早期血小板与淋巴细胞比值在静脉-动脉体外膜肺氧合患者中的预后价值分析

目的:研究早期血小板与淋巴细胞比值（platelet-to-lymphocyte ratio，PLR）在静脉-动脉体外膜肺氧合（arterial-venous extracorporeal membrane oxygenation，VA-ECMO）成人患者中的应用并探讨其对预后的影响。方法:回顾性分析2018年6月至2020年6月于江苏省人民医院急诊中心行VA-ECMO治疗的成人患者共83例。比较生存组（ n=46）和死亡组（ n=37）患者的基线资料差异，通过Logistic回归分析能够预测VA-ECMO患者28 d病死率的相关危险因素，采用ROC曲线计算最佳临界值。 结果:PLR（ECMO后48 h）（ OR=1.018，95% CI: 1.001~1.036， P=0.039）、连续性肾脏替代治疗（continuous renal replacement therapy, CRRT）（ OR=7.095，95% CI: 1.099~45.799， P=0.039）为VA-ECMO患者28 d病死率的相关危险因素，其中PLR（ECMO后48 h）的最佳临界值为156.3，敏感度为57.8%，特异度为86.1%（曲线下面积：0.756）。与高PLR组（>156.3）相比，低PLR组（<156.3）的急性肾损伤（acute kidney injury, AKI）发生率（ P<0.01）、出血发生率（ P=0.013）均较高。 结论:VA-ECMO辅助过程中早期PLR的降低以及CRRT的应用与不良预后相关。     

从73例重度创伤患者的凝血功能与输血方案论大量输血协议建设的必要性

目的:本研究通过重度创伤患者首次输血时间用血情况及预后分析,以探讨规范大量输血协议（massive transfusion protocols, MTP）建设的必要性和意义。方法:回顾性分析2017年1月至2019年12月就诊的重度创伤73例。以重度创伤患者从受伤到患者输注血制品的时间差为Δ t,根据Δ t将患者分为首次输血4 h内组( n=26)和大于4 h组( n=47),比较两组患者输注血制品总量。采用入院后的首次血常规﹑TEG﹑传统凝血等指标及Δ t对73例重度创伤患者28 d病死率进行统计分析。 结果:73例不同预后重度创伤患者各项指标结果显示,患者以28 d死亡区分,42例为死亡组,其余31例为存活组,死亡组与存活组相比,血小板（PLT）、纤维蛋白聚合功能（Angle）、血小板聚集功能（MA）、纤维蛋白原（Fbg）均明显降低( P<0.05或 P<0.01),而活化部分凝血活酶时间（APTT）和D二聚体（DD）则明显增高( P<0.05或 P<0.01);73例重度创伤患者有26例首次输血时间4 h内,而47例在首次输血大于4 h,比较发现首次输血4 h内组患者输注血制品总量明显减少（ P<0.01),病死率也明显降低（ P<0.05)。73例重度创伤患者凝血相关指标判断28 d病死率的二分类logistic回归分析结果发现,Fbg是患者28 d病死率的风险因素( P<0.05),Δ t是28 d病死率的保护因素( P<0.05),其他指标对重度创伤患者预后无明显影响。重度创伤患者Δ t预测28 d死亡ROC曲线分析显示曲线下面积为0.774（95% CI,0.653~0.895）( P<0.01);Fbg预测的28 d生存ROC曲线显示曲线下面积为0.735（95% CI,0.616~0.854）( P<0.01)。 结论:4 h内首次输血可以明显降低重度创伤患者的28 d病死率和减少血制品的使用,Δ t和Fbg分别对28 d死亡和生存有明显的预测作用;规范的MTP体系建设对于提高重度创伤患者的救治有重要意义。     

