主动脉夹层术后患者出现低氧血症的原因分析及护理

目的探讨主动脉夹层术后患者出现低氧血症的原因及护理对策。方法回顾性分析本院2008年1月-2010年1月85例主动脉夹层术后发生低氧血症患者的临床资料,并总结护理要点。结果 85例患者发生低氧血症的原因与吸烟、术前肺部感染、围术期营养状况不佳、术中体外循环时间太长、术前心功能较差及术中大量输血有关。结论主动脉夹层术后易发生低氧血症,应对相关因素进行分析,并实施针对性的护理对策,以降低或避免患者发生低氧血症。     

Ⅲ型主动脉夹层围手术期应用硝普钠致精神异常的护理

目的Ⅲ型主动脉夹层非体外循环腔内支架隔离术在围手术期应用硝普钠控制性降压易导致精神失常,总结相关护理经验。方法 2009年7月2010年2月确诊Ⅲ型主动脉夹层动脉瘤患者36例,围手术期应用硝普钠控制性降压,均采用非体外循环主动脉腔内隔离术治疗,排除手术、麻醉等因素所致脑损伤而产生的术后精神异常。结果有5例出现不同程度精神失常,经加用口服降压药,减少硝普钠泵入剂量,缩短硝普钠使用时间,经过精心治疗及护理,患者精神异常症状逐渐减轻直至消失。结论长期、大剂量应用硝普钠易导致精神失常,需加强护理,及时发现,及时处理。     

主动脉夹层病人术后精神障碍相关因素分析及护理

[目的]探讨主动脉夹层病人术后精神障碍的相关因素及护理措施。[方法]对29例主动脉夹层术后出现精神障碍的病人进行回顾性分析,找出原因,实施科学、合理、有效的护理干预。[结果]术后精神障碍发病时间多集中在术后3d~6d,占86.21%(25例);29例病人中,活动过度型19例,活动减退型10例;Logistic分析显示:睡眠障碍、合并基础疾病对主动脉夹层术后精神障碍有影响;29例病人全部康复出院,且出院时精神症状均消失。[结论]总结术后精神障碍的相关因素,给予及时、专业的心理疏导,合理的治疗以及悉心的护理可以改善病人的精神状态,加快病人精神康复进程。     

倍他乐克、硝普钠联合治疗主动脉夹层分离23例分析

主动脉夹层分离及时进行适当的药物和手术等治疗,生存率可大为提高,病死率降为18％～27％。本病最常见病因为高血压,其次有马凡综合征、妊娠、主动脉缩窄等。作者2000年1月～2004年12月对23例合并高血压的主动脉夹层分离患者采用了倍他乐克、硝普钠联合治疗,取得了较好疗效。现报告如下。     

主动脉夹层患者精神症状的护理体会

2002年5月~2003年8月,我院收治主动脉夹层(AD)患者16例,发现10例患者出现不同程度的精神症状。针对其发生原因,实施相应的护理措施,效果满意。现报告如下。1临床资料本组16例,26~76岁,平均51岁,均符合AD临床诊断标准。患者均合并高血压,经硝普钠持续静脉泵入降压治疗,其中5例合用冬眠合剂。治疗过程中出现精神症状10例,其中2例合用冬眠合剂、2例合并老年神经系统疾病。主要精神症状为感知觉障碍、思维障碍、注意障碍、智能障碍、情感或心境障碍、运动与行为障碍、意识障碍等。2原因分析2.1药物引起的精神症状①硝普钠:本组16例患者使用硝…     

硝普钠联合冬眠合剂治疗主动脉夹层动脉瘤护理体会

主动脉夹层动脉瘤起病急,变化快,如不及时处理易导致死亡[1].2000年3月～2004年2月,我院共收治主动脉夹层患者28例,应用微量泵持续静脉注射硝普钠、冬眠合剂治疗主动脉夹层动脉瘤,缓解了患者临床症状,取得满意效果.现报告如下.     

