbles under low ambient pressure / 生物医学工程学杂志

Correlation between nonlinear subharmonic scattering of ultrasound contrast agent microbubbles and ambient pressure is expected to be used for local brain tissue pressure monitoring. Although high-frequency ultrasound has achieved high-resolution imaging of intracranial microvessels, the research on high-frequency subharmonic scattering characteristics of microbubbles is insufficient at present, which restricts the research progress of estimating local brain tissue pressure based on high-frequency subharmonic scattering of microbubbles. Therefore, under the excitation of 10 MHz high-frequency ultrasound, the effects of different acoustic pressures and ambient pressures on the high-frequency subharmonic scattering characteristics of three different ultrasound contrast agents including SonoVue, Sonazoid and Huashengxian were investigated in this in vitro study. Results showed that the subharmonic scattering amplitudes of the three microbubbles increased with the increase of ambient pressure at the peak negative acoustic pressures of 696, 766 and 817 kPa, and there was a favorable linear correlation between subharmonic amplitude and ambient pressure. Under the above three acoustic pressures, the highest correlation coefficient of SonoVue was 0.948 ( P = 0.03), the highest sensitivity of pressure measurement was 0.248 dB/mm Hg and the minimum root mean square error (RMSE) was 2.64 mm Hg. Sonazoid's highest correlation coefficient was 0.982 ( P < 0.01), the highest sensitivity of pressure measurement was 0.052 dB/mm Hg and the minimum RMSE was 1.51 mm Hg. The highest correlation coefficient of Huashengxian was 0.969 ( P = 0.02), the highest sensitivity of pressure measurement was 0.098 dB/mm Hg and the minimum RMSE was 2.00 mm Hg. The above in vitro experimental results indicate that by selecting ultrasound contrast agent microbubbles and optimizing acoustic pressure, the correlation between high-frequency subharmonic scattering of microbubbles and ambient pressure can be improved, the sensitivity of pressure measurement can be upgraded, and the measurement error can be reduced to meet the clinical demand for local brain tissue pressure measurement, which provided an important experimental basis for subsequent research in vivo.

Application of a novel artificial perfusate based on oxygen-carrying nanoparticles in normothermic machine perfusion for porcine liver preservation after cardiac death / 浙江大学学报·医学版

OBJECTIVE@#To investigate the efficacy of a novel artificial perfusate based on oxygen-carrying perfluoronaphthalene-albumin nanoparticles in normothermic machine perfusion (NMP) for preservation of porcine liver donation after cardiac death.@*METHODS@#Artificial perfusate with perfluoronaphthalene-albumin nanoparticles was prepared at 5% albumin (w/v) and its oxygen carrying capacity was calculated. The livers of 16 Landrace pigs were isolated after 1 h of warm ischemia, and then they were divided into 4 groups and preserved continuously for 24 h with different preservation methods: cold preservation with UW solution (SCS group), NMP preservation by whole blood (blood NMP group), NMP preservation by artificial perfusate without nanoparticles (non-nanoparticles NMP group) and NMP preservation by artificial perfusate containing nanoparticles (nanoparticles NMP group). Hemodynamics, tissue metabolism, biochemical indices of perfusate and bile were monitored every 4 h after the beginning of NMP. Liver tissue samples were collected for histological examination (HE and TUNEL staining) before preservation, 12 h and 24 h after preservation.@*RESULTS@#The oxygen carrying capacity of nanoparticles in 100 mL artificial perfusate was 6.94 μL/mmHg (1 mmHg=0.133 kPa). The hepatic artery and portal vein resistance of nanoparticles NMP group and blood NMP group remained stable during perfusion, and the vascular resistance of nanoparticles NMP group was lower than that of blood NMP group. The concentration of lactic acid in the perfusate decreased to the normal range within 8 h in both nanoparticles NMP group and blood NMP group. There were no significant differences in accumulated bile production, alanine aminotransferase and aspartate aminotransferase in perfusate between nanoparticles NMP group and blood NMP group (all P>0.05). After 24 h perfusion, the histological Suzuki score in blood NMP group and nanoparticles NMP group was lower than that in SCS group and non-nanoparticles NMP group (all P<0.05), and the quantities of TUNEL staining positive cells in blood NMP group and non-nanoparticles NMP group was higher than those in nanoparticles NMP group and SCS group 12 h and 24 h after preservation (all P<0.05).@*CONCLUSION@#Artificial perfusate based on oxygen-carrying nanoparticles can meet the oxygen supply requirements of porcine livers donation after cardiac death during NMP preservation, and it may has superiorities in improving tissue microcirculation and alleviating ischemia-reperfusion injury.

