Hypoxemia Research Articles

Platypnea Orthodeoxia Syndrome in a Patient With Pulmonary Arterial Hypertension

Platypnea orthodeoxia syndrome (POS) is a rare syndrome traditionally defined as dyspnea or hypoxemia observed when changing from a recumbent to an upright or seated position. A patent foramen ovale (PFO) is often part of the underlying pathophysiology. Here, a 70-year-old woman with known PFO presented with new symptoms of a POS. A pulmonary arterial hypertension (PAH), treated with ambrisentan for years, was also known. In order to clarify the etiology of the new hemodynamic state, we performed a transesophageal echocardiography (TEE) in an upright position, which excluded a PFO-related cause of symptoms. A further investigation showed a chronic obstructive pulmonary disease, the treatment of which relieved of symptoms. This is the first described case of POS in patient with PAH. Although PFO is a common cause of POS and a PFO closure is often advised, careful differential diagnosis should be kept in mind. J Med Cases. 2017;8(6):187-190 doi: https://doi.org/10.14740/jmc2840e

Salvage treatment for non-invasive ventilation intolerance in cardiac surgical patients with dexmedetomidine: a pilot feasibility trial

Objective To investigate the efficacy of dexmedetomidine on sedation in post-cardiac surgery patients with NIV intolerance. The changes of respiratory function and hemodynamics of the patients as well as non-invasive ventilation (NIV) failure rate were also under evaluation. Methods Thirty-five post-cardiac surgery patients with NIV intolerance and hypoxemia were enrolled in this prospective study. All patients were sedated with dexmedetomidine. NIV was standardized according to the uniform protocol. The main outcome was NIV success (avoiding endotracheal intubation) or NIV failure (requiring endotracheal intubation or die). The cardiorespiratory parameters (BP, HR and RR) and artery blood gas analysis were prospectively recorded before and after sedation. The respiratory function and hemodynamics changes in both groups (NIV success group and NIV failure group ) were then evaluated. Factors independently associated with NIV failure were identified using a logistic regression model. Results Twenty out of 35 patients (57.14%) survived while 15 (42.86%) patients failed NIV. After 1 h and 4 h of NIV with dexmedetomidine sedation, respiratory rate in both groups were decreased compared with baseline, especially in NIV success group. The PaO2/FiO2 was also improved after 1h and 4h of NIV treatment compared with baseline. The improvement was more significantly in NIV success group. The heart rate was decreased compared with baseline with no differences between two groups. There were no significant changes on PaCO2 and mean arterial pressure (MAP) during the treatment. The respiratory and hemodynamics variables identified as predictors of NIV failure were included in a multivariate logistic regression. RR>23 time/min(OR=3.2, 95%CI: 2.043~4.301, P 20 time/min(OR=2.1, 95%CI: 1.659~3.231, P=0.025)4 h after NIV, PaO2/FiO2 <178 mmHg(OR=2.4, 95%CI: 1.892~3.287, P<0.01)1 h after NIV and PaO2/FiO2 <185 mmHg(OR=1.7, 95%CI: 1.243~2.365, P=0.041)4 h after NIV independently predicted NIV failure. Conclusions Dexmedetomidine might be considered as an effective and safe sedative for post-cardiac surgery patients with NIV intolerance. Early identification of predictors of NIV failure may facilitate early intervention. Key words: Non-invasive ventilation; Sedation; Dexmedetomidine; Cardiac surgery

The application effect of different doses of dexmedetomidine combined with remifentanil anesthesia in oral and maxillofacial surgery

Objective To explore the clinical effect of different doses of dexmedetomidine combined with remifentanil anesthesia in oral and maxillofacial surgery. Methods 135 patients with oral and maxillofacial surgery were randomly divided into three groups according to the random number table method, 45 cases in each group.All patients received dexmedetomidine and remifentanil anesthesia, the dexmedetomidine doses of A, B and C group were 0.4, 0.6, 0.8μg·kg-1·h-1.MAP, HR, SpO2 and Rasmay score in the three groups were observed before administration(T0), after administration of 5min(T1), 10min(T2), 20min(T3), 30min(T4), and the analgesic effects of patients were observed. Results Comparison within the group, the MAP, HR at T0-T4 showed a significant downward trend in all groups, the differences were statistically significant(F=3.651, 3.985, 4.212, all P 0.05). The analgesic effect of C group was significantly better than B group and A group(93.3%, 82.3%)(χ2=3.998, 4.234, all P<0.05). In C group, the incidence rates of hypoxemia, bradycardia(less than 55 times/min) were significantly higher than those of A group and B group (χ2=3.365, 3.112, 3.365, 3.365, all P<0.05). Conclusion In oral and maxillofacial surgery anesthesia, dexmedetomidine combined with remifentanil has good anesthetic effect, with the increase of dexmedetomidine dose, sedative effect is better, but the incidence rate of adverse reaction is increased. Key words: Anesthesia; Dexmedetomidine; Remifentanil; Oral and maxillofacial surgery

