Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.
ObjectiveTo systematically evaluate the clinical value of machine learning (ML) for predicting the neurological outcome of out-of-hospital cardiac arrest (OHCA), and to develop a prediction model. MethodsWe searched the PubMed, Web of Science, EMbase, CNKI, Wanfang database from January 1, 2011 to November 24, 2021. Studies on ML for predicting neurological outcomes in OHCA pateints were collected. Two researchers independently screened the literature, extracted the data and evaluated the bias of the included literature, evaluated the accuracy of different models and compared the area under the receiver operating characteristic curve (AUC). ResultsA total of 20 studies were included. Eleven of the studies were from open source databases and nine were from retrospective studies. Sixteen studies directly predicted OHCA neurological outcomes, and four predicted OHCA neurological outcomes after target temperature management. A total of seven ML algorithms were used, among which neural network was the ML algorithm with the highest frequency (n=5), followed by support vector machine and random forest (n=4). Three papers used multiple algorithms. The most frequently used input characteristic was age (n=19), followed by heart rate (n=17) and gender (n=13). A total of 4 studies compared the predictive value of ML with other classical statistical models, and the AUC value of ML model was higher than that of classical statistical models. ConclusionExisting evidence suggests that ML can more accurately predict OHCA nervous system outcomes, and the predictive performance of ML is superior to traditional statistical models in certain situations.
ObjectiveTo evaluate the effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction via tibial tunnel made by three-portal technique.MethodsBetween July 2015 and December 2016, 45 patients with ACL ruptures were treated. There were 29 males and 16 females with an average age of 27.5 years (range, 18-42 years). There were 18 cases in the left side and 27 cases in the right side. There were 28 cases of sports injuries, 13 cases of traffic accidents, and 4 cases of other injuries. The average time from injury to operation was 21.6 days (range, 5-36 days). There were 25 cases of simple ACL injury and 20 cases of ACL complicated with medial collateral ligament, medial meniscus or lateral meniscus injuries. The Lachman tests of all patients were positive. The pivot shift tests of all patients were positive with grade Ⅰ in 27 cases, grade Ⅱ in 13 cases, and grade Ⅲ in 5 cases. The preoperative International Knee Documentation Committee (IKDC) score was 70.28±6.12, and the Lysholm score was 63.27±7.62. All patients underwent arthroscopic single-bundle ACL reconstruction, and the tibial tunnel was created through the anterolateral, high anteromedial, and additional low anteromedial approaches.ResultsAll incisions healed by the first intention. All patients were followed up 18.7 months on average (range, 14-32 months). The three-dimensional CT at 3 days after operation showed that the tibial tunnel positions were accurate and the middle points were located in the 36.81%-43.35% of tibial plateau on sagittal plane. The medial borders of the tibial tunnel on coronal plane were located at the lateral to the medial eminence of the tibia. There were 3 cases of thrombosis of intermuscular vein of lower limbs, 2 cases of joint swelling and pain, and 3 cases of stiffness of knee joint. At last follow-up, the Lachman tests of all patients were negative and the pivot shift test were negative in 42 patients and positive in 3 patients (grade Ⅰ). The IKDC score (92.59±4.36) and Lysholm score (93.15±5.53) were significantly higher than preoperative scores (t=11.35, P=0.00; t=12.27, P=0.00).ConclusionArthroscopic ACL reconstruction via tibial tunnel made by three-portal technique, which was simple and accurate, can obtain the satisfactory function of the knee in the early stage after operation.
Background Acute pancreatitis is one of the most severe acute abdominal conditions. Recently with the understanding of pathophysiology and pathogenesis of acute pancreatitis, cytokines, especially platelet-activating factor (PAF), have been shown to play an important role. Lexipafant is a potent inhibitor of PAF. It has shown exiting results in the animal experiments, so randomized controlled studies are needed to assess the impact of lexipafant for acute pancreatitis. Objectives To determine whether lexipafant can alter the course, prevent or treat organ failure and reduce mortality in acute pancreatitis. Search strategy Electronic databases were searched and reference lists from included studies were also handsearched. Published abstracts from conference proceedings and ten kinds of Chinese medical journals were handsearched for additional citations. Personal contaction with colleagues and experts in the field of pancreatitis was performed to identify potentially relevant trials. Selection criteria Randomized, controlled trials, In which participants went in hospital within 72 hours of belliache episode, comparing lexipafant to placebo or other interventions on organ failure rate or mortality of acute pancreatitis. Data collection and analysis Data related to the clinical outcomes were extracted by two reviewers independently, if there was any divarication, they would have a discussion. Main Results Three studies meet the inclusion criteria up to 2001. Compared with control group, lexipafant had the tendency of reducing the early deaths (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.23 to1.38, P=0.2), accelerating the recovery of organ failure (OR 0.40, 95%CI 0.12 to 1.32, P=0.13) and reducing the occurrence of new organ failure OR 0.34, but these results had no statistical significance. A large-scale multicentre randomized controlled trial including 1 500 patients has been completed in America, but the result has not been published. Reviewers’ Conclusions Current evidence couldn’t draw the final conclusion. So the large-scale of randomized controlled trials is required.
