限制性补液在创伤失血性休克合并ARDS患者中的应用

目的探讨限制性补液在创伤失血性休克合并急性呼吸窘迫综合征(ARDS)患者的应用效果。方法将80例创伤失血性休克合并ARDS的患者按照随机数字表法分为对照组和观察组各40例,对照组采用常规液体复苏,观察组采用限制性补液法,2组均采用标准的急救护理程序,对创伤患者进行急救,比较2组复苏率、死亡率、多器官功能障碍(MODS)发生率以及患者家属对急救护理工作的满意度。结果观察组复苏率为83%、死亡率为17%、MODS发生率为4.3%以及护理工作满意度为(97.12±3.02)分,对照组复苏率为61%、死亡率为39%、MODS发生率为25%以及护理工作满意度为(90.03±4.58)分,2组差异均具有统计学意义(P0.05);观察组复苏时间(102.3±28.5)min,对照组复苏时间(127.1±30.7)min,2组复苏时间无统计学差异(P0.05)。结论创伤失血性休克合并ARDS的患者采用限制性补液以及标准的急救护理程序可提高患者的复苏率,降低患者的死亡率和MODS的发生率,同时还能提高患者家属对急救护理工作的满意程度。     

限制性液体复苏联合绿色通道在腹外伤休克患者的应用效果

目的:探讨限制性液体复苏联合绿色通道的急救模式在严重腹部创伤合并休克患者的应用效果,为临床急救护理提供有效的护理方法。方法:选择2011年1月~2013年12月我院就诊的腹部创伤合并休克的患者81例,随机分为观察组41例与对照组40例。两组都应用程序化急救护理措施,观察组运用限制性液体复苏联合绿色通道治疗,对照组使用常规补液复苏治疗。比较两组中患者抢救成功率及对急救护理工作满意度。结果:观察组抢救成功率优于对照组,护理工作满意度优于对照组,差异有统计学意义(P0.05)。结论:对严重腹部创伤合并休克患者应用限制性液体复苏联合绿色通道,同时根据急救护理程序进行急救护理,能降低死亡率,提高救治成功率。     

创伤失血性休克患者限制性液体复苏的探讨

目的评估创伤失血性休克(HTS)患者在出血未控制时限制性液体复苏的效果。方法创伤失血性休克73例,随机分为限制性液体复苏组(观察组)和常规液体复苏组(对照组)。监测两组病例的初次、24h、48h胃黏膜pH值、血乳酸(BL)、剩余碱(BE)、中心静脉氧饱和度(SCVO2)变化,对比分析两组方法的输液量、治愈率、病死率及多器官功能衰竭(MODS)和急性呼吸窘迫综合症(ARDS)的发生率。结果24h、48h胃黏膜pH值和血乳酸变化,差异有显著意义(P<0.05),两组间观察组输液量显著降低(P<0.05),治愈率显著升高(P<0.05),死亡率显著降低(P<0.05),ARDS和MODS发生率显著降低(P<0.05)。结论限制性液体复苏可提高治愈率,降低病死率,减少MODS和ARDS的发生率。     

创伤失血性休克早期液体复苏策略及氧代谢监测的临床观察

目的:观察创伤失血性休克限制性液体复苏及充分液体复苏的临床疗效及对氧代谢的影响。方法:将218例创伤失血性休克患者随机分为治疗组(n=110)及对照组(n=108),分别进行限制性液体复苏及充分液体复苏。比较两组输液量、病死率及并发症(ARDS、MODS、脓毒血症)发生率,复苏2 h后氧输送(DO-2)、氧消耗(VO2)、混合静脉血氧饱和度(SVO2)情况及24 h乳酸恢复情况。结果:治疗组输液量显著少于对照组(P0.01),治疗组死亡率、并发症发生率明显低于对照组(P0.05);治疗组DO_2、VO_2、SVO_2及24 h乳酸恢复正常例数均明显高于对照组(P0.05)。结论:与充分液体复苏比较,对创伤失血性休克进行限制性液体复苏能减少输液量,降低病死率及并发症发生率,且在组织供氧及纠正乳酸酸中毒方面有明显优势。     

限制性液体复苏治疗创伤失血性休克52例临床分析

目的：探讨限制性液体复苏对创伤失血性休克的救治效果。方法：将我院2011年1月至2013年6月收治的创伤性失血性休克的患者104例随机分为对照组（n=52）和研究组（n=52）,分别应用常规液体复苏和限制性液体复苏治疗,比较两组输液量、平均动脉压、实验室指标（PLT、PT、HGB、BE、hsCRP、乳酸等）、入院2周内的死亡率、严重并发症（ARDS、MODS）的发生率等。结果：研究组在人院2周内的死亡率、ARDS、MODS发生率均明显低于对照组（P均〈0．05）,具有显著性差异。结论：限制性液体复苏能够降低创伤性失血性休克患者病死率和存活患者严重并发症的发生率,改善预后。     

