Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.
Objective To determine the incidence of vitamin B1 deficiency in critically ill patients, to compare vitamin B1 levels between septic and non-septic patients, and to explore the relationship between vitamin B1 levels and lactate levels. Methods Using a retrospective study method, critically ill patients admitted to the Department of Intensive Care of Nanjing Drum Tower Hospital from February 2022 to November 2022 were included in the study, and the patients were divided into sepsis and non-sepsis groups according to the admission diagnosis, and the differences in the vitamin B1 levels of the patients between the two groups were analyzed, as well as the correlation between the vitamin B1 levels and the lactic acid levels. Results There was a significant difference in serum vitamin B1 levels between the sepsis patients and the non-sepsis patients [(1.6±0.3)ng/mL vs. (2.1±0.2)ng/mL, P=0. 009]. For all patients, there was no correlation between vitamin B1 levels and lactate levels. But when the patient was in a hyperlactate state (lactate level ≥2 mmol/L), vitamin B1 levels were significantly negatively correlated with lactate levels (r=–0. 229, P=0. 004). Conclusions Vitamin B1 deficiency is prevalent in critically ill patients and is strongly correlated with whether or not the patient is septic. Vitamin B1 levels are significantly and negatively correlated with lactate levels when the patient's lactate level is ≥2 mmol/L.
Objective To investigate the value of central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ratio [P(cv-a)CO2/C(a-cv)O2] in predicting oxygen metabolism after fluid resuscitation in patients with septic shock. Methods A prospective observational study was carried out on septic shock patients admitted in the intensive care unit of Nanjng Drum Tower Hospital from November 2013 to April 2014. All patients underwent fluid challenge (300 ml saline for 20 min, rapid intravenous infusion). The patients were divided into a fluid responded group (ΔCI≥10%) and a fluid unresponded group (ΔCI＜10%), according to the change of cardiac output index (ΔCI) after fluid challenge. Then the patients were divided into two subgroups in the fluid responded group, namely a ΔVO2≥10% group and a ΔVO2＜10% group, according to the change of VO2 (ΔVO2). Cardiac output index (CI) were determined by pulse indicator continuous cardiac output (PICCO). Hemoglobin, arterial carbon dioxide (PaCO2), arterial oxygen (PaO2), arterial oxygen saturation (SaO2), arterial blood lactate, central venous carbon dioxide (PcvCO2), central venous oxygen (PcvO2) and central venous oxygen saturation (ScvO2) were measured by blood gas analysis. P(cv-a)CO2/C(a-cv)O2 and oxygen consumption (VO2) were calculated. P(cv-a)CO2/C(a-cv)O2 before and after fluid challenge was compared between two subgroups. Results Fluid challenges were performed in 23 instances in 18 patients, among which 17 instances were defined as the fluid responded group. Compared with the fluid unresponded group, P(cv-a)CO2/C(a-cv)O2, arterial lactate and ScvO2 had no significant difference [P(cv-a)CO2/C(a-cv)O2](mm Hg/ml): 2.05±0.75vs. 1.58±0.67; arterial lactate (mmol/l): 3.78±2.50vs. 3.26±2.42; ScvO2(%): 73.71±9.64vs. 70.30±12.01,P＞0.05] in the fluid responded group before resuscitation. In the fluid responded group, there were 10 instances in the ΔVO2≥10% group and 7 instances in the ΔVO2＜10% group. P(cv-a)CO2/C(a-cv)O2 (mm Hg/ml) was significantly higher in the ΔVO2≥10% group before resuscitation compared with the ΔVO2＜10% group (2.43±0.73vs. 1.51±0.37,P＜0.01). Lactate (mmol/l) was also higher in the ΔVO2≥10% group before resuscitation (4.53±2.52vs. 1.46±0.82,P＜0.01). ScvO2 (%) had no significant difference between two groups (70.79±9.15vs. 72.13±13.42,P＞0.05). The areas under ROC curve (AUCs) of P(cv-a)CO2/C(a-cv)O2, lactate and ScvO2 for predicting ΔVO2≥10% were 0.843, 0.921, and 0.529, respectively. The sensitivity and specificity of P(cv-a)CO2/C(a-cv)O2≥1.885 mm Hg/ml for predicting ΔVO2≥10% after fluid resuscitation were 70% and 86%, respectively. Conclusion For septic shock patients with fluid responsiveness, P(cv-a)CO2/C(a-cv)O2 can predict oxygen metabolism after fluid resuscitation and can be used as a reliable parameter to guide fluid resuscitation.
