BACKGROUND: When regional citrate anticoagulation (RCA) is used in continuous renal replacement therapy (CRRT), one of the key aspects to achieve safe and effective extracorporeal circulation is the management of calcium ions. For calcium-free RCA-CRRT, there are generally two ways to do this: The deep vein and the venous line. The anticoagulant effects of different calcium supplementation pathways have not yet been explored. OBJECTIVE: In this trial, we would test our hypothesis that compared with the subclavian vein, when calcium was infused through the venous line of blood filter catheter, the arterial iCa2+ was lower. METHODS: This was a prospective, single-center, randomized crossover trial. From December 2018 to December 2019, 48 patients with RCA-CRRT at the Department of Intensive Care Unit of the First Hospital of Lanzhou University were selected. According to the different calcium sites, the patients were randomly divided into two groups. The calcium supplementation order of group A (n=24) was the venous line of the blood filter catheter-subclavian vein. Group B (n=24) was supplemented with subclavian vein-the venous line. Blood gas analysis results were compared using blood gas analyzers before and after replacement of the calcium supplementation route in all cases. The primary measurement outcome was the differences between arterial iCa2+ and post-filtration iCa2+ with different calcium supplementation pathways, and the simultaneous recording of pH, K+, and total hemoglobin. The secondary measurement outcomes were the incidences of catheter dysfunction and hypocalcemia during the intervention. The trial was approved by the Ethics Committee of the First Hospital of Lanzhou University (approval No. LDYYLL2018-165) in December 2018. The study was registered on the China Clinical Trial Registration Center (ChiCTRI 800020046) in December 2018. Sample and data collection time is from December 2018 to November 2019, data analysis time and test completion time is December 2019. DISCUSSION: This is the first trial on the anticoagulant effects of calcium-free RCA-CRRT through different calcium supplement routes. We will confirm that the arterial iCa2+ level is slightly lower when calcium is infused in the venous line of blood filter catheter than in the subclavian vein, and the incidence rates of catheter dysfunction and hypocalcemia will help us to determine which site is safer.

Objective? To analyze the relevant literatures of research on Intensive Care Unit-acquired weakness(ICU-AW) by visualization analysis method based on the large data visualization analysis background, understand the current researches on ICU-AW treatment as a whole, and find out the hot spots and shortcomings of ICU-AW related researches, so as to provide reference for clinical researches. Methods? To retrieve the PubMed, Embase, Web of Science, the Cochrane Library, and the Chinese Biomedical Literature Database, WanFang, CNKI and VIP Chinese databases from the databases' establishment data to September 1st, 2018. All published Chinese and English articles about ICU-AW were included. Endnote software was used to extract the main contents of literatures and generate co-occurrence matrix by BICOMB 2 software after manual de-duplication. Then Ucinet 6.0 was used to map the main information social network graph. Finally, gCluto 1.0 was used to draw the visualization graphs. Results? A total of 1 053 literatures were extracted. Since the publication of the first one in 1993, scholars began to pay attention to the disease in 2006. A total of 41 countries and regions all over the world had collaborative research in varying levels, of which 223 (21.18%) have been published in the United States. Up to 259 articles (24.6%) were summaries and systematic reviews, while few studies were clinical trials, observation and cohorts. Totally 48 authors participated in the publication of 10 or more papers, and the number of authors who had published one article was 2 080 (69.15%). The literatures were published in 385 journals. Only 14 journals (3.64%) contained more than 10 articles, and 450 journals (42.73%) accumulated. The citation frequency of published literatures was relatively low, and only 80 (7.60%) of them were cited more than 50 times. The visualization graph of key words showed that the research hot spots of ICU-AW included pathophysiological mechanism, diagnosis and rehabilitation treatment. Conclusions? The research on ICU-AW is still in the preliminary stage, and its depth and breadth need to be further explored. More multi-center and single-center clinical studies are needed to explore the diagnosis, related risk factors, treatment measures,prevention of ICU-AW and its impact on patients' outcomes and quality of life.

