急性缺血性脑卒中患者早期活动优势方案研究

目的 基于正交设计优化急性缺血性脑卒中患者早期活动方案.方法 对影响早期活动的3个因素(活动强度B、活动频率C、每次活动时间D)及对应的3水平按正交设计L9(33)形成9种不同的早期活动方案;选取急性缺血性脑卒中患者63例,随机分成9组,各组分别采用一种方案进行早期活动,实验中未对因素A(活动开始时间)进行控制.观察患者出院时及出院1个月Barthel指数、疲劳严重程度、脑卒中康复自我效能、生活质量、自主参与,情绪及神经功能评分的变化.结果 因素A(活动开始时间)对出院时及出院1个月时的疲劳严重程度、出院1个月时生活质量的影响差异有统计学意义(P＜0.05,P＜0.01),A2为最佳水平;因素B(活动强度)对出院时及出院1个月时的Barthel指数、出院时的疲劳严重程度、出院1个月时的生活质量和自主参与的影响差异有统计学意义(P＜0.05,P＜0.01),B3为最佳水平;因素C(活动频率)对出院时神经功能评分、出院1个月时Barthel指数、脑卒中康复自我效能、生活质量、自主参与的影响差异有统计学意义(均P＜0.05),C2为最佳水平;因素D(每次活动时间)的3个水平对出院时及出院1个月时所有评价指标的变化无影响(均P＞0.05).结论 急性缺血性脑卒中患者早期活动的优势方案为:活动开始时间为卒中发生后24～48 h,活动频率为每日2～3次,活动强度推荐在活动能力允许情况下实施床椅转移、离床坐位、站立及行走或爬楼,每次活动时间可根据患者的实际情况决定.     

急性缺血性脑卒中患者家属参与早期活动方案的研究

目的探讨科学、可行的家属参与急性缺血性脑卒中患者早期活动方案。方法在文献回顾、半结构式访谈的基础上,基于互动式患者参与患者安全理论框架,初步形成急性缺血性脑卒中患者家属参与早期活动方案。通过19名专家进行2轮德尔菲法专家咨询,修订急性缺血性脑卒中患者家属参与早期活动方案。结果 2轮专家咨询的问卷回收率分别为89.47%和100%,专家权威系数为0.786和0.797。最终形成的急性缺血性脑卒中患者家属参与早期活动方案包括决策性参与、照护性参与、诉求性参与及安全保障方案4项一级指标,二级指标8项,三级指标29项。结论患者家属参与急性缺血性脑卒中患者早期活动方案的制订可提高家属对患者活动的关注与支持,对促进卒中患者康复有积极作用。     

行动研究法验证基于循证的脊柱术后早期佩戴支具下床活动方案

目的通过行动研究法验证脊柱术后早期佩戴支具下床活动方案,提高用证安全性。方法通过循证护理方法建立脊柱术后早期佩戴支具下床活动方案,根据行动研究理想模型,以诊断、计划、实施、观察、改进5个阶段为基础,选取椎间盘手术患者20例,循环进行活动评估、指导,共实践7周,完成4轮循环,每轮根据患者反馈对方案进行调整。结果第1~3轮实践均发现问题并对方案进行调整,第4轮未再发现新的问题。19例患者入院及出院当天舒适度得分均90分,1例患者入院、出院当天舒适度得分90分。16例患者住院期间完全依从行动方案下床活动,4例患者未按要求活动。用证过程中未发生一起跌倒、坠床、继发性损伤等不安全事件。结论基于循证的的脊柱术后早期佩戴支具下床活动方案能够提高椎间盘患者术后早期活动的舒适度及依从性,运用行动研究法验证活动方案能提高用证安全性。     

实施护理专案缩短急性脑梗死患者血管内取栓时间

目的通过护理专案活动缩短急性缺血性脑卒中患者血管内取栓时间。方法成立护理专案小组,调查2018年1～3月31例(对照组)急性缺血性脑卒中患者经绿色通道行血管内取栓的现状,对2018年10～12月41例急性缺血性脑卒中患者(干预组)开展护理专案改善活动,进行原因分析和目标制定,拟定对策并实施。结果干预组入室至穿刺时间、穿刺至再通时间显著短于对照组(均P0.01)。结论通过护理专案活动,可将急性缺血性脑卒中血管内取栓患者入室-穿刺-再通的工作流程细化、完善,规范护理干预措施,有效缩短了AIS患者血管内取栓时间。     