Effect of hypoxemia factor on hippocampal long-term potentiation in newborn rats undergoing propofol anesthesia

Objective To evaluate the effect of hypoxemia factor on hippocampal long-term potentiation(LTP)in newborn rats undergoing propofol anesthesia. Methods Forty-two pathogen-free healthy Sprague-Dawley rats(21 males, 21 females), aged 7 days, weighing 14-18 g, were divided into 3 groups(n=14 each)using a random number table: propofol plus air group(group PA), propofol plus pure oxygen group(group PO)and intralipid plus pure oxygen group(group IO). Propofol 50 mg/kg was injected intraperitoneally once a day for 7 consecutive days in PA and PO groups. Intralipid 5.0 ml/kg was injected intraperitoneally once a day for 7 consecutive days in IO group. The rats were exposed to air or pure oxygen for 6 h after the end of each injection. The arterial oxygen saturation and respiratory rate were determined after administration. The rats were returned to the cage after recovery of righting reflex. Six rats in each group were selected for preparation of hippocampal slices at 24 h after the last injection on 7th day, and the electric stimulation-induced field excitatory post synaptic potential(fEPSP)and success rate of LTP induction were recorded. Morris water maze test was performed in the other rats at 2 weeks after administration to assess the cognitive function. Results Compared with group IO, the respiratory rate, amplitude of fEPSP and success rate of LTP induction were significantly decreased, and the escape latency was prolonged in group PO(P<0.05). Compared with group PO, the arterial oxygen saturation, amplitude of fEPSP and success rate of LTP induction were significantly decreased, the escape latency was prolonged, and the number of crossing the original platform was decreased in group PA(P<0.05). Conclusion Hypoxemia factor increases propofol-induced neurotoxicity in the central nervous system of newborn rats. Key words: Oxygen; Propofol; Hippocampus; Long-term potentiation; Cognition

Factors related to death of thoracic trauma emergency in children

Objective To investigate the factors related to death of thoracic trauma emergency in children. Methods Total 528 children and infants aged 0-14 years with thoracic injuries, including 317 boys and 211 girls, admitted in emergency department from January 2010 to January 2014 were included in the study. The factors related to emergency death were investigated by using conditional logistic analysis. Results Among 528 cases, emergency death occurred in 34 cases with an emergency mortality rate of 6.44%.Single-factor analysis showed that emergency death was correlated with complication with other organ trauma, the time of first medical intervention, the time of arriving at first contact hospital, the rank of first contact hospital, hypoxemia and causes of injuries (all P 0.05). Logistic analysis showed that the time of first medical intervention>30 min (B=1.467, 95%CI: 0.412-0.975), complication with other organ trauma (B=2.342, 95%CI: 0.415-0.943), hypoxemia (B=2.915, 95%CI: 0.749-0.819), and first visiting to tertiary hospital (B=-1.861, 95%CI: 1.023-1.742) were influencing factors of emergency death. Conclusion The results indicate that to improve the success rate of emergency treatment of thoracic trauma in children, it is necessary to reduce the time of first medical intervention and to correct the hypoxemia promptly. Key words: Thoracic injuries; Child; Emergency death

COPD with hypoxemia- CPAP, LTOT, NIV-When How What: Review

COPD with hypoxemia- CPAP, LTOT, NIV-When How What: Review

Efficacy and safety of single versus repeated stepwise cycling recruitment maneuver during one-lung ventilation in patients with normal pulmonary function undergoing video-assisted thoracoscopic lung surgery: a randomized, controlled trial