Objective To examine the adrenal function of critically ill patients received mechanical ventilation, and explore the relationship between the occurrence of relative adrenal insufficiency ( RAI) and weaning outcome.Methods Critically ill patients who were mechanically ventilated over 48 hours were enrolled in this study. Every patient was given one shot of corticotrophin 250 μg intravenously on the first day of admission and the first day of spontaneous-breathing-trial ( SBT) . Plasma contisol level was detected by radio-immunoassay before ( T0 ) and 30 minutes ( T30 ) after the shot. Meanwhile the following parameters were recorded including APACHEⅡ, age, and cause of disease, etc. RAI was defined as the difference between T0 and T30 ≤9 μg/dL. Receiver operating characteristic ( ROC) curve was used to evaluate the accuracy of the indicators towards the weaning outcome. Results A total of 45 patients with mechanical ventilation were recruited. The successful weaning group consisted 29 patients and the failure weaning group consisted 16 patients. The incidence of RAI in the successful weaning group ( 37.9% , 11/ 29) was significantly lower than that in the failure weaning group ( 75.0% , 12 /16) ( P=0. 017) . On the first day of admission, there was no significant difference of Δcortisol between the successful weaning group and the failure weaning group [ ( 10.3 ±5.7) μg/dL vs. ( 7.5 ±4.5) μg/dL, P=0.100) . On the first SBT day, Δcortisol of the successful weaning group was significantly higher than that in the failure weaning group [ ( 10.9 ±5.1) μg/dL vs. ( 4.9 ±2.9) μg/dL, P= 0.043] . Logistic regression analysis showed that Δcortisol was an independent risk factor of weaning. ROC curve analysis showed that on the first SBT day, the area under the curve of Δcortisol was 0.872; The sensitivity and the specificity of accurate judgmentwere 0.813 and 0.828 if Δcortisol ≤6. 95 μg/dL. Conclusions The occurrence of RAI is common in critically ill patients with mechanical ventilation. The adrenal function affects the outcome of weaning, and Δcortisol may be used as an important predictive indicator for weaning outcome.
Objective To explore the relationship between central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ration [P(cv-a)CO2/C(a-cv)O2] and arterial lactate in patients with sepsis. Methods A retrospective analysis was carried on 36 septic patients who were admitted to the Intensive Care Unit of Nanjng Drum-tower Hospital affiliated to Medical School of Nanjing University from May 2013 to November 2013. Cardiac index was measured by transpulmonary thermodilution. At the same time, femoral artery and central venous blood were collected to measure the value of arterial lactate and central venous oxygen saturation (ScvO2) by blood gas analysis and calculate central venous-to-arterial carbon dioxide difference [P(cv-a)CO2], arterial-to-venous oxygen difference [C(a-cv)O2], and their ration [P(cv-a)CO2/C(a-cv)O2], oxygen delivery (DO2) and oxygen consumption (VO2). The subjects were divided intoahyperlactatemia group (≥2 mmol/L) andanormal lactate group (< 2 mmol/L) according to arterial lactate value. P(cv-a)CO2/C(a-cv)O2 and other oxygen metabolism parameters were compared between two groups. Receiver operating characteristic (ROC) curve was used to evaluate the accuracy of P(cv-a)CO2/C(a-cv)O2 and other parameters for diagnosis of hyperlactatemia. Results A total of 36 patients with 119 data were collected. Compared with the normal lactate group, P(cv-a)CO2/C(a-cv)O2 was significantly higher [(1.38±0.76)mm Hg/mL vs. (2.31±1.01) mm Hg/mL, P < 0.01], ScvO2, DO2 and VO2 were significantly lower in the hyperlactatemia group [ScvO2: (74.26±9.13)% vs. (70.29±9.72)%; DO2: (505.52±208.39) mL/(min·m2) vs. (429.98±173.63) mL/(min·m2)]; VO2: (129.01±54.94) mL/(min·m2) vs. (109.99±38.79) mL/(min·m2), P < 0.05]. P(cv-a)CO2 had no significant difference between two groups [(5.76±3.70) mm Hg vs. (6.59±3.70) mm Hg, P > 0.05]. P(cv-a)CO2/C(a-cv)O2 was positively correlated with lactate (r=0.646, P < 0.01). ScvO2 was negatively correlated with lactate (r=-0.277, P < 0.01). DO2 and VO2 had no significant correlation with lactate (P > 0.05). The area under ROC curve (AUC) of P(cv-a)CO2 /C(a-cv)O2 for diagnosis of hyperlactatemia was 0.820, with 95% confidence interval (95%CI) of 0.715 - 0.925(P < 0.001); The AUC of ScvO2 was 0.622, with 95%CI of 0.520 - 0.724(P=0.025). Conclusion Compared with the traditional oxygen metabolism parameters, P(cv-a)CO2/C(a-cv)O2 can accurately diagnose hyperlactatemia, and isareliable parameter to reflect oxygen metabolism in patients with sepsis.
