经过数十年全球的共同努力，脓毒血症（Sepsis）在临床治疗以及在病因、病理生理、诊断与治疗策略上都取得了令人鼓舞的成绩，但在ICU的重症患者中，其发病率与死亡率居高不下，仍然是引发脏器功能不全及死亡的高风险因素。在美国，Sepsis是前十位的死亡原因，年死亡约为23万6千人。中国的一项调查显示，在大型医院外科ICU中严重脓毒血症（Severe Sepsis）的发病率为8.68%，死亡率为48.7%，与发达国家的调查相近。在对Sepsis调查及干预研究中，与其相关的综合征的定义及命名仍然主要采用1991年美国胸科医师协会/危重病医学会芝加哥联席会议的建议，包括了从全身炎性反应综合征（systemic inflammatory response syndrome, SIRS）、Sepsis、严重脓毒血症（Severe Sepsis）、感染性休克（Septic Shock）直至多器官功能不全综合征（multiple organ dysfunction syndrome, MODS）的概念与定义，这些概念虽未得到完全的认可，但在建立统一和规范的临床诊断及研究基线和标准上仍然发挥了很大的作用。经过10年的不断改进，2001美国及欧洲的重症医学会，提出了改进的Sepsis诊断标准。
Objective To discuss the feasibility and safety of early enteral nutrition (EN) on treatment of severe acute pancreatitis (SAP) and its influence. Methods The advancement about application of early EN on treatment of SAP in recent years were reviewed. Results In patients with SAP, early EN via catheter placed in the jejunum could protect the integrity of intestinal barrier and reduce infectious complications. But no consensus had been reached about the starting time, ingredient and infusion mode yet. Conclusion Early EN may have positive effects on treatment of SAP, but further researches are still needed.
【Abstract】 Objective To discuss the mechanism of growth hormone (GH) in infection and its safety. Methods Advances in the application of GH in infection of recent years were reviewed. Results In infectious patients, GH may promote protein synthesis, strengthen the immunity of body, and protect the integrity of intestinal barrier function. But some patients present GH resistance. The safety of GH for infectious patients needs further evaluation. Conclusion GH may play a supplementary role in infection therapy, but further research is needed.
Objective To identify evidence-based treatment choices for a patient with increased intracranial pressure after acute traumatic brain injury. Methods We searched The Cochrane Library (Issue 2, 2006), MEDLNE (1981 to August 2006) and CBMdisc (1978 to August 2006) to identity systematic reviews (SRs), randomized controlled trials (RCTs), controlled clinical trials (CCTs) and prospective cohort studies involving the efficacy and safety of pharmacotherapy and non-pharmacotherapy for increased intracranial pressure after acute traumatic brain injury. Results We found 2 SRs and 8 RCTs on pharmacotherapy, and 6 SRs and 2 RCTs on non-pharmacotherapy. Conventional-dose mannitol was no better than hypertonic saline, but was better than other intracranial pressure lowering agents. High-dose mannitol can reduce mortality and the incidence of severe disability compared with conventional-dose mannitol. There were no studies comparing high-dose mannitol and hypertonic saline. Non-pharmacotherapy was not recommended for routine use due to the lack of good quality evidence. Conclusion For patients with increased intracranial pressure after acute traumatic brain injury, mannitol is effective in reducing the mortality and the incidence of severe disability. However, more large-scale RCTs are required to compare high-dose mannitol versus other drugs. Non-pharmacotherapy is not recommended as an adjunct therapy at present.
