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Advances in targeted temperature management in sepsis and the clinical value of application in ;patients

Chinese Journal of Emergency Medicine.2016;25(9):1204-1209. doi:10.3760/cma.j.issn.1671-0282.2016.09.025

Sepsis is one of the serious illnesses leading to high mortality in ICU.Some animal experiments and clinical trails show that target temperature management has a protective effect on target organ function in sepsis,but the optimal timing,length of targeted temperature managment continued,intervention measures,and optimal target temperature obtained in sepsis remains in the great controversy.Whether the patients with sepsis would be truly benefited from the body temperature management is still worthy issue for further study.The aim of this article reviews is to trace the recent research progress on the body temperature management in sepsis.

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Current status and prospects of endovascular mechanical thrombectomy for treatment of acute ;ischemic stroke

Yuyou ZHU ; Guoping WANG

Chinese Journal of Emergency Medicine.2016;25(9):1200-1204. doi:10.3760/cma.j.issn.1671-0282.2016.09.024

Acute ischemic stroke has already become common cause of death in our country.Until now,the intravenous thrombolysis therapy produces a limited therapeutic efficacy in patients with acute ischemic stroke,because the recanalization rate is very low in patients with large vessel occlusion,especially with interal carotid artery occlusion.As a novel modality of primary treatment,endovascular mechanical recanalization using clot removal has become a noticeably efficient intervention and a hot research focus of acute ischemic stroke.In this paper,we reviewed recent large multicenter trials of endovascular mechanical recanalization in the world.

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The effect of soluble CD14-st on the assessment and prognosis of patients with acute paraquat ;poisoning

Weizhan WANG ; Hongna QI ; Xun GAO ; Qingmian XIAO ; Baoyue ZHU ; Wei LI ; Yongjian LIU ; Jing LI ; Pu WANG ; Guoying MA

Chinese Journal of Emergency Medicine.2016;25(9):1159-1165. doi:10.3760/cma.j.issn.1671-0282.2016.09.013

Objective To investigate the relationship between soluble CD14-st (Presepsin)and assessment,prognosis in patients with acute paraquat poisoning (APP).Methods A total of 82 patients with APP treated in Emergency Department of Harrison International Peace Hospital Affiliated to Hebei Medical University from January 2013 to January 2016 were divied into three groups:mild poisoning group (n =20),moderate poisoning group (n =36)and severe poisoning group (n =26).According to the outcomes,patients were divided into survivor group (n =28)and non-survivor group (n =54).Another 50 healthy subjects were selected as control group.In control group,samples of 3 mL venous blood from 50 healthy subjects were collected for laboratory examination.Samoles of 10 mL venous blood from all patients were collected before and 72 hours,7 days after treatment to detect presepsin,C reactive protein (CRP), tumor necrosis factor α(TNF-α),interleukin-6 (IL-6)and interleukin-10 (IL-10).Before and 72 hours, 7 days after treatment,the change of Acute physiology and chronic health evaluation (APACHE)Ⅱscore and the outcomes in 28 days were observed.The variance analysis of repeated measures was used for comparison among multiple groups,and the t test was used to compare changes of detected biomarkers between two groups,and the outcomes in 28 days between two groups were compared with chi square test. Pearson correlation test was used to analyze the correlation between Presepsin in patients with APP and the survival rate.Results APACHE Ⅱ scores and the serum level of prespsin,CRP,TNF-α,IL-6 at admission and 72 hours,7 days after treatment in three poisoning groups were significantly increased compared with control group,IL-10 were decreased compared with control group (P <0.05 ),and there were significant differences in those biomarkers between moderate group and mild group,and between severe group and mild group,moderate group (P <0.05).At admission,72 h,7 d after admission,APACHEⅡscore and the serum levels of presepsin,CRP,TNF-α,IL-6 in non-survivor group were higher than those in survivor group,and IL-10 in non-survivor was lower than that in survivor group (P <0.05).The mortality rates of these 3 groups were 25.00%,69.44% and 92.31%,demonstrating significant differences among three groups (P <0.05).The AUCs were 0.862 and 0.731 for presepsin and APACHEⅡscore respectively at admission.The predictive capability of presepsin for 28-day mortality was superior over that of APACHEⅡscore (P <0.05).The level of serum presepsin in patients with APP was negatively correlated with the survival rate (r =-0.285,P =0.009).Conclusions The detection of prespsin has important clinical value in the severity assessment and prognosis in patients with APP.It is an important guidance for early therapeutic strategy.

