简介：Acutepancreatitis(AP)isafrequentdiseasewithdegreesofincreasingseverityresponsibleforhighmorbidity.Despitecontinuousimprovementincare,mortalityremainssignificant.Becausehypovolemia,togetherwithmicrocirculatorydysfunctionleadtopooroutcome,fluidtherapyremainsacornerstoneofthesupportivetreatment.However,poorclinicalevidenceactuallysupporttheaggressivefluidtherapyrecommendedinrecentguidelinessinceavailabledataarecontroversial.Fluidmanagementremainsunclearandleadstocurrentheterogeneouspractice.DifferentstrategiesmayhelptoimprovefluidresuscitationinAP.Ononehand,integrationoffluidtherapyinaglobalhemodynamicresuscitationhasbeendemonstratedtoimproveoutcomeinsurgicalorsepticpatients.Tailoredfluidadministrationafterearlyidentificationofpatientswithhigh-riskofpooroutcomepresentinginadequatetissueoxygenationisamajorpartofthisstrategy.Ontheotherhand,newdecisionparametershavebeendevelopedrecentlytoimprovesafetyandefficiencyoffluidtherapyincriticallyillpatients.Inthisreview,weproposeapersonalizedstrategyintegratingthesenewconceptsintheearlyfluidmanagementofAP.ThisnewapproachpavesthewaytoawiderangeofclinicalstudiesinthefieldofAP.

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简介：AbstractFluid resuscitation is an essential intervention in critically ill patients, and its ultimate goal is to restore tissue perfusion. Critical illnesses are often accompanied by glycocalyx degradation caused by inflammatory reactions, hypoperfusion, shock, and so forth, leading to disturbed microcirculatory perfusion and organ dysfunction. Therefore, maintaining or even restoring the glycocalyx integrity may be of high priority in the therapeutic strategy. Like drugs, however, different resuscitation fluids may have beneficial or harmful effects on the integrity of the glycocalyx. The purpose of this article is to review the effects of different resuscitation fluids on the glycocalyx. Many animal studies have shown that normal saline might be associated with glycocalyx degradation, but clinical studies have not confirmed this finding. Hydroxyethyl starch (HES), rather than other synthetic colloids, may restore the glycocalyx. However, the use of HES also leads to serious adverse events such as acute kidney injury and bleeding tendencies. Some studies have suggested that albumin may restore the glycocalyx, whereas others have suggested that balanced crystalloids might aggravate glycocalyx degradation. Notably, most studies did not correct the effects of the infusion rate or fluid volume; therefore, the results of using balanced crystalloids remain unclear. Moreover, mainly animal studies have suggested that plasma may protect and restore glycocalyx integrity, and this still requires confirmation by high-quality clinical studies.

简介：Tofindouttheoptimalconcentration,infusionrateanddosageofsalineforresuscitation.Methods:Forty-fivedogswereusedtoestablishhypovolemicshockmodels.Thedogswereresuscitatedwithsalineofdifferentconcentrationsanddifferentdosagesunderdifferentinfusionrates,andtheresuscitationresultswerecompared.Results:Thebestconcentrationwas7.5%,thebestrateofinfusion20ml/min(avolumeequivalentto15%oftheshedblood)andthebestdosage5.71ml/kg.Themethodwaseffectiveforresuscitation,themeanarterialpressure(MAP)couldbeelevatedto89%ofthebaseline,andthisMAPcouldbekeptformorethanonehour.Conclusions:Using7.5%sodiumchloridesolutionequivalentto15%oftheshedbloodataninfusionrateof20ml/mincanachieveabestresuscitationresult.

