The main clinical research advances of critical care in 2023 includes: new trials of Chinese herbal medicine, hydroxocobalamin (vitamin B12), methylene blue as well glucocorticoids have shown the potential to improve outcomes of patients with sepsis and septic shock; international committees launched new global definition and managing recommendations for acute respiratory distress syndrome (ARDS). Besides, a cluster of new evidences has emerged in many aspects as following: fluid control strategy in sepsis (restrictive/liberative), antibiotic infusion strategy (continuous/intermittent), oxygen-saturation targets for mechanical ventilation (conservative/liberative), blood pressure targets after resuscitation from out-of-hospital cardiac arrest (hypotension/hypertension), blood pressure targets after successful stroke thrombectomy (intensive/conventional), and nutritional support strategies (low protein-calories/conventional protein-calories, fasting/persistent feeding before extubation). Thus, given above progress, carrying out high -quality domestic multi-center clinical registration researches, constructing shareable standardized databases, as well raising public awareness of sepsis, should be the essential steps to improve our level of intensive care medicine.

Objective To study the safety and efficacy of laparoscopic resection of hemangioma in the right posterior hepatic section without any blood flow occlusion.Methods Patients with hemangiomas in the right posterior section of liver operated from January 2016 to June 2018 in the Affiliated Hospital of Youjiang Medical College for Nationalities were studied retrospectively.There were 19 females and 9 males.The average age was (37.9 ± 6.1).The operation methods,perioperative factors,hospitalization cost and follow-up outcomes were recorded and analyzed.Results 28 patients with hemangiomas were treated with laparoscopic resection of right posterior hepatic section without any blood flow occlusion.An ultrasound scalpel was applied to split the liver in 27 patients,and ultrasound scalpel combined with Ligasure to split the liver in 1 patient.The mean diameter of the hepatic hemangiomas was (6.7 ± 1.3) cm.The intraoperative blood loss was (330.4 ± 139.0) ml and the operation time was (87.4 ±27.9) min.One patient required conversion to open surgery due to rupture and bleeding of the hemangioma.The conversion rate was 3.6％ (1/28).The postoperative drainage time was (45.4 ± 18.9) h.The postoperative hospitalization time was (7.5 ± 1.3) d,and the hospitalization cost was (3.1 ± 0.5) ten thousand yuan.No death or serious complications occurred.No reoperation was needed.The follow-up period ranged from 1 to 30 months,and all the patients were well on follow-up.Conclusions Laparoscopic resection of hemangioma in the right posterior hepatic section without any blood flow occlusion was safe and efficacious.This method can be used for hemangiomas in the right posterior section of liver.

Objective:To establish an air-pouch bladder cancer (APBCa) model and investigate whether it could be a new animal model to evaluate the efficacy of intravesical therapy through chemotherapeutics and BCG instillation.Methods:Filtered sterile air was injected subcutaneously into the backs of BALB/c Nude mice to create a 2.5 cm×3.5 cm air pouch. After 24 hours, human bladder cancer cells EJ were seeded on the inner face of the pouch wall to establish APBCa of human cancer (H-APBCa). Gemcitabine instillation was used to investigate whether chemotherapy could inhibit tumor growth in the H-APBCa model, and Tunel staining was used to verify the apoptosis of tumor cells 20-day treatment. Filtered sterile air was injected subcutaneously into the backs of C57BL/6 mice to create a 2.5 cm×3.5 cm air pouch. After 24 hours, mice bladder cancer cells MB49 were seeded on the inner face of the pouch wall to establish APBCa with intact immunity (I-APBCa). BCG instillation was used to investigate whether BCG could inhibit tumor growth in the APBCa model. Immunofluorescence was used to verify the infiltration of immune cells after 20-day treatment.Results:H-APBCa and I-APBCa mice models could be established by immune deficiency and intact mice. At day 20, chemotherapeutic instillation therapy could inhibit tumor growth (781.02±241.02 vs. 1213.88±214.02 mm 3, P<0.05) by inducing tumor cell apoptosis with statistically significant differences (77.33±4.63 vs. 14.67±2.60, P<0.05). BCG instillation was able to inhibit tumor growth (645.02±156.63 vs. 948.84±221.76, P<0.05) by increasing CD80 + macrophage (49.67±7.57 vs. 16.33±5.69, P<0.05) and T cells in the tumor with statistically significant differences (18.00±3.46 vs. 4.67±1.45, P<0.05). Conclusions:APBCa model could evaluate the efficacy of drug instillation and was expected to be a new animal model for studying drug for intravesical therapy.