Background One-lung ventilation (OLV)-associated hypoxemia is a major concern and a challenge for the anesthesiologist. Lung recruitment maneuvers (RMs) are ventilator strategies in which the main goal is to restore the functional residual capacity and improve arterial oxygenation. Hemodynamic side effects are mainly associated with ‘fast’ RM not with ‘slow’ cycling RM and their effects are self-limited; therefore, they must be performed repetitively. Aim The aim of this study was to evaluate the efficacy and safety of single versus repeated stepwise cycling RMs during OLV in patients with normal lung function. Settings and design The study design is a randomized, double-blinded, controlled one. Patients and methods Sixty adult patients of ASA I–II who were scheduled for elective thoracoscopic lung surgery were randomized into groups C, single recruitment maneuver (SRM), and repeated recruitment maneuver (RRM) comprising 20 patients each. Group C patients received standard ventilation protocol: volume-controlled ventilation mode, VT 6 ml/kg, I : E ratio 1 : 2, positive end expiratory pressure (PEEP) 5 cmH2O, and respiratory rate 10–12 breaths/min. SRM patients received standard ventilation protocol with one alveolar RM 10 min after initiation of OLV with a PEEP of 10 cmH2O until end of surgery. RRM patients received standard ventilation protocol with first RM 10 min after initiation of OLV and then repeated every 30 min during OLV and a PEEP of 10 cmH2O until end of surgery. The following were assessed: hemodynamic parameters – heart rate, mean arterial blood pressure, and central venous pressure; respiratory mechanical parameters – peak airway pressure (Paw-peak), plateau pressure (Paw-plat), and static lung compliance; and oxygenation parameters – partial arterial oxygen tension (PaO2), PaO2/FiO2, and oxygen saturation (SpO2). Results PaO2 and PaO2/FiO2 ratio increased in the SRM and RRM groups after RM from T2 (10 min after first RM) to T4 (45 min from first RM), with a significant difference compared with group C (P Conclusion Single or repeated cycling RM was considered effective with high safety profile in patients with normal pulmonary function undergoing thoracoscopic lung surgery using OLV.

Efficacy of an airway topical anesthesia catheter for topical anesthesia using a spray-as-you-go technique via fiberoptic bronchoscope

Objective To evaluate the efficacy of an airway topical anesthesia catheter for topical anesthesia using a spray-as-you-go technique via the fiberoptic bronchoscope (FOB). Methods Forty American Society of Anesthesiologists physical status Ⅰ-Ⅲ patients with obstructive sleep apnea syndrome, aged 20-64 yr, with body mass index of 23-35 kg/m2, with no upper respiratory tract infection within 1 week before operation, scheduled for elective uvulopalatopharyngoplasty, were divided into 2 groups (n=20 each) using a random number table: routine control group (group C) and FOB-airway topical anesthesia catheter group (group F). In group C, the pharynx and larynx were sprayed with lidocaine FOB by using a laryngo-tracheal mucosal atomization device, and cricothyroid membrane puncture was performed and then lidocaine was injected.In group F, airway topical anesthesia was performed using a spray-as-you-go technique via the FOB with an airway topical anesthesia catheter spraying lidocaine via the nose.At 5 min after topical anesthesia of the airway, FOB-guided intubation was performed, and dexmedetomidine was intravenously infused at 0.1 μg·kg-1·min-1 for sedation in both groups.Ramsay sedation scores were assessed after topical anesthesia and before intubation.The scores for the intubating condition and tolerance of tracheal tube were assessed during FOB-guided intubation.Successful intubation and the development of responses to intubation and hypoxemia were recorded.The patients were followed up one day after the end of operation, and parents′ satisfaction with the procedure of intubation was recorded. Results Compared with group C, the intubating condition score, tolerance of tracheal tube score, success rate of intubation at first attempt and rate of parents′ satisfaction with the procedure of intubation were significantly increased, and the incidence of responses to intubation was decreased (P 0.05). Conclusion When the FOB is used to guide awake nasotracheal intubation, the airway topical anesthesia catheter provides better efficacy, better intubating conditions, and fewer side effects when applied for topical anesthesia using a spray-as-you-go technique via the FOB, it can be easily accepted by the patients and the efficacy is better that of routine airway topical anesthesia. Key words: Administration, spray; Anesthesia, intratracheal; Bronchoscopy; Intubation, intratracheal

Short-term Effects of Supplemental Oxygen on 6-Min Walk Test Outcomes in Patients With COPD: A Randomized, Placebo-Controlled, Single-blind, Crossover Trial

The acute effect of supplemental oxygen during exercise has been shown to differ largely among patients with COPD. It is unknown what factors influence oxygen response. In a randomized, single-blind fashion, 124 patients with COPD underwent one 6-min walk test on supplemental oxygen (6MWTO2) and one 6-min walk test on room air after a practice 6-min walk test. Both gases were delivered via standard nasal prongs (2L/min). For analyses, patients were stratified on the basis of PaO2 values and compared: (1) 34 patients with resting hypoxemia (HYX); (2) 43 patients with exercise-induced hypoxemia (EIH); and (3) 31 patients with normoxemia (NOX). Oxygen supplementation resulted in an increase in the 6-min walk distance in the total cohort (27 ± 42 meters; P< .001) and in the subgroups of HYX (37 ± 40 meters; P< .001) and EIH (28 ± 44 meters; P< .001) but not in the NOX subgroup (15 ± 43 meters; P= .065). Forty-two percent of patients with HYX and 47%of patients with EIH improved their 6-min walk distance to a clinically relevant extent (≥ 30 meters) by using oxygen. These oxygen responders were characterized by significantly lower 6-min walk distance using room air compared with patients without a relevant response (306 ± 106 meters vs358 ± 113 meters; P< .05). Although oxygen saturation was significantly higher during 6MWTO2 compared with the 6-min walk test on room air in all 3 subgroups, it dropped to< 88%during 6MWTO2 in 73.5%of patients with HYX. In contrast to patients with NOX, patients with HYX and EIH generally benefit from supplemental oxygen by increasing exercise capacity. However, less than one-half of patients reached the threshold of clinically relevant improvements. These oxygen responders were characterized by significantly lower exercise capacity levels. ClinicalTrials.gov; No.: NCT00886639; URL: www.clinicaltrials.gov.