Objective To determine the safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit (ICU) by systematic review.Methods Randomized controlled trails (RCTs) and cohort studies about early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in ICU were retrieved in CBM,CNKI,Wanfang Data,PubMed,Cochrane Library and Web of Science from their foundation to March 2018,and other sources as supplement was also retrieved.The intervention program of RCT study was ICU routine nursing in control group,early activity in observation group,and early activity in cohort study without control group.Early activities included active and passive activities on the bed,sitting upright,bed-chair transfer,standing and walking.Literature screening and data extraction were performed independently by two researchers.Variables or parameters.related to cardiovascular,respiratory,nervous,orthopedic and other systems were collected for safety criteria.Variables or parameters used in at least three literatures were collected for each system.Cochrane 5.1.0 was used to evaluate the quality of RCT study,and Newcastle-Ottawa scale (NOS) was used to evaluate the quality of cohort study.Results A total of 24 articles about early activity of patients undergoing mechanical ventilation in ICU were enrolled,involving 4647 patients,including 11 RCT studies involving 1 031 patients,509 in control group and 522 in observation group;13 cohort studies including 3616 patients.It was shown by systematic review that safety criteria for early activity in patients undergoing mechanical ventilation in ICU involved five systems,20 variables or parameters.The cardiovascular system included 8 variables or parameters,such as 40 bpm ＜ heart rate (HR) ＜ 130 bpm (n =4),hemodynamic stability (n =5),no myocardial infarction (n =3),no arrhythmia (n =4),no vascular active drugs (n =4),90 mmHg ＜ systolic blood pressure (SBP) ＜ 200 mmHg (1 mmHg =0.133 kPa,n =4),65 mmHg ≤ mean arterial pressure (MAP) ≤ 110 mmHg (n =3),no history of cardiopulmonary resuscitation (CPR,n =5).The respiratory system included 4 variables or parameters,involving 5 times/min ＜ respiratory rate (RR) ＜ 40 times/min (n =5),fraction of inspired oxygen (FiO2) ≤ 0.60 and positive end-expiratory pressure (PEEP) ≤ 10 cmH2O (1 cmH2O =0.098 kPa,n =4),FiO2 ＜ 0.60 or PEEP ＜ 10 cmH2O (n =3),pulse blood oxygenation (SpO2) ＞ 0.88 (n =5).The nervous system included 4 variables,including no neuromuscular disease (n =7),no increase in intracranial pressure (n =7),no coma (n =4),understand and do the right thing (n =4).The orthopedic system included 2 variables,including no fracture (n =3),no unstable fracture (n =8).Other factors included 2 variables,including no open abdomen wound (n =4),and no palliative care (n =3).Conclusions This study identified safety criteria for early goal-directed rehabilition exercise in patients undergoing mechanical ventilation in ICU included five systems of cardiovascular,respiratory,neurological,orthopedic,and other systems,in which cardiovascular and respiratory systems were the most frequently cited variables or parameters.The consistency of each system security criteria or variables reported by different literatures was high,but the parameters need to be further verified by high-quality study.

Objective:To investigate the cognitive impairment after intensive care unit (ICU) discharge and provide theoretical basis for prevention and intervention.Methods:Studies about cognitive impairment after ICU discharge were retrieved in PubMed, Embase, Cochrane Library, Web of Science, Wanfang data, CNKI and SinoMed from their foundation to December 2019. The literature screening and data extraction were performed by two researchers independently, and the quality of different types of researches was evaluated using Cochrane Handbook 5.1.0, Newcastle-Ottawa scale (NOS) and agency for healthcare research and quality criteria (AHRQ). The Meta-analysis was performed by Stata 13.0 software. Sensitivity analysis was used to determine the reliability of the combined effect values. Funnel plot and Egger test were used to analyze publication bias. The non-parametric clipping was used to evaluate the impact of publication bias on the results.Results:A total of 35 studies were enrolled, including 27 prospective cohort studies, 4 retrospective cohort studies, 2 randomized controlled trial (RCT) studies, 1 case-control study, and 1 cross-sectional study. Three literatures were published in Chinese and 32 were in English, which covered 13 countries, and a total of 102 504 ICU survivors were followed up successfully. Literature quality evaluation results showed that the NOS scores of 31 cohort studies were between 6 and 9, of which the case-control study scored 9. The quality grade of 2 RCT studies were both B. According to the AHRQ criteria, 1 cross-sectional study's design was scientifically rigorous and of high quality. Thirty-five studies reported that the overall incidence of cognitive impairment after ICU discharge ranged from 2.47% to 66.07%. For the multiple follow-ups studies, the first survey data was selected for Meta-analysis, and the results showed that the pooled incidence was 38.44% [95% confidence interval (95% CI) was 29.32-47.55]. Each study was removed for sensitivity analysis and the pooled results did not change much, which indicated that the results were reliable. The sub-group analysis was performed on different evaluation methods for cognitive impairment after ICU discharge, different types of ICU patients, and different follow-up time. The results showed that the pooled incidence of studies using neuropsychological test to evaluate cognitive impairment after ICU discharge was 31.42% (95% CI was 21.82-41.02), the pooled incidence of studies using questionnaires or scales was 38.75% (95% CI was 29.54-47.96), and the difference between the two groups was statistically significant ( P < 0.01). The pooled incidence of cognitive impairment after ICU discharge in general ICU patients was 43.42% (95% CI was 30.88-55.95), acute respiratory distress syndrome (ARDS) patients' pooled incidence was 34.40% (95% CI was 23.02-45.79), and the pooled incidence of elderly ICU patients was 12.93% (95% CI was 8.48-17.37), the difference among the three groups was statistically significant ( P < 0.01). The incidences of cognitive impairment < 1 year, 1 to 4 years, ≥ 5 years after ICU discharge were 43.30% (95% CI was 29.47-57.13), 34.21% (95% CI was 26.70-41.72), and 20.22% (95% CI was 4.89-35.55), respectively, and the differences among the three groups were statistically significant ( P < 0.01). The funnel plot showed that the distribution of all studies was asymmetric, and the Egger test result also suggested that there might be publication bias ( P < 0.05). The non-parametric clipping was used to estimate the impact of publication bias on the results, and the result showed that the difference in the incidence of cognitive impairment after ICU discharge before and after non-parametric clipping was large, suggesting that publication bias might influence the stability of the research results. Conclusions:The incidence of cognitive impairment after ICU discharge is relatively high and persistent for a long time, but diagnostic criteria of cognitive impairment and follow-up time are quite different. It is necessary to develop consistent evaluation criteria and rigorous designed research in the further.

