This case describes an 82-year-old male patient presenting with persistent upper abdominal colic, diagnosed as severe acute pancreatitis. The patient then suffered a cytokine storm, as well as renal dysfunction. Therefore, the patient underwent two sessions of coupled plasma filtration adsorption (CPFA) therapy utilising the CA330 cytokine adsorption cartridge as the adsorbent. The first CPFA session lasted 8 h, followed by a 4-h interval (during which continuous veno-venous haemodialysis therapy was provided), and the second 8-h CPFA session started. Due to family requests and comprehensive consideration by the medical team, the second CPFA session was extended to 20 h. Ultimately, the patient was weaned off blood purification therapy (43 h after its initiation). The study demonstrated a significant reduction in cytokine levels as the course of treatment increased. However, beyond a specific threshold, cytokine adsorption may reach saturation. The medicinal applications of CPFA (particularly CA330) deserve more investigation.

A 48-year-old male patient was diagnosed with critical acute pancreatitis, renal dysfunction and liver dysfunction. Because of the presence of multiorgan dysfunction, continuous renal replacement therapy (CRRT) was required on the first day of the patient's admission to the ICU in order to help stabilize the patient's internal environment. Meanwhile, the patient also received a total of five double plasma molecular adsorption system plus sequential half-dose plasmapheresis (DPMAS-PE) treatments, of which the first, fourth, and fifth DPMAS-PE treatments were chosen to be administered concurrently with CRRT. This report is to clarify how four CRRT machines using three parallel modalities successfully completed DPMAS-PE in tandem with CRRT (DPMAS-PE-CRRT). Furthermore, DPMAS-PE-CRRT showed similar effectiveness in removing total bilirubin and total bile acid when compared to nonparallel CRRT. During the parallel therapy, there were no serious adverse reactions. To validate this case, more clinical trials are needed.

BACKGROUND:Catheter-related bloodstream infections (CRBSIs) are a major cause of complications in critically ill patients receiving continuous renal replacement therapy (CRRT), especially those with nontunneled catheters. These infections can lead to longer hospital stays, higher costs, and worse patient outcomes. Although sterile dressings are commonly used to prevent CRBSIs, antimicrobial dressings, such as those containing chlorhexidine, may offer better protection. This study aimed to compare the effectiveness of antimicrobial glucose chlorhexidine dressings and sterile dressings in preventing CRBSIs in patients receiving CRRT. METHODS:A prospective, randomized controlled, single-blind study was conducted. All participants were kept blinded to group assignment. We enrolled patients admitted to the Intensive Care Unit (ICU) of West China Hospital, Sichuan University between September 2022 and November 2023 who were scheduled for vascular catheter placement before receiving continuous renal replacement therapy (CRRT). The participants were randomly allocated to either the intervention group (receiving glucose chlorhexidine antimicrobial dressing) or the control group (receiving sterile dressing) via a random number table. The dressing was changed every 7 days for the glucose chlorhexidine antimicrobial group and every 48 h for the sterile dressing group, in accordance with the guideline. Dressings were replaced immediately if they became rolled, loose, or visibly soiled. The primary outcomes were the local infection rate at the catheter insertion site, suspected catheter-related bloodstream infections (CRBSIs), incidence of CRBSIs, length of hospital stay, ICU stay duration, and hospital mortality rates. RESULTS:A total of 520 patients were screened, and 410 patients were ultimately included in the study, with 205 patients in each group (glucose chlorhexidine antimicrobial dressing group and sterile dressing group). The incidence of local infection at the catheter insertion site was 40.0% in the sterile dressing group, which was significantly greater than the 15.6% reported in the glucose chlorhexidine antimicrobial dressing group (p < 0.001). The total CRBSI rate in the intervention group was significantly lower (6.3%) than that in the control group (13.7%) (p = 0.014). No significant differences were found between the two groups in terms of suspected catheter-related bloodstream infections (CRBSIs), CRBSI incidence, length of hospital stay, ICU stay duration, or hospital mortality rates (p > 0.05). The Cox proportional hazards model suggested that patients in the control group were at a substantially greater risk of local infections and CRBSIs over time than those in the intervention group. CONCLUSION:Glucose chlorhexidine antimicrobial dressings significantly reduce catheter insertion site infections and overall CRBSI incidence, demonstrating their clinical value in preventing infection in patients receiving CRRT.

