Core competencies in neurocritical care training in China: consensus developed by a national Delphi consensus survey combined with nominal group technique.

OBJECTIVES: To define the core competencies essential for specialist training in neurocritical care in China. DESIGN: Modified Delphi method and nominal group (NG) technique. SETTING: National. PARTICIPANTS: A total of 1094 respondents from 33 provinces in China participated in the online survey. A NG of 11 members was organised by the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians and the National Center for Healthcare Quality Management in Neurological Diseases. RESULTS: 1094 respondents from 33 provinces in China participated in the online survey. A formal list containing 329 statements was generated for the rating by a NG. After five rounds of NG meetings and one round of comments and iterative review, 198 core competencies (54 on neurological diseases, 64 on general medical diseases, 42 on monitoring of practical procedures, 20 on professionalism and system management, five on ethical and legal aspects, three on the principles of research and certification and 10 on scoring systems) formed the final list. CONCLUSION: By using consensus techniques, we have developed a list of core competencies for neurocritical care training, which may serve as a reference for future specialist training programmes in China.

Dose-related effects of dexmedetomidine on immunomodulation and mortality to septic shock in rats.

BACKGROUND: Dexmedetomidine has already been used in septic patients as a new sedative agent, few studies have examined its effects on immunomodulation. Therefore, the authors have designed a controlled experimental study to characterize the immunomodulation effects of dexmedetomidine in the cecal ligation and puncture (CLP) model in rats. METHODS: After CLP, 48 Wistar rats were randomly allocated into four groups: (1) CLP group; (2) small-dose treatment group (2.5 µg·kg-1·h-1); (3) medium-dose treatment group (5.0 µg·kg-1· h-1); and (4) large-dose treatment group (10.0 µg·kg-1·h-1). HLA-DR and plasma cytokine (IL-4, IL-6, IL-10 and TNF-α) levels were measured, and the mean arterial blood pressure (MAP), heart rate (HR), arterial blood gases, lactate concentrations and mortality were also documented. RESULTS: The HLA-DR level, inflammatory mediator levels, MAP and HR had no obvious changes among Dexmedetomidine treatment groups (DEX groups). Compared with the CLP group, the DEX groups exhibited decreased HLA-DR levels (Pgroup=0.0202) and increased IL-6 production, which was increased at 3 h (P= 0.0113) and was then attenuated at 5 h; additionally, the DEX groups exhibited decreased HR (P<0.001) while maintaining MAP (Pgroup=0.1238), and remarkably improving lactate (P<0.0001). All of these factors led to a significant decrease in the mortality, with observed rates of 91.7%, 66.7%, 25% and 18% for the CLP, DEX2.5, DEX5.0, DEX10.0 groups, respectively. CONCLUSION: Dexmedetomidine treatment in the setting of a CLP sepsis rat model has partially induced immunomodulation that was initiated within 5 h, causing a decreased HR while maintaining MAP, remarkably improving metabolic acidosis and improving mortality dose-dependently.

Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study.

BACKGROUND: Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. METHODS: We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. RESULTS: Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss's kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). CONCLUSIONS: The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (registration number NCT01704066 ) on 6 October 2012.

Value of Kidney Disease Improving Global Outcomes Urine Output Criteria in Critically Ill Patients: A Secondary Analysis of a Multicenter Prospective Cohort Study.

BACKGROUND: Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGOUO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGOSCr). METHODS: We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGOUOand KDIGOSCr. Hospital mortality of patients with more severe AKI classification based on KDIGOUOwas compared with other patients by univariate and multivariate regression analyses. RESULTS: The prevalence of AKI increased from 52.4% based on KDIGOSCrto 55.4% based on KDIGOSCrcombined with KDIGOUO. KDIGOUOalso resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGOUO. Compared with non-AKI patients or those with maximum AKI classification by KDIGOSCr, those with maximum AKI classification by KDIGOUOhad a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141-13.873, P< 0.001). In a multivariate logistic regression analysis, AKI based on KDIGOUO (OR: 2.891, 95% CI: 1.964-4.254, P< 0.001), but not based on KDIGOSCr (OR: 1.322, 95% CI: 0.902-1.939, P = 0.152), was an independent risk factor for hospital mortality. CONCLUSION: UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.

Lung-protective Ventilation in Patients with Brain Injury: A Multicenter Cross-sectional Study and Questionnaire Survey in China.