不同时间的血管活性药物评分对脓毒性休克患者死亡风险的预测价值

目的:评估不同时间的血管活性药物评分（vasoactive inotropic score, VIS）预测脓毒性休克患者28 d病死率的价值，以期降低患者的死亡风险、改善预后。方法:为单中心回顾性队列研究，通过收集2016年2月至2020年2月徐州医科大学附属医院重症医学科收治的275例接受血管活性药物治疗的成人脓毒性休克患者的临床资料，根据28 d生存情况分为死亡组和存活组，计算所有患者第1个24 h、第2个24 h最大血管活性药物评分，分别以VIS max24、VIS max48表示。采用多因素Logistic回归分析影响患者预后的独立危险因素，受试者工作特征曲线（ROC）对VIS的预测价值进行分析。 结果:死亡组和存活组在年龄、性别、体质量、感染部位、血培养结果、心脏骤停、激素的使用、24 h补液量的差异均无统计学意义( P>0.05)，死亡组的VIS、急性生理与慢性健康评分（APACHE Ⅱ）、基础乳酸，治疗24 h时乳酸均明显升高（ P<0.05）。VIS max24可以准确预测28 d病死率(AUC=0.953，95% CI：0.924~0.982），较APACHE Ⅱ评分（AUC=0.865，95% CI：0.818~0.913）、VIS max48（AUC=0.919，95% CI：0.881~0.957）、基础乳酸（AUC=0.937，95% CI：0.900~0.966）预测效能更高。 结论:VIS max24能够更准确地预测脓毒性休克患者的28 d病死率。     

乳酸及乳酸清除率评估静脉-动脉体外膜肺氧合治疗心源性休克患者预后的价值

目的 探讨乳酸及乳酸清除率对静脉-动脉体外膜肺氧合（VA-ECMO）治疗心源性休克（CS）患者预后的评估价值。方法 回顾性分析2012年6月至2020年3月浙江大学附属杭州市第一人民医院收治的CS患者60例,收集VA-ECMO病例及临床资料,记录VA-ECMO上机前和上机后6 h、24 h、48 h、72 h患者血乳酸水平,根据28 d预后存活分组,分析确定与28 d病死率的相关变量。进一步按乳酸清除率水平高低分组,比较各时间点乳酸清除率在VA-ECMO治疗CS患者的预后评估中的效能。结果 60例CS患者经VA-ECMO治疗后48 h乳酸水平降至正常,其中48例（80%）成功脱离体外膜肺氧合（ECMO）,43例（71.7%）在ECMO治疗后28 d仍存活,48 h血乳酸水平高于1.35 mmol/L是28 d全因病死率的最佳单项预测指标（P=0.014）,RCO曲线下面积（AUC）为0.704。在ECMO支持后6 h、48 h和72 h测得的乳酸清除率表明,高乳酸清除率（≥10%）组的ICU住院时间、机械通气时间更长（P<0.05）。结论 及早恢复患者的乳酸水平可改善预后,乳酸及...     

血小板计数与脓毒症患者28d预后的关系及其阈值效应的研究

目的:分析血小板计数与脓毒症患者28d预后的关系及阈值效应。方法:收集2013-01—2018-12期间就诊于眉山市心脑血管病医院及延安大学咸阳医院的脓毒症患者的资料,共有1 248例病例纳入本研究。通过单因素及多因素分析探讨血小板计数与脓毒症患者的28d预后的关系,通过曲线拟合和阈值效应分析确定其阈值效应。结果:单因素及多因素分析均显示血小板计数与脓毒症患者的28d病死率相关,其OR值分别为0.996(95%CI:0.994～0.998,P0.001)和0.996(95%CI:0.993～0.998,P0.001)。曲线拟合发现随着血小板计数的增加,脓毒症患者的28d病死率呈下降趋势。阈值效应分析发现当血小板计数低于70×109/L,脓毒症患者28d病死率随着血小板增加而下降;当血小板计数大于70×109/L,脓毒症患者28d病死率与血小板的计数无明显相关性。结论:血小板计数与脓毒症患者的28d病死率具有相关性,血小板计数的安全阈值为70×109/L。     