Objective:To explore the threshold and diagnostic value of Chinese version of the Chelsea Physical Function Assessment Tool (CPAx-Chi) for ICU acquired weakness(ICU-AW).Methods:To learn the details and precautions of the CPAx-Chi scale, and then two researchers used the CPAx-Chi scale and MRC-Score scale to independently evaluate 200 patients who come from a comprehensive ICU in a top first-class hospital in Gansu Province simultaneously. The best cut-off point and value of the CPAx-Chi scale in the diagnosis of ICU-AW were determined by calculating the Receiver Operating Characteristic (ROC) curve, the Youden index(YI) and the consistency test that are all based on the MRC-Score≤48.Results:The ROC Area Under Curve(AUC) of the CPAx-Chi scale diagnosis ICU-AW which based on the MRC-Score≤48 were as follows: ROC AUC of group A was 0.899 (95% CI 0.862-1.025); ROC AUC of group B was 0.874 (95% CI 0.824-0.925). When the best cut-off point of CPAx-Chi scale for diagnosis ICU-AW was 31.5, the maximum YI=0.643, the sensitivity was 87%, and the specificity was 77% in group A; and the maximum YI= 0.62, the sensitivity was 75%, and the specificity was 87% in group B. Meanwhile, when the best cut-off point of CPAx-Chi scale for diagnosis ICU-AW was 30.5, the maximum YI=0.62, the sensitivity was 79%, and the specificity was 83% in group B. Taking the CPAx -Chi≤31 as the best cut-off point, the score differences in ICU-AW group and the non-ICU-AW group were not detected, A group ( F value was 4.53, P=0.035) or B group ( F value was 6.51, P=0.011). The consistency of CPAx -Chi≤31 and MRC-Score≤48 in the diagnosis of ICU-AW was high, and the Kappa=0.845 ( P=0.02) in the group A; the Kappa=0.839( P=0.04) in the group B, and the group differences were detected. Conclusions:CPAx-Chi≤31 is the best cut-off point for diagnosing ICU-AW, and has good sensitivity and specificity. CPAx-Chi scale can be popularized and applied in the critical care medicine in China.

Objective:To investigate the current status of intensive care unit-acquired weakness (ICU-AW) assessment, analyze the assessment barriers, and to provide reference to improve ICU-AW assessment.Methods:A convenient sampling cross-sectional survey was conducted. First, an interview outline which based on related domestic and international literatures and combining with the research purpose of this study were designed. Thirteen medical personnel (8 ICU nurses, 3 ICU doctors, 1 respiratory therapist and 1 physiotherapist) who worked in the intensive care unit (ICU) of the First Hospital of Lanzhou University were enrolled with convenience sampling method to interview. Second, the topics were comprehensively analyzed and extracted, and then a questionnaire was constructed, and the reliability and validity was assessed. Finally, the questionnaire survey including the general situation of ICU medical staffs, the current practices of ICU-AW and influencing factors was implemented in China.Results:The retest reliability was 0.92 and expert validity was 0.96 of the questionnaire. There were 3 563 respondents in 31 provinces, municipalities and autonomous regions which eliminated 357 unqualified questionnaires, including 173 respondents from neonatal or pediatric ICU, 89 respondents whose working time was less than 6 months, and 95 invalid respondents, and then there were finally 3 206 valid questionnaires and the response rate were 90.0%. Those 3 206 respondents included 616 doctors (19.2%), 2 371 nurses (74.0%), 129 respiratory therapists (4.0%), 51 physiotherapist (1.6%) and 39 dietitians (1.2%). The mean age was (30.7±6.3) years old. Most of them had bachelor's degree (65.9%), master and above was 14.1%. Associate senior physician and above was 8.0%; ICU working time was (5.94±4.50) years. In clinical practice, only 26.5% of the ICU medical staffs confirmed that they had treated or taken care for ICU-AW patients; 52.9% of medical staffs evaluated ICU-AW only based on clinical experience, and only 12.3% used ICU-AW assessment tools. The majority of respondents believed that ICU-AW knowledge training should be performed (81.8%), ICU-AW assessment should be as important as other complications (pressure sore, infected ventilator associated pneumonia, etc., 75.1%), and ICU-AW assessment should be part of daily treatment and care activities (61.2%). However, only 10.2% of respondents had received ICU-AW