Objective To explore the early predictors of patients with 2009 H1N1 pneumonia by analyzing the clinical features.Methods The 2009 H1 N1 pneumonia patients,admitted to our emergency intensive care unit (EICU) from October 2009 to January 2010,were retrospectively analyzed. The 86patients were divided into died and survival groups. The chi-square test and T test were used to examine the difference between groups.Results Of the 86 patients we studied,15 ( 17.4％ ) cases died and 12 cases received mechanical ventilation. All patients underwent chest radiography on admission and the findings were consistent with pneumonia in all cases.The median duration of symptoms before admission was 3.2 days.The first laboratory test results indicated the average total number of white blood cell (WBC) was (6358 ±483) /mm3.Of the 86 patients,47 (54.7％ ) showed a reduction in WBC.Of the 71 patients who survived,35 (49.3％) had leucopenia and12 (80％) in died group (x2 =4.71,P ＜ 0.05).In survival group,39 (54.9％) had lymphopenia and 13 (86.7％) in died group (x2 =5.22,P ＜0.05).Of 72 patients had T-lymphocyte subsets results,CD4 + T cell counts on average was (424.8 ±231.6 ) /mm3 in57 survival cases and (242.5 ±99.1) /mm3 in 15 died cases (t=2.14,P ＜ 0.05).On admission,serum creatine kinase (CK) in died group was (794.5 ± 85.1 ) U/L,higher than (632.3 ±47.9) U/L in survival group (t =2.25,P ＜ 0.05).Elevated CK was found in 14 (93.3％)of 15 died cases and 50 (70.4％) in survival group (x2 =5.87,P ＜ 0.05). Serum lactate dehydrogenase (LDH) in died group was (1028.6 ± 97.3) U/L,higher than (832.3 ± 56.1 ) U/L in survival group (t =2.31,P ＜ 0.05). According to the criterion of body mass index (BMI) ≥25 kg/m2,33 (38.4％) cases were obesity,in which 13 (86.7％ ) in died group and 20 (28.2％) in survival group ( x2 =17.92,P ＜ 0.01 ),The mortality was increasing along with the BMI was increasing ( r =0.37,P =0.048). Conclusions SOFA,MEDS,CURB-65 score used in emergency room as the risk stratification methods can not effectively predict the 2009 H1N1 pneumonia patients. Peripheral blood lymphocyte counts,serum creatine kinase and lactate dehydrogenase,body mass index in the early course may be factors associated with outcomes of 2009 H1N1 pneumonia patients.

Objective To study the prognostic value of initial arterial lactate level and to explore the relationship between early arterial lactate and the outcome of patients with acute paraquat poisoning by analyzing the clinical data of 235 cases.Methods A total of 235 patients with acute paraquat poisoning were admitted to the Emergency Intensive Care Unit (EICU) from January 2009 to June 2012.Demographics,clinical and laboratory findings were compared between the survivors and non-survivors.Receiver operating characteristic (ROC) curves were used to identify the optimal cut-off points for initial arterial lactate level.Results Totally 235 patients with average age of (33.6 ± 11.5) years old (ranging from 18 to 74),89 male and 146 female.The median estimated amount of 20％ paraquat ingested was 55 mL,(ranging from 10 to 280,IQR:27 mL,77 mL),the median length of time between paraquat ingestion and the arrival at the emergency department was 4.5 h (ranging from 0.5 to 10.5,IQR:2.3 h,6.8 h).The overall mortality rate was 74.0％ (174/235) during a 28 days follow-up period,only 61 of 235 patients survived.The initial arterial lactate level was higher in non-survivors than that in survivors (2.79 ± 0.76) mmol/L vs.(1.62 ± 0.48) mmol/L,P =0.028).Correlation analyses showed that the initial arterial lactate level was associated with increased risk of 28-day mortality (r =0.26,P =0.004),and as the initial lactate increased,the survival time of non-survivors shortened (F =3.246,P =0.037).Using the ROC curve analysis,the initial arterial lactate level had an area of 0.799 (95％ CI:0.745-0.866) and the cut-off point of concentration was 2.57 mmol/L for prediction of prognosis in patients with acute paraquat poisoning (sensitivity 85.2％,specificity 79.6％,the best Youden index was 0.648).The initial arterial lactate level was higher in patients died from circulatory failure rather than from respiratory failure (5.22 ± 1.46) mmol/L vs.(1.87 ± 0.62) mmol/L,P =0.042.And the survival time of patients died from circulatory failure was shorter than that from respiratory failure (4.1 ± 1.3) d vs.(11.6 ± 3.2)d,P =0.023.With the ROC curve analysis,the initial arterial lactate level had an area of 0.882 (95％ CI:0.805-0.941) and the cut-off point of concentration was 3.65 mmol/L for prediction of prognosis of patients died from circulatory failure (sensitivity 87.6％,specificity 82.5％,the best Youden index was 0.701).Conclusions The initial arterial lactate level may be one of early indicators of prognosis in patients with acute paraquat poisoning and it had high potential in predicting the outcome of patients died from circulatory failure.

