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Value of glucocorticoid steroids in the treatment of patients with severe community-acquired pneumonia complicated with septic shock

Gang LI ; Chengdong GU ; Suqiao ZHANG ; Rui LIAN ; Guoqiang ZHANG

Chinese Critical Care Medicine.2016;28(9):780-784. doi:10.3760/cma.j.issn.2095-4352.2016.09.003

Objective To discuss the value of glucocorticoid steroids (GCs) in the treatment of patients with severe community-acquired pneumonia (SCAP) complicated with septic shock.Methods A prospectively controlled randomized trial was conducted.Fifty-eight SCAP patients complicated with septic shock admitted to emergency intensive care unit (ICU) of China-Japan Friendship Hospital from May 2014 to February 2016 were enrolled.The patients were randomly divided into conventional treatment group (n =29) and GCs group (n =29).Fluid resuscitation,vasopressors,mechanical ventilation if needed,antibiotics and other general treatment including symptomatic treatment and eliminating phlegm were given to patients in both groups.Beside the treatment mentioned above,80 mg methylprednisolone once a day for 7 days was added to patients in GCs group.The changes in oxygenation index (PaO2/FiO2) and C-reactive protein (CRP) at 1,4,8 days after treatment as well as the imaging improvement in both groups were observed.Discharge or death was set as a cut-off point,the average time of temperature controlling,duration of mechanical ventilation,time of vasopressors usage and 28-day mortality were observed.The incidence of hyperglycemia,infection and hemorrhage of digestive tract were observed.Results There were no statistically differences in gender,age and body mass between the two groups,indicating that baseline data for the two groups were balanced.PaO2/FiO2 after treatment in the two groups was gradually increased,and it was significantly higher at 8 days after treatment in GCs group than that of conventional treatment group [mmHg (1 mmHg =0.133 kPa):426.46 ± 86.97 vs.363.00 ± 83.96,P ＜ 0.05].CRP after treatment in the two groups was gradually decreased,and it was significantly lower at 4 days and 8 days after treatment in GCs group than that of conventional treatment group (mg/L:95.78 ± 47.38 vs.124.72 ± 51.01,57.60 ± 47.44 vs.88.85 ± 48.18,both P ＜ 0.05).Radiographic imaging improved rate at 4 days and 8 days after treatment in GCs group was significantly higher than that of conventional treatment group (55.2％ vs.27.6％,75.9％ vs.51.7％,both P ＜ 0.05),and average time of temperature controlling (days:3.94 ± 2.39 vs.7.22 ± 3.11),time of vasopressors usage (hours:13.64 ± 6.47 vs.28.34 ± 12.56),and the average hospitalization days (days:28.50 ± 8.61 vs.36.21 ± 15.26)in GCs group were significantly shorter than those of conventional treatment group (all P ＜ 0.01).There was no significant difference in duration of mechanical ventilation between GCs group and conventional treatment group (days:13.39 ± 2.62 vs.16.16 ± 5.85,P ＞ 0.05).28-day mortality of the two groups was 10.3％ equally (P ＞ 0.05).No significant differences in the incidences of hyperglycemia (10.3％ vs.6.9％),infection (51.7％ vs.55.2％) and gastrointestinal bleeding (3.4％ vs.0) were found between GCs group and conventional treatment group (all P ＞ 0.05),indicating that glucocorticoid steroids could not increase the common side effects.Conclusion GCs is an important adjuvant treatment of patients with SCAP complicated with septic shock.

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Diagnosis and prognosis evaluation value of neutrophil elastase in ventilator-associated pneumonia

Tianshu LIANG ; Minzhi WU ; Jiayu TAN ; Zhixiong WU ; Bo YANG ; Chunlei YUAN

Chinese Critical Care Medicine.2016;28(9):785-789. doi:10.3760/cma.j.issn.2095-4352.2016.09.004

