Objective Abdominal pain, shoulder pain, and incision pain after laparoscopic cholecystectomy ( LC) are com-mon complaints of the patients.This study was to observe the effects of pulmonary recruitment ( PR) in reducing post-LC abdominal pain, shoulder pain, and incision pain. Methods A total of 138 patients treated by LC were randomly assigned to a PR ( n=67) and a control group (n=71).The former underwent postoperatively five 5-second-long manual inflations of the lungs by positive pres-sure ventilation with 40 cmH2 O to discharge CO2 from the abdominal cavity, while the latter received traditional passive deflation of CO2 .At 6, 12, 24, and 48 h after surgery, we recorded the incidences of abdominal pain, shoulder pain, and incision pain and as-sessed the pain intensity using the visual analogue scale ( VAS) . Results Compared with the control group at 12 and 24 h after sur-gery, the PR group showed significant decreases in the incidence rate of upper abdominal pain (90.14%vs 74.63%and 91.55%vs 73.13%, both P<0.05), with VAS scores of 4.32 ±2.73 vs 2.72 ±1.67 and 4.04 ±2.55 vs 2.67 ±1.49 (both P<0.05), as well as in that of shoulder pain (56.34% vs 47.76% and 74.65% vs 56.72%, both P<0.05), with VAS scores of 3.68 ±3.10 vs2.61 ±1.97 and 4.15 ±3.23 vs 2.78 ±1.88, both P <0.05). However, no significant differences were observed in the incidence or severity of incision pain between two groups at any time points after surgery (P>0.05). Conclusion Pulmonary recruitment can re-duce the incidence rates and severity of upper abdominal pain and shoulder pain, but has no effect in alleviating incision pain following laparoscopic cholecystectomy.

Objective To evaluate the protective effects of stroma-free bovine hemoglobin(SFBHB)on preservation of the donor heart.Methods 24 isolated perfused rabbit hearts were equally divided into two groups.In control group,the cardiac arrest were induced with St Thomas Ⅱ solution and repeated every 30 min.the myocardial temperature remained at 40℃.In experimental group,the isolated rabbit hearts were perfused continuously with St Thomas Ⅱ solution containing stroma-free bovine hemoglobin and the myocardial temperature remained at 37℃.The preservation lasted 6 h.Results There were significant differences between the two groups in the follows:(1)The mean values of the left ventricular developed pressure(LVDP)and coronary flow rate(CFR)were higher in experimental group(P＜0.001);(2)The ATP level and myocardial oxygen uptake were significantly decreased in control group(P＜0.001);(3)The mean values of released creatine phosphate kinase(CPK),lactec dehydrogenase(LDH)and myocardial contents of malondialdehyde(MDA)were higher in control group(P＜0.01);(4)More water was present in the myocardial in control group(P＜0.01);(5)The myocardial ultrastructural injuries were greater in control group.Conclusion The stroma-free bovine hemoglobin could offer great protective effects on preservation of the isolated rabbit hearts.

Objective The effectiveness of continuous veno-venous hemofiltration (CVVH) in clearing cytokines and reducing mortality in endotoxic shock is still controversial. The purpose of this study was to investigate the effects of CVVH on hemodynamies and plasma proinflammatory cytokines (TNF-?, IL-6, IL-10) during endotoxic shock in sheep. Methods Twelve male sheep weighing 14.5-20.5 kg were randomly divided into two groups of six animals :(A) control group and (B) CVVH group. Endotoxin (L-2880 sigma) 1 mg?kg-1 was infused intravenously(i.v. ) over 30 min and lactated Ringer's solution at 15 mlf44kg-1 f44h-1 for 6h in both groups. In CVVH group (B) CVVH was used for 5 h starting from 1h after the beginning of endotoxin infusion. The animals were anesthetized with midazolam and vecuronium. After tracheal intubation the animals were mechanically ventilated. Femoral artery was cannulated for continuous direct BP monitoring. 5F Swan-Ganz catheter was inserted into pulmonary artery via right internal jugular vein. Cardiac output ( CO), stroke volume ( SV), cardiac index (CI), MPAP, PAWP, SVRI, PVRI and LVSWI were measured, calculated and recorded before endotoxin infusion (T0 , baseline) and at 30, 60, 90, 120, 210 and 360 min (T6) after endotoxin infusion was started. Blood and ultrafiltrate samples were taken at T6 for determination of TNF-a,IL-6 and IL-10 concentrations. Results MAP and SVRI were significantly decreased while HR and SVRI were significantly increased after T, in both groups. MAP and SVRI were significantly higher at T6 in CVVH group than in control group ( P

