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Objective To explore the predictive values of procalcitonin (PCT) and lactate combined with acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score for disseminated intravascular coagulation (DIC) in patients with septic shock. Methods The clinical data of 164 patients with septic shock admitted to the Department of Critical Care Medicine of Shenzhen Second People's Hospital from January 1, 2015 to December 30, 2018 were analyzed retrospectively. According to International Society on Thrombosis and Haemostasis (ISTH) scoring criteria, the patients were divided into DIC group (n=58, 35.4%) and non-DIC group (n=106, 64.6%). Comparing the differences in clinical data of patients, we can establish a ROC curve to determine the sensitivity and specificity of DIC patients with septic shock for PCT, lactate and APACHE Ⅱ score, and calculate the best cut-off point. Results The AUC of PCT in predicting septic shock with DIC was 0.701(95% CI 0.619-0.784, P

Sepsis-associated encephalopathy (SAE) is commonly complicated by septic conditions, and is responsible for increased mortality and poor outcomes in septic patients. Uncontrolled neuroinflammation and ischemic injury are major contributors to brain dysfunction, which arises from intractable immune malfunction and the collapse of neuroendocrine immune networks, such as the cholinergic anti-inflammatory pathway, hypothalamic-pituitary-adrenal axis, and sympathetic nervous system. Dysfunction in these neuromodulatory mechanisms compromised by SAE jeopardizes systemic immune responses, including those of neutrophils, macrophages/monocytes, dendritic cells, and T lymphocytes, which ultimately results in a vicious cycle between brain injury and a progressively aberrant immune response. Deep insight into the crosstalk between SAE and peripheral immunity is of great importance in extending the knowledge of the pathogenesis and development of sepsis-induced immunosuppression, as well as in exploring its effective remedies.

Beginning at early December 2019, there is an outbreak of a novel 2019-nCoV in Wuhan, China. Then, Public Health Emergency of International Concern (PHEIC) was declared on 30 January 2020, by the World Health Organization (WHO) Emergency Committee. The 2019-nCoV pandemic could lead to an influx of critically ill into the already strained hospital systems in mainland China. Dealing with the pandemic requires a robust hospital- and city-wide command and control structure that could make quick and informed decisions among Chinese hospitals. We recommend that a proper plan can enable the local government, healthcare systems, hospitals, and healthcare workers to better cope with such public eventuality. The response should be flexible and adjustable according to the size of the population impacted.

Objective To explore the risk factors of acute kidney injury (AKI) complicating hemorrhagic shock (HS). Methods Clinical data of 1589 patients admitted to Intensive Care Unit (ICU) of the Second People's Hospital of Shenzhen from January 1st, 2010 to December 31th, 2015 were analyzed retrospectively. Univariable and multivariable logistic regressions were used to analyze the independent risk factors of AKI induced by HS. The area under receiver operating characteristic (AU-ROC) and Youde's index were used to determine the optimal cut-off value of nadir platelet count in AKI induced by HS. The Kaplan-Meier method was used to draw the 28-day survival curve and log-rank test was done to evaluate it in AKI and non-AKI groups. Results Of 1589 patients screened, 84 (mean age 37.1 years) were included in the primary analysis in whom 30 suffered AKI. Univariate and multivariate logistic regression analyses showed platelet count, lactic acid, carbon dioxide partial pressure, alanine aminotransferase, APACHE Ⅱ score, sequential organ failure assessment (SOFA) score, and mechanical ventilation were the independent factors for HS complicated by AKI, the differences were statistically significant (P

Objectives: To investigated the relationships between procalcitonin (PCT) and disseminated intravascular coagulation (DIC) during septic shock. Methods: A retrospective study was performed, which included septic shock patients admitted into intensive care unit (ICU) from January 1, 2015 to December 31, 2018. DIC was defined as international society of thrombosis and homeostasis criteria (ISTH≥5). PCT was based on the first value after admission into ICU and the routine biochemical coagulation data based on the worst value extracted from electronic medical records within 24 hours on admission into ICU.Results: Among 2156 patients screened, 164 patients with septic shock were included in the finally analysis and 35.4% (58/164) of whom developed DIC after admission. PCT level was significantly higher in septic shock patients who developed DIC than those who did not (54.6[13.6-200] vs12.6[2.4-53.3] ng/ml, P Conclusions: Our data suggest that PCT level over 42.1ng/ml on admission is associated with DIC during septic shock, and PCT is a potential predictive factor of DIC induced by septic shock at early stage.