Objective To investigate the diagnosis and prognosis evaluation value of neutrophil elastase (NE) in ventilator-associated pneumonia (VAP).Methods A retrospective analysis was conducted.The data of patients undergoing mechanical ventilation admitted to Department of Central Intensive Care Unit (ICU) of Boai Hospital of Zhongshan City Affiliated to Southern Medical University from September 2012 to October 2015 were enrolled.The patients were divided into two groups according to whether they suffered from VAP or not.The content of NE in serum and bronchoalveolar lavage fluid (BALF) at the time of mechanical ventilation start,VAP diagnosis (the worst value from 48 hours after mechanical ventilation start to weaning in non-VAP patients),and at the time before mechanical ventilation weaning,as well as inflammation parameters,clinical pulmonary infection score (CPIS),duration of mechanical ventilation and prognosis were recorded.Receiver operating characteristic curve (ROC) was used to analyze the predictive value of NE on VAP diagnosis and prognosis.Results Finally 38 patients were enrolled in the VAP group,and 40 in non-VAP group,and baseline data was similar between the two groups.There was no significant difference in the content of NE in serum and BALF between VAP group and non-VAP group [serum NE (μg/L):67.04 (63.00,75.75) vs.69.00 (63.75,75.00),BALF NE (μg/L):96.26 (85.26,176.01) vs.95.26 (86.76,107.11),both P ＞ 0.05].From continuous monitoring,no significant change in the content of NE in serum and BALF during mechanical ventilation was found in the non-VAP group,but the content of NE in serum and BALF at the time of VAP diagnosis in VAP group was significantly higher than that at mechanical ventilation start [μg/L:157.00 (153.04,165.75) vs.67.04 (63.00,75.75),178.04 (153.00,188.25) vs.96.26 (85.26,176.01),both P ＜ 0.05],and NE content in serum and BALF was significantly decreased at the time after VAP clinical recovery and before mechanical ventilation weaning [μg/L:75.67 (64.51,110.55) vs.157.00 (153.04,165.79),95.50 (66.56,183.02) vs.178.04 (153.00,188.25),both P ＜ 0.05].The NE in the start time of VAP in VAP group was divided into four groups according to quartile,it was found that with the increase of NE content in serum and BALF,the CPIS was increased,the duration of mechanical ventilation was prolonged,and the prognosis was poor (all P ＜ 0.01).Compared with non-VAP group,white blood cell count (WBC),neutrocyte proportion,C-reactive protein (CRP),and procalcitonin (PCT) in VAP group were significantly increased (all P ＜ 0.01).NE in BALF was significantly positively correlated with WBC,neutrocyte proportion,CRP and PCT (r value was 0.507,0.432,0.779,and 0.519,respectively,all P =0.000),among which the highest correlation was CRP.NE in BALF used for VAP diagnosis has good accuracy,with sensitivity of 87.4％,and specificity of 90.6％,and sensitivity and specificity of NE in serum for VAP diagnosis was 78.6％ and 79.2％ respectively.Conclusion NE can be used as one of the indicators for VAP diagnosis,and it is related to the prognosis of VAP.

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Correlation of contact system activation with occurrence of thrombotic events in patients with systemic lupus erythematosus

Xiuchan LIU ; Zhi WANG ; Renxiao BAI

Chinese Critical Care Medicine.2016;28(9):834-838. doi:10.3760/cma.j.issn.2095-4352.2016.09.013

