血管外肺水指数在脓毒症相关性ALI/ARDS患者液体管理中的意义

Objective The management of fluid infusion is crucial in severe sepsis/septic shock patients.The correlation of extravascular lung water index(EVLWI) versus oxygenation index ( PaO2/FiO2 ) and EVLWI versus intrathoracic blood volume index(ITBVI) were analysed in this present study. Method Totally 24 patients,admitted to the Intensive Care Unit of Second Affiliated Hospital of Zhejiang University, College of Medicine and diagnosed as severe sepsis/septic shock with acute lung injury and/or acute respiratory distress syndrome,were enrolled. ITBVI and EVLWI were detected with PiCCO technique. Correlation of EVLWI and PaO2/FiO2, ITBVI and EVLWI were analysed,respectively. Simple correlation and simple linear regression were used for statistical analysis. Results Significant negative correlation was found of EVLWI and PaO2/FiO2 ( r = - 0. 45, P ＜ 0.01).EVLWT = 14 mL/kg was defined as the cutoff value for the subgroup analysis. No correlation was found between EVLWI and PaO2/FiO2 in the subgroup with EVLWI≤ 14 mL/kg ( r = 0. 12, P = 0.243), but in the subgroup with EVLWI ＞ 14 mL/kg, significant negative correlation was found ( r = - 0. 47, P ＜ 0. 01 ). When EVLWI was higher than 14 mL/kg,EVLW should be decreased to improve oxygenation and other aspects should be taken into account. No significant correlation was found between ITBVI and EVLWI. A ITBVI value 1000 mL/m2 was also defined as the cutoff value for the subgroup analysis. No significant correlation was found in the subgroup with ITBVI≤ 1000 mL/m2( r = 0.13, P = 0.17), while significant positive correlation was found in the subgroup with ITBVI ＞ 1000 mL/m2. This result suggested that in patients of severe sepsis/septic shock with ALI/ARDS, when the blood volume is high, ITBV should be decreased to improve the oxygenation,however,it is not useful in the situation of high pulmonary vascular permeability. Conclusions Extravascular lung water has a important role in the fluid management in patients of severe sepsis/septic shock with ALI/ARDS.     

强制性脓毒症治疗流程对严重脓毒症和脓毒性休克预后影响

目的 研究强制性脓毒症治疗流程对严重脓毒症和脓毒性休克患者预后的影响.方法 前瞻性研究2008年6月至2009年12月就诊于两个三级教学医院急诊科的严重脓毒症及脓毒性休克患者195例;应用拯救脓毒症运动标准数据库(SSC database)研究脓毒症患者临床的特点、治疗和预后.纳人标准:符合SSC database诊断标准.2008年6月至12月就诊患者进行现况调查,依据临床医师经验治疗,为对照组.2009年1月至12月间就诊患者采用强制性脓毒症治疗流程治疗,即治疗组.比较强制性脓毒症治疗流程实施前后两组住院病死率.采用SPSS 15.0软件进行数据分析.组间比较采用独立样本t检验.计数资料以率和构成比表示,采用χ2检验.用Kaplan-Meier进行生存曲线分析,以P＜0.05为差异具有统计学意义.结果 治疗组[98.3%(115/117)]与对照组[2.56%(2/78)]比较显著提高血乳酸的检测率(P＜0.01);治疗组69.2%(81/117)患者可以在来诊3 h内给予抗生素,对照组为35.8%(28/78)(P＜0.01);治疗组[47.9%(56/117)]与对照组[25.6%(20/78)]比较显著增加抗生素应用前血培养送检率(P=0.003);治疗组[80.3%(53/66)]与对照组[27%(10/37)]比较显著增加标准液体复苏率,P＜0.01;治疗组[8.1%(3/37)]与对照组[27.3%(18/66)]比较中心静脉压达标率增加(P=0.023);治疗组[29.1%(34/117)]与对照组[44.8%(35/78)]比较住院病死率显著下降(P=0.032).结论 强制性实施脓毒症治疗流程提高了严重脓毒症和脓毒性休克标准治疗依从性,住院病死率下降15.7%.

Abstract：

Objective To study the impact of therapy strategy on outcomes of patients suffering from severe sepsis and/or septic shock. Method A total of 195 patients diagnosed as severe sepsis or septic shock were enrolled for prospective study from June 2008 to December 2009. Patient's clinical manifestation,treatments and outcomes were studied by using SSC database. Patients were divided into control group and treatment group. In control group, patients enrolled from June 2008 to December 2008, were treated with conventional medical care In treatment group, patients enrolled from January 2009 to December 2009 were treated with a novel algorithm of mandatory treatment for sepsis In-hospital mortality of two groups was compared. SPSS15.0 software was used for analysis of data. Chi-square test and unpaired t-test were used for comparisons between groups. Results Compared to the control group The need for blood lactate test was significantly grown in treatment group [98.2% (115/117) versus 2.56% (2/78), P ＜ 0.001]. Antibiotics was administered to 69.2% (81/117) patients of treatment group within 3 hours after their arrival at the emergency department compared to 35.8% (28/78) in the control group (P ＜ 0. 001). Blood cultures made before antibiotics given were 47.9% (56/117) in the treatment group compared to the control group 25.6%(20/78), P = 0. 003. The rate of fluid resuscitation was 80.3% (53/66) in the treatment group and 27%(10/37) in the control group, P ＜0.001. The rate of CVP (8 mmHg was 27.3% (18/66) in the treatment group and 8.1% (3/37) in the control group, P = 0. 023. In-hospital mortality was 29.1% (34/117) in the treatment group and 44.8% (35/78) in the control group, P =0. 032. Conclusions The algorithm of mandatory treatment for sepsis improved the therapeutic efficacy of the treatment for severe sepsis and septic shock, decreasing in-hospital mortality.     