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“Diffusion index”used to evaluate the prognosis of ARDS

Lihua TENG ; Zhiyi XIE ; Jun XU ; Zhong WANG

Chinese Journal of Emergency Medicine.2016;25(9):1154-1158. doi:10.3760/cma.j.issn.1671-0282.2016.09.012

Objective To propose the concept of “Diffusion Index”to replace Oxygenation Index as independent indicators to evaluate prognosis on ARDS patients under mechanical ventilation treatments,and comparison carried out between them preliminarily.Methods Calculation of “1 000 × (PaO2 /FiO2 /PEEP)”was taken as “Diffusion Index”.A total of 130 ARDS patients under mechanical ventilation support (MVS)were admitted to Peking Union Medical College Hospital ICU from July 2013 to July 2014.The data of these patients were retrospectively analyzed.Of them,15 patients were excluded because these patients refused invasive ventilation support.Respirator parameter setting and haemogas figures were recorded accordingly. Both Diffusion Index and Oxygenation Index were used separately to predict detachment of MVS from patients in 28 days,and the correlation between these two indexes and ARDS prognosis were determined.Results According to the outcomes of patients in 28 days,patients were divided into 3 groups:detached group (n =44),failed to detach group (n =14)and death group (n =57).There was obvious difference in trend diagrams observed among three groups between diffusion index and oxygenation index.COX regression analysis of survival curve demonstrated that if Diffusion Index kept greater than 405.8,probability of detachment of MVS from patients was higher and the correlation was significant (P =0.009 ).Conclusions Compared with Oxygenation Index,“Diffusion Index” is a comprehensive indicator for ARDS prognosis with better reliability and validity.

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Yan MA ; Xiangyou YU

Chinese Journal of Emergency Medicine.2016;25(9):1149-1153. doi:10.3760/cma.j.issn.1671-0282.2016.09.011

Objective To study the immunomodulation effects of different dosage of dexmedetomidine (Dex)in the septic shock model of rats after cecal ligation and puncture (CLP).Methods After CLP, 48 wistar rats were randomly (random number)allocated in four groups:(1)CLP group;(2)small-dose Dex group [2.5 μg/(kg·h)];(3)medium-dose Dex group [5.0 μg/(kg·h)];(4) large-dose Dex group [10.0 μg/(kg·h)].HLA-DR (human leukocyte antigen-DR)and plasma cytokine (IL-4, IL-6,IL-10 and TNF-α)were measured,meanwhile mean arterial blood pressure (MAP),heart rate (HR)and mortality were also documented at 1,3,and 5 h after the CLP procedure.Results There were no obvious differences in HLA -DR level,levels of inflammatory mediators,MAP and HR among there Dex treatment groups.Compared with CLP group,HLA-DR level decreased in three Dex treatment groups (P =0.020)and pro-inflammatory mediator (IL-6)increased at 3 h (P =0.011 )then declined at 5 h with decreased HR (P <0.01),and without obvious change in MAP (P =0.124),and all of them led to a significantly decrease in the mortality.The mortalities in CLP group,small dose group,medium dose group and large dose group were 91.7%, 66.7%, 25.0% and 18.0%, respectively. Conclusions Dexmedetomidine used in rats with septic shock rats partially induced immunomodulation initiated within 5 h after CLP evidenced by decreased HR,maintenance of MAP and reduction of mortality rate in dose-dependent fashion.

