ObjectivesThe purpose of this study was to evaluate the performance of urinary C-C motif chemokine ligand 14 (CCL14) and the renal resistive index (RI) in predicting persistent AKI in unselected critically ill patients.MethodsThis prospective observational study was conducted in a tertiary hospital's general intensive care unit (ICU). Consecutive adults who were admitted to the ICU were enrolled, with a primary endpoint of AKI lasting 48 h or longer. Urinary CCL14 was evaluated upon inclusion, and the renal RI was determined within 12 h of ICU admission. The individual discriminative ability of urinary CCL14 and the renal RI to predict persistent AKI was evaluated by the area under the receiver operating characteristic curve (AUC).ResultsOverall, 166 patients were included, of whom 56 had persistent AKI. Urinary CCL14 showed good ability to predict persistent AKI, with an AUC of 0.817. However, the overall performance of the renal RI was fair, with an AUC of 0.739. Forty-nine patients presented with mild AKI at inclusion, and the values of CCL14 were significantly lower than those of patients with moderate or severe AKI (0.205 [0.125-0.300] vs. 0.302 [0.157-0.501]; p = 0.034). In the subgroup analysis, although the diagnostic performance of CCL14 was excellent in patients with moderate or severe AKI, it was fair in patients with mild AKI [AUC = 0. 738; 95% confidence interval (CI) 0.593-0.853].ConclusionUrinary CCL14 was an excellent predictor of persistent AKI in patients with moderate or severe AKI, but its performance was not good in patients with mild AKI. The renal RI cannot discriminate between transient and persistent AKI.

目的 观察微小RNA-21(miR-21)对脓毒症小鼠急性肺损伤(ALI)的改善作用,并探讨其可能作用机制.方法 40只雄性昆明小鼠随机分为miR-21前体 + ALI组(Pre-miR-21 + ALI组)、miR-21前体 + 磷脂酰肌醇3 激酶(phosphatidylinositol 3 kinase,PI-3K)/丝氨酸-苏氨酸蛋白激酶(Akt)抑制剂LY294002 + ALI组(Pre-miR-21 + LY + ALI组)、PI3K/Akt抑制剂LY294002 + ALI组(LY + ALI组)、ALI组、假手术组,每组各8只.ALI组小鼠采用盲肠结扎穿孔术(CLP)造成脓毒症ALI;Pre-miR-21 + ALI组小鼠先尾静脉注射miR-21 前体腺病毒 0.2 mL(1×109pfu/mL),4天后采用CLP造成脓毒症ALI;Pre-miR-21 + LY + ALI组小鼠先尾静脉注射miR-21前体腺病毒0.2ml(1×109pfu/mL),4天后尾静脉注射LY(0.3 mg/g),注射30 min后进行CLP;LY + ALI组小鼠先尾静脉注射LY(0.3 mg/g),注射30 min后进行CLP;假手术组小鼠仅开腹探查盲肠.干预24 h时麻醉各组小鼠后取腹主动脉血,测算各组小鼠氧合指数(OI),采用ELISA法检测血清炎症因子TNF-α、IL-6和氧化应激指标ROS、SOD;处死各组小鼠后取右肺组织,HE染色观察肺组织病理学变化,测算肺组织肺湿重/干重比值(W/D);取各组小鼠左肺组织,采用qRT-PCR法检测miR-21,采用WESTERN Blotting法检测各组小鼠左肺组织磷脂酶和张力蛋白同源物(PTEN)、磷酸化Akt(p-Akt)蛋白.结果 与假手术组比较,ALI组小鼠OI下降,血清TNF-α、IL-6、ROS、SOD水平、肺组织W/D、miR-21表达升高(P均<0.05),光镜下可见肺泡结构破坏、肺泡出血,PTEN蛋白相对表达量下降,p-Akt蛋白相对表达量增加(P均<0.05);与ALI组比较,Pre-miR-21 + ALI组小鼠OI高,血清TNF-α、IL-6、ROS、SOD水平、肺组织W/D降低,miR-21相对表达量高(P均<0.05),光镜下可见肺泡结构破坏、肺泡出血减轻,PTEN蛋白相对表达量下降,p-Akt蛋白相对表达量增加(P均<0.05);与ALI组比较,Pre-miR-21 + LY + ALI组OI降低,血清TNF-α、IL-6、ROS、SOD水平、肺组织W/D、miR-21相对表达量升高(P均<0.05),光镜下可见肺泡结构破坏、肺泡出血加重,PTEN蛋白相对表达量下降,p-Akt蛋白相对表达量升高(P均<0.05);与ALI组比较,LY + ALI组OI降低,血清TNF-α、IL-6、ROS、SOD水平、肺组织W/D升高(P均<0.05),肺泡结构破坏、肺泡出血加重;与Pre-miR-21 + LY + ALI组比较,LY + ALI组OI降低,血清TNF-α、IL-6、ROS、SOD水平、肺组织W/D升高,miR-21相对表达量下降(P均<0.05),光镜下可见肺泡结构破坏、肺泡出血加重,PTEN蛋白相对表达量升高,p-Akt蛋白相对表达量下降(P均<0.05).结论 尾静脉预注射miR-21前体腺病毒的脓毒症小鼠急性肺损伤程度较轻,肺组织PTEN蛋白相对表达量低、p-Akt蛋白相对表达量高.miR-21可能通过抑制肺组织PTEN表达、促进p-Akt表达,减轻脓毒症小鼠肺组织炎症反应和氧化应激水平,从而减轻脓毒症小鼠ALI.

