A risk prediction model for efficient intubation in the emergency department: A 4-year single-center retrospective analysis.

Objective: To analyze the risk factors associated with intubated critically ill patients in the emergency department (ED) and develop a prediction model by machine learning algorithms. Methods: This study was conducted in an academic tertiary hospital in Hangzhou, China. Critically ill patients admitted to the ED were retrospectively analyzed from May 2018 to July 2022. The demographic characteristics, distribution of organ dysfunction, parameters for different organs' examination, and status of mechanical ventilation were recorded. These patients were assigned to the intubation and non-intubation groups according to ventilation support. We used the eXtreme Gradient Boosting (XGBoost) algorithm to develop the prediction model and compared it with other algorithms, such as logistic regression, artificial neural network, and random forest. SHapley Additive exPlanations was used to analyze the risk factors of intubated critically ill patients in the ED. Results: Of 14,589 critically ill patients, 10,212 comprised the training group and 4377 comprised the test group; 2289 intubated patients were obtained from the electronic medical records. The mean age, mean scores of vital signs, parameters of different organs, and blood oxygen examination results differed significantly between the two groups (p < 0.05). The white blood cell count, international normalized ratio, respiratory rate, and pH are the top four risk factors for intubation in critically ill patients. Based on the risk factors in different predictive models, the XGBoost model showed the highest area under the receiver operating characteristic curve (0.84) for predicting ED intubation. Conclusions: For critically ill patients in the ED, the proposed model can predict potential intubation based on the risk factors in the clinically predictive model.

On the way to the azygos vein: a road of return rather than ruined.

BACKGROUND: The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter. CASE PRESENTATION: A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications. CONCLUSIONS: CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.

SULFORAPHANE ALLEVIATES POSTRESUSCITATION LUNG PYROPTOSIS POSSIBLY VIA ACTIVATING THE NRF2/HO-1 PATHWAY.

ABSTRACT: Introduction: Sulforaphane (SFN), known as the activator of the nuclear factor E2-related factor 2 (Nrf2)/heme oxygenase 1 (HO-1) pathway, has been proven to protect the lung against various pathological stimuli. The present study aimed to investigate the effect of SFN on lung injury induced by systemic ischemia reperfusion after cardiac arrest and resuscitation. Methods: After animal preparation, 24 pigs were randomly divided into sham group (n = 6), cardiopulmonary resuscitation group (CPR, n = 9), or CPR + SFN group (n = 9). The experimental model was then established by 10 min of cardiac arrest followed by 6 min of CPR. Once spontaneous circulation was achieved, a dose of 2 mg/kg of SFN diluted in 20 mL of saline was intravenously infused with a duration of 5 min. During 4 h of observation after resuscitation, extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI), and oxygenation index were regularly evaluated. At 24 h after resuscitation, lung tissues were harvested to evaluate the score of lung histopathological injury, the activity of superoxide dismutase, the contents of malondialdehyde, IL-1ß, and IL-18, and the expression levels of NOD-like receptor pyrin domain 3, cleaved caspase 1, gasdermin D (GSDMD), GSDMD N-terminal, Nrf2, and HO-1. Results: During CPR, spontaneous circulation was achieved in six and seven pigs in the CPR and CPR + SFN groups, respectively. After resuscitation, the indicators of lung injury (ELWI, PVPI, and oxygenation index) were all better in the CPR + SFN group than in the CPR group, in which the differences in ELWI and PVPI at 2, and 4 h after resuscitation were significant between the two groups. In addition, SFN significantly reduced lung injury score, improved oxidative imbalance (superoxide dismutase, malondialdehyde), decreased pyroptosis-related proinflammatory cytokines (IL-1ß, IL-18), downregulated pyroptosis-related proteins (NOD-like receptor pyrin domain 3, cleaved caspase 1, GSDMD, GSDMD N-terminal), and activated the Nrf2/HO-1 pathway when compared with the CPR group. Conclusion: SFN produced effective postresuscitation lung protection through alleviating lung pyroptosis possibly via activating the Nrf2/HO-1 pathway in pigs.

ALDA-1 TREATMENT ALLEVIATES LUNG INJURY AFTER CARDIAC ARREST AND RESUSCITATION IN SWINE.