Analysis of risk factors of polymyxin B-associated acute kidney injury in intensive care unit patients with severe infection / 中华危重病急救医学

Objective:To investigate the incidence and risk factors of polymyxin B-associated acute kidney injury (AKI) in patients with severe infections caused by extensive drug resistance Gram negative bacteria (XDR-GNB)in intensive care unit (ICU).Methods:A retrospective study of adult patients with severe infection who received polymyxin B for more than 3 days in the department of critical care medicine of Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School from April 1st 2018 to January 31st 2020 were performed. AKI was diagnosed by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The baseline data, indicators during treatment period and prognostic factors were compared between AKI group and non-AKI group. Factors with statistically significant difference in univariate analysis and important clinical factors were included in the Logistic regression model to analyze the risk factors of AKI.Results:Seventy-two patients were treated with polymyxin B for more than 3 days. Forty-nine patients were finally enrolled, with 32 patients developing polymyxin B-associated AKI, and the incidence was 44.4%. The baseline data was balanced in AKI group and non-AKI group, and there was no significant difference in the prognosis [death or discharge without medial order (cases): 14 vs. 6, discharged for improvement (cases): 18 vs. 11, χ 2 = 0.329, P = 0.566]. Polymyxin B-associated AKI occurred from 1 day to 14 days after treatment, with an average of (6.8±3.8) days. Among the 32 AKI patients, 2 cases were lost to follow up after discharge, while renal function recovered in 18 cases and unrecovered in 12 cases. The prognosis of patients without recovery of renal function was significantly worse than that of patients with renal function recovery [death or discharge without medial order (cases): 12 vs. 2, discharged for improvement (cases): 0 vs. 16, P = 0.000]. Single factor analysis showed that daily dosage of polymyxin B in AKI group was higher than that in non-AKI group (mg: 151.6±23.7 vs. 132.4±30.3), numbers of patients with daily polymyxin B dose ≥ 150 mg, using vasoactive drugs, or severe hypoalbuminemia (albumin≤25 g/L) were higher than those in non-AKI group (cases: 29 vs. 10, 18 vs. 4, 9 vs. 0), with statistically significant differences (all P < 0.05). Multivariate Logistic regression analysis showed that daily dosage of polymyxin B ≥ 150 mg and use of vasoactive drugs were independent risk factors for polymyxin B-associated AKI [odds ratio ( OR) = 37.466, 95% confidence interval (95% CI) was 2.676-524.586, P = 0.007; OR = 22.960, 95% CI was 1.710-308.235, P = 0.018]. Conclusions:Comparing with non-AKI patients, more patients with polymyxin B-associated AKI had severe hypoalbuminemia, and the probability of using vasoactive drugs and the daily dose of polymyxin B were higher than non-AKI patients. Daily dose of polymyxin B ≥ 150 mg and using vasoactive drugs were independent risk factors for polymyxin B-associated AKI.

Effect of early enough protein intake on outcomes of critically ill patients / 中华临床营养杂志

Objective To investigate the effects of protein intake in the early phase and later phase on the outcomes of critically ill patients.Methods A total of 326 critically ill patients admitted in intensive care unit of our hospital from September 2016 to March 2018 were enrolled in this prospective observational study.According to the 28-day prognosis of patients,they were divided into death group and survival group.Early protein target (EPT) was defined as the daily protein intake≥0.8 g/ (kg · d) on days 1-3,and late protein target (LPT) was defined as the daily protein intake≥0.8 g/ (k · d) on days 4-7.Results Daily protein intakes on day 1 and day 3 and cumulative protein intakes on days 1-3 were significantly higher in non-survivors than in the survivors (P＜0.05),but daily protein intakes on day 2,4,5,6 and 7 and cumulative protein intakes on days 4-7 and 1-7 showed no significant difference between two groups (P＞0.05).Hospital mortality was the lowest in the LPT group,the highest in the EPT,and in the middle in the EPT+LPT group and non-EPT+non-LPT group (P＜0.05).The survival curve analysis showed that the survival time of the EPT-only group was significantly lower than that of the LPT-only group (P＜0.05).Multivariate analysis showed that age,sex,cumulative protein and caloric intakes on days 1-7 were the independent risk factors for mortality.Conclusion Early low protein intake is benefit for the outcomes of critically ill patients,and combined with adequate intake of protein in the later stage may further improve the outcomes.

