Objective To investigate the accuracy and efficiency of hand-held echocardiography (VSCAN) used by intensivist for the diagnosis and treatment decisions in emergency consultation for patients getting worse at risk of life-threatening setting in non-ICU ward.Methods A prospective study in acutely deteriorated patients needed the intensivist for emergency consultation in general wards was carried out.The consultation process was executed as follows:(1) The intensivist established an initial diagnosis based on medical history,physical examination and laboratory findings,and assessed the hemodynamics and the cause of acute respiratory failure and cardiac arrest according the documented information.The data recorded as control group (Pre-VSCAN) for comparison with the later available data in subsequent analysis.(2) Problem-based ultrasound examination was performed with VSCAN.For patients suffered cardiac arrest,the FEEL protocol was used to find the potential cause of cardiac arrest such as pericardial tamponade and massive pulmonary embolism screened.For the other patients,a simplified eFATE or BLUE-plus protocols were used based on clinical requirement.With the findings of ultrasound examination the intensivist established an final diagnosis and identified the hemodynamics and the lung pathologies.The consultation advice was then provided to the attending doctors of the patient.The intensivist kept the records of echo results,final diagnosis and consultation advice as data of study group data (Post-VSCAN).The response of the treatment and outcome were followed up.Two attending ICU doctors analyzed these data and judged the correctness of Pre-VSCAN and Post-VSCAN based on the response to treatment and the outcome.Results Ninety patients were finally included in statistical analysis.Sixteen (17.8％) cases,40 (44.4％) cases,29 (32.2％) cases and 5 (5.6％) were consulted for acute circulation dysfunction,acute respiratory failure,both reasons and cardiac arrest,respectively.Compared to pre-VSCAN,VSCAN verification can significantly improve the accuracy of the diagnosis (81.1％ vs.58.9％,P =0.001),assessment of hemodynamics (78.3％ vs.52.2％,P =0.009) and can find more accurate judgment of acute respiratory failure (71.0％ vs.43.5％,P =0.001).Conclusion The hand-held echocardiography used by intensivist is valuable for the diagnosis and the assessment of cardiopulmonary status in case of request for emergency consultation in general wards.

Objective To provide epidemiological data as a reference for the coming research and clinical practice by analyzing the problem based critical care ultrasound (CCUS) examination database in Department of Critical Care Medicine,West China Hospital, Sichuan University. Methods A retrospective study of the database was performed. The clinical problems prompting the CCUS examination were classified, the ultrasonnic findings representing the pathophysiological changes were collected and gathered into categories, and the pathophysiological etiology for each classification of clinical problems was stated after referring to the clinical information. Results In the 135 cases with a mean age of (51±18) years, 386 times of problems based examinations were performed (2.85 times per patient). The problems prompting the examinations were acute circulatory dysfunction (271 times, 70.2%), acute respiratory dysfunction (34 times, 8.8%), acute circulatory dysfunction combined with acute respiratory dysfunction (76 times, 19.7%), and suspected diaphragm disorder and others (5 times, 1.2%). In the 347 times of examination for acute circulatory dysfunction, the pathophysiological changes discovered by the CCUS examination included hypovolemia (55 times, 15.9%), hypervolemia (85 times, 24.5%), decreased systemic vascular resistance index (22 times, 6.3%), and increased right ventricular (RV) afterload (15 times, 4.3%). In the 246 times of examination for cardiac dysfunction, the underlying etiology detected included left ventricular (LV) systolic dysfunction (31 times, 12.6%), LV diastolic dysfunction (108 times, 43.9%), LV systolic dysfunction associated with diastolic dysfunction (49 times, 19.9%), RV dysfunction (23 times, 9.4%), and whole heart failure (35 times, 14.2%). Acute respiratory disorders was identified 110 times in total, which consisted of lung consolidation (40 times, 36.4%), diffuse ultrasonic interstitial syndrome (DIS; 27 times, 24.5%), consolidation associated with DIS (18 times, 16.4%), focal interstitial syndrome (17 times, 14.6%), and others (9 times, 8.2%). Causes of deterioration of the cases were cardiogenic pulmonary edema, diastolic dysfunction, RV failure, acute valve insult or chronic valve insufficiency and so on. Conclusions The main problems prompting the CCUS examinations are acute circulatory dysfunction and acute respiratory dysfunction. CCUS examination can provide physicians with valuable information on the full picture of the pathophysiology characteristics of hemodynamics and lung pathology to help diagnose the causes of the deterioration and guide clinical treatment.