基于IScore评分的早期神经功能恶化预测模型的构建与评价

目的探讨急性缺血性脑卒中患者早期神经功能恶化的危险因素,构建基于IScore评分的预测模型,并评价其预测效果。方法选取452例急性缺血性脑卒中患者的临床病例资料,根据是否发生早期神经功能恶化分为恶化组(n=73)和非恶化组(n=379),比较两组的危险因素,通过二分类Logistic回归模型建立预测模型,采用ROC曲线下面积评价模型的预测效果。结果早期神经功能恶化发生率为16.15%。最终进入预测模型的指标包括IScore评分、白细胞计数、大脑中动脉M1段中重度狭窄、颈动脉中重度狭窄共4个预测因子,模型ROC曲线下面积为0.790,特异度为0.834,灵敏度为0.635,准确度为0.798,约登指数为0.469。结论基于IScore评分的预测模型对急性缺血性脑卒中患者早期神经功能恶化具有较好的预测效能与可重复性。     

动脉内机械取栓治疗急性后循环缺血性脑卒中临床效果及预后影响因素

目的探讨机械取栓治疗急性后循环缺血性脑卒中患者的临床效果及预后影响因素。方法对15例急性后循环缺血性脑卒中患者行动脉内机械取栓治疗,统计血管成功再通率,并观察术后24 h内脑出血、脑梗死等不良反应发生情况。术后3个月随访,以改良Rankin量表(mRS)评估患者预后;对比预后良好(mRS评分0～2分)与不良(mRS评分3～6分)患者间基线资料及治疗相关指标的差异。结果对15例患者均成功开通闭塞血管,血管成功再通率100%(15/15)。术后24 h内1例发生脑出血,5例发生大面积脑梗死。术后3个月9例患者预后良好,5例预后不良,1例死亡。与预后不良患者比较,预后良好患者发病至入院时间更短(t=-2.435,P=0.030),入院时后循环Alberta卒中项目早期CT评分(pc-ASPECTS)更高(t=5.925,P0.001),术前美国国立卫生研究院卒中量表(NIHSS)评分更低(t=3.053,P=0.009)。结论动脉内机械取栓治疗急性后循环缺血性脑卒中效果好且安全性高;发病至入院时间、术前NIHSS评分及pc-ASPECTS是影响患者预后的因素。     

入院血清白蛋白水平对缺血性脑卒中患者预后影响的Meta分析

目的评价入院时血清白蛋白对急性缺血性脑卒中患者预后的影响。方法计算机检索国内外知名数据库,搜集入院时血清白蛋白水平对急性缺血性脑卒中患者预后影响的观察性研究,并对纳入文献采用RevMan5.0软件进行Meta分析或描述性分析。结果共纳入6篇文献(中、英文各3篇),涉及1 693例患者。入院时血清白蛋白水平与患者Barthel指数相关,正常血清白蛋白组患者Barthel指数比低血清白蛋白组高21.91分,合并效应量WMD为-21.91(95%CI-26.02,-17.80);2篇文献报道入院血清白蛋白水平可以预测患者的神经功能预后。结论入院时血清白蛋白水平可以评价急性缺血性脑卒中患者的预后。     

肝癌术后早期下床活动方案的构建及应用

目的制订肝癌术后早期下床活动方案,探讨实施效果。方法按照入院时间将93例肝癌行肝切除术患者分为对照组45例和观察组48例。对照组实施术后常规活动护理;观察组实施早期下床活动循证实践方案,通过检索数据库获取最佳证据及整合证据,制定肝癌术后早期下床活动实践方案及流程。结果观察组术后24 h内下床活动率、首次下床时间及术后活动量指标显著优于对照组,术后排气排便时间、胃管留置时间显著短于对照组,术后24 h疼痛评分、疼痛控制满意度显著优于对照组(P0.05,P0.01);两组早期活动不良事件发生率比较,差异无统计学意义(P0.05)。结论肝癌术后早期下床活动最佳实践方案的实施,可加快肝癌患者术后康复,促进患者安全(并不增加患者安全事件)。     