Using Digestive Fluid Biomarkers to Predict Acute Gastrointestinal Injury in Critically Ill Patients: A Pilot Study.

BACKGROUND: Acute gastrointestinal injury is associated with significantly increased mortality in critically ill patients. However, markers for measuring acute gastrointestinal injury are neither sensitive nor specific. OBJECTIVE: To determine whether enzymes in digestive fluid are predictive of the severity of acute gastrointestinal injury. METHODS: A prospective observational study was conducted between June 2015 and December 2015 in a surgical intensive care unit. Enrolled patients were classified by acute gastrointestinal injury grade according to the 2012 European Society of Intensive Care Medicine system. Digestive fluid was collected through nasointestinal tubes and analyzed 24 hours after the diagnosis of acute gastrointestinal injury. Intestinal markers of injury (pH, interleukin 6, interleukin 10, tumor necrosis factor α, and secretory immunoglobulin A) were measured in digestive fluid. RESULTS: Of the 76 patients included, acute gastrointestinal injury was grade I in 41, grade II in 20, grade III in 8, and grade IV in 7. Secretory immunoglobulin A was an independent predictor of grade III acute gastrointestinal injury. When data from patients with grades I and II injury and patients with grades III and IV injury were grouped together, analysis revealed that pH, interleukin 10, and secretory immunoglobulin A were independent predictors of acute gastrointestinal failure. CONCLUSIONS: Secretory immunoglobulin A was predictive of grade III acute gastrointestinal injury. Digestive fluid markers of injury (pH, interleukin 10, and secretory immunoglobulin A) were predictors of acute gastrointestinal failure. Further study is required to determine if other markers are specific or sensitive for acute gastrointestinal injury.

Analysis of clinical characteristics of bloodstream infection in patients with immune function inhibition / 中华危重病急救医学

Objective To analyze the clinical characteristics of bloodstream infection in patients with immune function inhibition. Methods A retrospective analysis was conducted. 234 patients with bloodstream infection admitted to intensive care unit (ICU) of the Affiliated Drum Tower Hospital of Nanjing University Medical School from August 1st in 2015 to December 31st in 2017 were enrolled. According to the immune function on the day of bloodstream infection, they were divided into normal immune function group [human leukocyte antigen DR (HLA-DR) > 30%, n = 144] and immunosuppression group (HLA-DR ≤30%, n = 90). The gender, age, primary disease, complication, acute physiology and chronic health evaluationⅡ (APACHEⅡ) with 24 hours after ICU admission, sequential organ failure assessment (SOFA) score, etiology, infection parameters on the day of bloodstream infection [peak temperature, white blood count (WBC), neutrophils ratio, procalcitonin (PCT), and C-reactive protein (CRP)] and prognosis parameters (bacterial clearance time, the length of ICU and hospital stay, 28-day mortality) between the two groups were analyzed. Results 234 patients were enrolled in the final analysis, including 132 males and 102 females, with an average age of (60.5±18.4) years old. Severe pneumonia and abdominal infection were the main causes of primary diseases. There was no significant difference in gender composition, age, APACHEⅡ, SOFA score, other complications and primary morbidity between the two groups except that the proportion of malignant tumors in the immunosuppressive group was higher than that in the normal immune function group [43.3% (39/90) vs. 41.7% (60/144), P < 0.05]. Compared with the normal immune function group, the Gram-positive cocci infection rate in the immunosuppressive group was significantly lowered [40.0% (36/90) vs. 56.2% (81/144)], Gram-negative bacilli infection rate [50.0% (45/90) vs. 39.6% (57/144)] and fungus infection rate [10.0% (9/90) vs. 4.2% (6/144)] were significantly increased (both P < 0.05). The levels of WBC, neutrophils ratio, and PCT on the day of bloodstream infection in the immunosuppressive group were significantly lower than those of normal immune function group [WBC (×109/L): 10.2±2.1 vs. 13.5±3.6, neutrophils ratio: 0.87±0.17 vs. 0.96±0.22, PCT (μg/L): 1.3±1.1 vs. 4.7±2.1, all P < 0.05], but no significant difference in the peak temperature (℃: 38.5±1.7 vs. 38.9±1.3) or CRP (mg/L: 134.0±42.6 vs. 164.0±55.8) was found as compared with normal immune function group (both P > 0.05). Compared with the normal immune function group, the bacterial clearance time in the immunosuppressive group was significantly prolonged (days: 16.0±10.1 vs. 12.3±4.7), 28-day mortality was significantly increased [61.1% (55/90) vs. 44.4% (64/144)] with statistical significances (both P < 0.05), but no significance was found in the length of ICU stay (days: 21.0±17.1 vs. 18.7±10.4) or the length of hospital stay (days: 36.0±28.1 vs. 33.8±16.8, both P > 0.05). Conclusion Gram-negative bacilli was the main pathogen of bloodstream infection in immunosuppressive patients, and the fungal infection rate was high, inflammation reaction was not obvious, bacterial clearance time was long, and prognosis was poor.

