Abdominal organs are important organs that sense and respond to ischemia and hypoxia, but there are few evaluation methods. We use ultrasonography to evaluate abdominal organ function and blood flow in patients with mechanical ventilation after cardiopulmonary bypass and to obtain a semiquantitative score for abdominal organ function and blood flow. Patients with cardiopulmonary bypass in the Critical Care Department of Peking Union Medical College Hospital in China from March to July 2021 were enrolled in this prospective observational study. The correlation of the celiac visceral blood flow and function score with the ventilator assistance time, number of days spent in the intensive care unit (ICU), acute physiology and chronic health evaluation II (APACHE-II), sequential organ failure assessment (SOFA), lactate, epinephrine, and norepinephrine use was analyzed at t1 (0–12 h after operation) and t2 (12–24 h after operation), and the results were used to assess the predictive value of the receiver operating characteristic curve (ROC) regression analysis score for the mechanical ventilation time. Of the 92 patients who underwent cardiopulmonary bypass, 41 were finally included. The celiac visceral blood flow and function scores at t1 and t2 were significantly correlated with the ventilator assistance time, number of days spent in the ICU, APACHE-II score, SOFA score, and norepinephrine use time. The scores obtained for the blood flow and function of abdominal organs in a group of patients using ventilators for 36 h or more were significantly higher than those obtained for a group of patients using ventilators for less than 36 h (P <0.05). The evaluation results for the abdominal-visceral-blood-flow-and-function score (t1) were as follows: area under the ROC curve (AUC)=0.876 (95% confidence interval [CI]: 0.767–0.984), cut-off value=2.5, specificity=0.842, and sensitivity=0.773. Abdominal visceral organ function and blood perfusion can be used to evaluate gastrointestinal function. It is related to early and late extubation after cardiac surgery.
To evaluate the diagnostic value and potential therapeutic impact of Peking Union Medical College Hospital critical ultrasonic management (PCUM) in the early management of critically ill patients with acute respiratory failure (ARF).Patients admitted into the ICU of Peking Union Medical College Hospital for ARF were consecutively recruited over a 18-month period. Patients were randomly divided into conventional group and PCUM group (critical care ultrasonic examination was added in addition to conventional examinations). The two groups were compared with respect to time to preliminary diagnosis, time to final diagnosis, diagnostic accuracy, time to treatment response, time to other examination.A total of 187 patients were included in this study. The two groups showed no significant differences in general clinical information or final diagnosis (P > 0.05). The PCUM group had a shorter time to preliminary diagnosis, time to final diagnosis, time to treatment response, time to X-ray/CT examination, and a higher diagnostic accuracy than the conventional group (P < 0.001). PCUM had high sensitivity and specificity for the diagnosis of acute respiratory distress syndrome (ARDS) (sensitivity 92.0%, specificity 98.5%), acute pulmonary edema (sensitivity 94.7%, specificity 96.1%), pulmonary consolidation (sensitivity 85.7%, specificity 98.6%), COPD/asthma (sensitivity 84.2%, specificity 98.7%).The PCUM is seem to be an attractive complementary diagnostic tool and able to contribute to an early therapeutic decision for the patients with ARF.