Objective To explore the role of contact system activation in the mechanism of systemic lupus erythematosus (SLE) patients with thrombotic events.Methods A simple sample drawing study was conducted.Sixty-nine patients with SLE admitted to Department of Rheumatism in Tianjin Hospital from June 2014 to February 2016 were enrolled.The patients were divided into simple SLE group (n =38) and SLE + vascular diseases (VD) group (n =31) according to whether the patients complicated with VD or not.The VD patients were subdivided into three subgroups including SLE complicated with myocardial infarction (SLE + MI,n =10),SLE complicated with deep vein thrombosis (SLE + DVT,n =13),and SLE complicated with arterial thrombosis (SLE + AT,n =8).Sixty-eight healthy age and gender-matched volunteers without history of VD were served as controls.Enzyme-linked immunosorbent assay (ELISA) was used to detect the content of FⅫa-C1 inhibitor (FⅫa-C1INH) and FⅫa-antithrombin (FⅫa-AT) in plasma.Flow cytometry was used to analyze the contents of platelets associated factors.The correlation between platelet associated factor and FⅫA-C1INH and FⅫa-AT was analyzed by Spearman correlation analysis.Receiver operating characteristic curve (ROC) was plotted to analyze the predictive value of FⅫA-C1INH and FⅫa-AT for SLE thrombotic events.Results Compared with health control group,the expression of FⅫa-C1INH in plasma in SLE group was significantly decreased [nmol/L:0.00 (0.00,0.07) vs.0.08 (0.03,0.13),P ＜ 0.01],the expression of FⅫa-AT was significantly up-regulated [nmol/L:0.18 (0.07,0.38) vs.0.16 (0.12,0.26),P ＜ 0.05].Compared with the simple SLE group,the expression of FⅫa-C1INH in SLE + DVT and SLE + AT groups was significantly decreased [nmol/L:0.03 (0.02,0.07),0.02 (0.01,0.04) vs.0.07 (0.02,0.11),both P ＜ 0.05],and the expression of FⅫa-AT in plasma in SLE + AT group was significantly increased [nmol/L:0.34 (0.21,0.53) vs.0.17 (0.06,0.30),P ＜ 0.01].It was shown by correlation analysis that FⅫa-C1INH was negatively related with FⅫa-AT in patients with SLE (r =-0.24,P =0.041 6).Activated platelet associated factors such as the production of interferon mediated by transmembrane protein 1 (IFTMI1) and interferon induced by double stranded RNA dependent activation agent (PRKRA) were positively related with up-regulation of FⅫa-AT and down-regulation of FⅫa-C1INH (IFITM1 and FⅫa-AT:r =0.39,P =0.001 2;IFITM1 and FⅫa-C1INH:r =-0.30,P =0.0146;PRKRA and FⅫa-AT:r =0.29,P =0.017 6;PRKRA and FⅫa-C1INH:r =-0.36,P =0.0029).The thrombospondin-1 (TSP-1) and platelet P-selectin were positively related with up-regulation of FⅫa-AT (r1 =0.72,P1 ＜ 0.0001;r2 =0.34,P2 =0.003 8).It was shown by ROC curve analysis that the area under the ROC curve (AUC) for FⅫa-C1INH on evaluating the risk of SLE thrombotic events was 0.998,the sensitivity was 100％,and specificity was 97.4％ when cut-off ＜ 0.01 nmol/L;AUC for FⅫa-AT for evaluating the risk of SLE thrombotic events was 0.954,the sensitivity was 95.0％,and specificity was 84.2％ when cut-off ＞ 0.40 nmol/L;predicted probability of two markers for predicting diagnosis was 0.5,the sensitivity and specificity were both 100％.Conclusions Contact system is activated in patients with SLE.FⅫA-C1INH and FⅫa-AT levels are closely related with platelet associated factors IFITM1 and PRKRA.FⅫA-C1INH and FⅫa-AT can be served as a promising potential biomarker for evaluation of the risk of thrombotic events in SLE.

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Safety evaluation of dexmedetomidine sedation in ICU patients undergoing mechanical ventilation

Mingquan YANG ; Jie ZHOU ; Jianwei CAO ; Yonghong ZENG ; Gang ZHENG

Chinese Critical Care Medicine.2016;28(9):839-844. doi:10.3760/cma.j.issn.2095-4352.2016.09.014