Meta-analysis of laparoscopic surgery versus conservative treatment for appendiceal abscess / 中华胃肠外科杂志

OBJECTIVE@#To systematically evaluate the safety and efficacy of laparoscopic surgery versus conservative treatment for appendiceal abscess.@*METHODS@#The databases of CNKI, Wangfang, VIP, PubMed, EMBASE and Cochrane Library were searched to retrieve randomized controlled trials (RCT) or clinical controlled trials (CCT) comparing laparoscopic surgery with conservative treatment for appendiceal abscess published before June 2018. The search terms were Chinese or English. Chinese search terms included appendix, abscess, and laparoscopy; English search terms included appendix, abscess, and laparoscope. References of the resulted papers, related reviews or meta-analysis references were also induded. Literature inclusion criteria: (1)RCT or CCT, whether or not to assign concealment or blinding; (2) appendiceal abscess was diagnosed at admission; (3) laparoscopic group: laparoscopic appendectomy or laparoscopy surgical methods, such as irrigation and drainage, for appendiceal abscess; conservative treatment group: conservative methods, such as antibiotics or percutaneous abscess drainage were used to treat appendiceal abscess.@*EXCLUSION CRITERIA@#(1) review, case report, single cohort study and other non-controlled studies literature; (2) single study sample size ≤ 20; (3) subjects with simple appendicitis or perforation of appendix to form diffuse peritonitis; (4) no valid data available for extraction; (5) repeated publication of the literature. Data were extracted from the included studies, and the Cochrane Collaboration RevMan 5.1.0 version software was used for this meta-analysis.@*RESULTS@#Three RCTs and four CCTs with a total of 591 patients were included in this study. There were 312 patients in the laparoscopic group and 279 patients in the conservative group. Compared with the conservative group, the laparoscopic group had higher uneventful recovery rate (OR=11.91, 95%CI: 4.59 to 30.88, P0.05).@*CONCLUSIONS@#Laparoscopic surgery for appendiceal abscess is safe and feasible. It can improve the recovery with shorter postoperative hospital stay and less recurrent or residual abscess.

Research advance in causes of postoperative gastrointestinal dysfunction / 中华胃肠外科杂志

Gastrointestinal dysfunction is a common and major complication after surgery. The syndrome covers a wide spectrum of clinical signs, ranges from mild feeling to severe discomfort and varies from person to person. The mild patients need no care, but severe ones may have long hospital stay, and even suffer from multiple organ dysfunction syndrome, severely affecting postoperative rehabilitation. However, the etiology of postoperative gastrointestinal dysfunction has not been fully elucidated. Much research demonstrates that many factors, such as operative procedures, surgical operation, homeostasis disturbance, anesthesia and analgesia, blood perfusion, inflammation, and neuroendocrine factors, are responsible for the development and progression of postoperative gastrointestinal dysfunction. This study therefore reviewed the causes of postoperative gastrointestinal dysfunction in the published literatures.