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A descriptive analysis of triage,surge,and medical resource use in a university affiliated hospital ;after 8·12 explosion and burn at Tianjin Port

Guoqiang LI ; Xin YU ; Xiangtao MENG ; Liangliang LIU ; Pengbo YAN ; Mengna TIAN ; Shaolei CHEN ; Huijuan HAN

Chinese Journal of Emergency Medicine.2016;25(9):1119-1125. doi:10.3760/cma.j.issn.1671-0282.2016.09.005

Objective To analyze the massive explosions and burn at Tianjin Port in 2015 resulted in a mass casualty event,and the entire course of response of a hospital to deal with such major sudden accident in order to find a rational strategy for optimal use of medical resources and reduce the critical mortality.Methods This study was done by a retrospective analysis of data from one trauma center at an academic hospital.Data including outcome,triage,severity and pattern of injuries,patient flow,and medical resources used were obtained by the review of hospital records.Results This disaster caused 165 deaths,8 missing contact,and 797 non-fatal casualties.The Pingjin Hospital admitted 298 casualties,and 29 of them were seriously injured referred to by Tianjin Emergency Medical Center.Excessive triage rate made after transfer to another hospital was 62.07% with 11 of the 29 severely injured patients.Maximum (also the first)surge had 147 injured patients arrived around one hour after incident,the second surge had 31 seriously injured patients occurred around 4 hours after incident.Of them,17 patients needed surgery and 17 patients were admitted to the intensive care unit.Conclusions These data showed that the number of casualties in the first surge was substantially larger than predicted and those casualties had less severe trauma,whereas the number of the injured in the second surge was less but the trauma was more severe.In order to maintain the hospital surge capacity,an effective re-triage and a hospital-wide damage control principle can be used to deal with.

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Effect of propofol on the patients under neurally adjusted ventilator assist

Lei ZHANG ; Fangchao YAO ; Bing WANG ; Yongqiang WANG

Chinese Journal of Emergency Medicine.2016;25(9):1171-1175. doi:10.3760/cma.j.issn.1671-0282.2016.09.015

Objective To investigate the effects of different depths of propofol sedation on patients under neurally adjusted ventilator assist (NAVA)ventilation.Methods A total of fifty patients supported by NAVA ventilation admitted from June 2012 to June 2015 into intensive care unit (ICU)were enrolled for prospective study.The patients were randomly divided into light sedation group (n =20)and deep sedation group (n =20).The respiratory mechanics index:peak inspiration pressure (PIP),mean airway pressure (Pmean),electrical activity of the diaphragm (EAdi),gas exchange index,pH value of arterial blood, partial pressure of oxygen (PaO2 ), partial pressure of carbon dioxide (PaCO2 ), patient-ventilator synchrony,trigger delay time,off cycle delay time,hemodynamic indexes,mean arterial blood pressure (MAP),heart rate (HR)of the two groups were detected and documented.Enumeration data were analyzed with χ2 test,measurement data were analyzed with t test,and P <0.05 was considered to be significant.Results The PIP,Pmeam and EAdi under light sedation and deep sedation were lower than those in wakefulness (compared with wakefulness,the t values of PIP,Pmean and EADi under light sedation were 2.519,2.363,2.980,respectively and the t values of those under deep sedation were 3.158, -4.307,4.462,P <0.05).Compared with light sedation,the PIP,Pmeam and EAdi were significant decrease under deep sedation (the t values were 2.018, -2.441,3.402,respectively,P <0.05).There were no significant differences in MAP,HR,PaCO2 between light sedation and before sedation (the t values were 1.620,1.492, -0.267,respectively,P >0.05 ),while under the deep sedation,MAP and HR were lower than those in wakefulness and under light sedation (compared with wakefulness,the t values of deep sedation respectively were 2.805,2.944,and compared with light sedation,the t values of deep sedation were significantly reduced to 2.175,2.019,respectively,P <0.05)and PaCO2 under deep sedation (the t values respectively were -4.644,-0.315,P <0.05)was significant increased compared with light sedation and before sedation.There were no significant difference in pH,PaO2 ,trigger delay,off cycle delay between after sedation and before sedation,and between light sedation and deep sedation (compared with wakefulness,the t values of light sedation were -1.470, 1.250, -0.745, -0.555,respectively,and the t values of deep sedation respectively were -1.090,-0.333, -1.088, -0.717,while compared with light sedation,the t values of deep sedation respectively were -0.612, -0.542,0.379,1.225,P >0.05 ).Conclusions Light sedation of propofol could reduce the EAdi and airway pressure without effect on gas exchange,haemodynamics and patient-ventilator synchrony in the patients under NAVA ventilation.