Efficacy of high frequency jet ventilation via nasopharyngeal catheter in assissting ventilation in patients with OSAHS undergoing gastroscopy

Objective To investigate the efficacy of high frequency jet ventilation via the nasopharyngeal catheter in assissting ventilation in patients with obstructive sleep apnea hypopnea syndrome (OSAHS) undergoing gastroscopy. Methods Eighty patients with OSAHS of both sexes, aged 40-64 yr, weighing 65-99 kg, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, with an apnea-hypopnea index 20-40 events/h, scheduled for elective painless gastroscopy, were divided into control group and test group using a random number table, with 40 patients in each group.In control group, a nasopharyngeal catheter 6.0-7.0 mm in internal diameter was inserted, and oxygen was inhaled at 4 L/min through the catheter.In test group, a nasopharyngeal catheter 4.0 mm in internal diameter was inserted, and a high frequency jet ventilator was connected (inspiratory/expiratory ratio 1.0∶1.5, frequency 150 bpm, peak pressure 0.4 kPa, tidal volume 180 ml). Anesthesia was maintained with propofol in both groups.The occurrence of hypoxemia during ventilation, and peak value of partial pressure of end-tidal CO2 before induction of anesthesia and during ventilation, and occurrence of chin lift, mask ventilation, and epistaxis after insertion of the catheter during operation were recorded. Results Compared with control group, the incidence of hypoxemia, peak value of partial pressure of end-tidal CO2 during ventilation, and incidence of chin lift, mask ventilation and epistaxis during operation were significantly decreased in test group (P<0.05). Conclusion High frequency jet ventilation via the nasopharyngeal catheter can be safely and effectively used to assisst ventilation in patients with OSAHS undergoing gastroscopy. Key words: High-frequency ventilation; Sleep apnea, obstructive; Gastroscopy

Clinical value of the lung protective ventilation strategy in thoracoscopic and laparoscopic radical resection of esophageal cancer