Different doses ofearly enteral nutrition for patients with ac ute gastrointestinal dysfunction / 医学研究生学报

Objective Acute gastrointestinal dysfunction (AGD) is a common problem in critically ill patients, for whomearly enteral nutrition ( EN) is widely used, but its application dosage remains controversial.This study aimed to observe the influence of dif-ferent doses of early EN on acute gastrointestinal tolerance, new infections and other complications, inflammation indexes, and prognosis in AGD patients. Methods We selected 120 critically ill patients that met thecriteria of class-ⅡAGD and needed EN support andequal-ly randomized them intoa standard-dose and a low-dose ENgroup.The former group received EN at 20 mL/h, with an addition of 10 mL/h every 12 hours according to the tolerance and supplemented byparenteral nutrition (PN) to achieve the target calories(60%) on the 3 rd day, while the latterat 20 mL/h for 7 days, supplemented by PN to achieve the target calories on the 3 rd day and from the 7 th day gradu-ally increased to the full volume.We recorded the patients′ICUdays, hospitaldays, mortality rate, organ function support days, incidence of feeding intolerance within 7 days, incidence of new infections within 7 and 28 days, and levels of C-reactive protein (CRP), procalci-tonin (PCT), tumor necrosis factor-α(TNF-α) and interleukin-6 (IL-6) and compared these indexes between the two groups. Resulst There were no statistically significant differences between the low -and standardd-ose EN groups in the patients′ICU days, hospital days, mortality rate,organ function support days, or incidence of new infections within 7 and 28 days ( P>0.05) .The incidence of feeding intol-erance on the 7 th day was significantly lower in the low-dose than in the standard-dose EN group ( 13.3 vs 36.7%, P<0.05).On the 1st, 3rd, and 7 th day, the level of CRP was (5.90±0.72), (16.52± 3.09) , and ( 32.11 ±4.33 ) ng/L, respectively, in the low-dose groupversus(5.83±0.59), (15.83±1.19), and (33.16±4.51)ng/L in the standard-dose group, while that of PCTwas (4.71±1.25), (10.63± 2.21), and ( 16.89±3.39) ng/mL, respectively, in the former versus (4.55±0.67), (10.41±1.99), and (17.49±3.87)ng/mL in the latter, both increased in a time-dependent manner and with significant differ-ences among the three time points within the same group ( P<0.05) .The levels of TNF-αand IL-6 were elevated in the same manner and also with significant differences among the three time points within the same group ( P<0 .05) . Conc lusion Lowdose of early enteral nutrition can improve the feeding tolerance of AGDpatients, but does not influence the incidence of new infections and prognosis.

Efficacy of pectin in the treatment of diarrhea predominant irritable bowel syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy of pectin, a kind of soluble dietary fiber, in diarrhea predominant irritable bowel syndrome(IBS-D).</p><p><b>METHODS</b>A total of 87 patients with IBS-D were selected in the Jinling Hospital between July 2011 and December 2013. Using a randomized, controlled trial, the efficacy of pectin for IBS-D was prospectively evaluated. Subjects were randomly assigned to receive 24 g pectin powder/d (n=46) or a placebo (n=41). Before and after 6 weeks of treatment, colonic microflora was examined by real-time PCR and compared between groups. Changes in stool frequency and form (Bristol stool scale), composite score of symptoms (Likert scale) and QOL scores (IBS-QOL questionnaire) were also monitored. Peripheral blood sample from patients with IBS-D was obtained to estimate the cytokines level, which was compared with that obtained from a group of age- and sex-matched healthy volunteers (n=20).</p><p><b>RESULTS</b>Those patients randomized to pectin experienced a greater reduction in composite symptom scores and Bristol stool scale scores, as well as significant improvement in QOL scores (P<0.05). The pectin acted as prebiotics and significantly enhanced faecal bifidobacteria and decreased total Clostridium sp (P<0.05). At baseline, patients with IBS-D demonstrated an abnormal IL-10/IL-12 ratio, which was normalized by pectin feeding alone (P<0.01). Placebo did not exert these effects on the aforementioned parameters after treatment. No significant adverse effects were reported during the study.</p><p><b>CONCLUSIONS</b>Pectin acts as a prebiotic in specifically stimulating gut bifidobacteria in IBS-D patients and is effective in alleviating clinical symptoms, balancing colonic microflora and relieving systemic inflammation. In view of its ability to re-establish a healthy gut ecosystem, pectin has the potential of being a therapeutic agent in IBS-D.</p>