Acute respiratory and circulatory disorders are the most common critical syndromes, the essence of which is damage to the organs/systems of the heart and lungs. These comprise the essential manifestation of disease and injury progression to the severe stage. Its development involves the following components: individual specificity, primary disease strike, dysregulation of the host′s response, and systemic disorders. Admission for acute respiratory and circulatory disorders is a clinical challenge. Based on a previously proposed flow, a critical care ultrasound-based stepwise approach (PIEPEAR) as a standard procedure to manage patients with acute cardiorespiratory compromise and practical experience in recent years, a modified seven-step analysis and treatment process has been developed to help guide clinicians with rational thinking and standardized treatment when faced with acute respiratory and circulatory disorders. The process consists of seven steps: problem-based clinical analysis, intentional information acquisition, evaluation of core disorder based on critical care ultrasound, pathophysiology and host response phenotype identification, etiology diagnosis, act treatment through pathophysiology-host response and etiology, and re-check. The modified seven-step approach is guided by a “modular analysis” style of thinking and visual monitoring. This approach can strengthen the identification of clinical problems and facilitate a three-in-one analysis. It focuses on pathophysiological disorders, body reactions, and primary causes to more accurately understand the condition′s key points, and make treatment more straight forward, to finally achieve the aim of “comprehensive cognition and refined treatment”.

The epidemic of coronavirus disease 2019 (COVID-19) puts higher demands on critical care medicine. Lots of studies have been conducted to solve COVID-19-related problems. Therefore, we reviewed the annual progress for COVID-19-related issues including antivirals threapies, respiratory support and immunomodulatory therapies and other critical issues, including the effect of antibiotic on mitochondrial damage and its relationship with sepsis, the goal and direction of antimicrobial de-escalation, drug prophylaxis of constipation, bleeding in gastrointestinal disorders and management of critical illness in the informalization era and so on. We hope to provide reference for clinical and scientific research work of the intensivists.

Critical ultrasonography is widely used in ICU and has become an indispensable tool for clinicians. However, besides operator-dependency of critical ultrasonography, lack of standardized training mainly result in the physicians′ heterogenous ultrasonic skill. Therefore, standardized training as well as strict quality control plays the key role in the development of critical ultrasonography. We present this quality control standards to promote better development of critical ultrasonography.

Objective:To investigate the application value of multimodal image three-dimensional reconstruction combined with facial nerve tracking in acoustic neuroma surgery.Methods:Forty-five patients with single acoustic neuroma accepted primary surgical treatment at Department of Neurosurgery, Yibin Hospital, West China Hospital, Sichuan University from November 2018 to June 2022 were chosen. The head, skull, brain tissues, arteriovenous system, tumor and facial nerves were reconstructed preoperatively by multimodal three-dimensional image reconstruction combined with facial nerve tracking. Preoperative planning was carried out according to the relationship between tumor and surrounding structures. The accuracy of facial nerve tracking was evaluated by intraoperative microscopic observation and nerve electrophysiological monitoring. House-Brackmann (H-B) criteria was used to evaluate facial nerve functions 2 weeks after surgery. Three months after surgery, all patients underwent enhanced MRI scanning, and combined with intraoperative findings, the degrees of acoustic neuroma resection were determined.Results:The facial nerves and their relations with acoustic neuroma were successfully tracked in all 45 patients; as confirmed by intraoperative microscopy and nerve electrophysiological monitoring, the results of facial nerves and their relations with acoustic neuroma were consistent in 42 patients and inconsistent in 3 patients. Using intraoperative nerve electrophysiological monitoring as gold standard, the accuracy of multimodal image three-dimensional reconstruction of the facial nerves was 93.3%. Preoperative facial nerve tracking results were highly consistent with intraoperative nerve electrophysiological monitoring results (Kappa=0.903, P<0.001). The facial nerves were intraoperatively preserved in 91.1% patients (41/45), and the facial nerve function was good in 86.7% patients (39/45) at 2 weeks after surgery. The total/subtotal resection rate of acoustic neuroma was 88.9% (40/45). No death, cerebrospinal fluid leakage, hematoma, or cerebral infarction were noted during the perioperative period. Conclusion:Multimodal image three-dimensional reconstruction combined with facial nerve tracking can help to protect blood vessels and nerves, improve total resection rate and facial nerve function retention rate in surgery of acoustic neuroma.

