Volume 130 · Issue 10 · 2017

2016年期间重症医学取得了许多新进展，包括脓毒症的新定义-3，生存脓毒症指南提出，增加护理点超声检查的使用等。此外，重症监护领域趋于更加精确、更加循证。

脓毒症是一个主要的威胁生命的医疗保健问题。据统计，全球每年新发脓毒症病例2000-3000万，其造成的死亡人数相当于急性心肌梗死，致死人数超过乳腺癌、脑卒中、艾滋病的总和。约41%的脓毒症病例进展为多器官功能障碍综合征（MODS），导致死亡率高达30-50%。^[1]我们认为过度炎症导致内皮相关蛋白和分子的一系列改变，最终导致凝血障碍、炎症反应过度激活和血管渗漏。

The antibiotic meropenem is commonly administered in patients with severe sepsis and septic shock. We compared the pharmacokinetic, clinical, and bacteriological efficacies of continuous infusion of meropenem versus intermittent administration in such patients.

Patients admitted to the Intensive Care Unit (ICU) with severe sepsis or septic shock who received meropenem were randomly assigned to either the continuous (n = 25) or intermittent groups (n = 25). The continuous group received a loading dose of 0.5 g of meropenem followed by a continuous infusion of 3 g/day; the intermittent group received an initial dose of 1.5 g followed by 1 g for every 8 h. Clinical success, microbiological eradication, superinfection, ICU mortality, length of ICU stay, and duration of meropenem treatment were assessed. Serial plasma meropenem concentrations for the first and third dosing periods (steady state) were also measured.

Clinical success was similar in both the continuous (64%) and intermittent (56%) groups (P = 0.564); the rates of microbiological eradication and superinfection (81.8% vs. 66.7% [P = 0.255] and 4% vs. 16% [P = 0.157], respectively) showed improvement in the continuous group. The duration of meropenem treatment was significantly shorter in the continuous group (7.6 vs. 9.4 days; P = 0.035), where a better steady-state concentration was also achieved. Peak and trough concentrations were significantly different between the continuous and intermittent groups both in the first (Cmax: 19.8 mg/L vs. 51.8 mg/L, P = 0.000; Cmin: 11.2 mg/L vs. 0.5 mg/L, P = 0.000) and third dosing periods (Cmax: 12.5 mg/L vs. 46.4 mg/L, P = 0.000; Cmin: 11.4 mg/L vs. 0.6 mg/L, P = 0.000). For medium-susceptibility pathogens, continuous infusion concentrations above the minimal inhibitory concentration were 100%, which was better than that in the intermittent group.

Continuous infusion of meropenem provides significantly shorter treatment duration and a tendency for superior bacteriological efficacy than intermittent administration. Continuous infusion may be more optimal against intermediate-susceptibility pathogens.

Shock is a life-threatening condition in emergency departments (EDs) and is associated with a high mortality; however, its clinical characteristics and current interventions in China are seldom reported. This study investigated the clinical characteristics and current interventions of shock patients in Chinese EDs.

This multicenter prospective cohort study was conducted in the EDs of 33 academic hospitals in 16 Chinese provinces. Adult shock patients were enrolled from December 2013 to April 2014. Age, sex, comorbidities, shock subtype, and vital signs were recorded on ED arrival; details of subsequent interventions and treatments were added. We compared those data between survivors and nonsurvivors. All patients were followed up for 3 days. The primary outcome was 3-day mortality. Binary logistic regression analysis identified the independent predictors of that mortality.

We enrolled 1095 shock patients. The 3-day mortality was 27.5%, 36.3%, and 29.0%, respectively, in the whole cohort and for cardiogenic and septic shock. Within the first 24 h, 1039 patients (94.9%) were admitted to the Intensive Care Unit. Use of bicarbonate, epinephrine, and dopamine is an independent predictor for mortality. Hemorrhage and trauma (39.1%), along with sepsis (40.4%) were the most commonly observed causes of shock in the ED. In nondiabetic patients with cardiogenic shock, 3-day mortality was 69.2% for patients needing glucose control — much higher than in those not needing glucose control (30.0%, P = 0.01). Hydroxyethyl starch (HES) was applied in 29.6% of septic shock patients, and the mortality of septic patients who received HES was much higher than those who did not (38.2% vs. 25.1%, P = 0.006).