Objective To investigate the clinical factors dominant in the efficacy of lung recruitment maneuver (RM) with high-level positive end-expiratory pressure (PEEP) under pressure control ventilation in patients with 2009 influenza A (H1N1)-associated acute respiratory distress syndrome (ARDS) by analyzing the clinical data of 24 patients treated with mechanical ventilation.Methods A retrospective study was carried out in a 16-bed capacity emergency intensive care unit (EICU) of the First Affiliated Hospital of China Medical University from October 2009 to January 2010.Twenty-four patients with influenza-associated ARDS were included.During pressure control ventilation,when SpO2 persisted lower than 88％ for more than 30 min,RM with high-level PEEP was initiated to normalize lung volume at 30 cmH2O for 60 s.The RM was responded as SpO2 increased more than 3％ within 15 min; otherwise,the increase below 3％ in SpO2 would be considered non-responded.Variations in respiratory mechanics,oxygen metabolism and hemodynamic parameters were measured before and after RM.Results Of 24 patients with influenza-associated ARDS,16 survived and 8 deceased.The median duration of mechanical ventilation (DMV) in EICU was 5.5 days (range from 3.5 to 12.0 days).During the entire study period,a total of 158 RMs with high-level PEEP were done,including 76 (48.1％) responded RMs (the responded group) and 82 (51.9％) non-responded RMs (the non-responded group).In survivor group,the ratio of effective RM was higher than in nonsurvivors group (66.2％ vs.33.3％,P ＜ 0.01).Compared with the data before RM,HR was increased (92.6 ± 11.8) vs.(73.0 ± 12.6),P =0.038 and MAP was decreased (66.1 ±9.3) mmHg vs.(73.9 ± 11.4) mmHg,P=0.049 during RM,and these difference were not statistically significant at 3 min after RM.The decrease in SpO2 after 134 procedures of RMs in 85.9％ patients,and the minimum value of SpO2 occurred at (2.1 ±0.6) min after RM.In the responded group,the maximum SpO2 were higher than that before RM by (6.9 ± 1.6) ％ occurred at (12.7 ±2.6) min after RM.Compared with the data before RM,SpO2 were increased (90.4 ± 4.4) ％ vs.(86.7 ± 7.6) ％,P =0.047) in responded group at 30 min after RM.The initial PEEP level in the responded group was lower than that of the non-responded group (8.6 ± 3.4) cmH2O vs.(11.3 ±4.2) cmH2O,P=0.028.The initial mean DMV in the responded group was also shorter than that in the non-responded group (4.1 ± 3.1) d vs.(5.8 ± 2.5) d,P =0.011.Furthermore,the initial dynamic lung-thorax compliance (Cdyn) was obviously higher in the responded group than that in the non-responded group (30.8 ±6.2) mL/cmH2O vs.(26.1 ±5.1) mL/cmH2O,P=0.038.Conclusion The lung RM with high-level PEEP may cause temporary hemodynamic changes and the initial PEEP level,DMV,and Cdyn may be potential factors influencing the efficacy of lung RM.