目的 分析影响脓毒症休克患者肾阻力指数(RRI)的因素.方法 前瞻性观察研究,选取该院重症医学科2017年11月至2018年10月连续收治的脓毒症休克患者117例,以RRI值是否≥0.74分为高RRI组(RRI值≥0.74)和低RRI组(RRI值<0.74),比较两组患者的性别、年龄、基础疾病、感染部位、急性生理和慢性健康状况评分Ⅱ(APACHEⅡ评分)、序贯器官功能衰竭评分(SOFA)、血流动力学指标[心率、收缩压、舒张压、平均动脉压(MAP)、中心静脉压、心脏指数]、去甲肾上腺素用量及实验室指标,发生急性肾损伤(AKI)的比例、需肾脏替代治疗(RRT)的比例、重症监护室(ICU)住院时间、ICU死亡率、28 d死亡率等.采用logistic回归分析确定脓毒症休克患者RRI的影响因素.结果 剔除10例患者,最终纳入107例,其中高RRI组42例,低RRI组65例.两组年龄、高血压患者百分比、APACHEⅡ评分、SOFA、舒张压、MAP、ICU死亡率、28 d死亡率有明显差异(P<0.05).单因素logistic回归分析发现,年龄、高血压、APACHEⅡ评分、SOFA、舒张压、MAP与RRI有关.将以上因素纳入多因素logistic回归分析,结果显示,年龄[OR=1.068,95％CI(1.024,1.113),P=0.002]、MAP[OR=0.932,95％CI(0.879,0.988),P=0.043]为脓毒症休克患者RRI的影响因素.结论 年龄、MAP为脓毒症休克患者RRI的影响因素.

目的 应用胃肠超声监测胃残余量及胃窦动力,探讨其在机械通气患者营养治疗中的应用价值.方法 选择呼吸衰竭需行机械通气的患者98例,随机分为2组,对照组及观察组各49例,观察组应用超声每4～6 h进行一次ACF、ACA和MI及GRV监测.对照组经验性给予肠内营养,根据肠内营养耐受性评分调整肠内营养泵入速度.结果 肠内营养开始时间、达到80％ 目标喂养量时间观察组短于对照组,差异有统计学意义(P<0.05);72 h达到80％ 目标喂养量比例观察组高于对照组,差异有统计学意义(P<0.05).结论 胃肠超声监测胃残余量及胃窦动力可为机械通气的呼吸衰竭患者制定个体化的营养治疗方案,有助于尽早启动肠内营养,尽快达到目标喂养量.