ABSTRACT: Introduction: Alda-1, an aldehyde dehydrogenase 2 (ALDH2) activator, has been shown to protect the lung against a variety of diseases including regional ischemia-reperfusion injury, severe hemorrhagic shock, hyperoxia, and so on. The present study was designed to investigate the effectiveness of Alda-1 treatment in alleviating lung injury after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) in swine. Methods: A total of 24 swine were randomized into three groups: sham (n = 6), CA/CPR (n = 10), and CA/CPR + Alda-1 (n = 8). The swine model was established by 8 min of electrically induced and untreated CA, and then 8 min of manual CPR. A dose of 0.88 mg/kg of Alda-1 was intravenously injected at 5 min after CA/CPR. After CA/CPR, extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI), and oxygenation index (OI) were regularly evaluated for 4 h. At 24 h after resuscitation, lung ALDH2 activity was detected, and its injury score, apoptosis, and ferroptosis were measured. Results: After experiencing the same procedure of CA and CPR, five swine in the CA/CPR group and six swine in the CA/CPR + Alda-1 group restored spontaneous circulation. Subsequently, significantly increased ELWI and PVPI, and markedly decreased OI were observed in these two groups compared with the sham group. However, all of them were gradually improved and significantly better in the swine treated with the Alda-1 compared with the CA/CPR group. Tissue analysis indicated that lung ALDH2 activity was significantly decreased in those swine experiencing the CA/CPR procedure compared with the sham group; nevertheless, its activity was significantly greater in the CA/CPR + Alda-1 group than in the CA/CPR group. In addition, lung injury score, and its apoptosis and ferroptosis were significantly increased in the CA/CPR and CA/CPR + Alda-1 groups compared with the sham group. Likewise, Alda-1 treatment significantly decreased these pathological damages in lung tissue when compared with the CA/CPR group. Conclusions: Alda-1 treatment was effective to alleviate lung injury after CA/CPR in a swine model, in which the protective role was possibly related to the inhibition of cell apoptosis and ferroptosis. It might provide a novel therapeutic target and a feasible therapeutic drug for lung protection after CA/CPR.

A new method using surface landmarks to locate resuscitative endovascular balloon occlusion of the aorta based on a retrospective CTA study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) can timely prevent the wounded from fatal hemorrhage. However, blind insertion of REBOA in field or emergency room may result in catheter malposition and serious complications. We aim to develop a new method based on surface landmarks to guide the accurate placement of REBOA in zone III of aorta without fluoroscopy. METHODS: A retrospective study was conducted in a university hospital, including 57 subjects who underwent computed tomography angiography (CTA) from April to December in 2019. External distances and intravascular lengths were measured by three-dimensional reconstruction of CT images, including the distances from the insertion site of femoral artery to the xiphoid process (FA-Xi), the midpoint between the xiphoid process and the umbilicus (FA-mXU), the umbilicus (FA-Ui), the midpoint of the zone III of aorta (FA-mZIII), the lowest renal artery (FA-LRA), and aortic bifurcation (FA-AB). The distal and proximal ideal margin and predicted accuracy were calculated by curvature plane reconstruction. The predicted probability of balloon positioning in zone III by different methods was compared. RESULTS: The mean age of all patients was 60 years (SD = 9.4). The average length of zone III of aorta was 9.4 cm (SD = 1.0), and the length of FA-mZIII on the right and left sides were 24.4 cm (SD = 2.1), 23.8 cm (SD = 2.1), respectively. FA-Xi was longer than FA-LRA, and FA-Ui was shorter than FA-AB (paired two-tailed test, p < 0.001). Using three methods including the optimal quartering distances, the optimal distances below the xiphoid and above the umbilicus to predict the length of REBOA catheter positioning in zone III showed no statistically significant difference. The predicted accuracy of catheter positioning in zone III on the left and right sides guided by FA-mXU were 84.2% and 86%. CONCLUSIONS: The midpoint between the xiphoid process and the umbilicus may be a new surface landmark for people of normal weight to guide rapid positioning REBOA in zone III of aorta without fluoroscopy.

High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study.

BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Lung ultrasound score in establishing the timing of intubation in COVID-19 interstitial pneumonia: A preliminary retrospective observational study.

PURPOSE: To investigate the role of lung ultrasound score (LUS) in assessing intubation timing for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. MATERIALS AND METHODS: Seventy-two patients with critical coronavirus disease 2019 (COVID-19) were admitted to a makeshift intensive care unit (ICU). All patients underwent bedside lung ultrasonography one to two times per day. The patients were either intubated, treated with noninvasive ventilation (NIV), or given high-flow nasal cannula (HFNC) after a discussion with the multidisciplinary group after their conditions worsened. Bedside lung ultrasound was performed daily after intubation, and patients received mechanical ventilation. Lung ultrasound was performed on days 1, 2, 3, 5, and 7 after patients were admitted to the ICU; if the patient was intubated, LUS determination was performed before intubation within 24 h (T1) and on days 1, 2, 5, and 7 after intubation (T2, T3, T4, and T5, respectively).The goal of this study was to evaluate the severity of lung aeration loss in intubated and non-intubated patients with SARS-CoV-2 pneumonia by ultrasound at different time points within one week. RESULTS: A total of 16 patients were included in this study, including nine who were intubated and mechanically ventilated and seven patients without intubation. The number of elderly individuals in the intubated group was higher than in the non-intubated group (P < 0.05). In addition, there were more male than female patients in both groups. Patient characteristics (BMI, SOFA, and PaO2/FiO2 value) were similar between the two groups (P > 0.05). The 28-day mortality rate of intubated patients was higher than that of non-intubated patients; six patients in the intubated group and two patients in the non-intubated group died. Nine intubated patients showed changes in LUS within seven days (n = 9). The mean LUS within 24 h before intubation was 12.8 ± 1.3. LUS was significantly higher on T1 than on T5 (P <0.05), and did not significantly differ from T1 to T4. Comparing LUS between intubated and non-intubated patients on T1 showed that the LUS of intubated patients was significantly higher than that of non-intubated patients (P <0.05). Between the two patient groups, oxygenation index was 140.1 ± 7.7 vs. 137.8 ± 5.9 on T1, and the respiratory rate of the two groups was 26 ± 5 vs. 28 ± 4 breaths/min. Neither oxygenation index nor RR significantly differed between the two groups. CONCLUSION: LUS may be an effective tool for assessing intubation timing in critically ill patients with Covid-19 interstitial pneumonia.