Objective To explore the clinical value of the lung protective ventilation strategy in thoracoscopic and laparoscopic radical resection of esophageal cancer. Methods The prospective study was conducted. The clinicopathological data of 160 patients who underwent thoracoscopic and laparoscopic radical resection of esophageal cancer at the Tumor Hospital Affiliated to Xinjiang Medical University between June 2015 and June 2016 were collected. All the patients undergoing thoracoscopic and laparoscopic radical resection of esophageal cancer were allocated respectively into the experimental group and control group according to the random number table, and intraoperative single-lumen endotracheal tube intubation and continuous CO2 artificial pneumothorax was conducted. Patients in the experimental group received mechanical ventilation using lung protective ventilation strategy. Parameters of mechanical ventilation: tidal volume (VT) 6 mL/kg+ positive end expiratory pressure (PEEP) 5 cmH2O (1 cmH2O=0.098 kPa)+ plat pressure (Pplat)≤30 cmH2O+ recruitment maneuver (RM). Patients in the control group received the traditional ventilation (parameters of ventilation: VT=9 mL/kg). Observation indicators: observation points were at 10 minutes after tracheal intubation in general anesthesia (T1), at 1 hour after one-lung ventilation (T2), at the end of surgery (T3) and at 24 hours postoperatively (T4). (1) Comparison of parameters of respiratory mechanic: peak airway pressure (Ppeak), Pplat and resistance of airway (Raw) . (2) Comparison of the blood gas analysis: arterial oxygen partial pressure (PaO2), arterial carbon dioxide partial pressure (PaCO2) and pH. (3) Comparison of inflammatory reaction indexes: serum IL-6, IL-8, TNF-α and C-reactive protein. (4) Comparison of postoperative pulmonary complications: pulmonary infection, pulmonary atelectasis, pulmonary edema, bronchospasm, hypoxemia and acute respiratory distress syndrome (ARDS). Measurement data with normal distribution were represented as ±s. Comparisons between groups were evaluated with an independent sample t test. Comparisons of count data were done using the chi-square test. Ordinal data were analyzed using the Kruskal-Wallis test. Repeated measurement data were analyzed by the repeated measures ANOVA. Results All the 160 patients were screened for eligibility, 80 in each group. (1) Comparison of parameters of respiratory mechanic: Ppeak, Pplat and Raw from T1 to T3 were respectively from (18.5±3.4)mmHg (1 mmHg=0.133 kPa) to (22.5±4.6)mmHg, from (15.3±3.6)mmHg to (17.5±2.7)mmHg, from (15.1±1.8)cmH2O/(L·s) to (16.8±2.6)cmH2O/(L·s) in the experimental group and from (17.2±3.7)mmHg to (32.5±4.8)mmHg, from (15.1±3.8)mmHg to (21.5±4.5)mmHg, from (15.6±2.8)cmH2O/(L·s) to (19.5±4.0)cmH2O/(L·s) in the control group, with statistically significant differences in the changing trend between the 2 groups (F=10.35, 12.57, 18.63, P<0.05). (2) Comparison of the blood gas analysis: PaO2 from T1 to T4 was from (505±38)mmHg to (490±34)mmHg in the experimental group and from (523±35)mmHg to (460±43)mmHg in the control group, with a statistically significant difference between 2 groups (F=11.56, P<0.05). (3) Comparison of inflammatory reaction indexes: serum IL-6, IL-8, TNF-α and C-reactive protein from T1 to T4 were respectively from (157±35)ng/L to (213±48)ng/L, from (19.3±2.5)ng/L to (21.2±4.3)ng/L, from (158±35)ng/L to (293±46)ng/L, from (7.5±3.5)mg/L to (47.7±5.8)mg/L in the experimental group and from (162±33)ng/L to (326±45)ng/L, from (16.2±3.5)ng/L to (34.2±4.8)ng/L, from (156±35)ng/L to (393±48)ng/L, from (8.6±2.8)mg/L to (78.2±6.5)mg/L in the control group, with statistically significant differences in the changing trend between 2 groups (F=8.85, 10.45, 13.27, 19.68, P<0.05). (4) Comparison of postoperative pulmonary complica-tions: incidence of postoperative pulmonary complications in the experimental group and control group was respectively 17.5%(14/80) and 31.3%(25/80). Pulmonary infection, pulmonary atelectasis, pulmonary edema, bronchospasm, hypoxemia and ARDS were respectively detected in 7, 6, 5, 6, 10, 0 patients in the experimental group and 16, 13, 13, 14, 20, 2 patients in the control group, showing a statistically significant difference between 2 groups (χ2 =4.10, P<0.05). Conclusion Lung protective ventilation strategy can reduce Ppeak and Raw and improve oxygenation in thoracoscopic and laparoscopic radical resection of esophageal cancer, meanwhile, it can also reduce intra- and post-operative inflammatory reaction and postoperative complications. Key words: Esophageal neoplasms; Lung protective ventilation strategy; Pulmonary protection

Neurochemical changes following combined hypoxemia and hemorrhagic shock in a rat model of penetrating ballistic-like brain injury: A microdialysis study.

Energy metabolic dysfunction is a key determinant of cellular damage following traumatic brain injury and may be worsened by additional insults. This study evaluated the acute/subacute effects of combined hypoxemia (HX) and hemorrhagic shock (HS) on cerebral interstitial levels of glucose, lactate, and pyruvate in a rat model of penetrating ballistic-like brain injury (PBBI). Rats were randomly assigned into the sham control, PBBI, and combined injury (P + HH) groups. The P + HH group received PBBI followed by 30-minute HX and 30 minute HS. Samples were collected from striatum (perilesional region) using intracerebral microdialysis at 1 to 3 hours after injury and then at 1 to 3, 7, and 14 days after injury. Glucose, lactate, and pyruvate were measured in the dialysate samples. Glucose levels dropped significantly up to 24 hours following injury in both PBBI and P + HH groups (p < 0.05). A reduction in pyruvate was observed in the PBBI group from 24 to 72 hours after injury (vs. sham). In the P + HH group, the pyruvate was significantly reduced from 2 to 24 hours after injury (p < 0.05 vs. PBBI). This prominent reduction persisted for 14 days after injury. In contrast, lactate levels were significantly increased in the PBBI group during the first 24 hours after injury and remained elevated out to 7 days. The P + HH group exhibited a similar trend of lactate increase as did the PBBI group. Critically, P + HH further increased the lactate-to-pyruvate ratio by more than twofold (vs. PBBI) during the first 24 hours. The ratio reached a peak at 2 hours and then gradually decreased, but the level remained significantly higher than that in the sham control from 2 to 14 days after injury (p < 0.05). This study identified the temporal profile of energy-related neurochemical dysregulation induced by PBBI and combined injury in the perilesional region. Furthermore, combined HX and HS further reduced the pyruvate level and increased the lactate-to-pyruvate ratio following PBBI, indicating the exacerbation of posttraumatic metabolic perturbation.