目的 探讨床旁胃肠超声联合肠内营养耐受性评分在中重症急性胰腺炎患者营养治疗中的作用.方法 选择中重症急性胰腺炎患者54例,随机分为观察组和对照组各27例.观察组应用床旁胃肠超声联合肠内营养耐受性评分指导肠内营养治疗,对照组根据胃残余量及肠内营养耐受性评分指导肠内营养治疗.对比两组首次置入鼻肠管成功率、置管成功时间、肠内营养开始时间、达到70％目标喂养量时间及96 h达到70％目标喂养量比例,并发症发生情况,住ICU时间及28 d病死例数.结果 观察组21例进行鼻肠管置入,超声引导下首次置管成功18例(85.7％);对照组20例进行鼻肠管置入,盲插法首次置管成功13例(65％).两组首次置管成功率比较差异无统计学意义(P>0.05).观察组、对照组置管成功时间分别为2(1,3)、3(2,4)h,观察组置管成功时间短于对照组(P<0.05).观察组肠内营养开始时间、达到70％目标喂养量时间及96 h达到70％目标喂养量比例分别为2.5(2.1,3.0)、2.3(1.7,3.0)d及20例(74.1％);对照组分别为2(1.7,2.5)、3.5(2.4,5.0)及12例(44.4％).观察组肠内营养开始时间、达到70％目标喂养量时间均短于对照组(P均<0.05),96 h到达70％目标喂养量比例高于对照组(P<0.05).观察组发生反流、误吸、营养中断分别为2、1、2例;对照组发生反流、误吸、营养中断分别为3、1、3例.两组并发症发生情况比较差异无统计学意义(P>0.05).观察组住ICU时间及28 d病死例数分别为7.9(6.5,10)d、3例;对照组住ICU时间及28 d病死例数分别为12(5.8,13)、4例.两组住ICU时间及28 d病死例数比较差异无统计学意义(P均>0.05).结论 床旁胃肠超声联合肠内营养耐受性评分可为中重症急性胰腺炎患者提供个体化的营养治疗方案,缩短了其达到目标喂养量的时间.

目的:探讨床旁胃肠超声在重型颅脑损伤病人中的应用价值.方法:选择2019年8月至2021年8月人住河北省人民医院重症医学科的重型颅脑损伤病人56例,随机分为2组,对照组和干预组各28例,干预组病人全部应用超声进行胃窦运动指数、胃窦横截面积监测,并联合应用肠道超声指导肠内营养的应用.对照组病人根据胃残余量经验性调整肠内营养的速度.结果:干预组肠内营养开始时间及达到目标喂养量时间均短于对照组,差异有统计学意义(P＜0.05);观察组返流发生率低于对照组,差异有统计学意义(P＜0.05);2组误吸、腹泻及营养中断率、住ICU时间及28 d病死率比较差异无统计学意义(P＞0.05).结论:胃肠超声可为重型颅脑外伤病人提供个体化的营养治疗方案,尽早达到目标喂养量,并可减少返流发生率.

