Background: Extracorporeal membrane oxygenation (ECMO) has been used for treating myocarditis for years. To extubate and be awake have been proven to be useful in adult patients supported with ECMO, especially for long-term pulmonary support. However, the role of awake ECMO remains still unclear in pediatric patients with acute fulminant myocarditis (AFM). Objectives: The objective is to summarize the application of awake ECMO during the treatment of pediatric AFM. Methods: Seven patients with AFM received ECMO from October 2018 to March 2020 in the Pediatric Intensive Care Unit, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital. During the process, the patients were extubated and supported with awake ECMO. Retrospective analysis of basic characteristics, clinical vital signs, outcomes, and parameters of ECMO was carried out. Results: All the patients received venoarterial mode ECMO during the treatment, and awake ECMO was implemented after the patients were stable. During the period, all the patients were fed with enteral nutrition. The respiratory and circulatory conditions were improved during the awake ECMO. Finally, all the patients successfully weaned from ECMO and survived to discharge from hospital. Conclusion: It is possible for pediatric ECMO-supported patients with AFM to extubation and keep awake. The choice of patients, close monitoring during process, and good coordination are key factors for the successful implementation of awake ECMO.

Background: We aimed to establish a modified cecal ligation and puncture (CLP) rat model with omentectomy for simulating moderate-to-severe septic kidney injury (AKI). Subjects and Methods: Rats were randomly divided into four groups subjected to: Traditional CLP (n = 40); the modified CLP procedure (n = 40); sham surgery (abdominal incision only) (n = 6); and abdominal incision and omentectomy only (n = 6). We evaluated the severity of renal injury according to serum creatinine levels at 0, 24, and 48 h postoperatively and cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) levels at 12 h postoperatively, graded the severity of sepsis, monitored the degree of peritonitis, and examined animal survival. Results: Compared with the traditional CLP group, the modified CLP group developed more severe sepsis at postoperative 48 h, had more severe renal pathology, and developed more severe AKI with high homogeneity. Most rats in the traditional CLP group exhibited complete wrapping of the puncture site by omentum with limited peritonitis, while partial wrapping with pus spreading was observed in some. All rats in the modified CLP group developed puncture site necrosis, with pus spreading without formation of an encapsulated abscess, and a consistent degree of peritonitis. The 7-day survival rates in the traditional and modified CLP groups were 65.0% and 50.0%, respectively. Conclusion: The traditional CLP approach was associated with an even distribution of different AKI severities among treated animals, whereas the modified CLP approach established a consistently more severe rat model of septic AKI, constituting an important advance for optimizing septic AKI animal models.

Endogenous sulfur dioxide (SO₂) used to be perceived as a notorious, toxic pollutant of the atmosphere. However, recently several studies revealed that in vivo generated mainly from sulfur-containing amino acids, SO₂ serves as an essential novel gasotransmitter involved in the regulation of extensive biological activities. Several studies indicate that endogenous SO₂ protects against inflammation by inhibiting the production of inflammatory mediators via different molecular pathways. The present review, therefore, summarized the anti-inflammatory effect of endogenous SO₂ and its molecular mechanisms.

During assisted mechanical ventilation, the respiratory system is exposed to the positive pressure from the ventilator and the negative pressure generated by the respiratory muscles. Both excessively high and low respiratory drive and effort can injure the respiratory muscles and lungs resulting in worse patient's outcomes. Monitoring respiratory drive and inspiratory effort are key to prevent harm by adjusting sedation and ventilation to meet safe targets of respiratory drive and inspiratory effort. Based on physiological studies and observational data, it is currently recommended to target an intermediate range of drive and effort in most patients, however, these targets need to be validated prospective and adjusted for different patient populations. The gold standard for measuring inspiratory effort requires the insertion of an esophageal catheter and additional equipment. However, recently, several noninvasive techniques using end-expiratory or end-inspiratory occlusions on the ventilator have been validated to estimate respiratory drive and effort allowing clinicians to monitor drive and effort easily at the bedside. In this narrative review, we discuss potential beneficial and deleterious consequences of breathing effort during assisted ventilation, available monitoring techniques, and propose a structured approach for bedside implementation.

