Objective To explore the effect of early goal-directed therapy (EGDT) according to pulse indicated continuous cardiac output (PiCCO) on septic shock patients.Methods Eighty-two septic shock patients in Subei People's Hospital of Jiangsu Province from January 2009 to December 2012 were enrolled and randomly divided into two groups using a random number table,standard surviving sepsis bundle group (n=40) and modified surviving sepsis bundles group (n =42).The patients received the standard EGDT bundles in standard surviving sepsis bundle group.PiCCO catheter was placed in modified surviving sepsis bundles group.Fluid resuscitation was guided by intrathoracic blood volume index (ITBVI) with the aim of 850-1 000 mL/m2.Dobutamine was used to improve the heart function according to left ventricular contractile index (dPmax) and stroke volume index (SVI).The mean arterial blood pressure (MAP) was maintained 65 mmHg (1 mmHg=0.133 kPa) or above with norepinephrine.Extra-vascular lung water was monitored for the titration of liquid and diuretics.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,the number of patients needed vasopressor,serum procalcitonin (PCT),lactic acid and lactate extraction ratio,the amount of fluid resuscitation,duration of mechanical ventilation,duration of intensive care unit (ICU) stay,hospital mortality were recorded in both groups.Results After treatment,the APACHE Ⅱ score,SOFA score and the number of patients needed vasopressor were gradually reduced in both groups,and those in modified surviving sepsis bundle group were significantly lower than those of standard sepsis bundle group at 72 hours (APACHE Ⅱ score:13.1 ± 6.5 vs.20.9 ± 7.5,SOFA score:8.8 ± 4.3 vs.14.6 ± 4.9,the number of patients needed vasopressor:8 vs.17,all P＜0.05).Arterial blood lactate clearance rate was gradually increased after treatment in both groups.Lactate clearance rate in modified surviving sepsis bundle group was significantly higher than that of standard surviving sepsis bundle group [6 hours:(18.2 ± 8.3)％ vs.(10.8 ± 7.5)％,t=-6.036,P=0.001 ; 12 hours:(22.6 ± 7.3)％ vs.(12.4 ± 8.1)％,t=-4.536,P=0.001 ; 24 hours:(27.8 ± 5.6)％ vs.(16.4 ± 9.5)％,t=-5.882,P=0.000].The amount of fluid resuscitation within 6 hours in modified surviving sepsis bundle group increased significantly compared with standard surviving sepsis bundle group (mL:3 608 ± 715 vs.2 809 ± 795,t=-3.865,P=0.033).The amount of fluid resuscitation within 24,48 and 72 hours in modified surviving sepsis bundle group was significantly less than that of standard modified surviving sepsis bundle group with the nadir at 72 hours (mL:918 ± 351 vs.1 805 ± 420,t=5.907,P=0.037).Duration of mechanical ventilation (hours:98.4 ± 20.3 vs.143.3 ± 29.6,t=9.766,P=0.001) and ICU stay (days:7.1 ± 3.1 vs.9.5 ± 2.5,t=2.993,P=0.004) were significantly reduced in modified surviving sepsis bundle group compared with standard surviving sepsis bundle group.The hospital mortality in modified surviving sepsis bundle group was slightly lower than that in standard surviving sepsis bundle group [16.7％(7/42)比 17.5％(7/40),x2=0.010,P=0.920].Conclusions Modified surviving sepsis bundle treatment according PiCCO can reduce the severity of disease in patients with septic shock,can make more accurately guide fluid resuscitation,and can reduce lung water and duration of mechanical ventilation and ICU stay.It has great clinical significance.