Severe patients with coronaviras disease 2019 (COVID-19) are characterized by persistent lung damage, causing respiratory failure, secondary circulatory changes and multiple organ dysfunction after virus invasion. Because of its dynamic, real-time, non-invasive, repeatable and other advantages, critical ultrasonography can be widely used in the diagnosis, assessment and guidance of treatment for severe patients. Based on the recommendations of critical care experts from all over the country who fight against the epidemic in Wuhan, this article summarizes the guidelines for the treatment of COVID-19 based on critical ultrasonography, hoping to provide help for the treatment of severe patients. The recommendations mainly cover the following aspects: (1) lung ultrasound in patients with COVID-19 is mainly manifested by thickened and irregular pleural lines, different types of B-lines, shred signs, and other consolidation like dynamic air bronchogram; (2) Echocardiography may show right heart dysfunction, diffuse cardiac function enhancement, stress cardiomyopathy, diffuse cardiac depression and other multiple abnormalities; (3) Critical ultrasonography helps with initiating early treatment in the suspect patient, screening confirmed patients after intensive care unit admission, early assessment of sudden critical events, rapid grading assessment and treatment based on it; (4) Critical ultrasonography helps to quickly screen for the etiology of respiratory failure in patients with COVID-19, make oxygen therapeutic strategy, guide the implementation of lung protective ventilation, graded management and precise off-ventilator; (5) Critical ultrasonography is helpful for assessing the circulatory status of patients with COVID-19, finding chronic cardiopulmonary diseases and guiding extracorporeal membrane oxygenation management; (6) Critical ultrasonography contributes to the management of organs besides based on cardiopulmonary oxygen transport; (7) Critical ultrasonography can help to improve the success of operation; (8) Critical ultrasonography can help to improve the safety and quality of nursing; (9) When performing critical ultrasonography for patients with COVID-19, it needs to implement three-level protection standard, pay attention to disinfect the machine and strictly obey the rules from nosocomial infection. (10) Telemedicine and artificial intelligence centered on critical ultrasonography may help to improve the efficiency of treatment for the patients with COVID-19. In the face of the global spread of the epidemic, all we can do is to share experience, build a defense line, We hope this recommendations can help COVID-19 patients therapy.

Objective:To describe the features of point-of-care cardiopulmonary ultrasound (POCUS) in the critically ill patients and analyze the independent factors associated with treatment changes after POCUS assessment.Methods:This was a prospective multicentric observational study from January to December 2018 in 13 intensive care units (ICU) in China. Consecutive patients admitted to the ICU were enrolled, POCUS were performed within the first 24 h of admission. The POCUS parameters included acute or chronic cardiac abnormality, diameter of inferior vena cava (IVC) at end-expiration, right ventricular systolic function, systolic and diastolic function of left ventricle (LV) and lung ultrasound score. The general features of patients and performers were recorded. Based on the treatment proposed by the performer before and after POCUS assessment, the patients were divided into treatment changed and unchanged groups. Factors associated with treatment changes were identified by multiple logistic regression analysis.Results:Totally 1 913 patients were enrolled including 322 (16.8%) patients with shock, 638 (33.3%) patients with respiratory failure, 139 (7.3%) patients with both shock and respiratory failure and 814 (42.6%) perioperative patients. POCUS had contributed to treatment changes in 1 204 (62.9%) patients, including 867 (72.0%) cases involved fluid management. Univariate analysis showed that there were significant differences in general characteristics of patients, performers and POCUS parameters between groups(all P<0.05). Logistic regression analysis showed that independent factors of treatment changes included ministry of education or university affiliated teaching hospitals (vs.general hospitals, OR=1.891, 95% CI=1.314-2.722, P<0.001 and OR=1.644, 95% CI=1.152-2.347, P=0.006 separately), middle and senior title performers (vs.primary title, OR=2.112, 95% CI=1.358-3.284, P=0.001, OR=3.271, 95% CI=2.129-5.025, P<0.001 separately), mechanical ventilation (vs.without, OR=0.488, 95% CI 0.381-0.626, P<0.001), IVC diameter ≤1 cm (vs.1-2 cm, OR=0.317, 95% CI 0.231-0.434, P<0.001), LV ejecting fraction <50% (vs.≥50%, OR=0.328, 95% CI=0.210-0.512, P<0.001), lung ultrasound score of 6-12 and >12 points(vs.score ≤ 6 points, OR=0.237, 95% CI=0.178-0.315, P<0.001 and OR=0.619, 95% CI=0.457-0.837, P=0.002 separately). Conclusions:POCUS assessment contributes to treatment changes, most of which involves fluid management strategy, in 62.9% critical patients. The independent influencing factors associated with POCUS parameters includes IVC diameter at end-expiratory, LV systolic function and lung ultrasound score. The performers′ title and hospital grade also have a noticeable effect.