Objective To explore the right timing of mechanical ventilation in patients with bronchial asthma in emergency room.Methods A total of 67 patients with bronchial asthma undergoing mechanical ventilation were admitted into our Emergency Intensive Care Unit (EICU) from January 2010 to December 2012.According to PaCO2 before intubation,they were divided into 3 groups of low levels of PaCO2 [PaCO2 ≤35 mmHg (1 mmHg =0.133 kPa)] (n =19),normal PaCO2 (35 mmHg ＜ PaCO2 ＜ 45 mmHg) (n =21) and high PaCO2 (PaCO2 ≥ 45 mmHg) (n =27).Their clinical data were retrospectively analyzed.Results The in-hospital mortality of three groups were 5.3％ (1/19),9.5％ (2/21) and 14.8％ (4/27) and the difference was not statistically significant (x2 =1.16,P ＞ 0.05).However the average duration of mechanical ventilation of three groups were (5.6 ± 1.7),(8.3 ± 2.1) and (13.5 ±3.6) days and the difference was statistically significant (F =3.36,P =0.042).The average ICU treatment time was (7.4 ± 2.1),(11.5 ± 3.3) and (16.4 ± 3.5) days and the difference was statistically significant (F =3.23,P =0.047).PaCO2 levels before intubation was positively correlated with the duration of mechanical ventilation and the ICU treatment time (r2 =0.366,0.316,P =0.031,0.029).Conclusion The patients with bronchial asthma undergoing intubation in right time in emergency room will affect the duration of mechanical ventilation and ICU treatment time.

Objective To explore the clinic efficacy on early repeated hemoperfusion in patients with acute paraquat (PQ) poisoning by analyzing the clinical data of 168 patients.Methods A total of 168 patients with acute paraquat poisoning,admitted to our emergency intensive care unit (EICU) from January 2008 to February 2011 were retrospectively analyzed.The PQ poisoning patients were divided into HP group (n =81,group A) and non-HP group (n =87,group B).The early repeated HP was carried out for at least 2 times within 24 hours after poisoning.The chi-square test and t test were used to detect the difference in outcome between groups.Results There were 52 patients (64.2％) in group A died and 68 fatalities (78.2％) in group B (x2 =4.01,P =0.042).The first HP was carried out in patients of group A within (3.6 ± 3.3) h after poisoning,and the patients in the group A received HP for (2.9 ± 1.4) times.On the second day after poisoning,sequential organ failure assessment (SOFA) scores of 168 patients were higher than those at admission (P ＜ 0.05).SOFA scores of patients in the group A were higher than that in the group B on the third day and on the forth day (P ＜ 0.05).In the group B,alanine aminotransferase (ALT)＞ 80 U/L and total bilirubin (TBIL) ＞ 34.2 μmol/L occurred earlier than those in group A (P ＜ 0.05)and there were more patients with abnormal creatinine and arterial oxygen and those abnormalities occurred earlier than those in group A (P ＜0.05).The maximum value of ALT,TBIL,creatinine,amylase (AMS)and CK-MB in the group B were higher than those in group A (P ＜ 0.05),the lowest value of PaO2 (＜ 60mm Hg) in group B were lower than that in group A (P ＜ 0.05).Conclusions The early repeated HP can delay organ injury after acute paraquat poisoning and reduce the extent of injure,giving ample time to get advanced treatment measures to improve the prognosis of patients.