Hyperprolactinemia: An Unfamiliar Acquired Cause of Pulmonary Embolism

Despite our knowledge of congenital and acquired hypercoagulable states, many unprovoked venous thromboemboli remain idiopathic. High prolactin levels may add diagnostic differential to these unexplained thrombi. We report a case of prolactinemia as a potential cause of a pulmonary embolus (PE) and review the literature to elucidate the connection between high prolactin levels and thrombosis. A 68-year-old female presented with dyspnea and frontal headaches. Exam showed tachycardia, tachypnea, and hypoxemia with an oxygen saturation of 91% on room air. Labs were positive for an elevated troponin. Imaging with a computed tomography (CT) angiogram of the chest and an echocardiogram confirmed a diagnosis of sub-massive PE. A CT of the head showed a mass lesion in the pituitary fossa. A hypercoagulable workup was negative and pituitary hormone levels were within normal limits aside from a high prolactin of 270.9 ng/mL. In our patient, high prolactin secondary to a prolactinoma remained the main culprit in her venous thromboembolism given a thorough negative history and workup for other etiologies. Literature investigating prolactin’s effect on adenosine diphosphate-mediated platelet aggregation along with clinical scenarios in which elevated prolactin is the only sound explanation for a venous thrombosis may make it a risk factor which should be checked following a patient history indicative of a prolactin derangement. J Med Cases. 2016;7(11):491-492 doi: http://dx.doi.org/10.14740/jmc2651w

The clinical research of surgical treatment in off-pump coronary artery bypass

Objective To summarize clinical effect and experience for surgical treatment in off-pump coronary artery bypass in 128 patients. Methods 128 cases of age older than 60 years with Coronary heart disease (CHD) undergoing surgical repair in off-pump coronary artery bypass from October 2013 to June 2016 were analyzed retrospectively in our department. All the patients received surgical repair in off-pump coronary artery bypass under general anesthesia by the sternum midline incision line. Summary the complications following surgery. Results Surgical operations were performed in all patients and no death occurred during surgery.The perioperative complications after surgery: low cardiac syndrome (3 cases), arrhythmia(7 cases),including supraventricular tachicardia(2cases),complete atrioventricular block (1 cases), atrial fibrillation(4 cases); pulmonary infection with hypoxemia(5 cases).Secondary endotracheal intubation (2 cases),pleural effusion(3 case),atelectasis (2 cases), kidney injury(1 case),brain injury(1 case). The average drainage of chest was 350 ml, the time for making use of respirometer was (10.12±3.46) h, the length of hospital stay was (10±6) d. All patients were followed up from 3 months to 3 years.As a result,postoperative cardiac function improved significantly. Conclusions Surgical repair in off-pump coronary artery bypass for older patients with Coronary heart disease is safe and effective, surgical technical experience accumulation and the improvement of postoperative care can help to further reduce the incidence of complications. Key words: Off-pump coronary artery bypass; Coronary heart disease; Cardiac surgical treatment

Application value of high frequency chest wall oscillation after operation of abdominal incisional hernia

Objective To investigate the application value of high frequency chest wall oscillation (HFCWO) after operation of abdominal incisional hernia. Methods A prospectively randomized double-blind study was adopted. Fifty patients who underwent operation of abdominal incisional hernia at the Huadong Hospital Affiliated to Fudan University between January 2014 and September 2015 were allocated into the HFCWO group (undergoing postoperative HFCWO) and control group [undergoing postoperative conventional chest physiotherapy (CPT )] using random number table. Observation indicators included: (1) adverse events, (2) pain perception index: postoperative pain intensity from 1 day to 5 days was assessed by visual analogue scale (VAS), (3) respiratory function: arterial oxygen saturation (SaO2), oxygenation index (OI), arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) at postoperative day 1, 3 and 5, (4) follow-up. The follow-up using outpatient examination and telephone interview was performed to detect the recovery of patients up to March 2016. Measurement data with normal distribution were represented as ±s. The comparisons between groups were evaluated with the t test. The repeated measurement data were done using the repeated measures ANOVA and the count data were analyzed using the chi-square test. Results Fifty patients were screened for eligibility and were allocated into the 2 groups, 25 in each group. (1) Adverse events: all the patients in the 2 groups underwent successfully treatment, without the occurrence of hypoxemia, hemodynamic instability, arrhythmia, bronchospasm, vomiting, wound dehiscence, shedding catheter and so on. (2) Pain perception index: VAS from before chest treatment to postoperative day 5 was from 1.7±1.0 to 1.5±1.1 in the HFCWO group and from 1.4±0.8 to 1.8±0.6 in the control group, with a statistically significant difference in the change trend of pain intensity between the 2 groups (F=0.02, P 0. 05). (4) Follow-up: 43 patients were followed up after discharge from hospital for 1-6 months, with a median time of 5 months. During the follow-up, patients were not complicated with chest tightness and shortness of breath, with good wound healing. Conclusion Compared with conventional chest physiotherapy, HFCWO could improve tolerability of patients and reduce the pain after operation of abdominal incisional hernia. Key words: Abdominal incisional hernia; Surgical procedures, operative; High frequency chest wall oscillation