Therapeutic effect of high-flow nasal cannula on severe COVID-19 patients in a makeshift intensive-care unit: A case report.

INTRODUCTION: Several intensive-care units (ICUs) in Wuhan are nonstandard wards that were repurposed from general wards. Considering the shortage of medical resources and the need to prevent nosocomic infection, the respiratory-treatment strategy in these nonstandard ICUs is different from those in general wards and standard ICUs. High-flow nasal cannula (HFNC) plays an important role in nonstandard ICUs and is beneficial to the patients therein. PATIENT CONCERNS: In this study, we analyzed four cases of HFNC-treated patients with severe coronavirus disease 2019 (COVID-19) in a makeshift ICU and summarized our experience. DIAGNOSES: Four patients diagnosed with COVID-19 according to World Health Organization (WHO) interim guidance were admitted to the makeshift ICU. INTERVENTIONS: All patients had oxygen treatment with HFNC, as well as regular treatment of antivirals and traditional Chinese medicine. OUTCOMES: Two patients survived after treatment, while the other two died from acute respiratory distress syndrome (ARDS) and heart failure, respectively. CONCLUSION: Patients with severe and critical COVID-19 often have poor prognoses after mechanical ventilation, exhibiting corresponding complications such as ventilator-associated pneumonia and deep-vein thrombosis, which significantly prolongs length of stay in the ICU. HFNC could prevent intubation in some patients, thereby avoiding the above complications; however, this needs confirmation in further clinical studies. This treatment reduced difficulty and workloads for healthcare professionals, had good tolerability for patients, might not significantly increase the risk of infection for healthcare professionals, and do not require additional preventive measures against nosocomic infection. HFNC treatment has its advantages in providing oxygen therapy in COVID-19, but healthcare professionals should still pay close attention to changes in patients' oxygenation rates and respiratory frequency.

Risk factors and clinical significance of trauma-induced coagulopathy in ICU patients with severe trauma.

OBJECTIVE: To investigate the incidence and risk factors for trauma-induced coagulopathy (TIC) and the impact of TIC on outcomes of patients with severe trauma admitted to an emergency intensive care unit. METHODS: We retrospectively reviewed clinical data from 223 patients with severe trauma admitted to emergency intensive care unit within 24 h after injury. Injury Severity Score (ISS), Acute Physiology and Chronic Health Evaluation II score, coagulation function, routine blood and biochemical tests, and blood gas parameters were obtained from medical records. Patients were divided into two groups according to the presence or absence of coagulopathy. ISS, Acute Physiology and Chronic Health Evaluation II score, and the incidence rates of hypothermia and tissue hypoperfusion were compared. The risk factors of TIC were analyzed and a multivariate logistic regression equation was developed. Coagulation function and the incidence of TIC were also compared between surviving and dead patients. RESULTS: Overall, 52/223 (23.3%) patients fulfilled the diagnostic criteria for TIC. Their mortality rate was significantly higher than that of patients without coagulopathy (36.5 vs. 9.4%, P<0.01). ISS, incidence rates of hypothermia and tissue hypoperfusion, and the prevalence of severe traumatic brain injury were significantly higher (P<0.01), whereas Glasgow Coma Scale, hemoglobin, hematocrit, and platelet counts were significantly lower (P<0.01) in patients with coagulopathy than those without. Base deficit at least 6, Glasgow Coma Scale 8 or less, and platelet count were independent risk factors for TIC. Compared with surviving patients, the patients who died had significantly reduced coagulation function. CONCLUSION: The incidence of TIC is particularly high among patients with severe trauma. TIC is associated with increased ISS, brain injury, shock and hypothermia, and mortality.

Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter.