To the Editor: In the past decades, there were at least 31.5 million sepsis patients worldwide. Of these patients, 5.3 million sepsis patients face death every year.[1] Studies have shown the mortality from sepsis can be reduced by compliance with the surviving sepsis campaign guidelines (Cssc).[2] Compliance with guidelines depends on the execution of the medical team. We assume that the medical quality of the intensive care unit (QICU) will have an important impact on the Cssc. We designed this experiment to investigate the Cssc and QICU and determine the relationships between the Cssc and QICU in China. The total number of secondary and tertiary hospitals registered in China National Critical Care Quality Control Center (China-NCCQC) was 7525 in 2018. Hospitals with patients of septic shock admitted in ICUs <20/year and incomplete data were excluded from this study. Finally, 1854 hospitals were involved. The data were collected between January 1, 2018, and December 31, 2018. The quality indicators of ICUs included deep vein thrombosis (DVT) prophylaxis rate, unplanned extubation rate, reintubation rate within 48 h, rate of unplanned ICU admission, return rate within 48 h. Each indicator is divided into four grades according to the implementation. Each 25% from bad to good is one level, with 0, 1, 2, or 3 points. According to the scores, they are divided into the lowest group, the lower group, the higher group, and the highest group. The endpoints were the 3-and 6-h Cssc. Monitoring indicators included 3-h Cssc (1. Completion of lactate concentration was determined, 2. Completion of appropriate routine microbiologic cultures [including blood] obtained before starting antimicrobial therapy, 3. Completion of empiric broad-spectrum therapy, 4. Completion of resuscitation with 30 mL/kg crystal liquid) and 6-h Cssc (1. Completion of repeated measurement of lactate levels in patients with initial hyperlactatemia, 2. Completion of resuscitation with vasopressor in patients with mean arterial pressure [MAP] ≤65 mmHg after fluid resuscitation, 3. Completion of central venous pressure [CVP] and central venous oxygen saturation [ScvO2] measured in patients with lactate ≥4 mmol/L). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The trial protocol was approved by the Central Institutional Review Board at Peking Union Medical College Hospital (NO. S-K1297) and individual consent for this retrospective analysis was waived. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Statistical analysis was performed using SPSS software, version 16.0 (IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was employed to check whether the data were normally distributed. The results are described as mean ± standard deviation. Comparisons between multiple groups were analyzed by one-way analysis of variance (ANOVA), and pairwise comparisons after ANOVA were conducted using the Tukey multiple comparisons test. All of the statistical tests were two-tailed, and a P < 0.05 was considered to be statistically significant. The completion of 3-h Cssc is generally higher than the completion of 6-h Cssc. The main constraint on the 6-h Cssc is the completion of CVP and ScvO2 measured in patients with lactate ≥4 mmol/L. In the lower, higher, and highest groups of the DVT prophylaxis rate, the 6-h Cssc, the sub-indicators of 3-h Cssc, and the sub-indicators of 6-h Cssc were significantly higher than those in the lowest group (P < 0.05) [Figure 1A]. In the higher and highest groups of the DVT prophylaxis rate, the sub-indicators of 6-h Cssc were significantly higher than those in the lower group (P < 0.05) [Figure 1A]. In the lower, higher, and highest groups of the unplanned extubation rate, the 6-h Cssc, the sub-indicators of 3-h Cssc, and the sub-indicators of 6-h Cssc were significantly higher than those in the lowest group (P < 0.05) [Figure 1B]. In the lower, higher, and highest groups of the reintubation rate within 48 h, the 6-h Cssc, the sub-indicators of 3-h Cssc, and the sub-indicators of 6-h Cssc were significantly higher than those in the lowest group (P < 0.05) [Figure 1C]. In the highest group of the reintubation rate within 48 h, the sub-indicators of 6-h Cssc were significantly higher than those in the higher group (P < 0.05) [Figure 1C]. In the lower, higher, and highest groups of the rate of unplanned intensive care unit (ICU) admission, the 6-h Cssc and the sub-indicators of 3-h Cssc were significantly higher than those in the lowest group (P < 0.05) [Figure 1D]. In the lower, higher, and highest groups of the rate of unplanned ICU admission, completion of repeated measurement of lactate levels in patients with initial hyperlactatemia and completion of resuscitation with vasopressor in patients with MAP ≤ 65 mmHg after fluid resuscitation were significantly higher than those in the lowest group (P < 0.05) [Figure 1D]. The above results indicated that factors related to 3-and 6-h Cssc include DVT prophylaxis rate, unplanned extubation rate, reintubation rate within 48 h, and rate of unplanned ICU admission. In the lower and higher groups of the return rate within 48 h, 6-h Cssc was significantly higher than in the lowest group of ICU re-admission rates within 48 h (P < 0.05) [Figure 1E]. However, the same phenomenon was not observed in the hour-3 bundle [Figure 1E]. These results indicated that the relationship between Cssc and the return rate within 48 h is uncertain.Figure 1: Correlation between clinical quality control