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Immunological Treatment for Sepsis and Septic Shock

The Influence of Norepinephrine on Pulmonary Vessel Pressure in the Treatment Process of Septic Shock

ObjectiveTo investigate the influence of norepinephrine on pulmonary vessel pressure in animal model of septic shock. MethodsTwelve health mongrel dogs were randomly divided into a control group (n=5, intravenously injected with normal saline 1 mL/kg) and an endotoxin group(n=7, intravenously injected with lipopolysaccharide 1 mg/kg). When the systemic blood pressure decreased by more than 40% of baseline before administration, the dogs in two groups were intravenously injected with NE 0.5, 1.0, 2.0, 5.0μg·kg-1·min-1. The interval of each dose was more than 10 minutes. The changes of the pulmonary arterial pressure (PAP), pulmonary venous pressure (PVP), and systemic arterial rressure (SAP) were recorded and compared between two groups. ResultsIn the control group, PAP didn't change significantly after administration (P < 0.05), however, PVP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.01). In the endotoxin group, PAP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), while PVP didn't change significantly (P > 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). There were significant differences in SAP (P < 0.05), not in PAP and PVP (P > 0.05), between two groups after NE administration at dose of 1.0, 2.0 and 5.0μg·kg-1·min-1. The PVP/SAP and PAP/SAP values didn't change significantly after administration in the control group (P > 0.05). In the endotoxin group, the PVP/SAP and PAP/SAP values increased significantly after LPS administration, and decreased slightly after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). ConclusionsNE administration in septic shock can not increase the angiotasis of the pulmonary vein. NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 can cause the increase of PAP and SAP, but the increase of PAP is lower than the increase of SAP.

Effects of Fluid Resuscitation on Homeostasis and Acute Physiology and Chronic Health EvaluationsⅡof Patients with Septic Shock

Objective　To evaluate the effects and the clinical significances of liquid resuscitation on blood gas analysis， acid-base balance， electrolytes， acute physiology and chronic health evaluationsⅡ（APACHEⅡ） score of patients with septic shock， and then to analyze the relations between serum chlorine （Cl－） level and APACHEⅡscore and the volume of liquid resuscitation. Methods　According to the target of resuscitation （centre venous pressure 8-12mm Hg and mean arterial pressure≥65mm Hg）， 21 patients with septic shock received enough fluid for resuscitation during 24h . The results of blood gas analysis， acid-base balance， electrolytes， and APACHE Ⅱ score were compared between pre-resuscitation and 24h post-resuscitation by self-controlled prospective study. The relationships of the level of serum Cl－ and APACHEⅡ score with the volume of liquid used in resuscitation were analyzed . Results　The mean resus-citation duration was （18.09±4.57） h， and the volume of liquid during 24 h resuscitation was 5 320-11 028mL with mean volume of （7 775±1 735） mL in 21 patients with septic shock. Serum sodium （Na＋， mmol/L） and Cl－（mmol/L）levels of post-resuscitation were significant higher than those of pre-resuscitation （Na＋：138.71±5.67 versus 135.62±7.23， P=0.024；Cl－：109.10±4.90 versus 101.67±8.59， P=0.000）. Compared with the levels of pre-resuscitation， the blood pH value， hematocrit （Hct，%）， anion gap （AG， mmol/L）， lactic acid （mmol/L）， and APACHE Ⅱscore significantly decreased （pH：7.31±0.05 versus 7.37±0.06， P=0.000；Hct：28.48±2.56 versus 32.76±9.19， P=0.049；AG：8.33±3.45 versus 14.17±8.83， P=0.004；lactic acid：1.66±0.89 versus 2.96±1.23， P=0.001；APACHEⅡ：10.90±3.73 versus 17.24±4.06， P=0.000） after 24h resuscitation. The correlation analysis showed that the level of serum Cl- was positively correlated with the volume of liquid used in resuscitation （r=0.717，P＜0.01）. However， there was no correlation between APACHEⅡscore and the volume of liquid used in resuscitation （P＞0.05）. Conclusions　The target of liquid resuscitation in patients with septic shock should be cautiously determined， including control of the volume of crystal liquid for resuscitation， in order to avoid acid-base imbalance or hyperchloraemia. At the same time， the change in internal environment should be monitored. An optimistic fluid resuscitation to decrease APACHE Ⅱ score in patients with septic shock is unrelated to the volume of liquid resuscitation.