癌症患者手术备血策略和手术用血的危险因素分析

目的 探讨癌症患者的手术备血策略和影响手术用血的危险因素.方法 选择2012年1月至2014年1月,于东营鸿港医院择期手术的1 520例癌症患者的备血申请资料和550例癌症手术患者的用血资料为研究对象.回顾性分析癌症患者不同手术部位红细胞（RBC）和血浆的备血及用血情况,制定本院癌症手术患者的备血策略,并采用单因素分析及多因素非条件logistic回归分析,考察影响手术用血的危险因素.结果 本组癌症患者的手术输血率为36.2％（550/1 520）.多因素非条件logistic回归分析结果显示,癌症患者手术前的红细胞比容（Hct）（OR=2.301,95％CI：1.093～4.844,P=0.028）,血红蛋白（Hb）水平（OR=3.012,95％CI：1.203～7.541,P=0.019）,血小板（PLT）计数（OR=1.782,95％CI：1.194～2.660,P=0.005）,凝血酶原时间（PT） （OR=1.993,95％CI：1.002～3.887,P=0-042）及白蛋白（ALB）水平（OR=2.942,95％CI：1.101～7.861,P=0.031）是影响患者手术中输注RBC的危险因素;癌症患者手术前的Hct（OR=1.612,95％CI：1.189～2.185,P=0.002）,Hb浓度（OR=1.321,95％CI：1.634～1.068,P=0.010）,部分活化凝血酶原时间（APTT） （OR=2.911,95％CI：1.191～7.115,P=0.019）,ALB水平（OR=2.212,95％CI：1.231～3.975,P=0.008）,PT（OR=1.593,95％CI：1.229～2.065,P=0.004）及总蛋白（TP）水平（OR=1.193,95％CI：1.329～1.071,P=0.001）是影响患者手术中输注血浆的危险因素.结论 癌症患者手术备血,应充分考虑患者的个体情况,合理进行备血申请,输血应严格把握输血适应证,保证用血的科学性和安全性.     

早期血小板计数动态变化对脓毒症患者预后的预测价值北大核心CSCD

目的探讨血小板计数(platelet count,PLT)早期动态变化在评估脓毒症患者预后中的价值。方法采用回顾性研究方法,选取2013年1月至2017年12月收住温州医科大学附属第一医院急诊重症监护病房(EICU)的脓毒症患者,根据患者入住EICU后28 d的预后情况分成存活组和死亡组,比较两组患者的基础及临床数据,筛选脓毒症患者28 d预后的危险因素,评估血小板变化量(ΔPLT)在脓毒症预后中的价值。结果共纳入549例脓毒症患者,28 d内死亡184例,存活365例,28 d病死率33.5%。与存活组相比,死亡组男性比例更高、年龄更大,合并慢性阻塞性肺病(chronic obstructive pulmonary disease,COPD)等慢性疾病和肿瘤者更多,简化急性生理学Ⅱ评分(SAPS-Ⅱ)、序贯器官衰竭评分(SOFA)、降钙素原、C-反应蛋白、尿素氮指标更高,纤维蛋白原、平均动脉压指标更低,PLT d1~d5更低,ΔPLT d2~ΔPLT d5的数值降低更明显,血小板/淋巴细胞比值(platelet to lymphocyte ratio,PLR)更高,差异有统计学意义(P<0.05);但两组患者在平均血小板体积、血小板分布宽度方面差异无统计学意义(均P>0.05)。多因素Logistic回归分析显示:COPD(OR=4.167,95%CI:1.769~9.815,P<0.001)、恶性肿瘤(OR=1.815,95%CI:1.034~3.817,P=0.038)、SAPS-Ⅱ评分(OR=1.071,95%CI:1.046~1.096,P<0.001)、SOFA评分(OR=1.060,95%CI:1.001~1.021,P=0.041)、PLR值(OR=1.001,95%CI:1.001~1.002,P<0.001)是影响脓毒症患者28 d病死率的独立危险因素。PLT d1(OR=0.996,95%CI:0.995~0.998,P<0.001)为预后较好的保护因素。ROC曲线分析显示:SAPS-Ⅱ评分、SOFA评分能够预测ICU脓毒症患者28 d预后情况,以SAPS-Ⅱ评分的ROC曲线下面积最大(AUC=0.726)。ΔPLT d4的AUC(0.678)大于其余时间点,其最佳临界值为-26.5×109/L时,敏感度为57.8%,特异度为71.7%。结论早期PLT动态变化与脓毒症患者预后具有密切相关性,值得临床借鉴推广。     

