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.
This article reports the management of thirty elderly patients of septic shock during anesthesia. Twenty-four of them received continious epidural anesthesia, five of them were under intravenous general anesthesia with endotracheal intubation, and onr patients recerived intravenous ketamine anesthesia. The effects of these patients on enesthesia wer satisfactory. Twenty-four patients recouverd after roperation. Six patients died. The authors atresses the high risk of anesthetic management in these patients. Experiences are introduced in per-anesthetic preparation and medication selection and maintenance of anesthesia, monitoring and treatment during anesthesia and postoperative care of septic shock of the elderly.
Objective To evaluate the effects of intensive care unit (ICU)-acquired hypernatremia (IAH) on the outcome of septic shock patients. Methods This retrospective study analyzed 116 septic shock patients admitted to the ICU of the First Affiliated Hospital of Soochow University from August 2018 to December 2022. Patients were divided into two groups: IAH group and normonatremia group. χ2 test, t test and the Mann-Whitney U test of the non-parametric test were used to compare the differences in clinical data between the two groups. Independent risk factors for IAH were identified by unconditioned Logistic regression analysis, and receiver operating characteristic (ROC) curves were constructed to determine their role in predicting IAH. The Kaplan-Meier curve was used to evaluate the effects of IAH and its duration on 28-day survival. Results Renal insufficiency, K+ concentration, body temperature max, mechanical ventilation, chronic critical illness, rapid recovery, sepsis-associated encephalopathy, persistent inflammation, immunosuppression and catabolism syndrome, and the length of stay in ICU had significant differences (P<0.05). Multivariate logistic regression analysis showed: total urine volume in the previous 3 days [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.01 - 1.16, P=0.019] and sodium content in enteral nutrition preparations (670 mg) (OR 6.00, 95%CI 1.61 - 22.42, P=0.006) were independent risk factors for IAH. In addition, the area under the ROC curve of total urine output in the first 3 days was 0.800 (95%CI 0.678 - 0.922, P=0.001). Finally, the duration of IAH was significantly correlated with 28-day survival rate (P=0.020). Conclusions IAH is a common and serious complication in septic shock, and is the main cause of poor prognosis. Sodium status may act as an ideal screening tool for patients with septic shock.
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.
目的通过漂浮导管（Swan-Ganz导管）监测外周血管阻力指数（SVRI）作为优化的心功能不全状态下感染性休克早期目标导向治疗（EGDT）的临床意义。 方法2012年1月至2014年1月第四军医大学附属西京医院心血管外科ICU收治体外循环心脏术后感染性休克患者8例，其中男7例、女1例，年龄（50.9±11.1）岁。以中心静脉压（CVP）为复苏目标行经验性容量复苏治疗，循环未见改善，则实施漂浮（Swan-Ganz）导管监测血流动力学指标，以外周血管阻力指数（SVRI）为优化目标复苏，观察Swan-Ganz导管复苏前及复苏6 h、24 h后的血流动力学及氧代谢指标，分析复苏达标所需时间。 结果8例患者平均住ICU时间（16.87±3.35）d，发生肺部并发症8例，急性肾功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好转存活，死亡2例。8例感染性休克患者经Swan-Ganz导管目标导向治疗6 h和24 h后平均动脉压（MAP）分别为（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心静脉压（CVP）分别为（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指数（CI）分别为（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指数（SVRI）分别为（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各项指标均较治疗前升高；治疗6 h和24 h后动脉血乳酸分别为（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，较治疗前[（14.98±0.45）mmol/L]下降。 结论采用Swan-Ganz导管监测SVRI作为优化目标导向治疗心功能不全状态下感染性休克可以提高6 h复苏成功率，改善患者预后。
Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.