Objective To evaluate the role ofpleth variability index (PVI) by passive leg raising (PLR) test in volume responsiveness and volume status prediction in patients with septic shock.Methods A prospective randomized controlled trial (RCT) was conducted.Eighty-seven patients suffering from septic shock undergoing mechanical ventilation in Department of Critical Care Medicine of Subei People's Hospital from June 2012 to September 2014 were enrolled.The hemodynamic changes before and after PLR were monitored by pulse indicated continuous cardiac output (PiCCO) and PVI monitoring.Responsive group:positive fluid response was defined as an increase in cardiac index (CI) ≥ 10％ after PLR.Unresponsive group:negative fluid response was defined as an increase in CI ＜ 10％ after PLR.The hemodynamic parameters,including heart rate (HR),mean arterial pressure (MAP),central venous pressure (CVP),stroke volume variation (SVV),CI and PVI,and the changes in cardiac parameters (△ HR,△ MAP,△ CVP,△ SVV,△ CI,and △ PVI) before and after PLR were determined.The relations between hemodynamic parameters and their changes with △ CI were analyzed by the Pearson analysis.The role of the parameters for volume responsiveness prediction was evaluated by receiver operating characteristic (ROC) curves.Results 145 PLRs in 87 patients with septic shock were conducted,with 67 in responsive group and 78 in unresponsive group.There were no statistically significant differences in HR,MAP,CVP and CI before PLR between the responsive and unresponsive groups.SVV and PVI in responsive group were significantly higher than those in the unresponsive group [SVV:(16.9± 3.1)％ vs.(8.4±2.2) ％,t =9.078,P =0.031; PVI:(20.6±4.3)％ vs.(11.1 ±3.2)％,t =19.189,P =0.022].There were no statistically significant differences in HR,MAP,CVP,SVV,and PVI after PLR between the responsive group and unresponsive group.CI in the responsive group was significantly higher than that in the unresponsive group (mL·s-1·m-2:78.3±6.7 vs.60.0±8.3,t =2.902,P =0.025).There were no statistically significant differences in △HR,△MAP,△ CVP between responsive group and unresponsive group.△ SVV,△ CI and △ PVI in responsive group were significantly higher than those in the unresponsive group [△ SVV:(4.6 ± 1.5)％ vs.(1.8 ± 0.9)％,t =11.187,P =0.022;△ CI (mL·s-1·m-2):18.3 ± 1.7 vs.1.7 ± 0.5,t =3.696,P =0.014; △ PVI:(6.4 ± 1.1)％ vs.(1.3 ± 0.2)％,t =19.563,P =0.013].No significant correlation between HR,MAP or CVP before PLR and △ CI was found.SVV (r =0.850,P =0.015) and PVI (r =0.867,P =0.001) before PLR were correlated with △ CI.It was shown by ROC curve that the area under ROC curve (AUC) for SVV fluid responsiveness prediction was 0.948,and cut-off of SVV was 12.4％,the sensitivity was 85.4％,and specificity was 86.6％.The AUC for PVI fluid responsiveness prediction was 0.957,and cut-off was 14.8％,the sensitivity was 87.5％,and specificity was 84.8％.It was higher than other hemodynamic parameters (HR,MAP,CVP).Conclusions PVI and SVV can better predict fluid responsiveness in mechanically ventilating patients with septic shock after PLR.PVI as a new continuous,noninvasive and functional hemodynamic parameter has the same accuracy as SVV.

Objective To explore the correlations of extravascular lung water index (ELWI),oxygenation index and intrathoracic blood volume index (ITBI) in patients with acute exacerbation chronicobstructive pulmonary disease (AECOPD) and examine the significance of ELWI in fluid management.Methods A total of 63 hospitalized AECOPD patients with respiratory failure were recruited from our hospital from October 2010 to April 2013.Pulse indicator continuous cardiac output (PiCCO) technology was employed to monitor ITBI and ELWI.We compared the relationship of ELWI,ITBI and oxygenation index.And simple correlation analysis was used for statistical processing.Results Significant negative correlation existed in ELWI and oxygenation index (r =-0.741,P ＜ 0.01).ELWI 14 ml/kg was defined as a cutoff value for subgroup analysis.A negative correlation existed between ELWI and oxygenation index in the subgroup with ELWI ＜ 14 ml/kg,but there was no significant difference (r =-0.524,P =0.080) ; in the subgroup with ELWI ≥ 14 ml/kg,there was significant negative correlation (r =-0.952,P ＜ 0.01).No significant correlation existed between ELWI and ITBI (r =0.477,P =0.072).ITBI 1 000 ml/m2 was defined as a cutoff value for subgroup analysis.No significant difference existed in the subgroup with ITBI ＜ 1 000 ml/m2 (r =0.332,P =0.117).However,significant positive correlation existed in the subgroup with ITBI≥ 1 000 ml/m2 (r =0.677,P ＜ 0.01).Conclusion Excessive extravascular lung water is an important factor for acute exacerbation of COPD leading to respiratory failure.