BACKGROUND The widespread coronavirus disease 2019 (COVID-19) has led to high morbidity and mortality. Therefore, early risk identification of critically ill patients remains crucial. AIM To develop predictive rules at the time of admission to identify COVID-19 patients who might require intensive care unit (ICU) care. METHODS This retrospective study included a total of 361 patients with confirmed COVID-19 by reverse transcription-polymerase chain reaction between January 19, 2020, and March 14, 2020 in Shenzhen Third People's Hospital. Multivariate logistic regression was applied to develop the predictive model. The performance of the predictive model was externally validated and evaluated based on a dataset involving 126 patients from the Wuhan Asia General Hospital between December 2019 and March 2020, by area under the receiver operating curve (AUROC), goodness-of-fit and the performance matrix including the sensitivity, specificity, and precision. A nomogram was also used to visualize the model. RESULTS Among the patients in the derivation and validation datasets, 38 and 9 participants (10.5% and 2.54%, respectively) developed severe COVID-19, respectively. In univariate analysis, 21 parameters such as age, sex (male), smoker, body mass index (BMI), time from onset to admission (> 5 d), asthenia, dry cough, expectoration, shortness of breath, asthenia, and Rox index < 18 (pulse oxygen saturation, SpO2)/(FiO2 × respiratory rate, RR) showed positive correlations with severe COVID-19. In multivariate logistic regression analysis, only six parameters including BMI [odds ratio (OR) 3.939; 95% confidence interval (CI): 1.409-11.015; P = 0.009], time from onset to admission (≥ 5 d) (OR 7.107; 95%CI: 1.449-34.849; P = 0.016), fever (OR 6.794; 95%CI: 1.401-32.951; P = 0.017), Charlson index (OR 2.917; 95%CI: 1.279-6.654; P = 0.011), PaO2/FiO2 ratio (OR 17.570; 95%CI: 1.117-276.383; P = 0.041), and neutrophil/lymphocyte ratio (OR 3.574; 95%CI: 1.048-12.191; P = 0.042) were found to be independent predictors of COVID-19. These factors were found to be significant risk factors for severe patients confirmed with COVID-19. The AUROC was 0.941 (95%CI: 0.901-0.981) and 0.936 (95%CI: 0.886-0.987) in both datasets. The calibration properties were good. CONCLUSION The proposed predictive model had great potential in severity prediction of COVID-19 in the ICU. It assisted the ICU clinicians in making timely decisions for the target population.

Background: Early detection of suspected critical patients infected with coronavirus disease 2019 (COVID-19) is very important for the treatment of patients. This study aimed to investigate the role of COVID-19 associated coagulopathy (CAC) to preview and triage. Methods and Results: A cohort study was designed from government designated COVID-19 treatment center. CAC was defined as International Society on Thrombosis and Haemostasis (ISTH) score ≥2. Data from 117 patients COVID-19 were reviewed on admission. The primary and secondary outcomes were admission to Intensive Care Unit (ICU), the use of mechanical ventilation, vital organ dysfunction, discharges of days 14, 21 and 28 from admission and hospital mortality. Among them, admission to ICU was increased progressively from 16.1% in patients with non-CAC to 42.6% in patients with CAC (P, Highlights • COVID-19 patients with ISTH score ≥ 2 on admission need more admission to ICU and mechanical ventilation. • The incidence is high in acute hepatic injury and acute respiratory distress syndrome in COVID-19 patients with ISTH score ≥ 2. • The discharges of 14 days, 21 days and 28 days from admission were less in COVID-19 patients with ISTH score ≥ 2. • ISTH score ≥ 2 is an important indicator to preview and triage for COVID-19 patients on early admission.