Objective To observe the occurrence of cardiovascular adverse events in patients undergoing mechanical ventilation with dexmedetomidine sedation,and to evaluate its safety in intensive care unit (ICU).Methods A prospective randomized controlled trial was conducted.Adult critical patients undergoing mechanical ventilation over 48 hours admitted to ICU of Zigong First People's Hospital in Sichuan Province were enrolled.The patients were divided into dexmedetomidine group (Dex group) and midazolam group (Mid group) according to the randomise number generated by computer.The patients in both groups were given slow intravenous infusion of 0.05 mg/kg midazolam and 1-2 μg/kg fentanyl to induce anesthesia before tracheal intubation,followed by 0.06 mg· kg-1· h-1 midazolam and 20-50 μg· kg-1 · h-1 fentanyl or 0.1-0.2 μg· kg-1 · h-1 sufentanil for continuous intravenous pumping to maintain analgesia and sedation;on the next day,the patients in Dex group was given dexmedetomidine (with the initial dose of 0.4 μg· kg-1 · h-1,and maintenance dose of 0.1-0.7 μg· kg-1 · h-1),and midazolam was stopped half an hour later;the original sedation and analgesia plan remained unchanged in Mid group.The goal of sedation was to maintain a Richmond agitation-sedation scale (RASS) score of-2 to 1 or a Ramsay sedation score of 3 to 4;patients were given midazolam if obvious agitation occurred,in combination with propofol for sedation if necessary;wakeup test was performed every day.Observation endpoints included patients discharged from ICU,death or mechanical ventilation over 28 days.Occurrence of cardiovascular adverse events during sedation such as hypertension,hypotension,bradycardia,tachycardia and arrhythmia,dose of sedatives and analgesics,duration of mechanical ventilation,length of ICU stay and 28-day mortality were observed in two groups.Results A total of 383 patients were enrolled,with 190 patients in Dex group and 193 in Mid group.There was no statistically significant difference in general data such as gender,age,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and predicted mortality between two groups.Doses of midazolam,propofol and fentanyl in Dex group were reduced as compared with those of Mid group,while the dose of sufentanil was similar in two groups.The Ramsay score and RASS score of Dex group were significantly reduced as compared with those of Mid group (3.34± 0.63 vs.3.95 ± 0.86,-1.33 ±0.87 vs.-1.98 ± 1.27,both P ＜ 0.01).Bradycardia was prominent in Dex group,which was observed in more than half of patients at the beginning of the treatment (1-2 hours),but the patients requiring isoprenaline treatment for heart rate lower than 50 bpm were less than that of Mid group (3.7％ vs.5.2％,x 2 =0.506,P =0.477).The incidences of hypotension (45.3％ vs.68.4％),tachycardia (16.3％ vs.33.7％) and arrhythmia (14.7％ vs.31.1％) in Dex group were significantly lower than those of Mid group (all P ＜ 0.01),and no other cardiovascular adverse events such as cardiac arrest,sinus arrest,hyperglycemia or hypoglycemia were observed in two groups.There was no statistically significant difference in duration of mechanical ventilation between Dex group and Mid group [days:5 (2,28) vs.4 (2,56),Z =-1.917,P =0.055],but compared with Mid group,the length of ICU stay in Dex group was significantly prolonged [days:9 (2,67) vs.6 (2,57),Z =-4.302,P =0.000],and the 28-day mortality in Dex group was significantly reduced (22.6％ vs.44.6％,x2 =20.610,P =0.000).Conclusion Long time dexmedetomidine sedation is safe in critical patients undergoing mechanical ventilation,which can significantly reduce cardiovascular adverse events except bradycardia,and lower the 28-day mortality.

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Effects of long-term use of simvastatin on ventilator-induced lung injury

Haigang SONG ; Wen HUO ; Wenjing ZHAO

Chinese Critical Care Medicine.2016;28(9):845-848. doi:10.3760/cma.j.issn.2095-4352.2016.09.015