To establish the experts consensus on the management of delirium in critically ill patients.A special committee was set up by 15 experts from the Chinese Critical Hypothermia-Sedation Therapy Study Group.Each statement was assessed based on the GRADE (Grading of Recommendations Assessment,Development,and Evaluation) principle.Then the Delphi method was adopted by 36 experts to reassess all the statements.(1) Delirium is not only a mental change,but also a clinical syndrome with multiple pathophysiological changes.(2) Delirium is a form of disturbance of consciousness and a manifestation of abnormal brain function.(3) Pain is a common cause of delirium in critically ill patients.Analgesia can reduce the occurrence and development of delirium.(4) Anxiety or depression are important factors for delirium in critically ill patients.(5) The correlation between sedative and analgesic drugs and delirium is uncertain.(6) Pay attention to the relationship between delirium and withdrawal reactions.(7) Pay attention to the relationship between delirium and drug dependence/ withdrawal reactions.(8) Sleep disruption can induce delirium.(9) We should be vigilant against potential risk factors for persistent or recurrent delirium.(10) Critically illness related delirium can affect the diagnosis and treatment of primary diseases,and can also be alleviated with the improvement of primary diseases.(11) Acute change of consciousness and attention deficit are necessary for delirium diagnosis.(12) The combined assessment of confusion assessment method for the intensive care unit and intensive care delirium screening checklist can improve the sensitivity of delirium,especially subclinical delirium.(13) Early identification and intervention of subclinical delirium can reduce its risk of clinical delirium.(14) Daily assessment is helpful for early detection of delirium.(15) Hopoactive delirium and mixed delirium are common and should be emphasized.(16) Delirium may be accompanied by changes in electroencephalogram.Bedside electroencephalogram monitoring should be used in the ICU if conditions warrant.(17) Pay attention to differential diagnosis of delirium and dementia/depression.(18) Pay attention to the role of rapid delirium screening method in delirium management.(19) Assessment of the severity of delirium is an essential part of the diagnosis of delirium.(20) The key to the management of delirium is etiological treatment.(21) Improving environmental factors and making patient comfort can help reduce delirium.(22) Early exercise can reduce the incidence of delirium and shorten the duration of delirium.(23) Communication with patients should be emphasized and strengthened.Family members participation can help reduce the incidence of delirium and promote the recovery of delirium.(24) Pay attention to the role of sleep management in the prevention and treatment of delirium.(25) Dexmedetomidine can shorten the duration of hyperactive delirium or prevent delirium.(26) When using antipsychotics to treat delirium,we should be alert to its effect on the heart rhythm.(27) Delirium management should pay attention to brain functional exercise.(28) Compared with non-critically illness related delirium,the relief of critically illness related delirium will not accomplished at one stroke.(29) Multiple management strategies such as ABCDEF,eCASH and ESCAPE are helpful to prevent and treat delirium and improve the prognosis of critically ill patients.(30) Shortening the duration of delirium can reduce the occurrence of long-term cognitive impairment.(31) Multidisciplinary cooperation and continuous quality improvement can improve delirium management.Consensus can promote delirium management in critically ill patients,optimize analgesia and sedation therapy,and even affect prognosis.

BACKGROUND: Functional mitral regurgitation (FMR) is common in critically ill patients and may cause left atrial (LA) pressure elevation. This study aims to explore the prognostic impact of synergistic LA pressure elevation and FMR in patients with shock. METHODS: We retrospectively screened 130 consecutive patients of 175 patients with shock from April 2016 to June 2017. The incidence and impact of FMR and early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio (E/e') ≥ 4 within 6 h of shock on the prognosis of patients were evaluated. Finally, the synergistic effect of FMR and E/e' were assessed by combination, grouping, and trend analyses. RESULTS: Forty-four patients (33.8%) had FMR, and 15 patients (11.5%) had E/e' elevation. A multivariate analysis revealed FMR and E/e' as independent correlated factors for 28-day mortality (P = 0.043 and 0.028, respectively). The Kaplan-Meier survival analysis revealed a significant difference in survival between patients with and without FMR (χ2 = 7.672, P = 0.006) and between the E/e' ≥ 14 and E/e' < 14 groups (χ2 = 19.351, P < 0.010). Twenty-eight-day mortality was significantly different among the four groups (χ2 = 30.141, P < 0.010). The risk of 28-day mortality was significantly higher in group 4 (E/e' ≥ 14 with FMR) compared with groups 1 (E/e' < 14 without FMR) and 2 (E/e' < 14 with FMR) (P = 0.001 and 0.046, respectively). CONCLUSIONS: Patients with shock can be identified by the presence of FMR. FMR and E/e' are independent risk factors for a poor prognosis in these patients, and prognosis is worst when FMR and E/e' ≥ 14 are present. It may be possible to improve prognosis by reducing LA pressure and E/e'. TRIAL REGISTRATION ClinicalTrials.gov, NCT03082326.
Humans ; Mitral Valve/diagnostic imaging* ; Mitral Valve Insufficiency/diagnostic imaging* ; Prognosis ; Retrospective Studies ; Shock