Sepsis is a pathologic syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection.Early and appropriate anti-infection treatment can improve the prognosis.β-lactam antibiotics are common antibiotics for the treatment of sepsis.Extended infusion of β-lactam antibiotics is a simple and effective method to optimize pharmacokinetic/pharmacodynamics and improve the efficiency.In the experts consensus, we discuss the basic theory, efficiency, safety, and clinical application on extended infusion of β-lactam antibiotics in adult sepsis patients, and summarize the evidence-based medicine for reference.
Analgesia and sedation play important roles in critically ill patients, with the target shifting from improving patient comfort to organ function protection.For mechanically ventilated patients,the newly proposed concept of lung-protective sedation represents a further understanding of the inherent interconnection between optimizing mechanical ventilation, sedation strategies, and respiratory-related lungdiaphragm injuries.It also reminds clinicians that in the analgesic and sedation management of mechanically ventilated patients, they should evaluate and regulate respiratory drive and inspiratory effort in a targeted manner based on the arousal scale assessments to achieve the purpose of lung-diaphragm protective ventilation.
Patients in the ICU typically undergo frequent daily diagnostic tests to monitor hidden risks.Nevertheless, there are numerous additional repetitive, routine, and non-essential tests performed on regularly that are not specifically focused on addressing clinical concerns.Non-essential blood testing related to blood collection can lead to hospital-acquired anemia, which is associated with prolonged hospital stays,increased blood transfusion demand, and a higher mortality rate.Simultaneously, conducting non-essential testing imposes a significant economic strain.We reviewed the current situation, hazards, and measures of non-essential laboratory testing in the ICU, with the aim of increasing attention to ICU patients receiving nonessential blood testing and promoting high-quality development of the ICU.
Atomization inhalation of antibacterial agents is one of the commonly used bundle airway management in mechanically ventilated patients with antimicrobial-resistant bacteria pneumonia and chronic pulmonary infection.This article reviews the clinical implementation of atomization inhalation of antibacterial agents in mechanically ventilated patients, including selection of antibacterial agent dosage form, drug configuration, use of atomization device, mechanical ventilation setting, and elaborates prevention and treatment of related adverse events, in order to standardize clinical nursing of atomization inhalation of antibacterial agents in mechanically ventilated patients and provide reference for formulating appropriate atomization management plan of antibacterial agents.
Acute respiratory distress syndrome (ARDS) is a type of non-cardiogenic pulmonary edema with a high mortality rate.With the pandemic of novel coronavirus infection (COVID-19), the diagnosis and treatment of ARDS have attracted renewed attention in clinical practice.Based on the updated evidence-based research, the American Thoracic Society issued guidelines for the treatment of ARDS in 2023, involving four parts: the use of corticosteroids, the selection of extracorporeal membrane oxygenation (ECMO), the application of neuromuscular blocking agents, and the use of positive end-expiratory pressure (PEEP) in ARDS patients.The guidelines recommends corticosteroids for patients with ARDS.Venovenous extracorporeal membrane oxygenation (V-V ECMO) is recommended for selected patients with severe ARDS.Neuromuscular blockers are recommended for patients with early severe ARDS.For patients with moderate-to-severe ARDS, a higher PEEP is recommended over a lower PEEP without lung recruitment maneuvers (LRMs).Prolonged lung recruitment maneuvers are not recommended for patients with moderate-to-severe ARDS.This article briefly interprets the relevant content in order to provide clinical references for the diagnosis and treatment of ARDS patients.
To investigate the safety of high-frequency oscillatory ventilation (HFOV)control technique for controlling respiratory movement in patients with thoracic and abdominal tumors with carbon ion precision therapy.
Methods
A total of 33 patients with thoracic and abdominal malignant tumors who were hospitalized in Wuwei Cancer Hospital of Gansu Province from January 2023 to July 2024 and treated with carbon ion under the control of HFOV were selected as the study group.Heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SO2), transcutaneous oxygen pressure (tcpO2), transcutaneous carbon dioxide partial pressure (tcpCO2) before treatment, after endotracheal intubation, 4D-CT positioning, target delineation for 30 min, 4D-CT reduction, carbon ion therapy for 30 min, 60 min, 90 min, 120 min, resuscitation,after extubation, and the maximum motion degree of diaphragm in the direction of head and foot in the state of spontaneous breathing and HFOV were statistically analyzed.42 patients with thoracic and abdominal malignant tumors treated with carbon ion therapy without HFOV were selected as the control group, and the positioning error, margin of planning target volume (MPTV), and adverse reaction and treatment of the two groups were analyzed.