简介：TheAmericanHeartAssociationandtheEuropeanResuscitationCouncilrecentlyrecommendedthatvasopressincanbeusedforcardiopulmonaryresuscitation,insteadofepinephrine.However,theguidelinesdonotdiscusstheeffectsofvasopressinduringcerebralresuscitation.Inthisstudy,weintraperitoneallyinjectedepinephrineand/orvasopressinduringcardiopulmonaryresuscitationinaratmodelofasphyxialcardiacarrest.Theresultsdemonstratedthat,comparedwithepinephrinealone,thepathologicaldamagetonervecellswaslessened,andthelevelsofc-JunN-terminalkinaseandp38expressionweresignificantlydecreasedinthehippocampusaftertreatmentwithvasopressinaloneorthevasopressinandepinephrinecombination.Nosignificantdifferenceinresuscitationeffectswasdetectedbetweenvasopressinaloneandthevasopressinandepinephrinecombination.Theseresultssuggestthatvasopressinaloneorthevasopressinandepinephrinecombinationsuppresstheactivationofmitogen-activatedproteinkinaseandc-JunN-terminalkinasesignalingpathwaysandreduceneuronalapoptosisduringcardiopulmonaryresuscitation.

简介：1定义及抢救意义心脏的有效收缩停止，引起全身组织缺血、缺氧，继之呼吸停止及意识丧失。心肺复苏(CPR)的目的是为了保证脑的复苏，因此，CPR不如CPCR更为确切。

简介：Objective:Toestablishagoodrecoverableratmodelofcardiopulmonarybypass(CPB)tolaythefoundationforstudyingthepathophysiologyofCPB.Methods:TwentyadultmaleSprague-Dawleyratsweighing480g±20gwererandomlydividedintoCPBgroup(n=10)andShamgroup(n=10).Allratswereanaesthetized,intubatedandventilated.Thecarotidarteryandjugularveinwerecannulated.Thebloodwasdrainedfromtherightatriumviatherightjugularveinandfurthertransferredbyaminiaturizedrollerpumptoahollowfiberoxgenatorandbacktotheratviatheleftcarotidartery.Primingconsistedof8mlofhomologousbloodand6mlofcolloid.Thesurfaceofthehollowfiberoxgenatorwas0.075m~2.Ratswerecatheterizedandbroughtinbypassfor120minataflowrateof100-120ml/kg/min.Oxygenflow/perfusionflowwas0.8to1.0,themeanarterialpressure(MAP)keptin60-80mmHg.Bloodgasanalysis,lactatedehydrogenase(LDH),andsurvivalratewereexaminedsubsequently.Resnits:AllCPBratsrecoveredfromtheoperativeprocesswithoutincidentandremaineduneventfulwithinoneweek.Normalcardiacfunctionaftersuccessfulweaningwasconfirmedbyelectrocardiographyandbloodpressuremeasurements.MAPremainedstable.Theresultsofbloodgasanalysisatdifferenttimepointswerewithinanormalrange.NosignificanthaemolysiscouldbedetectedinthegiventimeframeunderbypassconditionbyusingLDH.Conclusions:TheratmodelofCPBcanprincipallysimulatetheclinicalsettingofhumanCPB.Thenon-transthoracicmodeliseasytoestablishandisassociatedwithexcellentrecovery.ThiswellreproduciblemodelmayopenthefieldforvariousstudiesonpathophysiologicalprocessofCPBandalsoofsystemicischemia-reperfusioninjuryinvivo.

