适时序贯组合模式机械通气在危重病人救治中的应用

目的探讨在危重病人救治过程中应用适时序贯组合模式机械通气的临床意义。方法通过对235例次危重病人采用机械通气救治的临床资料进行回顾性分析,并将120例次序贯组合模式组与115例次单一通气模式组进行比较,建立在此类病人进行机械通气时具有肺保护作用的模式组合、参数设置及其适时序贯调节的方法。结果两组危重病人的APACHEⅡ评分和平均年龄比较,差异无统计学意义(P>0.05)。序贯组合模式组64.2%和单一通气模式组52.2%均达到通气目标,组间比较,差异有显著意义(P<0.01)。前组35.8%和后组47.8%因多脏器功能衰竭(MOF)而死亡(APACHEⅡ评分均>29分),组间比较,差异有显著意义(P<0.01)。序贯组合模式组Vt 7.15±1.12 mL/kg、PSV 8.5±2.1 cmH2O、PEEP/CPAP5.16±1.05 cmH2OP、plat 18.5±2.5 cmH2OP、IP 23.5±3.6 cmH2O均低于单一通气模式组(P<0.01)。前组f 20±2.5次/min高于后组(P<0.05)。结论在各种类型危重病人的救治中,应用A/CV+PEEP、SIMV+PSV+PEEP、CPAP+PSV和PSV的适时序贯组合模式通气,采用动态的线性撤机过程,能提高通气达标率和降低病死率,并具有肺保护作用。参数的设置和调节宜在动脉血气指标的量化控制下,应用小Vt、小PSV、小PEEP/CPAP和适当f。     

有创-无创序贯性机械通气治疗老年肺内源性急性呼吸窘迫综合征随机对照临床研究

目的 评价有创-无创序贯性机械通气治疗老年肺内源性急性呼吸窘迫综合征(ARDS)患者的疗效及可行性.方法 32例老年肺内源性ARDS患者被随机分为序贯治疗组及常规治疗对照组,每组16例.两组均建立人工气道,以辅助/控制模式+呼气末正压(PEEP)+间隙性控制性肺膨胀(SI)方式通气24 h,随病情改善改用同步间歇指令通气(SIMV)+压力支持通气(PSV)+PEEP的方式.待"ARDS控制窗"出现,序贯组改换为无创正压通气(NIPPV),以持续气道正压(CPAP)方式通气并逐渐脱离呼吸机;对照组以SIMV+PSV+PEEP常规方式脱机.动态观察两组患者的通气及氧合指标,记录有创和总机械通气时间、呼吸机相关性肺炎(VAP)发生情况及住呼吸重症监护病房(RICU)的天数.结果 两组患者治疗前血气分析结果相仿(P均>0.05);序贯组有创通气时间[(4.6±1.0)d]、总机械通气时间[(12.7±4.0)d]、住RICU时间[(16±7)d]较对照组[分别为(21.9±9.0)d、(21.9±9.0)d、(29±13)d]明显缩短,VAP发生率[6.25%(1/16)]和病死率[25.00%(4/16)]也较对照组[分别为75.00%(12/16)、56.25%(9/16)]明显降低,差异均有统计学意义(P<0.05或P<0.01).结论 对老年肺内源性ARDS插管机械通气以ARDS控制窗为时机及时改用无创通气可显著改善其疗效.     

肺表面活性物质稀释剂延迟肺灌洗治疗烟雾吸入性损伤

目的 探讨外源性肺表面活性物质(PS)稀释剂延迟肺灌洗对大鼠严重烟雾吸入伤后内源性PS功能障碍和急性呼吸衰竭的治疗效果.方法 90只Wistar大鼠随机分为5组:Ⅰ组,正常对照(n=14);Ⅱ组,烟雾吸入(n=27);Ⅲ组,烟雾+PS灌洗+机械通气(MV),n=21;Ⅳ组,烟雾+盐水灌洗+MV,n=10;V组,烟雾+MV,n=18.伤后2 h经气管插管注入含PS(100ms/ks)的等渗盐水30 ml/kg或等量盐水行肺灌洗,MV 4 h,观察24 h;检测动脉血气、肺水量、静态肺顺应性(Cst)、支气管肺泡灌洗液(BAIF)蛋白含量、BALF表面张力特性和24 h病死率等.结果 致伤动物伤后立即出现严重缺氧和一氧化碳中毒;Ⅱ组发生急性呼吸衰竭、高通透性肺水肿和PS功能障碍;Ⅲ组Cst和BALF表面张力特性显著改善(P<0.05),但氧合能力、肺水量和BALF蛋白含量无明显好转(P>0.05).Ⅳ、V组疗效不佳.结论 外源性PS稀释剂延迟肺灌洗可一定程度恢复烟雾吸入所致内源性PS功能抑制,改善肺功能,但不能显著减轻高通透性肺水肿和呼吸衰竭,不能降低早期病死率.     

