ObjectiveTo assess the value of legs passively lifted as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis.Methods Twenty-eight mechanically ventilated patients with severe sepsis admitted from May 2010 to May 2011 for volume resuscitation were collected.Patients with non-sinus rhythm or arrhythmia and parturients were excluded. Variation of hemodynamics of the patients in a semi-recumbent position,after passive leg raising (PLR) and after volume expansion (500 ml 6％ hydroxyethyl starch infusion within 30 mins) was studied by using the technique of pulse indicator continuous cardiac output (PiCCO) system.The volume resuscitation were resulted into two groups,responder and non-responder,as per △SVI (stroke volume index) over 15％.HR,arterial systoicblood pressure (ABPs),arterial diastolic blood pressure (ABPd),mean arterial blood pressure (ABPm),mean central venous pressure (CVPm) and cardiac index (CI) were compared between two groups.The changes of ABPs,ABPm,CVPm and SVI after PLR and after fluid resuscitation werc compared with those before PLR and fluid resuscitation.The ROC curve was drawn to evaluate the value of △SVI and △CVPm in predicting volume responsiveness. SPSS 17.0 software was used for statistic analysis. ResultsOf 28 patients,8 were responders and 10 were non-responders.In responders after PLR,some hemodynamic variables including ABPs,ABPm and CVPm were significantly increased [(100.1 ± 18.1) vs.(115.9 ±13.1),P=0.005; (68.1±12.4) vs.(77.8±13.0),P=0.03and(7.2±3.4) vs.(10.1±4.1),P=0.03,respectively ].After PLR,the area under curve (AUC) of the ROC curve of △SVI and △CVPm to predict the responsiveness after fluid resuscitation were 0.897 ± 0.059 (95 ％ CI 0.762-1.000) and 0.819±0.081 (95％CI 0.661-0.977),respectively.When the cut-off levels of △SVI and △CVPm were 10.5％ and 12.7％,the sensitivities were 72.2％ and 72.2％,the specificities were 90％ and 80％.Conclusions Changes in △SVI and △CVPm induced by passive leg raising are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.

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Objective To investigate the accuracy of the plasma DNA concentration in evaluating the prognosis in patients with sepsis.Methods One hundred and sixty patients with sepsis were enrolled as the sepsis group (group SE).Another 109 patients without sepsis hospitalized during the same period served as the control group (group C).The venous blood sample was taken on admission for determination of plasma DNA concentration by polymerase chain reaction,C reactive protein (CRP) concentration by ELISA.APACHE Ⅱ score and SOFA score were evaluated at 24 h after admission.The 160 patients with sepsis were divided into two groups according to the result of prognosis:survival group ( n =103) and death group ( n =57).Results Compared with group C,the plasma DNA concentration,CRP concentration,APACHE Ⅱ score and SOFA score were significantly increased in group SE (P＜0.05).Compared with survival group,the plasma DNA concentration,APACHEⅡ score and SOFA score were significantly increased in death group ( P ＜ 0.05).The areas under receiver operating characteristic (ROC) curves of the plasma DNA concentration was significantly larger than those of APACHE Ⅱ score and SOFA score (0.81(95％ CI,0.74-0.88) versus 0.68(95％ CI,0.60-0.77),or 0.72(95％ CI,0.63-0.82)).Conclusion The plasma DNA concentration can accurately evaluate the prognosis in patients with sepsis.As compared with the plasma CRP concentration,APACHE Ⅱ score and SOFA score,the plasma DNA concentration is more accurate to evaluate the prognosis in patients with sepsis.

