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.
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.
Objective To investigate the value of extravascular lung water index ( EVLWI) and intrathoracic blood volume index ( ITBVI) monitoring in fluid management of severe pneumonia patients with sepsis shock.Methods A prospective controlled study was conducted in106 patients who were diagnosed as severe pneumonia with sepsis shock in intensive care unit fromJanuary 2010 to February 2013. 54 patients who received pulse indicator continuous output ( PiCCO) monitoring were enrolled into the EVLWI + ITBVI group, and EVLWI and ITBVI were used as indicator of fluid management. 52 patients who received central venous pressure ( CVP) as indicator of traditional fluid managementwere enrolled into the control group. The time and the rate to achieve early goal-directed therapy ( EGDT) target were compared between two groups. Acute physiology and chronic health evaluation Ⅱ ( APACHE Ⅱ ) , sepsis related organ failure assessment ( SOFA) , noradrenaline dosage, serumlactic acid, serum creatinine were compared between 1 day and 3 days after treatment. The characteristics of fluid management were recorded and compared within 72 hours. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-day mortality were compared between two groups. Results The ratio of achieving EGDT target in 6 hours was significantly higher in the EVLWI + ITBVI group than that in the control group ( 75.9% vs. 55.7% , Plt;0.05) , whereas the time and the ratio to achieve EGDT target in 24 hours were not statistically different. APACHE Ⅱ, SOFA, norepinephrine dosage, serum lactate were significantly decreased 3 days after treatment in the EVLWI + ITBVI group, but did not change significantly in the control group. On3 days after treatment, serumcreatinine was increased in the control group, and did not change significantly in the EVLWI + ITBVI group. The fluid intake and fluid balance volume during 0-6 hours period were significantly higher in the EVLWI + ITBVI group than those in the control group ( Plt;0.05) , but showed no difference ( Pgt;0.05) in other periods. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-days mortality were significantly lower in the EVLWI + ITBVI group compared with the control group ( Plt;0.05) . Conclusion Compared with CVP, ITBVI and EVLWI can more accurately assess and guide fluid management in severe pneumonia patients with septic shock with less duration of mechanical ventilation, ICU stay and mortality.
Objective To summarize and explore the clinical features, diagnosis and treatment of severe pulmonary tuberculosis (TB). Methods One death case of pulmonary TB in The First Affiliated Hospital of Soochow University was analyzed, related publications of case reports and articles relevant on the analysis and study of pulmonary tuberculosis deaths from Pubmed between January 2012 and March 2022 were also reviewed. Results A 25-year-old female patient was admitted for "intermittent cough with sputum for more than 1 year, aggravated with chest tightness and shortness of breath for 5 days". She had no underlying disease. Pulmonary TB was diagnosed by TB bacterium smear and next-generation sequencing of bronchoalveolar lavage fluid. The patient was in shock compensation period and developed acute respiratory distress syndrome immediately after admission. Through active anti-tuberculosis, invasive mechanical ventilation, intra-aortic balloon counterpulsation and continuous renal replacement therapy, the disease continued to deteriorate and she died on the third day after admission. A total of 269 pulmonary TB deaths were retrieved. An analysis of 244 patients' past medical history showed that human immunodeficiency virus co-infection was the most common among young people and chronic diseases were the most common among the elderly. All 269 patients died of septic shock, respiratory failure and multiple organ dysfunction syndrome (MODS), among which hyponatremia was also a significant complication. The shortest time from admission to death was 7 days, while the longest average time was only 35 days. Conclusions Pulmonary TB could develop into septic shock and MODS with poor prognosis and high mortality. Health education on TB should be strengthened.
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.
ObjectiveTo explore the value of inferior vena cava inspiratory collapsibility (ΔIVC) in guiding septic shock resuscitation with early goal-directed therapy (EGDT).MethodsA single center, randomized controlled trial was conducted at an 812-bed hospital in Mianyang, Sichuan. Adult patients with early septic shock in the intensive care unit were assessed and treated at defined intervals over 6 h using an ΔIVC-guided resuscitation protocol or an EGDT protocol. Feasibility outcomes were fluid balance and norepinephrine administration. The primary clinical outcomes were in-hospital mortality rate, 90-day survival rate. Secondary outcomes included incidence of acute kidney injury and consumption of health resources.ResultsSixty-eight patients with septic shock were enrolled in this study. Baseline characteristics were similar between the two groups. The ΔIVC-guided septic shock resuscitation group was lower than the EGDT group in the ICU 24 h fluid replacement (L): 3.8 (4.0, 5.3) vs. 4.7 (4.0, 6.6), 72 h liquid positive balance (L): 0.2 (–0.65, 1.2) vs. 2.5 (0.0, 4.1), intensive care unit length of stay (d): 7.5 (5.0, 14.0) vs. 15.0 (7.0, 21.5), mechanical ventilation cumulative time (d): 3.0 (0.0, 7.0) vs. 7.5 (2.2, 12.0), ICU costs (ten thousand yuan): 3.4 (2.1, 5.9) vs. 8.6 (4.2, 16.5), bedside blood purification treatment costs (ten thousand yuan): 2.3 (1.1, 3.3) vs. 6.8 (2.1, 10.0) (P<0.05). No difference was observed in the incidence of acute kidney injury (P > 0.05), in-hospital mortality and 90-day survival between the two groups (log-rank χ2=0.35, P>0.05).ConclusionsAmong patients with septic shock, a ΔIVC-guided septic shock resuscitation, compared with EGDT, did not reduce in-hospital mortality. It might prevent the risk of over resuscitation, shorten the duration of mechanical ventilation, and lead to a better utilization of intensive care unit resources.
