Objective To identify evidence-based treatment choices for a patient with increased intracranial pressure after acute traumatic brain injury. Methods We searched The Cochrane Library (Issue 2, 2006), MEDLNE (1981 to August 2006) and CBMdisc (1978 to August 2006) to identity systematic reviews (SRs), randomized controlled trials (RCTs), controlled clinical trials (CCTs) and prospective cohort studies involving the efficacy and safety of pharmacotherapy and non-pharmacotherapy for increased intracranial pressure after acute traumatic brain injury. Results We found 2 SRs and 8 RCTs on pharmacotherapy, and 6 SRs and 2 RCTs on non-pharmacotherapy. Conventional-dose mannitol was no better than hypertonic saline, but was better than other intracranial pressure lowering agents. High-dose mannitol can reduce mortality and the incidence of severe disability compared with conventional-dose mannitol. There were no studies comparing high-dose mannitol and hypertonic saline. Non-pharmacotherapy was not recommended for routine use due to the lack of good quality evidence. Conclusion For patients with increased intracranial pressure after acute traumatic brain injury, mannitol is effective in reducing the mortality and the incidence of severe disability. However, more large-scale RCTs are required to compare high-dose mannitol versus other drugs. Non-pharmacotherapy is not recommended as an adjunct therapy at present.
Objective To discuss the feasibility and safety of early enteral nutrition (EN) on treatment of severe acute pancreatitis (SAP) and its influence. Methods The advancement about application of early EN on treatment of SAP in recent years were reviewed. Results In patients with SAP, early EN via catheter placed in the jejunum could protect the integrity of intestinal barrier and reduce infectious complications. But no consensus had been reached about the starting time, ingredient and infusion mode yet. Conclusion Early EN may have positive effects on treatment of SAP, but further researches are still needed.
The publication of the 2016 version of the Surviving Sepsis Campaign guidelines is a further step to the treatment of sepsis worldwide. This version of guidelines approves new definition of Sepsis-3. Overall, the new guidelines do not change the previous principle of treatment significantly. Some detailed and specific modifications have been made. Understanding and rational use of the new guidelines based on clinical practice, are the key to managing sepsis and performing accurate and effective treatment.
【Abstract】 Objective To discuss the mechanism of growth hormone (GH) in infection and its safety. Methods Advances in the application of GH in infection of recent years were reviewed. Results In infectious patients, GH may promote protein synthesis, strengthen the immunity of body, and protect the integrity of intestinal barrier function. But some patients present GH resistance. The safety of GH for infectious patients needs further evaluation. Conclusion GH may play a supplementary role in infection therapy, but further research is needed.
Objective To evaluate the effectiveness and safety of total enteral nutrition (TEN) versus total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP). Methods The databases such as Pubmed (1996 to June 2011), EMbase (1984 to June 2011), Cochrane Central Register of Controlled Trials of The Cochrane Library (Issue 6, 2011) and CBM (1978 to June 2011) were electronically searched, and the relevant references of the included papers were also manually searched. Two reviewers independently screened the trials according to inclusion and exclusion criteria, extracted the data, and assessed the methodology quality. Meta-analyses were performed using the Cochrane Collaboration’s RevMan 5.1 software. Results Seven randomized controlled trials (RCTs) involving 379 patients with SAP were included. The results of meta-analyses showed that compared with TPN, TEN could significantly reduce the risk of mortality (RR=0.33, 95%CI 0.20 to 0.55, Plt;0.000 1), pancreatitis-related infections (RR=0.35, 95%CI 0.25 to 0.50, Plt;0.000 01), required rate of surgical intervention (RR=0.43, 95%CI 0.23 to 0.82, P=0.01), and incidence of multiple organ failure (MOF) (RR=0.28, 95%CI 0.17 to 0.46, Plt;0.000 01). There was no significant difference in the nutrition strategies associated complications between TPN and TEN (RR=1.16, 95%CI 0.42 to 3.22, P=0.78). Conclusion Meta-analyses show that compared with TPN, TEN can reduce the risk of mortality, pancreatitis-related infections, required rate of surgical intervention, and incidence of MOF; and it will not increase the nutrition strategies associated complications. Consequently, TEN should be considered a better choice for SAP patients as early as possible.