Objective To evaluate the clinical effects of PiCCO in the treatment of COPD patients with sepsis shock.Methods 43 COPD patients with sepsis shock were randomly divided into two groups.The control group (n =23) were guided fluid resuscitation according to CVP.The study group (n =20) were placed PiCCO,and according to the PiCCO for fluid resuscitation.The average amount of fluid resuscitation,the amount of norepinephrine and the blood lactate level in 24 hours were observed.The average duration of mechanical ventilation and ICU mortality were also observed.Results After 24 hours,the average amount of fluid resuscitation was (3 986.2 ± 542.1) ml of control group and (4 927.9 ± 761.8)ml of study group,the difference between the two groups was statistically significant (t =-4.71,P ＜ 0.05).The average norepinephrine dosage was (0.38 ± 0.21) μg · min-1 · kg-1 of control group and (0.14 ±0.08)μg · min-1 · kg-1 of study group,the difference between the two groups was statistically significant (t =2.45,P ＜ 0.05).The blood lactate level was (4.79 ± 1.95) mmol/L of control group and (3.44 ±1.45) mmol/L of study group,the difference between the two groups was statistically significant(t =2.59,P ＜ 0.05).Five patients died in control group(mortality 21.7％),and three patients died in study group(mortality 15.0％).Mortality between the two groups was not statistically different (x2 =0,03,P ＞ 0.05).The duration of mechanical ventilation in the control group was (101.22 ± 44.77) h,that in the study group was (74.71 ± 20.25) h,the difference between the two groups was statistically significant (t =2.234,P ＜ 0.05).Conclusion Long-term COPD patients maybe have right ventricular dysfunction,and CVP is difficult to truly reflect the volume status of patients,PiCCO can make up for deficiencies in CVP.PiCCO used to guide these patients with fluid resuscitation,which could guide fluid management of patients,reduce the amount of vasoactive drugs,improve tissue hypoxia,and could reduce the duration of mechanical ventilation.

Objective To evaluate the relationship between the extravascular lung water (EVLW) and other markers of lung injury and determine whether or not EVLW predicts survival in patients with acute respiratory distress syndrome (ARDS) and examine if indexing EVLW with predicted body weight (EVLWp) strengthens its discriminative power.Methods EVLW and other markers of lung injury [including:PaO2/FiO2(P/F),oxygenation index (OI) =mean pressure (Pm) × FiO2 × 100/PaO2,static compliance (Cst) and lung injury score (LIS)] were measured prospectively for 3 days in 27 patients with early ARDS between January 2011 and December 2011 at intensive care units (ICU) of Subei People's Hospital.The relationship between indexing EVLW with actual body weight (EVLWa),EVLWp and other markers of lung injury,the 28-day mortality were evaluated.Results Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ),fluid balance in first 3 days,days of mechanical ventilation and ICU stay were significantly higher on admission in nonsurvivors compared with survivors (P ＜ 0.05).Nonsurvivors had higher OI,LIS,EVLWa and EVLWp than survivors at Days 1 and 3 (P ＜ 0.05).EVLWa and EVLWp were correlated positively with LIS (r =0.471,0.528 P ＜ 0.05) and OI (r =0.527,0.627,P ＜ 0.05) and negatively with P/F (r =-0.467,-0.646,P ＜ 0.05).EVLWp had a stronger correlation to LIS,OI and P/F than did EVLWa.No obvious correlation existed between EVLWa,EVLWp and Cst (r =-0.260,0.226,P ＞ 0.05).ROC curve analysis indicated that EVLWp (0.759,P ＜ 0.05) but not EVLWa (0.661,P＞0.05) discriminated between survivors and nonsurvivors.Three-dav average EVLWp ≥12.5ml/kg predicted the 28-day mortality with 62.5％ specificity and 80％ sensitivity.Conclusion Increased extravascular lung water is a feature of early ARDS and predicts survival.EVLWp,instead of EVLWa,improves the predictive value of extravascular lung water for survival and it is correlated with markers of disease severity.

Objective To evaluate the compliance of sepsis bundles and its impact on the mortality rate in patients with sepsis shock.Methods Fifty-eight adult patients with sepsis shock admitted in the intensive care units from January to December 2007 were enrolled in the study,and the compliance with the 6-h bundle was analyzed.Age,gender,sites of infection,acute physiology and chronic health evaluation II (APACHE II)score,duration of mechanical ventilation,ICU stay and the mortality rate were compared between patients completed 6-h bundles and those not completed 6-h bundles.Results Compliance with the 6-h bundle was obtained in 22 out of 58 patients(37.9%).Patients receiving bundle care had shorter duration of mechanical ventilation and shorter length of ICU stay than non-bundle patients(t=-2.225 and -3.702,P=0.037 and 0.001,respectively),and the mortality rate in 6-h bundle patients was also lower (X2=10.236,P=0.000).Conclusion The application of 6-h bundle care can reduce the mortality rate of the patients with sepsis shock.and the compliance should be improved.