Nutrition support treatment for refractory constipation patients complicated with superior mesenteric artery syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To determine the incidence and risk factors associated to with refractory constipation patients complicated with superior mesenteric artery syndrome (SMAS), and to observe the role of nutritional support in its treatment.</p><p><b>METHODS</b>A prospective nested case-control study was conducted from a constipation cohort(n=973) to assess the incidence and risk factors of SMAS. Pitents with SMAS were matched to controls with a ratio of 1:4 by age and gender. Cases developed SMAS in long-term follow-up(n=26) and controls did not(n=104). Nutritional support was used in 26 patients with SMAS. The efficacy of nutritional support was evaluated by retrospective analysis.</p><p><b>RESULTS</b>The incidence of SMAS in this cohort of patients was 2.7%. Multivariate logistic analysis revealed BMI≤18 kg/m(2) (OR=2.89, 95%CI:1.14-7.31) and prolonged colon transit time(OR=3.57, 95%CI:1.36-9.35) were independent risk factors of SMAS in patients with refractory constipation. A total of 22 patients recovered after treatment of nutritional support. The successful rate of conservative treatment was 84.6%. The clinical symptoms, gastrointestinal quality of life index, Wexner constipation score and nutritional status were all significantly improved after treatment.</p><p><b>CONCLUSION</b>A BMI of less than 18 kg/m(2) and prolonged colon transit time are independent risk factors in refractory constipation patients complicated with SMAS. Nutrition support should be carried out according to illness condition and nutritional status, and combined with theatment of constipation simultaneously.</p>

Effects of continuous renal replacement therapy on renal inflammatory cytokines during extracorporeal membrane oxygenation in a porcine model.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been recommended for the treatment of patients with acute, potentially reversible, life-threatening respiratory failure which unresponsive to conventional therapy. But it is unclear about how ECMO affects renal tissue. METHODS: Twenty-four piglets weighing 25 to 32 kg were used in this experiment. The piglets were randomly allocated to 4 groups of 6 animals each: sham group (S group), control group (C group), VV-ECMO group (E group), VV-ECMO combined with CRRT group (EC group). The piglets were sacrificed and the kidney tissue were harvest to determine the levels of IL-1ß, IL-6, TNF-α and NF-КB by using the ELISA and RT-PCR method, respectively. RESULTS: Compared with C group and S group, E group renal tissue IL-1ß, IL-6, TNF-α and NF-КB expression increased significantly, respectively (p < 0.01). Compared with E group, EC group showed renal tissue IL-1ß, IL-6, TNF-α and NF-КB expression decreased significantly, respectively (p < 0.05). CONCLUSION: ECMO enables to inflammatory cytokines including IL-1ß, IL-6, TNFα, NF-КB released significantly, renal function impaired and immune homeostasis were to imbalance; ECMO combined with CRRT treatment can alleviate levels of inflammatory cytokines, maintain immune homeostasis balance and thus ameliorate the ECMO-related acute kidney injury(AKI).

Clinical study on thromboelastography-indicated postoperative blood requirements after abdominal surgery / 中华急诊医学杂志

Objective To investigate the accuracy and promptness of thromboelastography (TEG) to assess the blood transfusion requirements after abdominal operation in comparison with conventional assessments including vital signs (MAP,heart rate,breathing rate),urine output,hemoglobin and hematocrit.Methods From June to December in 2010,there were 57 patients were suspected bleeding in abdominal cavity after operation in SICU.Recorded data including vital signs (MAP,heart rate,breathing rate,oxygen saturation),urine volume per hour,the coagulation tests (Fib,PT,aPTT,INR),TEG parameters (R,K,Angle,MA,CI),the results of blood routine (Hb,Hct,Ph) and whether bleeding or not,blood product requirements within 24 h.Results Vital signs (MAP,heart rate,breathing rate,oxygen saturation),urine output per hour and the coagulation tests (Fib,PT,INR) showed no significant correlations (P ＞ 0.05) with blood transfusion requirements,but aPTT (R =0.513,P =0.000) and MA (R =0.578,P =0.000) correlated with the blood transfusion requirement.Patients with reduced MA needed more blood transfusion requirements.Patients were divided into active bleeding group and insidious bleeding group.MA had significant difference between two groups (P =0.025),but aPTT had not.Conclusions Thrombelastography is a more accurate indicator of blood transfusion requirements,especially in active bleeding patients.