Objective To study the effects of long-term use of simvastatin on mechanical ventilation induced lung injury.Methods Forty SPF adult male Sprague-Dawley (SD) rats weighing 300-350 g were randomly divided into four groups (n =10,each):normal saline (NS) control group (group A),mechanical ventilation group (group B),simvastatin control group (group C),and simvastatin + mechanical ventilation group (group D).The rats in groups C and D were treated with simvastatin dissolved in 1 mL NS by gavage with a dose of 10 mg/kg,and the rats in groups A and B were treated with the same volume of NS by gavage for 28 days.Half an hour after the last garage,the rats in groups B and D underwent tracheostomy and intubation for 4 hours,and then received a tidal volume of 30 mL/kg with the respiratory frequency of 40 times/min,inspiratory:expiratory ratio of 1:3,and the rats in groups A and C received tracheostomy and intubation,spontaneous breathing for 4 hours.Four hours later rats were sacrificed by abdominal aorta bloodletting,and the lung tissue was harvested for hematoxylin and eosin (HE) staining to observe pathological changes under light microscope.The activity of malondialdehyde (MDA),superoxide dismutase (SOD),and myeloperoxidase (MPO) was determined.The lung wet/dry weight ratio (W/D) and white blood cell (WBC) count in bronchoalveolar lavage fluid (BALF) were determined.The levels of interleukins-6 (IL-6) and tumor necrosis factor-α (TNF-α) in BALF were determined by enzyme linked immunosorbent assay (ELISA).Results Under light microscope,the structure of lung tissue was integrity in groups A and C without obvious edema and inflammatory cells aggregation;the pathological changes in lung tissue in group B was obvious;and the alveolar structure was clear in group D,pulmonary edema and inflammatory cells aggregation were significantly reduced as compared with those of group B.Compared with group A,SOD activity in group B was significantly decreased (U/g:17.97±2.27 vs.28.51 ±4.58,P ＜ 0.01),while MDA,MPO,lung W/D ratio and WBC,IL-6,TNF-α in BALF were significantly increased [MDA (μmol/g):5.40 ± 0.71 vs.3.56 ± 0.55,MPO (U/g):1.26±0.29 vs.0.68±0.12,lung W/D ratio:6.60±0.99 vs.4.84±0.26,WBC (× 109/L):6.59±0.82 vs.2.35±1.31,IL-6 (ng/L):207.11± 18.67 vs.123.17±20.15,TNF-o (ng/L):421.38±36.27 vs.207.15±44.39,all P ＜ 0.01].Compared with group B,SOD activity in group D was significantly increased (U/g:22.05±2.45 vs.17.97±2.27,P ＜ 0.05),MDA,MPO,lung W/D ratio,and WBC,IL-6,TNF-α in BALF were significantly decreased [MDA (μmol/g):3.77±0.55 vs.5.40±0.71,MPO (U/g):0.96±0.14 vs.1.26±0.29,lung W/D ratio:5.16±0.42 vs.6.60±0.99,WBC (× 109/L):3.18± 1.24 vs.6.59±0.82,IL-6 (ng/L):147.90±21.70 vs.207.11 ± 18.67,TNF-α (ng/L):237.16±50.83vs.421.38 ± 36.27,all P ＜ 0.01].There were no significant difference in all parameters between group C and group A.Conclusion The long-term simvastatin treatment could significantly reduce lung injury induced by mechanical ventilation in rats,and its mechanism was related with simvastatin reduced oxidation-antioxidant imbalance and the inflammatory cytokines activity changes.

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New progress of pathogenesis in ventilator-induced lung injury

Yiyi YANG ; Shanglong YAO ; You SHANG

Chinese Critical Care Medicine.2016;28(9):861-864. doi:10.3760/cma.j.issn.2095-4352.2016.09.020

Mechanical ventilation is not only an important treatment method of acute respiratory distress syndrome (ARDS),but also one of the basic treatments in the intensive care unit (ICU).However,mechanical ventilation itself can cause or aggravate acute lung injury,which is called ventilator-induced lung injury (VILI).Currently,clinical pathogenesis of VILI includes four categories such as barotrauma,volutrauma,atelectrauma and hiotrauma.The pathogenesis of mechanical injury has been widely accepted,but the biological injury pathogenesis is unclear.With further research,we found that in the late stage VILI patients occured proliferation of puhnonary fibrosis,which may be formed by partial epithelial-mesenchymal transdifferentiation (EMT).Further study of specific pathogenesis of biotrauma and ARDS pulmonary fibrosis proliferation could provide new ideas for the clinical treatment of VILI.