Objective?To evaluate the diagnostic accuracy of procalcitonin (PCT) for ventilator-associated pneumonia (VAP). Methods?We searched MEDLINE, EMbase, The Cochrane Library, CBM, BIOSIS to identify all diagnostic tests which evaluated the diagnostic value of PCT in patients with VAP. QUADAS items were used to evaluate the quality of the included studies. Pooled sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), summary receiver operating characteristic (SROC) curve, and the heterogeneity of the included studies were calculated by using the Meta-disk software. Results?Five studies which were identified from 103 references met the inclusion criteria. The summary sensitivity, specificity, +LR, and –LR values were 0.70 (95%CI 0.62 to 0.77), 0.76 (95%CI 0.69 to 0.82), 5.651 (95%CI 1.237 to 25.810), and 0.349 (95%CI 0.155 to 0.784), respectively. Overall area under the curve (AUC) of SROC curve was 0.884 (DOR=19.416, 95%CI 2.473 to 152.47), demonstrating significant heterogeneity (I2gt;50%). Conclusion?The use of PCT for VAP diagnosis has only a moderate sensitivity and specificity. Although the overall accuracy of VAP diagnosis is relatively high, there is significant heterogeneity between the studies, so more high-quality studies are needed. Besides, using PCT alone to diagnose VAP is not sufficient, and a combination with other clinical evaluations is necessary.
Objective To evaluate the sedative effects of fentanyl on ventilated patients in intensive care unit (ICU ).Methods Thirty orotracheal intubated and mechanical ventilated medical patients in ICU were randomly divided into two groups，ie.Midazolam group (group M) and midazolam combined with fentanyl group with a proportion of 100∶1 (group M+F) The sedatives were continuously intravenously infused to achieve a target motor activity assessment scale (MAAS) of 3 and ventilator synchrony score of adaptation to the intensive care environment (ATICE) ≥3 after loading dose of midazolam.The sedation level was evaluated and the infusion rate was adjusted to maintain the target sedation goal every 2 h and the hemodynamic，respiratory and sedative parameters were recorded simultaneously.The oxygenation index were measured at 12 and 24 h.The infusion were ceased after 24 h,then the sedative degree was assessed every 30 min until MAAS ≥3 and the recover time were recorded.Results There were no significant differences in blood pressure，oxygenation index and adjustive frequency of drugs between the two groups (all Pgt;0.05).The heart rate，respiratory rate and airway pressure in group M+F decreased significantly than those in Group M (Plt;0.05).The amount of midazolam used and cost of sedatives were lower than those in group M (Plt;0.05).Satisfactory degree of sedation or ventilator synchrony and awakeness score of ATICE in group M+F were higher than those in group M.The recover time was shorter in groupM+F (Plt;0.05).Conclusion In medical ventilated patients, fentanyl improves the sedative effect of midazolam and reduces the dose of midazolam,hence,reduce the total cost of sedatives.
ObjectiveTo explore the clinical value of fibrinogen-albumin-ratio (FAR) in adult extracorporeal membrane oxygenation (ECMO) hemorrhage. MethodsThe clinical data of adult patients receiving ECMO in the West China Hospital from 2018 to 2020 were analyzed retrospectively. Patients were divided into a bleeding group and a non-bleeding group based on whether they experienced bleeding after ECMO. Logistic regression analysis was used to study the relationship between FAR and bleeding, as well as risk factors for death. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive ability of FAR. According to the optimal cut-off value of FAR for predicting hemorrhage, patients were divided into a high-risk group and a low-risk group, and the occurrence of bleeding was compared between the two groups. ResultsA total of 125 patients were enrolled in this study, including 85 males and 40 females, aged 46.00 (31.50, 55.50) years. Among them, 58 patients received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 67 patients received veno-venous extracorporeal membrane oxygenation (VV-ECMO). There were 49 patients having bleeding, and the lactate level was higher (P=0.026), the platelet count before ECMO initiation and 24 h after ECMO initiation was lower (P=0.031, 0.020), the fibrinogen level 24 h after ECMO initiation was lower (P=0.049), and the proportion of myocarditis patients was higher (P=0.017) in the bleeding group than those of the non-bleeding group. In the subgroup analysis of ECMO mode, the higher D-Dimer, lactate level and lower FAR before and 24 h after ECMO initiation were associated with bleeding in the VA-ECMO group (P=0.017, 0.011, 0.033, 0.005). The 24 h FAR was independently correlated with bleeding (P=0.048), and AUC was 0.714. The cut-off value was 55.73. According to this optimal cut-off value, 25 patients were divided into the high-risk group (≤55.73) and 33 into the low-risk group (>55.73). There was a higher incidence of bleeding in the high-risk group compared to the low-risk group (unadjusted P=0.002; P=0.013 for multivariable adjustment). In the VV-ECMO group, the relationship between FAR and bleeding events was not significant (P>0.05). ConclusionLow 24 h FAR is an independent risk factor for bleeding in VA-ECMO patients, and the diagnostic cut-off value is 55.73.