脑梗死患者血清miR-181d和miR-210水平表达与颈动脉狭窄程度及预后的相关性研究

目的　探讨分析脑梗死（cerebral infarction）患者血清microRNA-181d（miR-181d）,microRNA-210（miR-210）水平表达与颈动脉狭窄程度及预后的相关性。方法　选取2017年10月～2019年10月邢台市第三医院收治的480例脑梗死患者,根据颈部超声结果将其分为颈动脉狭窄组278例和无颈动脉狭窄组202例。检测两组患者血清miR-181d和miR-210水平,分析其水平变化与颈动脉狭窄的关系。然后随访其半年内预后情况,根据预后情况将患者分为预后良好组192例和预后不良组288例,并对影响预后不良因素进行分析比较。对影响预后不良的相关高危因素进行单因素χ2检验,并筛选出可能影响的单因素,再进行多因素Logistic回归分析,根据以上因素绘制ROC曲线,评估其对预测预后不良的价值。结果　颈动脉狭窄组患者血清miR-181d表达量水平显著高于无颈动脉狭窄组,而miR-210表达量水平均显著低于无颈动脉狭窄组,差异均有统计学意义（t=17.513,10.888,均P＜0.05）。而颈动脉轻度狭窄患者血清miR-181d表达量显著低于中度狭窄、重度狭窄患者,而颈动脉轻度狭窄患者血清miR-210表达量显著高于中度狭窄和重度狭窄患者,差异均有统计学意义（t=5.874,6.246,2.172和5.427,均P＜0.05）。随访半年内预后情况,预后良好192例,占40.00%;预后不良288例,占60.00%。两组各危险因素比较,性别、年龄、并发高血脂、并发冠心病、吸烟史、饮酒史等资料较为接近,差异无统计学意义（χ2=0.237~2.475,均P＞0.05）。而两组高血压、糖尿病、心房颤动、血清miR-181d和血清miR-210差异有统计学意义（χ2=8.539~21.713,均P＜0.05）。将有统计学意义的危险单因素纳入多因素回归分析,采用Logistic回归方程进行分析,结果显示,血清miR-181d表达量升高（OR=1.164,95%CI:1.137~1.192）,血清miR-210表达量降低（OR=10.196,95%CI:6.677～15.570）是脑梗死患者预后不良的独立危险因素（OR＞1,P＜0.05）。并且血清miR-181d预测脑梗死患者预后不良的ROC曲线下面积为0.76（95% CI:1.013~1.124）,敏感度和特异度分别为71.23%和73.45%,而血清miR-210预测脑梗死患者预后不良的ROC曲线下面积为0.79（95% CI:1.125~1.206）,敏感度和特异度分别为73.42%和75.36%,联合检测的ROC曲线为0.83（95% CI:1.147~1.235）,敏感度和特异度分别为79.33%和82.41%。结论　血清miR-181d水平与预后不良呈正相关关系,而血清miR-210水平与预后不良呈负相关关系,血清miR-181d和miR-210是脑梗死患者预后不良的独立影响因素,检测其水平表达对于预测脑梗死患者不良事件发生具有较高价值,值得临床推广。     

基于CT小肠成像预测中重度期克罗恩病的列线图模型构建

  目的  探索中重度克罗恩病（CD）的CT小肠造影特征,构建预测中重度期CD的列线图。  方法  收集2019年1月~2022年6月期间扬州大学附属医院收治的180例CD患者,随机分为训练组（n=120）和验证组（n=60）。依据克罗恩病简化内镜评分评估CD的活动性,分为缓解、轻度期（n=94）、中重度期（n=86）。比较分析训练组和验证组不同分期CT小肠造影征象差异,并使用Rstudio4.1.2软件R包构建模型,绘制ROC曲线、校准曲线及临床决策曲线。  结果  二项Logistic回归分析CT小肠造影征象显示:肠壁厚度（OR=1.746,95% CI:1.085~2.811)、ΔV-P（ΔV-P =静脉期肠壁CT值-平扫肠壁CT值）（OR=1.148,95% CI:1.062~ 1.241）、肠壁分层强化（OR=14.183,95% CI:3.737~53.824）、肠系膜脂肪密度高（OR=5.332,95% CI:1.278~22.246）4个参数是诊断中重度度CD独立参数。模型在训练组和验证组ROC曲线下面积分别为0.952（95% CI:0.925~0.979,P < 0.05）、0.955（95% CI:0.911~0.997,P < 0.05）,模型校准曲线与理想曲线贴合良好,决策曲线显示在一定阈值范围内患者净收益较大。  结论  肠壁厚度、ΔV-P、肠壁分层强化及肠系膜脂肪密度增高是诊断中重度期CD的独立因素,以此构建的列线图能够预测中重度期CD活动性。      