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Risk factors of acute kidney injury in patients with acute myocardial infarction

Yuanyuan PEI ; Yunhui MA ; Xiaolu MA ; Jihong ZHU

Chinese Journal of Emergency Medicine.2016;25(9):1166-1170. doi:10.3760/cma.j.issn.1671-0282.2016.09.014

Objective To explore the risk factors for acute kidney injury (AKI)in patients with acute myocardial infarction (AMI).Method The medical data of hospitalized patients with AMI admitted from October 2013 to May 2014 were reviewed.All patients were divided into AKI group and non-AKI group.The univariate comparison analysis were performed to obtain the AKI risk factors.Results A total of 565 patients were enrolled.The incidence of AKI (n =91 )was 16.1% and there were 474 non-AKI patients.The mortality of AKI group was 19.8% and mortality of non-AKI group was 0.4% (P <0.01). Univariate analysis demonstrated that the risk factors of AKI were age,hypertension,previous myocardial infarction,heart failure history,chronic kidney disease,cerebral infarction history,peripheral vascular disease;ventricular fibrillation,heart rate,Killip grade ≥3 stage,left ventricular ejection fraction,serum creatinine,eGFR,hemoglobin,blood urea nitrogen,troponin I,B-type natriuretic peptide and C-reactive protein,fasting glucose,albumin,maximum daily dose of furosemide,non-use of ACEI /ARB and statins, the use of intra-aortic balloon pump, temporary pacemaker and pulmonary mechanical ventilation, implementation of PCI and coronary artery bypass graft surgery.Conclusions These risk factors for AKI after AMI were found to identify high-risk patients,helping the clinicians to make decision for preventive intervention.

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The effect of dexmedetomidine combined with ischemic preconditioning on liver ischemic reperfusion ;injury in rats

Youxiang GUO ; Kunhua QIU ; Lei ZHANG ; Yong LI ; Jiakun ZHANG ; Tingqiang WANG ; Jun OUYANG

Chinese Journal of Emergency Medicine.2016;25(9):1142-1148. doi:10.3760/cma.j.issn.1671-0282.2016.09.010