Background Early recognition of persistent acute kidney injury (AKI) could optimize management and prevent deterioration of kidney function. The Doppler-based renal resistive index (RI) has shown promising results for predicting persistent AKI in preliminary studies. Here, we aimed to evaluate the performance of renal RI, clinical indicators, and their combinations to predict short-term kidney prognosis in septic shock patients.Method We performed a retrospective study based on data from a prospective study in a single-center general ICU between November 2017 and October 2018. Patients with septic shock were included. Clinical indicators were evaluated immediately at inclusion, and renal RI was measured within the first 12 h of ICU admission after hemodynamic stabilization. Persistent AKI was defined as AKI without recovery within 72 h. A multivariable logistic regression was used to select significant variables associated with persistent AKI. The discriminative power was evaluated by a receiver operating characteristic curve analysis.Result Overall, 102 patients were included, 39 of whom had persistent AKI. Renal RI was higher in the persistent AKI patients than in those without persistent AKI: 0.70 ± 0.05 vs. 0.66 ± 0.05; p = 0.001. The performance of RI to predict persistent AKI was poor, with an area under the receiver operating characteristic curve (AUROC) of 0.699 [95% confidence interval (CI) 0.600–0.786]. A clinical prediction model combining serum creatinine at inclusion and the nonrenal SOFA score showed a better prediction ability for nonrecovery, with an AUROC of 0.877 (95% CI 0.797–0.933, p = 0.0012). The addition of renal RI to this model did not improve the predictive performance.Conclusion The Doppler-based renal resistive index performed poorly in predicting persistent AKI and did not improve the clinical prediction provided by a combination of serum creatinine at inclusion and the nonrenal SOFA score in patients with septic shock.

目的 探讨大黄在重症医学科(ICU)合并急性胃肠功能损伤的机械通气患者中的应用对临床治疗及预后的影响.方法 将80例知识分子ICU行机械通气患者随机分为大黄治疗组和常规治疗(对照)组各40例,两组均给予常规治疗,大黄治疗组经鼻饲给予中草药大黄制剂.入组后观察两组感染指标(白细胞、C反应蛋白、降钙素原、临床肺部感染评分)及临床预后指标(喂养达标、反流/误吸、呼吸机相关性肺炎发生、机械通气时长、ICU住院时长、90 d病死率等指标).结果 大黄治疗组白细胞计数、C反应蛋白、降钙素原水平明显低于对照组(P<0.05).且大黄治疗组较对照组更易实现喂养达标并减少返流/误吸的发生(P<0.05).呼吸方面,大黄治疗组与对照组比较可减少呼吸机相关性肺炎的发生、缩短机械通气时长(P<0.05).此外,大黄治疗组与对照组比较可缩短ICU住院时长、降低90 d病死率(P<0.05).结论 大黄治疗可改善机械通气患者感染、呼吸功能,促进肠内营养实施且明显改善临床预后.

目的 评估肾阻力指数对术后脓毒症休克患者发生持续性急性肾损伤(AKI)的预测价值.方法 选取外科手术后脓毒症休克患者50例,行床旁超声测定入选患者的肾阻力指数(RRI).根据是否发生持续性AKI分为非持续性AKI组和持续性AKI组,比较两组间的基础情况及可能与持续性AKI有关的指标,采用Logistic回归分析影响术后脓毒症休克患者持续性AKI危险因素.描记受试者工作特征(ROC)曲线评价RRI对术后脓毒症休克患者发生持续性AKI的预测价值.结果 持续性AKI组的年龄、APACHEⅡ评分、SOFA评分、血肌酐、RRI较非持续性AKI组高,差异有统计学意义(P<0.05).SOFA评分、RRI为术后脓毒症休克患者持续性AKI危险因素.肾阻力指数≥0.695预测术后脓毒症休克患者持续性AKI的ROC曲线下面积为0.741,预测价值不高.联合RRI和SOFA评分预测价值大于其中任何一个指标,其ROC曲线下面积为0.893(95％CI,0.615～0.809).结论 肾阻力指数对术后脓毒症休克患者发生持续性AKI的预测价值不高,联合SOFA评分的预测能力大于单一指标,为临床早期预防及干预提供线索.