OBJECTIVE: To evaluate the efficacy and safety of the treatment of traumatic hemothorax by closed pleural drainage using a central venous catheter (CVC), compared with using a conventional chest tube. METHODS: A prospective controlled study with the Ethics Committee approval was undertaken. A total of 407 patients with traumatic hemothorax were involved and they were randomly assigned to undergo closed pleural drainage with CVCs (n=214) or conventional chest tubes (n=193). The Seldinger technique was used for drainage by CVC, and the conventional technique for drainage by chest tube. If the residual volume of the hemothorax was less than 200 ml after the daily volume of drainage decreased to below 100 ml for two consecutive days, the treatment was considered successful. The correlative data of efficacy and safety between the two groups were analyzed using t or chi-squared tests with SPSS 13.0. A P value of less than 0.05 was taken as indicating statistical significance. RESULTS: Compared with the chest tube group, the operation time, fraction of analgesic treatment, time of surgical wound healing, and infection rate of surgical wounds were significantly decreased (P<0.05) in the CVC group. There were no significant differences between the two groups in the success rate of treatment and the incidence of serious complications (P>0.05), or in the mean catheter/tube indwelling time and mean medical costs of patients treated successfully (P>0.05). CONCLUSIONS: Management of medium or large traumatic hemothoraxes by closed thoracic drainage using CVC is minimally invasive and as effective as using a conventional large-bore chest tube. Its complications can be prevented and it has the potential to replace the large-bore chest tube.

[Netrin-1 protein expression in gastric cancer and its correlation with clinicopathologic features and prognosis].

OBJECTIVE: To evaluate the relationship between netrin-1 protein, clinicopathologic features and prognosis in gastric cancer patients. METHODS: Tissue micro-array and immunohistochemistry were used to detect expression of netrin-1 protein and Ki67. And clinicopathological relevance of netrin-1 protein and Ki67 in gastric cancer were analyzed. Survival rates was evaluated by Kaplan-Meier survival curves. Cox regression analysis was performed to evaluate the possibility of netrin-1 expression as an independent prognostic factor for gastric cancer. RESULTS: The positive-expression rate of netrin-1 protein, paracancerous netrin-1 protein and Ki67 in tumor tissue from 67 patients with gastric cancer were 49%, 42% and 60%, respectively. netrin-1 protein expression might be related to depth of invasion, lymth node metastasis and distant metastasis (P<0.05). But no correlation was observed in sex, tumor diameter and tumor grade (P>0.05). There was correlation between different degrees of netrin-1 expression and distant metastases (P<0.05). No correlation was found in the expression of Ki67 and clinicopathological features. The correlation between the expression of netrin-1 and Ki67 was observed (r=0.359, P<0.05). Using Kaplan-Meier survival curves and the log-rank test, the correlation of netrin-1 expression, different degrees of netrin-1 expression and survival (P<0.05) were also observed. But netrin-1 expression was not significantly correlated with the prognosis of gastric cancer (RR = 1.335, 95% CI: 0.612-2.914). CONCLUSION: netrin-1 protein may be related with tumorigenesis and tumor progression by affecting proliferation. The detection for netrin-1 may be helpful to evaluate the clinicopathological parameters and survival time. However, it is not an independent prognostic factor for gastric cancer.

Basic fibroblast growth factor alleviates brain injury following global ischemia reperfusion in rabbits.

The aim of this study was to explore the protective effect of basic fibroblast growth factor (bFGF) on brain injury following global ischemia reperfusion and its mechanisms. Brain injury following global ischemia was induced by four vessels occlusion and systemic hypotension. Twenty-four rabbits were randomized into three groups: group A, only dissection of vessels; group B, intravenous infusion of normal saline after reperfusion for 6 h; group C, 30 microg/kg bFGF injected intravenously at the onset of reperfusion, then infused with 10 microg/(kg.h) for 6 h. Serum neuron specific enolase (NSE), S-100B, tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), interleukin-8 (IL-8) were measured before ischemia, 30 min after ischemia, 0.5, 1, 3, 6 h after reperfusion. Brain water content was determined and cerebral histopathological damages were compared. NSE and S-100B were increased 1 h after reperfusion and reached their peaks 6 h after reperfusion, but were much higher in group B than those in group C 3, 6 h after reperfusion. In groups B and C, TNF-alpha was increased after ischemia and IL-1 and IL-8 were increased significantly 0.5 h after reperfusion, then reached their peaks 6 h, 3 h, 6 h after reperfusion respectively. TNF-alpha and IL-8 at the time points of 1 h and 3 h and IL-1 at 3 h and 6 h in group C were correspondingly lower than those in group B. These indices in group A were nearly unchanged. There were less severe cerebral histopathological damages in group C compared with group B, but no difference in brain water content. It could be concluded that bFGF alleviates brain injury following global ischemia and reperfusion by down-regulating expression of inflammatory factors and inhibiting their activities.