老年缺血性脑卒中患者的早期综合护理体会

<正>随着社会老龄化进程加快,脑卒中已成为严重威胁老年人健康和生活质量的常见疾病。缺血性脑卒中常急性起病,多因脑供血障碍导致脑组织缺血,缺氧引起,占脑卒中的70%。且常伴有高血压、糖尿病、高脂血症等危险因素。本病好发于50岁以上的中老年人。2011-01―2013-01,我们对180例老年缺血行脑卒中患者规范实施早期全面护理措施,有效提高患者功能恢复,改善预后,现将护理体会报告如下。     

入院血清白蛋白水平对缺血性脑卒中患者预后影响的Meta分析

目的评价入院时血清白蛋白对急性缺血性脑卒中患者预后的影响。方法计算机检索国内外知名数据库,搜集八院时血清白蛋白水平对急性缺血性脑卒中患者预后影响的观察性研究,并对纳入文献采用RevMan5．0软件进行Meta分析或描述性分析。结果共纳入6篇文献（中、英文各3篇）,涉及1693例患者。入院时血清白蛋白水平与患者Barthel指数相关,正常血清白蛋白组患者Barthel指数比低血清白蛋白组高21．91分,合并效应量WMD为-21．91（95％CI-26．02,-17．80）;2篇文献报道入院血清白蛋白水平可以预测患者的神经功能预后。结论入院时血清白蛋白水平可以评价急性缺血性脑卒中患者的预后。     

急性缺血性脑卒中后吞咽障碍发病率及影响因素分析

目的探讨急性缺血性脑卒中后吞咽障碍发病率、危险因素及预后,为采取干预措施提供参考.方法对急性缺血性脑卒中患者在入院48 h内,采用洼田饮水试验结合容积一黏度吞咽测试完成吞咽功能评估,收集年龄、性别、既往史、卒中部位、肌力、Barthel指数、美国国立卫生研究院脑卒中量表(NIHSS)评分等资料,并随访患者出院后1、3个...     

心脏机械瓣膜置换术后低强度抗凝治疗中的缺血性脑卒中

目的探讨心脏机械瓣膜置换术后低强度抗凝治疗中缺血性脑卒中发生的危险因素及其防治方法。方法将2004年3月至2008年7月我科收治的机械瓣膜置换术后发生缺血性脑卒中患者23例纳入研究（缺血性脑卒中组）,随机选择同期行心脏机械瓣膜置换术后患者120例作为对照（对照组）,比较两组患者的性别、年龄、华法林用量、抗凝强度[国际标准化比值（INR）]及INR复查间隔时间、左心房内径、心律等指标,采用logistic回归分析缺血性脑卒中发生的危险因素。结果（1）缺血性脑卒中组患者入院后经相关治疗均顺利出院,住院期间无1例死亡,出院后随访1个月～3年,全组患者神经系统并发症均有明显恢复,无再发栓塞及抗凝治疗中的严重出血发生;（2）两组患者性别、年龄、华法林用量比较差异无统计学意义（P〉0．05）;（3）对影响因素进行非条件logistic回归分析结果,心房颤动（P=0．000）、左心房增大（P=0．002）、抗凝强度过低（P=0．012）、INR复查间隔过长（P=0．047）为心脏机械瓣膜置换术后低强度抗凝治疗中缺血性脑卒中发生的危险因素。结论（1）心脏机械瓣膜置换术后低强度抗凝治疗中缺血性脑卒中的预后相对于颅内出血较好,其发生与多个危险因素有关;（2）临床上应该尽可能减少各项危险因素对抗凝治疗的影响,以避免缺血性脑卒中的发生;（3）心脏机械瓣膜置换术后抗凝治疗中发生缺血性脑卒中的患者早期进行低强度抗凝治疗较安全、有效。     