Background Complication of disseminated intravascular coagulation (DIC) is a determinant of the prognosis in patients with sepsis shock. Procalcitonin (PCT) has been advocated as a marker of bacterial sepsis. The purpose of this study was to evaluate the relationship between serum PCT levels and DIC with sepsis shock Methods A cohort study was designed which included patients that admitted in intensive care unit (ICU) between January 1, 2015 and December 31, 2018 and the follow-up to discharge. 164 septic shock patients were divided into DIC and non-DIC groups according to international society of thrombosis and homeostasis (ISTH). PCT was measured at the admission to ICU, and all the participants received routine biochemical coagulation test subsequently. Results PCT levels were considerably higher in septic shock patients who developed DIC than those who did not (54.6[13.6–200]vs12.6[2.4–53.3]ng/ml), respectively, P

Objective This study aims to assess the relationship between serum procalcitonin (PCT) and acute kidney injury (AKI) induced by sepsis shock.Methods A case-control study was designed which included patients that admitted in intensive care unit (ICU) between January 2015 and October 2018. The worst values of biochemical parameters in the first 48 hours from septic shock admission to ICU were evaluated. According to KDIGO guideline, these patients were divided into AKI and non-AKI groups.Results Of 1631 patients screened, 157 patients were included in the primary analysis in which 84 (53.5%) patients with AKI. Multiple logistic regression results showed that PCT (OR=1.017, 95% CI 1.009- 1.025, P

Recent clinical data suggest that terlipressin, a vasopressin analogue, may be more beneficial in septic shock patients than catecholamines. However, terlipressin’s effect on mortality is unknown. We set out to ascertain the efficacy and safety of continuous terlipressin infusion compared with norepinephrine (NE) in patients with septic shock. In this multicentre, randomised, double-blinded trial, patients with septic shock recruited from 21 intensive care units in 11 provinces of China were randomised (1:1) to receive either terlipressin (20–160 µg/h with maximum infusion rate of 4 mg/day) or NE (4–30 µg/min) before open-label vasopressors. The primary endpoint was mortality 28 days after the start of infusion. Primary efficacy endpoint analysis and safety analysis were performed on the data from a modified intention-to-treat population. Between 1 January 2013 and 28 February 2016, 617 patients were randomised (312 to the terlipressin group, 305 to the NE group). The modified intention-to-treat population comprised 526 (85.3%) patients (260 in the terlipressin group and 266 in the NE group). There was no significant difference in 28-day mortality rate between the terlipressin group (40%) and the NE group (38%) (odds ratio 0.93 [95% CI 0.55–1.56]; p = 0.80). Change in SOFA score on day 7 was similar between the two groups: − 7 (IQR − 11 to 3) in the terlipressin group and − 6 (IQR − 10 to 5) in the NE group. There was no difference between the groups in the number of days alive and free of vasopressors. Overall, serious adverse events were more common in the terlipressin group than in the NE group (30% vs 12%; p