Idiopathic Perforation of Colon: 9 Cases Report and Literature Review

目的 探討特發性結腸穿孔的治療方法及成因。方法 結合文獻分析2001～2009年期間我院收治的特發性結腸穿孔患者的診治經過。結果 共收治特發性結腸穿孔9例，占同期結腸穿孔患者的28.1%（9/32），其中5例穿孔（5/9）發生在乙狀結腸。修剪破口后直接縫合者2例，行結腸雙腔造瘺者7例。術后死亡3例。結論 特發性結腸穿孔好發于乙狀結腸，與其解剖和生理上的特點有關。不明原因結腸穿孔的患者要想到本病的可能。及時、合理的手術治療，仔細周到的術后管理是治療成功的關鍵。

The Value of Early Base Excess in Predicting the Severity of Septic Shock

目的　探討早期堿剩余對感染性休克患者病情嚴重程度的預測價值。 方法　對2009年2月－2011年2月資料完整入院的感染性休克患者60例進行回顧性分析，按死亡及存活進行分組，對最初24 h的堿剩余值差異及血乳酸清除率情況進行對照研究。 結果　死亡組堿剩余值變化及乳酸清除率低于存活組（P＜0.05）。治療后堿剩余≤?6 mmol/L較堿剩余＞?6 mmol/L的患者病死率明顯增加，尤其是治療后24 h 堿剩余仍≤?6 mmol/L病死率高達92.23%。 結論　早期堿剩余有助于感染性休克預后評估和指導臨床治療。

血管升壓藥物在感染性休克中的應用

“拯救膿毒癥運動”提出通過液體復蘇和應用血管升壓藥物等手段盡早恢復中心靜脈壓、平均動脈壓及中心靜脈血氧飽和度等指標, 以此改善重癥感染與感染性休克患者氧供應與氧需求的失衡狀態, 并最終達到降低病死率的目的[ 1] 。該運動同時提出去甲腎上腺素或多巴胺可作為血管升壓藥物的首選[ 2] , 但目前關于哪種升壓藥物更好仍無定論[ 3, 4] 。近期有大量關于各種血管升壓藥物的應用及比較的研究報道, 對臨床工作有較大的啟示作用。

Effects of Metoprolol on Hemodynamics of Early Septic Shock Patients with Myocardial Injury

ObjectiveTo explore the effects of metoprolol on hemodynamics of early septic shock patients with myocardial injury. MethodsWe prospectively recruited 22 septic shock patients with myocardial injury, who were admitted to the ICU of Xiaolan Hospital during March 2014 and February 2015.The metoprolol was injected through central venous catheter to reduce heart rate by 20% from baseline and maintain for 6h.Hemodynamic and oxygen metabolic parameters were collected to establish database. ResultsHeart rate decreased significantly to (98±18), (95±16) and (92±18) beat/min respectively at 1h, 3h and 6h post-dosing, compared with (125±28) beat/min at pre-dosing (P < 0.05).Cardiac index decreased significantly to (3.2±1.5), (3.3±1.9) and (3.3±1.6) L·min-1·m-2 respectively at 1h, 3h and 6h post-dosing, compared with (3.9±2.5) L·min-1·m-2 at pre-dosing (P < 0.05).The mean blood pressure, central venous pressure, pulmonary artery wedge pressure, pulmonary vascular resistance index, systemic vascular resistance index and stroke volume index showed no significant changes between pre-dosing and post-dosing (all P > 0.05). Lactate concentration decreased significantly to (9.8±4.1) and (8.1±3.6)mmol/L respectively at 3h and 6h post-dosing, compared with (13.4±5.2)mmol/L at pre-dosing (all P < 0.05), but mixed venous oxygen saturation showed no significant changes (P > 0.05). ConclusionMetoprolol may reduce heart rate and cardiac output in septic shock patients with myocardial injury, without obvious adverse effects on circulatory function and systemic perfusion.