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简介：AbstractBackground:It is still unclear what the minimal infusion volume is to effectively predict fluid responsiveness. This study was designed to explore the minimal infusion volume to effectively predict fluid responsiveness in septic shock patients. Hemodynamic effects of fluid administration on arterial load were observed and added values of effective arterial elastance (Ea) in fluid resuscitation were assessed.Methods:Intensive care unit septic shock patients with indwelling pulmonary artery catheter (PAC) received five sequential intravenous boluses of 100 mL 4% gelatin. Cardiac output (CO) was measured with PAC before and after each bolus. Fluid responsiveness was defined as an increase in CO >10% after 500 mL fluid infusion.Results:Forty-seven patients were included and 35 (74.5%) patients were fluid responders. CO increasing >5.2% after a 200 mL fluid challenge (FC) provided an improved detection of fluid responsiveness, with a specificity of 80.0% and a sensitivity of 91.7%. The area under the ROC curve (AUC) was 0.93 (95% CI: 0.84-1.00, P < 0.001). Fluid administration induced a decrease in Ea from 2.23 (1.46-2.78) mmHg/mL to 1.83 (1.34-2.44) mmHg/mL (P = 0.002), especially for fluid responders in whom arterial pressure did not increase. Notably, the baseline Ea was able to detect the fluid responsiveness with an AUC of 0.74 (95% CI: 0.59-0.86, P < 0.001), whereas Ea failed to predict the pressure response to FC with an AUC of 0.50 (95% CI: 0.33-0.67, P = 0.086).Conclusion:In septic shock patients, a minimal volume of 200 mL 4% gelatin could reliably detect fluid responders. Fluid administration reduced Ea even when CO increased. The loss of arterial load might be the reason for patients who increased their CO without pressure responsiveness. Moreover, a high level of Ea before FC was able to predict fluid responsiveness rather than to detect the pressure responsiveness.Trial registration:ClinicalTrials.gov, NCT04515511

简介：Objective:Toinvestigatethetherapeuticeffectofcisaprideongastricinjuryfollowinghemorrhagicshockresuscitation.Methods:108Wistarratsweighing(200g±30g)wererandomlydividedintoashamshock(SS)group(n=36),ahemorrhagicshockresuscitation(HS)group(n=36)andahemorrhagicshockcisapridetreated(HSC)group(n=36).Samplingat1,2and4hoursafterresuscitationwasdoneand6samplesforeachobservationitemweretaken.Thegastricbloodflowvolumewasmeasuredbyisotopelabelbiologicalmicroglobulin.GastricpHi,gastricemptying,MDAandNa+-K+-ATPaseofgastricmucosaweremeasured.Results:IntheHSCgroup,therelativeresidualrateofgastricpigmentdecreasedsignificantly,thegastricbloodflowvolumeelevated;gastricpHiincreasedsignificantlyat2hours;thelevelofmucosalMDAdecreasedat4hours,theactivityofNa+-K+-ATPaseincreasedandthelacticacidlevelintheportalveindecreasedsignificantlycomparedtotheHSgroup.Conclusions:Afterhemorrhagicshockresuscitation,cisapridecontainedthefollowingfunctions,1)promotinggastricemptying,2)increasingthebloodflowofgastricbloodflowvolumeandgastricpHi,3)depressingthelacticacidconcentrationoftheportalveinandimprovingMDAvolumeandNa+-K+-ATPaseactivityofgastricmucosa.Itsuggeststhataftercomplementingeffectivecirculatingbloodvolumeforhemorrhagicshockresuscitation,earlyuseofcisaprideforgastricmotilityishelpfulforanimprovementoflastingischemiaandhypoxiainstomach.

简介：摘要目的本系统综述旨在总结有关儿童体外心肺复苏(extracorporeal cardiopulmonary resuscitation，ECPR)的可用文献以描述其应用，实践和预后现状，同时强调当前认知差距。数据来源PubMed，Embase，Scopus，Cochrane图书馆和ClinicalTrials.gov数据库。研究选择本文检索经同行评议的关于儿童ECPR(<18岁)的原始研究发表物，包括所有出版年份。数据抽取本系统综述利用了结构化系统评价和荟萃分析首选报告项目(preferred reporting items for systematic reviews and meta-analyses，PRISMA)方法。于2019年2月11日进行初次文献检索，于2019年8月28日进行更新检索。三名医师评审员独立评估了检索到的研究报告以确定是否纳入系统综述综合分析。使用选定的搜索词共检索到4 095份发表物，其中96份被纳入最终综合分析。使用非随机化研究偏倚风险干预工具(Risk of Bias in Non-Randomized Studies of Interventions tool，Robins-I)评估纳入研究中的偏倚风险。数据综合没有儿童ECPR的随机对照研究。绝大多数儿童ECPR发表物都是报道院内心跳骤停(in-hospital cardiac arrest，IHCA)预后的单中心回顾性研究。已发表文献中大多数儿童ECPR用于心脏病患儿。纳入研究中IHCA患儿ECPR后出院存活率从8%～80%不等且在心脏病患儿中与预后改善有关。31项研究报告了ECPR后的神经系统预后，其中仅有6项为前瞻性随访研究。本文总结了以下方面的可用文献：候选资格确认，ECPR启动时机，人员配备/后勤，置管策略，预后以及模拟培训的应用。结论本篇综述突出描述了我们对儿童ECPR最佳实践理解上的差距。本文总结了现有可用的研究成果，并为未来研究发展提供了框架。