限制性液体复苏抢救非控制性失血性休克临床观察

目的探讨限制性液体复苏在抢救创伤非控制性失血性休克中的价值。方法创伤非控制性失血性休克患者114例随机分为限制性液体复苏组（观察组）和积极液体复苏组（对照组）各57例,比较2组术前输液量、病死率、血红蛋白、血小板计数、凝血酶原时间、血气剩余碱及并发症发生率。结果对照组病死率（15．79％）高于观察组（10．53％）（P〈O．05）,并发症发生率（29．17％）高于观察组（21．57％）（P〈0．05）;术前剩余碱对照组（（215±87）mmol／L）较观察组（（272±93）mmol／L）减少（P〈0．05）,对照组凝血酶原时间（（14．5±1．8）s）较观察组（（12．3±1．7）s）延长（P〈0．05）。结论术前急救采用限制性液体复苏可维持重要器官血流灌注,降低早期大量输液导致的并发症,降低病死率。     

限制性液体复苏治疗重症胸部创伤合并创伤失血性休克临床分析

目的研究分析限制性液体复苏治疗重症胸部创伤合并创伤失血性休克的临床效果。方法选取2013年2月~2015年2月我院收治的96例重症胸部创伤合并创伤失血性休克患者,随机分为对照组和观察组各48例。对照组采用常规液体复苏治疗,观察组采用限制性液体复苏治疗,对比两组治疗情况、并发症发生率和病死率情况。结果观察组输液量、复苏起始时间显著少于对照组,差异显著(P0.05);观察组胶体液量显著高于对照组,差异显著(P0.05);观察组并发症发生率和病死率显著低于对照组,差异显著(P0.05)。结论限制性液体复苏治疗重症胸部创伤合并创伤失血性休克疗效确切,能够显著提高临床治疗效果,值得推广。     

急性失血性休克抢救护理流程在手术室中的应用

目的:探讨急性失血性休克抢救护理流程在手术室中的应用。方法:将2013年10月~2014年9月我院收治的50例失血性休克患者设为对照组,将2014年10月~2016年10月收治的50例失血性休克患者设为观察组。对照组患者采取常规护理方法,观察组患者采用急救护理方法,即准备阶段、伤情评估、抢救阶段、术后护理、患者家属护理等。结果:观察组抢救成功率、患者家属的抢救满意度高于对照组,抢救时间短于对照组。两组比较差异均有统计学意义(P0.05)。结论:急救护理流程提高了急性失血性休克患者的救治成功率,值得在临床中推广使用。     

限制性液体复苏对创伤失血性休克合并慢性肾功能衰竭代偿期的影响

目的:探讨限制性液体复苏对创伤失血性休克合并慢性肾功能衰竭代偿期的影响。方法:创伤失血性休克合并慢性肾功能衰竭代偿期患者180例,随机分为观察组和对照组,观察组(n=92例)采用限制性液体复苏措施,对照组(n=88例)采用充分液体复苏措施。对比分析两组患者急性呼吸窘迫综合征(ARDS)、急性肾功能衰竭(ARF)、多器官功能障碍综合征(MODS)、脓毒血症和病死率的发生率。结果:观察组复苏后30min和复苏后1h与复苏前呼吸频率(RR)和脉搏血氧饱和度(SPO2)比较差异均有显著性(P<0.01或P<0.05);对照组复苏后30min与复苏前比较均有显著性(P<0.01),而复苏后1h与复苏前比较差异无显著性(P>0.05)。观察组与对照组肌酐(Cr)复苏后30min和1h后与复苏前比较差异均无显著性(P>0.05),观察组复苏后30min和1hCr值均高于同一时间点对照组的Cr值,两组同时间点比较差异无显著性(P>0.05)。两组间除ARF发生率比较差异无显著性外(P>0.05),其余并发症发生率比较差异均有显著性(P<0.05)。结论:对创伤失血性休克合并慢性肾功能衰竭代偿期的患者给予限制性液体复苏,能避免早期积极液体复苏带来的不良反应,能降低患者并发症的发生率。     

限制性液体复苏治疗失血性休克的应用研究

目的探讨液体复苏对创伤失血性休克的救治效果。方法回顾性总结创伤失血性休克早期不同的液体复苏方法对救治效果和凝血功能的影响。结果在243例创伤失血性休克患者中,充分液体复苏组(127例)病死率37·80%(48例),限制液体复苏组(116例)病死率23·28%(27例),两组总病死率及1~2h病死率比较差异均具有统计学意义(P<0·05)。充分液体复苏组血浆凝血酶原时间(PT)长于和存活患者并发症的发生率高于限制性液体复苏组。结论限制性液体复苏能降低创伤失血性休克患者病死率,提高存活率,并降低存活患者并发症的发生率,改善预后。     

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.