Objective:To investigate the predictive value of serum hypersensitive C-reactive protein (hs-CRP) for stroke-associated pneumonia (SAP) in patients with acute ischemic stroke (AIS) who received intravenous thrombolysis.Methods:From May 2015 to April 2017, the clinical data of the patients with AIS treated with intravenous thrombolysis in Nanjing First Hospital were collected retrospectively. Multivariate logistic regression analysis was used to determine the independent risk factors for SAP in patients with AIS after intravenous thrombolysis. Receiver operating characteristic (ROC) curve and nomogram-based methods were used to analyze the predictive value of hs-CRP for SAP. Results:A total of 243 patients with AIS who received intravenous thrombolysis were included, and 63 (34.6%) of them had SAP. There were significant differences in age ( P=0.006), leukocyte count ( P=0.044), fasting blood glucose level ( P=0.003), serum hs-CRP level ( P=0.001), hs-CRP classification ( P=0.001) and dysphagia rate ( P=0.035) between the SAP group and non-SAP group. Multivariate logistic regression analysis showed that after adjusting for the confounding factors, taking the first quartile of serum hs-CRP level as a reference, the third quantile (odds ratio [ OR] 18.790, 95% confidence interval [ CI] 4.771-74.007; P=0.001) and the fourth quantile ( OR 54.054, 95% CI 12.248-324.088; P=0.001) of hs-CRP were the independent predictors of SAP. The area under the ROC curve of the baseline serum hs-CRP level for predicting SAP was 0.805 (95% CI 0.742-0.868; P<0.001). When the optimal cut-off value of hs-CRP was 5.54 mg/L, the sensitivity and specificity of predicting SAP were 76.11% and 76.19%, respectively. The analysis of nomogram also showed that hs-CRP was an independent predictor of SAP (consistency index 0.862, 95% CI 0.738-0.986; P<0.001). Conclusions:The increased serum hs-CRP was an independent predictor of SAP in patients with AIS receiving intravenous thrombolysis, and had a higher predictive value.

Objective:To study the feasibility and safety in treatment of trauma to right posterior liver using laparoscopic surgery with patients in the left semiprone position.Methods:The clinical data of consecutive patients who were diagnosed to have trauma to the right posterior liver and were treated with laparoscopic surgery with patients in the left semiprone position at the Department of Hepatobiliary Surgery, the Affiliated Hospital of Youjiang Medical University for Nationalities between February 2016 and August 2020 were retrospectively analysed. The patients’ gender, age, mechanisms of injury, operative methods, operative time, amounts of abdominal effusion, degrees of liver injury, extents of intraoperative bleeding, amounts of postoperative drainage, lengths of postoperative hospital stay, and major postoperative complications were recorded and analyzed.Results:Among the 18 patients, there were 16 males and 2 females, aged (41.6±14.4) years. The mechanisms of liver trauma were caused by fall injury ( n=10), traffic accidents ( n=4), blunt injury ( n=2) and penetrating injury ( n=2). The levels of injuries were level Ⅲ in 16 patients and level Ⅳ in 2 patients. Laparoscopic suture repair was performed in 8 patients, partial hepatectomy in 4 patients, electrocoagulation hemostasis in 4 patients and ligation of bleeding vessels in 2 patients. All were successful in hemostasis. Abdominal effusion was (1 528.8±373.2) ml, intraoperative blood loss (80.6±16.7) ml, operation time (88.5±9.1) min, postoperative hospital stay 7 days and postoperative total drainage (93.8±13.6) ml. Ten patients were complicated with right pleural effusion, and they recovered with conservative treatment. There were no bile leakage, infection and other complications. Conclusion:Trauma to right posterior liver treated with laparoscopic with surgery patients in the left semiprone position had the advantages of adequate exposure which facilitated surgical hemostasis, resulting in minimal collateral damages and short hospital stay. The treatment was feasibility and safe.

The progress of critical care medicine in 2021 is still encouraging. The new international guideline for management of sepsis and septic shock came out after 4 years. Besides, a couple of preferable clinical evidences were released including restrictive blood transfusion strategy for patients with acute myocardial infarction, prevention of peripheral venous catheter infection, heparin inhalation and driving pressure setting in patients with acute respiratory distress syndrome (ARDS), lower oxygenation target for acute hypoxemic respiratory failure, low level positive end-expiratory pressure in non-ARDS patients with respiratory failure, light sedation or non-sedation strategy, biological phenotypes, as well machine learning in sepsis and ARDS. However, we also encounter negative results such as balanced solution during fluid resuscitation, hypothermia therapy after out-of-hospital cardiac arrest or traumatic brain injury, adrenomedullin-specific antibody adrecizumab therapy and coupled plasma filtration-adsorption (CPFA) therapy for patients with septic shock, extracorporeal carbon dioxide removal (ECCO 2R) implementation in acute hypoxic respiratory failure, continuous infusion of hypertonic saline in patients with traumatic brain injury. Collectively, in the future, individualized diagnosis and management based on the principle of "wise choice" will become the daily practice scene for all intensivists.