热休克蛋白70含量变化与脓毒症严重程度的关系

目的 探讨脓毒血症患者热休克蛋白(heat shock protein,HSPs)70含量与疾病严重程度相关关系,及其对病情预后的判断价值.方法 选择2009年4月至2010年11月上海市浦东新区公利医院院急诊科收治确诊脓毒症患者120例进行前瞻性研究,按照SAPSⅡ评分法分为轻、中、重3组,每组40例.另选40例年龄、性别、体质量构成与上述各组差异无统计学意义的体检健康人群作为健康对照组.又根据患者最后转归分为死亡组和存活组.患者入院后立即外周静脉采血5 mL,用流式细胞术测定实验组患者外周血中性粒细胞胞内HSPs70的水平,以及血清中降钙素原(PCT)、C-反应蛋白(CRP)含量.单因素方差分析比较各组间HSPs70,PCT、CRP的变化差异.结果 ①脓毒症患者中性粒细胞胞内热休克蛋白(HSPs)70的含量随SAPS Ⅱ评分增高而逐渐升高,轻度、中度、重度脓毒症之间差异具有统计学意义(P<0.05);血清降钙素原(PCT)含量也随SAPSⅡ评分增高逐渐升高,轻度与重度脓毒症之间差异具有统计学意义(P<0.05).②在所有脓毒症患者中,死亡患者均出现在重度组内,与其他标志物相比,死亡患者的热休克蛋白HSPs70的含量比存活患者明显升高(P<0.05).③在脓毒症患者的受试工作者曲线分析中,中性粒细胞胞内热休克蛋白(HSPs)70的含量与PCT、CRP相比,曲线下面积明显增多.结论 热休克蛋白HSPs70对脓毒症患者病情及预后判断有一定的临床价值.

Abstract：

Objective To investigate the relationships between the level of heat shock protein (HSPs) 70 and severity of sepsis in order to find its effects on the status of sepsis and the prognosis of the patients. Methods In total, 120 patients diagnosed to be suffering from sepsis from the emergency department were selected as studying subjects. According to SAPS Ⅱ score, all of these patients were divided into mild, moderate and severe groups (n =40 in each group) , and at the same time, 40 healthy volunteers were studied as controls. The levels of intracellular HSPs70 in peripheral blood neutrophil cells in the mild, moderate and severe groups were determined by using flow cytometry, while serum levels of procalcitonin (PCT) and C-reactive protein ( CRP) were measured as well. Results ① The levels of heat shock proteins HSPs70 in neutrophil cells and PCT in patients with sepsis escalated gradually with the increase in SAPS Ⅱ score, and there were significant different among the mild, moderate, and severe sepsis groups(P<0.05). ② In all septic patients, the death happened only in the severe group. Compared other markers in the survivals , the level of heat shock protein HSPs70 was significantly higher in fatal patients. ③ In curve plot analysis in the patients with sepsis done by the curve of receiver operating characteristic (ROC) , the area of HSPs70 in neutrophil cells under the curve was significantly larger as compared with that of PCT and CRP. Conclusions Heat shock protein HSPs70 has a certain clinical value in determining the severity of disease and prognosis of patients suffering from sepsis.     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

Objective To investigate the effect of early goal-directed therapy (EGDT) on treatment of critical patients with severe sepsis/septic shock.Methods A multi-center, prospective, randomized,controlled study was deployed.Totally 314 critical patients, from eight comprehensive hospitals in Zhejiang Province admitted during January, 2005 to January, 2008, suffering from severe sepsis/septic shock were randomized into conventional treatment group (n=151) and EGDT group (n = 163), the patients of the former underwent fluid resuscitation guided by central venous pressure (CVP), systolic blood pressure (SBP) or mean artery pressure (MAP) and urinary output (UO), and the latter guided by CVP, SBP orMAP and UO plus central venous oxygen saturation (ScvO2).The patients were treated with fluid, blood transfusions and cardiac stimulants in a period of 6 hours after enrollment to reach the goal.The difference of 28-day survival rate and intensive care unit (ICU) mortality (primary end points), the length of ICU stay,the duration of mechanical ventilation, duration of antibiotics treatment, incidence of newly occurredinfection, and severity scores (secondary end points) were compared between two groups.Results Finally,a total of 303 patients were eligible to enter this study, with 157 patients in EGDT group and 146 patients in conventional treatment group.In comparison with conventional treatment group, the 28-day survival rate of EGDT group was increased by 17.7% (75.2% vs.57.5%, P=0.001) and the ICU mortality of EGDT group was decreased by 15.7% (35.0% vs.50.7%, P=0.035), the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score (14.4±8.5 vs.18.0±7.1, P=0.043), multiple organ dysfunction syndrome (MODS) score (5.8±3.1 vs.8.9±3.7, P=0.014) and sepsis-related organ failure assessment (SOFA) score (5.6 ± 2.9 vs.10.4 ± 3.7, P = 0.001) were significantly decreased in EGDT group.Meanwhile, a significant shortening of duration of using antibiotics was also found [(13.4±10.0) days vs.(19.7 ± 13.5) days, P = 0.004], with a lowering of incidence of occurrence of new infection (37.6% vs.53.4%, P=0.014).There were no differences in other parameters for secondary end points.Conclusion EGDT improves 28-day survival rate and clinical scores, and it shows beneficial effects on outcome of critical patients with severe sepsis/septic shock.     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