Objective To evaluate the effectiveness and safety of total enteral nutrition (TEN) versus total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP). Methods The databases such as Pubmed (1996 to June 2011), EMbase (1984 to June 2011), Cochrane Central Register of Controlled Trials of The Cochrane Library (Issue 6, 2011) and CBM (1978 to June 2011) were electronically searched, and the relevant references of the included papers were also manually searched. Two reviewers independently screened the trials according to inclusion and exclusion criteria, extracted the data, and assessed the methodology quality. Meta-analyses were performed using the Cochrane Collaboration’s RevMan 5.1 software. Results Seven randomized controlled trials (RCTs) involving 379 patients with SAP were included. The results of meta-analyses showed that compared with TPN, TEN could significantly reduce the risk of mortality (RR=0.33, 95%CI 0.20 to 0.55, Plt;0.000 1), pancreatitis-related infections (RR=0.35, 95%CI 0.25 to 0.50, Plt;0.000 01), required rate of surgical intervention (RR=0.43, 95%CI 0.23 to 0.82, P=0.01), and incidence of multiple organ failure (MOF) (RR=0.28, 95%CI 0.17 to 0.46, Plt;0.000 01). There was no significant difference in the nutrition strategies associated complications between TPN and TEN (RR=1.16, 95%CI 0.42 to 3.22, P=0.78). Conclusion Meta-analyses show that compared with TPN, TEN can reduce the risk of mortality, pancreatitis-related infections, required rate of surgical intervention, and incidence of MOF; and it will not increase the nutrition strategies associated complications. Consequently, TEN should be considered a better choice for SAP patients as early as possible.
The publication of the 2016 version of the Surviving Sepsis Campaign guidelines is a further step to the treatment of sepsis worldwide. This version of guidelines approves new definition of Sepsis-3. Overall, the new guidelines do not change the previous principle of treatment significantly. Some detailed and specific modifications have been made. Understanding and rational use of the new guidelines based on clinical practice, are the key to managing sepsis and performing accurate and effective treatment.
ObjectiveTo investigate the antibody concentration and immune status of intensive care medical staff after vaccination against COVID-19. Methods From October 1, 2021 to February 28, 2022, the serial numbers of 47 hospitals were randomly selected by cluster stratified random sampling method. Blood samples were collected from 192 medical staff in intensive care department who had received inactivated novel coronavirus vaccine in 7 hospitals. The antibody concentration was determined by chemiluminescence method to find the antibody rule. Logistic regression analysis was used to determine the related factors affecting the production of antibodies. ResultsTotal antibody concentration of 192 blood samples was 23.25 (5.09, 270.22), IgG concentration was 0.94 (0.15, 4.48), IgM concentration was 0.05 (0.03, 0.12). Logistic regression analysis showed that the total antibody concentration might be related to gender and age, and the IgG concentration was significantly related to whether the third injection was administered. One hundred and twenty-seven people received 2 doses of inactivated vaccine, and the positive rate of IgG was the highest within 1 to 2 months, and decreased significantly after 3 months. The positive rate of IgG antibody was 95.4% within 60 days after receiving 3 doses of vaccine, 70% within 1 month after receiving the third dose of vaccine, and 100.0% within 1 to 2 months (P<0.05). The total antibody positive rate was 96.3% in people aged 17 to 35 years and 73.3% in people aged 36 to 58 years, showing statistical difference (P<0.05). The total antibody production rate of those who received the third dose of vaccine was 100.0%, and no severe case of COVID-19 occurred during the sampling period. Conclusions After the first, second, and third doses of COVID-19 vaccine, the total antibody concentration of the virus gradually increases to 100.0%, indicating initial immunity. However, the antibody concentration decreased gradually after 3 months of inoculation. The concentration of IgG in women is higher than that in men, and the concentration of antibody in young people is higher than that in middle-aged and elderly people during the same period.
Objective To study endotoxin release induced by differential antibiotics in gram negative bacterial infection. Methods Thirty critical patients accompanied with gram negative bacterial infection were divided into group A (imipenem group, n=15) and group B (ceftazidine group, n=15). Imipenem (0.5 g iv q8h) and ceftazidine (1.0 g iv q8h) were given respectively. White blood cell (WBC), systolic blood pressure (SBP), lipopoly sacchride (LPS), tumor necrosis factor alpha (TNFα) and high density lipoprotein (HDL) were determined in 0, 1, 2, 3, 5 and 7 day. Results There was no difference in the change of WBC between two groups. Group A had a more stable SBP than group B. There was lower endotoxin release in group A than in group B and so were the cytokines release. HDL level was lower in group B than in group A. Conclusion Imipenem has lower endotoxinliberating potential than ceftazidine and mediate lower cytokines release. HDL may protect the patients from LPS damage.