Post-operative myocardial dysfunction does not affect the physiological response to early mobilization after coronary artery bypass grafting

BACKGROUND: An acute increase in oxygen demand can be compensated for either by increased cardiac index (CI) or increased oxygen extraction, resulting in reduced mixed venous oxygen saturation (SvO2). We tested the hypothesis that post-operative cardiac dysfunction may explain why oxygen extraction alone is increased during early mobilization after cardiac surgery. METHODS: Twenty patients with a pre-operative ejection fraction > 50% were included in an open prospective observational study comparing the changes in SvO2 and hemodynamics during mobilizations immediately prior to surgery and on the first post-operative morning. RESULTS: Mobilization induced an absolute reduction in SvO2 of 17.7 +/- 7.4% pre- and 19.0 +/- 5.5% post-operatively (NS). ANOVA for a series of measurements throughout the mobilization sequence identified no different effect on SvO2 between pre- and post-operative mobilizations (P = 0.567). The SvO2 level was reduced post-operatively resulting in a SvO2 during standing exercise of 55% before and 49% after the surgery (P < 0.01). Mobilization increased the heart rate (HR) and decreased the stroke volume index (SVI), leaving CI unchanged. This response was similar pre- and post-operatively (NS). Compared with pre-operative measurements, CI and HR increased post-operatively while SVI remained unchanged despite elevated cardiac filling pressures and reduced systemic vascular resistance. The left ventricular stroke work index was reduced, indicating reduced myocardial performance. CONCLUSION: Myocardial function was reduced on the first morning after coronary artery bypass grafting (CABG), but during post-operative mobilization this reduction did not significantly influence the changes in CI or SvO2.     

Inflammatory responses and CNS injury: implications,prophylaxis, and treatment

EXCERPT: Early detection of perioperative stroke is essential if there is to be any opportunity to improve outcome. If there is suspicion of cerebral embolic stroke, scanning with computerized tomography can rule out acute hemorrhage and demonstrate diagnostic changes in a majority of patients within 5 hours of onset of symptoms. Strategies for reperfusion of ischemic tissue may include intraarterial thrombolysis in select patients with acute ischemic stroke even after recent cardiac operation. In one series, 13 patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. Recanalization was complete in 1 patient and partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax; 2 others received transfusions for low hemoglobin. No operative intervention for bleeding was necessary. In addition to thrombolysis, mechanical clot removal may be attempted. Thromboaspiration requires favorable anatomy and a fresh nonadhesive clot. It reduces the time for recanalization, has no hemorrhagic risk, and may prevent distal clot migration. Thromboaspiration may be attempted as an adjunct or alternative to intraarterial fibrinolysis for basilar artery recanalization. If massive cerebral gas embolism is suspected and hyperbaric facilities are available, confirmation can be obtained by early single-photon emission tomography (SPET) and hyperbaric oxygen therapy instituted. This process was successfully undertaken in a case of paradoxical air embolism in a patient undergoing percutaneous nephrolithotripsy in the prone position and presenting with blindness and neurological deficits 8 hours later. Treatment with hyperbaric oxygen therapy was successful in this case.     

急性中央颈脊髓损伤MRI表现及其与预后的关系

目的 探讨急性中央颈脊髓损伤的ＭＲＩ表现及其与预后的关系。方法 对３５例急性中央颈脊髓损伤的早期ＭＲＩ检查资料进行分析,并与ＡＳＩＡ评分改善率进行比较。结果 非手术治疗组与手术治疗组ＡＳＩＡ评分改善率差异无显著性（Ｐ〉０．０５）,脊髓受压程度与改善率呈显著负相关（Ｐ〈０．０１）,脊髓信号无异常、脊髓水肿与脊髓血肿３组病例的改善率差异有显著性（Ｐ〈０．０１）,脊髓血肿组预后最差。结论 ＭＲＩ检查对选     