Objective To investigate the effect of early goal-directed therapy (EGDT) on treatment of critical patients with severe sepsis/septic shock.Methods A multi-center, prospective, randomized,controlled study was deployed.Totally 314 critical patients, from eight comprehensive hospitals in Zhejiang Province admitted during January, 2005 to January, 2008, suffering from severe sepsis/septic shock were randomized into conventional treatment group (n=151) and EGDT group (n = 163), the patients of the former underwent fluid resuscitation guided by central venous pressure (CVP), systolic blood pressure (SBP) or mean artery pressure (MAP) and urinary output (UO), and the latter guided by CVP, SBP orMAP and UO plus central venous oxygen saturation (ScvO2).The patients were treated with fluid, blood transfusions and cardiac stimulants in a period of 6 hours after enrollment to reach the goal.The difference of 28-day survival rate and intensive care unit (ICU) mortality (primary end points), the length of ICU stay,the duration of mechanical ventilation, duration of antibiotics treatment, incidence of newly occurredinfection, and severity scores (secondary end points) were compared between two groups.Results Finally,a total of 303 patients were eligible to enter this study, with 157 patients in EGDT group and 146 patients in conventional treatment group.In comparison with conventional treatment group, the 28-day survival rate of EGDT group was increased by 17.7% (75.2% vs.57.5%, P=0.001) and the ICU mortality of EGDT group was decreased by 15.7% (35.0% vs.50.7%, P=0.035), the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score (14.4±8.5 vs.18.0±7.1, P=0.043), multiple organ dysfunction syndrome (MODS) score (5.8±3.1 vs.8.9±3.7, P=0.014) and sepsis-related organ failure assessment (SOFA) score (5.6 ± 2.9 vs.10.4 ± 3.7, P = 0.001) were significantly decreased in EGDT group.Meanwhile, a significant shortening of duration of using antibiotics was also found [(13.4±10.0) days vs.(19.7 ± 13.5) days, P = 0.004], with a lowering of incidence of occurrence of new infection (37.6% vs.53.4%, P=0.014).There were no differences in other parameters for secondary end points.Conclusion EGDT improves 28-day survival rate and clinical scores, and it shows beneficial effects on outcome of critical patients with severe sepsis/septic shock.     

脉冲高容量血液滤过对脓毒症患者细胞免疫功能的影响

目的 探讨脉冲高容量血液滤过对脓毒症患者外周血辅助性T细胞(T helper,Th)17及CD4+ CD25+ 调节性T细胞(Treg)影响及其临床价值.方法 本研究为前瞻性对照研究,将2008年1月至2010年11月在安徽省立医院ICU住院的脓毒症患者40例(男/女=24/16),年龄25～75岁,按照疾病严重程度分为3组:脓毒症组14例(男/女=8/6);严重脓毒症组15例(男/女=9/6);脓毒症休克组11例(7/4).入选和疾病严重程度分级标准:根据1992年美国胸科医师学院(ACCP)/美国危重病医学会(SCCM)共识会议制定的脓毒症诊断标准.排除标准:患有自身免疫系统疾病、急性脑卒中、心肌梗死、病毒性肝炎、HIV感染的患者以及入院前3个月内使用过激素或免疫抑制剂的患者.其中入组5 d内未行血液净化治疗患者15例(男/女=8/7)入选为A组;5 d内行脉冲高容量血液滤过的25例患者(男/女=16/9)入选为B组.两组一般资料具有可比性.连续性血液净化以24 h为1周期,两次血滤之间间隔24 h.其中高容量血液滤过(70 mL·kg-1·h-1)治疗6～8 h后续行常规CVVH治疗16～18 h剂量(35 mL·kg-1·h-1).所有入选的40例脓毒症患者在入选当天和第5天清晨空腹抽外周血送检,行流式细胞术检测血中Th17细胞及CD4+ CD25+调节性T细胞的比例.计量资料采用t检验,配对t检验和One way ANOVA分析.小样本率的比较采用确切概率法.相关分析采用Peason相关分析.另选取本院体检中心的20例健康人为健康对照组.结果 健康对照组Th17表达率为(0.91±0.38)%,CD4+ CD25+ Treg细胞表达率为(0.39±0.23)%.40例脓毒症患者在第1天这两项指标明显升高(P<0.05):其中脓毒症组分别为(2.09±0.53)%,(1.72±0.59)%;严重脓毒症组(3.90±0.80)%,(2.72±0.22)%;脓毒性休克组(1.85±0.35)%,(3.55±0.51)%.Th17表达率,严重脓毒症组最高(P<0.05).而脓毒症休克组与脓毒症组比较差异无统计学意义(P>0.05).CD4+ CD25+ 调节性T细胞表达率则呈现:脓毒症休克组>严重脓毒症组>脓毒症组(P<0.05).B组与A组比较,脉冲高容量血液滤过能显著的下调脓毒症患者Th17[(1.87±0.43)vs.(2.48±1.05),P<0.05]和CD4+ CD25+ 调节性T细胞[(1.92±0.89)vs.(2.63±0.92),P<0.05]的表达.结论 脓毒症患者外周血Th17细胞和CD4+ CD25+调节性T细胞表达增加,提示Th17细胞和CD4+ CD25+调节性T细胞在脓毒症的免疫发病机制中可能起着重要作用.脉冲高容量血液滤过能有效的调整Th17细胞和CD4+ CD25+ 调节性T细胞的表达,可作为脓毒症免疫调节治疗的重要手段之一.