indicators and compliance of surviving sepsis campaign (SSC) guidelines (Cssc). Monitoring indicators included deep vein thrombosis (DVT) prophylaxis rate, unplanned extubation rate, reintubation rate within 48 h, rate of unplanned ICU admission, return rate within 48 h. Each indicator is divided into four grades according to the implementation. Each 25% from bad to good is one level, with 0, 1, 2, or 3 points. According to the scores, they are divided into the lowest group, the lower group, the higher group, and the highest group. Results are presented as mean ± standard error. ∗ P < 0.05 compared to the lowest group, † P < 0.05 compared to the lower group, ‡ P < 0.05 compared to the higher group. DVT: Deep vein thrombosis; ICU: Intensive care unit.The intrinsic risk of an ICU patient (the underlying disease, pathophysiologic derangements, etc) is added to the extrinsic risk created by the process of care itself. Nearly 20% of medication errors in ICUs are life-threatening, and 40% require treatment.[3] Improving the quality of care given to ICU patients is highly desirable. Since the establishment of China-NCCQC, our center has released Quality Control Requirements for Critical Care Medicine in China (2015). The Quality Improvement of Critical Care Program, led by China-NCCQC, was initiated in 2015. This study is part of the above program. Wang et al[4] found that the Cssc of emergency physicians is often hindered by the doctors' awareness and attitudes. Cssc is related to DVT prophylaxis rate, unplanned extubation rate, reintubation rate within 48 h, and rate of unplanned ICU admission. There are several possible reasons for this phenomenon. First, DVT prophylaxis rate, unplanned extubation rate, reintubation rate within 48 h, and rate of unplanned ICU admission are more relevant to physician decisions than other indicators. Second, from the perspective of QICU, prevention of DVT and implementation of the SSC guideline bundle are both clustered treatments, fully reflecting doctors' awareness and attitudes toward critical care patients, which is likely why 3-and 6-h Cssc and DVT prophylaxis rate have a good consistency. Third, adverse events, such as unplanned extubation rate, reintubation rate within 48 h, and the rate of unplanned ICU admission reflect management ability of ICU.[5] The stronger that the management ability is, the better that the 3- and 6-h Cssc is. The relationship of 3- and 6-h Cssc with ICU re-admission rate within 48 h is uncertain. Compared with other adverse events, factors that cause return within 48 h after transferring out of the ICU might be more complex and occur outside of the ICU. Therefore, it is difficult to effectively manage these factors that cause return within 48 h after transferring out of the ICU. The above phenomenon might be the main reason for the poor test titers of this indicator. In this study, it was found that the groups with the worst scores tended to have the worst bundle compliance compared to other groups, with significant differences, while differences between other groups were often not significant. The reason might be that Cssc has been ahead of the implementation of most quality control indicators due to the universal promotion of the concept of early goal-directed therapy. As a result, the completion of quality control indicators cannot test the differences in Cssc. However, for hospitals where the treatment of sepsis is still not standardized, it is still of great significance to strengthen the construction of QICU. There are some limitations of our study. First, since only one year of data was included in this study, the relationships of QICU on 3- and 6-h Cssc could not be analyzed continuously and dynamically. Second, additional study is needed to determine whether differences in mortality from sepsis might emerge with follow-up beyond 1 year. Funding The study was supported by grants from the National Key R&D Program of China (No. 2020YFC0861000) and the National Natural Science Foundation of China (No. 81801901). Conflicts of interest None.
For hemodynamic monitoring, the pressure transducer is suggested to be fixed at the level of the phlebostatic axis in critically ill patients [1,2]. The correction and adjustment of pressure transducer are emphasized in central venous pressure monitoring in clinical practice. The exact position of the transducer is relatively easy to be ignored for invasive arterial blood pressure monitoring [3,4]. Improper position of the transducer may cause inaccurate value and shape of the arterial blood pressure wave, which would result in an invalid PiCCO (Pulsion Medical Systems AG, Munich, Germany) algorithm for pulse contour waveform-derived measurements. This study was conducted as a prospective quantitative evaluation of the relationship between arterial transducer level and pulse contour waveform-derived measurements. In total, 22 patients were enrolled in the 28-bed department of critical care medicine of a university hospital. All of the patients had a femoral artery catheter for PiCCO hemodynamic monitoring. The site of the phlebostatic axis was defined as the zero level (reference level). We moved the arterial pressure transducer up and down at eight different levels (� 5c m,�10 cm, �15 cm, �20 cm, 5 cm, 10 cm, 15 cm, 20 cm). At each level, continuous cardiac index (CCI), rate of left ventricular pressure rise during systole (dP/dtmax), and systemic vascular resistance index (SVRI) were simultaneously recorded.