目的 观察厚朴排气合剂治疗脓毒症急性胃肠功能损伤的临床疗效.方法 将136例脓毒症急性胃肠功能损伤患者按照随机数字表法分为2组,治疗组68例予厚朴排气合剂治疗,对照组68例予马来酸曲美布汀片治疗.2组均治疗7 d.比较2组治疗前后腹压、肠功能障碍评分、便秘情况及肝肾功能[总胆红素(TBiL)、天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、尿素氮(BUN)、肌酐(Cr)],记录2组肠内营养达标时间、住重症加强护理病房(ICU)时间、机械通气时间、30 d病死率,并统计2组疗效.结果 治疗组总有效率92.65％(63/68),对照组总有效率76.47％(52/68),治疗组疗效优于对照组(P<0.05).治疗后2组腹压、肠功能障碍评分均较本组治疗前降低(P<0.05),治疗组便秘比例较本组治疗前降低(P<0.05);治疗组肠内营养达标时间短于对照组(P<0.05).治疗后对照组便秘比例与本组治疗前比较差异无统计学意义(P>0.05),治疗后2组腹压、肠功能障碍评分及便秘比例组间比较差异无统计学意义(P>0.05).治疗前后2组TBiL、AST、ALT、BUN、Cr比较差异无统计学意义(P>0.05).2组住ICU时间、机械通气时间、30 d病死率比较差异无统计学意义(P>0.05).结论 厚朴排气合剂能够降低脓毒症急性胃肠功能损伤患者的腹压水平,缩短肠内营养达标时间,对肝肾功能无明显影响.

The gastrointestinal (GI) tract has long been hypothesized to play an integral role in the pathophysiology of sepsis, and gut microbiota (GM) dysbiosis may be the key factor. Previous studies have shown that the gut flora was significantly altered in critically ill patients. This study aimed to observe what kind of GM dysbiosis is in the early stage of sepsis and whether the application of fecal microbiota transplantation (FMT) can reconstruct the GM of septic mice and restore its protective function on the intestinal mucosal barrier. The study investigated the effect of FMT on gut microbiota, mucosal barrier function, inflammatory response, and survival in a murine model of sepsis established by cecal ligation and puncture (CLP). It is found that FMT can not only reduce morbidity and mortality and restore the abundance and diversity of the gut flora in septic mice, but can also improve the intestinal barrier function by reducing epithelial cell apoptosis, improving the composition of the mucus layer, upregulating the expression of tight junction proteins, and reducing intestinal permeability and the inflammatory response. After FMT, Lachnospiraceae contributed the most to intestinal protection through enhancement of the L-lysine fermentation pathway. FMT offers a microbe-mediated survival advantage in a murine model of sepsis. Therefore, an improved understanding of the connection between microbiota, and systemic illness may yield new therapeutic strategies for patients with sepsis.

目的 使用超声监测膈肌功能,评价膈肌新指标对老年机械通气患者撤机结果的预测价值.方法 回顾性分析河北省人民医院重症医学科收治的行机械通气治疗时间大于48 h的老年患者44例,满足撤机条件后常规进行自主呼吸试验(SBT)并应用床旁超声监测患者膈肌移动度(DE)、膈肌增厚率(DTF),并结合既往浅快呼吸指数(RSBI)得出新指标膈肌移动度浅快呼吸指数(DE-RSBI)、膈肌增厚率浅快呼吸指数(DTF-RSBI).记录撤机结果并采用受试者工作特征(ROC)曲线评价各指标对撤机成败的预测价值.结果 撤机成功30例,失败14例,失败组较成功组具有较低的DE和DTF及较高的DE-RSBI和DTF-RSBI(P<0.05).膈肌超声指标DE和DTF预测撤机曲线下面积(AUC)分别为0.725(0.535～0.915)和0.674(0.479～0.869),灵敏度分别为80.0％和73.3％,特异度分别为78.6％和64.3％.膈肌超声新指标DE-RSBI和DTF-RSBI预测撤机的曲线下面积(AUC)分别为0.745(0.566～0.925)和0.871(0.767～0.976),敏感度分别为71.4％和100.0％,特异度分别为66.7％和70.0％.结论 膈肌超声新指标DE-RSBI和DTF-RSBI对预测撤机结果有较精准的实用价值.