BACKGROUND: Over the years, the mechanical ventilation (MV) strategy has changed worldwide. The aim of the present study was to describe the ventilation practices, particularly lung-protective ventilation (LPV), among brain-injured patients in China. METHODS: This study was a multicenter, 1-day, cross-sectional study in 47 Intensive Care Units (ICUs) across China. Mechanically ventilated patients (18 years and older) with brain injury in a participating ICU during the time of the study, including traumatic brain injury, stroke, postoperation with intracranial tumor, hypoxic-ischemic encephalopathy, intracranial infection, and idiopathic epilepsy, were enrolled. Demographic data, primary diagnoses, indications for MV, MV modes and settings, and prognoses on the 60th day were collected. Multivariable logistic analysis was used to assess factors that might affect the use of LPV. RESULTS: A total of 104 patients were enrolled in the present study, 87 (83.7%) of whom were identified with severe brain injury based on a Glasgow Coma Scale ≤8 points. Synchronized intermittent mandatory ventilation (SIMV) was the most frequent ventilator mode, accounting for 46.2% of the entire cohort. The median tidal volume was set to 8.0 ml/kg (interquartile range [IQR], 7.0-8.9 ml/kg) of the predicted body weight; 50 (48.1%) patients received LPV. The median positive end-expiratory pressure (PEEP) was set to 5 cmH2O (IQR, 5-6 cmH2O). No PEEP values were higher than 10 cmH2O. Compared with partially mandatory ventilation, supportive and spontaneous ventilation practices were associated with LPV. There were no significant differences in mortality and MV duration between patients subjected to LPV and those were not. CONCLUSIONS: Among brain-injured patients in China, SIMV was the most frequent ventilation mode. Nearly one-half of the brain-injured patients received LPV. Patients under supportive and spontaneous ventilation were more likely to receive LPV. TRIAL REGISTRATION: ClinicalTrials.org NCT02517073 https://clinicaltrials.gov/ct2/show/NCT02517073.

Prevalence, risk factors, clinical course, and outcome of acute kidney injury in Chinese intensive care units: a prospective cohort study.

BACKGROUND: Acute kidney injury (AKI) has been recognized as a major healthcare problem affecting millions of patients worldwide. However, epidemiologic data concerning AKI in China are still lacking. The objectives of this study were to characterize AKI defined by RIFLE criteria, assess the association with hospital mortality, and evaluate the impact of AKI in the context of other risk factors. METHODS: This prospective multicenter observational study enrolled 3,063 consecutive patients from 1 July 2009 to 31 August 2009 in 22 ICUs across mainland China. We excluded patients who were admitted for less than 24 hours (n = 1623), younger than 18 years (n = 127), receiving chronic hemodialysis (n = 29), receiving renal transplantation (n = 1) and unknown reasons (n = 28). There were 1255 patients in the final analysis. AKI was diagnosed and classified according to RIFLE criteria. RESULTS: There were 396 patients (31.6%) who had AKI, with RIFLE maximum class R, I, and F in 126 (10.0%), 91 (7.3%), and 179 (14.3%) patients, respectively. Renal function deteriorated in 206 patients (16.4%). In comparison with non AKI patients, patients in the risk class on ICU admission were more likely to progress to the injury class (odds ratio (OR) 3.564, 95% confidence interval (CI) 1.706 - 7.443, P = 0.001], while patients in the risk class (OR 5.215, 95% CI 2.798-9.719, P < 0.001) and injury class (OR 13.316, 95% CI 7.507-23.622, P < 0.001) had a significantly higher probability of deteriorating into failure class. The adjusted hazard ratios for 90-day mortality were 1.884 for the risk group, 3.401 for the injury group, and 5.306 for the failure group. CONCLUSIONS: The prevalence of AKI was high among critically ill patients in Chinese ICUs. In comparison with non-AKI patients, patients with RIFLE class R or class I on ICU admission were more susceptibility to progression to class I or class F. The RIFLE criteria were robust and correlated well with clinical deterioration and mortality.

[The study of AutoFlow role in volume controlled ventilation].

OBJECTIVE: To evaluate the efficacy and safety of automatic variable flow rate (AutoFlow) for volume control ventilation through monitoring the number of ventilator alarm. METHODS: Forty-eight adult patients receiving the Drager Evita 4 ventilator with an expectation of more than 2 days duration were divided into two groups by randomly digital methods, each n=24. The patients in control group were received routinely mode with synchronized intermittent mandatory ventilation (SIMV), and the others in observation group were given SIMV and assist with AutoFlow. The midazolam and fentanyl was given to retain the Ramsay score 2-3 by continuous micro-pump. The ventilator alarm, blood gas analysis and respiratory function were recorded. RESULTS: There were no significant differences in respiratory rate (RR), tidal volume (VT), positive end-expiratory pressure (PEEP), fraction of inspired oxygen (FiO2), pH, arterial partial pressure of carbon dioxide (PaCO2), arterial partial pressure of oxygen (PaO2), oxygenation index (PaO2/FiO2), as well as sedative dose and time between two groups within 5 days of mechanical ventilation. Duration of mechanical ventilation in all patients was 164 days (3756 hours), and 78 days (1812 hours) in control group, 86 days (1944 hours) in observation group. The duration of mechanical ventilation in observation group was longer than that in control group [3 (1-15) days vs. 2 (1-28) days, P>0.05]. A total of 23 843 alarms were recorded, approximately 6 times/h, and 17 386 alarms in control group, averagely 9.6 times/h, 6457 alarms in the observation group, averagely 3.3 times/h. The number of ventilator alarm in observation group was less than that in control group (P<0.01). The number of airway pressure alarm in observation group was less than that in the control group [122 (8-1068) vs. 565 (13-1898), P<0.01]. There was no significant difference in sequential organ failure assessment (SOFA) score within 5 days between the two sets of mechanical ventilation. In the observation group ventilator-associated pneumonia (VAP) was occurred in 4 cases, and no pneumothorax happened, while in the control group there were 8 cases and 2 cases respectively. The mortality rate in intensive care unit (ICU) in observation group was lower than that in control group, but there was no statistical difference (25.0% vs. 37.5%, P>0.05). CONCLUSIONS: AutoFlow is confirmed be safe for volume control ventilation mode, and could significantly reduce the alarm of ventilator.