简介：AbstractEndoscopic drainage of pancreatic fluid collections (PFCs) with fewer complications and less trauma has gradually replaced surgery or percutaneous drainage to become the first-line treatment for PFCs. In recent years, the differential efficacy of various stent techniques to drain different types of PFCs has been controversial. This review summarizes the clinical applications of endoscopic ultrasound-guided stent placement for PFCs drainage.

简介：TherevisedAtlantaclassificationofacutepancreatitiswasadoptedbyinternationalconsensus,andisbasedonactuallocalandsystemicdeterminantsofdiseaseseverity.Thelocaldeterminantispancreaticnecrosis(sterileorinfected),andthesystemicdeterminantisorganfailure.Localcomplicationsofpancreatitiscanincludeacuteperi-pancreaticfluidcollection,acutenecroticcollection,pseudocystformation,andwalledoffnecrosis.Interventionalendoscopicultrasound(EUS)hasbeenincreasingutilizedinmanagingtheselocalcomplications.AfterperformingaPubMedsearch,theauthorsmanuallyappliedpre-definedinclusioncriteriaorafiltertoidentifypublicationsrelevanttoEUSandpancreaticcollections(PFCs).Theauthorsthenreviewedtheutility,efficacy,andrisksassociatedwithusingtherapeuticEUSandinvolvedEUSdevicesintreatingPFCs.Duetothedevelopmentandregulatoryapprovalofimprovedandnovelendoscopicdevicesspecificallydesignedfortransmuraldrainageoffluidandnecroticdebris(accessandpatencydevices),theauthorspredictcontinuingevolutioninthemanagementofPFCs.WebelievethatEUSwillbecomeanindispensablepartofproceduresusedtodiagnosePFCsandperformimage-guidedinterventions.AfterdrainingaPFC,theamountoftissuenecrosisisthemostimportantpredictorofasuccessfuloutcome.Hence,itseemslogicaltoclassifythesecollectionsbasedontheirpercentageofnecroticcomponentordebrispresentwhenviewedbyimagingmethodsorEUS.Finally,theauthorsproposeanalgorithmformanagingfluidcollectionsbasedontheirsize,location,associatedsymptoms,internalechogenicpatterns,andcontent.

简介：Osteocytesactasmechanosensorsinbone,whichcansendmechanicalsignalsdirectlytoosteoblaststhroughgapjunctions.However,underphysiologicalconditionsthenumberofgapjunctionsislimitedbecauseofthequantityvarianceofthetwokindsofcells.Inthisstudy,thepossibilityofindirectinteractionbetweenthesetwocellswasinvestigated.Anewflowchamperwasdesignedinwhichosteocytesandosteoblastswerecoculturedintwochampersseparately.OsteocyteswereexposedtofluidflowandthentheALPactivity,osteocalcinandosteopotinofosteoblastsweredetermined.TheresultsshowedthateitherALPactivityorproductionofosteocalcinandosteopotininosteoblaststhatwerecoculturedwithshearedosteocytesincreased,whichindicatedthatosteocytescouldregulateosteoblastsindirectlythroughsomesolublefactors.