Objective: The objective of the study is to describe the clinical characteristics, risk factors, and prognosis for acute kidney injury (AKI) among patients with coronavirus disease (COVID-19). Methods: Retrospective study of 456 consecutive patients with confirmed COVID-19 infection at the whole hospital from January 1 to March 1, 2020 was enrolled. Demographic, clinical characteristics, the risk factors, and prognosis were collected and analyzed. Results: Of 456 patients with COVID-19, 38 patients developed AKI. Patients with AKI were older and predominantly male sex and were more likely to have comorbidities such as hypertension, cardiovascular, and cerebrovascular diseases. Among patients with AKI, the white blood cell count, neutrophil count, neutrophil-to-lymphocyte ratio, alanine aminotransferase, and C-reaction protein were increased, and lymphocyte and platelet count were decreased. Multivariate analysis showed that age, hypertension, and lymphocyte count were independent risk factors for AKI. The overall mortality rate of 456 patients was 9.9%, and the mortality rate of patients with AKI was 23.7%. In particular, increasing AKI severity was associated with increased risk. Conclusions: The risk of AKI was high in patients with COVID-19. Older age, hypertension, and lower lymphocyte count were independent risk factors for AKI. COVID-19-associated AKI was associated with higher risk of death in patients with COVID-19.

Background: The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) on the coronavirus disease 2019 (COVID-19) remains controversial from clinic evidence. Objectives: The objectives of this study were to report the major characteristics and clinical outcomes of COVID-19 patients treated with ACEIs and ARBs and compare the different effects of the two drugs for outcomes of COVID-19 patients. Methods: This is a retrospective, two-center case series of 198 consecutive COVID-19 patients with a history of hypertension. Results: Among 198 patients, 58 (29.3%) and 16 (8.1%) were on ARB and ACEI, respectively. Patients who were on ARB or ACEI/ARB had a significantly lower rate of severe illness and acute respiratory distress syndrome (ARDS) when compared with patients treated with ACEI alone or not receiving RAAS blocker (P < 0.05). The Kaplan–Meier survival curve showed that patients with ARB in their antihypertensive regimen had a trend toward a higher survival rate when compared with individuals without ARB (adjusted hazard ratio, 0.27; 95% confidence interval [CI], 0.07–1.02; P = 0.054). The occurrence rates of severe illness, ARDS, and death were similar in the two groups regardless of receiving ACEI. The Cox regression analyses showed a better survival in the ARB group than the ACEI group (adjusted hazard ratio, 0.03; 95% CI, 0.00–0.58; P = 0.02). Conclusions: Our data may provide that some evidence of using ARB, but not ACEI, was associated with a reduced rate of severe illness and ARDS, indicating their potential protective impact in COVID-19. Further large sample sizes and multiethnic populations are warranted to confirm our findings.

Regional citrate anticoagulation (RCA) is the preferred anticoagulation method of continuous renal replacement therapy (CRRT) which is recommended by international guidelines, but the use of citrate anticoagulation is relatively complicated. If correct prescription and timely adjustment of RCA are not performed, disorders of fluid electrolyte and acid-base balance are prone to occur, especially hypocalcemia, which is a fatal complication. This article introduces the use of RCA with calcium-containing replacement fluid for postdilution continuous veno-venous hemofiltration, which provides a simple and easy CRRT anticoagulation protocol for clinical practice.

Background: COVID-19 outbreak has spread around the world. Liver dysfunction (LD) was related with high mortality in COVID-19. Methods: Retrospective, single-center study case series of 425 consecutive hospitalized COVID-19 patients were enrolled. Demographic, clinical, laboratory, and treatment data were collected. Results: A total of 425 patients were included in this study, 145 of whom had LD. The overall mortality rate was 8.9%, while 17.9% in the LD group and 4.3% in the nonliver dysfunction (NLD) group. Age, sex, and hypertension were the independent risk factors of LD. LD was an independent risk factor for incidence of severe illness, acute respiratory distress syndrome, and death. The survival rate of patients in LD group was lower than that in NLD group (P < 0.001). A similar trend was observed by the multivariate regression analysis (adjusted hazard ratio, 3.52; 95% confidence interval [CI], 1.69–7.33; P = 0.001). Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers had effect to reduce LD (odds ratio of 0.48 [95% CI, 0.232–0.989; P = 0.045]). Conclusions: LD is one of the main features of hospitalized patients of COVID-19, with a worse prognosis. Patients of COVID-19 with LD on admission should be more cautions.