Regional citrate anticoagulation (RCA) is standard in continuous renal replacement therapy (CRRT). Post-Filter ionized calcium (Post-Filter iCa) is the gold standard for monitoring anticoagulation efficacy, but it requires blood sampling. Effluent fluid iCa can be measured without blood sampling. This study assessed the correlation and agreement between Effluent Fluid iCa and Post-Filter iCa in critically ill patients undergoing RCA-CRRT. We conducted a prospective non-interventional study from June to November 2024 at West China Hospital of Sichuan University. Thirty-six critically ill patients receiving CVVHDF with RCA were enrolled, yielding 216 paired samples. Ionized calcium was measured in Pre-Filter, Post-Filter, and Effluent Fluid samples using a point-of-care analyzer. CRRT was performed using the Prismaflex system with ST150 filters and Oxiris tubing. Post-filter blood and effluent fluid samples were drawn simultaneously to ensure direct comparability. This study analyzed 216 paired samples from 36 critically ill patients on CVVHDF with RCA to assess the relationship between Post-Filter and Effluent Fluid ionized calcium. A moderate correlation was found (r = 0.551 [CI 0.45,0.64], p < 0.001). Bland-Altman analysis showed a mean difference of − 0.024 mmol/L (95

Introduction Nafamostat mesylate (NM) is widely recognised as a premier anticoagulant, especially in Japan and Korea. However, it has not yet been used as an anticoagulant in double plasma molecular adsorption system (DPMAS) plus sequential half-dose plasmapheresis (PE) therapy. This study aims to comprehensively evaluate the safety and efficacy of NM-integrated anticoagulation during DPMAS plus sequential half-dose PE therapy for patients with liver failure.Methods and analysis A two-arm, open-label, parallel, randomised controlled trial involving 132 patients with liver failure will be conducted in China. Eligible participants will be randomly allocated to either the nafamostat mesylate integrative anticoagulation group or the heparin integrative anticoagulation group, employing a central randomisation system at a 1:1 ratio throughout the course of DPMAS plus sequential half-dose PE therapy. The primary outcome includes the number of successfully completed DPMAS plus sequential half-dose PE therapy. The secondary outcomes include liver function indicators, extracorporeal circulation pressures, coagulation function parameters, all-cause mortality rates and survival rates. Clinical safety will be assessed by analysis of the number of bleeding events, the number of clotting events and adverse events. Outcome analyses will be performed on both the intention-to-treat population, which includes all patients randomised, and the per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups.Ethics and dissemination The trial protocol was approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (approval number (2022)860). During the protocol revision process, all changes were reexamined and reapproved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University. The results will be presented at national and international conferences and published in peer-reviewed journals.Trial registration number ChiCTR2200064725.