Objective To analyze the risk factors of renal replacement therapy (RRT) in acute kidney injury (AKI) patients after liver transplantation, and to investigate the prognosis effect of initial RRT treatment time. Methods Clinical data of 132 recipients undergoing organ donation for cardiac death (DCD) allograft orthotopic liver transplantation admitted to Ningbo Medical Center Lihuili Hospital and Ningbo Medical Center Lihuili Eastern Hospital from July 2014 to July 2018 was retrospectively analyzed. AKI was defined and staged by the criteria of Kidney Disease Improving Global Outcomes (KDIGO) guideline in the first 7 days. According to the implementation of RRT, the patients were divided into non-RRT group and RRT group. The differences in gender, age, body mass index (BMI), model for end-stage liver disease with serum sodium (MELD-Na) score, serum creatinine (SCr), and intraoperative norepinephrine (NE) dose, blood loss, fluid infusion, anhepatic phase time, duration of operation between two groups were compared. The statistically significant risk factors of AKI found by univariate analysis were selected and analyzed to find independent risk factors of RRT in AKI patients after liver transplantation with multivariate Logistic regression analysis. The receiver operating characteristic (ROC) curve was drawn to evaluate the test efficiency of all risk factors of RRT implementation. According to the implementation of RRT on KDIGO stage-2, all the patients on KDIGO stage-2 and stage-3 were divided into early group (initial RRT on KDIGO stage-2) and delayed group (including self-improvement without RRT on KDIGO stage-2 and initial RRT on KDIGO stage-3). The duration of mechanical ventilation, the length of intensive care unit (ICU) stay, AKI duration, incidence of catheter related bloodstream infection (CRBSI) and 28-day mortality were compared between the two groups. Results All 132 receptors were enrolled in the final analysis, and 77 patients developed AKI, accounting for 58.3%, among which 52 cases were in RRT group (67.5%) and 25 were in non-RRT group (32.5%). As shown by univariate analysis, the MELD-Na score (21.6±4.4 vs. 18.0±4.3), intraoperative NE dose (μg·kg-1·h-1: 7.5±1.2 vs. 5.2±1.7), blood loss [mL: 3 000 (2 200, 4 000) vs. 2 600 (1 800, 3 200)], fluid infusion [mL: 6 400 (4 500, 7 800) vs. 5 600 (4 200, 6 800)], and anhepatic period (minutes: 65.6±4.5 vs. 63.0±5.0) were significantly increased in RRT group as compared with those in non-RRT group (all P < 0.05). There was no significant difference in gender, age, BMI, SCr before operation or the duration of operation. It was shown by multivariate Logistic regression analysis that MELD-Na score before operation [odds ratio (OR) = 1.398, 95% confidence interval (95%CI) = 1.062-1.841, P = 0.017], intraoperative NE dose (OR = 4.724, 95%CI = 2.036-10.961, P = 0.000) and fluid infusion (OR = 1.002, 95%CI = 1.001-1.004, P = 0.010) were independent risk factors of RRT implementation in AKI patients after liver transplantation. It was shown by ROC curve analysis that the area under the ROC curve (AUC) of MELD-Na score, NE dose and fluid infusion for predicting the implementation of RRT in AKI patients after liver transplantation was 0.719, 0.867, and 0.670, respectively, which suggesting that NE dose had moderate predictive value, but MELD-Na score and fluid infusion had low predicative value. When the optimal cut-off value of NE dose was 6.5 μg·kg-1·h-1, the sensitivity was 84.6% and the specificity was 80.0%. The 28-day mortality was both 0 in early group (n = 25) and delayed group (n = 39). Compared with the early group, the duration of mechanical ventilation (hours: 41.0±1.0 vs. 35.8±6.7) and the length of ICU stay (hours: 98.8±6.6 vs. 94.2±7.3) were significantly increased in delayed group (both P < 0.05), there was no significant difference in AKI duration (days: 11.8±4.2 vs. 10.6±4.9) or the incidence of CRBSI [5.1% (2/39) vs. 4.0% (1/25), both P > 0.05]. Conclusions MELD-Na score, intraoperative NE dose and fluid infusion were the independent risk factors of RRT implementation in AKI patients after liver transplantation. NE dose had moderate predictive value, but MELD-Na score and fluid infusion had low predicative value. Initial RRT on KDIGO stage-2 could reduce the duration of mechanical ventilation and the length of ICU stay.

Objective To analyze the risk factors of prognosis in elderly patients with septic shock in ICU.Methods Clinical data of 113 elderly patients with septic shock admitted in the ICU of Ningbo Medical Center Lihuili Eastern Hospital from November 2015 to March 2019 were retrospectively analyzed. Among them, 40 patients died ( death group) and 73 patients survived (survival group) within 28 d after diagnosis confirmed.The general information ,underlying disease,laboratory findings and invasive operations were compared between the two groups.Multivariate Logistic regression was used to analyze the risk factors for prognosis of patients, and ROC curve was used to analyze the predictive value of risk factors for death . Results Multivariate Logistic regression analysis showed that APACHEII score ( OR ＝1.344, 95%CI 1畅187-1.520,P＜0.01) and lactic acid level at admission (OR＝1.311,95%CI 1.075-1.599,P＜0.01) were independent risk factors for prognosis ,while platelet counts (OR＝0.986,95%CI 0.976-0.996,P＜0畅01)and albumin level(OR＝0.812,95%CI 0.697-0.945,P＜0.01)were protective factors for prognosis. ROC curve analysis showed that the area under the curve of APACHEII score ,lactic acid level at admission and APACHEII score combined with lactic acid level at admission were 0.861(95%CI 0.784-0畅919,P＜0畅01),0.752(95%CI 0.662-0.828,P＜0.01) and 0.904(95%CI 0.834-0.951,P＜0.01),respectively. The predictive value of APACHEII score combined with lactic acid level at admission was better than those of APACHEII score and lactic acid level at admission ( Z ＝2.175 and 2.879, P ＜0.05 and P ＜0畅01). Conclusions Lower APACHEII score and lactic acid level ,increased platelet counts and albumin level may be associated with a favorable prognosis for elderly patients with septic shock .APACHEII score combined with lactic acid level at admission has better predictive value for prognosis .

Objective To investigate the effect of ulinastatin on the expression of serum inflammatory mediators in pa tients with acute myocardial infarction (AMI) after thrombolysis. Methods 84 patients with AMIin our hospital from January 2017 to December 2017 were selected and randomly divided into the control group and the experimental group with 42 cases in each group. The control group received recombinant streptokinase intravenous thrombolytic therapy, while the experimental group was given intravenous infusion of ulinastatin in the foundation of thrombolytic therapy. Two groups of patients were extracted venous blood to measure the expression levels of inflammatory mediators including hs-CRP, IL-1, IL-10 and TNF-a before treatment, 24 h and 72 h after treatment. Results 24 h after treatment, the expression levels of hs-CRP, IL-1, IL-10 and TNF-a in the two groups were higher than those before the treatment, and the difference was statistically significant (P＜0. 05). However, the increase in the experimental group was lower than that of the control group (P＜0. 05). 72 h after treatment, the levels of inflammatory mediators in the two groups were significantly lower than those before and 24 h after the treatment(P＜0. 05). The decrease in the experimental group was higher than that of the control group and the difference between the two groups was statistically significant(P＜0. 05). There was no significant difference in the incidence of adverse reactions and adverse cardiovascular events between the two groups during hospitalization after thrombolysisP＞0. 05). Conclusion The use of ulinastatin before and after thrombolytic therapy can effectively inhibit the expression levels of inflammatory mediators and relieve myocardial ischemia reperfusion injury in patients with AMI.