Effects of intravenous fluid restriction on complications after biliary surgery / 中华消化外科杂志

Objective To investigate the effects of intravenous fluid restriction on complications after biliary surgery.Methods The clinical data of 168 patients who received biliary surgery at the Nanjing General Hospital of Nanjing Military Command from October 2006 to March 2008 were prospectively analyzed.All patients were randomly divided into test group(85 patients received fluid restriction treatment)and control group(83 patients received conventional treatment)by the sealed envelope method.The difference in the fluid volume between the 2groups was observed.Differences in systemic complication rate,local complication rate,general complication rate,time to bowl movement,length of hospital stay and mortality between the 2 groups were compared.All data were analyzed using the chi-square test,t test,Fisher exact test,Results The median total volumes of fluid in test group and control group were 1450 ml and 2420 ml,respectively,with significant difference between the 2 groups (t=-5.067,P0.05).Conclusion Fluid restriction reduces the complication rate,shortens the length of hospital stay and accelerates recovery after biliary operation.

Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy.

BACKGROUND: Our objective was to compare the effect of a restricted intravenous fluid regimen adjusted by serum lactate level with a standard restricted regimen on complications after major elective surgery for gastrointestinal malignancy. METHODS: This is a randomized, observer-blinded, single-center trial conducted across a time span of 13 months. A total of 299 patients were allocated to either a restricted intravenous fluid regimen with supplementary intravenous fluids given based on serum lactate level (group A) or a standard restricted regimen (group R). In group A, the serum lactate level was monitored closely postoperatively to maintain a normal pre-operative serum lactate level. Group R involved patients treated with a restricted fluid regimen in whom additional fluid and electrolytes were administered when deemed necessary based on the usual clinical criteria. The primary outcome measure was complications; the secondary measures were death and adverse effects. RESULTS: Additional fluid supplementation was needed in some patients in both groups (group A [28%] vs group R [26%]). In group A, the time for additional fluid infusion occurred earlier in the postoperative period than group R. Patients in group A received their first supplementary fluid treatment within the first 12 h more commonly than those in group R (74% vs 37%, respectively; P < .004). The regimen adjusted by serum lactate decreased systemic postoperative complications in group A versus group R (10% vs 22%, respectively; P = .023) but not overall total complications (23% vs 33%, respectively; P = .090). In contrast, in patients who required additional fluid infusion, the difference in complications between the 2 groups was greater (overall complication, 45% vs 85%, respectively; P = .023; major complication, 16% vs 44%, respectively; P = .018; systemic complications, 19% vs 63%, respectively; P = .001). One patient died in group A and 4 died in group R (1% vs 4%, respectively; P = .206). CONCLUSION: A fluid-restricted regimen after elective gastrointestinal operations for malignancy may lead to fluid insufficiency and low tissue perfusion in up to 28% of patients. Close monitoring of serum lactate levels with adjustment of intravenous fluid administration intraoperatively and in the early postoperative period may improve the early detection and correction of inadequate tissue perfusion, thereby decreasing the rate of complications.

Regulation effect of insulin on the hypermetabolism of the skeletal muscles of septic patients through ubiquitin-proteasome pathway / 肠外与肠内营养

Hypermetabolism syndrome,especially in skeletal muscles,is exceedingly common in septic patients.Many studies suggest that the activity of ubiquitin-proteasome pathway is a vital procedure for hypermetabolism of skeletal muscles of septic patients and its activation can be influenced by a variety of factors,such as proinflammatory cytokine and glucocorticoid,etc.Evidences indicate that insulin has played an important role in opsonizing the activation of ubiquitin-proteasome pathway.This paper reviews the regulation effect of insulin to the hypermetabolism of the skeletal muscles of septic patients through ubiquitin-proteasome pathway.

