住院患者肠内营养护理质量敏感性指标的构建

目的构建适用于住院患者肠内营养护理质量的敏感性指标,为提高肠内营养护理质量提供参考。方法在文献检索基础上,以结构—过程—结果质量管理模式为理论依据,结合专题会议讨论构建住院患者肠内营养护理质量敏感性指标初稿,对20名专家进行两轮函询。结果最终构建的住院患者肠内营养护理质量的敏感性指标包含一级指标3项,二级指标11项。两轮专家积极系数为100%,Kendall协调系数分别为0.305和0.368(均P0.01),专家权威系数分别为0.870和0.860。结论构建的住院患者肠内营养护理质量敏感性指标可为专科护理质量评价提供客观、可量化的参考。     

临床护士信息安全素养评价指标体系的构建研究

目的 构建临床护士信息安全素养评价指标体系,为临床护士信息安全培训及考核评价提供参考。方法 以知信行理论为指导,通过文献研究、现场调研的方法初步拟定指标体系并编制专家函询问卷,邀请全国20名专家进行2轮德尔菲法专家函询,采用层次分析法确定各指标权重。结果 2轮函询问卷有效回收率均为100%,专家权威系数分别为0.945、0.950,肯德尔和谐系数分别为0.179、0.193(均P<0.05)。最终确定的临床护士信息安全素养评价指标体系包括信息安全知识、信息安全意识及信息安全行为3项一级指标、12项二级指标、59项三级指标。结论 构建的临床护士信息安全素养评价指标体系内容全面、科学可靠,可为临床护士信息安全培训及考核评价提供客观的量化依据。     

基于德尔菲法构建泌尿外科护理安全管理评价体系

目的构建泌尿外科护理安全管理评价体系,为提高泌尿外科护理安全管理提供依据。 方法通过文献回顾初步构建泌尿外科护理安全管理评价体系初稿,采用德尔菲法（Delphi）对16名泌尿外科护理专家进行2轮函询,最终形成泌尿外科护理安全管理评价体系。 结果2轮函询中问卷回收率分别为100%、94.12%,专家意见的集中程度波动在4.25~5.00,专家意见的协调程度波动在0.00~0.20,专家权威系数分别为0.910、0.929,专家Kendall's W协调系数分别为0.119和0.114,最终构建包含10项一级指标,55项二级指标,41项三级指标的泌尿外科护理安全管理评价体系。 结论构建的泌尿外科护理安全管理评价体系内容全面,具有较高的科学性、权威性、实用性,为提高泌尿外科护理安全管理提供参考。     

输尿管皮肤造口患者延续护理质量评价指标体系的构建

目的 构建输尿管皮肤造口患者延续护理质量评价指标体系，为评价延续护理质量提供工具。 方法 以三维质量结构模式为理论框架，采用文献回顾、半结构式访谈、2轮专家函询及层次分析法，确立输尿管皮肤造口患者延续护理质量评价指标体系及各级指标权重。 结果 2轮专家函询问卷有效回收率为95.83%、100%，专家权威系数为0.900、0.909，肯德尔和谐系数为0.161~0.217（均P＜0.05）。最终确立输尿管皮肤造口患者延续护理质量评价指标体系，包括3项一级指标，13项二级指标，54项三级指标。各级指标权重一致性检验系数均＜0.1。 结论 输尿管皮肤造口患者延续护理质量评价指标体系具有较好的专家认可度，可进一步开展临床验证研究。     

ICU医护人员肠内营养中断管理知信行量表的编制及信效度检验

目的 研制ICU医护人员肠内营养中断管理知信行量表，并进行信效度检验。 方法 基于知信行理论框架，通过文献回顾法、访谈法和专家函询法形成量表初稿。便利选取400名ICU医护人员进行调查，对量表进行项目分析和信效度检验。 结果 形成的ICU医护人员肠内营养中断管理知信行量表包括3个维度共41个条目；3个维度累积方差贡献率分别为70.341%、70.437%和66.550%；总量表Cronbach′s α系数为0.953，重测信度为0.795。总量表的条目水平效度为0.800～1.000，量表水平效度为0.975。 结论 ICU医护人员肠内营养中断管理知信行量表具有良好的信效度，可用于ICU医护人员肠内营养中断管理知信行现状评估。     