Objective To investigate the evaluation value of oxygenation index at different times of mechanical ventilation (MV) on the prognosis of patients with acute respiratory distress syndrome (ARDS).Methods A retrospectively analysis was conducted. A total of 228 patients with ARDS admitted to Department of Emergency of China Medical University Affiliated First Hospital from February 2014 to June 2016 were enrolled. All patients underwent MV treatment, and recruitment maneuver (RM) was performed by pressure-controlled ventilation (PCV) 30 minutes after the implementation of the protective ventilation strategy. Arterial blood gas analysis was performed at MV immediately, after RM and at 6, 12, 24 hours of MV, and oxygenation index was calculated. Vital signs, laboratory data, ultrasonic echocardiography, sequential organ failure assessment (SOFA) score, duration of MV, and ventilator related parameters of patients were collected. The patients were divided into survivors and non-survivors according to the prognosis of 28 days. The survivors were subdivided into high and low oxygenation group (oxygenation index was ≥ 150 mmHg and < 150 mmHg, respectively, 1 mmHg = 0.133 kPa). Differences in clinical indicators between survivors and non-survivors were compared. The correlation between the oxygenation index after RM and the oxygenation index at each time after MV was analyzed by bivariate correlation analysis. Receiver operating characteristic (ROC) curve was plotted to analyze predictive value of oxygenation index measured at different times for the 28-day outcome of patients with ARDS.Results Among 228 patients, 99 patients died within 28 days, and 129 survived, with mortality rate of 43.4%. ① The oxygenation index after RM and at 6, 12, 24 hours after MV in survivors and non-survivors showed a continuously increased tendency, which was significantly lower in non-survivors than that in survivors (allP < 0.05). There was no significant difference in the duration of MV between high oxygenation group and low oxygenation group at MV immediately and after RM, but the duration of MV in high oxygenation group was significantly shorter than that of the low oxygenation group at 6, 12, 24 hour of MV (allP < 0.01). ② After ventilation for 24 hours, serum creatinine (SCr), brain natriuretic peptide (BNP), lactate (Lac), right ventricular internal diameter, and SOFA score in non-survivors were significantly higher than those of survivors, and arterial partial pressure of oxygen (PaO2), platelet (PLT) and right ventricular ejection fraction (RVEF) were significantly lower than those of survivors (allP < 0.05). ③ After 24 hours ventilation, positive end-expiratory pressure (PEEP), tidal volume (VT), and minute ventilation (VE) in non-survivors were significantly higher than those of survivors, and static compliance of thorax (Cdyn) was significantly lower than that of survivors (allP < 0.01). ④ It was shown by correlation analysis that the oxygenation index after RM was positively correlated with those at 6, 12, 24 hours of MV (r values were 0.856, 0.765, and 0.758, respectively, allP < 0.001). ⑤ It was shown by ROC curve that the area under the ROC curve (AUC) of the oxygenation index after RM for predicting 28-day prognosis was 0.688. When the cut-off value was 80.75 mmHg, the sensitivity was 97.7%, and the specificity was 42.4%, which could only be used for preliminary judgment of prognosis. The AUC of oxygenation index at 6, 12,24 hours of MV for 28-day survival of ARDS patients were 0.719, 0.727, 0.754, respectively. When the cut-off values were 171.50, 192.14, and 161.75 mmHg, the sensitivity was 69.8%, 67.4%, 86.0%, and the specificity was 78.8%, 78.8%, and 63.6%, respectively. It indicated that the predictive value was higher, and no significant difference was found among the oxygenation index at different time points.Conclusions The oxygenation index after the early stage of RM can preliminarily determine the prognosis of patients. The predictive value of oxygenation index after MV for 28-day survival of ARDS patients was higher, so the oxygenation index measured at 6 hours of MV may be considered to evaluate the prognosis of patients with ARDS.