[Effect of intensive glucose control during peri-operative period on prognosis of patients undergoing cardiac surgery: a Meta-analysis].

OBJECTIVE: To systematically review the literature to determine the effects of intensive versus normal glycaemic control during peri-operative period on prognosis of patients undergoing cardiac surgery. METHODS: The literature was systematically reviewed based on searching criteria established by Cochrane Collaboration. PubMed database searching was conducted for literature and the language was limited to English. Each paper was reviewed by 2 independent reviewers and data extracted for statistical analysis. Data from identified studies were collected for Meta-analysis (RevMan 5.0). RESULTS: Seven randomized controlled trials (RCTs), involving a total of 2329 patients, were identified in the literature. The results showed that intensive glycaemic control could reduce the incidence of infection [odds ratio (OR) = 0.42, 95% confidence interval (95%CI) 0.25 to 0.73, P = 0.002], mortality (OR = 0.54, 95%CI 0.34 to 0.87, P = 0.01), the duration of mechanical ventilation [weighted mean difference (WMD) = -2.68, 95%CI -4.99 to -0.37, P = 0.02], and length of stay in the intensive care unit (ICU, WMD = -15.49, 95%CI -16.14 to -14.83, P < 0.000 01), and also could slightly reduce the incidence of post-surgical atrial fibrillation (OR = 0.77, 95%CI 0.60 to 1.00, P = 0.05). However, intensive glycaemic control could not reduce the use of epicardial pacing (OR = 0.32, 95%CI 0.09 to 1.05, P = 0.06). CONCLUSION: Intensive blood glucose control during peri-operative period could improve the prognosis of patients undergoing cardiac surgery.

[Effects of different doses of ulinastatin on inflammatory response and pulmonary function after cardiopulmonary bypass].

OBJECTIVE: To evaluate the effect of ulinastatin (UTI) on the changes in inflammatory cytokines and inflammatory response as a result of cardiopulmonary bypass (CPB) in cardiac valvular replacement surgery and to investigate the protective effect of UTI on lungs. METHODS: A prospective randomized control clinical trial was designed, and 42 patients scheduled for elective cardiac valvular replacement were randomly divided into three groups: control group, UTI 8 kU/kg group (group U1) and UTI 12 kU/kg group (group U2), with 14 patient in each group. Blood samples were obtained from central vein for determination of plasma tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and IL-10 concentrations before operation (T1), 1 hour (T2), 4 hours (T3), and 24 hours (T4) after CPB respectively. At the same time points, arterial blood gas analysis were recorded for calculation of oxygen index (PaO2/FiO2) and respiratory index (RI). RESULTS: (1)There was no significant difference in the plasma concentrations of TNF-alpha, IL-6 and IL-10 at T1 among the three groups (all P>0.05), but increased at T2-4 as compared with the T1 in three group (P<0.05 or P<0.01). Compared with the control group, the plasma level of TNF-alpha and IL-6 of both UTI groups at T2-4 were significantly lower, IL-10 of both UTI groups was significantly higher, and changes were more marked in group U2 than those in group U1 (P<0.05 or P<0.01). (2) There was no significant difference in PaO2/FiO2 and RI at T1 among the three groups (all P>0.05), but PaO2/FiO2 was decreased, RI was increased at T2-4 as compared with the T1 in three group (P<0.05 or P<0.01). Compared with the control group, the PaO2/FiO2 of the two UTI groups was significantly higher, the RI of the two UTI groups was lower at T2-4, and changes were more marked in group U2 than those in group U1 (P<0.05 or P<0.01). CONCLUSION: During the CPB, UTI can significantly inhibit the inflammatory cytokine release and reduce the inflammatory response, lessen the lung inflammatory response to CPB and protect lung function, the effect of UTI shows a dose-effect relationship.