related knowledge training, and 42.7% respondents believed that their ICU-AW related knowledge could not meet clinical needs. Only 18.7% respondents would actively assess whether patients suffered from ICU-AW or not, and 42.3% respondents thought that ICU-AW should be assessed every day, and the assessment tools were also inconsistent. There were 44.0% respondents considered the Medical Research Council Muscle score (MRC-score) scale was the optimal tool for diagnosing ICU-AW, the following were neuro-electrophysiological examination (17.2%) and manual muscle strength (MMT, 11.1%). The main cause of the ICU-AW assessment barriers was the lack of ICU-AW related knowledge (88.1%), and the following were lack of ICU-AW assessment guidelines (76.5%), patients' cognitive impairment or limited understanding ability (84.6%), unable to cooperate with the assessment due to critical illness (83.0%), and inadequate attention to ICU-AW assessment by the department (77.5%).Conclusion:The current status of ICU-AW assessment were unsatisfying in China, and the main barriers were lack of skills and knowledge.

Objective To explore effective and objective diagnostic tools for evaluating intensive care unit acquired weakness (ICUAW). Methods The studies about evaluation and diagnosis of adult ICUAW in PubMed, Embase, Web of Science, the Cochrane Library, CNKI, CBM, VIP and Wanfang databases from the date of their foundation to July 1st in 2018 were retrieved by computer. The literatures in Chinese and English were searched. Two investigators independently screened literature and evaluated the literature quality ratings, and extracted the research design, sample size, research object, evaluation item, reliability, validity, clinical application and other indicators, and then systematically analyzed the reliability and validity of ICUAW diagnostic tools, and evaluated diagnostic tools' advantages, disadvantages and application status. Results There were 19 literatures including 14 assessment scales and ultrasound diagnosis. The 14 assessment scales were medical research council score (MRC-Score), Barthel index (BI), 6-minute walk test (6MWT), clinical outcome variables scale (COVS), the Chelsea critical care physical assessment tool (CPAx), functional independence measure (FIM), functional status score for the intensive care unit (FSS-ICU), the ICU mobility scale (IMS), rivermead mobility index (RMI), the Perme ICU score (PERME), the physical function ICU test (PFIT), the physical function ICU test score (PFIT-s), the surgical ICU optimal mobility score (SOMS), and the Manchester mobility score (MMS). Nine scales (60%) were tested reliability and the rang of inter-rater reliability was 0.600-0.996, and the test reliability was 0.970, and the range of internal consistency reliability was 0.680-0.992. Validity of 6 scales (40%) were evaluated, and the range of structure validity was 0.57-0.94, the range of content validity was 0.830-0.988, the range of concurrent validity was 0.730-0.823. It was shown that the reliability of ICUAW assessment scale was relatively good at present, but the degree of accurate assessment of ICUAW was relatively low. The evaluation content of ICUAW can be divided into three categories: in the first, they measured the muscles strength of body just like MRC-Score; in the second, they evaluated the physical function and mobility, such as COVS, CPAx, FIM, FSS-ICU, IMS, PERME, PFIT, RMI, SOMS and MMS; in the third, they evaluated daily activity and physiology parameter just as 6MWT, BI and ultrasound. Different scales were correlated with the length of ICU stay (ICU-LOS), the hospital discharge, and the mortality. For example: COVS, CPAx, FSS-ICU, PFIT, PFIT-s and SOMS could predict the ICU-LOS and hospital discharge, RMI and SOMS can predict patient mortality. However, there was no evidence to testify the consistency between them. Now, the specialist consensus about the observation nodes of threshold and electrophysiological records were the complex action potential (CMAP) range < 0.43-0.65 mV and the sensory nerve action potential (SNAP) range < 17.6 μV. Conclusions There are many diagnostic tools in ICUAW, and the reliability of each scale is relatively good. In future studies, we should collect the advantages of each scale, explore the specific indicators to evaluate ICUAW and improve the accuracy and validity of diagnostic ICUAW.