Abstract：

Objective To study the effects of pulse high volume hemofiltration (PHVHF) on the changes of Th17 cells (T helper 17 cells) and CD4 + CD25 + reguratory T cells (Treg cells) in peripheral blood of patients with sepsis and to evaluate the clinical value of this intervention. Methods The patients were included in this prospective study as per the criteria of sepsis set by America Chest Physicians College/America Society for Critic Care Medicine in 1992. The patients were excluded: ① immune system disorder, ② acute stroke, ③ myocardial infarction, ④ virus hepatitis,⑤ human immunodeficiency virus infection, ⑥ under immunosuppressive therapy. Forty patients (24 males, 16 females, aged from 25 to 75years) with sepsis in ICU were enrolled from January. 2008 to November. 2010. According to the severity of disease, the patients were divided into three groups; moderate sepsis group (n = 14, 8 males, 6 females) , severe sepsis group (n = 15, 9 males, 6 females) , and septic shock group (n = 11, 7 males, 4 females). The initially clinical data of three groups were comparable. Twenty healthy individuals served as controls. According to the mode of treatment, forty patients were also divided into two groups: conventional treatment group (group A, n= 15) in which patients were treated without PHVHF within 5 days after admission and trial group (group B, n=25) in which patients were treated with pulsed high volume hemofiltration (PHVHF) within 5 days after admission. In group B, high volume hemofiltration (70 mL · kg-1 · h-1) was given to patients for 6 ～ 8 hours, and then conventional continuous vein - vein hemofiltration (35 mL · kg-1 · h-1) for 16 ~ 18 hours. The total length of period for continuum blood scavenging was 24 hours as one cycle. The interval between two cycles of blood scavenging was 24 hours. The changes of Th17 cells and CD4+ CD25 + Treg cells of 40 patients were detected with flow cytometry on the 1st day and the 5th day after admission. The data were analyzed by using SPSS version 13. 0 software. Measurement data were analyzed with Paired-samples t-test, independent-samples t-test or one way ANOVA . Ratio of small samples was compared with fisher's exact test, and the correlation was analyzed by using Pearson correlation analysis. Results The rates of Th17 cells were( 0.91 ±0.38)%, (2.09 ±0. 53)% , (3.90 ±0. 80)% , and ( 1. 85 ±0.35)% in control, moderate sepsis, severe sepsis, and septic shock groups, respectively, while the rates of CD4+ CD25+ Treg cells were (0.39 ±0.23)%, (1. 72 ±0. 59)% , (2.72 ±0. 22)% , and (3. 55 ±0. 51)% , respectively. The rate of Thl7 cells on the 1st day was higher in severe sepsis group than that in other two groups ( P < 0. 05 ) without significant difference between septic shock and moderate sepsis groups ( P > 0. 05). Moreover , the rate of CD4+ CD25 + Treg cells was up - regulated on the 1st day in the following order from high to low: septic shock group > severe sepsis group > sepsis group (P < 0.05). The rates of Th17 cells and CD4 + CD25 + Treg cells in patients of group B decreased in greater degree than that did in patients of group A (P < 0.05 ). Conclusions The changes of Th17 cells and CD4 + CD25 + Treg cells may play an important role in pathogenesis of sepsis, and the pulsed high volume hemofiltration may be one of the effective treatments for the patients with sepsis by regulating the rates of Thl7 cells and CD4 + CD25 + Treg cells.     

