Zhongguo wei zhong bing ji jiu yi xue = Chinese critical care medicine = Zhongguo weizhongbing jijiuyixue最新文献

Objective: To systemically analyze the effect of 45 degree angle semirecumbent position on the incidence of ventilator-associated pneumonia (VAP) and other outcomes in mechanical ventilated patients, and to evaluate whether 45 degree angle semirecumbent position is superior to 25 degree angle-30 degree angle head of bed (HOB).

Methods: The randomized controlled trials (RCTs) comparing the effect of different HOB on the outcomes of mechanical ventilated patients were searched (from 1st January 1990 to 20th July 2012) from five databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, China Knowledge Resource Integrated Database (CNKI), and Wanfang Database. Meta analysis was conducted using RevMan 5.0 software.

Results: Data extracted from five RCTs with a total of 427 patients were analyzed. The risks of developing clinically diagnosed VAP were significantly lower among the patients in semirecumbent 45 degree angle position compared to the patients in lower position [15.96% (34/213) vs. 26.64% (57/214), relative risk (RR)=0.57, 95% confidence interval (95%CI) 0.39 to 0.83, P=0.003], while no significant differences were detected between the two groups regarding the mortality rate [27.04% (53/196) vs. 28.22% (57/202), RR=0.93, 95%CI 0.68 to 1.27, P=0.66], the length of intensive care unit (ICU) stay [weighted mean difference (WMD)=-0.45, 95%CI -1.08 to 0.18, P=0.16] and the percentage of antibiotics treatment [71.11% (32/45) vs. 60.87% (28/46), RR=1.14, 95%CI 0.85 to 1.53, P=0.37]. Two of the five trials (91 patients) were included in the sub-analysis between 45 degree angle group (45 patients) and 25 degree angle-30 degree angle group (46 patients). The results showed that comparing with 25 degree angle-30 degree angle, 45 degree angle semirecumbent position had no significance in improving patients' clinical outcomes.

Conclusion: This study proved that the clinically preferred semirecumbent 45 degree angle position did have effect in reducing the incidence of VAP, nevertheless, whether it's superior to 25 degree angle-30 degree angle needs to be confirmed by larger-scale, higher-quality RCTs.

Objective: To assess the effect of prone position on the oxygenation of patients with acute respiratory distress syndrome (ARDS) after recruitment maneuvers (RM) failure at high altitudes.

Methods: Forty-one ARDS patients who were invalid for RM therapy at the altitude of 2260 metres area hospital were enrolled[mean oxygenation index (PaO(2)/FiO(2)) increased than RM<20% considered as RM invalid]. All were divided into acute respiratory distress syndrome (ARDSp) and extra-acute respiratory distress syndrome (ARDSexp) based on different etiology, and each group was randomly divided into the supine and the prone position group, i.e. that ARDSp prone position group (n=11), ARDSp supine group (n=9), ARDSexp prone position group (n=10), and ARDSexp supine group (n=11). Before ventilation and 1, 2, 3, 4 hours after ventilation, arterial partial pressure of oxygen (PaO(2)), PaO(2)/FiO(2), static lung compliance (Cst), airway resistance (Raw) were monitored.

Results: One hour after ventilation in ARDSexp prone position group, PaO(2)/FiO(2) was significantly higher than before ventilation (157.4±40.6 mm Hg vs. 129.3±48.7 mm Hg, P<0.05), and increased by ventilation time, peaked at 4 hours (219.1±41.1 mm Hg). Within 3 hours ventilation in ARDSexp prone position group, PaO(2)/FiO(2) was significantly higher compared with the other three groups, and there were no significant differences among the other three groups. PaO(2)/FiO(2) in ARDSp prone position group and ARDSexp prone position group at 4 hours of ventilation were significantly higher compared with the corresponding supine group (208.8±39.7 mm Hg vs. 127.4±47.1 mm Hg, 219.1±41.1 mm Hg vs. 124.9±50.8 mm Hg, both P<0.05). There was no statistically significant difference in Cst before and after ventilation, and there was no significant changes among the groups. Raw in ARDSp prone position group at 4 hours of ventilation were significantly reduced than before ventilation (6.8±1.7 cm H(2)O×L(-1)×s(-1) vs. 10.7±1.8 cm H(2)O×L(-1)×s(-1), P<0.05), and significantly lower than the other three groups. There was no statistically significant difference in RAW among other three groups at each time point.

Conclusion: Prone position can improve RM oxygenation invalid ARDS patients at high altitudes.

Objective: To evaluate the efficacy and safety of domestic imipenem cilastatin sodium for the treatments of severe aspiration pneumonia.