目的 观察大黄联合早期肠内营养辅助治疗重症急性胰腺炎的疗效.方法 将2017年1月—2018年12月河北省人民医院重症医学科收治的50例重症急性胰腺炎患者随机分为大黄治疗组和常规治疗组,每组25例.2组均给予常规治疗,大黄治疗组同时经鼻饲给予大黄制剂,常规治疗组鼻饲温开水.检测2组入组当天及第3天炎症指标[白细胞计数(WBC)、C反应蛋白(CRP)、血清淀粉酶(AMY)],比较2组临床疗效指标(腹痛缓解时间、肠鸣音恢复时间、首次排便时间及胃肠不耐受情况)的差异.结果 入组当天,2组患者白细胞计数、CRP及血AMY水平比较差异均无统计学意义(P均>0.05);入组第3天,2组患者WBC、CRP及AMY较入组当天均有不同程度降低(P<0.05),但大黄治疗组较常规治疗组下降更明显(P均<0.05).大黄治疗组腹痛缓解时间、肠鸣音恢复时间、首次排便时间均明显短于常规治疗组(P均<0.05),喂养不耐受率明显低于常规治疗组(P<0.05).结论 大黄联合早期肠内营养可减轻重症急性胰腺炎患者炎症反应,促进胃肠功能恢复.

目的 评估超声检测膈肌增厚率对预测机械通气(MV)患者拔管结局的价值.方法 选取重症医学科(ICU)行MV＞48 h且准备拔管的54例患者,于自主呼吸试验(SBT)期间以床旁超声测量并计算膈肌增厚率(DTF)和膈肌增厚浅快呼吸指数(DTF-RSBI),同时记录浅快呼吸指数(RSBI)及其他生理指标.采用ROC曲线评价DTF和DTF-RSBI预测拔管成败的价值.结果 36例拔管成功(成功组),18例失败(失败组),成功组患者DTF明显高于失败组,RBSI及DTF-RBSI明显低于失败组(P均＜0.05).取28.50％为截断值,DTF预测拔管的AUC为0.702,敏感度和特异度分别为78.80％和61.10％;DTF-RBSI取72.6次/(min· mm)为截断值,预测拔管的AUC为0.903,敏感度和特异度分别为100.00％和72.20％.结论 DTF-RSBI预测拔管结果比DTF及传统RSBI更准确,具有较高实用价值.

目的:评价膈肌超声对机械通气(MV)患者撤机结果的预测价值.方法:选取行MV时间＞48h的重症患者41例,在符合撤机条件后使用T管进行自主呼吸试验(SBT),于SBT 30min时使用床旁超声测量患者右侧躯体的膈肌移动度(DE)和膈肌厚度,并计算膈肌增厚率(DTF),根据撤机成败与否将患者分为撤机成功组(26例)和撤机失败组(15例).采用受试者工作特征(ROC)曲线评价膈肌功能超声指标对撤机的指导价值.结果:撤机成功组患者DE及DTF高于撤机失败组(均P＜0.05).分别选取1.08 cm和30％作为DE和DTF的截断值,其预测撤机成功的敏感度分别为80.77％和65.38％,特异度分别为80.00％和60.00％,ROC曲线下面积分别为0.751(95％ CI:0.571 ～0.932)和0.668(95％ CI:0.484～0.852).结论:膈肌功能超声监测可作为重症医学科MV患者撤机能力的预测指标,对撤机具有较好的指导价值.