Objective To investigate the effect of dexmedetomidine (Dex)combined with ischemic preconditioning on liver ischemic reperfusion injury in rats in order to explore its possible mechanism. Methods Sixty healthy male SD rats weighing (251 ±18)g,were randomly (random number)divided into five groups (n =12 in each):sham-operation group (Group S:operation without ischemia), ischemia-reperfusion group (Group IR:hepatic pedicle occlusion for 30 min and reperfusion for 6 h), dexmedetomidine preconditioning group (Group Dex: dexmedetomidine 25 μg/kg was given intra-peritoneally at 30 min before operation),ischemic preconditioning group (Group IP:10 min ischemia,10 min reperfusion,followed by hepatic IR)and Dex combined with ischemic preconditioning group (Group Dex +IP:Dex 25μg/kg was given intra-peritoneally at 30 min befor operation,10 min ischemia and 10 min reperfusion was given followed by hepatic IR).The hepatic inflow of blood stream was occluded for 30 min by Pringle maneuver to establish hepatic ischemic reperfusion injury (HIRI)rat model.At the end of reperfusion for 6 h,the concentration of ALT,AST and LDH (lactate dehydrogenase)in serum were measured.The liver histological changes were examined after HE staining.The liver cell apoptosis were examined by TUNEL. The expression of heme oxygenase-1 were examined by Westeren blot and immunohistochemistry.H2 O2 and GSH (r-glutamylcysteinylglycine ) in liver tissue were detected by spectrophotometer.Differences among the groups were analyzed by one-way analysis of variance (ANOVA) and Student-Newman-Keul test by using SPSS version 17.0 software.Differences were considered significant at P <0.05.Results Serum concentrations of ALT,AST and LDH in group IR,Dex,IP and Dex +IP were significantly higher than those in group S (P =0.000).And those biomarkers in group Dex,IP and Dex +IP,were significantly lower than those in group IR (P =0.000).Furthermore,those biomarkers in group Dex +IP,were significantly lower than those in group Dex and IP (P =0.000).There were no significant difference in the serum concentrations of ALT and AST between group Dex and IP (P =0.550, 0.771),and the serum level of LDH in group Dex was significantly lower than that in group IP (P =0.000).The liver histopathological score and apoptosis index were the lowest in group S and the highest in group IR,and those in group Dex and group IP were significantly lower than those in group IR (P =0.000),and those in group Dex +IP were significantly lower than those in group Dex and group IP (P =0.000),and there were no significant difference between group Dex and IP (P =0.704,0.661 ).The expression score of HO-1 was the lowest in group S and the highest in group Dex +IP,and that in group Dex and group IP was significantly lower than that in group Dex +IP (P =0.000,0.002),and that in group IR was significantly lower than that in group Dex and group IP (P =0.000),and there was no significant difference between group Dex and IP (P =0.099).In respect of H2 O2 level and GSH level in liver tissue, compared with group S,the H2 O2 levels in groups IR,Dex,IP and Dex +IP were significantly higher (P=0.000,0.000,0.000,0.001)while the GSH levels were significantly lower (P =0.000).Compared with group IR,the H2 O2 level in group Dex,IP and Dex +IP was significantly lower than that in group IR while the GSH level was significantly higher (P =0.000 ).The H2 O2 level in group Dex +IP was significantly lower than that in group Dex and IP while the GSH level was significantly higher (P =0.000).There were no significant difference between group Dex and IP (P =0.480,0.667).Conclusions Both of dexmedetomidine and ischemic preconditioning can protect liver from ischemia reperfusion injury in rats to some extent,and the combined application of two gives better effects,which is attributed to the increasing expression of HO-1 to a certain extent.

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Improvement of cardiac function after cardiopulmonary resuscitation by using isosorbide ;mononitrate in porcine models

Chenchen HANG ; Tao WANG ; Ziren TANG ; Caijun WU

Chinese Journal of Emergency Medicine.2016;25(9):1136-1141. doi:10.3760/cma.j.issn.1671-0282.2016.09.009

Objective To determine the protective effect of isosorbidemononitrate (IM) on myocardial injury after restoration of spontaneous circulation (ROSC)in swine models of cardiac arrest induced by ventricular fibrillation.Methods The experiment was carried out in Animal Lab of Beijing Chao-Yang Hospital,Capital Medical University.Ventricular fibrillation was induced and untreated for 8 min in twenty WhuZhiShan piglets.CPR was performed until ROSC occurred.The animals were randomized (random number)into two groups:IMgroup (n =10)and control group (n =10).IM [2 μg/(kg· min)]or the equivalent volume in saline was administered respectively for 6 h after ROSC.Hemodynamics and post-resuscitation cardiac function were monitored until 24 h after ROSC. Echocardiography and transmission electron microscopy were useed at 72 h after ROSC.Results There was no significant difference in survival rate between the two groups.No significant differences in mean arterial pressures (mmHg)at ROSC 6 h (88.5 ±5.6 vs.87.8 ±6.0,P =0.790)and ROSC 24 h (89.3 ±3.8 vs.86.9 ± 5.0,P =0.245)between the two groups were found.Cardiac outputs (L/min)were significantly increased at ROSC 6 h (2.40 ±0.17 vs.1.60 ±0.14,P <0.01)and ROSC 24 h (2.49 ±0.17 vs.2.09 ±0.21,P<0.01);and ejection fraction at ROSC 72 h (0.67 ±0.08 vs.0.56 ±0.09,P =0.044)was improved too,and significant differences were found between the two groups.The ultra-structural myocardial injury was ameliorated in the MI group at 72 h after CPR observed by using electron microscopy.Conclusions IM can ameliorate post-resuscitation cardiac dysfunction in porcine models of cardiac arrest induced by ventricular fibrillation.

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