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND Sepsis is fatal in patients with gastrointestinal perforation(GIP).However,few studies have focused on this issue.AIM To investigate the risk factors for postoperative sepsis in patients with GIP.METHODS This was a retrospective study performed at the Department of General Surgery in our treatment center.From January 2016 to December 2018,the medical records of patients with GIP who underwent emergency surgery were reviewed.Patients younger than 17 years or who did not undergo surgical treatment were excluded.The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group.Clinical data for both groups were collected and compared,and the risk factors for postoperative sepsis were investigated.The institutional ethical committee of our hospital approved the study.RESULTS Two hundred twenty-six patients were admitted to our department with GIP.Fourteen patients were excluded:Four were under 17 years old,and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members.Two hundred twelve patients were finally enrolled in the study;161 were men,and 51 were women.The average age was 62.98±15.65 years.Postoperative sepsis occurred in 48 cases.The prevalence of postoperative sepsis was 22.6%[95%confidence interval(CI):17.0%-28.3%].Twenty-eight patients(13.21%)died after emergency surgery.Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery[odds ratio(OR)=1.021,95%CI:1.005-1.038,P=0.006],colonic perforation(OR=2.761,CI:1.821–14.776,P=0.007),perforation diameter(OR=1.062,95%CI:1.007-1.121,P=0.027),and incidence of malignant tumorrelated perforation(OR=5.384,95%CI:1.762-32.844,P=0.021)were associated with postoperative sepsis.CONCLUSION The time interval from abdominal pain to surgery,colonic perforation,diameter of perforation,and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.     

脓毒症患者辅助性T细胞17和CD4+CD25+调节性T细胞表达及血必净注射液的干预作用

目的 观察脓毒症患者外周血辅助性T细胞17(Th17)及CD4+CD25+调节性T细胞(Treg)的水平,并探讨其意义及血必净注射液的干预作用.方法 ①将64例重症监护病房(ICU)脓毒症患者按疾病严重程度分为脓毒症组(26例)、严重脓毒症组(21例)、脓毒性休克组(17例),同时选取18例健康体检者作为对照组.观察不同严重程度脓毒症患者外周血Th17和CD4+CD25+Treg的表达及其与病情严重程度的关系.②按随机原则将64例患者分为常规治疗组(25例,给予常规集束化治疗)和血必净治疗组(39例,在常规治疗基础上加用血必净注射液50 ml静脉滴注,每日2次),两组均以7 d为1个疗程.入ICU当日和治疗7 d用流式细胞术检测外周血Th17及CD4+CD25+Treg表达,观察血必净注射液的干预作用.结果 ①健康对照组Th17表达率为(0.84±0.29)%,CD4+CD25+Treg表达率为(0.43±0.20)%;脓毒症患者细胞表达均较健康对照组明显升高(均P<0.05),其中Th17表达以严重脓毒症组最高[(3.18±0.84)%],CD4+CD25+Treg 表达以脓毒性休克组最高[(3.28±0.76)%].脓毒症患者CD4+CD25+Treg与急性生理学与慢性健康状况评分系统Ⅰ(APACHE Ⅰ)评分和血乳酸均呈正相关(r1=0.519,r2=0.451,均P=0.01).②与常规治疗组比较,血必净注射液能更有效降低脓毒症患者Th17和CD4+CD25+Treg的异常表达[Th17:(1.72±0.69)%比(2.35±0.81)%,CD4+CD25+Treg:(1.78±1.00)%比(2.30±0.85)%,均P<0.05],纠正免疫平衡紊乱,缩短住ICU时间[(4.7±2.6)d比(7.5±4.3)d,P=0.0023,使脓毒症患者28 d病死率有降低趋势(20.5%比28.0%,P>0.05).结论 脓毒症患者外周血Th17和CD4+CD25+Treg表达增加,且与病情严重程度呈正相关,提示Th17和CD4+CD25+Treg在脓毒症发生发展的免疫机制中可能起着重要作用.血必净注射液能有效降低脓毒症患者Th17和CD4+CD25+Treg的异常表达,有降低脓毒症患者病死率的趋势.

Abstract：

Objective To study the level and significance of T helper 17(Th17)and CD4+CD25+regulatory T cells(Treg)in peripheral blood of patients with sepsis and to evaluate the effects of Xuebijing of Anhui Provincial Hospital were divided into three groups:sepsis group(n=26),severe sepsis group (n=21),and septic shock group(n=17).Eighteen healthy individuals served as controls.The comparison in the expression of Th17 and CD4+CD25+Treg within groups and the correlation between their levels and group(n=25,received routine bundle treatment)and Xuebijing treatment group(n=39,received bundle treatment+Xuebijing treatment).Patients in Xuebijing treated group were given 50 ml Xuebijing injection two times per day in addition to routine bundle treatment.Seven days constituted one course of treatment.The expressions of Th17 and CD4+CD25+Treg of 64 patients on the 1 day and 7 days after treatment were detected by flow cytometry.The effects of Xuebijing injection on the patients were evaluated.Results in control group,and they were lower than that of patients with sepsis(P<0.05).The expression rate of Th17 was higher in severe sepsis group [(3.18±0.84)%]than that of other two groups(P<0.05).Moreover,The expression rate of CD4+CD25+Treg was highest [(3.28±0.76)%]in septic shock group (P<0.05),and it was positive correlated with acute physiology and chronic health evaluation Ⅰ(APACHE routine group,our study indicated that Xuebijing injection could reduce the abnormal expression of Th17[(1.72±0.69)%vs.(2.35±0.81)%,P<0.05] and CD4+CD25+Treg[(1.78±1.00)% vs.(2.30±0.85)%,P<0.05] and decrease length of stay in ICU[(4.7±2.6)days vs.(7.5±4.3)days,P=0.002].It also lowered 28-day mortality of patients with sepsis,but the difference between two groups was not significant(20.5%vs.28.0%,P>0.05).Conclusion The expression of Th17 and CD4+CD25+Treg was increased in sepsis patients and was positively correlated with severity of sepsis,suggesting that they may play an important role in pathogenesis of sepsis.Xuebijing injection could decrease the abnormal expression of Th17 and CD4+CD25+Treg and tend to decrease the fatality rate of sepsis.     

