Critical care medicine(CCM)is a multifaceted discipline challenged by the inherent heterogeneity and complexity of critical illnesses.Establishing precise,standardized diagnostic and therapeutic systems has emerged as a crucial challenge requiring urgent resolution in this field.Surgical critical care,a pivotal branch of CCM,plays an indispensable role in managing patients with severe trauma,postoperative intra-abdominal infections,solid organ transplantation,and other life-threatening conditions.Evidence-based,etiology-guided therapy serves as the cornerstone of surgical critical care,where accurate identification and timely interventions constitute vital determinants for enhancing patient survival rates and improving prognoses.This article proposes an innovative diagnostic and therapeutic paradigm termed the urgency/physics-biology-chemistry(U/P-B-C)model.Built upon the established principle of urgent(urgency,U)life support in surgical critical care,this model emphasizes a novel conceptual framework centered on etiology-based(physics-biology-chemistry,P-B-C)diagnosis and treatment.Implementing the U/P-B-C innovative diagnostic and therapeutic model in surgical critical care facilitates precise identification of the fundamental pathological mechanisms underlying critical clinical conditions with complex and dynamic clinical environments,enables systematic clarification of clinical reasoning,and ultimately supports evidence-informed decision-making.Its core objectives encompass enhancing surgical intensivists' diagnostic-therapeutic capabilities and ensuring rigorous adherence to the principle of etiology-guided therapy,thereby providing both theoretical foundation and practical guidance for improving the success rate of patient resuscitation and optimizing prognosis in surgical critical care settings.

Critical care medicine(CCM)is a multifaceted discipline challenged by the inherent heterogeneity and complexity of critical illnesses.Establishing precise,standardized diagnostic and therapeutic systems has emerged as a crucial challenge requiring urgent resolution in this field.Surgical critical care,a pivotal branch of CCM,plays an indispensable role in managing patients with severe trauma,postoperative intra-abdominal infections,solid organ transplantation,and other life-threatening conditions.Evidence-based,etiology-guided therapy serves as the cornerstone of surgical critical care,where accurate identification and timely interventions constitute vital determinants for enhancing patient survival rates and improving prognoses.This article proposes an innovative diagnostic and therapeutic paradigm termed the urgency/physics-biology-chemistry(U/P-B-C)model.Built upon the established principle of urgent(urgency,U)life support in surgical critical care,this model emphasizes a novel conceptual framework centered on etiology-based(physics-biology-chemistry,P-B-C)diagnosis and treatment.Implementing the U/P-B-C innovative diagnostic and therapeutic model in surgical critical care facilitates precise identification of the fundamental pathological mechanisms underlying critical clinical conditions with complex and dynamic clinical environments,enables systematic clarification of clinical reasoning,and ultimately supports evidence-informed decision-making.Its core objectives encompass enhancing surgical intensivists' diagnostic-therapeutic capabilities and ensuring rigorous adherence to the principle of etiology-guided therapy,thereby providing both theoretical foundation and practical guidance for improving the success rate of patient resuscitation and optimizing prognosis in surgical critical care settings.

Objective To explore the value of CT derived fractional flow reserve(CT-FFR)combined with pericoronary adipose tissue(PCAT)fat attenuation index(FAI)in predicting major adverse cardiac events(MACE)in patients with obstructive coronary heart disease(CHD).Methods A total of 149 patients with obstructive CHD who underwent coronary computed tomography angiography(CCTA)examination were analyzed retrospectively.The patients were divided into MACE group and non-MACE group according to the occurrence of MACE.The clinical data,CCTA characteristics,CT-FFR,PCAT volume and FAI differences between the two groups were compared.Multiple logistic regression analysis was used to screen the independent predictors of MACE.The area under the curve(AUC)of the receiver operating characteristic(ROC)curve was used to evaluate the efficiency of a single independent predictor and its joint prediction of MACE.Results CT-FFR≤0.8 and right coronary artery(RCA)FAI(RCA-FAI)were independent risk factors for MACE in patients with obstructive CHD.The AUC of CT-FFR≤0.8 and RCA-FAI to predict MACE in patients with obstructive CHD were 0.773 and 0.766,respectively,while of their combination was 0.865.Conclusion Compared with single imaging parameters,the combined imaging parameters of CT-FFR and RCA-FAI can significantly improve the predictive efficiency of MACE in patients with obstructive CHD.