机械通气治疗慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭32例观察与护理

目的:总结机械通气治疗慢性阻塞性肺疾病(COPD)伴Ⅱ型呼吸衰竭的方法和疗效。方法:根据病情调整呼吸机为强制指令容量控制通气(IPPV)或同步间歇指令和压力支持(SIMV PSV)模式,根据血气分析及临床症状调节参数,同时加强人工气道管理,严密观察病情变化,强化生命体征监护,做好心理及各项基础护理,观察通气前后患者血气变化。结果:32例患者机械通气治疗后,血气分析与治疗前比较有显著差异(P<0.01),27例症状明显改善,顺利脱机。结论:机械通气是治疗慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭的有效措施,系统的护理是顺利进行有效通气的重要保证。     

老年患者施行不同通气模式对单肺通气氧合及气道压力的影响

目的观察老年患者胸科手术时单肺通气期间不同通气模式对患者气道压力和氧合的影响。方法需行单肺通气麻醉的老年手术病人120例,其中男性80例,女性40例,年龄60岁以上。将120名患者分为例组,施行全麻诱导双腔插管后行双肺通气,进胸后分别再进行不同通气模式的单肺通气,单肺通气开始后,其中容量控制通气模式(VCV)组(Ⅰ组)VT=10 ml/kg,f=10;压力控制通气模式(PCV)(Ⅱ组)压力设定为达10 ml/kg潮气量的压力值,f=10;VCV组(Ⅲ组)VT=7 ml/kg,f=14;PCV组(Ⅳ组)压力设定为达7 ml/kg潮气量的压力值,f=14;VCV+选择性通气肺呼气末正压组(PEEP)(Ⅴ组)VT=7 ml/kg,f=14,PEEP=5 cm H2O;PCV+PEEP组(Ⅵ组)压力设定为达7 ml/kg潮气量的压力值,f=14,PEEP=5 cm H2O。定时记录数据。结果单肺通气30 min后、单肺通气60 min后,Ⅲ组和Ⅳ组相比氧合具有显著统计学差异(P<0.05),Ⅲ组和Ⅴ组相比氧合具有显著统计学差异(P<0.05),Ⅳ组和Ⅵ组相比氧合具有显著统计学差异(P<0.05)。结论为了改善单肺通气时出现的低氧血症和确保患者在手术中的安全,需要合理选择通气模式,达到提高单肺通气效果的目的,使单肺通气技术得到广泛的推广。     

序贯性机械通气治疗慢性阻塞性肺疾病合并严重Ⅱ型呼吸衰竭疗效观察

目的：观察序贯性机械通气治疗慢性阻塞性肺疾病（COPD）合并严重Ⅱ型呼吸衰竭的疗效。方法：20例COPD并严重Ⅱ型呼吸衰竭患者，经鼻插管进行机械通气，出现“肺部感染控制窗”时，改用鼻面罩双水平气道正压通气（BiPAP）模式行序贯性机械通气。与20例COPD并严重Ⅱ型呼吸衰竭患者，插管行机械通气，后常规应用SIMv＋PSV模式常规脱机的相应指标做回顾性比较。结果：利用有创-无创序贯通气能够在较短时间内控制患者病情，并且能够使总机械通气时间和VAP发生例数均显著减少（P〈20．001）。结论：序贯性机械通气可明显改善COPD并严重Ⅱ型呼吸衰竭患者的病情，优于传统有创机械通气治疗。     