Patient safety and critical care quality remain a challenging issue in the ICU. However, the effects of the national quality improvement (QI) program remain unknown in China.A national ICU QI program was implemented in a controlled cohort of 586 hospitals from 2016 to 2018. The effects of the QI program on critical care quality were comprehensively investigated.A total of 81,461,554 patients were enrolled in 586 hospitals, and 1,587,724 patients were admitted to the ICU over 3 years. In 2018, there was a significantly higher number of ICU beds (2016 vs. 2018: 10668 vs. 13,661, P = 0.0132) but a lower doctor-to-bed ratio (2016 vs. 2018: 0.64 (0.50, 0.83) vs. 0.60 (0.45, 0.75), P = 0.0016) and nurse-to-bed ratio (2016 vs. 2018: 2.00 (1.64, 2.50) vs. 2.00 (1.50, 2.40), P = 0.031) than in 2016. Continuous and significant improvements in the ventilator-associated pneumonia (VAP) incidence rate, microbiology detection rate before antibiotic use and deep vein thrombosis (DVT) prophylaxis rate were associated with the implementation of the QI program (VAP incidence rate (per 1000 ventilator-days), 2016 vs. 2017 vs. 2018: 11.06 (4.23, 22.70) vs. 10.20 (4.25, 23.94) vs. 8.05 (3.13, 17.37), P = 0.0002; microbiology detection rate before antibiotic use (%), 2016 vs. 2017 vs. 2018: 83.91 (49.75, 97.87) vs. 84.14 (60.46, 97.24) vs. 90.00 (69.62, 100), P < 0.0001; DVT prophylaxis rate, 2016 vs. 2017 vs. 2018: 74.19 (33.47, 96.16) vs. 71.70 (38.05, 96.28) vs. 83.27 (47.36, 97.77), P = 0.0093). Moreover, the 6-h SSC bundle compliance rates in 2018 were significantly higher than those in 2016 (6-h SSC bundle compliance rate, 2016 vs. 2018: 64.93 (33.55, 93.06) vs. 76.19 (46.88, 96.67)). A significant change trend was not found in the ICU mortality rate from 2016 to 2018 (ICU mortality rate (%), 2016 vs. 2017 vs. 2018: 8.49 (4.42, 14.82) vs. 8.95 (4.89, 15.70) vs. 9.05 (5.12, 15.80), P = 0.1075).The relationship between medical human resources and ICU overexpansion was mismatched during the past 3 years. The implementation of a national QI program improved ICU performance but did not reduce ICU mortality.
Objective Despite its frequency and associated negative effect, delirium remains poorly recognized in postoperative patients after ICU admission, especially among those who have undergone cardiac surgery with cardiopulmonary bypass. Postoperative delirium is triggered by a wide variety of acute medical conditions associated with impaired neuronal network connectivity. The lack of objective biomarkers primarily hinders the early detection of delirium. Seeking early biomarkers for tracking POD could potentially assist in predicting the onset of delirium and assessing the severity of delirium and response to interventions. Methods QEEGs were taken from 46 sedated postoperative patients, with 24 of them having undergone cardiac surgery. The assessment of delirium was performed twice daily using the Confusion Assessment Method for the ICU (CAM-ICU) to screen for postoperative delirium (POD). QEEG data were interpreted clinically by neurophysiologists and processed by open-source EEGLAB to identify features in patients who had or did not have POD after cardiac or non-cardiac surgery. Results The incidence of delirium in patients after undergoing cardiac surgery was nine times greater than in those after non-cardiac surgeries (41.7% vs. 4.5%; p = 0.0046). Patients with delirium experienced longer use of mechanical ventilation (118 h (78,323) compared to 20 h (18,23); p < 0.0001) and an extended ICU length of stay (7 days (6, 20) vs. 2 days (2, 4); p < 0.0001). The depth of anesthesia, as measured by RASS scores ( p = 0.3114) and spectral entropy ( p = 0.1504), showed no significant difference. However, notable differences were observed between delirious and non-delirious patients in terms of the amplitude-integrated EEG (aEEG) upper limit, the relative power of the delta band, and spectral edge frequency 95 (SEF95) ( p = 0.0464, p = 0.0417, p = 0.0337, respectively). Conclusion In a homogenous population of sedated postoperative patients, robust qEEG parameters strongly correlate with delirium and could serve as valuable biomarkers for early detection of delirium and assist in clinical decision-making.