In the present study, we examined the activity of p53 protein in Jurkat cells treated with high mobility group box-1 protein (HMGB1), thereafter we investigated the mechanism of extracellular HMGB1 mediated p53 expression in immune dysfunction of T lymphocytes. mRNA expression of p53, mdm2, and p21 was determined by Real-time reverse transcription-polymerase chain reaction(RT-PCR). The apoptotic rate of Jurkat cells was analyzed by flow cytometry. Expressions of bcl-2, bax, caspase-3, phosphorylated (p) extracellular signal-regulated kinase (ERK)1/2, ERK1/2, p-p38 mitogen-activated protein kinase (MAPK), p38 MAPK, and p-c-jun amino-terminal kinase (JNK)1/2 and JNK1/2 were simultaneously determined by Western blotting. After treatment with HMGB1 (100 ng/ml or 1000 ng/ml), the proliferative activity of Jurkat cells was significantly decreased, and a low and medium concentration of HMGB1 induced an up-regulation of p53 mRNA, p-p53 and p53 protein expression. Meanwhile, levels of mdm2 and p21 were elevated by incubated with HMGB1 (100 ng/ml) for 24 or 48 hours. Moreover, the proliferation of Jurkat cells in response to HMGB1 (100 ng/ml) in the vector group was significantly depressed. The bax and caspase-3 levels in p53 shRNA-expressed cells treated with HMGB1 (100 ng/ml) was markedly decreased, whereas expression of bcl-2 was obviously enhanced. Among ERK1/2, p38 MAPK and JNK1/2 signaling, only p38 MAPK pathway could be significantly activated by treatment with HMGB1, and the specific inhibitor of p38 MAPK was used, p53 and p-p53 expression induced by HMGB1 were significantly down-regulated. Taken together, our data strongly indicated that HMGB1 might enhance p53 expression, which was associated with both the proliferative activity as well as apoptosis of T cells.

Objectives Data about the critical care resources in China remain scarce. The purpose of this study was to investigate the variation and distribution of critical care resources in Guangdong province from 2005 to 2015. Design Data in regard to critical care resources were collected through questionnaires and visits every 5 years from 2005. Setting All hospitals in Guangdong province were screened and hospitals that provide critical care services were enrolled. Intervention None. Measurements and main results One hundred eleven, 158, and 284 hospitals that provide critical care services were enrolled in the three consecutive surveys respectively. The number of ICUs, ICU beds, intensivists, and nurses increased to 324, 3,956, 2,470, and 7,695, respectively, by 2015. Adjusted by population, the number of ICU beds per 100,000 (100,000) population increased by 147.7% from 2005 to 2015, and the number of intensivists and nurses per 100,000 population increased by 35.3% and 55.1% from 2011 to 2015. However, the numbers in the Pearl River Delta, a richer area, were higher than those in the non-Pearl River Delta area (ICU beds: 4.64 vs 2.58; intensivists: 2.90 vs 1.61; nurses: 9.30 vs 4.71 in 2015). In terms of staff training, only 17.85% of intensivists and 14.29% of nurses have completed a formal accredited critical care training program by 2015. Conclusions Our study was the first one to investigate the trend and distribution of critical care resources in China. The quantity of ICU beds and staff has been increasing rapidly, but professional training for staff was inadequate. The distribution of critical care resources was unbalanced. Our study can be beneficial for healthcare policymaking and the allocation of critical care resources in Guangdong province and other provinces in China.

Objective To investigate the effects of cholinergic pathway on acute renal tubular cell injury induced by acute oxygen and glucose deprivation. Methods Rat kidney macrophages were isolated and cultured for constructing macrophages and renal epithelial cells co-cultivating model of oxygen-glucose deprivation (OGD), and the model cells were divided into three groups: OGD alone group, acetylcholine (ACh 100μmol/L)+OGD group and ACh + galantamine (Gal 10μmol/L)+OGD group. The cells underwent OGD treatment for 1 hour, and normally cultured for 24 hours. The expressions of TNF alpha, IL-1 beta, and IL-10 in supernatant fluid were detected by ELISA, the renal tubular cell viability was determined by MTT assay, the expression of acetylcholine esterase (AChE) mRNA and protein were determined by RT-qPCR and Western blotting. The activity of AChE was determined by colorimetric method. Results The expressions of TNF alpha (pg/ml) in OGD, Ach+OGD group, Ach+Gal+OGD groups were 140.2±44.81, 119.46±4.42 and 103.31±1.62 respectively (P0.05); The values of renal tubular cell proliferation were 55.02%±6.28%, 66.65%±6.47%, and 79.75%±4.22% respectively (P0.05); those of AchE protein were 0.66±0.07, 0.74±0.04 and 0.67±0.06 respectively (P>0.05); The activity of AChE (kU/L) was 0.51±0.02, 0.35±0.05 and 0.32±0.04 respectively (P=0.001, 0.001 and 0.368). Conclusions ACh and Gal could inhibit the secretion of inflammatory mediators and cholinesterase activity and can reduce the acute hypoxic renal tubular cell injury. The modulation of the cholinergic pathway in macrophages may be the important treatment method for acute renal injury in the future. DOI: 10.11855/j.issn.0577-7402.2017.08.01