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

Risk Factors for Mortality of Bacteremic Patients in the Emergency Department

Objectives: Patients with bacteremia have a high mortality and generally require urgent treatment. The authors conducted a study to describe bacteremic patients in emergency departments (EDs) and to identify risk factors for mortality. Methods: Bacteremic patients in EDs were identified retrospectively at a university hospital from January 2007 to December 2007. Demographic characteristics, underlying illness, clinical conditions, microbiology, and the source of bacteremia were collected and analyzed for their association with 28-day mortality. Results: During the study period, 621 cases (50.2% male) were included, with a mean (±SD) age of 62.8 (±17.4) years. The most common underlying disease was diabetes mellitus (39.3%). Escherichia coli (39.2%) was the most frequently isolated pathogen. The most common source of bacteremia was urinary tract infection (41.2%), followed by primary bacteremia (13.2%). The overall 28-day mortality rate was 12.6%. Multivariate stepwise logistic regression analysis showed age > 60 years (odds ratio [OR] = 2.52, 95% confidence interval [CI] = 1.29 to 4.92, p = 0.007), malignancy (OR = 2.66, 95% CI = 1.44 to 4.91, p = 0.002), liver cirrhosis (OR = 2.08, 95% CI = 1.02 to 4.26, p = 0.044), alcohol use (OR = 5.73, 95% CI = 2.10 to 15.63, p = 0.001), polymicrobial bacteremia (OR = 3.99, 95% CI = 1.75 to 9.10, p = 0.001), anemia (OR = 2.33, 95% CI = 1.34 to 4.03, p = 0.003), and sepsis (OR = 1.94, 95% CI = 1.16 to 3.37, p = 0.019) were independent risk factors for 28-day mortality. Conclusions: Bacteremic patients in the ED have a high mortality, particularly with these risk factors. It is important for physicians to recognize the factors that potentially contribute to mortality of bacteremic patients in the ED.     

输注血液制品与心脏术后结局相关性的系统分析

  目的  系统评价心脏围术期输血与术后近远期结局的关系。  方法  检索中英文文献数据库中1990年1月至2014年12月关于输血和心脏术后结局关系的回顾性病例对照研究, 使用RevMan 5.3软件, 应用Meta分析方法对所纳入文献的研究结果进行定量综合分析。  结果  本研究共纳入13项回顾性病例对照临床研究, 总样本量88 808例, 其中输血组42 991例, 未输血组45 817例。输血组和未输血组的各心脏术后结局指标差异均有统计学意义:30 d死亡率(OR=2.39, 95% CI:1.71~3.34, P < 0.000 01), 1年死亡率(OR=3.08, 95% CI:2.18~4.35, P < 0.000 01), 5年死亡率(OR=1.90, 95% CI:1.42~2.56, P < 0.0001), 缺血事件(OR=2.23, 95% CI:1.71~2.90, P < 0.000 01), 感染(OR=2.18, 95% CI:1.74~2.75, P < 0.000 01)。  结论  围术期输血与心脏手术后近远期死亡率和缺血事件、感染的发生具有明显相关性。     

