For critically ill patients, enteral nutrition at early phase can not only provide nutrition but also maintain the function and microecology of intestine. The therapeutic effects of medicines depend on their dosages, and so does nutrition therapy. Ideally, the quantity and quality of enteral nutrition make maximum benefit and minimum damage in critically ill patients, with the ultimate goal of sufficient nutrition therapy and no iatrogenic malnutrition. Intolerance of early enteral nutrition is a common problem, and challenge for critically ill patients. Improper nutrition therapy will have adverse and even harmful effects, which should be well learned by doctors and nurses of intensive care unit. In serious or some special medical situations, regimen of nutrition should be evaluated and adjusted timely to achieve the ideal goal and make maximumbenefit for patients.

To investigate the effects of carbachol on lipopolysaccharide (LPS)-induced intestinal barrier breakdown.

C57BL/6 mice were randomly divided into four groups (n=10 per group): control group, lipopolysaccharide group, carbachol group, and α-bungarotoxin group. Endotoxemia was induced by administering 10 mg/kg lipopolysaccharide via intraperitoneal injection. The mice were intraperitoneally treated with 0.1 mg/kg carbachol 15 min after LPS administration. Mice were sacrificed at 3 h after LPS administration for biochemical studies and histological examination. The localization and expression of Claudin-2 and myosin light chain kinase (MLCK), and pathologic changes of the ileum were examined.

The levels of FITC-glucan in the control group, endotoxemia group, carbachol group, and α bungarotoxin group were (2.33±0.51) μg/ml, (55.25±5.41) μg/ml, (19.27±3.53) μg/ml, and (48.45 ±9.50) μg, respectively; there was a significant difference among the four groups (F=111.8, P<0.05), as well as between the endotoxemia group and control group, between the endotoxemia group and carbachol group, and between the α bungarotoxin group and carbachol group (t=22.52, 15.31, and 12.42, P<0.05). The contents of Claudin-2 protein in the control group, endotoxemia group, carbachol group, and α bungarotoxin group were (0.82±0.08) μg/ml, (0.52±0.09) μg/ml, (0.77±0.05) μg/ml, and (0.53±0.09) μg, respectively; there was a significant difference among the four groups (F=11.61, P<0.05), as well as between the endotoxemia group and control group, between the endotoxemia group and carbachol group, and between the α bungarotoxin group and carbachol group (t=6.518, 5.366, and 5.167, respectively, P<0.05). The contents of MLCK protein in the control group, endotoxemia group, carbachol group, and α bungarotoxin group were (0.58±0.07) μg/ml, (1.07±0.17) μg/ml, (0.69±0.11) μg/ml, and (0.94 ±0.05) μg, respectively; there was a significant difference among the four groups (F=12.64, P<0.05), as well as between the endotoxemia group and control group, between the endotoxemia group and carbachol group, and between the α bungarotoxin group and carbachol group (t=7.79, 5.881, and 3.892, respectively, P<0.05).

Carbachol treatment can protect against LPS-induced intestinal barrier dysfunction and the protective effects are associated with the activation of the cholinergic anti-inflammatory pathway.

To study the clinical value of serum citrulline in predicting acute gastrointestinal injury at different time after multiple trauma.

Forty patients with multiple trauma, admitted to the ICU of Shanghai General Hospital from June 2017 to February 2018, were studied prospectively. These patients were first divided into mild trauma group (ISS<16, n=21) and severe trauma group (ISS≥16, n=19) according to the injury severity score (ISS), and then subdivided into AGI 0 (n=12), AGI Ⅰ (n=9), AGI Ⅱ(n=14) and AGI Ⅲ group (n=5) based on their acute gastrointestinal injury (AGI) grade. 10 healthy people were selected as the control group. On day 1, day 3 and day 6, the levels of citrulline were detected by high-performance liquid chromatography (HPLC), and the levels of diamineoxidase, D-lactate and endotoxin were detected by analysis system of biochemical indexes of intestinal barrier function.

Compared with the control group, serum citrulline levels were decreased significantly in both mild trauma group and severe trauma group on day 1, day 3 day 6 (P<0.05). Serum citrulline levels were lower in severe trauma group than those in mild trauma group on day 1 (P<0.05). In mild trauma group, serum citrulline were decreased further on day 3 compared to serum citrulline on day 1 (P<0.05). Serum citrulline levels were lower in both mild trauma group and severe trauma group than those in control group on day 6. The higher grade of AGI, the lower level of serum citrulline (P<0.05). In all AGI subgroups, serum citrulline levels on day 3 were further decreased compared to day 1(P<0.05). Serum citrulline level was negatively associated with number of ICU days, ISS score, AGI grade, serum diamineoxidase level and D-lactate level. Serum citrulline≤19.56 μmol/L may be the best value of predicting AGI after severe trauma.

Serum citrulline has some clinical value in predicting early intestinal dysfunction in patients with severe multiple trauma.

Refeeding syndrome is a common complication of malnutrition patients receiving nutritional support, especially in patients with a lost of more than 10% body weight during a few last months. Patients often present with clinical manifestations such as hypotension, shortness of breath, chest tightness and disturbance of consciousness, which need to be differentiated from other diseases. When the patients suffer from refeeding syndrome, removal of incentives, correction of electrolyte disturbance, support for cardiopulmonary function, and adjustment of nutritional treatment programs can improve therapeutic effect. Here, we reported a case with feeding syndrome that occurred in a malnourished patient who received nutritional support.

