2017年 · 第56卷第05期

Shock, as a well-known disease, has been a major problem in medical research and clinical treatment for many years. Shock in the traditional sense refers to the sharp reduction of effective circulating blood volume, and tissue perfusion cannot meet the needs of metabolism. With the deepening of the understanding of shock, the monitoring indicators of shock gradually increase, which brings the trouble of clinical treatment. It is very important to understand the original meaning of monitoring indicators and the positioning of treatment priority. Professor Liu Dawei was invited to write a monograph "Shock Resuscitation: The Leading Effect of Flow Indicators", which was deeply explained from the essence of shock formation and the core of treatment.

Shock, as a well-known disease, has been a major problem in medical research and clinical treatment for many years. Especially in critically ill patients, almost the vast majority of critically ill patients have shock involvement to varying degrees, which does not include the pre-death state. The diagnosis and treatment of shock has experienced many years of development, and the monitoring indicators have changed from the worship of blood pressure to the re-recognition of lactic acid, which has made the amount of clinical information greatly increase. At the same time, due to the guiding role of monitoring indicators on treatment, new breakthroughs are constantly made in clinical treatment processes and specific methods. The appearance of a large number of monitoring indicators also brings many troubles, such as contradictory indicators, inconsistent changes of indicators and treatment methods, whether indicators can be substituted for each other, how to obtain indicators correctly, etc., and even excessive preference for some familiar indicators and exaggeration of their clinical application. It is not difficult to see the important position of monitoring indicators and the clinical value of correctly understanding indicators^[1]。

Correct empirical antibiotic therapy is the key to improve the prognosis of systemic infection. The most likely pathogenic microorganisms should be individualized according to the patient's specific situation to guide the selection of empirical antibiotics. Neither biomarkers nor infection prediction models can accurately predict pathogenic microorganisms. Clinicians should comprehensively judge the most likely pathogenic microorganisms based on medical history, clinical manifestations and laboratory tests.

In September 2015, the "Kyoto Global Consensus Report on Helicobacter Pylori Gastritis" (hereinafter referred to as "Kyoto Global Consensus") was officially published onGutJournal, consensus states that: Helicobacter pylori (Hp) gastritis is an infectious disease; Treat all patients with Hp infection unless there are counterbalance factors^[1]。 The publication of "Kyoto Global Consensus" has stirred up a thousand waves in China, which has caused extensive discussion on Hp infection among Chinese scholars. Is the "Kyoto Global Consensus" in line with China's national conditions? How should China formulate the strategy of Hp infection management?

Helicobacter pylori (Helicobacter pylori,Hp) has an amazing history! At the end of the 20th century, people cultured Hp by chance. In fact, with the birth and development of microscope, scientists have been able to observe this bacterium, but because it can't be successfully cultured in vitro, the existence of Hp has been unable to be confirmed. Since Hp was discovered in the "difficult to survive acidic gastric cavity", more and more studies have shown that it is related to chronic gastritis, gastroduodenal ulcer and gastric cancer, and until it was identified as a class I biological carcinogen of gastric cancer, Hp has become the "target of public criticism" of gastric diseases. However, biogeographic research has found that Hp is a witness to the history of human migration. Paleomicrobiologists observed the existence of Hp in the stomach cavity of the oldest mummy, the Alpine Iceman, 5,200 years ago.

Patients in the Department of Critical Care Medicine (ICU) are critically ill, and their immunity is often severely impaired. They are high-risk groups and objects of severe infection, and they are also high-risk groups of nosocomial infection^[1,2,3,4]。 The occurrence of nosocomial infection leads to a series of adverse consequences such as prolonged hospitalization of critically ill patients, increased use of antibiotics, proliferation of multi-drug resistant bacteria (MDROs), increased medical expenses, waste of medical resources and increased mortality rate. Therefore, the infection control in ICU, especially the management and control of MDROs, is particularly important. It should be fully recognized that infection control in ICU is a complex problem involving multi-disciplines, multi-links and multi-departments, and it is the core link of hospital infection control. It is necessary to fully cooperate and work together with hospital infection control departments and infection control personnel, so that it is possible to formulate a perfect process from the source of hospital infection, during ICU and after ICU transfer, and implement it well. Carbapenem-resistant Acinetobacter baumannii (CRAB) has become the most common MDROs in ICU in China, which makes the infection control in ICU face a severe test. Taking CRAB management in ICU as an example, this paper expounds how to manage CRAB from three major links: early recognition, effective treatment and holistic prevention. Among them, holistic prevention with the help of nosocomial infection control is the core of severe infection control in ICU.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is a very common and intractable type of infection in ICU. Compared with methicillin-sensitive Staphylococcus aureus (MSSA) infection, the prognosis of patients with MRSA infection is worse. In the face of such patients, on the basis of active and adequate drainage, the selection of antibiotic types and dose adjustment to achieve the pharmacokinetic (PK) /pharmacodynamic (PD) goal is still a difficult clinical problem.