Objective: To investigate the ability of white blood cell (WBC), procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP) in the super-elderly patients with bloodstream infection. Methods: It was a retrospective study. A total of 77 patients (≥85 years) admitted to the ICU of Peking Union Medical College Hospital from June, 2016 to December, 2017 were enrolled. The patients included 67 males and 10 females, with an age of 85-105 years and the average age was (92±5) years. According to the results of blood culture, patients were divided into positive blood culture group (n=50) and negative blood culture group (n=27). The data which obeyed normal distribution were compared with single sample t test between the two groups. Results: There was no significant difference in WBC level between the positive blood culture group and the negative blood culture group[12.4(7.8, 36.6)×10(9)/L vs 10.7(8.5, 18.7)×10(9)/L, U=0.109, P=0.124]. Compared to the positive blood culture group, the PCT level [2.6(0.8, 7.4)μg/L vs 1.5(0.6, 5.3)μg/L, U=3.015, P=0.004] and hs-CRP level [119(62, 220) mg/vs 54 (24, 80) mg/L, U=7.791, P<0.001] were significantly higher in the negative blood culture group. The ROC analysis showed that the area under the curves (AUC) of WBC, PCT and hs-CRP was 0.704(95%CI: 0.586-0.822, P<0.01), 0.896(95%CI: 0.829-0.964, P<0.01) and 0.864(95%CI: 0.778-0.949, P<0.01), respectively. The best cutoff value of PCT for discrimination of positive blood culture was 0.44 μg/L, which resulted in a sensitivity of 70.0% and a specificity of 92.6%. The best cutoff value of hs-CRP was 50.35 mg/L, which resulted in a sensitivity of 62.0% and a specificity of 88.9%. Conclusion: Compared to WBC, both PCT and hs-CRP have a better ability to predict bloodstream infection in the Super-elderly patients.目的： 比较白细胞（WBC）、降钙素原（PCT）及超敏C反应蛋白（hs-CRP）在超高龄重症患者中对血流感染的诊断预测价值。 方法： 回顾分析2016年6月至2017年12月北京协和医院重症医学科收治的77例超高龄重症感染患者（≥85岁），男性患者67例，女性患者10例，年龄85~105岁，平均年龄（92±5）岁，以血培养结果进行分组，其中血培养阳性组50例，血培养阴性组27例，分析WBC、PCT、hs-CRP对血流感染的预测价值。两组间正态分布参数比较应用独立样本t检验。 结果： 血培养阳性组与阴性组WBC无显著差异[12.4（7.8，36.6）×10(9)/L比10.7（8.5，18.7）×10(9)/L，U=0.109，P=0.124]，血培养阳性组PCT[2.6（0.8，7.4）μg/L比1.5（0.6，5.3）μg/L，U=3.015，P=0.004]和hs-CR[119（62，220）mg/L比54（24，80）mg/L，U=7.791，P<0.001]显著高于血培养阴性组。WBC、PCT和hs-CRP预测血培养阳性的受试者工作特征（ROC）曲线下面积分别为0.704（95%CI：0.586~0.822，P<0.01）、0.896（95%CI：0.829~0.964，P<0.001）和0.864（95%CI：0.778~0.949，P<0.001）。其中PCT预测血培养阳性临界值为0.44 μg/L，敏感度为70.0%，特异度为92.6%；hs-CRP预测的临界值为50 mg/L，敏感度为62.0%，特异度为88.9%。 结论： PCT和hs-CRP能较WBC更好地早期预测超高龄重症患者的血流感染，PCT和hs-CRP的诊断阈值值得重视。.
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