Objective To observe the influence of ulinastatin (UTI) on curative effect,inflammatory response and cellular immune function in patients with acute respiratory distress syndrome (ARDS).Methods 96 patients with ARDS were randomly divided into two groups:the control group (48 cases) were treated with conventional treatment,and the UTI group (48 cases) were added with UTI injection based on the control group treatment.The changes of oxygenation index,vital signs,inflammatory factors and T lymphocyte subsets of patients in the two groups were compared before treatment and after treatment in 7 days,recorded the duration of mechanical ventilation time,ICU treatment time and mortality rate in ICU in the two groups.Results After treatment in 7 days,the vital signs (RF,HR,MAP),inflammatory factors (TNF-α,IL-6,IL-8,PCT,CRP,WBC),liver function (AST,ALT),renal function (BUN,Cr) and APACHE Ⅱ score,MODS score of UTI patients in the UTI group were lower than those in the control group (P ＜ 0.05 or P ＜ 0.01).Oxygenation index (PaO2/FiO2) and cellular immunity (CD4+,CD4+/CD8+) in the UTI group were higher than those in the control group (P ＜ 0.01).Mechanical ventilation time,ICU treatment time in the UTI group were shorter than those in the control group (all P ＜ 0.05),the mortality rate of ICU in the UTI group was lower than that in the control group (P ＜ 0.05).There was no significant difference in the incidence of adverse reactions between the two groups (P ＞ 0.05).Conclusions UTI can more effectively improve oxygen metabolism,vital signs for ARDS,liver and kidney function,reduce the APACHE Ⅱ score and MODS score,shorten the mechanical ventilation time and ICU treatment time,reduce the mortality rate of ICU.Its mechanism may relate to clearance of inflammatory factors and regulate cellular immune function of UTI.

Objective To evaluate the excursion of the diaphragm and analyze the value in predicting weaning from mechanical ventilation in intensive care unit patients.Methods The patients with mechanical ventilation (＞48 hours) in ICU at Hebei Forth Medical University Hospital from June 2014 to December were classified into a success group or a failure group according to the weaning outcome.T-piece spontaneous breathing (SBT),airway occlusion pressure at 0.1 sec (P0.1) and maximal inspiratory pressure (MIP),rapid shallow breathing index (RSBI) and P0.1/MIP were measured or calculated.During the period of the 1 st hour SBT,the excursion of diaphragm was measured with ultrasonography.The predictive value of each parameter to weaning was evaluated with ROC curve.Results A total of 98 patients were enrolled in this study,including 74 successfully weaning and 24 failed.There were significant differences between two groups (success group and failure group) in P0.1 [(2.00 ± 2.00) cmH2O (1 cmH2O =0.098 kPa) vs (3.00 ±2.75)cmH2O,P ＜0.05],RSBI (39.14 ± 16.81 vs 52.00 ± 19.18,P ＜0.05),left diaphragmatic excursion [(1.12 ± 0.97) cm vs (0.69 ± 1.00) cm,P ＜ 0.001],right diaphragmatic excursion(1.87 ± 0.75) cm vs (1.17 ± 0.76) cm,P ＜ 0.001] and mean value of left and right diaphragmatic excursion [(1.57 ± 0.52) cm vs (0.83 ± 0.53) cm,and P ＜ 0.001].The ventilation time [2.00 (2.00-4.00) d vs 4.00 (2.00-5.00) d],ICU hospital lengths of stay [4.50 (3.00-7.25) d vs 8.50 (6.25-15.25) d] and total hospital lengths of stay [20.00 (15.00-25.25) d vs 25.00 (20.25-37.25)d] were also statistically significant in success group and failure group respectively (all P ＜ 0.05).The cutoff value of diaphragmatic excursion for predicting successful extubation was determined to be 1.14 cm by ROC curve analysis.The sensitivity of diaphragmatic excursion to predict successful weaning was 89.2％ and the specificity was 75.0％,the AUCROC was 0.849.Conclusion As an early predictor of diaphragmatic dysfunction,diaphragmatic excursion is probably superior to the traditional parameters in predicting weaning from ventilator in ICU patients.