Objective:To explore the technical focus of robotic-assisted laparoscopic surgery for the treatment of horseshoe kidney combined with renal tumor.Methods:The clinical data of a patient with horseshoe kidney combined with renal tumor treated by robot-assisted laparoscopic partial nephrectomy in the Second Hospital of Dalian Medical University in September 2021 were retrospectively analyzed. PubMed, CNKI, Wanfang and VIP databases were searched for all the literature on the use of robot-assisted laparoscopic nephrectomy or partial nephrectomy for the treatment of horseshoe kidney combined with renal tumor from the time of establishment to December 2022.Results:A total of 11 patients from 10 articles were retrieved and 12 patients were enrolled. Among the 12 patients, 4 cases used the retroperitoneal approach and 8 cases used the transperitoneal approach. Two cases were operated by traditional laparoscope, and the arteries were searched for and controlled before the robotic arm was placed to perform the partial nephrectomy and suture; and 10 cases were operated with the robotic-assisted laparoscopic approach throughout the whole procedure. Five cases of nephrectomy were performed on one side, and 7 cases were performed in the partial nephrectomy. Postoperative pathological diagnosis was clear cell carcinoma in 8 cases, chromophobe cell carcinoma in 1 case, eosinophilic cell carcinoma in 1 case, renal cell carcinoma in 1 case, and renal abscess in 1 case. The patient in the Second Hospital of Dalian Medical University was 38 years old female who was admitted to the hospital with a fever. After CT arteriography and three-dimensional reconstruction, robotic-assisted laparoscopic partial nephrectomy of right kidney and isthmus dissecting was performed. During the operation, tumor trophoblast vessels were ligated and dissected one by one by using single-use tissue closure clips, and the isthmus was dissected using endoscopic cutting anastomosis on the left side of the tumor, with the tumor edges sharply resected and completely dissected. The operation time was 240 min, without thermal ischemia time, and the bleeding volume was about 300 ml. The patient recovered well after the operation, and the postoperative pathological diagnosis was renal abscess.Conclusions:Robot-assisted laparoscopic treatment of horseshoe kidney combined with renal tumor is safe and effective, and has more advantages than traditional laparoscopic surgery. Preoperative CT arteriography or three-dimensional reconstruction examination should be applied to fully evaluate the variant vessels. The surgical access and plan should be decided according to the size and location of the tumor. The variant vessels should be properly handled during operation. The use of endoscopic cutting anastomosis to deal with the isthmus can be more conducive to the surgical operation.

ObjectiveTo systematically evaluate the incidence rate of low-level viremia （LLV） in chronic hepatitis B （CHB） patients and related influencing factors， and to provide evidence-based medicine evidence for effective intervention and prevention of LLV in clinical practice. MethodsThis study was conducted according to the PRISMA guideline， with a PROSPERO registration number of CRD42023455304. CNKI， Wanfang Data， VIP， SinoMed， PubMed， Embase， Web of Science， and the Cochrane library were searched for observational studies on LLV and related influencing factors in CHB patients published up to July 21， 2023. Stata 16.0 software was used to perform the meta-analysis. ResultsA total of 12 articles were included， with a total sample size of 3408 cases， among whom there were 1181 patients with LLV. The meta-analysis showed that the incidence rate of LLV was 32.8% （95% confidence interval ［CI］： 27.6%‍ ‍—‍ ‍38.3%） in treatment-experienced CHB patients. High HBsAg quantification （odds ratio ［OR］=2.107， 95%CI： 1.782‍ ‍—‍ ‍2.491， P<0.001）， positive HBeAg （OR=3.258， 95%CI： 2.629‍ ‍—‍ ‍4.038， P<0.001）， high HBV DNA level at baseline （OR=1.286， 95%CI： 1.157‍ ‍—‍ ‍1.430， P<0.001）， and history of entecavir treatment （OR=3.089， 95%CI： 1.880‍ ‍—‍ ‍5.074， P<0.001） were risk factors for LLV； duration of antiviral therapy ≥3 years （OR=0.175， 95%CI： 0.093‍ ‍—‍ ‍0.331， P<0.001） and high alanine aminotransferase level at baseline （OR=0.985， 95%CI： 0.978‍ ‍—‍ ‍0.992， P<0.001） were protective factors against LLV. The sensitivity analysis showed no significant change in effective value， suggesting that the results of the meta-analysis were relatively stable. The funnel plot of the studies included was basically symmetrical， and the results of the Egger’s test and the Begg’s test suggested that there was no obvious publication bias in the articles included. ConclusionClinicians should guide decision making based on the influencing factors for LLV and related clinical evidence， so as to reduce long-term clinical risks and avoid adverse outcomes.