Objective To investigate the transduction pathway of TREM-1 during endotoxininduced acute lung injury ( ALI) in mice through the specific activating or blocking TREM-1.Methods 40 mice were randomly divided into a saline control group, an ALI group, an antibody group, and a LP17 group ( 3.5 mg/kg) . All mice except the control group were intraperitoneally injected with lipopolysaccharide ( LPS) to establish mouse model of ALI. Two hours after LPS injection, anti-TREM-1mAb ( 250 μg/kg) was intraperitoneally injected in the antibody group to activation TREM-1, and synthetic peptide LP17 was injected via tail vein in the LP17 group to blocking TREM-1. After 6,12,24, 48 hours, 3 mice in each group were sacrificed for sampling. The expression of NF-κB in lung tissue was determined by immunohistochemistry. The levels of TNF-α, IL-10, TREM-1, and soluble TREM-1 ( sTREM-1) in lung tissue and serumwere measured by ELISA. Pathology changes of lung were observed under light microscope, and Smith’s score of pathology was compared. Results Administration of anti-TREM-1mAb after ALI modeling significantly increased the NF-κB expression in lung tissue at 48h, resulting in a large number of pro-inflammatory cytokines releasing in the lung tissue and serumand lung pathology Smith score increasing. Administration of LP17 after modeling significantly down-regulated the expressions of NF-κB and pro-inflammatory cytokines, while led to a slight increase of anti-inflammatory cytokines and a decline of lung pathology Smith’s score.Conclusion TREM-1 may involve in inflammatory response by promoting the generation of inflammatory factors via NF-κB pathway, thus lead to lung pathological changes in ALI.
Objective To explore the relationship between central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ration [P(cv-a)CO2/C(a-cv)O2] and arterial lactate in patients with sepsis. Methods A retrospective analysis was carried on 36 septic patients who were admitted to the Intensive Care Unit of Nanjng Drum-tower Hospital affiliated to Medical School of Nanjing University from May 2013 to November 2013. Cardiac index was measured by transpulmonary thermodilution. At the same time, femoral artery and central venous blood were collected to measure the value of arterial lactate and central venous oxygen saturation (ScvO2) by blood gas analysis and calculate central venous-to-arterial carbon dioxide difference [P(cv-a)CO2], arterial-to-venous oxygen difference [C(a-cv)O2], and their ration [P(cv-a)CO2/C(a-cv)O2], oxygen delivery (DO2) and oxygen consumption (VO2). The subjects were divided intoahyperlactatemia group (≥2 mmol/L) andanormal lactate group (< 2 mmol/L) according to arterial lactate value. P(cv-a)CO2/C(a-cv)O2 and other oxygen metabolism parameters were compared between two groups. Receiver operating characteristic (ROC) curve was used to evaluate the accuracy of P(cv-a)CO2/C(a-cv)O2 and other parameters for diagnosis of hyperlactatemia. Results A total of 36 patients with 119 data were collected. Compared with the normal lactate group, P(cv-a)CO2/C(a-cv)O2 was significantly higher [(1.38±0.76)mm Hg/mL vs. (2.31±1.01) mm Hg/mL, P < 0.01], ScvO2, DO2 and VO2 were significantly lower in the hyperlactatemia group [ScvO2: (74.26±9.13)% vs. (70.29±9.72)%; DO2: (505.52±208.39) mL/(min·m2) vs. (429.98±173.63) mL/(min·m2)]; VO2: (129.01±54.94) mL/(min·m2) vs. (109.99±38.79) mL/(min·m2), P < 0.05]. P(cv-a)CO2 had no significant difference between two groups [(5.76±3.70) mm Hg vs. (6.59±3.70) mm Hg, P > 0.05]. P(cv-a)CO2/C(a-cv)O2 was positively correlated with lactate (r=0.646, P < 0.01). ScvO2 was negatively correlated with lactate (r=-0.277, P < 0.01). DO2 and VO2 had no significant correlation with lactate (P > 0.05). The area under ROC curve (AUC) of P(cv-a)CO2 /C(a-cv)O2 for diagnosis of hyperlactatemia was 0.820, with 95% confidence interval (95%CI) of 0.715 - 0.925(P < 0.001); The AUC of ScvO2 was 0.622, with 95%CI of 0.520 - 0.724(P=0.025). Conclusion Compared with the traditional oxygen metabolism parameters, P(cv-a)CO2/C(a-cv)O2 can accurately diagnose hyperlactatemia, and isareliable parameter to reflect oxygen metabolism in patients with sepsis.
0bjective To compare the effect of closed airway management system and open suction system on distribution and drug susceptibility of pathogenic bacteria in lower respiratory tract of mechanical ventilated patients.Methods Fifty-nine cases in ICU who received mechanical ventilation for more than 48 h from May 2006 to Dec 2006 were randomly divided into two groups.Group A(29 patients)received closed—tracheal suction and Group B(30 patients)received open-tracheal suction.Quantitative bacteriological culture and sensitivity of antibacterial drugs were conducted on lower respiratory tract secretion samples.Results In group A，a total of 91 strains were isolated，in which a single pathogen infection(41.4％)was the most frequent，followed by mixed infection of two pathogens(34.5％)and three or more pathogens(24.1％).In group B，a total of 141 strains were isolated，in which three or more pathogen infection(53.33％)was the most frequent，followed by two pathogen infection(30％)and a single pathogen infection(16.7％ ).Pathogen distribution between the two groups was not significantly different(Pgt;0.05).Drug susceptibility test did not show significant difference in main pathogens between the two groups(Pgt;0.05).Conclusions Closed airway management system can reduce the infection or colonization of mixed pathogens，but can not change the distribution and drug susceptibility of pathogens.