Background and Objectives: To explore the superiority of flipping-classroom lended learning in which the stay-home e-learning and traditional internship complements each other in resident training of endcorinology during coronavirus disease 2019 restriction period. Materials and Methods: A total of 44 residents were randomized as the study population. In the endocrine-rotation training, we reformed the clinical learning by unified online-teaching led by teachers' combination with individual guidance by residents. Moreover, the final implementation assessment was conducted by standard double-blind examinations. Results: After 4–8 weeks training, the 44 residents were assessed for clinical skills from six dimensions, including medical history collection, physical examination, history report and inpatient record writing, case analysis, and overviewing capability. Compared with the mean scores of 68 residents rotated in internal medicine in 2019, the mean scores on physical examination, inpatient record writing, and overviewing capability in 2020 group were higher with significance ([85.72 ± 8.33] vs.[79.22 ± 10.12], P = 0.0006), ([90.28 ± 10.70] vs. [81.82 ± 8.03], P < 0.0001), ([80.31 ± 8.70] vs. [73.04 ± 12.74], P = 0.0012), whereas scores on skills of medical history collection and history report were slightly lower ([82.11 ± 9.02] vs. [85.06 ± 7.23], P = 0.0586), ([79.30 ± 8.17] vs. [83.21 ± 5.01], P = 0.0022), while scores on case analysis did not show huge gap but with polarized performance in 2020 group ([74.38 ± 10.29] vs. [78.13 ± 8.53], P = 0.0386). Conclusions: Providing the novel pattern of unified online-teaching combined with individual-guidance at the bedside to the front-line residents can reduce the risk of cluster epidemics and effectively ensure the training effect on them but still with shortcomings. The future online teaching reform is better for focus more on how to make up for or reduce the actual problem of disconnection between theory and practice in the process of online clinical skills training for residents and teachers.

Introduction: The diagnostic and prognostic value of thromboelastogram (TEG) in sepsis has not been determined. This study aimed to assess whether TEG is an early predictor of coagulopathy and is associated with mortality in patients with sepsis. Methods: In total, 518 patients with sepsis on the intensive care unit (ICU) admission were prospectively evaluated. We measured TEG and conventional coagulation tests on preadmission to ICU and observed for the development of 1 and 3 days and 1, 3, and 7 days, respectively. Multivariable logistic regression was utilized to determine the odds of ICU/hospital mortality. The parameter of TEG (maximum amplitude, reaction time; MA/R ratio) was calculated to evaluate sepsis-induced coagulopathy. The patients were divided into three groups : MA/R0 group (MA/R = 5–14 mm/min); MA/R1 group (MA/R <5 mm/min); and MA/R2 group (MA/R >14 mm/min). Results: Four hundred and ten patients were included. At enrolment, 10.73%, 65.85%, and 23.41% of the patients had lower, normal, and higher MA/R state, respectively. Compared to MA/R0 group, patients with lower and higher MA/R both had significantly increase risk of hospital mortality (hazards ratio [HR] 2.83 [95% confidence interval [CI] 1.577–5.079], P < 0.01); (HR 1.982 [95% CI 1.073–3.66], P = 0.029), respectively (adjusted with Acute Physiology and Chronic Health Evaluation [APACHEII] score) and ICU mortality (HR 2.512 [95% CI 1.301–4.852], P = 0.006); (HR1.644 [95% CI 1.024–2.639], P = 0.002) (adjusted with APACHEII score). Patients with higher MA/R had significantly increase risk of hospital mortality APACHE II score (HR 1.635 [95% CI 1.016–2.632], P = 0.043). Conclusions: In our cohort of patients with severe sepsis, coagulopathy defined by MA/R ratio was associated with increased risk of ICU/hospital mortality.

It has been described that COVID-19 is a dynamic behavior and systemic affectation entity, so it is essential to develop the diagnostic and prognostic tools which allows to specifically identify target organ damage. The electrocardiographic finding of an inverse T-wave suggests transient apical dysfunction of the left ventricle, generating confusion among different heart diseases. However, despite the lack of troponin elevation and other myocardial injury signs, this finding is unspecific, especially in the patient with COVID-19. The aim of this manuscript is to present the case of a patient with COVID-19 without a previous diagnosis of heart disease, which manifests an isolated inverse T-wave.