In China, short-term mortality of shock patients in EDs is still high, especially among those with cardiogenic and septic shock. HES application needs to be restricted — particularly in septic shock patients.

Propofol is increasingly used during partial support mechanical ventilation such as pressure support ventilation (PSV) in postoperative patients. However, breathing pattern, respiratory drive, and patient-ventilator synchrony are affected by the sedative used and the sedation depth. The present study aimed to evaluate the physiologic effects of varying depths of propofol sedation on respiratory drive and patient-ventilator synchrony during PSV in postoperative patients.

Eight postoperative patients receiving PSV for <24 h were enrolled. Propofol was administered to achieve and maintain a Ramsay score of 4, and the inspiratory pressure support was titrated to obtain a tidal volume (VT) of 6–8 ml/kg. Then, the propofol dose was reduced to achieve and maintain a Ramsay score of 3 and then 2. At each Ramsay level, the patient underwent 30-min trials of PSV. We measured the electrical activity of the diaphragm, flow, airway pressure, neuro-ventilatory efficiency (NVE), and patient-ventilator synchrony.

Increasing the depth of sedation reduced the peak and mean electrical activity of the diaphragm, which suggested a decrease in respiratory drive, while VT remained unchanged. The NVE increased with an increase in the depth of sedation. Minute ventilation and inspiratory duty cycle decreased with an increase in the depth of sedation, but this only achieved statistical significance between Ramsay 2 and both Ramsay 4 and 3 (P < 0.05). The ineffective triggering index increased with increasing sedation depth (9.5 ± 4.0%, 6.7 ± 2.0%, and 4.2 ± 2.1% for Ramsay 4, 3, and 2, respectively) and achieved statistical significance between each pair of depth of sedation (P < 0.05). The depth of sedation did not affect gas exchange.

Propofol inhibits respiratory drive and deteriorates patient-ventilator synchrony to the extent that varies with the depth of sedation. Propofol has less effect on breathing pattern and has no effect on VT and gas exchange in postoperative patients with PSV.

Little is known about the long-term outcomes of severe acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO). This study aimed to investigate the 1-year outcomes of these patients or patients receiving mechanical ventilation (MV) and compare their health-related quality of life (HRQoL) to the general population.

Severe ARDS survivors admitted to two ICUs in China between January 2012 and January 2014 were enrolled. Of the severe ARDS survivors enrolled, 1-year postdischarge, HRQoL assessment using the Short-Form 36 (SF-36) and EuroQol questionnaire dimensions, 6-min walking distance, chest computed tomography scan, pulmonary function, and arterial blood gas analysis were compared for ARDS patients with or without ECMO.

ARDS patients receiving ECMO had a significantly higher Acute Physiology and Chronic Health Evaluation II score (30.3 ± 6.7 vs. 26.5 ± 7.3, P = 0.036), lung injury score (3.3 ± 0.4 vs. 2.8 ± 0.5, P = 0.000), Sequential Organ Failure Assessment score (10.8 ± 3.5 vs. 7.9 ± 3.1, P = 0.000), lower PaO₂/FiO₂ ratio ([mmHg, 1 mmHg = 0.133 kPa], 68.3 ± 16.1 vs. 84.8 ± 16.5, P = 0.000), and increased extrapulmonary organ failure (2 [1, 3] vs. 1 [1, 1], P = 0.025) compared with patients not receiving ECMO. ECMO and non-ECMO survivors showed similar pulmonary function, morphological abnormalities, resting arterial blood gas values, and 6-min walking distance. Mild pulmonary dysfunction and abnormal morphology were observed in a few survivors. In addition, ECMO and non-ECMO survivors showed a similar quality of life. ECMO survivors showed lower SF-36 physical functioning and role-physical domain scores (minimum clinically significant difference at least 5 points), and non-ECMO survivors had similar outcome.