CONTEXT:Global morbidity from chronic obstructive pulmonary disease (COPD) is high worldwide. Diaphragm pacing (DP) can maintain the natural, negative pressure breathing of COPD patients with diaphragmatic muscle dysfunction. The YiqiDitanTongfu (YDTF) decoction has been used clinically with COPD patients to help them to wean from mechanical ventilation, with their ventilation functions being improved and the success rate of weaning being largely increased.OBJECTIVE:The study intended to investigate the combined therapeutic effects of external DP and the YDTF decoction for COPD patients who have had difficulty weaning from mechanical ventilation.DESIGN:This study was a retrospective cohort study.SETTING:The study occurred at the Hebei General Hospital and Hebei Province Chest Hospital (Hebei Province, Shijiazhuang, China).PARTICIPANTS:Participants were 90 patients with COPD + type 1 respiratory failure, 101 patients with COPD + Type 2 respiratory failure, and 96 patients with COPD at the compensated stage.INTERVENTION:The participants were randomly divided into 3 groups: (1) traditional treatment (control group), (2) traditional treatment plus treatment with a diaphragm pacemaker (DP group), and (3) traditional treatment plus treatment with a DP and a YDTF decoction (DP + YDTF group). All treatments occurred for 12 d.OUTCOME MEASURES:Relevant outcomes were measured and compared at baseline and postintervention, including the rapid shallow breathing index, tidal volume, maximum inspiratory pressure, degree of diaphragmatic muscle activity, maximum expiratory pressure, the successful rates of weaning from mechanical ventilation, the potential of hydrogen, the partial pressure of oxygen, partial pressure of carbon dioxide, and oxygen saturation.RESULTS:The patients treated with the DP plus the YDTF decoction were more successful in weaning from mechanical ventilation than those treated with DP. Of the patients with COPD + type 1 respiratory failure, 86.67% succeeded vs 70.00% of the DP patients. Of patients with COPD + type 2 respiratory failure, 87.88% succeeded vs 79.41% of the DP patients.CONCLUSION:The DP plus the YDTF concoction acted as a successful treatment for heart failure caused by CPOD in comparison with the DP or YDTF alone, providing evidence that the DP + YDTF concoction can serve as a competitive method for helping COPD patients to wean from mechanical ventilation.

OBJECTIVE:To explore a better indicator that can predict septic shock induced acute kidney injury (AKI) by combining renal resistive index (RRI) and central venous pressure (CVP).METHODS:A prospective observational study was conducted. Patients with septic shock admitted to department of critical care medicine of Hebei General Hospital from November 2017 to October 2018 were enrolled. Baseline characteristics such as age, gender, underlying diseases, infection sites, acute physiology and chronic health evaluation II (APACHE II) in the first 24-hour, sequential organ failure assessment (SOFA) were recorded; Doppler-based RRI was obtained on the first day when hemodynamics was relatively stable, meanwhile the dose of norepinephrine and hemodynamic parameters were assessed. Urine output per hour, the total duration of mechanical ventilation, the length of intensive care unit (ICU) stay and 28-day mortality were also collected. Observational end point was death at discharge or the 28th day after ICU admission, whenever which came first. The patients were divided into AKI and non-AKI groups according to the 2012 Kidney Disease: Improving Global Organization (KDIGO) clinical practice guideline. The baseline and prognostic indicators, variables potentially associated with AKI were compared between the two groups. The variables independently associated with septic shock induced AKI were identified using multivariable Logistic regression. The predictive value of RRI and RRI combining CVP for AKI were analyzed by the receiver operating characteristic (ROC) curve.RESULTS:A total of 107 patients were enrolled, with 59 patients in AKI group and 48 patients in non-AKI group. There was significant difference in RRI, CVP, percentage of norepinephrine dosage ≥ 0.5 μg×kg-1×min-1, procalcitonin (PCT), lactate (Lac), and serum creatinine (SCr) between the two groups. Logistic regression analysis showed that high CVP, RRI, Lac and PCT were independent risk factors for septic shock induced AKI [CVP: odds ratio (OR) = 1.20, 95% confidence interval (95%CI) was 1.03-1.40, P = 0.022; RRI: OR = 3.02, 95%CI was 2.64-3.48, P = 0.006; Lac: OR = 2.43, 95%CI was 1.32-4.50, P = 0.005; PCT: OR = 1.20, 95%CI was 1.05-1.38, P = 0.009]. ROC curve analysis showed that the area under ROC curve (AUC) values of CVP ≥ 9.5 mmHg (1 mmHg = 0.133 kPa) and RRI ≥ 0.695 for predicting septic shock induced AKI were 0.656 and 0.662 respectively. The AUC value of the combination of RRI and CVP was greater compared with either RRI or CVP alone in predicting septic shock induced AKI, which AUC value was 0.712, 95%CI was 0.615-0.809, the sensitivity was 59% and the specificity was 75%.CONCLUSIONS:High CVP and RRI were independent risk factors for septic shock induced AKI. The combination of RRI and CVP performs poorly in predicting septic shock induced AKI. Further studies are needed to describe factors influencing Doppler-based assessment of RRI, which may help clinicians to prevent AKI early.