简介：Objective:Theexpressionofvascularendothelialgrowthfactor(VEGF)iscorrelatedtotheinvasionandmetastasisoftumorcellsinmanyclinicalcarcinomas.Inthisstudy,wedetectedsolubleVEGFlevelsinascitesandperitonealfluidandexploreditsclinicalsignificance.Methods:Atotalof91sampleswerecollectedanddividedinto5experimentalgroups:petitonealfluidofpatientswithbenign(n=10)andmalignantdisease(n=14),cirrhoticascites(n=36),tuberculousascites(n=8)andmalignantascites(n=23).Usingasandwichenzyme-linkedimmunoadsorbentassay,theconcentrationofsolubleVEGFwasmeasuredinascites(n=67)andpetitonealfluid(n=24).Results:VEGFlevelsinmalignantasciteswere640.74(264.81pg/ml,significantlyhigherthanthoseincirrhoticascites,tuberculousascitesandperitonealfluidofpatientswithbenignandmalignantdisease(P<0.01,separately).However,thedifferenceofVEGFlevelsamongthelatter4groupshadnostatisticsignificance(P>0.05),separately).Furthermore,VEGFlevelsinmalignantascitesfrompatientswithovariancancerwerehigherthanthosewithgastricandcoloncancer(P<0.01,respectively),whiletherewasnosignificantdifferencebetweengastriccancerandcoloncancer(P>0.05).UsingVEGFlevelof118.96pg/mlasaminimumcutofflimit,thesensitivityandspecificityofVEGFofthisassaytodiagnosemalignantasciteswere91.3%and73.9%respectively.Conclusion:TheelevatedlevelsofVEGFmaybeusefulasanindexindifferentialdiagnosisofbenignandmalignantascites.ItappearsthatVEGFplaysanimportantroleinmalignantascitesformation.

简介：AbstractBackground:Neuronavigation is a very beneficial tool in modern neurosurgical practice. However, the neuronavigation is not available in most of the hospitals in our country raising the question about its importance in localizing the calvarial extra-axial lesions and to what extent it is safe to operate without it.Methods:We studied twenty patients with calvarial extra-axial lesions who underwent surgical interventions. All lesions were preoperatively located with both neuronavigation and the usual linear measurements. Both methods were compared regarding the time consumed to localize the tumor and the accuracy of each method to anticipate the actual center of the tumor.Results:The mean error of distance between the planned center of the tumor and the actual was 6.50 ± 1.762 mm in conventional method, whereas the error was 3.85 ± 1.309 mm in IGS method. Much more time was consumed during the neuronavigation method including booting, registration, and positioning. A statistically significant difference was found between the mean time passed in the conventional method and IGS method (2.05 ± 0.826, 24.90 ± 1.334, respectively), P-value < 0.001.Conclusion:In the setting of limited resources, the linear measurement localization method seems to have an accepted accuracy in the localization of calvarial extra-axial lesions and it saves more time than neuronavigation method.

简介：Inthisstudy,ratswereputintotraumaticbraininjury-inducedcomaandtreatedwithmediannerveelectricalstimulation.Weexploredthewake-promotingeffect,andpossiblemechanisms,ofmediannerveelectricalstimulation.Electricalstimulationupregulatedtheexpressionlevelsoforexin-AanditsreceptorOX1Rintheratprefrontalcortex.Orexin-Aexpressiongraduallyincreasedwithincreasingstimulation,whileOX1Rexpressionreachedapeakat12hoursandthendecreased.Inaddition,aftertheOX1Rantagonist,SB334867,wasinjectedintothebrainofratsaftertraumaticbraininjury,fewerratswererestoredtoconsciousness,andorexin-AandOXIRexpressionintheprefrontalcortexwasdownregulated.Ourfindingsindicatethatmediannerveelectricalstimulationinducedanup-regulationoforexin-AandOX1Rexpressionintheprefrontalcortexoftraumaticbraininjury-inducedcomarats,whichmaybeapotentialmechanisminvolvedinthewake-promotingeffectsofmediannerveelectricalstimulation.