INTRODUCTION:Regional citrate anticoagulation (RCA) is now recommended as the first choice of anticoagulation for continuous renal replacement therapy (CRRT). However, impaired citrate metabolism can lead to citrate accumulation (CA), resulting in severe metabolic acidosis and hypocalcemia, which poses a challenge for clinicians when making decision about the use of RCA. METHODS:In this retrospective cohort study performed in West China Hospital of Sichuan University, we evaluated patients who underwent RCA-CRRT from 2021 to 2023. Participants were randomly allocated into training and validation groups at a 7:3 ratio. In the training group, significant risk factors for CA were determined by a binary logistic regression analysis and established a risk prediction model, and the validation group validated and evaluated the model. A nomogram was constructed to visualize the prediction model, calibration and receiver operating characteristic (ROC) curves were used to evaluate the prediction accuracy, and decision curve analysis (DCA) was used to evaluate the clinical effectiveness. RESULTS:Of the 1,259 patients with RCA-CRRT, 882 were randomly stratified into the training group and 377 into the validation group. CA was reported in 16.2% and 16.7%, respectively. We developed and validated a nomogram to predict the risk of CA, incorporating significant factors including male, age, body surface area, citrate concentration, systolic blood pressure, lactate, total bilirubin, and international normalized ratio. The area under the ROC curve of the nomogram was 0.760 (95% CI, 0.737-0.765) and 0.752 (95% CI, 0.744-0.787) in both groups. The calibration curve further confirmed its effective discrimination and calibration abilities. DCA analysis emphasized its clinical utility when the CA probability threshold for intervention is between 11% and 76%. CONCLUSION:We developed and validated a prediction model for CA in critically ill patients who received RCA-CRRT, providing a basis for clinicians to develop individualized anticoagulation protocols.

The demand for double-filtration plasmapheresis (DFPP) in clinical settings is growing steadily, yet the range and availability of specialized equipment designed to support DFPP are relatively limited. We aimed to assess the efficacy and safety of a designed auxiliary line for DFPP treatment using standard continuous renal replacement treatment (CRRT) machines. This prospective self-controlled study was conducted between May 2021 and April 2024. Patients who underwent DFPP treatment using both specialized DFPP machines and standard CRRT machines (using designed auxiliary line) were enrolled in the study. DFPP sessions were divided into the specialized DFPP machine group and the standard CRRT machine group. The rates of completed DFPP treatments, DFPP cost, circuit clotting, hypotension, anaphylaxis, hypocalcemia, and nurse operating time were compared. A total of 440 DFPP sessions were performed for 80 patients, with 330 (75.0%) sessions in the specialized DFPP machine group and 110 (25.0%) in the standard CRRT machine group. There were no statistically significant differences between the two groups in terms of the completed DFPP treatment rate (89.4% vs. 88.2%, p = 0.724), circuit clotting (8.2% vs. 7.3%, p = 0.760), anaphylaxis (12.7% vs. 11.8%, p = 0.803), hypotension (10.6% vs. 9.1%, p = 0.650), hypocalcemia (17.3% vs. 20.0%, p = 0.519), and nurse operation time (35.08 ± 2.27 min vs. 36.62 ± 1.94 min, p = 0.082). However, the cost per DFPP session in the standard CRRT machine group was lower than in the specialized DFPP machine (976.81 ± 14.38 $ vs. 1007.43 ± 35.30 $, p < 0.001). Standard CRRT machines can effectively and safely perform DFPP treatment using a specially designed auxiliary line, which is more cost-effective. Even in primary hospitals without specialized DFPP machines, CRRT machines can be used to perform DFPP treatment.

Regional citrate anticoagulation (RCA) is the preferred strategy during continuous renal replacement therapy (CRRT). However, saline flushing is often used when anticoagulants are contraindicated, although its effectiveness remains uncertain. This study evaluated the efficacy of different saline flushing strategies in preventing circuit clotting during anticoagulant-free CRRT in critically ill patients. This prospective, three-arm randomized controlled trial included critically ill patients initiating CRRT who had contraindications to anticoagulants. Patients were randomized into three groups: 30-minute flush (200 mL every 30 minutes), 2-hour flush (200 mL every 2 hours), or no flush. The primary outcome was circuit lifespan. The secondary outcomes included the delivered CRRT dose, filtration fraction, nurse satisfaction, length of hospital stay, 28-day mortality, and hypotension incidence within 2 hours of CRRT initiation. Among 144 randomized patients, 117 (81