Results
Most lung and liver tumors had multiple lesions, with a maximum of 24 lesions is 33 cases of the study group.All patients with multiple lesions were treated at one time.There were no significant differences in HR, MAP before, during, or after treatment (P＞0.05).SO2, tcpO2 were lower than those in other stages before treatment (P＜0.001).SO2 was lower at resuscitation and after extubation than at the end of endotracheal intubation to carbon ion therapy, and higher than before treatment (P＜0.001).tcpO2 and tcpCO2 were higher than those in other stages after 90 minutes and 120 minutes of carbon ion treatment (P＜0.001).The maximum motion degree in the head and foot direction of the diaphragm in HFOV was 1.30 (0.80, 2.00) mm,which was significantly lower than that of 19.00 (11.30, 31.20) mm in the spontaneous breathing state (P＜0.001).The positioning errors of carbon ion therapy in study group were 1.13 (0.16, 2.02) mm on X-axis, 1.57 (0.12,5.26) mm on Y-axis and 1.21 (0.10, 6.19) mm on Z-axis.In the control group, the X-axis was 1.23 (0.98,2.85) mm, Y-axis was 2.52 (1.27, 3.51) mm, Z-axis was 1.64 (0.73, 3.08) mm, there were significant differences between the two groups (P＜0.001).The external boundary in the study group were 1.13 (0.70, 1.47) mm on the X-axis, 1.57 (0.89, 2.41) mm on the Y-axis, and 1.21 (0.74, 1.61) on the Z-axis mm, the external boundary of the control group was 1.22 (1.15, 1.29) mm on the X-axis, 2.51 (2.04, 2.66) mm on the Y-axis and 1.63 (1.49, 1.75)mm on the Z-axis, there were significant differences in the Y-axis and Z-axis of the external boundary between the two groups (P＜0.001), while there was no statistically significant difference in the X-axis of the external boundary between the two groups (P＞0.05).Hypertension occurred in 1 patient and CO2 retention occurred in 1 patient.After extubation, 2 patients developed nausea and vomiting, 9 of 33 patients developed radiation pneumonia, in which 7 cases of grade 1 and 2 cases of grade 2.
Conclusion
The HFOV control technique is safe for controlling the respiratory movement of patients with thoracic and abdominal tumors.It can reduce the positioning error of patients during carbon ion therapy, narrow MPTV, and enable patients to get high-dose, more accurate and less side effects of carbon ion therapy, and improve the curative effect.
To establish a quality control index system for continuous renal replacement therapy (CRRT), and explore key factors that affect outcome indicators by collecting real-world data.
Methods
A three-dimensional quality evaluation model as the theoretical framework was used, a quality control index system was constructed using literature analysis and expert consultation methods; information on patients receiving CRRT treatment from 6 hospitals in 4 provinces and 6 medical institutions were collected,and a retrospective cohort study was used to explore factors affecting outcome indicators.
Results
A total of 2 rounds of expert consultation were conducted, ultimately forming a CRRT quality control indicator system consisting of 2 first level indicators, 6 second level indicators, and 26 third level indicators; the results of multiple factor regression analysis showed that the indications for machine use and the type of disease diagnosis were key factors affecting the outcome indicators.
Conclusion
The CRRT quality control indicator system constructed in this study has a certain degree of scientificity and rationality, providing reference for clinical quality control of CRRT.In practice, key links that affect outcome indicators should be emphasized,and the CRRT clinical quality control indicator system should be continuously improved.
To measure the efficiency of continuous renal replacement therapy technology (CRRT) in intensive care units (ICUs) in Chinese medical institutions and analyze the influencing factors, to provide a reference for further standard CRRT services in China and improving the efficiency of ICU in local medical institutions.
Methods
The ICU input-output information of 126 medical institutions in five provinces of China from March 1 to 31, 2021 was collected.The three-stage data envelope analysis(DEA) model and super efficiency model were used to measure the CRRT efficiency of ICU.
Results
The average comprehensive efficiency, pure technical efficiency and scale efficiency of the 126 medical institutions were 0.300, 0.506 and 0.598, respectively.The comprehensive efficiency of the five provinces was C (0.364)＞ A (0.345)＞ B (0.286)＞ D (0.213)＞ E (0.169), and the hospital grade showed a positive and significant relationship with the efficiency of CRRT.
Conclusion
The overall efficiency level of CRRT in ICUs of sample institutions in five provinces is low with regional differences.It is necessary to optimize hospital internal control operation management, establish CRRT resource allocation standards, innovate and standardize human resource management and training mechanisms, and carry out CRRT through interdisciplinary cooperation.
To analyze the resource allocation, indications, and clinical utilization of continuous renal replacement therapy (CRRT) in ICUs, and provide references for the development of relevant policies regarding the application of CRRT in ICU settings.