血清冷诱导RNA结合蛋白与脓毒性休克患者病情严重程度及预后的相关性

目的探讨血清冷诱导RNA结合蛋白(CIRP)与脓毒性休克患者病情严重程度及预后的相关性。方法回顾性选取2018年1月至2020年1月海南医学院第二附属医院急诊重症监护室(EICU)收治的脓毒性休克患者107例为研究对象。收集患者一般资料、急性生理和慢性健康状况评估系统Ⅱ(APACHEⅡ)评分、序贯器官衰竭估计(SOFA)评分、CIRP、血乳酸(Lac)、血清肌酐(s Cr)、血白细胞计数(WBC)、中性粒细胞百分比(NeuR)及降钙素原(PCT)。根据患者28 d预后情况将其分为死亡组和存活组。采用Pearson相关分析探讨脓毒性休克患者CIRP与SOFA评分及APACHEⅡ评分的相关性;采用Logistic回归分析探讨脓毒性休克患者28 d死亡的危险因素;绘制受试者工作特征(ROC)曲线并评估各指标对脓毒性休克患者28 d死亡的预测价值。结果随访28 d后,25例(23.4%)患者死亡(死亡组),82例(76.6%)患者存活(存活组)。死亡组APACHEⅡ评分、SOFA评分、CIRP、血Lac、s Cr及PCT水平明显高于存活组(P <0.05)。Pearson相关分析结果显示,脓毒性休克患者CIRP与SOFA评分及APACHEⅡ评分均呈正相关(r=0.337,P=0.005;r=0.249,P=0.039)。多因素Logistic回归分析结果显示,APACHEⅡ评分[OR=1.138,95%CI(1.066,1.214)]、SOFA评分[OR=1.326,95%CI(1.174,1.478)]、CIRP[OR=1.322,95%CI(1.141,1.502)]及PCT[OR=1.055,95%CI(1.003,1.108)]为脓毒性休克患者28 d死亡的危险因素(P <0.05)。CIRP、SOFA评分、APACHEⅡ评分、PCT预测脓毒性休克患者28 d死亡的ROC曲线下面积(AUC)分别为0.915[95%CI(0.823,0.969)]、0.834[95%CI(0.726,0.913)]、0.798[95%CI(0.684,0.885)]、0.685[95%CI(0.562,0.792)]。CIRP预测脓毒性休克患者28 d死亡的AUC大于SOFA评分、APACHEⅡ评分、PCT预测脓毒性休克患者28 d死亡的AUC(Z=2.134,P=0.041;Z=2.348,P=0.026;Z=3.64,P <0.001)。CIRP的最佳临界值为2.6μg/L时,预测脓毒性休克患者28 d死亡的敏感度为96.8%,特异度为73.7%。结论血清CIRP与脓毒性休克患者病情严重程度及预后密切相关,为28 d死亡的独立危险因素,可作为评价脓毒性休克患者预后的较好指标。     

Liberal Transfusion versus Restrictive Transfusion and Outcomes in Critically Ill Adults: A Meta-Analysis

ObjectiveWe aimed to determine whether the restrictive red-cell transfusion strategy was superior to the liberal one in reducing all-cause mortality in critically ill adults.MethodsThe MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Library Central Register of Controlled Trials databases were searched from inception to January 2019 to identify meta-analyses or systematic reviews and published randomized controlled trials which were restrictive versus liberal blood transfusion with mortality as the endpoint in critically ill adults. We used two search routes whereby one search was restricted to systematic reviews, reviews, or meta-analysis, and the other was not restricted. There were no date restrictions, but language was limited to English and the population was restricted to critically ill adults. The data of study methods, participant characteristics, and outcomes were extracted and analyzed independently by 2 reviewers. The main outcome was all-cause mortality.ResultsThrough screening the obtained records, we enrolled 7 randomized clinical trials that included information on restrictive versus liberal red-cell transfusion and mortality of intensive care unit (ICU) patients. Involving a total of 7,363 ICU adult patients, ICU mortality (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.08, p = 0.15), 28/30-day mortality (RR 0.98, 95% CI 0.84, 1.13, p = 0.74), 60-day mortality (RR 1.01, 95% CI 0.87, 1.16, p = 0.91), 90-day mortality (RR 1.02, 95% CI 0.92, 1.14, p = 0.69), 120-day mortality (RR 1.29, 95% CI 0.67, 2.47, p = 0.44), and 180-day mortality (RR 0.91, 95% CI 0.75, 1.12, p = 0.38) were not statistically significantly different when the restrictive transfusion strategy was compared with the liberal transfusion strategy. However, we surprisingly discovered that 112 out of 469 (24%) patients who received a unit RBC transfusion when hemoglobin was less than 7 g/dL, and 142 out of 469 (30.3%) who received a unit of RBC transfused with hemoglobin less than 9 g/dL, had died during hospitalization (RR 0.79, 95% CI 0.64, 0.97, p = 0.03). The results showed that the restrictive transfusion strategy could decrease in-hospital mortality compared with the liberal transfusion strategy. It was safe to utilize a restrictive transfusion threshold of less than 7 g/dL in stable critically ill adults.ConclusionsIn this study, we found that the restrictive red-cell transfusion strategy potentially reduced in-hospital mortality in critically ill adults with anemia compared with the liberal strategy.     