This study aimed to assess the safety and therapeutic efficacy of increasing the dosage of the double plasma molecular adsorption system (DPMAS) in patients with liver failure during regional citrate anticoagulation (RCA). A prospective nonrandomized controlled trial was conducted. Three groups (3 L group, 4.5 L group, and 6 L group) of patients with liver failure receiving DPMAS treatment were created on the basis of various therapeutic plasma volumes. A total of 303 patients were included, with 110 in the 3 L group, 121 in the 4.5 L group, and 72 in the 6 L group. At the end of treatment, there was a statistically significant difference in the bilirubin clearance rate among the groups (H = 15.239, p < 0.001). Pairwise comparisons revealed that only the difference in the bilirubin clearance rates between the 6 L group and the 3 L group was statistically significant (p < 0.001). With the exception of base excess, no statistically significant differences were found between these three groups for any of the relevant laboratory indicators (p > 0.05). The incidence of hypotension, hypocalcemia, acidosis, alkalosis, hypernatremia, hyperlactatemia, and allergic reactions did not differ significantly among these three groups (p > 0.05). Furthermore, a statistically significant difference was found in clotting events among these three groups (p = 0.027), with a higher incidence observed in the 6 L group than in the 3 L group (p = 0.011). Increasing the therapeutic dose of RCA-DPMAS further removed bilirubin and did not increase the complications associated with citrate anticoagulation, but the coagulation risk is a concern.

BackgroundCircuit clotting remains a major problem during continuous kidney replacement therapy (CKRT), particularly in patients with contraindications to anticoagulant use. We hypothesized that the different options of alternative replacement fluid infusion sites might affect circuit lifespan. However, research-based evidence supporting an optimal replacement fluid infusion strategy is limited. Therefore, we aimed to evaluate the effect of three dilution modes (pre-dilution, post-dilution, and pre- to post-dilution) on circuit lifespan during continuous veno-venous hemodiafiltration (CVVHDF). MethodsThis prospective cohort study was conducted between December 2019 and December 2020. Patients requiring CKRT were enrolled to receive pre-dilution, post-dilution, or pre- to post-dilution fluid infusion with CVVHDF. The primary endpoint was circuit lifespan, and the secondary outcomes included the clinical parameters of patients, such as changes in serum creatinine (Scr) and blood urea nitrogen (BUN) levels, 28-day all-cause mortality, and length of stay. For all patients included in this study, only the first circuit used was recorded. ResultsAmong the 132 patients enrolled in this study, 40 were in the pre-dilution mode, 42 were in the post-dilution mode, and 50 were in the pre- to post-dilution mode. The mean circuit lifespan was significantly longer in the pre- to post-dilution group (45.72 h, 95% CI, 39.75-51.69 h) than in the pre-dilution group (31.58 h, 95% CI, 26.33-36.82 h) and the post-dilution group (35.20 h, 95% CI, 29.62-40.78 h). There was no significant difference between the pre- and post-dilution group circuit lifespan (p > 0.05). Kaplan-Meier survival analysis revealed a significant difference between the three dilution modes (p = 0.001). No significant differences were observed in terms of changes in the Scr and BUN levels, admission day, and 28-day all-cause mortality among the three dilution groups (p > 0.05). ConclusionThe pre- to post-dilution mode significantly prolonged circuit lifespan but did not reduce Scr and BUN levels, compared with the pre-dilution and post-dilution modes during CVVHDF when no anticoagulants were used.