Objective To investigate risk factors for postoperative delirium in elderly patients with hip fractures and determine whether the delirium can influence the outcome of hip fracture.Method A retrospective case control study was performed for 521 patients (≥60 years) with hip fractures treated surgically from January 2012 to December 2014.There were 170 males and 351 females, with the age of (79.3±8.3)years.Confusion assessment method (CAM) was applied to diagnose delirium after surgery, and the subjects were divided into delirium group (n=159) and control group (n=362) according to the presence of delirium.Univariate and multivariate analyses were performed to identify the riks factors for postoperative delirium, including age, gender, comorbidities, body mass index, American Society of Anesthesiologists (ASA) classification, type of fracture, haemoglobin, PaO2, albumen, type of anesthesia, type of anesthesia, amount of bleeding, time between admission to surgery, length of operation, type of operation and amount of blood transfusion.Perioperative complications and mortality within 1 year after operation were compared between the two groups.Results Univariate analysis revealed dementia, ASA classification, haemoglobin, PaO2, albumen, interval between admission to surgery, anesthesia method, operation time, and surgery methods were risk factors for postoperative delirium incidence (P<0.05).While multivariate analysis showed only dementia (OR=6.211, 95%CI 2.482-23.498), long interval between admission to surgery (OR=3.505, 95%CI 1.478-6.342), arthroplasty (OR=2.015, 95%CI 1.783-3.481), and PaO2≤60 mmHg (OR=2.766,95%CI 1.783-5.039) were the significant risk factors for postoperative delirium after hip surgery in the elderly.Incidences of lung infection, wound infection, cardiovascular events, cerebrovascular events and deep venous thrombosis in delirium group were higher than those in control group, but only incidences of lung infection and wound infection reached significant differences (P<0.05).Mortality in delirium group was higher than that in control group within 1 year after operation, but there was significant difference only within 3 months after operation (P<0.05).Conclusions Incidence of delirium is high after hip fracture surgery in the elderly.Dementia, long interval between admission to surgery, arthroplasty and PaO2≤60 mmHg are significant risk factors for postoperative delirium incidence, and the delirium patients are associated with high early mortality.

Delirium is a common complication after elderly hip fracture, and is associated with high rates of mortality and morbidity. There is no enough attention for delirium compared to deep vein thrombosis, pulmonary embolism, heart failure, etc. This paper reviews the definition, diagnosis, incidence, prognosis, treatment and other aspects of delirium in order to better under?stand delirium clinically. Delirium is an acute mental disorder of consciousness, attention, perception, thinking ability, memory, mental activity, and emotion. It is characterized by the disorder of sleep or wakefulness, and these changes are difficult to explain by dementia. The confusion assessment method (confusion assessment method, CAM) is generally accepted as the current diagnos?tic tools for delirium, and mainly depends on the patient's consciousness and cognitive function. The mechanisms of delirium are unclear, and it is influenced by many factors, such as agedness, cognitive impairment, pain, sleep rhythm disorders, and theories mainly include neurotransmitter theory, the central inflammatory response theory, the theory of stress response, sleep wake cycle, et al. The delirium is difficult to explain by using single, liner factor, but is elaborated by many various factors. However, the influ?ences of delirium on outcome for hip fracture are unclear, and it is definite that these patients have poor functional recovery, poor independent living ability, longer time in bed, demand for more care. The prevention should be implemented as mainly measures for delirium. Elimination of risk factors, including correct hypoxia, reduce pain, avoid water electrolyte disorders, improve sleep rhythm, and avoid using of opioids should be tried. In addition, adequate analgesia and appropriate anesthesia should used, and some inappropriate drugs should be avoided. Multidisciplinary cooperation mode, including doctors from orthopedics, anesthesiolo?gy, and geriatric department should be conducted to reduce the incidence of delirium as far as possible. Once diagnosed, some measures should be applied, such as maintaining of airway patency, adequate nutritional support, correction of water and electro?lyte disorders, anemia and low serum albumin, to ensure adequate physical and mental support, and to create a good environment for the ward, as well as to remove the possible etiological factors, such as anemia, low protein acidosis and electrolyte disturbance.