One-year posthospital discharge, severe ARDS survivors receiving ECMO or MV demonstrated comparable outcomes. Compared with the general population, ARDS survivors showed reduced HRQoL. Pulmonary function and lung morphology revealed sufficient recovery with minor lung impairment.

Septic cardiomyopathy is a common finding in septic shock patients. The accepted definition of septic cardiomyopathy is often based on the left ventricular ejection fraction (LVEF). The aim of this study was to determine whether the left ventricular longitudinal systolic function was more sensitive than the LVEF in heart function appraisal of septic shock patients.

This was a case-control study conducted at a 40-bed Intensive Care Unit (ICU) of Peking Union Medical College Hospital. Septic shock patients admitted to the ICU were consecutively enrolled in the study group from March 1, 2016 to September 1, 2016. The control group was selected from nonsepsis patients who were admitted to the ICU and were comparable to the study group. Transthoracic echocardiography was performed to obtain the LVEF measurement, mitral annular plane systolic excursion (MAPSE), tissue Doppler velocity measurement of mitral annulus (Sa), and tricuspid annular plane systolic excursion.

The study group consisted of 45 septic shock patients. Another 45 nonsepsis patients were selected as the control group. There was no difference in the LVEF between the two groups (64.6% vs. 67.2%, t = −1.426, P = 0.161). MAPSE in the study group was much lower than in the control group (1.2 cm vs. 1.5 cm, t = −4.945, P < 0.001). Sa in the study group was also lower than in the control group (10.2 cm/s vs. 11.8 cm/s, t = −2.796, P = 0.014).

Compared to the LVEF, longitudinal systolic function might be more sensitive in the detection of cardiac depression in septic shock patients. In the heart function appraisal of septic shock patients with a normal ejection fraction, more attention should be given to longitudinal function parameters such as MAPSE and Sa.

In cardiac surgery, elevation of procalcitonin (PCT) could be observed postoperatively in the absence of any evidence of infection and also seems to be a prognostic marker. PCT levels measured in patients undergoing Type A aortic dissection (TAAD) were used to determine prognostic values for complications and surgical outcomes.

Measurements of PCT, C-reactive protein (CRP), and leukocyte count were observed in TAAD surgery patients (n = 251; average age: 49.02 ± 12.83 years; 78.5% male) at presurgery (T0) and 24 h (T1), 48 h (T2), and 7 days (T3) postsurgery. PCT clearance (PCTc) on days 2 and 7 was calculated: (PCT_day1 − PCT_day2/day7)/PCT_day1 × 100%. Endotracheal intubation duration, length of stay (LOS) in the Intensive Care Unit (ICU)/hospital, and complications were recorded.

PCT peaked 24 h postsurgery (median 2.73 ng/ml) before decreasing. Correlation existed between PCT levels at T1 and duration of cardiopulmonary bypass (P = 0.001, r = 0.278). Serum PCT concentrations were significantly higher in nonsurvivor and multiple organ dysfunction syndrome groups on all postoperative days. PCT levels at T1 correlated with length of time of ventilation support and ICU/hospital LOS. Comparing PCT values of survivors versus nonsurvivors, a PCT cutoff level of 5.86 ng/ml at T2 had high sensitivity (70.6%) and specificity (74.3%) in predicting in-hospital death. PCTc-day 2 and 7 were significantly higher in survivor compared with nonsurvivor patients (38% vs. 8%, P = 0.012, 83% vs. −39%, P < 0.001). A PCTc-day 7 cutoff point of 48.7% predicted survival with high sensitivity (77.8%) and specificity (81.8%).

PCT level and PCTc after TAAD surgery might serve as early prognostic markers to predict postoperative outcome. PCT measurement may help identify high-risk patients.

The management of pain, agitation, and delirium (PAD) in Intensive Care Unit (ICU) is beneficial for patients and makes it widely applied in clinical practice. Previous studies showed that the clinical practice of PAD in ICU was improving; yet relatively little information is available in China. This study aimed to investigate the practice of PAD in ICUs in China.