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D-dimer can reflect severity of patients with community-acquired pneumonia and predict prognosis

Jie ZHANG ; Lixin XIE ; Liangdi XIE

Chinese Critical Care Medicine.2016;28(9):769-774. doi:10.3760/cma.j.issn.2095-4352.2016.09.001

Objective To investigate the utility of plasma D-dimer and fibrinogen (FIB) for the severity assessments and predicting the prognosis of patients with community-acquired pneumonia (CAP).Methods The clinical data of patients with CAP admitted to First Affiliated Hospital of Fujian Medical University were retrospectively analyzed.The patients were divided into Ⅰ-Ⅴ level groups according to pneumonia severity index (PSI),and they were divided into non-survivors and survivors according to 30-day prognosis.The data including gender,age,PSI score,platelets count (PLT),white blood cell count (WBC),D-dimer,FIB,and C-reactive protein (CRP) were compared among groups.The correlations between PSI score and D-dimer,CRP as well as FIB were analyzed by Spearman or Pearson correlation analysis.Receiver operating characteristic curve (ROC) was used to assess the prognostic value of these indicators.Results A total of 499 patients with CAP were enrolled with 298 male and 201 female,the average age was (63.4 ± 17.8) years old,and the 30-day mortality was 6.4％ (32/499).There were 77,80,104,162 and 76 patients in PSI Ⅰ-Ⅴ level groups,and there were more male patients in PSI Ⅵ and Ⅴ level groups.There were no significant differences in PLT and FIB among the groups of different PSI levels,but the levels of WBC,D-dimer and CRP were significantly increased as PSI level increased from Ⅰ to Ⅴ (F1 =3.810,x 22 =102.361,F3 =7.070,all P ＜ 0.01).Compared with survivors,the non-survivors were elder (t =-4.773,P ＜ 0.001) with lower PLT (t =3.026,P =0.003)and higher WBC,PSI score,D-dimer and CRP levels (t1 =-2.545,t2 =-8.421,Z3 =-6.947,t4 =-3.770,all P ＜ 0.05).Plasma D-dimer levels in elderly patients (≥ 65 years old) were statistically higher than those in younger patients (＜ 65 years old;Z =-5.338,P ＜ 0.01).It was shown by correlation analysis that PSI score was positively correlated with D-dimer and CRP (r values were 0.475 and 0.260,both P ＜ 0.001),and no correlation was found between PSI score and FIB (r =-0.062,P =0.170).The area under the ROC curve (AUC) for predicting 30-day death of PSI score,D-dimer and CRP was 0.858 [95％ confidence interval (95％CI) =0.802-0.914],0.867 (95％CI =0.812-0.922) and 0.732 (95％CI =0.641-0.823).The combination of D-dimer and PSI score was better than any single indicator for predicting the prognosis with higher AUC up to 0.905 (95％CI =0.867-0.944),all P ＜ 0.001.The sensitivity and specificity for PSI in predicting 30-day death respectively were 78.1％ and 82.4％ with the cut-off of greater than 122,and those for D-dimer were 75.0％ and 82.9％ with the cut-off of greater than 2.10 mg/L,50.0％ and 84.4％ for CRP with the cut-off of greater than 100.50 mg/L.Conclusions D-dimer could well reflect the severity of CAP and be a good indicator for predicting the prognosis.The combination of D-dimer and PSI might improve the accuracy in predicting prognosis.

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Effects of mild hypothermia on pulmonary vascular permeability in patients with acute respiratory distress syndrome

Juntao HU ; Yiping PAN ; Xianfeng CHEN ; Chi ZHANG ; Jie LAI ; Zhanhong TANG

Chinese Critical Care Medicine.2016;28(9):775-779. doi:10.3760/cma.j.issn.2095-4352.2016.09.002