This review discusses the clinical beneficial effects of peptide-based enteral nutrition (EN) for critically ill patients, especially those with gastrointestinal (GI) dysfunction. The GI dysfunction is very common in critically ill patients and always leads to intolerance of enteral feeding. Experimental and clinical studies suggest that peptide-based EN can be easily digested and absorbed by the GI tract which improving the feeding intolerance and provide better nutritional effects for critically ill patients. In addition, peptide-based EN may also have anti-inflammation, anti-oxidation, and immune-modulation effects and can facilitate muscle protein synthesis to improve muscle weakness which is commonly seen in critically ill patients. Peptide-based EN may have both nutritional and nonnutritional beneficial effects for critically ill patients. Further, large prospective randomized clinical trials should to be done to make the definite results.

Sepsis is one of the most common severe diseases in clinic. With the progression of the disease, it is very likely to occur acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). Despite years of research, the mortality rate from sepsis-associated lung injury remains high. MicroRNAs (miRNAs) are a class of non-coding small RNAs with the function of regulating gene expression. In recent years, miRNAs have become a research hotspot in the field of biomedicine. Therefore, this review summarizes a large body of evidence implicating miRNAs and their target molecules in ALI/ARDS originating largely from studies using animal and cell culture model systems of ALI/ARDS. First, the pathophysiology and potential molecular mechanism of sepsis-associated ALI were briefly discussed at the cellular level, and the regulatory effect of miRNA on sepsis-associated ALI was summarized from the molecular mechanism so as to provide the possibility to find new targets for the treatment of sepsis-associated lung injury. Finally, some promising methods and some shortcomings of existing research are introduced.

Background: The prevalence of clinical manifestations in severe patients with COVID-19 was highly variable across region, populations, and assessment methods. We investigated the characteristics in patients with COVID-19 and the risk factors associated with severe cases and progression to severe patients during hospitalization. Methods: In this retrospective, multicenter observational study, we collected the clinical manifestations and laboratory regarding from 125 patients with laboratory-confirmed COVID-19 in Liaoning province, China. The collected COVID-19 patients were divided into two groups, including nonsevere group and severe group which were according to the Chinese national guideline for COVID-19 diagnosis and treatment. Results: One hundred and twenty-five laboratory-confirmed COVID-19 patients from three centralized diagnosis and treatment centers were enrolled. The median age was 44 years old, 68 (54.4%) were male. One hundred and twelve (81.6%) patients were in nonsevere group and 23 (18.4%) were in severe group. The overall hospital mortality is 1.6%. About 34% patients had been to Wuhan, 35.2%patients had contact with confirmed COVID-19 patient in Wuhan. Thirty-five (28%) patients were local and 11 (8.8%) patients had a history of direct contact with wildlife. About 20.8% of the patients had comorbidity, hypertension was the most common comorbidity (14.4%). Four patients changed from nonsevere to severe during hospitalization. Most patients were admitted in January and February (98.4%). The median hospital stay was 16 days (interquartile range [IQR]: 12–21). On admission, fever was the most common symptom (60.8%). Duration from onset symptom to hospitalization was 5 days (IQR, 2–8). Compared with nonsevere group, severe cases were associated with significant increased NE (74.19 ± 13.87 vs. 62.32 ± 12.80, P = 0.001), C-reactive protein (CRP) (33.27 ± 38.60 vs. 15.53 ± 29.35, P = 0.003), D2 (1.52 ± 2.83 vs. 0.44 ± 0.93, P = 0.021), lower lymphocyte count (0.81 ± 0.41 vs. 2.32 ± 6.63, P = 0.042), and lymphocyte percentage (LY%) (15.94 ± 10.47 vs. 28.83 ± 11.66, P < 0.001). Kaletra and Chinese medicine were most widely used, the proportion was 61.6% and 66.4%, respectively. Age (odds ratio [OR] = 1.030, 95% confidence interval [CI], 0.99–1.09; P = 0.042), fever on admission (OR = 5.23, 95% CI, 1.32–20.79; P = 0.019), increased NE (OR = 10.53, 95% CI, 3.55–31.25; P = 0.000), and decreased LY% (OR = 7.72, 95% CI, 2.61–22.83; P = 0.000) were independently associated with the severe COVID-19. Age (OR, 1.12; 95% CI, 1.01–1.23; P = 0.025), myalgia (OR, 30.82; 95% CI, 1.58–600.16; P = 0.024), and CRP (OR = 1.04, 95% CI, 1.004–1.073; P = 0.030) were associated with higher risk of development to severe COVID-19 cases. Conclusions: 1. Identification of individuals at risk for severe COVID-19 after severe acute respiratory syndrome coronavirus 2 infection is important 2. The effects of conventional methods on predicting those patients who will go on to develop severe COVID-19 are limited 3. Age, fever on admission, increased NE, and decreased LY% were independently associated with the severe COVID-19 4. Age, myalgia, and CRP were independent risk factors associated with development to severe COVID-19.