Dopamine versus Norepinephrine for Septic Shock: A Systemic Review

Objective To systemically review the efficacy and safety of dopamine versus norepinephrine in patients with septic shock. Methods Database searches of MEDLINE, EMbase, Cochrane Controlled Trials Register, VIP, CNKI, and CBM (from the date of database establishment to June 2011) were conducted. Additional studies for collecting relevant data were retrieved via both references of articles and direct contact with authors. Prospectively, randomized controlled trials (RCTs) of dopamine compared with norepinephrine therapy in septic shock patients were selected. The quality of included trials was assessed and relevant data were extracted. Then statistical analysis was performed using RevMan 5.1. Results Nine trials with 3 179 participants were included. The results of meta-analysis showed: compared with norepinephrine, dopamine was associated with a significant 12% elevation in the risk ratio of in-hospital death events of septic shock patients (RR=1.12, 95%CI 1.04 to 1.21, P=0.002). The risk of arrhythmias in dopamine group was 2.63-fold than that in norepinephrine group (RR=2.63, 95%CI 1.51 to 4.55, P=0.000 6). The cardiac index of septic patients in dopamine group was higher than that in norepinephrine group (MD=0.42, 95%CI 0.21 to 0.63, Plt;0.000 1). No significant difference could be found in the heart rate (MD=17.05, 95%CI –0.71 to 34.81, P=0.06) and mean arterial pressure (MD= –0.87, 95%CI –24.97 to 7.62, P=0.30). Conclusion Findings from this meta-analysis suggest that compared with dopamine, norepinephrine significantly reduces both 28-day mortality of septic shock patients and incidence rate of arrhythmias. Norepinephrine is better than dopamine in aspects of efficacy and safety.

疑似氣性壞疽合并感染性休克、急性呼吸窘迫綜合征急救護理一例

Optimizing Early Goal Directed Therapy for Septic Shock after Heart Operation

目的通過漂浮導管（Swan-Ganz導管）監測外周血管阻力指數（SVRI）作為優化的心功能不全狀態下感染性休克早期目標導向治療（EGDT）的臨床意義。 方法2012年1月至2014年1月第四軍醫大學附屬西京醫院心血管外科ICU收治體外循環心臟術后感染性休克患者8例，其中男7例、女1例，年齡（50.9±11.1）歲。以中心靜脈壓（CVP）為復蘇目標行經驗性容量復蘇治療，循環未見改善，則實施漂浮（Swan-Ganz）導管監測血流動力學指標，以外周血管阻力指數（SVRI）為優化目標復蘇，觀察Swan-Ganz導管復蘇前及復蘇6 h、24 h后的血流動力學及氧代謝指標，分析復蘇達標所需時間。 結果8例患者平均住ICU時間（16.87±3.35）d，發生肺部并發癥8例，急性腎功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好轉存活，死亡2例。8例感染性休克患者經Swan-Ganz導管目標導向治療6 h和24 h后平均動脈壓（MAP）分別為（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心靜脈壓（CVP）分別為（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指數（CI）分別為（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指數（SVRI）分別為（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各項指標均較治療前升高；治療6 h和24 h后動脈血乳酸分別為（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，較治療前[（14.98±0.45）mmol/L]下降。 結論采用Swan-Ganz導管監測SVRI作為優化目標導向治療心功能不全狀態下感染性休克可以提高6 h復蘇成功率，改善患者預后。