Clinical effectiveness study on artificial airway sequential mechanical ventilation patients withdraw machine pull out

Objective On patients with mechanical ventilation spontaneous breathing trial (SBT) success, out of breath machine smoothly pulled out after endotracheal intubation for active airway moist sequential therapy of clinical new method and new technology. Methods Between January 2013 and May 2014 respiratory endotracheal intubation implementation of mechanical ventilation with intensive medicine successful withdraw machine pulled out of 135 patients with tracheal intubation, they were divided into group A(68 cases) and group B(67 cases) by random digits table method. The patients in group A were treated with buoy type oxygen device, group B with active airway moist heat treatment unit. The breathing rate, PaO2, SpO2, heart rate, Clinical Pulmonary Infection Score(CPIS) were measured after 72 h of pull out endotracheal intubation in two groups. Sputum viscosity was evaluated by Airway Secretions Score before pull out endotracheal intubation and after 24, 48, 72 h of pull out endotracheal intubation in two groups. Results There were no significant differences between two groups in gender, age, clinical diagnosis, mechanical ventilation time, acute physiology and chronic health evaluation system Ⅱ rating etc (P >0.05). The breathing rate, heart rate and CPIS score respectively (20.94±0.89), (80.79±4.67) times/min and (7.13±2.54) points after 72 h of pull out endotracheal intubation in group B, and (24.12±0.97), (86.32±5.12) times/min and (8.79±3.56) points in group A, and there were significant differences(t=5.113, 7.298, 5.597, all P 0.05). After 24, 48 and 72 h of pull out endotracheal intubation, group B of patients with sputum viscosity was suitable in group A (Z=-2.684,-2.870,-2.771, all P < 0.01). Conclusions Mechanical ventilation in patients with ventilator buoy type oxygen device for the pull out after endotracheal intubation success does not favor the sputum drainage, improve patients with dyspnea and hypoxemia is not obvious. By positive airway plus temperature humidity to sequential therapy is helpful to correct hypoxemia, improve the patients' respiratory function, reduce the breathing difficulties, reduce sputum viscosity, promote the airway drainage unblocked, shortening the time of lung infection. Key words: Ventilators, mechanical; Airway management; Ventilator weaning; Intubation; Intratracheal

Progress and perspectives in definition of acute respiratory distress syndrome

Acute respiratory distress syndrome(ARDS) is a disease of acute onset characterized by hypoxemia and infiltrates on chest radiographs that affects both adults and children of all ages.This article reviewed the evolution of the definition of ARDS over nearly five decades, with a special focus on the new pediatric definition, also discuss recommendations for future definition of this syndrome. Key words: Acute respiratory distress syndrome; Diagnosis; Child

Early postoperative complications of renal cell cancer surgery with inferior vena cava tumor thrombus invasion

Objective To analyze the early postoperative complications in renal cell cancer (RCC) surgery with inferior vena cava tumor thrombus(IVCTT) invasion. Methods The clinical data of 27 patients with RCC and IVCTT from February 2015 to April 2016 were analyzed retrospectively. Of the 27 patients, 21 were male and 6 were female. The average age was (61.7±9.8) years old (47 to 84 years). The average body mass index (BMI) was (22.2±2.9) kg/m2 (17.6 to 30.8 kg/m2). Imaging suggested the right renal tumor in 18 cases and left renal tumor in 9 cases. The tumor size ranged from 3.6 to 21.1 cm.The renal vein tumor thrombus or inferior vena cava tumor thrombus was found in all patients, including type 0 thrombus in 6 cases, typeⅠ thrombus in 6 cases, type Ⅱ thrombus in 8 cases, type Ⅲ thrombus in 5 cases and type Ⅳ thrombus in 2 cases (Mayo Medical Center classification). We completed laparoscopic surgery for RCC with IVCTT in 14 cases and open surgery in 13 cases. Postoperative complications were graded according to the modified Clavien classifications, respectively. Serious complications were defined as grade Ⅲ or higher. Results Among 27 patients, early postoperative complications occurred in 14 cases (51.9%). Chyle leak occurred in 2 cases, they were cured after treated with diet control and subcutaneous injection of somatostatin. Lower extremity venous thrombosis occurred in 3 cases, they were cured after treatment with low molecular weight heparin. Three cases had postoperative pulmonary infection and were cured after antibiotics treatment. Bilateral thigh rash occurred in 1 case. Considering related with antibiotic induced allergy, we stopped the drug and treated with intravenous drip of vitamin C and glucose acid calcium. Serious postoperative complication rate was 18.5% (5 cases). One case had postoperative abdominal distension and peritoneal effusion. He underwent ultrasound guided puncture and drainage. Renal insufficiency and hyperkalemia occurred in 2 cases, they were cured after treatment with hemodialysis. One case died of postoperative blood pressure decrease and cardiac arrest. One case died of postoperative hypoxemia, septic shock, multiple organ dysfunction. Conclusions Postoperative complications or serious complications may occur after surgery for RCC with IVCTT. Understanding the causes and characteristics of complications, prevention and early treatment are key measures to reduce the incidence rates. Key words: Postoperative complications; Carcinoma, renal cell; Tumor thrombus; Vena cava, inferior