Objective To investigate the value of central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ratio [P(cv-a)CO2/C(a-cv)O2] in predicting oxygen metabolism after fluid resuscitation in patients with septic shock. Methods A prospective observational study was carried out on septic shock patients admitted in the intensive care unit of Nanjng Drum Tower Hospital from November 2013 to April 2014. All patients underwent fluid challenge (300 ml saline for 20 min, rapid intravenous infusion). The patients were divided into a fluid responded group (ΔCI≥10%) and a fluid unresponded group (ΔCI＜10%), according to the change of cardiac output index (ΔCI) after fluid challenge. Then the patients were divided into two subgroups in the fluid responded group, namely a ΔVO2≥10% group and a ΔVO2＜10% group, according to the change of VO2 (ΔVO2). Cardiac output index (CI) were determined by pulse indicator continuous cardiac output (PICCO). Hemoglobin, arterial carbon dioxide (PaCO2), arterial oxygen (PaO2), arterial oxygen saturation (SaO2), arterial blood lactate, central venous carbon dioxide (PcvCO2), central venous oxygen (PcvO2) and central venous oxygen saturation (ScvO2) were measured by blood gas analysis. P(cv-a)CO2/C(a-cv)O2 and oxygen consumption (VO2) were calculated. P(cv-a)CO2/C(a-cv)O2 before and after fluid challenge was compared between two subgroups. Results Fluid challenges were performed in 23 instances in 18 patients, among which 17 instances were defined as the fluid responded group. Compared with the fluid unresponded group, P(cv-a)CO2/C(a-cv)O2, arterial lactate and ScvO2 had no significant difference [P(cv-a)CO2/C(a-cv)O2](mm Hg/ml): 2.05±0.75vs. 1.58±0.67; arterial lactate (mmol/l): 3.78±2.50vs. 3.26±2.42; ScvO2(%): 73.71±9.64vs. 70.30±12.01,P＞0.05] in the fluid responded group before resuscitation. In the fluid responded group, there were 10 instances in the ΔVO2≥10% group and 7 instances in the ΔVO2＜10% group. P(cv-a)CO2/C(a-cv)O2 (mm Hg/ml) was significantly higher in the ΔVO2≥10% group before resuscitation compared with the ΔVO2＜10% group (2.43±0.73vs. 1.51±0.37,P＜0.01). Lactate (mmol/l) was also higher in the ΔVO2≥10% group before resuscitation (4.53±2.52vs. 1.46±0.82,P＜0.01). ScvO2 (%) had no significant difference between two groups (70.79±9.15vs. 72.13±13.42,P＞0.05). The areas under ROC curve (AUCs) of P(cv-a)CO2/C(a-cv)O2, lactate and ScvO2 for predicting ΔVO2≥10% were 0.843, 0.921, and 0.529, respectively. The sensitivity and specificity of P(cv-a)CO2/C(a-cv)O2≥1.885 mm Hg/ml for predicting ΔVO2≥10% after fluid resuscitation were 70% and 86%, respectively. Conclusion For septic shock patients with fluid responsiveness, P(cv-a)CO2/C(a-cv)O2 can predict oxygen metabolism after fluid resuscitation and can be used as a reliable parameter to guide fluid resuscitation.