Objective:To investigate the clinical characteristics of abdominal infection related secondary hemorrhage and partition of intra-abdominal infection after pancreaticoduodenectomy (PD).Methods:The retrospective and descriptive study was conducted. The clinical data of 25 patients with abdominal infection related secondary hemorrhage after PD who were admitted to The First Affiliated Hospital of Xi ′an Jiaotong University from January 2009 to December 2017 were collected. There were 18 males and 7 females, aged (63±11)years. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3). Count data were described as absolute numbers. Results:(1) Clinical charac-teristics of abdominal infection related secondary hemorrhage after PD. Of 25 patients, there were 21 cases diagnosed with pancreatic fistula, 2 cases with negative for amylase test in abdominal drainage fluid, and 2 cases with unknown conditions of pancreatic fistula. There were 16 cases with sentinel hemorrhage and 9 cases without sentinel hemorrhage. Of 25 patients, 10 cases were evaluated as grade A bleeding, 10 cases were evaluated as grade B bleeding, and 5 cases were evaluated as grade C bleeding. The types of pathogenic microorganisms cultured in the peritoneal drainage fluid of 25 patients included 7 cases of simple Gram positive (G +) bacteria, 6 cases of simple Gram negative (G -) bacteria, 8 cases of both G + bacteria and G - bacteria, 1 case of G + bacteria and fungi, and 3 cases of G + bacteria, G - bacteria and fungi. There were 3 cases cultured with carbapenem-resistant Acinetobacter baumannii. There were 17 patients with fluid accumulation in the D region confirmed by abdominal computered tomography, including 2 cases of simple fluid accumulation in the D region and 15 cases of fluid accumulation in the D region and other regions. Of 25 patients, 12 cases underwent simple conservative medical treatment, 8 cases underwent digital subtraction angiography (DSA) hemostasis, 2 cases underwent DSA combined with surgical hemostasis, 1 case underwent endoscopic hemostasis, 1 case underwent surgical hemostasis, and 1 case underwent endoscopic + DSA hemostasis. Of 25 patients, 5 patients died. (2) Treatment methods and clinical outcomes of patients with abdo-minal infection in different regions of the partition of intra-abdominal infection. Of the 17 patients with clear regions of the partition of intra-abdominal infection, there were 6 cases with D region combined with ≤ 1 other region of the partition of intra-abdominal infection who did not receive surgical treatment survived, there were 11 cases with D region combined with ≥2 other regions of the partition of intra-abdominal infection who mainly received DSA or combined treatment, including 8 cases survived and 3 cases dead. Conclusions:The abdominal infection related secondary hemorrhage after pancreaticoduodenectomy is mainly due to D region of the partition of intra-abdominal infection, and the pathogen mainly presents as mixed infection and multi-drug-resistant bacterial infection. When the spread of infected lesions leads to D region combined with ≥2 other regions of the partition of intra-abdominal infection, the intervention measures are significantly upgraded, and the risk of patient death increases.

It was previously believed that hepatic portal venous gas (HPVG) was an "ominous sign" or "death sign", and once it appeared, the disease progressed rapidly with a high mortality rate which required immediate surgical treatment. However, with the continuous progress of medical technology, researchers have gained a deeper understanding that various causes can lead to HPVG, not all of which required surgical treatment, and the prognosis was not poor. Unfortunately, there is no guideline or consensus on the diagnosis and treatment of HPVG to guide clinical management and standardize diagnostic and therapeutic behaviors. Therefore, the authors review previous literatures with combined clinical diagnosis and treatment experience to conduct profound discussion on the epidemiological features, etiology, pathogenesis, imaging features, treatment strategies, and progno-sis of HPVG, and develop corresponding diagnosis and treatment procedures with the aims to help clinicians to improve diagnostic and therapeutic outcomes and prognosis of patients.