A multicenter, nationwide survey was conducted using a clinician-directed questionnaire from September 19 to December 18, 2016. The questionnaire focused on the assessment and management of PAD by the clinicians in ICUs. The practice of PAD was compared among the four regions of China (North, Southeast, Northwest, and Southwest). The data were expressed as percentage and frequency. The Chi-square test, Fisher’s exact test, and line-row Chi-square test were used.

Of the 1011 valid questionnaire forms, the response rate was 80.37%. The clinicians came from 704 hospitals across 158 cities of China. The rate of PAD assessment was 75.77%, 90.21%, and 66.77%, respectively. The rates of PAD scores were 45.8%, 68.94%, and 34.03%, respectively. The visual analog scale, Richmond agitation-sedation scale, and confusion assessment method for the ICU were the first choices of scales for PAD assessment. Fentanyl, midazolam, and dexmedetomidine were the first choices of agents for analgesic, sedation, and delirium treatment. While choosing analgesics and sedatives, the clinicians put the pharmacological characteristics of drugs in the first place (66.07% and 76.36%). Daily interruption for sedation was carried out by 67.26% clinicians. Most of the clinicians (87.24%) used analgesics while using sedatives. Of the 738 (73%) clinicians titrating the sedatives on the basis of the proposed target sedation level, 268 (26.61%) clinicians just depended on their clinical experience. Totally, 519 (51.34%) clinicians never used other nondrug strategies for PAD. The working time of clinicians was an important factor in the management of analgesia and sedation rather than their titles and educational background. The ratios of pain score and sedation score in the Southwest China were the highest and the North China were the lowest. The ratios of delirium assessment and score were the same in the four regions of China. Moreover, the first choices of scales for PAD in the four regions were the same. However, the top three choices of agents in PAD treatment in the four regions were not the same.

The practice of PAD in China follows the international guidelines; however, the pain assessment should be improved. The PAD practice is a little different across the four regions of China; however, the trend is consistent.

The study is registered at http://www.clinicaltrials.gov (No. ChiCTR-OOC-16009014, www.chictr. org.cn/index.aspx.).

The normal range of red cell distribution width (RDW) level is <15%. Several studies have indicated that a high RDW level was associated with mortality in critically ill patients, and the patients with a high RDW level need increased focus in clinical practice. In view of the difficulty in defining the specific value of high RDW level, the key is to focus on the patient with the level beyond the normal upper limit. This study aimed to determine whether dynamic change of RDW levels, rather than the level itself, is predictive of death in elderly patients with septic shock when RDW level is beyond 15%.

Between September 2013 and September 2015, the elderly septic shock patients with RDW level beyond 15% were enrolled in this study. The RDW levels were measured at enrollment (day 1), and days 4 and 7 after enrollment. Sequential Organ Failure Assessment (SOFA) scores were recorded simultaneously.

A total of 45 patients, including 32 males and 13 females, were included in the final analysis. Based on their hospital outcomes, these patients were divided into the survivor group (n = 26) and the nonsurvivor group (n = 19). There were no significant differences in age, gender, body mass index, initial level of RDW, Acute Physiology and Chronic Health Evaluation II scores, and SOFA scores between survivors and nonsurvivors. At days 4 and 7 measurement, both RDW level (median [interquartile range]: day 4: 15.8 [2.0]% vs. 16.7 [2.0]%, P = 0.011; and day 7: 15.6 [1.8]% vs. 17.7 [2.5]%, P = 0.001) and SOFA scores (day 4: 7.0 [4.0] vs. 16.0 [5.0], P < 0.001, day 7: 5.5 [4.0] vs. 17.0 [5.0], P < 0.001) were significantly lower in survivors than those in nonsurvivors. Dynamic changes of RDW and SOFA scores in survivor group were significantly different from those in nonsurvivor group (all P < 0.05). Continuous increase in RDW level was observed in 10 of the 13 nonsurvivors, but only in 3 of the 26 survivors. The level of RDW7 and dynamic changes significantly correlated with their counterparts of SOFA scores (all P < 0.05), whereas the levels of RDW1 and RDW4 had no significant correlation with their counterparts of SOFA scores (all P > 0.05).