Objective To find out some possible risk factors of death postcardiac surgery undergoing cardiopulmonary bypass.Method Totally 36 patients,who underwent postcardiotomy undergoing cardiopulmonary bypass in Subei Hospital of Jiangsu Provience from March 2005 to June 2006,were retrospectively analyzed.The criteria for the selection of patients were as follow:(1)patients underwent on-pump cardiopulmonary bypass;(2)patients with heart function in Ⅰ-Ⅲ degree; (3)all patients didn't have organ dysfunction before operation;(4)patients died within 28 days postcardiotomy.Therefore,6 patients who died were admitted as death group,the other 30 patients were admitted as control group.The analysis included: (1)preoperative factors,including gender,age,diagnosis preoperative,NYHA grade,APACHEⅡscore,left ventricular end-diastolic diameter.(2)operative factors:operation time,block aorta time. (3)postoperation factors:hemorrhage volume,mechanical ventilation time,and factors of hemodynamics and oxygen metabolism 6 hour postoperative:heart rate(HR),central venous pressure(CVP),pulmonary arteria wedged pressure(PAWP),cardiac output index(CI),arterial blood lactic acid,partial pressure of oxygen(PaO2),mixed venous oxygen saturation(SvO2),oxygen delivery index(DO2I),oxygen comsume index(VO2I),oxygen extraction ratio (O2ext).Comparisons between two group was made with SPSSl0.0 for windows.Firstly,the data were analyzed with process of single variable analysis and Some parameters,which showed the significant difference,were sorted out from two groups.Then these parameters were put to the IDGISTIC regression analysis.Consequently,the independent risk factors of death of postcardiac surgery could be found.Results The single variable analysis showed that the parameters of APACHE Ⅱ score,left ventricular end-diastolic diameter,block aorta time,mechanical ventilation time,arterial blood lactic acid,SvO2 had significant difference betwen groups(P＜0.05).The LOGISTIC regression showed that left ventricular end-diastolic diameter and arterial blood lactic acid ale the two independent risk factors of death(P＜0.05).Conclusions Arterial lactatemia and left ventricular end-diastolic diameter can be used to predict the prognosis of postcardiotomy undergoing cardiopulmonary bypass.

Objective To evaluate the effects of prone position ventilation (PPV) combined with inhalation of NO on oxygenation of acute respiratory distress syndrome (ARDS) patients.Methods A total of 21 patients with ARDS composed of 15 male and 6 female aged ranging from 2 to 74 years with mean age of 39 ± 17.4 years were hospitalized from September 2008 through January 2011.After application of mechanical ventilation with optimal PEEP,patients still needed the high concentration oxygen inhalation (FiO2 ≥ 60％).They were randomly (random number) divided into three groups for controlled study.Patients of group A were given NO in addition to oxygen inhalation for 4 hours,patients of group B were put in prone position ventilation with oxygen inhalation for 2 hours,then they were returned to the supine position ventilation,and patients of group C were put into prone position ventilation with inhalation of oxygen plus NO for 2 hours,and then they were returned to the supine position ventilation,but they were continued to inhaled NO.The oxygenation indexes of three groups of patients were measured before the intervention,2 hours and 4 hours after the procedure of experiment.Results The oxygenation indexes of three groups of patients were improved in terms of comparison between pre-intervention and 2 hours after intervention,but there was no statistically significant difference found in group A (P ＞ 0.05),the differences in group B and group C were statistically significant (P ＜ 0.05).Compared the oxygen index between pre-intervention and 4 hours after intervention,the differences in group A and group B were not statistically significant (P ＞0.05),but the difference in group C was statistically significant (P ＜ 0.05).Conclusions PPV could improve oxygenation in acute respiratory distress syndrome (ARDS) patients.PPV with NO inhalation could improve oxygenation in acute respiratory distress syndrome (ARDS) patients as well as effectively maintain the oxygenation after patients were returned to the supine position ventilation.Therefore prone position ventilation combined with inhalation of NO improved oxygenation and at the same time reduced the prone position time.

OBJECTIVETo investigate the changes of plasma fibrinogen level among acute ischemic stroke (ACI) subtypes according to Trial of Org10172 in Acute Stroke Treatment (TOAST) criteria and effects of Songling Xuemaikang.

METHODThe 160 patients with acute ischemic stroke were divided into two groups randomly: treatment group 85 cases (Songling Xuemaikang + Shuxuetong + Aspirin enterie coated tablets), control group 75 cases (Shuxuetong + Aspirin enterie ccoated tablets). The plasma fibrinogen was detected before and after treatment.

RESULTCompared with OC subtype, Fbg was higher in LAA, CE and SAO subtypes (P < 0.05). Compared with UE subtype, Fbg was higher in LAA, CE and SAO subtypes (P < 0.05). There was a significantly difference between LAA and SAO (P < 0.05). In LAA, SAO, CE of treatment group,the Fbg level were lowered significantly at the 15th day compared with pretherapy (P < 0.05). There was a significantly difference of Fbg between treatment group and control group In LAA, SAO and CE subtypes at the 15th day (P < 0.05).