Objective: Postoperative cognitive dysfunction (POCD) and neurologic deficit continues to be an important neuropsychological adverse affecting patients' outcome. We conducted this systematic review to investigate the relationship between regional cerebral oxygen saturation (rSO2) and early POCD in postoperative patients. Materials and Methods: Our search included MEDLINE (PubMed) and Cochrane library, from inception to October 31, 2018. We included studies reporting values of rSO2 at the beginning of and/or during surgery, and the primary outcome was POCD, and excluded articles who do not put postoperative cognitive function as the main observation. Two reviewers assessed the quality of the included articles using the Newcastle-Ottawa Scale and extracted the data. Results: Seven prospective cohort studies that included 532 patients incorporate into this systematic review. About 37.78% (201/532) patients achieved POCD. POCD was associated with significantly lower overall values of rSO2 during surgery compared to the population that did not achieve POCD (mean difference [MD] −1.98; 95% confidence interval [CI] −3.30 to −0.66; P = 0.003). In the subgroup, the lowest rSO2 values intraoperative period were a better predictor of POCD (MD −2.91; 95% CI −4.37 to − 1.46; P < 0.0001) than the mean rSO2 values (MD − 2.94; 95% CI −5.71 to − 0.17; P = 0.04). However, all of two were proved superior to baseline rSO2 values (MD −0.13; 95% CI -1.33 to 1.07; P = 0.83); patients with intraoperative cerebral oxygen <50% are nearly four times more likely to have early POCD (odds ratio = 3.65; 95% CI 1.62–8.23, P = 0.002). Conclusions: Patients with POCD have significantly lower cerebral oxygenation during operation than their counterparts. The lowest rSO2 values intraoperative period and patients with intraoperative cerebral oxygen <50% were a better predictor of POCD.

Artificial intelligence provides a vast opportunity and conquest of the science of knowledge. Twenty-first-century medicine will be characterized by an extraordinary ability to access and process medical information to provide patient-specific, timely, and effective clinical decision support. The knowledge gained by patient care experience and clinicians' expertise has led to many clinical care advances. Access to a large volume of data, along with ever-growing information and knowledge of diseases, can allow us to optimize diagnoses and management strategies by using advances in machine learning and artificial intelligence. Changing the medical culture from only relying on the experts to use medical informatics advances to improve the experts' clinical judgment would be an uphill battle. It is necessary to overcome the clinicians' traditional training to empower them into moving in the data science, statistics, and artificial intelligence era. As the incorporation of artificial intelligence in clinical practice seems inevitable, a thorough understanding of its capacities and flaws is essential to the emergence of a new clinical practice world. This review paper describes some of the nuances of past, current, and future clinical decision support systems and artificial intelligence's impact on this process.

Coagulopathy is common in critically ill patients. Under pathogenic factors, the homeostasis of coagulation, anticoagulation, and fibrinolytic system is disrupted, causing a series of cascade reactions that ultimately lead to coagulopathy. The pathophysiology of coagulopathy markedly varies according to the etiology. For sepsis-induced coagulopathy, inflammation interacts with coagulation. This process involves various cells, including endothelial cells, neutrophils, and platelets. Thrombocytopenia, as a common coagulopathy disorder among intensive care unit (ICU) patients, is indicative of poor outcome, and its differential diagnosis is crucial. However, the standardized diagnostic criteria for disseminated intravascular coagulation are yet to be established, and the existing ones have limitations. Therefore, we used PubMed to search literature related to “thrombocytopenia,” “sepsis,” “coagulopathy,” “disseminated intravascular coagulation,” and “coagulation biomarkers” and expected ICU doctors to fully understand knowledgeable of the pathophysiology of Coagulopathy. The traditional coagulation indicators can be combined with novel coagulation-related biomarkers for the accurate diagnosis and treatment of coagulopathy.