BACKGROUND: The study aims to illustrate the clinical characteristics and development of septic shock in intensive care unit (ICU) patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to perform a comprehensive analysis of the association between septic shock and clinical outcomes in critically ill patients with coronavirus disease (COVID-19). METHODS: Patients confirmed with SARS-CoV-2 infection, who were admitted to the ICU of the Third People’s Hospital of Shenzhen from January 1 to February 7, 2020, were enrolled. Clinical characteristics and outcomes were compared between patients with and without septic shock. RESULTS: In this study, 35 critically ill patients with COVID-19 were included. Among them, the median age was 64 years (interquartile range [IQR] 59–67 years), and 10 (28.4%) patients were female. The median ICU length of stay was 16 days (IQR 8–23 days). Three (8.6%) patients died during hospitalization. Nine (25.7%) patients developed septic shock in the ICU, and these patients had a significantly higher incidence of organ dysfunction and a worse prognosis than patients without septic shock. CONCLUSIONS: Septic shock is associated with a poor outcome in critically ill COVID-19 patients and is one of the hallmarks of the severity of patients receiving ICU care. A dysregulated immune response, uncontrolled inflammation, and coagulation disorders are strongly associated with the development and progression of COVID-19-related septic shock.

Recently, the definition of sepsis was concluded to be a life-threatening organ dysfunction caused by a dysregulated host response to infection. Severe patients always present with uncorrectable hypotension or hyperlactacidemia, which is defined as septic shock. The new definition emphasizes dysregulation of the host response and multiple organ dysfunction, which is partially attributed to metabolic disorders induced by energy crisis and oxidative stress. Mitochondria are a cellular organelle that are well known as the center of energy production, and mitochondrial damage or dysfunction is commonly induced in septic settings and is a predominant factor leading to a worse prognosis. In the present review, we determine the major mitochondrial disorders from morphology to functions in sepsis. In the following, several clinical or pre-clinical assays for monitoring mitochondrial function are demonstrated according to accumulated evidence, which is the first step of specific therapy targeting to modulate mitochondrial function. Accordingly, various reagents used for regulating mitochondrial enzyme activities and promoting biogenesis have been documented, among which mitochondria-targeted cation, TPP-conjugated antioxidants are the most valuable for future trials and clinical treatment to improve mitochondrial function as they may take advantage of the prognosis associated with septic complications.

To investigate the direct relationship and significance between the pH value of gastric juice and positive fungi in culture critical patients with artificial airway in intensive care unit (ICU) by analyzing and identifying the type of fungi and their sensitivity to antifungal therapy.A prospective study was conducted.One hundred and sixty patients (between December, 2008 and October, 2011) with artificial airway lasting longer than 48 hours were studied in the ICU at the First Affiliated Hospital of Shenzhen University. The gastric juice specimens were collected through a nasogastric tube, their pH values were measured using precise litmus paper. These samples were divided into six groups according to their pH values: pH ≤ 2.0, pH 2.1-3.0, pH 3.1-4.0, pH 4.1-5.0, pH 5.1-6.0 and pH 6.1-7.0, and then fungi were cultured in these specimens with different pH values. Susceptibility of different fungicide drugs were also investigated. The susceptibility of fungi to gastric juice with different pH values was also investigated. The relationship between 28-day survival rate and the presence of fungi in gastric juice was analyzed in order to analyze the relationship of the presence of fungi in gastric juice and clinical outcome.(1) No fungal growth was found in the gastric juice with pH value lower than 4.0, and the positive rate of fungal culture was significantly increased when the pH value of gastric juice raised. (2) The positive rate of fungal growth was 27.9% (55/197), in which, the positive rate of Candida and non-Candida fungi was 38.2% (21/55) and 61.8% (34/55) respectively, and the difference was significant statistically [χ(2) = 4.16, P0.05]. (3) The fungal positive rate was 40.0% (22/55) and 60.0% (33/55) respectively, in survivors (102 cases) and non-survivors (58 cases). The percentage of Candida infection and non-Candida infection was 54.5% (12/22) and 45.5% (10/22) respectively, in survivors, and it was 27.3% (9/33) and 72.7% (24/33), respectively, in non-survivors. The rate of resistance of Candida and non-Candida fungi was 4.7%-14.3% (mean 10.1%) and 0-60% (mean 28.5%) respectively.Positive fungus culture rate was higher in critical patients with artificial airway and higher gastric juice pH values. Non-Candida fungi were mainly found in gastric juice with increasing resistance rate. Candida was more commonly found in survivors, and non-Candida fungi were more commonly found in non-survivors.