CONCLUSIONFbg produces a marked effect at the pathomechanism of LAA, SAO and CE subtypes. Songling Xuemaikang can depress the plasma fibrinogen level of ACI, and be an effective adjunctive therapy on ACI.

Aged ; Aged, 80 and over ; Aspirin ; therapeutic use ; Brain Ischemia ; drug therapy ; metabolism ; pathology ; Drugs, Chinese Herbal ; therapeutic use ; Female ; Fibrinogen ; metabolism ; Humans ; Male ; Middle Aged ; Stroke ; drug therapy ; metabolism ; pathology ; Treatment Outcome

Objective To explore the accuracy of fluid responsiveness assessment by variability of peripheral arterial peak velocity and variability of inferior vena cava diameter (ΔIVC) in patients with septic shock. Methods A prospective study was conducted. The patients with septic shock undergoing mechanical ventilation (MV) admitted to intensive care unit (ICU) of Beijing Electric Power Hospital from January 2016 to December 2017 were enrolled. According to sepsis bundles of septic shock, volume expansion (VE) was conducted. The increase in cardiac index (ΔCI) after VE ≥ 10% was defined as liquid reaction positive (responsive group), ΔCI < 10% was defined as the liquid reaction negative (non-responsive group). The hemodynamic parameters [central venous pressure (CVP), intrathoracic blood volume index (ITBVI), stroke volume variation (SVV), ΔIVC, variability of carotid Doppler peak velocity (ΔCDPV), and variability of brachial artery peak velocity (ΔVpeak-BA)] before and after VE were monitored. The correlations between the hemodynamic parameters and ΔCI were explored by Pearson correlation analysis. Receiver operating characteristic (ROC) curve was plotted to analyze the predictive value of all hemodynamic parameters on fluid responsiveness. Results During the study, 74 patients with septic shock were included, of whom 9 were excluded because of peripheral artery stenosis, recurrent arrhythmia or abdominal distension influencing the ultrasound examination, and 65 patients were finally enrolled in the analysis. There were 31 patients in the responsive group and 34 in the non-responsive group. SVV, ΔIVC, ΔCDPV and ΔVpeak-BA before VE in responsive group were significantly higher than those of the non-responsive group [SVV: (12.3±2.4)% vs. (9.2±2.1)%, ΔIVC: (22.3±5.3)% vs. (15.5±3.7)%, ΔCDPV: (15.3±3.3)% vs. (10.3±2.4)%, ΔVpeak-BA: (14.5±3.3)% vs. (9.6±2.3)%, all P < 0.05]. There was no significant difference in CVP [mmHg (1 mmHg = 0.133 kPa): 7.5±2.5 vs. 8.2±2.6] or ITBVI (mL/m2: 875.2±173.2 vs. 853.2±192.0) between the responsive group and non-responsive group (both P > 0.05). There was no significant difference in hemodynamic parameter after VE between the two groups. Correlation analysis showed that SVV, ΔIVC, ΔCDPV, and ΔVpeak-BA before VE showed significant linearity correlation with ΔCI (r value was 0.832, 0.813, 0.854, and 0.814, respectively, all P < 0.05), but no correlation was found between CVP and ΔCI (r = -0.342, P > 0.05) as well as ITBVI and ΔCI (r = -0.338, P > 0.05). ROC curve analysis showed that the area under ROC curve (AUC) of SVV, ΔIVC, ΔCDPV, and ΔVpeak-BA before VE for predicting fluid responsiveness was 0.857, 0.826, 0.906, and 0.866, respectively, which was significantly higher than that of CVP (AUC = 0.611) and ITBVI (AUC = 0.679). When the optimal cut-off value of SVV for predicting fluid responsiveness was 11.5%, the sensitivity was 70.4%, and the specificity was 94.7%. When the optimal cut-off value of ΔIVC was 20.5%, the sensitivity was 60.3%, and the specificity was 89.7%. When the optimal cut-off value of ΔCDPV was 13.0%, the sensitivity was 75.2%, and the specificity was 94.9%. When the optimal cut-off value of ΔVpeak-BA was 12.7%, the sensitivity was 64.8%, and the specificity was 89.7%. Conclusions Ultrasound assessment of ΔIVC, ΔCDPV, and ΔVpeak-BA could predict fluid responsiveness in patients with septic shock receiving mechanical ventilation. ΔCDPV had the highest predictive value among these parameters.