The correlation between the apolipoprotein E genetic polymorphisms and sepsis in children Liu北大核心CSCD

Objective To study the correlation between apolipoprotein E (APOE) genetic polymorphisms and sepsis in Chinese children. Methods The inpatients suffered with sepsis were enrolled as septic group and the healthy children from child health division were enrolled as control group. The study of APOE genotypes were carried out by polymerase chain reactions followed a high-resolution melting curve analysis. SPSS 16.0 statistical software was used for data analysis. Mann-Whitney U test was used to compare the age between the groups. Hardy-Weinberg equilibrium was tested using the Pearson χ2 -test. The χ2 -test was used to compare gender and the genotype distribution between the groups. The odd ratio (OR) was calculated together with its 95% confidence interval (CI). Potential confounding effects of variables were corrected using a multivariate unconditional logistic regression model. All statistical tests were two-sided and P < 0.05 indicates statistically significance. Results Among a total of 285 children collected from March 2011 to June 2012, there were 88 patients with sepsis and 197 healthy children. In the septic group, 15 septic patients were complicated with central nervous system infection. Four apolipoprotein E genotypes were identified to be ϵ3/ϵ3, ϵ2/ϵ3, ϵ3/ϵ4, and ϵ2/ϵ4. The percentage of each genotype found in patients of the septic group and the control group was 64.4% vs. 73.1% (ϵ3/ϵ3); 16.8% vs. 10.7% (ϵ2/ϵ3); 18.8% vs. 14.7% (ϵ3/ϵ4); 0% vs. 1.5% (ϵ2/ϵ4), respectively. The number of patients with the genotype ϵ3/ϵ3 among septic patients was significantly lower than that among the control individuals (P = 0.047, 1 -β =0.334, OR =0.585, adjusted OR = 0.559). The number of patients with the genotype ϵ3/ϵ3 among the septic patients with central nervous system infection was 33.3%, which was also significantly lower than that among the septic patients without CNS infection (67.1%). (P = 0.014, 1-β = 0.685, OR = 0.245, adjusted OR = 0.275). Conclusions Apolipoprotein E genetic polymorphisms were associated with the occurrence of sepsis and central nervous system complications in children. The susceptibility of children with genotype ϵ3/ϵ3 to sepsis and central nerve system infection complications is significantly lower than that of children with other genotypes.     

脓毒症患者血清可溶性髓系细胞表达的触发受体-1水平及与预后的关系

Objective To approach the relationship between the contents of soluble form of triggering receptor expressed on myeloid cells-1 (sTREM-1) and prognosis in patients with sepsis. Methods Using prospective, control study design, a total of 50 patients with sepsis who were admitted in intensive care unit (ICU) of the Second Hospital of Tianjin Medical University from March to December in the year of 2009 were enrolled. Firstly, the patients were divided into sepsis (n=28) and severe sepsis (n=22) groups according to the patients' condition. Then the patients were divided into survival group (n = 34) and death group (n = 16)according to the clinical outcome at 28 days after onset of sepsis. Clinical and laboratory data including blood routine tests, blood chemistry, blood gas analysis, C-reactive protein (CRP) and procalcitonin (PCT) were collected on the 1st, 3rd and 7th day after onset. Acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ ) score was determined. sTREM-1 levels were determined using enzyme linked immunosorbent assay (ELISA) method. Correlation analysis of the sTREM-1, APACHE I score, white blood cell count (WBC) and CRP, using Logistic regression analysis. A total of 30 healthy persons were enrolled into the control group. Results The sTREM-1 levels (ng/L) in 50 septic patients on the 1st day were higher than those of the healthy persons (52. 80±9. 30 vs. 23. 29±6. 22, P＜0. 01). The sTREM-1 levels (ng/L) in severe sepsis group on the 1st, 3rd and 7th day (58. 25±10. 59, 65. 75±13. 57, 50.18±21. 73) were higher than those of the sepsis group (48.55±5.20, 42.85±8.54, 34.02±12.86, P＜0.05 or P＜0.01). The sTREM-1 levels (ng/L) of the survival group on the 1st, 3rd and 7th day (53. 07± 10. 47, 45. 04±9. 89,32. 84 ±8. 42) were decreased with the progression of the ailment. The sTREM-1 levels did not differ significantly between the control group and survival group on the 7th day (P＞0. 05). The sTREM-1 levels (ng/L) in the death group on the 1st, 3rd and 7th day were increased with the progression of the ailment (52.27±6.42, 69.67±12.83, 75. 70± 10. 55), and the level was significantly higher than that in survival group on the 3rd and 7th day (both P＜0. 01). The contents of sTREM-1 were positive correlated with APACHE Ⅱ score (r= 0.657, P＜0. 01), but not correlated with WBC (r= 0.023, P＞0. 05), whilesomewhat correlated with CRP (r=0. 150, P＜0.10). Logistic regression analysis showed that sTREM-1 [odds ratio (OR) = 0. 893,P = 0. 000] and APACHE I score (OR = 0.771, P = 0.000) might be potential prognostic factors for septic patients. The area under the receiver operator characteristic curve was 0. 868 and 0.930. The sensitivity of prognostic evaluation was 81.1% and specificity was 74.5% with sTREM-1 50 ng/L, and the sensitivity was 83. 8% and specificity was 86. 3% with APACHE Ⅱ score 20 to estimate the outcome. Conclusion The serum sTREM-1 are elevated at early stage in sepsis patients. It can reflect the severity of the condition. The sTREM-1 level, which might be considered as a potential prognostic factor for septic patients, is significantly correlated with APACHE Ⅱ score.     