To investigate the effects of fluid resuscitation with different crystalloid-colloid ratio on extravascular lung water (EVLW) in patients with severe acute pancreatitis (SAP).Clinical data of 24 SAP patients,who had undergone intrathoracic blood volume index (ITBVI750 ml/m(2)),were analyzed retrospectively, in Department of Critical Care Medicine in the First Affiliated Hospital of Shenzhen University, during January of 2009 to December of 2010. ITBVI 850-1 000 ml/m(2) was confirmed the end criterion of the end point of resuscitation. Low crystalloid-colloid ratio group (n=13) and high crystalloid-colloid ratio group (n=11) were divided according to crystalloid-colloid ratio (3:1) as the borderline . Hemodynamic parameters, extravascular lung water index (EVLWI), oxygenation index (PaO(2)/FiO(2)), bladder pressure (ICP) and B type natriuretic peptide (BNP) were observed at the time point of before fluid resuscitation, and 0, 24,48, 72 hours after resuscitation, EVLWI was measured with thermal dilution pulse index continuous cardiac output (PiCCO), and BNP with radioimmunoassay.(1)Hemodynamic parameters can be improved at early fluid resuscitation stage in both groups.(2) The total amount of fluid [(16 438±1 758) ml], amount of crystalloid fluid [(13 459±425) ml] and crystalloid-colloid ratio (4.50±0.23) of the high crystalloid-colloid ratio group was significantly higher than that of the low crystalloid-colloid ratio group [(13 895±1 783) ml, (6 945± 454) ml, 2.32±0.18, respectively, P0.05 or P0.01] at the time point of 72 hours after resuscitation. (3) Compared with low crystalloid-colloid ratio group, PaO(2)/FiO(2)(mm Hg, 1 mm Hg=0.133 kPa) in high crystalloid-colloid ratio group was lowered significantly at 48 hours and 72 hours after resuscitation (48 hours: 186.51±42.26 vs. 268.35±34.18, 72 hours : 172.85±21.50 vs. 263.95±24.20); but EVLWI, ICP and BNP were increased significantly [EVLWI (ml/kg) 48 hours: 14.52±1.08 vs. 10.40±1.16, 72 hours: 14.92±0.86 vs. 10.52±1.02; ICP (cm H(2)O, 1 cm H(2)O=0.098 kPa) 48 hours: 16.23±1.32 vs. 13.05±1.70, 72 hours: 17.39±1.56 vs. 13.42±1.65; BNP (ng/L) 48 hours: 424.29±74.25 vs. 225.32±53.58, 72 hours: 620.49±79.53 vs. 288.28±68.78, P0.05 or P0.01]. (4) The Pearson correlation analysis showed that: EVLWI with PO(2)/FiO(2) was correlated negatively (r=-0.71, P0.01), but with the BNP, ICP showed positive correlation (r(1)=0.63, r(2)=0.56, both P0.01).In order to guide early fluid resuscitation,EVLW, ICP and BNP should be monitored and limited fluid resuscitation strategy with an increasing colloid ratio should be adopted for SAP patients.