Methods
A cross-sectional survey from a total of 167 hospitals in 5 provinces from the eastern, central, and western regions of China from March 1 to 31, 2021 was conducted based on literature research and expert consultation, resulting in the creation of a questionnaire on the current application status of CRRT in medical institutions (ICU).The contents of the questionnaire mainly include:(1) resource allocation in each region (medical staff allocation and training of CRRT equipment configuration,management and operation of CRRT technology); (2) composition of indications (kidney disease and non-renal disease); (3) clinical application (treatment mode and treatment duration, use of replacement fluid and filter, regular quality control and disinfection measures); and (4) treatment effect (patient prognosis and treatment cost).
Results
In terms of resource distribution, CRRT equipment resources and human resources were more abundant in the eastern part of China, and the proportion of healthcare personnel who had participated in the standardized training on CRRT organized by national or provincial societies/associations was relatively low (38.54%-62.70% for physicians;18.86%-35.26% for nurses); in terms of clinical use, indications for CRRT in ICUs were predominantly for nonrenal diseases, with the top 3 indications were sepsis or infectious shock (17%), followed by acute (13%) or chronic(12%) renal insufficiency combined with circulatory instability, and there was little difference in the distribution of the top indications across the region; the 2 treatment modes with the most applications were CVVHDF (37%)and CVVH (33%); the duration of CRRT treatment in each province spanned a wide range, but with a sub-average treatment duration of ＞24 h (59.3%); on the whole, more commercial replacement solutions (65.44%) were used than handmade replacement solutions (34.56%), but the proportion of handmade replacement solutions was higher in some regions (＞50% in Jiangsu and Xinjiang); the frequency of filter replacement was affected by the mode of anticoagulation, and the highest frequency of filter replacement was found in the case of no anticoagulation (about 10.50 h/times), and the service life of the filter was longer in the case of anticoagulation with citrate (about 26.65 h/times).In terms of treatment effect, the overall case fatality rate of patients during hospitalization in ICU was 21.40%, and the proportion of patients still needing long-term dialysis after CRRT treatment was 20.19%, with a significant difference in treatment effect between Henan and Xinjiang and other regions; in terms of treatment cost,there was a big difference in the charges of CRRT in various regions, with a range of 80-130 yuan/h.The average cost of hospitalization for CRRT patients was 74 000/person, of which CRRT-related costs account for about 20%,and the reimbursement ratio of medical insurance was higher (about 70% overall); the fee schedule usually included healthcare personnel hourly fee, machine depreciation fee, and replacement fluid (accounting for ＞50% of the total), while anticoagulant and hemodialysis tubing were usually not included in the fee schedule (accounting for＜30% of the total), of which the price of dialysis tubing was higher, which had a greater impact on the overall cost.
Conclusion
In the future, coordinated planning of CRRT technical resources, promotion of standardized management of procedures, and establishment of quality control systems will be needed to achieve the goal of improving the quality and efficiency of medical institutions and intensive care departments.
To explore the effect of the teaching method integrating ideological and political curriculum in critical care medicine.
Methods
The undergraduate students of grade 2016 from Xiangya Medical College, Central South University in semester 2020-2021 were in the recruited research.These students were randomly divided into experimental group and control group.The experimental group (91 students) adopted the case teaching method of critical care medicine integrating ideological and political curriculum, while the control group (89 students) adopted the teaching method of teaching critical care medicine and ideological and political curriculum separately.At the end of teaching, the student recognition rate was obtained through questionnaire survey.
Results
Compared with the students in the control group, the students in the experimental group thought that the new curriculum design was more reasonable (85.71% vs 68.54%, P=0.0075) and were more satisfactory(81.32% vs 67.42%, P=0.0403).The students in the experimental group believed that the case teaching method of professional courses integrating ideological and political curriculum was more realistic (78.02% vs 62.92%,P=0.0334), and could better enhance learning interests (72.53% vs 53.93%, P=0.0334), professional abilities(76.92% vs 55.06%, P=0.0027), teamwork ability (93.41% vs 80.90%, P=0.0140), earlier integration (83.52%vs 69.66%, P=0.0345); more teaching advantage (86.81% vs 69.66%, P=0.0065), students’ patriotism education(92.31% vs 79.78%, P=0.0178), and professional literacy (90.11% vs 78.65%, P=0.0404).The differences were statistically significant (P＜0.05).
Conclusion
The case teaching method of critical care medicine integrating ideological and political curriculum has significant advantages in enhancing students’ professional abilities and strengthening patriotism education, teamwork spirits, and the spirits of not giving up.
One of the major causes of death in critically ill patients is sepsis, which results from a dysregulated immune response to infection.Both physiological and pathological development of thymus atrophy impairs body immune function.Multiple studies have shown that sepsis also leads to dramatically thymic atrophy, mainly manifested by increased apoptosis of thymocytes and damage of thymic epithelial cells, which is one of the important mechanisms of immune dysfunction in sepsis.More importantly, reversible recovery of thymus function may be closely related to prognosis of sepsis patients.An in-depth understanding of the mechanisms of acute thymic atrophy in sepsis and the development of related strategies to promote thymic recovery may provide new insights for sepsis immunotherapy.