Objective To study the influence of mild hypothermia on pulmonary vascular permeability in patients with acute respiratory distress syndrome (ARDS) induced by infection.Methods A prospective randomized controlled trial was conducted.Patients with ARDS induced by infection satisfied criteria including age 18-70 years,endotracheal intubation and mechanical ventilation (MV),and without severe coagulation disorder admitted to intensive care unit (ICU) of the First Affiliated Hospital of Guangxi Medical University from May 2012 to November 2015 were enrolled,excluding tumor,burn,cardiac disease,vascular disease,and endovascular surgery within 3 months.The patients enrolled were randomly divided into non-temperature controlled group and mild hypothermia group.The primary diseases in all patients were treated according to the treating principles,including respiratory support,integrated treatment of organ support and symptomatic treatment.Besides,the patients in the mild hypothermia group were administered with systemic hypothermia,and the patients' core body temperature (nasopharyngeal temperature) was rapidly decreased to 34-35 ℃ within 1 hour.Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,oxygenation index (PaO2/FiO2),extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) in two groups at 1,24,48,and 72 hours after treatment or core temperature up to standards were monitored respectively.Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of vascular endothelial growth factor (VEGF) in venous blood as well as tumor necrosis factor-α (TNF-α) and surfactant apoprotein A (SP-A) in bronchoalveolar lavage fluid (BALF),and circulating endothelial cell (CEC) was counted.The duration of mechanical ventilation and 7-day survival rate were recorded.Results Fifty-six patients were enrolled,with 32 in non-temperature controlled group and 24 in mild hypothermia group.There was no difference in baseline variables including gender,age,APACHE Ⅱ score,PaO2/FiO2 between two groups.APACHE Ⅱ score,EVLWI,PVPI,VEGF,CEC,and TNF-α in both groups were gradually increased with treatment time prolongation,and PaO2/FiO2 and SP-A were gradually decreased.Compared with non-temperature controlled group,APACHE Ⅱ score (16.34±4.27 vs.19.24 ± 5.95),EVLWI (mL/kg:12.17 ± 2.26 vs.12.39 ± 4.71),PVPI (15.40 ± 10.95 vs.16.08 ± 10.24),VEGF (ng/L:127.92 ± 31.49 vs.159.12 ± 40.67),CEC (cells/μL:4.15 ± 1.79 vs.5.70 ± 2.38),and TNF-α (ng/L:147.18 ± 48.85 vs.257.17 ±40.84) in mild hypothermia group were significantly decreased from 24 hours (all P ＜ 0.05),and PaO2/FiO2 [mmHg (1 mmHg =0.133 kPa):175.03± 12.64 vs.162.53 ± 14.15] and SP-A (μg/L:80.85 ± 16.18 vs.62.06 ± 17.28) were significantly increased (both P ＜ 0.05),the duration of mechanical ventilation was significantly shortened (days:10.38 ± 1.50 vs.15.74 ± 3.06,P ＜ 0.01),and 7-day survival rate was significantly increased (75.0％ vs.46.9％,P ＜ 0.05).Conclusion Mild hypothermia can reduce the pulmonary vascular permeability,and improve pulmonary function in early phase in patients with ARDS,as well as shorten the duration of mechanical ventilation,and decrease short-term mortality.

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A comparison of effects of four different methods to locate tracheal tube

Le QI ; Rong LIU ; Shouchun LI ; Shaojun LYU ; Hao WENG

Chinese Critical Care Medicine.2016;28(9):812-816. doi:10.3760/cma.j.issn.2095-4352.2016.09.009