目的 探讨鼻饲大黄素对脓毒症急性胃肠功能损伤患者胃肠动力的改善作用.方法 60例脓毒症急性胃肠功能损伤患者随机分为大黄素治疗组和常规治疗组,两组均给予病因治疗、抗生素、营养支持等常规治疗;大黄素治疗组鼻饲大黄素(大黄制剂,溶于温开水50 mL中,浸泡至深褐色过滤取滤液,约38～40℃缓慢泵入胃管中,50 mL/h),10 g/次,3次/d,连续3 d;常规治疗组给予等量温开水.比较两组超声监测指标(胃窦收缩频率、胃排空速率、胃窦收缩幅度、动力指数)及临床观察指标(胃潴留量、反流/误吸、腹胀、腹泻、喂养中断).结果 与常规治疗组比较,大黄素治疗组胃窦收缩频率、胃排空速率、胃窦收缩幅度、动力指数增加(P均<0.001);胃潴留量、反流/误吸、腹胀、喂养中断的发生率降低(P均<0.05),但腹泻的发生未增加(P=0.389).结论 大黄素可促进脓毒症胃肠功能损伤患者胃肠动力的恢复,减少肠内营养喂养中断的发生且无明显胃肠不耐受表现.

BACKGROUND:Delirium is multifactorial. This study aimed at determining the association between different depths of sedation and the risk of delirium in adult mechanically ventilated patients.METHODS:A systematic literature retrieval was conducted in databases including Cochrane Central Register of Controlled Trials, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature for publications available till December 2019 without limitation in study type, and followed by a secondary retrieval for related literature. STATA15.1 and WinBugs 14.3 were used in statistical analyses for different sedation depths as the intervention. The main endpoint was delirium occurrence. Secondary endpoints were agitation-related adverse events and mortality.RESULTS:We included 18 studies comprising 8001 mechanically ventilated patients. Different sedation depths were not associated with the occurrence of delirium (OR = 1.00, 95%CI: 0.64-1.58, P = 0.993). Among the 18 enrolled studies, this finding was not confounded by the dosage of benzodiazepines (OR = 0.96, 95%CI: 0.79-1.17, P = 0.717) in eight randomized controlled trials(RCTs) or the patients' disease severity(OR 0.95, 95%CI: 0.79-1.13, P = 0.548) in 10 RCTs. However, contrasting results were found in non-RCTs. The deeper sedation group had a significantly increased risk for death(OR = 1.82, 95% CI: 1.23-2.69, P = 0.003), whereas lighter sedation seemed a potential risk for agitation-related adverse events (OR = 0.61, 95%CI: 0.45-0.84, P = 0.002).CONCLUSIONS:It is inconclusive whether significantly different sedation depths would change the risk of delirium in adult mechanically ventilated patients.TRIAL REGISTRATION NUMBER:The study was registered in PROSPERO(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42019145276.