Continuous increase in RDW level, rather than the level of RDW itself, was more useful in predicting hospital death in elderly patients with septic shock when the level of RDW was >15%. The dynamic changes of RDW were highly correlated with the SOFA score in the patients.

Aerosolized amikacin (AA) is a current option for the management of ventilator-associated pneumonia (VAP) caused by multidrug-resistant Gram-negative bacteria (MDR-GNB), as it is reported that AA could increase the alveolar level of the drug without increasing systemic toxicity. This study aimed to evaluate the efficacy and safety of AA as an adjunctive therapy for VAP caused by MDR-GNB.

In this single-center, double-blind study conducted in a 36-bed general Intensive Care Unit (ICU) in a tertiary hospital from June 2014 to June 2016, 52 ICU patients with confirmed MDR-GNB VAP were randomized to two groups (AA group, n = 27 and placebo group, n = 25). Amikacin (400 mg, q8h) or saline placebo (4 ml, q8h) was aerosolized for 7 days. The attending physician determined the administration of systemic antibiotics for VAP. Patients were followed up for 28 days. Bacteriological eradication, clinical pulmonary infection score (CPIS), and serum creatinine were assessed on day 7 of therapy. New resistance to amikacin, cure rate of VAP, weaning rate, and mortality were assessed on day 28.

The baseline characteristics of patients in both groups were similar. At the end of the treatment, 13 of the 32 initially detected bacterial isolates were eradicated in AA group, compared to 4 of 28 in placebo group (41% vs. 14%, P = 0.024). As for patients, 11 of 27 patients treated with AA and 4 of 25 patients treated with placebo have eradication (41% vs. 16%, P = 0.049). The adjunction of AA reduced CPIS (4.2 ± 1.6 vs. 5.8 ± 2.1, P = 0.007). New drug resistance to amikacin and the change in serum creatinine were not detected in AA group. No significant differences in the clinical cure rate in survivors (48% vs. 35%, P = 0.444), weaning rate (48% vs. 32%, P = 0.236), and mortality (22% vs. 32%, P = 0.427) were detected between the two groups on day 28.

As an adjunctive therapy of MDR-GNB VAP, AA successfully eradicated existing MDR organisms without inducing new resistance to amikacin or change in serum creatinine. However, the improvement of mortality was not found.

Evaluating the hemodynamic status and predicting fluid responsiveness are important in critical ultrasound assessment of shock patients. Transthoracic echocardiography with noninvasive diagnostic parameters allows the assessment of volume responsiveness. This study aimed to assess the hemodynamic changes in the liver and systemic hemodynamic changes during fluid challenge and during passive leg raising (PLR) by measuring hepatic venous flow (HVF) velocity.

This is an open-label study in a tertiary teaching hospital. Shock patients with hypoperfusion who required fluid challenge were selected for the study. Patients <18 years old and those with contraindications to PLR were excluded from the study. Baseline values were measured, PLR tests were performed, and 500 ml of saline was infused over 30 min. Parameters associated with cardiac output (CO) in the left ventricular outflow tract were measured using the Doppler method. In addition, HVF velocity and right ventricular function parameters were determined.

Middle hepatic venous (MHV) S-wave velocity was positively correlated in all patients with CO at baseline (r = 0.706, P < 0.01) and after volume expansion (r = 0.524, P = 0.003). CO was also significantly correlated with MHV S-wave velocity in responders (r = 0.608, P < 0.01). During PLR, however, hepatic venous S-wave velocity did not correlate with CO. For the parameter ΔMHV D (increase in change in MHV D-wave velocity after volume expansion), defined as (MHV D_afterVE − MHV D_Baseline)/MHV D_Baseline × 100%, >21% indicated no fluid responsiveness, with a sensitivity of 100%, a specificity of 71.2%, and an area under the receiver operating characteristic curve of 0.918.