Objective:To investigate the clinical characteristics of abdominal infection related secondary hemorrhage and partition of intra-abdominal infection after pancreaticoduodenectomy (PD).Methods:The retrospective and descriptive study was conducted. The clinical data of 25 patients with abdominal infection related secondary hemorrhage after PD who were admitted to The First Affiliated Hospital of Xi ′an Jiaotong University from January 2009 to December 2017 were collected. There were 18 males and 7 females, aged (63±11)years. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3). Count data were described as absolute numbers. Results:(1) Clinical charac-teristics of abdominal infection related secondary hemorrhage after PD. Of 25 patients, there were 21 cases diagnosed with pancreatic fistula, 2 cases with negative for amylase test in abdominal drainage fluid, and 2 cases with unknown conditions of pancreatic fistula. There were 16 cases with sentinel hemorrhage and 9 cases without sentinel hemorrhage. Of 25 patients, 10 cases were evaluated as grade A bleeding, 10 cases were evaluated as grade B bleeding, and 5 cases were evaluated as grade C bleeding. The types of pathogenic microorganisms cultured in the peritoneal drainage fluid of 25 patients included 7 cases of simple Gram positive (G +) bacteria, 6 cases of simple Gram negative (G -) bacteria, 8 cases of both G + bacteria and G - bacteria, 1 case of G + bacteria and fungi, and 3 cases of G + bacteria, G - bacteria and fungi. There were 3 cases cultured with carbapenem-resistant Acinetobacter baumannii. There were 17 patients with fluid accumulation in the D region confirmed by abdominal computered tomography, including 2 cases of simple fluid accumulation in the D region and 15 cases of fluid accumulation in the D region and other regions. Of 25 patients, 12 cases underwent simple conservative medical treatment, 8 cases underwent digital subtraction angiography (DSA) hemostasis, 2 cases underwent DSA combined with surgical hemostasis, 1 case underwent endoscopic hemostasis, 1 case underwent surgical hemostasis, and 1 case underwent endoscopic + DSA hemostasis. Of 25 patients, 5 patients died. (2) Treatment methods and clinical outcomes of patients with abdo-minal infection in different regions of the partition of intra-abdominal infection. Of the 17 patients with clear regions of the partition of intra-abdominal infection, there were 6 cases with D region combined with ≤ 1 other region of the partition of intra-abdominal infection who did not receive surgical treatment survived, there were 11 cases with D region combined with ≥2 other regions of the partition of intra-abdominal infection who mainly received DSA or combined treatment, including 8 cases survived and 3 cases dead. Conclusions:The abdominal infection related secondary hemorrhage after pancreaticoduodenectomy is mainly due to D region of the partition of intra-abdominal infection, and the pathogen mainly presents as mixed infection and multi-drug-resistant bacterial infection. When the spread of infected lesions leads to D region combined with ≥2 other regions of the partition of intra-abdominal infection, the intervention measures are significantly upgraded, and the risk of patient death increases.

It was previously believed that hepatic portal venous gas (HPVG) was an "ominous sign" or "death sign", and once it appeared, the disease progressed rapidly with a high mortality rate which required immediate surgical treatment. However, with the continuous progress of medical technology, researchers have gained a deeper understanding that various causes can lead to HPVG, not all of which required surgical treatment, and the prognosis was not poor. Unfortunately, there is no guideline or consensus on the diagnosis and treatment of HPVG to guide clinical management and standardize diagnostic and therapeutic behaviors. Therefore, the authors review previous literatures with combined clinical diagnosis and treatment experience to conduct profound discussion on the epidemiological features, etiology, pathogenesis, imaging features, treatment strategies, and progno-sis of HPVG, and develop corresponding diagnosis and treatment procedures with the aims to help clinicians to improve diagnostic and therapeutic outcomes and prognosis of patients.

Based on the theory of surgical membrane anatomy and the abnormality of membranous structure under the condition of intra-abdominal infection, the authors creatively propose the concept of partition of intra-abdominal infection, and briefly explain the definition, content and significance, which has caused widespread resonance in the academic community. Combining the clinical practices and relevant literatures, several key issues related with diagnosis and therapy in the view of D region are discussed in depth, aiming at theoretical basis for scientific planning of treatment strategies and optimal system of diagnosis and treatment of intra-abdominal infection.