住院患者肠造口护理质量敏感性指标体系的构建

目的 构建住院患者肠造口护理质量敏感性指标体系，为住院患者肠造口护理管理提供监测依据。方法 基于循证和小组讨论法，拟订肠造口护理质量敏感性指标初级条目池；通过2轮专家函询，修订并确立住院患者肠造口护理质量敏感性指标体系。结果 2轮函询专家积极系数均为100%，权威系数为0.898与0.908，协调系数为0.189～0.239与0.215～0.258（均P＜0.05）。构建的住院患者肠造口护理质量敏感性指标体系包含3项一级指标、6项二级指标、22项三级指标。结论 构建的住院患者肠造口护理质量敏感性指标体系严谨、全面，可用于住院患者肠造口护理质量管理。     

社区居家卧床患者压疮管理质量评价指标的构建

目的构建社区居家卧床患者压疮管理质量评价指标,以规范性评价社区居家卧床患者压疮管理质量。方法查阅国内外文献、小组讨论,形成社区压疮管理质量评价指标问卷,采用Delphi法对15名专家进行2轮咨询。结果构建的社区居家卧床患者压疮管理质量评价指标包括一级指标3项,二级指标11项,三级指标32项;专家的权威系数为0.794;2轮三级指标的协调系数分别为0.613、0.622(均P0.01)。结论社区居家卧床患者压疮管理质量评价指标及其内容可靠,经目标人群(大样本)验证后,可用于社区压疮护理质量的评价。     

基于儒家思想的护理人文关怀能力评价指标体系研究

目的构建基于儒家思想的护理人文关怀能力评价指标体系(下称评价指标体系),用于评价中国护理人员的人文关怀能力。方法拟定3项一级指标、8项二级指标及75项三级指标的"评价指标体系"咨询表,采用Delphi法对分布于临床护理、护理管理、护理教育及医学人文教育领域的30名国内外专家进行3轮咨询,采用层次分析法确定权重。结果获得包含4项一级指标、8项二级指标和59项三级指标的评价指标体系;专家积极系数为93.3%～100%,权威系数为0.86,第2、3轮调查肯德尔协调系数为0.358、0.335,集中度好。结论评价指标体系与中国文化紧密结合,具有客观、系统、可操作的特点,可用于护理人员人文关怀能力的自我定性评价。     

基于跨理论模型的膝骨关节炎患者行为分层管理系统的构建

目的 构建基于跨理论模型的膝骨关节炎患者行为分层管理系统,为实现膝骨关节炎患者正向且可持续的行为管理提供适用性方案。 方法 采用文献研究、德尔菲专家咨询法构建基于跨理论模型的膝骨关节炎患者行为分层管理系统。 结果 2轮专家函询问卷有效回收率均为100%;专家权威系数分别为0.87和0.90;第2轮指标重要性赋值均数为4.21～5.00,变异系数为0.00～0.20,协调系数为0.17～0.23（均P＜0.05）;指标可行性赋值均数为4.04～5.00,变异系数为0.00～0.21,协调系数为0.16～0.23（均P＜0.05）。最终形成由前意向阶段、意向阶段、准备阶段、行动阶段和维持阶段5项一级指标、10项二级指标、34项三级指标构成的膝骨关节炎患者行为分层管理系统。 结论 膝骨关节炎患者行为分层管理系统构建过程严谨,且有较好的可靠性,经临床验证后可用于膝骨关节炎患者的行为管理。     

思政视域下新护士规范化培训评价体系的构建

目的 构建思政视域下新护士规范化培训多维度评价体系，以全面评价培训效果。 方法 依据文献分析、半结构式访谈、小组讨论等拟订新护士规范化培训评价体系条目池，采用Delphi法对24名专家进行2轮函询，按指标入选准则及层次分析法确定指标及权重。 结果 构建的评价体系包含6项一级指标、24项二级指标及79项三级指标。2轮函询的专家积极系数分别为92.31%、100%，权威系数分别为0.859、0.867，协调系数分别为0.173、0.190。 结论 构建的新护士规范化培训评价体系，评价指标全面，专家权威性较高、一致性较好，经实用验证后可用于新护士规范化培训效果评价。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.