During fluid expansion, hepatic venous S-wave velocity can be used to monitor CO, whether or not it is increasing. ΔMHV D ≥21% indicated a lack of fluid responsiveness, thus helping to decide when to stop infusions.

Continuous renal replacement therapy (CRRT) is a continuous process of bedside blood purification which is widely used in the treatment of acute kidney injury (AKI) and for fluid management. However, since AKI and fluid overload are often found to be associated with hemodynamic abnormalities, determining the relationship between CRRT and hemodynamics remains a challenge in the treatment of critically ill patients. The aim of this review was to summarize key points in the relationship between CRRT and hemodynamics and to understand and monitor renal hemodynamics in critically ill patients, especially those with AKI.

This review was based on data in articles published in the PubMed databases up to January 30, 2017, with the following keywords: "continuous renal replacement therapy," "Hemodynamics," and "Acute kidney injury."

Original articles and critical reviews on CRRT were selected for this review.

CRRT might treat AKI by hemodynamic therapy, and it was an important form of hemodynamic therapy. The targets of hemodynamic therapy should be established when using CRRT. Therefore, hemodynamic management and stability were very important during CRRT. Most studies suggested that renal hemodynamics should be clearly identified.

CRRT is not only a replacement for organ function, but an important form of hemodynamic therapy. Improved hemodynamic management of critically ill patients can be achieved by establishing specific therapeutic hemodynamic targets and maintaining circulatory stability during CRRT. Over the long term, observation of renal hemodynamics will provide greater opportunities for the progression of CRRT hemodynamic therapy.

脓毒症被定义为由宿主对感染的反应失调引起的危及生命的器官功能障碍，是重症监护室（ICU）中死亡的主要原因。^[1]流行病学研究表明，在过去的几十年中，脓毒症的发病率一直在逐渐增加。^[2,3]对于临床医生来说，寻找改善脓毒症患者预后的潜在靶点仍然是一个重大挑战。

急性阑尾炎是普通人群中最常见的外科疾病之一，但在原位肝移植（OLT）后很少发生。这些患者的免疫功能受损通常使他们容易因非典型表现而延迟诊断，这可能会增加包括死亡在内的并发症。据报道，肝移植术后急性阑尾炎多发生在术后第14天（POD）后。在此，我们介绍了两例发生在POD 14内的OLT后的急性阑尾炎。

自2013年从3名中国成年患者获得的咽拭子样本被当地疾病控制和预防中心（CDC）确认为禽流感A（H7N9）病毒以来，^[1]中国大陆已报告多例确诊病例。尽管先前报告了确诊或疑似禽类H7N9病毒感染的家庭和医院聚集性病例，并提出了人与人之间的传播，但人类感染H7N9似乎与暴露于受感染的活禽或受污染的环境有关^[2]也没有明确的证据证明它可以在人与人之间传播。在此，我们报告一例与他的H7N9病友密切接触后确诊感染H7N9的病例，可能是病区病友之间感染的首例病例，因此我们在此报告。

常见可变免疫缺陷（CVID）是一种以抗体形成缺陷为特征的异质性免疫缺陷综合征。大约70-80%的患者是根据既往复发性鼻窦、肺部和胃肠道感染病史诊断的。诊断是基于排除其他已知的体液缺陷原因。^[1]除感染外，CVID中共存的发病率包括自身免疫、恶性肿瘤和自身免疫内分泌疾病。我们报告了一例CVID病例，其中闭经并存的并发症与静脉注射免疫球蛋白（IVIG）治疗后的戒断出血有关。

致编者：个体化医学教育对于医院医师的素质提升至关重要。然而，不同的医学生、国际医学生、住院医师和培训医生获得医学理论和临床技能的能力是不同的。^[1]他们的技能处于非常不同的水平。学习者特征的差异会导致与历史教学策略的不匹配。^[2]不同教授之间在医学理论、临床技能、管理、沟通等方面也有不同风格的师徒。在这里，我们认为对教学的持续评估有助于确保有效性。