Akute klinische Schlaganfallbehandlung

Stroke is an emergency. Treatment must begin as soon as possible because significant sustained neurological improvement has been demonstrated when thrombolytic treatment, mainly with recombined tissue plasminogen activator (rtPA) is initiated within the first hours of stroke onset. On the other hand in the acute phase of stroke it is critical that patients get adequate management for the prevention of early complications. Management of the acute phase of stroke is the target of this article. Preclinically started treatment must be continued in the neurological emergency unit. Clinical examination is followed by technical investigations: cerebral computer tomography (CCT) is the most useful radiological investigation in the acute phase. It allows to distinguish between ischemia and hemorrhagic lesions and also to rule out nonstroke brain conditions. Multimodal magnetic resonance imaging (mMRI) may provide data on viable versus irreversibly damaged tissue. Sufficient stroke treatment is based on well managed in-hospital infrastructure. Thrombolysis is the only causative treatment of stroke in selected patients. Complications of acute stroke comprise changes of blood pressure with hemodynamically relevant effects on cerebral perfusion pressure, acute post- ischemic brain edema, and intracerebral bleedings.     

Urgent open embolectomy for cardioembolic cervical internal carotid artery occlusion

Acute ischemic stroke attributable to cervical internal carotid artery (ICA) occlusion is frequently associated with severe disability or death and is usually caused by atherosclerosis. By contrast, the cardioembolic cervical ICA occlusion is rare, and feasibility of urgent recanalization remains unclear. We present the first study in the literature that focuses on urgent open embolectomy for the treatment of cardioembolic cervical ICA occlusion. A retrospective review of the charts for patients undergoing open embolectomy was performed. Between April 2006 and September 2007, 640 consecutive patients with acute ischemic stroke were treated. Of them, three patients (0.47%) with the acute complete cardioembolic cervical ICA occlusion underwent urgent open embolectomy. All patients presented with profound neurological deficits and atrial fibrillation. The urgent open embolectomy achieved complete recanalization in all patients without any complications. All emboli in three patients were very large and fibrinous in histological findings. Two of three patients showed rapid improvement in neurological functions after surgical treatments. The cardioembolic occlusion of the cervical ICA is rare, but its possibility should be considered in patients with acute ischemic stroke suffering profound neurological deficits and atrial fibrillation. Urgent open embolectomy may be a treatment option to obtain successful recanalization for cardioembolic cervical ICA occlusion and is recommended because it is technically easier and similar to carotid endarterectomy.     

急性心肌梗死患者早期活动评估指标的研究

目的 确定急性心肌梗死（AMI）患者早期活动评估指标,为制定个体化活动及护理方案提供依据.方法 建立AMI患者早期活动评估指标及分级草案;用德尔菲法对23名专家进行2轮调查.结果 2轮咨询专家的积极系数分别为92％、100％,权威系数均为0.94,协调系数为0.23、0.35.经2轮咨询,各项指标变异系数为13％～19％,指标分级满分比87％～100％,确立了用于AMI患者早期活动方式评定的10项指标和各指标的分级.结论 AMI患者早期活动评估指标有较好的代表性和可信度,后续研究将对指标分级赋值,从而用风险积分指导制定AMI患者早期活动方式.     

处方量化锻炼在指屈肌腱断裂术后功能康复中的应用

目的制定指屈肌腱断裂伤主动锻炼的要素和流程,以提高疗效。方法归纳出主动锻练运动剂量的3个要素：肌肉收缩力量、次数、每次肌肉收缩的持续时间;每天的运动量在不同时刻分组实施。本组53例食指指屈肌腱Ⅱ区切割断裂伤患者,手术修复后的45天内,将肌腱愈合过程分为四个阶段,对应给予四个运动处方指导锻炼。全过程好似用量化的运动之“药”治疗肌腱粘连之“病”,故称之“处方锻炼法”。结果患者在3min内可学会当天的锻炼内容并自主实施。术后45天,PIP关节活动度〉15。者31例：PIP关节活动度〉50者20例;1例由于疼痛综合征,无PIP关节活动度;1例由于瘢痕体质．无PIP关节活动度。结论主动锻炼可以量化控制。处方锻练法在指屈肌腱断裂伤早期康复中有良好疗效。