Methods: A randomize, open, parallel-controlled trial was conducted. Sixty-eight patients with severe aspiration pneumonia were divided into trial group (n=36) and control group (n=32) by random distribution method. The application of trial group domestic imipenem cilastatin sodium was 1.0 g intravenous drip, every 6-8 hours for 7-14 days. The control group application with imported injection imipenem cilastatin sodium was 1.0 g intravenous drip, every 6-8 hours for 7-14 days. The highest daily temperature (T), heart rate (HR), breathing rate (RR), pulse blood oxygen saturation (SpO(2)), blood oxygen partial pressure (PaO(2)), inhaled oxygen concentration (FiO(2)), oxygenation index (PaO(2)/FiO(2)), airway peak pressure (Paw), minute ventilation (MV) and white blood count (WBC), pro calcitonin (PCT), high-sensitivity C-reactive protein (hs-CRP) index before and 1, 3, 7 days after treatment, and liver and kidney function, chest X-rays, and sputum cultures of drug sensitive test were conducted. And the effectiveness and safety were determined according to the standards.

Results: After treatment indexes of the two groups were obviously improved, i. e. T, HR, RR, Paw, MV, the WBC, PCT, CRP were gradually declined, PaO(2)/FiO(2) was gradually raised. There were statistical significance before and 3 days after treatment in the trial and the control group [T: 37.35±0.91 centigrade vs. 38.43±1.06 centigrade, 37.28±0.88 centigrade vs. 38.35±1.11 centigrade; HR: 90.25±10.60 bpm vs. 118.94±15.46 bpm, 89.31±11.17 bpm vs. 124.34±17.87 bpm; RR: 25.14±3.17 bpm vs. 32.28±4.49 bpm, 24.81±2.43 bpm vs. 33.13±4.17 bpm; Paw: 23.03±3.04 cm H(2)O vs. 33.22±4.59 cm H(2)O, 22.75±3.22 cm H(2)O vs. 33.63±4.79 cm H(2)O; MV: 8.67±1.26 L/min vs. 11.80±2.01 L/min, 8.88±1.45 L/min vs. 13.21±2.90 L/min; WBC: 11.26±1.96 ×10(9)/L vs. 14.57±3.10 ×10(9)/L, 12.28±3.38 ×10(9)/L vs. 15.25±4.93 ×10(9)/L; PCT: 6.90±5.46 μg/L vs. 16.97±7.93 μg/L, 6.17±6.13 μg/L vs. 21.26±11.54 μg/L; CRP: 85.50±37.91 mg/L vs. 120.17±45.47 mg/L, 94.31±38.51 mg/L vs. 142.34±53.57 mg/L; PaO(2)/ FiO(2): 182.06±40.88 mm Hg vs. 98.67±20.62 mm Hg, 184.09±43.78 mm Hg vs. 96.22±22.59 mm Hg, all P<0.05]. There was no significant change in SpO(2) before and after treatment in two groups. And the total clinical effective rate in trial and control group were 83.4% and 81.2%, adverse reaction rate were 13.9% and 9.4%, bacterial removal rate were 90.3% and 87.0% respectively, and there was no significant difference between the two groups (all P>0.05).

Conclusion: Domestic imipenem cilastatin sodium can effectively control severe aspiration pneumonia, and it is safe and effective antibiotics.

Objective: To investigate the effect of postconditioning with propofol on Toll-like receptor 4 (TLR4) expression in the lung tissue in lipopolysaccharide (LPS)-induced acute lung injury (ALI) rats.

Methods: Thirty Sprague-Dawley (SD) rats were randomly assigned to control group, ALI group, and propofol postcondition group (each n=10). The model of ALI was reproduced by intravenous injection of LPS (8 mg/kg for 30 minutes) into the rats, equivalent normal saline was injected into the rats of control group. The rats were postconditioned with propofol injected intravenously by 20 mg/kg bolus dose and then continuously by 40 mg×kg(-1)×h(-1) with a constant speed for 1 hour. The rats were sacrificed 6 hours after drug injection. Lung wet/dry weight (W/D) ratio and lung permeability index (LPI) was taken. Tumor necrosis factor-α (TNF-α) level in bronchoalveolar lavage fluid (BALF) was detected using enzyme linked immunosorbent assay (ELISA) method and TLR4 mRNA expression in lung tissue was assessed by reverse transcription-polymerase chain reaction (RT-PCR).