骨科老年患者术后精神障碍的相关因素分析

目的探讨骨科老年患者手术后发生精神障碍的相关因素。方法选择2006年5月至2009年5月在我科接受手术治疗的146例60岁以上老年患者,按术后有无精神症状分为有症状组和无症状组。其中有症状组17例,年龄63～104岁,平均(74±8)岁;无症状组129例,年龄60～86岁,平均(68±6)岁。结果发现有症状组在年龄,吸入麻醉方式及时间,术中失血量,术后低血色素及低氧血症,水、电解质紊乱,术前合并糖尿病、高血压病、脑血管疾病、呼吸系统疾病等因素与无症状组比较,差异有统计学意义(P0.05)。结论骨科老年患者手术后发生精神障碍与年龄,吸入麻醉方式及时间,术中失血量,术后低血色素及低氧血症,水、电解质紊乱,术前合并糖尿病、高血压病、脑血管疾病、呼吸系统疾病等因素有关。     

硝普钠联合丙泊酚、芬太尼在主动脉夹层动脉瘤中的护理体会

总结了50例主动脉夹层动脉瘤病人采用硝普钠、丙泊酚、芬太尼联合用药的临床效果，主要包括控制疾病发展和减轻临床症状方面，认为联合硝普钠、丙泊酚、芬太尼对主动脉夹层动脉瘤病人有显著效果，能有效控制疾病发展，显著减轻了临床症状，为病人的继续治疗打下了很好的基础。     

Stanford A型主动脉夹层患者术前发生全身炎症反应综合征危险因素分析

目的探讨并分析Stanford A型主动脉夹层患者术前发生全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)的危险因素。方法回顾性分析157例Stanford A型主动脉夹层患者术前资料,对术前发生SIRS的影响因素分别进行单因素分析,单因素分析有意义的因素再进行多因素logistic回归分析独立危险因素。结果术前发生SIRS 74例,发生率47.13%;单因素分析显示年龄、夹层分期、左心室舒张末期内径、左心室收缩末期内径、主动脉瓣关闭不全程度、夹层内膜破口、夹层逆行剥离与Stanford A型主动脉夹层术前发生SIRS有关(P0.1);多因素分析显示主动脉夹层分期(OR=0.259,95%CI:0.136~0.492,P=0.000)、左心室舒张末期内径(OR=0.901,95%CI:0.820~0.990,P=0.031)是Stanford A型主动脉夹层术前发生SIRS的独立危险因素。结论 Stanford A型主动脉夹层术前SIRS发生率高,主动脉夹层进入慢性期和左心室舒张末期内径扩大预示术前发生SIRS减弱或消退。     

高龄患者疝手术后并发精神障碍的原因分析及护理

分析了10例高龄患者疝手术后精神障碍的原因,提出了预防措施及护理对策。原因有：心理因素、年龄因素、麻醉药物、睡眠紊乱、低氧血症等。主要措施有：加强心理护理、严格用药指针、保证良好的睡眠、预防低氧血症。认为及时有效地对患者进行有针对性的护理干预不仅有利于术后的康复,而且对预防术后精神障碍的发生具有重要指导意义。     

高血压伴夜间低氧血症对血压节律的影响

目的:观察高血压合并睡眠呼吸暂停综合征患者血压的变化节律。方法:选择夜间打鼾、体重指数≥25的高血压患者95例,监测夜间7 h的血氧饱和度和24 h动态血压。根据夜间氧饱和度情况分为高血压合并低氧血症组和单纯高血压组,所有患者均经病史、体检、实验室检查排除继发性高血压、心力衰竭、脑血管病、肾功能衰竭、哮喘。结果:高血压合并低氧血症组24 b平均收缩压、24 h平均心率、白昼平均收缩压、白昼平均心率、夜间平均收缩压、夜间平均心率与单纯高血压组相比有显著差异(P<0.05);高血压合并轻、中度低氧血症组中75.3%患者动态血压昼夜节律消失,单纯高血压组血压昼夜节律消失占7.1% 杓型组与非杓型组患者夜间平均收缩压及夜间平均舒张压有显著差异(P<0.05)。结论:高血压合并夜间低氧血症患者血压水平及心率较单纯高血压组明显增高,随着低氧血症的加重,增高趋势明显;高血压合并低氧血症组多数血压昼夜节律消失,非杓型组夜间血压较杓型组增高显著。     

慢性阻塞性肺疾病急性加重期患者近期预后的多因素分析

目的探讨影响慢性阻塞性肺病急性加重期(AECOPD)患者近期预后的主要相关因素。方法对190例住院治疗的慢性阻塞性肺病急性加重期患者,共五大类32项因素进行回顾性单因素分析,对单因素分析中P<0.2的因素进行Logistic多元逐步回归分析,寻找影响AECOPD患者近期预后的主要相关因素。结果多因素分析结果显示:是否使用呼吸兴奋剂、是否使用抗氧化剂、抗生素选择、淋巴细胞计数、白细胞计数、是否合并右心功能不全、血红蛋白、血肌酐值等因素是影响近期预后的主要因素。结论影响AECOPD近期预后的主要因素较多,其中,白细胞计数和淋巴细胞计数是影响预后的独立因素。     