Predictors of transfusion for spinal surgery in Maryland, 1997 to 2000

BACKGROUND: The purpose of this study was to identify preoperative patient, hospital, and surgeon characteristics associated with transfusion for spinal surgery. STUDY DESIGN AND METHODS: Discharge data were obtained from 39 Maryland hospitals for adult patients (n = 3988) who had a primary procedure code for spinal surgery between July 1997 through June 2000, and with these codes, surgeons and hospitals were characterized by annual patient volume. Outcome variables included any allogeneic transfusion, any transfusion, RBCs, autologous blood, FFP, or platelet transfusion. Logistic regression was used for univariate and multivariate analyses. RESULTS: Characteristics independently associated with an increased risk of receiving any allogeneic transfusion (n = 786) included age >54 (OR, 1.6; 95% CI, 1.3-2.1), age >66 (OR, 2.7; 95% CI, 2.0-3.5), female sex (OR, 1.6; 95% CI, 1.2-2.0), diabetes with chronic complications (OR, 2.5; 95% CI, 1.3-4.9), and metastatic tumor (OR, 4.9; 95% CI, 2.3-10.5), emergency room admission (OR, 2.3; 95% CI, 1.4-3.8), and greater hospital volume (OR, 4.0; 95% CI, 1.8-8.6). Characteristics independently associated with increased autologous transfusions (n = 574) included white race (OR, 1.7; 95% CI, 1.2-2.4), female sex (OR, 1.4; 95% CI, 1.1-1.8), and greater surgeon volume (OR, 3.5; 95% CI, 1.4-9.1). DISCUSSION: This information can be used to provide informed risk-benefit discussions with patients regarding the risk for blood transfusion as well as to target high-risk patients and institutions for interventions to reduce the risk of exposure to blood components.     

Risk factors for 28-day mortality in patients with sepsis-related myocardial injury in intensive care units

ObjectiveThis study aimed to identify the risk factors for death in patients with sepsis-related myocardial injury.MethodsA retrospective study was conducted in 158 patients with sepsis-related myocardial injury in a mixed medical intensive care unit from January 2009 to March 2020. The patients were divided into those who survived and those who died on the basis of whether they survived after 28 days. Demographic and clinical parameters were collected. Multivariate logistic regression was performed.ResultsSixty-nine (43.7%) patients died within 28 days after admission to the intensive care unit. Multivariate logistic regression analysis showed that the oxygenation index (odds ratio [OR]: 0.979, 95% confidence interval [CI]: 0.970–0.989), acute kidney injury (OR: 4.787, 95% CI: 1.674–13.693), norepinephrine dose (OR: 1.706, 95% CI: 1.375–2.117), and abdominopelvic cavity infection (OR: 0.257, 95% CI: 0.076–0.866) were significantly associated with mortality within 28 days after admission in patients with sepsis-related myocardial injury.ConclusionsPatients with sepsis-related myocardial injury have a high mortality rate. A high oxygenation index, occurrence of acute kidney injury, high norepinephrine dose, and occurrence of abdominopelvic cavity infection are independent risk factors for 28-day mortality in patients with sepsis-related myocardial injury.     

Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence,transfusion requirements,and outcome

OBJECTIVE: To determine prevalence, risk factors, and outcome of thrombocytopenia in medical intensive care patients. DESIGN: Prospective observational study. SETTING: The 12-bed medical intensive care unit of a university hospital. PATIENTS: All consecutively admitted patients with normal platelet count at admission and an intensive care unit stay of >48 hrs during a 13-month period (n = 145). MEASUREMENTS AND MAIN RESULTS: The prevalence of intensive care unit-acquired thrombocytopenia (platelet count, <150.0/nL) was 64 of 145 patients (44%). Intensive care unit mortality was 31% in thrombocytopenic patients and 16% in nonthrombocytopenic patients (p =.03). Mortality was higher in patients with a nadir platelet count of <100.0/nL (p <.001) and in patients with a drop in platelet count of >/=30% (p <.001). In nonsurvivors, the decrease in platelet count was greater (p <.001), the nadir platelet count lower (p <.001), and the duration of thrombocytopenia longer (p =.008) than in survivors. A logistic regression analysis identified septic shock (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.40-9.52), a higher Acute Physiology and Chronic Health Evaluation II Score at admission (OR, 1.06 for 1 point; 95% CI, 1.01-1.12), and a drop in platelet count exceeding 30% (OR, 3.73; 95% CI, 1.24-11.21), but not thrombocytopenia, as independent risk factors for intensive care unit death. Correction of thrombocytopenia was associated with reduced mortality (OR, 0.002; 95% CI, 0-0.08). Major bleeding prevalence and transfusion requirements were significantly higher with thrombocytopenia. Nadir platelet count was the only independent risk factor for bleeding (OR, 4.1 for every 100.0/nL; 95% CI, 1.9-8.8). Independently associated with thrombocytopenia were disseminated intravascular coagulation (OR, 14.94; 95% CI, 3.92-57.00), cardiopulmonary resuscitation as an admission category (OR, 5.17; 95% CI, 1.42-18.85), and a higher Sequential Organ Failure Assessment score (OR, 1.20 for a 1 point change; 95% CI, 1.02-1.40). CONCLUSIONS: Thrombocytopenia is common in medical intensive care unit patients. Thrombocytopenic patients have a higher prevalence of bleeding and greater transfusion requirements. A drop in platelet counts of > or = 30%, but not thrombocytopenia per se, is independently associated with intensive care unit death. Serial measurements of platelet counts are important and readily available markers for monitoring the patient's condition. Any drop in platelet count requires urgent clarification. Disseminated intravascular coagulation, signs of organ failure at admission, and cardiopulmonary resuscitation are predictors of intensive care unit-acquired thrombocytopenia.     

血小板相关指数与溶栓后急性脑卒中患者预后的关系

目的?研究血小板体积相关指数(platelet volume indices, PVIs)、中性粒细胞/淋巴细胞比率(neutrophil to lymphocyte ratio,NLR)以及这些参数的组合与接受静脉溶栓后的急性缺血性脑卒中(acute ischemic stroke,AIS)患者神经功能预后的关系。方法?回顾性研究2016年1月至2019年1月北京大学人民医院急诊科符合AIS诊断标准的147例静脉溶栓患者。根据3个月后随访结果,将研究人群依据MRS评分(modified rank in scale,MRS),分为MRS≤2和MRS≥3两组,比较两组患者的一般资料、既往病史、实验室检查结果等。采用Logistic回归分析溶栓后AIS患者神经功能预后不良的危险因素。结果?NLR(OR=1.045, 95%CI:1.032~2.350, P=0.032),平均血小板体积(mean platelet volume, MPV)(OR=4.212, 95%CI:1.074~16.513, P=0.039),MPV×NLR/血小板计数(PLT)(OR=5.711,95%CI:1.342~24.298, P=0.018),血小板分布宽度(platelet distribution width, PDW)(OR=1.015, 95%CI:1.001~2.372, P=0.032),美国国立卫生研究院中风量表(NIHSS)评分(OR=1.266, 95%CI:1.111~1.443, P<0.01)是接受静脉溶栓治疗后AIS患者神经功能预后不良的影响因素。结论?NLR、MPV、MPV×NLR/PLT、PDW、NIHSS评分是溶栓后急性缺血性脑卒中神经功能预后不良的危险因素。MPV×NLR/PLT可以较好地预测3个月后AIS神经功能严重程度。