Objective To compare the efficacy of four different methods to locate tracheal tube in the tracheal:modified transillumination method,21/23 cm rule,marked the intubation at a distance,and fiberoptic bronchoscope.Methods A prospective randomized controlled trial was conducted.120 endotracheally intubated adult patients with American Society of Anesthesiologists (ASA) classification Ⅰ-Ⅱ and admitted to Central Hospital of Fengxian in Shanghai from January to March 2015 were enrolled.The patients were randomly divided into four groups (n =30) and located by 21/23 cm rule,marked the intubation at a distance,fiberoptic bronchoscope and modified transillumination method (using homemade locator guided by a red laser fiber to position the depth of tube) respectively.An endotracheal tube was inserted and measured the distance of the tube tip to the carina (TTC),vocal cords to tracheal tube cuff (VC-TC) in three different neck positions,i.e.neck in flexion,neutral,and extension position.The number of improper position in four groups was recorded.Results There were no significant differences in gender,age,and body mass index among the four groups.Six of the 30 patients using marked tracheal tuba method failed to find vocal cords with laryngoscope,while the other three methods all completed successfully.① From neck flexion to extension,TTC was gradually increased,while VC-TC was gradually decreased.In neck flexion and extension positions,TTC distance in the 21/23 cm rule group was significantly shorter than that in the fiberoptic bronchoscope group (cm:1.44 ± 1.14 vs.2.11 ±0.54,3.01 ±1.18 vs.3.80±0.71,both P ＜ 0.05),and the distance was also shorter than that in modified transillumination method group (cm:1.44 ± 1.14 vs.1.93 ± 0.81,3.01--1.18 vs.3.45 ± 0.91,both P ＞ 0.05).VC-TC distance in the 21/23 cm rule group was significantly longer than that in the modified transillumination,the marked intubation,and the fiberoptic bronchoscope groups in neck neutral and extension positions,respectively (cm:3.07 ± 1.08 vs.2.28±0.76,2.29±0.90,2.49±0.86;2.64±0.94 vs.1.82±0.72,1.81-0.94,2.02±0.91,all P ＜ 0.05).TTC and VC-TC distances in three neck positions in the modified transiflumination group were shorter than those in the fiberoptic bronchoscope group without statistical significance.② If TTC was too short,an accidental bronchus intubation could happen,while if VC-TC was too short,an accidental damage of the vocal cord inducing by the cuff press could happen.In the 21/23 cm rule group,there were 7 cases that the tube wrongly inserted to bronchus in neck flexion,and 1 case in neutral and extension positions respectively.In the marked intubation group,there were 4 cases that the tube wrongly inserted into bronchus in neck flexion,and 1 case in neck neutral position,and there were 4 cases that the vocal cords were pressed by the cuffs in extension position.In the modified transillumintion and the fiberoptic bronchoscope groups,there was only 1 case that the tube wrongly inserted to bronchus in neck flexion respectively.Conclusions When neck position changed during trachea intubation,it was easier that the tube wrongly inserted to bronchus for 21/23 cm rule method to locate the position.Bronchus intubations and cuff press vocal cords could happen using the marked tube method,which was less be found using modified transillumination or fiberoptic bronchoscope methods.Finally,the modified transillumination methods can be used to locate with satisfactory effect.

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Influence of different ventilator circuit change frequency on ventilator-associated pneumonia

Ying TIAN ; Xueqin MA ; Yonggang LIU ; Guangying HAN ; Haiying WU

Chinese Critical Care Medicine.2016;28(9):817-821. doi:10.3760/cma.j.issn.2095-4352.2016.09.010

Objective To explore the appropriate frequency of ventilator tube replacement by researching the influence of different ventilator circuit change frequency on ventilator-associated pneumonia (VAP).Methods A prospective randomized sampling study was conducted.The patients undergoing invasive mechanical ventilation over or equal to 3 days admitted to emergency intensive care unit (EICU) of the First Affiliated Hospital of Kunming Medical University from December 2012 to December 2015 were enrolled.The patients were divided into 3,7 and 10 days group according to the frequency of ventilator tube replacement.Bacteriology of ventilator tube and the incidence of VAP were compared among the groups.Results Ninety-eight patients were enrolled,mainly with the artificial airway of endotracheal intubation or tracheotomy,with 56 male and 42 female,aging 8 to 86 years with mean of (51.97 ± 17.56) years.There were no statistical differences in gender,age,Glasgow coma scale (GCS) score,cough function and application of glucocorticoid,enteral nutrition,atomization and sedative therapy among three groups,indicating that the risk factors among three groups were consistent.The bacteria detection rates of extension tube,breathe out tube,breathe in tube,and hydrops collection cup were 36.7％,36.7％,33.3％,and 33.3％ respectively in 3 days group,and they were 73.0％,67.6％,62.2％,and 62.2％ in 7 days group respectively,and were all 90.3％ in 10 days group.It was showed that the bacteria detection rate in different pipe parts was almost the same with the same change frequency,and the rate was higher with the longer usage of ventilator tube (x2 values were 20.599,19.879,21.975,21.975,all P =0.000).The longer of the tube used time,the higher incidence of VAP.The incidence of VAP in 3,7,10 days groups were 26.7％,59.5％ and 77.4％,respectively,but there was statistically significant difference among all groups (x2 =30.486,P ＜ 0.001).Based on the value of 3 days group,the incidence of VAP in the 7 days group was 15.950 folds of 3 days group,and the incidence of VAP in the 10 days group was 18.333 folds of the 3 days group (both P ＜ 0.001).Conclusion This study suggests that the longer of pipeline using time,the more serious degree of bacterial contamination of pipeline,the higher incidence of VAP.

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