Independent contribution of psychological factors to fibrin turnover in subjects with sleep apnoea and/or systemic hypertension

By promoting atherosclerosis and thrombosis, a blood-clotting diathesis could contribute to excess cardiovascular morbidity and mortality in patients with systemic hypertension and/or obstructive sleep apnoea. Since psychological states affect haemostatic activity, we wondered about the contribution of behavioural factors to a hypercoagulable state in subjects with increased risk of cardiovascular disease. To tease apart the potential additive nature of cardiovascular disease risk, we examined four patient groups - hypertensives and normotensives, with and without sleep apnoea. The procoagulant molecules thrombin-antithrombin III complex, fibrin D-dimer and von Willebrand factor antigen were measured in 88 subjects (mean age 47 years; range 32-64 years) who underwent full polysomnography. Subjects completed the Center for Epidemiological Studies - Depression (CES-D) Scale, the Cook-Medley (CM) Hostility Scale, and the Profile of Mood States (POMS). Sleep apnoea, hypertension status, age, body mass index and psychological variables (CES-D, CM Stress, and POMS Vigour-Activity) together explained 29% of the variance in D-dimer, a marker of fibrin turnover ( r (2)=0.29, P =0.001). CES-D, CM Stress and POMS Vigour-Activity explained 17% of this variance even after controlling for sleep apnoea, hypertension status, age and body mass index (Delta r (2)=0.17, P =0.001). Thrombin-antithrombin III complex and von Willebrand factor were not significantly related to psychological variables, but this may reflect limited statistical power. Thus psychological factors are independently associated with D-dimer and explain as much of its variance as do traditional correlates (hypertension, sleep apnoea, age and body mass index). These results may provide a rationale for linking behavioural aspects with cardiovascular events.     

阻塞性睡眠呼吸暂停低通气综合征对血压的影响及护理干预

目的探讨阻塞性睡眠呼吸暂停低通气综合征（0SAHs）对高血压患者血压的影响及护理干预。方法经睡眠呼吸监测确诊的55例患者分为高血压合并OSAHS组和单纯高血压组,监测24h动态血压。结果2组24h平均收缩压、舒张压,夜间平均收缩压、舒张压差异存在统计学意义（P〈0．05）。2组血压节律变化存在显著差异（P〈0．01）。结论高血压合并OSAHS昼夜血压节律下降,临床护士可通过正确积极的护理干预来提高患者的生活质量。     

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

Objectives: A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS^® vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design. Methods: In adults with a mild‐to‐moderate primary hypertension and no significant comorbidities, 24‐h ambulatory blood pressure monitoring was conducted after a 2‐ to 4‐week placebo run‐in period and before treatment initiation. Individual blood pressure measurements at 20‐min intervals were analysed. Results: In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of ≥ 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge. Conclusions: In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24‐h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24‐h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.     

Accelerated idioventricular rhythm during flexible fiberoptic bronchoscopy

We report the case of a patient who developed severe hypoxemia and an unusual arrhythmia, accelerated idioventricular rhythm, during flexible fiberoptic bronchoscopy. Coronary artery disease was subsequently suspected despite an unremarkable history and physical examination, and confirmed by a thallium 201 imaging. The appearance of accelerated idioventricular rhythm during fiberoptic bronchoscopy should raise the possibility of underlying coronary artery disease.     

二尖瓣病变并肺动脉高压围术期低氧血症分析

目的总结二尖瓣病变并肺动脉高压患者围术期低氧血症的治疗方法。方法选择二尖瓣病变并肺动脉高压围术期发生低氧血症、低心排血量患者76例,给予呼吸机辅助呼吸、硝酸甘油0.5~1.0μg/（kg.min）持续泵入、米力农0.3~0.7μg/（kg.min）泵入。结果死亡3例,均因严重低氧血症、心衰,经治疗低氧血症等无改善,于术后7~10 d因继发多器官功能衰竭死亡;其余患者经治疗后好转出院,心功能Ⅱ、Ⅲ级。随访5月~5年,心功能Ⅰ级17例、Ⅱ级58例,术后3年死亡1例,该患者因置入生物瓣合并高血压死于脑出血。结论二尖瓣病变并肺动脉高压患者围术期易发生低氧血症,严重的低氧血症可通过扩张肺动脉降低肺动脉压并配合心功能支持药物及呼吸机治疗矫正。硝酸甘油、米力农等有效剂量泵入是降低肺动脉压改善低氧血症的有效方法。     