Results: The lung W/D ratio, LPI, TLR4 mRNA and TNF-α in BALF were all increased in ALI group compared with control group [lung W/D ratio: 5.30±0.28 vs. 4.21±0.14, LPI (×10(-3)): 8.7±2.2 vs. 3.3±2.0, TLR4 mRNA: 2.451±0.028 vs. 0.998±0.021, TNF-α: 643.46±62.31 ng/L vs. 120.43±12.65 ng/L, all P<0.05]. The above indexes were significantly reduced in the propofol group than those in the ALI group [lung W/D ratio: 4.68±0.19 vs. 5.30±0.28, LPI (×10(-3)): 5.8±2.0 vs. 8.7±2.2, TLR4 mRNA: 1.126±0.025 vs. 2.451±0.028, TNF-α: 290.53±32.01 ng/L vs. 643.46±62.31 ng/L, all P<0.05], but still higher than those in control group (all P<0.05).

Conclusion: Postconditioning with propofol may alleviate ALI via reducing TLR4 mRNA expression, and inhibit the waterfall-like inflammatory reaction.

Objective: To analyze the common reasons of invasive ventilator alarms between medical intensive care unit (ICU) and specialist ICU, and its related management methods.

Methods: Patients admitted to medical ICU and specialist ICU from January to December in 2011 of the First Hospital of China Medical University were studied. Ventilator alarms and their reasons need to be handle by the front-line doctors, respiratory therapists, attending physicians or medical ICU doctors were analyzed and compared.

Results: There were 375 ventilator alarms of the 59 patients in the medical ICU, incidence of the top three alarms parameters were high airway pressure alarms for 21.87%, high tide volume alarms for 15.73% and high minute ventilation alarms for 14.13%. In specialist ICU there were a total of 403 ventilator alarms with 249 patients, incidence of the top three alarms parameters were high airway pressure alarms for 32.51%, low airway pressure alarms for 15.38%, high respiratory rate alarms for 10.42%. The incidence of high airway pressure and low airway pressure alarms in medical ICU were significantly lower than the specialist ICU (21.87% vs. 32.51%, 8.53% vs. 15.38%, both P<0.01), and the incidence of high minute ventilation and high tidal volume alarms in medical ICU were higher than specialist ICU (14.13% vs. 7.20%, 15.73% vs. 9.68%, P<0.01 and P<0.05). The top three causes of the alarms were aerosol inhalation, sputum blockage, and oxygen battery expired in medical ICU, and sputum blockage, respiratory distress, and pipeline leak and oxygen expired battery in specialist ICU. The reasons of sputum blockage, tubes factors (intubation position change, pipeline water) and improper alarm parameters setting in medical ICU was significantly lower than those in specialist ICU (10.93% vs. 17.12%, 1.87% vs. 4.47%, 1.33% vs. 3.72%, 1.60% vs. 3.97%, all P<0.05). High tidal volume, high minute ventilation and serious breath-side filter blockage because of aerosol inhalation in medical ICU were significantly higher than those in specialist ICU (18.93% vs. 3.97%, P<0.01).

Conclusion: Doctors in medical ICU and specialist ICU should understand the ventilator alarms characteristics, prevention, detect and timely problems management.

Objective: To explore the expression of α-smooth muscle actin (α-SMA) during the lung injury induced by hyperoxia in infantile rats.

Methods: Sixty-four male Sprague-Dawley (SD) rats about 3 weeks were randomly assigned into normal control group which exposured to room air [fraction of inspired oxygen (FiO(2)) was 0.21] and hyperoxia exposure group (95%O(2)) according to random digits table. Eight rats in each group were randomly sacrificed at day 1, 7, 14 and 21.Pulmonary tissue remodeling was observed by hematoxylin-eosin (HE) staining. Immunohistochemistry method was performed to evaluate the expression of α-SMA in pulmonary tissue, further Western blotting was also made to determine the expression of α-SMA.

Results: The early histopathologic changes after HE were inflammation and edema in pulmonary tissue, while the later changes were interstitial hyperplasia and fibroblast proliferation. The expression of α-SMA was very slight in bronchial epithelium, alveolar epithelium and alveolar interstitium in normal control group, but increased with the time of hyperoxia exposure prolonged and peaked at 21st day. Western blotting detected that the expression of α-SMA after hyperoxia exposure for 1 day and 7 days in hyperoxia exposure group presented no difference compared with normal control group (1.02±0.12 vs. 1.00±0.13, 1.05±0.14 vs. 0.99±0.12, both P>0.05), but the expression of α-SMA after hyperoxia exposure for 14 days and 21 days was increased compared with normal control group (1.27±0.21 vs. 1.05±0.15, 2.26±0.28 vs. 1.05±0.14, P<0.05 and P<0.01).

Conclusions: Pulmonary fibrosis remodeling was caused by hyperoxia exposure. The expression of α-SMA in pulmonary tissue in hyperoxia exposure groups obviously increased, and could play an important role in pulmonary fibrosis remodeling.