Perioperative nutrition support in patients with Crohn's disease / 肠外与肠内营养

Objective: To investigate the potential role and our experience of perioperative nutritional support in the management of patients with Crohn's disease (CD).Methods: 150 CD patients (male to female=101:49) performed with operation and from the year 1997 to 2007 were analyzed retrospectively. Their nutritional index, Crohn's Disease Activity Index (CDAI), sites of lesion, causes and procedures of operation, usage of nutritional support pre-operatively and post-operatively, and operation-related complications were all recorded.Results: Malnutrition, as indicated as BMI10% over the recent 3 months,occurred in 130 patients (88.67%)on admission.After aggressive nutritional support,patients' nutritional index, such as blood haemoglobin, serum albumin, pre-albumin, transferrin and lymphocytes counts all increased significantly pre-operatively and on discharge compared with on admission, while the change of BMI was not significant. For 53 patients receiving home enteral nutrition after discharge, their BMI increased significantly on last follow-up compared with on admission (19.24 vs 17.64, P<0.001). Operation-related complications occurred in 14 patients (9.33%), and two of them died due to severe intra-abdominal infections. Two patients with severe retroperitoneal infection on admission were successfully treated using the damage-control surgery.Conclusion: Malnutrition is a common complication in CD patients receiving surgery, and aggressive perioperative nutritional support may have a positive effect on the morbidity and mortality in such patients. Long-term maintenance therapy with enteral nutrition may delay the postoperative recurrence of the Crohn's disease and should be considered. For critically ill CD, damage-control surgery may get a better outcome than conventional treatment procedures.

The clinical significance of acute insulin resistance during surgical sepsis / 解放军医学杂志

Objective To investigate the clinical significance of acute insulin resistance during surgical sepsis. Methods Forty surgical patients with sepsis in experimental group and twenty patients with similar APACHEⅡ but without sepsis in experimental control group were enrolled in our study. In the experimental group, the patients were categorized to sepsis group and septic shock and MODS(SM)group according to clinical manifestations, and were also grouped according to different causes of sepsis, i.e.severe acute pancreatitis(SAP)group, intestinal fistula group and other diseases group. Determinations of fasting blood glucose, fasting plasma insulin, clinical nutritional parameters, plasma TNF-α, APACHEⅡ, sepsis-related organ failure assessment(SOFA)and severe scores were simultaneously performed at designated time points. Insulin resistance index was calculated using homeostasis model assessment(HOMA)to assess insulin sensitivity of surgical patients with sepsis. Results (1)A significant elevation of lgHOMA-IR levels was found in 84% of tests in sepsis. Peak lgHOMA-IR values increased in all patients.(2)LgHOMA-IR was significantly higher in patients with sepsis than those without sepsis from the first 24 hours(1.22±0.23 vs 0.73±0.21, P＜0.01)to the 7th day(0.46±0.32 vs 0.30±0.13, P＜0.01).(3)There was no significant difference in lgHOMA-IR among SAP, intestinal fistula and other groups at different times(P＞0.05).(4)There was significant difference in lgHOMA-IR between sepsis group and SM group during the whole septic episode(P＜0.01).During the septic episode, there were significant correlation between lgHOMA-IR and APACHEⅡ(r=0.591, P＜0.01), lgHOMA-IR and SOFA(r=0.496, P＜0.01), lgHOMA-IR and SS(r=0.553, P＜0.01), and lgHOMA-IR and TNF-α(r=0.658, P＜0.01).(5)lgHOMA-IR was independently directly correlated with LDL, prealbumin, cholesterol and triglyceride. R2 of the equation was 0.188. Conclusion There usually is insulin resistance in surgical sepsis, regardless the primary diseases. Insulin resistance may simply be a marker reflecting an underlying physiological derangement, implying indicates higher mortality. Among several clinical nutrition parameters, LDL, prealbumin, cholesterol, and triglyceride showed closer relationship with insulin resistance in patients with sepsis.

Related factors and mechanism of impaired glucose tolerance in human with sepsis / 肠外与肠内营养

Objectives: To study the related factors and mechanism of the impaired glucose tolerance(IGT) in human with sepsis. Methods: According to the results of intravenous glucose tolerance test, forty patients were classified into two groups: 16 control subjects and 24 IGT subjects. The counterregulatory hormone, the basal levels of plasma insulin, glucagons, cortisol, IL 6 and TNF ? were compared in two groups, and the change of inflammatory cytokine and counterregulatory hormone after dextrose infusion were observed. Results: The severity of the disease (APACHEⅡscore, Sepsis score), mixed infection and bacteremia were significantly related to the results of glucose tolerance test( P