Acute respiratory failure is a common complication after radical resection of esophageal carcinoma. Dependent area alveolar collapse in and after surgery, pulmonary microvascular endothelial injury, intrathoracic stomach, sticky sputum and postoperation pain could lead to ventilational dysfunction. Noninvasive ventilation is relatively contraindicted for patients with these medical situations. High-flow nasal cannula oxygen therapy has a number of medical benefits: reduction of anatomical dead space, PEEP effects, increase in end-expiratory lung volume, improved comfort. High-flow nasal cannula oxygen can improve oxygenation of post-esophagectomy patients and avoid reintubation. This paper introduces the effects of high-flow nasal cannula oxygen therapy on respiratory failure in a post-esophagectomy patient.

To determine the predictive value of the end-expiratory occlusion test (EEOT) in fluid responsiveness evaluation by performing a systematic review and meta-analysis of studies.

Databases including PubMed, Embase and Cochrane Database were searched for relevant clinical trials before October 2017. Two independent investigators extracted data and study characteristics. Bivariate mixed-effects regression model was used to estimate the pooled sensitivity, specificity, positive and negative likelihood ratio and diagnostic odds ratio with 95% CIs. The SROC curve and Fagan graphs were produced, and the area under the curve was also calculated. Meanwhile, we calculated relative diagnostic odds ratio (RDOR) to compare diagnostic value of EEOT and PPV.

Seven studies (260 adult patients, 270 fluid challenges) were included. Fluid challenge test was used as standard reference in all studies. For the EEOT-induced changes in CO or its surrogate, the pooled sensitivity was 0.93 (95%CI: 0.86-0.96) and the pooled specificity was 0.90 (95%CI: 0.81-0.95). The area under the ROC curve was 0.97 (95%CI: 0.95-0.98). Four studies which compared EEOT and PPV at the same time, the RDOR was 3.13 (P=0.24).

EEOT-induced changes in CO or its surrogate can very reliably predict the response of CO to volume expansion in adult patients. There is no significant difference between the diagnostic value of EEOT and PPV.

Peri-operative cardiac arrhythmias are not uncommon in patients with underlying diseases or internal environment disturbance, some of which might be fatal and induce organ dysfunction. A quick recognition and proper treatment for malignant cardiac arrhythmias or symptomatic arrhythmias and treatment for underlying diseases, would prevent patients from deteriorating. Recognition and treatment for common peri-operative cardiac arrhythmias are reviewed in detail, including high-quality cardiopulmonary resuscitation, electrical cardio-version, cardio-pacing, anti-arrhythmic medicines and some cautions during these managements. Most evidence-based recommendations come from recent international/domestic guidelines or expert consensus, for example, AHA or ESC CPR guidelines, supra-ventricular arrhythmia management guidelines, atrial fibrillation management guidelines, pre-operational evaluation in non-cardiac surgery, ventricular arrhythmias management guidelines and so on. As a conclusion, the emergency of peri-operative arrhythmias depends on its effect on hemodynamics, ie, how life-threatening it is. The effect of some peri-operative factors, such as post-surgery bleeding, hypoxemia and so on should be taken in account while treating peri-operative arrhythmias.

To investigate observe intestinal barrier function injury in early heat stroke patients,and explore its correlation with inflammatory cytokines.

14 patients diagnosed with heat stroke were divided into early group (7 cases) or late group (7 cases) by whether the onset of heat stroke was more than 3 h. The blood from each patients was collected for detection of immune cells, inflammatory cytokines and intestinal barrier function.

Mean arterial pressure was significantly higher in late group [(73.28±7.49) mmHg vs (90.23±16.25) mmHg, P=0.028, 1 mmHg=0.133 kPa]. APACHE Ⅱ scores, mortality rate, level of interleukin-2 receptor, interleukin-6, interleukin-8 and interleukin-10 were significantly higher in late group [APACHE Ⅱscores: (25.71±3.04) scores vs (20.14±2.91) scores, P=0.004; mortality: 28.6% vs 0, P=0.000; IL-2 receptor: (738.00±197.40) U/ml vs (159.80±67.79) U/ml, P=0.025; IL-6: (380.10±401.90) pg/ml vs (6.72±3.38) pg/ml, P=0.049; IL-8: (2850.51±3512.88) pg/ml vs (33.35±28.27) pg/ml, P=0.023; IL-10: (497.20±470.60) pg/ml vs (41.55±66.47) pg/ml, P=0.043]. The total area under the ROC curves of interleukin-10 for liver function damage was 0.893. Interleukin-10 at a level of 92.5 was with best diagnostic accuracy, with sensitivityof 71.4%, and specificity of 100.0%.

Heat stroke within 3 hours of onset had a better prognosis. IL-6 is a good indicator for clinical severity in heat stroke. IL-10 can be used as an early warning marker of liver dysfunction in heat stroke.

Protein-energy wasting (PEW) has frequently been reported in patients with acute kidney injury (AKI) and renal replacement therapy, which is one major cause of further worsen renal function and increased mortality. Early approprite nutrition support is helpful to improve metabolic and nutritional status, recover renal functional and reduce mortality. High heterogeneity among patients with AKI and CRRT duration leads to challenges to appropriate nutritional supplements. Understanding the characteristic of nutrition and metabolism,individualized and dynamic assessment of AKI patients and avoiding underfeeding and overfeeding are important strategies to appropriate nutritional treatment.