"Near miss" death in obstructive sleep apnea: a critical care syndrome

OBJECTIVE: The objective of this study was to alert critical care physicians to the syndrome of obstructive sleep apnea with respiratory failure ("near miss" death) and to elucidate characteristics that might allow earlier recognition and treatment of such patients. DESIGN: We examined clinical and laboratory characteristics of eight patients with obstructive sleep apnea presenting to the ICU with respiratory failure. These characteristics were compared with those of eight stable apnea patients of similar severity but without a history of presentation with respiratory failure. SETTING: Medical ICU and pulmonary outpatient clinic at the Houston Veterans Administration Medical Center, a teaching hospital affiliated with Baylor College of Medicine. PATIENTS: Eight patients with obstructive sleep apnea who presented in, or developed, acute respiratory failure requiring tracheal intubation and mechanical ventilation were matched to eight stable obstructive sleep apnea outpatients from the chest clinic. MEASUREMENTS AND MAIN RESULTS: The records of these 16 patients were reviewed and multiple characteristics that might predict these obstructive sleep apnea patients prone to respiratory failure and death (called the "near miss" death group; n = 8) were examined. The mean age of the near miss group was 57 yrs. All eight patients presented with respiratory acidosis (mean pH 7.22), hypercarbia (mean PaCO2 82 torr [10.9 kPa]), and hypoxemia (mean PaO2 45 torr [6.0 kPa]). Six of the eight patients had concomitant chronic obstructive pulmonary disease as determined by clinical characteristics and spirometry. Predisposing factors included facial trauma, lower respiratory tract infections or bronchospasm, and use of pain medication. All but one of the near miss subjects had awake hypercarbia (mean PaCO2 49 torr [6.5 kPa]) and hypoxemia (mean PaO2 58 torr [7.7 kPa]) during periods of clinical stability while only two controls had concomitant chronic obstructive pulmonary disease and none had hypercarbia. The prevalence of a history of wheezing and prior hospitalization for "respiratory problems" were greater in the near miss group. Once cured of apnea, no patient presented with recurrence of respiratory failure in follow-up ranging from 6 to 80 months, and cor pulmonale recurred in only one patient during subsequent onset of central apneas. CONCLUSION: Patients with obstructive sleep apnea who have concomitant chronic obstructive pulmonary disease or hypercarbia and hypoxemia are more prone to develop severe respiratory failure and probable death than those patients with apnea alone. The current study shows that recurrent respiratory failure and presumably mortality from this acute complication can be reversed with effective treatment of the obstructive apnea.     

Treating obstructive sleep apnea improves essential hypertension and quality of life

About one half of patients who have essential hypertension have obstructive sleep apnea, and about one half of patients who have obstructive sleep apnea have essential hypertension. A growing body of evidence suggests that obstructive sleep apnea is a major contributing factor in the development of essential hypertension. Despite many patients with obstructive sleep apnea having clear symptoms of the disorder, an estimated 80 to 90 percent of cases are undiagnosed. When physicians routinely seek the diagnosis of obstructive sleep apnea by asking patients (especially those with hypertension) three basic sleep-related questions about snoring, excessive daytime sleepiness and reports of witnessed apneic events, the number of cases diagnosed and treated increases by about eightfold. Eliminating snoring and occurrences of apneic-hypopneic episodes will dramatically improve patients' quality of sleep and eliminate excessive daytime sleepiness, which has a detrimental effect on general functioning. Increased alertness will reduce the likelihood that patients will be involved in motor vehicle crashes. In most studies in which blood pressure was measured following treatment for obstructive sleep apnea, daytime and nighttime blood pressure levels were found to decrease significantly. This decrease in blood pressure may also reduce the likelihood of cardiovascular complications. The key to the diagnosis of obstructive sleep apnea is physician knowledge about the disorder. The dramatic improvement in quality of life that occurs when patients are successfully treated for obstructive sleep apnea makes detecting and treating this disorder imperative.     

Circadian rhythm sleep disorders

Individuals who have circadian rhythm sleep disorders present with symptoms of insomnia or excessive sleepiness and complain of an inability to sleep at their desired time. Although the primary etiology of these disorders is a misalignment between the endogenous circadian clock and the external environment, social and behavioral factors can also play important roles in perpetuating or exacerbating these disorders. Currently, the management of circadian rhythm disorders is limited to the use of bright light and melatonin to realign the circadian clock with the desired sleep time.However, as the understanding of the physiologic and genetic basis of sleep and circadian rhythm regulation advances, even more practical and effective treatments should become available.