机械通气对循环功能影响的临床研究

目的　评价机械通气对循环功能的影响。方法　通过监护仪测定 12例患者在自主呼吸和不同机械通气模式条件下的血流动力学参数。结果　与自主呼吸相比 ,辅助 控制 +呼气末正压 (A C +PEEP)模式和压力支持通气 +持续气道正压 (PSV +CPAP)模式时 ,心排血量 (CO)、心脏指数 (CI)、收缩血压 (SBP)、舒张血压 (DBP)及平均动脉压 (MBP)均降低 (P <0 0 1)。A C模式和PSV模式时 ,CO明显下降 (P <0 0 1) ,CI也有所下降 (P <0 0 5 ) ,而SBP、DBP及MBP无统计学差异。与PSV比较 ,A C、A C +PEEP和PSV +CPAP的最大吸气压力 (PIP)和平均气道压 (Paw)明显增高 (P <0 0 1)。与A C比较 ,A C +PEEP和PSV +CPAP的PIP和Paw明显增高 (P <0 0 1) ,PSV的PIP和Paw明显降低 (P <0 0 1)。结论　A C或PSV通气模式可引起CO及CI降低 ,但不影响动脉血压。A C +PEEP或PSV +CPAP通气模式不但引起CO及CI降低 ,而且导致动脉血压下降。机械通气对循环功能的影响决定于Paw。     

无创正压通气在慢性阻塞性肺疾病所致严重呼吸衰竭机械通气脱机过程中的应用

目的 探讨无创正压通气在慢性阻塞性肺疾病(COPD)并发呼吸衰竭患者有创机械通气撤机后的应用时机及治疗效果.方法 选择36例COPD患者,随机选取18例行气管插管机械通气并作为实验组,以同步间歇指令通气(SIMV) 压力支持通气(PSV) 呼气末正压(PEEP)方式行机械通气,待肺部感染控制窗出现,拔除气管插管,改为经面罩BIPAP无创通气,逐渐脱机.余18例做为对照组,行常规有创通气,最后以PSV方式至撤机.现察两组病例的呼吸机相关性肺炎(VAP)的发生例数、病死率、机械通气天数、总住院天数、动脉血气分析.结果 实验组住院时间少于对照组,(21.1±1.8)天vs(27.1±1.4)天(P<0.05);机械通气时间为(11.4±0.8)天vs(14.8±2.4)天(P<0.05);呼吸机相关性肺炎发生率为0 vs 5例(P<0.01);死亡例数为1例vs 4倒.实验组撤机前后血气分析比较差异无统计学意义(P>0.05);对照组撤机后pH降低、PaCO2升高(P<0.05).结论 对COPD并发呼吸衰竭患者采用早期有创机械通气,序贯应用无创正压通气可以显著降低VAP发生率,提高撤机成功率,缩短住院时间.     

肺表面活性物质联合CPAP治疗新生儿呼吸窘迫综合征的效果观察

目的观察肺表面活性物质联合持续气道正压通气(CPAP)治疗新生儿呼吸窘迫综合征的效果。方法选取本院2017年5月～2019年5月收治的84例呼吸窘迫综合征患儿,按照不同治疗方法分为试验组和对照组各42例,对照组行CPAP治疗,试验组行肺表面活性物质联合CPAP治疗。结果两组治疗前PEEP、FiO2、呼吸机氧合指数、p H值、PCO2、PO2比较无显著差异(P>0.05);治疗后,试验组PEEP、FiO2呼吸机参数低于对照组(P<0.05),pH值比较无显著差异(P>0.05),PCO2低于对照组(P<0.05),PO2高于对照组(P<0.05),呼吸机氧合指数高于对照组(P<0.05);试验组治疗效果显著高于对照组(P<0.05)。结论肺表面活性物质联合CPAP治疗可显著改善呼吸窘迫综合征患儿的血气指标、呼吸机参数和呼吸机氧合指数,提高临床治疗效果。     

慢性阻塞性肺疾病伴呼吸衰竭患者的机械通气治疗与治疗延迟时间之研究

目的探讨不同机械通气方式对慢性阻塞性肺疾病(COPD)呼吸衰竭患者的治疗结果与机械通气延迟治疗时间的关系。方法对我院急诊科ICU收治的44例接受机械通气COPD呼吸衰竭患者,根据机械通气方式分为无创通气组和有创通气组,进一步根据治疗结果分为无创成功18例、无创失败4例、有创成功10例、有创失败12例,回顾性分析其临床资料,观察不同情况下接受机械通气的延迟时间。结果无创通气组的APACHEⅡ评分值、延迟时间、严重并发症发生比例、治疗失败比例低于有创通气组(P<0.05);同一种机械通气的治疗成功与失败者之间机械通气延迟时间比较差异有统计学意义(P<0.05)。结论不同机械通气方式之间的机械通气延迟时间不同,机械通气延迟时间影响COPD伴呼吸衰竭患者治疗结果。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.