Objective To evaluate the feasibility of hyperinsulinemic normoglycemia strategy in critically ill patients. Methods Between January 2020 and October 2021, the critically ill patients with stress hyperglycemia in the Emergency Intensive Care Unit of the Fourth People’s Hospital of Langfang were randomly assigned into a trial group or a control group. The trial group adopted hyperinsulinemic normoglycemia therapy, while the control group adopted conventional glucose control therapy. The mean and variability (standard deviation) of blood glucose, incidences of severe hypoglycemia and abnormal hyperglycemia, as well as the percentage of blood glucose values within the target range were compared between the two groups, to evaluate the feasibility of hyperinsulinemic normoglycemia strategy in critically ill patients from the perspective of safety and effectiveness. The non-normally distributed measurement data were presented as median (lower quartile, upper quartile). Results A total of eighty patients were included, with forty cases in each group. The mean blood glucose level [6.00 (5.74, 6.70) vs. 9.51 (8.74, 10.01) mmol/L, P<0.001], the standard deviation of glucose level [1.58 (1.11, 2.15) vs. 2.20 (1.21, 2.76) mmol/L, P=0.028], and the glycemic lability index [175.52 (100.51, 346.69) vs. 408.51 (205.56, 651.91) mmol2/(L2·h·d), P<0.001] were all smaller in the trial group than those in the control group. The percentage of blood glucose values within the target range was 77.34% in the trial group and 5.33% in the control group, respectively, and the difference was statistically significant (P<0.001). No patients experienced severe hypoglycemia. There was a significant difference in the incidence of abnormal hyperglycemia between the two groups (5.08% vs. 36.16%, P<0.001). Conclusions Hyperinsulinemic normoglycemia strategy can effectively and safely provide normoglycemia, reduce glycemic variability, and achieve good glycemic control in critically ill patients. Hyperinsulinemic normoglycemia strategy may be a new approach to glycemic control in critically ill patients.
ObjectiveTo analyze the roles of three scoring systems, i.e. Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ, Ranson’s criteria, and Sequential Organ Failure Assessment (SOFA), in predicting mortality in patients with severe acute pancreatitis (SAP) admitted to intensive care unit (ICU), and explore the independent risk factors for mortality in SAP patients.MethodsThe electronic medical records of SAP patients who admitted to ICU of West China Hospital, Sichuan University between July 2014 and July 2019 were retrospectively analyzed. Data of the first APACHE Ⅱ, Ranson’s criteria, SOFA score, duration of mechanical ventilation, the use of vasoactive drugs and renal replacement therapy, and outcomes were obtained. The receiver operator characteristic (ROC) curve was used to evaluate the value of APACHE Ⅱ score, Ranson’s criteria, and SOFA score in predicting the prognosis of SAP. Logistic regression models were created to analyze the independent effects of factors on mortality.ResultsA total of 290 SAP patients hospitalized in ICU were screened retrospectively, from whom 60 patients were excluded, and 230 patients including 162 males and 68 females aged (51.1±13.7) years were finally included. The ICU mortality of the 230 patients with SAP was 27.8% (64/230), with 166 patients in the survival group and 64 patients in the death group. The areas under ROC curves of APACHE Ⅱ, Ranson’s criteria, APACHE Ⅱ combined with Ranson’s criteria, and SOFA score in predicting mortality in SAP patients admitted to ICU were 0.769, 0.741, 0.802, and 0.625, respectively. The result showed that APACHE Ⅱcombined with Ranson’s criteria was superior to any single scoring system in predicting ICU death of SAP patients. The result of logistic regression analysis showed that APACHE Ⅱ score [odds ratio (OR)=1.841, 95% confidence interval (CI) (1.022, 2.651), P=0.002], Ranson’s criteria [OR=1.542, 95%CI (1.152, 2.053), P=0.004], glycemic lability index [OR=1.321, 95%CI (1.021, 1.862), P=0.008], the use of vasoactive drugs [OR=15.572, 95%CI (6.073, 39.899), P<0.001], and renal replacement therapy [OR=4.463, 95%CI (1.901, 10.512), P=0.001] contributed independently to the risk of mortality.ConclusionsAPACHE Ⅱ combined with Ranson’s criteria is better than SOFA score in the prediction of mortality in SAP patients admitted to ICU. APACHE Ⅱ score, Ranson’s criteria, glycemic lability index, the use of vasoactive drugs and renal replacement therapy contribute independently to the risk of ICU mortality in patients with SAP.