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality

OBJECTIVE: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. DESIGN: Two-year prospective observational cohort. SETTING: Academic tertiary care facility. PATIENTS: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. INTERVENTIONS: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. MEASUREMENTS AND MAIN RESULTS: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). CONCLUSIONS: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.     

感染性休克集束治疗对病死率影响的前瞻性临床研究

目的 探讨集束治疗对感染性休克患者病死率的影响.方法 采用前瞻性研究方法,将2007年1月-2008年6月重症加强治疗病房(ICU)收治的成人感染性休克患者分为培训前(2007年1-9月)和培训后(2007年10月-2008年6月)两个阶段进行感染性休克集束治疗.分析6 h及24 h感染性休克集柬治疗各指标与预后的关系;采用多元回归分析方法,筛选出集束治疗对感染性休克预后影响的独立相关因素,并研究两个阶段感染性休克集束治疗的依从性、机械通气时间、ICU住院时间以及28 d病死率.结果 研究期间共收治符合条件的感染性休克患者100例,其中培训前51例,培训后49例;存活36例,死亡64例.多元回归分析显示,6 h早期目标导向治疗(EGDT)、24 h EGDT是与感染性休克28 d病死率相关的两个独立保护因素,优势比(OR)分别为0.046和0.120(P均<0.01).培训后集束治疗依从性均有明显提高,其中6 h EGDT和24 h EGDT分别从19.6%、35.3%提升至55.1%、65.3%(P均<0.01).培训后机械通气时间[(166.6±156.4)h比(113.6±73.6)h3、ICU住院时间[(9.4±7.6)d比(6.0±3.9)d]及28 d病死率(72.5%比55.1%)较培训前明显缩短(P<0.05或P<0.01).结论 继续教育培训可提高医务人员对感染性休克集束治疗的依从性,降低感染性休克患者的病死率.     

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department

BackgroundSepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.ObjectiveTo evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.MethodsWe performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.ResultsOf the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = −0.406; 95% CI = −0.809, −0.003; p = 0.048) and time of triage to physician (coeff = −0.543; 95% CI = −0.864, −0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.ConclusionEMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.     

Late compliance with the sepsis resuscitation bundle: impact on mortality

Early compliance with the sepsis resuscitation bundle has been suggested to reduce mortality. However, few data are available about the impact of late compliance with the bundle on outcomes. The aim of this study was to assess whether the completion of the resuscitation bundle within the first 6 h after admission to the intensive care unit (ICU), but beyond the specific time limit of the various bundle interventions, is related to an improvement in survival. This prospective, cohort study included 753 patients recruited from September 2005 until August 2010 with severe sepsis/septic shock in the three medical-surgical ICUs of a tertiary academic medical center. We assessed the compliance with the different tasks included in the resuscitation bundle. Furthermore, we ascertained within the first 6 h after ICU admission the compliance with those tasks not carried out within their specific time limits; we have termed this variable "bundle improvement in the ICU." Septic shock was present in 88.1%. The overall in-hospital mortality was 31.6%. In 51.5%, there was bundle improvement in the ICU; this variable was associated with a lower risk of mortality (adjusted hazard ratio, 0.52 [95% confidence interval, 0.34-0.78]). That association was observed only when the time from severe sepsis onset to ICU admission was 6 h or less. Importantly, similar results were found after excluding all patients with severe sepsis (rapid responders) and those with refractory shock (nonresponders). The task with highest improvement was the achievement of central venous oxygen saturation 70% or greater in 39% of patients. Compliance with the resuscitation bundle even beyond the recommended time is associated with improvement in survival in patients with severe sepsis/septic shock.     