目的 探讨磺达肝癸钠、低分子肝素(low molecular weight heparin,LMWH)这2种不同抗凝方案在连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)中应用的安全性和有效性.方法 回顾性分析2021年10月-2022年4月在四川大学华西医院行CRRT患者的临床资料.根据患者在CRRT期间使用磺达肝癸钠还是LMWH抗凝,分为磺达肝癸钠组和LMWH组.比较2组患者的一般情况、体外循环寿命、凝血事件、出血事件、血红蛋白、凝血功能相关指标的差异.结果 最终纳入78例次患者,其中LMWH组38例,磺达肝癸钠组40例.LMWH组患者年龄比磺达肝癸钠组大[76.0(57.0,85.0)vs.63.0(52.3,76.0)岁,P=0.016],2组患者其余临床基线情况(包括性别、血管通路部位、治疗指征)差异无统计学意义(P≥0.05).磺达肝癸钠组患者的体外循环寿命优于 LMWH 组[67.1(35.0,72.0)vs.42.0(20.0,55.3)h,P=0.003].磺达肝癸钠组 24、48、72 h 体外循环存活率均高于 LMWH 组(87.5％vs.65.8％,P=0.023;67.5％vs.36.8％,P=0.007;42.5％vs.13.2％,P=0.004).磺达肝癸钠组的血滤器凝血事件发生率低于LMWH组(50.0％vs.84.2％,P=0.001),2组患者的静脉壶凝血事件发生率和轻度出血事件发生率差异无统计学意义(P＞0.05).接受CRRT前后,2组患者的血红蛋白、凝血功能相关指标差异无统计学意义(P＞0.05).结论 磺达肝癸钠维持治疗连续性优于LMWH,且两者在CRRT过程中安全性相当.

To evaluate the efficacy and safety of topical oxygen therapy (TOT) in diabetic foot ulcers (DFUs), researchers systematically retrieved relevant studies from PubMed, EMBASE, Web of Science, CENTRAL and ClinicalTrials.gov. Relevant studies were searched from database inception to January 2022. Two researchers independently screened the literature, extracted data and assessed the quality of the included studies. Statistical analysis was performed in Stata 16.0. A total of seven RCTs involving 614 participants were included. Compared with the control group, the TOT group had a higher healing rate (RR = 1.63, 95% CI [1.33, 2.00]). According to descriptive analysis, TOT reduced the ulcer area and improved healing durability and quality of life. Furthermore, it had no effect on the occurrence of adverse events. However, it was unclear whether it would be able to reduce the healing time. The existing evidence suggests that TOT is effective and safe for chronic DFUs. Further studies are warranted to validate our findings.

目的 研发连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)护理信息化系统,旨在解决临床护理记录保存、资源共享、人力成本等问题,为患者提供安全优质护理.方法 采用问卷调查、文献检索和会议讨论,优选CRRT护理信息化系统所需信息项.从医院信息系统自动获取数据并进行解析、分类、可视化.通过问卷调查和质量管理,评价系统应用效果.结果 CRRT护理信息化系统共9大类128项,包括患者基本信息16项、CRRT治疗前护理评估20项、调整医嘱执行6项、用药医嘱执行17项、CRRT治疗过程中护理监测23项、护理措施3项、床旁血气分析20项、出入量总结6项、CRRT治疗后护理评估17项.与人工录入组相比,信息化组临床护理总时间明显缩短(t=29.305,P＜0.001).结论 CRRT护理信息化系统能优化CRRT护理流程,保障护理记录质量,提高工作效率,促进科研产出.

现有抗凝剂可能存在相应的使用禁忌和副作用,以致于无抗凝连续性肾脏替代治疗(con-tinuous renal replacement therapy,CRRT)仍很常见.甲磺酸萘莫司他(nafamostatmesylate,NM)半衰期短,能降低危重患者血液净化时出血风险,在韩国和日本被广泛应用于体外循环回路抗凝.然而,NM抗凝的标准处方、有效剂量、监测方法等尚未形成共识.笔者综述CRRT患者采用NM抗凝的作用机制、使用方法、抗凝效果、局限性等,为后续研究提供参考.