Objective To evaluate the matching degree of donor's and receptor's tissue typing and analyze the relationship between the degree and the early survival of cardiac transplantation with donor's and receptor's tissue typing of 9 cases of cardiac transplantation. Methods In accordance with the international standard, donor's and receptor's blood type, HLA antibody, lymphocytotoxicity and panel reactive antibody were determined in 9 cases of cardiac transplantation, and the donor's and receptor's matching degree evaluated by methods of amino acid triplets and cross-reactive group. Results Of 9 cases, 6 survived while 3 died. Of the 3 dead cases, 2 came respectively from the two best comprehensively evaluated matching cases and two worst, and postoperative biopsy showed that there was no rejection in either survival cases or the dead cases. Conclusion With the effective immunosuppressant, the HLA typing doesn't affect the early survival.

Objective To evaluate the effect of airway pressure release ventilation (APRV) in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS), to evaluate the extent of ventilator-induced lung injury (VILI), and to explore its possible mechanism. Methods A prospective study was conducted in the Department of Critical Care Medicine of the First Hospital of Hebei Medical University from December 2010 to February 2012. The patients with ALI/ARDS were enrolled. They were randomly divided into two groups. The patients in APRV group were given APRV pattern, while those in control group were given lung protection ventilation, synchronized intermittent mandatory ventilation with positive end-expiratory pressure (SIMV+PEEP). All patients were treated with AVEA ventilator. The parameters such as airway peak pressure (Ppeak), mean airway pressure (Pmean), pulse oxygen saturation (SpO2), mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), arterial blood gas, urine output (UO), the usage of sedation and muscle relaxation drugs were recorded. AVEA ventilator turning point (Pflex) operation was used to describe the quasi-static pressure volume curve (P-V curve). High and low inflection point (UIP, LIP) and triangular Pflex volume (Vdelta) were automatically measured and calculated. The ventilation parameters were set, and the 24-hour P-V curve was recorded again in order to be compared with subsequent results. Venous blood was collected before treatment, 24 hours and 48 hours after ventilation to measure lung surfactant protein D (SP-D) and large molecular mucus in saliva (KL-6) by enzyme linked immunosorbent assay (ELISA), and the correlation between the above two parameters and prognosis on 28 days was analyzed by multinomial logistic regression. Results Twenty-six patients with ALI/ARDS were enrolled, and 22 of them completed the test with 10 in APRV group and 12 in control group. The basic parameters and P-V curves between two groups were similar before the test. After 24 hours and 48 hours, mechanical ventilation was given in both groups. The patients' oxygenation was improved significantly, though there were no significant changes in hemodynamic parameters. The Pmean (cmH2O, 1 cmH2O = 0.098 kPa) in APRV group was significantly higher than that in control group (24 hours: 24.20±4.59 vs. 17.50±3.48, P < 0.01; 48 hours: 18.10±4.30 vs. 15.00±2.59, P < 0.05). After ventilation for 24 hours, the ratio of patients with increased Vdelta in APRV group was higher than that in control group (90% vs. 75%), but without statistical difference (P > 0.05). The SP-D level (μg/L) in serum in APRV group showed a tendency of increase (increased from 19.70±7.34 to 27.61±10.21, P < 0.05), in contrast there was a tendency of decrease in control group (decreased from 21.83±7.31 to 16.58±2.90, P > 0.05), the difference between the two groups was statistically significant (P < 0.05). After 48-hour ventilation, SP-D in APRV group was decreased, but no change was found in control group, and no significant difference was found as compared with that of the control group (16.45±8.17 vs. 17.20±4.59, P > 0.05). There was no significant difference in serum KL-6 between the two groups before and after ventilation. The SP-D and KL-6 levels in serum were unrelated with 28-day survival rate of the patients. The odds ratio (OR) of SP-D were 0.900 [95% confidence interval (95%CI) = 0.719-1.125], 1.054 (95%CI = 0.878-1.266), 1.143 (95%CI = 0.957-1.365), and the OR of KL-6 were 1.356 (95%CI = 0.668-2.754), 0.658 (95%CI = 0.161-2.685), 0.915 (95%CI = 0.350-2.394) before the test, 24 hours and 48 hours after ventilation (all P > 0.05). Conclusions APRV was similar to lung protective ventilation strategy in oxygenation and improvements in the lung mechanics parameters. APRV with a higher Pmean can recruit alveolar more effectively, and it had no impact on hemo-dynamics, but might exacerbate VILI.