Sepsis is an acute severe syndrome that develops into fatal organ dysfunction due to infection induced uncontrolled host response.Due to its complex and heterogeneous pathophysiology, sepsis has become the leading cause of death in critically ill patients.Transcriptomics refers to the collection of all transcription products in a cell under certain physiological or pathological conditions which reflects cellular activities in a specific environment and being studied with gene transcription and transcriptional regulation.In recent years, transcriptomics has made some breakthroughs in early identification, precise treatment and prognostic evaluation of sepsis, which is potential to construct a new system for diagnosing and managing sepsis.This paper reviews related articles to clarify research progress of transcriptomics in sepsis diagnosis and treatment.
Remimazolam Besylate is a novel, ultra-short-acting Benzodiazepine which rapidly hydrolyzed into an inactive carboxylic acid metabolite by non-specific tissue esterase.It has characteristics of fast onset, quick recovery, and predictable duration of action.Its sedative effect can be antagonized by Flumazenil.Prolonged infusion of Remimazolam besylate is unlikely to result in accumulation.Remimazolam Besylate has been currently approved for procedural sedation, induction and maintenance of general anesthesia in several countries.Preliminary studies have shown certain advantages in critically ill patients sedation.In this study, mechanisms, pharmacokinetics, clinical applications, adverse events and application prospects of Remimazolam besylate are reviewed to provide evidence for its development, research and application.
Airway closure refers to a lack of communication between proximal airways and alveoli due to airway collapse.It occurs in about 30% of patients, rising to up to 65% of patients with obesity and ARDS.“Liquid bridge formation,” “small airway compliant collapse,” or “surfactant depletion” can lead to airway closure, however, the exact mechanism is unknown.Airway closure not only affects the function of lung ventilation, but also in the process of mechanical ventilation, ignoring this phenomenon can lead to errors in lung recruitment assessment and respiratory mechanics measurement.This can affect the appropriate setting of ventilator parameters, even leading to or aggravating lung injury, and impacting on the fluid responsiveness assessment index based on heart-lung interaction.Airway closure can be monitored clinically by “low flow method” or “conductive pressure method”.This article reviews the phenomenon of airway closure and its impacts on respiration and circulation, emphasizing the importance of monitoring airway closure to deepen clinicians’ understanding and thereby improve the prognosis of mechanically ventilated patients with airway closure.
Patient-ventilatory asynchrony (PVA) is common during mechanical ventilation, and is closely associated with elevated work of breath, prolonged mechanical ventilation, ventilator-induced lung injury,as well as worse clinical outcomes.Identifying PVA requires careful observation of the patient and their ventilator waveforms, but clinical healthcare providers vary in their ability to recognize PVA, and continuous bedside monitoring is challenging, urging the development of automated monitoring methods.PVA automatic detection algorithms have rapidly developed in recent years, showing a trend of synergistic development driven by data and knowledge.This article reviews the development history of PVA automatic detection methods, outlines the advantages and disadvantages of technologies based on rules, traditional machine learning, deep learning, and physiological system models, introduces the development and clinical application status of real-time PVA detection and analysis systems, and discusses the challenges faced in PVA detection based on mechanical ventilation waveform big data, such as the lack of standard datasets and insufficient algorithm generalization capability.
Guillain-Barré syndrome (GBS) is an immune-mediated acute inflammatory polyneuropathy, characterized by its acute onset.This patient presented with symptoms of fever and cough following an upper respiratory tract infection two weeks before the onset of the disease, which gradually progressed to sensory disturbances in the distal extremities and flaccid weakness in the lower limbs.Routine cerebrospinal fluid (CSF) analysis and biochemical tests revealed the phenomenon of cytoalbuminological dissociation.The condition rapidly evolved to involve the respiratory muscles, leading to respiratory failure and hypoxemia, necessitating mechanical ventilation.CT scan of the patient’s chest demonstrated diffuse alveolar infiltrates, consistent with a diagnosis of GBS complicated by severe acute respiratory distress syndrome(ARDS).Despite early treatment with intravenous immunoglobulin and plasmapheresis at another facility with suboptimal outcomes and rapidly deteriorating condition, manifesting respiratory failure and symptoms of ARDS, in this case, we continued treatment with intravenous immunoglobulin in conjunction with Eculizumab.This approach effectively controlled the ARDS, led to a swift recovery of muscle strength, and progressively improved respiratory function and oxygenation indices, ultimately allowing for the successful weaning from mechanical ventilation support.