Background: Aspirin is widely used as an antiplatelet agent for secondary prevention in patients with atherosclerotic cardiovascular disease. However, it remains unclear whether aspirin can prevent the progression of carotid atherosclerosis or reduce vascular events and all-cause death.Methods: We performed a meta-analysis of the effect of aspirin in asymptomatic carotid atherosclerotic patients. Electronic databases including Pubmed, EMBase, ISI Web, Medline, Cochrane, and clinicaltrial.gov were searched for relevant randomized controlled trials. A total of five studies (841 individuals, 2,145 person-years) were included in this study. Two reviewers independently performed the study assessment and data extraction. Forest plots were used to assess the efficacy of aspirin. Egger’s test was used to evaluate publication bias.Results: Aspirin did not alleviate the progression of carotid intima-media thickness (cIMT) compared with control patients (WMD: −0.05 mm, 95% confidence interval 95%CI: −0.12, 0.03). In subset analysis, aspirin was only associated with regression of cIMT when compared with the empty/placebo group (WMD: −0.10 mm, 95%CI: −0.18, −0.02). In type 2 diabetes mellitus, there were no statistical significance between groups (WMD: 0.10 mm, 95%CI: −0.31, 0.50). For the main vascular events and all-cause death, there were no differences between the aspirin group (RR: 0.73, 95%CI: 0.41, 1.31) and the control group (RR: 0.88, 95%CI: 0.41, 1.90). For outcome events, similar results were observed when patients were classified by different cIMT value (p > 0.05). The risk of gastrointestinal bleeding was similar between participants receiving and not receiving aspirin therapy (RR: 1.04, 95%CI: 0.07, 16.46).Conclusion: In patients with asymptomatic carotid atherosclerosis, low-dose aspirin may slightly alleviate the progression of cIMT, but does not reduce vascular events and all-cause death.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier PROSPERO

呼吸衰竭患者因肺泡的通气及换气功能严重受损,在进行机械通气时可能会出现严重的二氧化碳(carbon dioxide,CO2)潴留[1].CO2潴留可能引起酸中毒或高碳酸血症,重则导致心脑血管问题、呼吸抑制,甚至死亡[2-4].临床医生通过调整容量负荷、启用呼吸机及俯卧位通气来改善CO2潴留[5],但效果不佳.虽然体外膜氧合(extracorporeal membrane oxygenation,ECMO)常用于危重症患者的呼吸循环支持治疗,但是存在费用高、操作复杂、机器数量少等局限性.体外二氧化碳去除(extracorporeal carbon dioxide removal,ECCO2R)是一种通过体外气体交换器从血液中去除CO2来提供人工呼吸支持的技术[6-7].已有研究表明急性呼吸窘迫综合征合并急性肾损伤患者进行ECCO2R联合连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)安全有效,并能增强肺保护性通气[8-9].目前,国内尚缺少CRRT联合ECCO2R清除CO2的报道.本文就1例呼吸衰竭合并高碳酸血症患者使用CRRT+ECCO2R的应用经验报道如下.

糖尿病足溃疡难治愈，易复发，远期预后差。糖尿病足溃疡标准治疗效果有限，发展辅助治疗已成为新趋势。目前，局部氧疗辅助治疗糖尿病足溃疡有助于创面愈合，特别是慢性创面，但目前尚缺少高质量循证证据支持，并且临床医师对局部氧疗缺少了解。因此，笔者通过综述创面愈合与氧气的关系，局部氧疗原理、发展与演变、常见形式及优缺点，国内发展现状等，以期提高临床医师对局部氧疗的认识和重视，使糖尿病足溃疡患者从中获益。

1 缺血性脑卒中概述 脑卒中俗称中风,是一种突发、进展迅速的脑缺血性或出血性疾病,复发率、致残率、致死率极高[1].缺血性脑卒中是一种因脑供血不足导致脑组织缺血缺氧性病变坏死的急性脑血管疾病,是脑卒中的主要类型.近年来,随着生活节奏的加快、老龄化加剧等原因,缺血性脑卒中的发病率逐年递增.最新全球疾病负担研究(Global Burdenof Disease Study,GBD)显示,我国总体卒中终生发病风险为39.90％,位居全球首位;2018年我国居民因脑血管病致死比例超过20.00％[2].患者在病情早期时会出现言语不清、一侧肢体麻木、双眼向一侧凝视或意识障碍等症状,及时对患者的病情进行诊断与评估,在有效时间窗内提高缺血脑组织的再灌注是临床治疗的关键[3-4].