ObjectiveTo evaluate whether AN69 ST membrane would prolong filter lifetime in continuous renal replacement therapy (CRRT) without anticoagulation in patients with high risk of bleeding.Methods A single-center, prospective, randomized, double-blind control trial with crossover design was conducted. From March 1st to December 31st in 2013, patients who were admitted to Department of Critical Care Medicine of the Fourth Hospital of Hebei Medical University meeting CRRT treatment indications, but could not receive systemic anticoagulation because of high risk of bleeding were studied. The selected patients were randomly divided into two groups according to a random number table, and four filters consisting of two AN69 ST100 membrane filters (A) and two traditional AN69 M100 membrane filters (B) were used for them. GroupⅠ with the filter order of A-B-A-B, and groupⅡ with the order of B-A-B-A. The clinical data of patients was recorded in detail, and conventional AN69 ST and AN69 membrane filter lifetime, their influence on coagulability, and the incidence of bleeding complications were compared.Results Seventeen patients were enrolled, with 10 in groupⅠ, and 7 in groupⅡ. The basic medical characteristics including gender, age, acute physiology and chronic health evaluationⅡ (APAECHⅡ) score, sequential organ failure score (SOFA), Acute Renal Injury Network (AKIN) stage, activated partial thromboplastin time (APTT), prothrombin time (PT), international normalized ratio (INR), platelet count (PLT), and use of mechanical ventilation were not significantly different between two groups. But the use of vasoactive drug was more frequent in groupⅡcompared with that of groupⅠ[100.0% (7/7) vs. 30.0% (3/10),χ2 = 8.330,P = 0.010]. AN69 ST filter lifetime (n =34) was (15.92±2.10) hours, there was no statistically significant difference compared with that of AN69 membrane (t = 0.088,P = 0.942), filter lifetime of which (n = 34) was (16.12±1.38) hours. It was also found by Kaplan-Meier survival analysis that there was no significant difference between the two membrane filter lifetime (χ2=1.589,P =0.208). Logistic regression analysis showed that the life of the first filter was not correlated with coagulation indicators, including APTT, PT, INR, and PLT [APTT: odds ratio (OR) = 0.977, 95% confidence interval (95%CI) = 0.892-1.071, P = 0.623; PT:OR = 1.001, 95%CI = 0.901-1.109,P = 0.988; INR:OR = 1.078, 95%CI = 0.348-3.340,P = 0.896;PLT:OR = 0.996, 95%CI = 0.974-1.019,P = 0.735]. The application rate of vasoactive drugs, which was different between two groups for basic medical indications showed no effect on filter life time (OR = 2.541, 95%CI = 0.239-26.955,P = 0.439). Reasons of clotting in filters were also analyzed, and it was found that blood coagulation in the filter ranked the top (88.2%), and the other reasons were catheter-related problems, death, and unscheduled transport. No difference in blood coagulation function was found in both groups after treatment for 12 hours, and there was no bleeding complication.ConclusionDuring the CRRT without systemic anticoagulant, both surface-treatment with polyethyleneimine AN69 and AN69 ST membrane cannot prolong filter lifetime.