Clinical and risk factors analysis of brain injury in very low birth weight infants

Objective To investigate the incidence of brain injury and analyze the risk factors in very low birth weight infants(VLBWI), in order to explore methods to improve neurodevelopmental outcome. Methods This was a retrospective study in which we reviewed the incidence of brain injury in 326 VLBWI who admitted to our NICU from October 2007 to September 2014.The differences of general characteristics, high-risk perinatal factors, complications of prematurity and respiratory support in brain injury group(n=132) and no brain injury group(n=194) were analyzed, and Logistic regression was used to analyze the related risk factors. Results In 326 VLBWI, premature brain injury was observed in 132 cases(incidence of 40.49%). Hemorrhagic brain injury was observed in 80 cases(incidence of 24.54%, 80/326), in whom total 66 cases(20.25%, 66/326) with periventricular-intraventricular hemorrhage(PVH-IVH), 41 cases with PVH-IVH gradeⅠ-Ⅱ, 25 cases with PVH-IVH grade Ⅲ-Ⅳ.Non-hemorrhagic brain injury was observed in 52 cases(incidence of 15.95%, 52/326), in whom 46 cases with periventricular leukomalacia(14.11%, 46/326). There were no statistically significant differences in general characteristics except gender differences between the two groups.Further analysis of the 28 factors including high-risk perinatal factors, premature complications and respiratory support between the two groups, showed that there were significant differences in 16 factors including asphyxia, chorioamnionitis, antenatal steroid use, neonatal respiratory distress syndrome, hypoxemia, apnea, pulmonary hemorrhage, patent ductus arteriosus, hypotension, acidosis, hypocapnia, anemia, hyperglycemia, thrombocytopenia, high frequency ventilation and extrauterine growth retardation.Further binary Logistic regression analysis showed that antenatal steroids use was negatively correlated with brain injury, chorioamnionitis, acidosis, and patent ductus arteriosus were positively correlated with brain damage, the relative risks of premature brain injury was 0.108, 7.222, 3.045 and 4.565 respectively. Conclusion The mortality rate and the incidence of brain injury in VLBWI are still high.Chorioamnionitis, acidosis and patent ductus arteriosus are closely associated with premature brain damage.Antenatal steroids can prevent premature brain injury.We should pay much attention to these risk factors in the perinatal management of VLBWI, in order to decrease the incidence of premature brain injury. Key words: Preterm infants; Brain injury; Risk factors

Hypoxemia in patients undergoing first hemodialysis procedure with respect to different clinical and biochemical parameters

Introduction: During hemodialysis, PaO 2 falls about 10-20 mmHg. In seriously ill patients with pre-dialysis hypoxemia, the drop in PaO 2 can be catastrophic. Hypoxemia and fall in PaO 2 do occur during hemodialysis and hence we looked to ascertain the clinical, physiological and biochemical parameters which predisposes such events. Secondly, does it develop post hemodialysis and finally its outcome in patients with hypoxemia? Methods: A hospital based study was conducted on 120 patients undergoing hemodialysis for first time to know the incidence of hypoxia and its correlation with physiological and biochemical parameters, during and six hours post hemodialysis and their clinical significance in terms of morbidity and mortality. Patients with SpO 2 >95% and not on oxygen support were enrolled in the study. Clinical status of patient’s general condition and biochemical parameters were measured as outcome. Results: Study showed that hypoxia (SpO 2 25% following hemodialysis. Hypoxia during hemodialysis (especially post dialysis period) was associated with unfavorable outcome mainly due to increased cardiovascular risk in diabetic nephropathy patients and due to multiple organ failure in septicemic patients.