Objective To investigate the role of interleukin-17A (IL-17A) in acute paraquat (PQ)-induced lung injury in mice.Methods A total of 120 healthy SPF grade ICR male mice were randomly (random number) divided into three groups (n =40 in each):normal saline control group (NS),PQ poisoning group (PQ) and antibody neutralization group (PQ + Ab).Mice of PQ group and PQ + Ab group were given 5 mg/mL PQ by one gavage in a dosage of 25 mg/kg body weight,and 5 μg IL-17A neutralizing antibody intra-peritoneally administered immediately after PQ poisoning in PQ + Ab group;Equivalent volume of normal saline instead of PQ was given to mice of NS group.Six survival mice from each group were taken for experiment at 8 h,1 d,3 d,5 d,7 d after PQ poisoning:Wet to dry ratio (W/D) of lung was determined in mice of each group.HE staining of lung tissue was used to observe the histopathological changes under the light microscope and the pathological scores were graded;Serum interleukin-17A (IL-17A),interleukin-22 (IL-22),interleukin-6 (IL-6),transforming growth factor-β (TGF-β) were detected with enzyme linked immunosorbent assay (ELISA);Expression of interleukin-23 receptor (IL-23R) in lung tissue was determined with immunohistochemical;real-time fluorescence quantification PCR (qRT-PCR) was used to detect the expression of retinoic acid related solitary nuclear receptors' mRNA in lung tissue.Results After administration of PQ,W/D ratio increased (P ＜ 0.01),lung injury was observed in mice of PQ and PQ + Ab groups,levels of cytokines (IL-17A,IL-22,IL-6 and TGF-β) in serum elevated (P ＜0.05),and the expressions of IL-23R mRNA and RORγt mRNA increased (P＜0.01).But in PQ +Ab group,W/D ratio decreased (P ＜0.05),lung injury was alleviated,the levels of cytokines (IL-17A,IL-22,IL-6 and TGF-β) decreased (P ＜ 0.05),and the expressions of IL-23R mRNA and RORγt mRNA reduced (P ＜ 0.05).Conclusions Since IL-17A involves in the lung injury of the mice induced by acute paraquat poisoning,blockade of IL-17A significantly alleviates the acute lung injury in mice.

Objective To explore the influence of the length of time elapsed from ingestion of paraquat to hemoperfusion on prognosis in patients with acute paraquat poisoning.Methods The investigation was carried out with retrospective analysis.A total of 303 patients with acute paraquat poisoning were admitted to the Emergency Intensive Care Unit (EICU) of the First Affiliated Hospital of China Medical University from January 2009 to December 2012.According to the length of time between ingestion and hemoperfusion,patients were divided into three groups,Group A:the time interval between ingestion and hemoperfusion ＜ 4 h ; Group B:4h ≤ the time interval between ingestion and hemoperfusion ＜ 8 h; Group C:8 h≤the time interval between ingestion and hemoperfusion ＜ 12 h.Compared the extent of target organ injury,28-d mortality and the survival time of non-survivors among three groups for determining the influence of the length of time elapsed from ingestion to hemoperfusion on the prognosis of patients.Results Totally 303 patients with average age of 34.8 ± 10.8 years old (ranging from 15 to 72 years),and 117 male and 186 female.The median estimated amount of 20％ paraquat ingested was 50 mL (ranging from 10 to 270 mL,IQR:45 mL).The hemoperfusion was employed (3.6 ±1.2) times (ranging from 2 to 5 times) for every paitient within 24 h after ingestion.The overall mortality rate was 68.6％ (208/304)during a 28 days follow-up period,and only 95 of 303 patients survived.The median length of time between paraquat ingestion and hemoperfusion at the emergency department was 6.6 h (ranging from 1.4 to 11.5 h,IQR:3.5 h).However,it was 7.2 h (ranging from 3.1 to 11.5 h,IQR:2.4 h) in non-survivors and 4.9 h (ranging from 1.4 to 7.6 h,IQR:1.5 h) in survivors.The difference was statistically significant (U =2.014,P =0.043).The difference in 28-day mortality among three groups was statistically significant (x2 =9.27,P =0.009),and the difference in average survival time of non-survivors among three groups was statistically significant (F =3.31,P =0.038).The length of time between ingestion and hemoperfusion and the survival time of non-survivors was a negative correlation (r2 =0.421,P =0.045).The difference in ALTmax,SCrmax,AMYmax and PaO2 min,as the severity indicators of acute liver injury,acute kidney injury,acute pancreas injury and acute lung injury among the three groups were statistically significant (all P ＜ 0.05).Conclusions Employment of hemoperfusion within 4 h after ingestion can attenuate the degree of target organ injury,reducing 28 day mortality of patients with acute paraquat poisoning.