ObjectiveTo investigate the extracorporeal clearance rate of imipenem in severe infection patients in the mode of continuous vena-venous hemofiltration (CVVH) during continuous renal replacement therapy (CRRT), in order to approach if the concentration of imipenem in plasma could achieve effective levels of anti-infection, and to explore the effect of time and anticoagulation measure on imipenem clearance during CRRT treatment.Methods A prospective observational study was conducted. All adult severe infection patients complicating acute kidney injury (AKI) in the Department of Critical Care Medicine of the Fourth Hospital of Hebei Medical University from March 2013 to September 2014, who were prescribed imipenem as part of their required medical care, and CRRT for treatment of AKI were enrolled. 0.5 g doses of imipenem was administered intravenously every 6 hours or 8 hours according to random number table, and infused over 0.5 hour. The unfractionated heparin was used for anticoagulation in the patients without contraindications, and no anticoagulation strategy was used in the patients with high risk of bleeding. At 24 hours after first time of administration, postfilter venous blood and ultrafiltrate samples were collected at 0, 0.25, 0.5, 0.75, 1, 2, 5, 6, and 8 hours after imipenem administration. The concentration of imipenem in above samples was determined with liquid chromatography-mass spectrometer/mass spectrometer (LC-MS/MS).Results A total of 25 patients were enrolled. Thirteen patients received imipenem intravenously every 6 hours, and 12 patients, every 8 hours. The anticoagulation was conducted with heparin in 13 cases, and 12 cases without anticoagulation. The intra-day precision, inter-day precision, matrix effect, and recovery rate in low, medium, and high concentration of plasma and ultrafiltrate, and the stability of samples under different conditions showed a good result, the error of accuracy was controlled in the range of±15%. With the application of Prismaflex blood filtration system and AN69-M100 filter, under the mode with CVVH, the total clearance rate of imipenem was (8.874±2.828) L/h when the actual dose of replacement fluid was (31.63±1.48) mL·kg-1·h-1, the total CRRT clearance rate of imipenem in vitro was (2.211±0.539) L/h, which accounting for (30.1±15.7)% of the total drug clearance. In 6 hours interval dosage regimen, the percentages of the time> 4×minimum inhibitory concentration (MIC) at specific 4×MIC of 2, 4, 6, and 8μg/mL of imipenem were more than 40% of the dosing interval. But in the 8 hours interval dosage regimen, when the level was above the 4×MIC of 4μg/mL, maintaining time would drop below 40% of the dosing interval, with significant differences compared with that in 6 hours interval dosage regimen [4×MIC = 2μg/mL: (60.84±20.25)%vs. (94.01±12.46)%,t = 4.977,P = 0.001; 4×MIC = 4μg/mL: (39.85±15.88)% vs. (68.74±9.57)%,t = 5.562, P = 0.000; 4×MIC = 6μg/mL: (27.58±13.70)% vs. (53.97±8.36)%,t = 5.867,P = 0.000; 4×MIC = 8μg/mL:(18.87±12.43)% vs. (43.48±7.83)%,t = 5.976,P = 0.000]. No significant change in sieving coefficient of imipenem was found within a short time (6 hours), which indicated that there was no effect of anticoagulation on clearance of imipenem by AN69-M100 filter, and no statistical significance was found with repeated measure analysis (F = 0.186, P> 0.05).ConclusionsThe clearance rate of imipenem is increased significantly in vitro under the mode of CVVH with the actual dose of replacement fluid was (31.63±1.48) mL·kg-1·h-1 in severe infective patients with severe sepsis complicating AKI, affecting the level of plasma drug concentration, need to adjust the dosage regimen. When the time of the dosing interval was shortened, the concentration of imipenem in patients' plasma could be increased significantly. In a short period of time, the sieving coefficient of imipenem through AN69 filter is not affected by anticoagulation measures and time cleaning efficiency will not decline.

Objective To investigate the cause,treatment and prevention of delayed gastric emptying (DGE) after operation for esophageal carcinoma.Methods The clinical data of 13 cases with DGE after operation for esophageal carcinoma were analyzed retrospectively.Results DGE occurred at 10th day after operation.10 cases with functional delayed gastric emptying(FDGE) recovered after conservative treatmeut.3 cases with mechanical delayed gastric emptying(MDGE) were given surgical treatment.Conclusions The anatomical displacement of stomach may be the main cause of DGE.DGE is also related to vagus nerve and postoperative inadequate gastrointestinal decompression.Clinical symptoms,X-ray barium meal radiography and gastroscopy examination are the important diagnostic method.Conservative treatment should be the first choice for FDGE.The use of some gastro-intestinal prokinetic drugs may have a beneficial effect on FDGE.Once the diagnosis of MDGE is established,surgical treatment should be performed as early as possible.The fully preoperative preparation,the precise and concise techniques in operation and postoperative appropriate management may decrease the occurrence of DGE.