Objective:To analyze the pathogens distribution, drug resistance and risk factors of bacterial infection in patients undergoing liver transplantation for liver failure.Methods:The retrospective case-control study was conducted. The clinical data of 88 patients with liver failure who underwent liver transplantation in The First Affiliated Hospital of Xi′an Jiaotong University from July 2020 to June 2023 were collected. There were 57 males and 31 females, aged (44±9)years. Observation indicators:(1) incidence and pathogens distribution of bacterial infection in patients undergoing liver transplantation for liver failure; (2) drug resistance of bacteria; (3) risk factors of bacterial infection in patients undergoing liver transplantation for liver failure. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers and percentages. Univariate analysis was conducted using the chi-square test or Fisher exact probability. Multivariate analysis was conducted using the Logistic regression model. Results:(1) Incidence and pathogens distribution of bacterial infection in patients undergoing liver transplantation for liver failure. Of 88 patients, 40 cases had bacterial infection after liver transplantation, with the incidence as 45.45% and occurrence time as postoperative 18(range, 1-57)days. Of the 40 cases with bacterial infection after liver transplantation, 9 cases had single strain infection and 31 cases had mixed bacterial infection. A total of 135 strains of different pathogenic bacteria were isolated from 40 patients, 106 of which were Gram-negative bacteria, 29 were Gram-positive bacteria. Of the Gram-negative bacteria, the top 4 pathogenic bacteria were 37 strains of Acinetobacter baumannii, 35 strains of Klebsiella pneumoniae, 11 strains of Pseudomonas aeruginosa, 9 strains of Stenotrophomonas maltophilia. Of the Gram-positive bacteria, there were 22 strains of Enterococcus faecium, 3 strains of Staphylococcus aureus, 3 strains of Staphylococcus epidermidis, 1 strain of Staphylococcus haemolyticus. Of the 135 strains of pathogenic bacteria, 64 strains were isolated from respiratory tract, 26 strains were from abdomen, 23 strains were from biliary tract, 16 strains were from blood, 6 strains were from other sites. (2) Drug resistance of bacteria. Of the Gram-negative bacteria, Acinetobacter baumannii had a resistance rate of lower than 30.0% to colistin, tigacyclinei, minocycline, a resistance rate of 30.0%-50.0% to amikacin and tobramycin, a resistance rate of over 70.0% to cefotetan, ceftazidime, cefepime, cefoperazone/sulbactam, piperacillin/tazobactam, meropenem, imipenem, ciprofloxacin, cotrimoxazole, levofloxacin. Klebsiella pneumoniae showed a resistance rate of lower than 30.0% to ceftazidime/avibactam, colistin, tigacyclinei and a resistance rate of more than 70.0% to other tested antibiotics. Pseudomonas aeruginosa showed a resistance rate of more than 50.0% to meropenem, imipenem, levofloxacin and a resistance rate of lower than 50.0% to other tested antibiotics. Stenotrophomonas maltophilia showed a resistance rate of lower than 30.0% to cotrimoxazole, levofloxacin, minocycline. Klebsiella oxytoca showed a resistance rate of more than 50.0% to piperacillin/tazobactam, cefoperazone/sulbactam and a resistance rate of lower than 50.0% to other tested antibiotics. The resistance rate of Escherichia coli to amikacin, tobramycin, ceftazidime/avibactam, colistin, and tigecycline was less than 30.0%, and the resistance rate to other tested antibiotics was more than 50.0%. Of the Gram-positive bacteria, Staphylococcus aureus showed a resistance rate of 0 to tigacyclinei, vancomycin, teicoplanin, linezolid, a resistance rate of lower than 50.0% to gentamicin and ciprofloxacin, and a resistance rate of more than 50.0% to erythromycin, penicillin G, ampicillin, tetracycline, levofloxacin. Staphylococcus showed a resistance rate of more than 50.0% to erythromycin, penicillin G, oxacillin, and a resistance rate of 0 to other tested antibiotics. (3) Risk factors of bacterial infection in patients undergoing liver transplantation for liver failure. Results of multivariate analysis showed that preoperative model for end-stage liver disease score ≥30 was an independent risk factor for bacterial infection in patients undergoing liver transplantation for liver failure ( odds ratio=6.440, 95% confidence interval as 2.155-19.248, P<0.05). Conclusions:The incidence of bacterial infection in patients undergoing liver transplantation for liver failure is high, with the most common sites of respiratory tract and abdomen. The pathogenic bacteria are mainly Gram-negative bacteria, which show an extensive and high drug resistance. Preoperative model for end-stage liver disease score ≥30 was an independent risk factor for bacterial infection in patients undergoing liver transplantation for liver failure.

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The injured organ is the main target of treatment. Organic functional reserve refers to the ability of an organ or system to return to its original physiological state following acute physiological stress or pathological injury, which has not received widespread attention. The organ reserve capacity is expected to complement the existing sepsis-related scoring system to optimize disease severity grading and evaluate prognosis. Source control, appropriate using of antibiotics and organ supporting can reduce further damage of organ reserve capacity, while nutritional therapy and rehabilitation may enhance it. Therefore, the authors believe that in further basic theoretical research and clinical practice, more attention can be paid to the monitoring and management of organ reserve capacity in sepsis, which may help improving the diagnosis and treatment of sepsis and prognosis of patients.