简介：AbstractBackground:The peripheral perfusion index (PI), as a real-time bedside indicator of peripheral tissue perfusion, may be useful for determining mean arterial pressure (MAP) after early resuscitation of septic shock patients. The aim of this study was to explore the response of PI to norepinephrine (NE)-induced changes in MAP.Methods:Twenty septic shock patients with pulse-induced contour cardiac output catheter, who had usual MAP under NE infusion after early resuscitation, were enrolled in this prospective, open-label study. Three MAP levels (usual MAP -10 mmHg, usual MAP, and usual MAP +10 mmHg) were obtained by NE titration, and the corresponding global hemodynamic parameters and PI were recorded. The general linear model with repeated measures was used for analysis of variance of related parameters at three MAP levels.Results:With increasing NE infusion, significant changes were found in MAP (F = 502.46, P < 0.001) and central venous pressure (F = 27.45, P < 0.001) during NE titration. However, there was not a significant and consistent change in continuous cardiac output (CO) (F = 0.41, P = 0.720) and PI (F = 0.73, P = 0.482) at different MAP levels. Of the 20 patients enrolled, seven reached the maximum PI value at usual MAP -10 mmHg, three reached the maximum PI value at usual MAP, and ten reached the maximum PI value at usual MAP +10 mmHg. The change in PI was not significantly correlated with the change in CO (r = 0.260, P = 0.269) from usual MAP -10 mmHg to usual MAP. There was also no significant correlation between the change in PI and change in CO (r = 0.084, P = 0.726) from usual MAP to usual MAP +10 mmHg.Conclusions:Differing MAP levels by NE infusion induced diverse PI responses in septic shock patients, and these PI responses may be independent of the change in CO. PI may have potential applications for MAP optimization based on changes in peripheral tissue perfusion.

简介：PURPOSE:Weinvestigatethepatternsoffailureinthetreatmentofglioblastoma(GBM)basedonclinicaltargetvolume(CTV)marginsize,dosedeliveredtothesiteofinitialfailure,andtheuseoftemozolomideandintensity-modulatedradiotherapy(IMRT).METHODS:BetweenAugust2000andMay2010,161patientswithGBMweretreatedwithradiotherapywithorwithoutconcurrenttemozolomide.PatientsweretreatedwithCTVexpansionsthatrangedfrom5to20mmusingashrinkingfieldtechnique.PatternsoffailureandtimetoprogressionandoverallsurvivalwerecomparedbasedonCTVmargin,useoftemozolomide,anduseofIMRT.KaplanMeieranalysiswasusedtoestimatesurvivaltimes,andχtestwasusedforcomparisonofcohorts.RESULTS:Forpatientstreatedwith5-,10-,and15-to20-mmCTV,79%,77%,and86%experiencedfailuresinthe60Gyvolume,respectively.Forty-eightpercent,55%,and66%ofpatientswith5-,10-,and15-to20-mmCTVexperiencedfailuresinthe46Gyvolume,respectively.Therewasnostatisticaldifferencebetweenpatientstreatedwith5-,10-,15-to20-mmmarginswithregardto60Gyfailure(P=0.76),46Gyfailure(P=0.51),ormarginalfailure(P=0.73).Eightypercentofpatientsreceivingtemozolomideexperiencedfailuresinthe60Gyvolume.TherewasnoincreasedlikelihoodofmarginalfailuresinpatientsreceivingIMRT(P=0.97).CONCLUSIONS:Moderntreatmenttechniquesincludinguseofconcurrenttemozolmide,limitedCTVmarginsize,andIMRThavenotgreatlychangedthepatternsoffailureofGBM.