Improvements in compliance with resuscitation bundles and achievement of end points after an educational program on the management of severe sepsis and septic shock

The objectives of this study were to determine whether an educational program could improve compliance with resuscitation bundles and the outcomes of patients with severe sepsis or septic shock and to evaluate which resuscitation bundle end points were associated with in-hospital mortality. This was a retrospective observational study of 366 patients (163 of historical controls and 203 of treatment patients) with severe sepsis or septic shock who presented to the emergency department between May 2007 and July 2009. Compliance with resuscitation bundles and achievement of the corresponding end points were compared before and after the 3-month educational program. Compliance with central line insertion and monitoring of central venous pressure (29% vs. 67%, P < 0.001) and central venous oxygen saturation (ScvO?) (25% vs. 68%, P < 0.001) was significantly improved after the educational program. The achievement of target ScvO? within the first 6 h was significantly improved (62% vs. 88%, P < 0.001). In-hospital mortality was independently associated with adequate fluid challenge (odds ratio [OR], 0.161; 95% confidence interval [CI], 0.046-0.559) and the achievement of target mean arterial pressure (OR, 0.056; 95% CI, 0.008-0.384) and ScvO? (OR, 0.251; 95% CI, 0.072-0.875) among the five sepsis resuscitation bundles. In conclusion, an educational program can improve compliance with resuscitation bundles and achievement of their corresponding end points.     

An audit of compliance with the sepsis resuscitation care bundle in patients admitted to A&E with severe sepsis or septic shock

Severe sepsis and septic shock are syndromes resulting in a systemic inflammatory response and the dysfunction of one or more organs following infection. The Surviving Sepsis Campaign is an international effort to reduce mortality in severe sepsis and septic shock by 25% by 2009 using a care bundle approach. It comprises evidenced-based interventions to be carried out within 6h of onset of sepsis. We conducted a prospective observational audit of 32 consecutive adult patients with severe sepsis or septic shock admitted via the A&E of a district general hospital. The compliance rate against each element, and overall compliance to the 6-h bundle were obtained. Patients' ages ranged from 55 to 75 years with 53% being male. Overall compliance was 19%. Arterial lactate was undertaken 100% of the time, and only just over half received an appropriate fluid challenge. Administration of an antibiotic was also very slow. Local recommendations include improvements to the track and trigger scoring system in A&E to improve recognition of sick patients, ensuring the doctor responsible for prescribing the antibiotic will administer it, and increasing awareness of the surviving sepsis campaign via education and training of all A&E staff. Given current evidence greater compliance to the care bundle may well improve patient outcomes for this client group.     

Clinical utility of B-type natriuretic peptide in early severe sepsis and septic shock

B-type natriuretic peptide (BNP) has diagnostic, therapeutic, and prognostic utility in critically ill patients. For severe sepsis and septic shock patients in particular, similar clinical utility from the most proximal aspects of hospital presentation to the intensive care unit has not been examined. BNP levels were measured at 0, 3, 6, 12, 24, 36, 48, 60, and 72 hours in 252 patients presenting to the emergency department with severe sepsis and septic shock. The clinicians were blinded to the BNP levels. Elevated BNP levels (>100 pg/mL) were seen in 42% and 69% of patients on presentation and at 24 hours, respectively. Elevated BNP ranges (>230 pg/mL) were significantly associated with myocardial dysfunction and severity of global tissue hypoxia. When adjusted for age, gender, history of heart failure, renal function, organ dysfunction, and mean arterial pressure, a BNP greater than 210 pg/mL at 24 hours was the most significant independent indicator of increased mortality: odds ratio 1.061 (1.026-1.097), P < .001, 95% confidence interval. Patients with severe sepsis and septic shock often have elevated BNP levels, which are significantly associated with organ and myocardial dysfunction, global tissue hypoxia, and mortality. Serial BNP levels may be a useful adjunct in the early detection, stratification, treatment, and prognostication of high-risk patients.     

The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study

Introduction  

Compliance with the ventilator care bundle affects the rate of ventilator-associated pneumonia. It was not known, however, whether compliance with sepsis care bundles has an impact on outcome. The aims of the present study were to determine the rate of compliance with 6-hour and 24-hour sepsis bundles and to determine the impact of the compliance on hospital mortality in patients with severe sepsis or septic shock.     

Sepsis与感染性休克的急诊救治及流程优化

Sepsis及感染性休克是临床常见的综合症,与患者预后密切相关。早期救治对Sepsis及感染性休克至关重要。急诊医师在早期诊断Sepsis、评价危险因素和早期复苏方面均起到至关重要的作用。目前证据表明,“Sepsis的集束化治疗”能够改善此类患者预后,2018年4月“拯救Sepsis运动”再次更新了相关推荐意见,提出了“1 h集束化治疗目标”,这对急诊医师提出了更高的要求。本文拟从救治流程、具体处理及可能的政策指导方面讨论Sepsis及感染性休克的急诊优化治疗,以期提高指南依从性和治疗质量,由此改善此类患者的预后。     

The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock

Introduction

The aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.

Methods

We analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.

Results

A total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).

Conclusions

ED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.