Treatment of Gram-negative bacterial infection in severe patients needs to follow the basic rules of antimicrobial therapy. First, it is necessary to clarify the diagnosis of bacterial infection. The diagnosis of infection includes the judgment of the site of infection and the judgment of the severity of infection. After the diagnosis of infection is clear, it is necessary to judge the possible pathogen. The pathogen judgment includes the judgment of the type of pathogen and the judgment of the pathogen's resistance to anti-infective drugs. Pathogen judgment is rooted in a detailed understanding and analysis of high-risk factors of patients, such as age, site of infection, place of acquisition of infection, exposure to prior antimicrobial drugs, invasive tests or treatments, epidemiology of the environment, and so on. Early and adequate antimicrobial therapy is performed after qualified specimens are obtained for microbiological testing according to the judgment of the site of infection and the infected pathogen. Or after identifying the pathogen, select an appropriate drug for adequate antimicrobial treatment. The key meaning of adequate antimicrobial therapy is that the selected antimicrobial drug can reach a sufficient concentration at the site of infection to inhibit bacterial growth or kill bacteria, and at the same time, it is necessary to weigh the adverse reactions caused by excessive drug doses. Whether antimicrobial drugs can inhibit or kill pathogenic bacteria at the site of infection depends on the metabolism and distribution of drugs in the body and the sensitivity of bacteria to drugs. The combination of pharmacokinetics (PK) and pharmacodynamics (PD) and the design of appropriate dosage and administration interval can improve the efficacy of antibacterial drugs and reduce the side effects of drugs.

In November 2016,Crit CarePublished a prospective study "Pulmonary ultrasound can be used to assess the potential and prognosis of prone position in patients with acute respiratory distress syndrome" in the Department of Critical Care Medicine, Peking Union Medical College Hospital "[Lung ultrasound can be used to predict the potential of prone positioning and assess prognosis in patients with acute respiratory distress syndrome. Crit Care, 2016, 20 (1): 385]^[1]The concept of prone position potential in patients with acute respiratory distress syndrome (ARDS) was proposed for the first time, and the way in which pulmonary ultrasound was used to evaluate the pulmonary ventilation status confirmed that pulmonary ultrasound can be used to evaluate the prone position potential in patients with ARDS and help judge the prognosis of patients with ARDS.

Metformin has been used clinically for 60 years. In recent years, studies have found that metformin can not only effectively lower glucose, but also have anti-aging, anti-tumor and other hypoglycemic external effects, so some people call it a "magic medicine". In order to help clinicians to correctly understand and use metformin reasonably, so that metformin can give full play to its magical effect, the following is an introduction to the problems that need attention in the clinical application of metformin.

Hashimoto's thyroiditis (HT) is a common organ-specific autoimmune thyroid disease with an incidence of about 0.3‰ ~1.5‰^[1]。 thyroglobulin antibody (TgAb) and thyroid peroxidase antibody (TPOAb) are signature antibodies to HT^[1,2,3]Both are predominantly IgG type^[4]。 HT includes several subtypes such as fibrosis, juvenile, and Hashimoto's thyrotoxicosis, so it can have different clinical manifestations and disease progression^[1]。

Metabolic surgery has been used clinically for more than 50 years. Although the domestic metabolic surgery started late, it has developed rapidly in recent years. Evidence from home and abroad shows that metabolic surgery not only has the efficacy of obesity and diabetes itself that cannot be matched by traditional medical treatment, but also has good improvement and relief effects on many complications and complications of obesity and diabetes, such as metabolic syndrome, sleep apnea syndrome, diabetic nephropathy, etc., which strongly confirms the clinical value and therapeutic status of metabolic surgery^{[1,2,3,4,5,6,7]}。

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