ICU患者肠内营养相关性腹泻列线图预测模型构建

目的 建立ICU患者肠内营养相关性腹泻风险预测模型，为预防性护理干预提供依据。方法 回顾分析335例ICU行肠内营养治疗的患者资料，采用单因素和多因素logistic分析肠内营养相关性腹泻的独立危险因素，构建风险预测模型，用列线图展示预测模型。采用Bootstrap法进行内部验证，受试者工作特征(ROC)曲线评价模型区分度，采用校准曲线评价模型准确度，采用临床决策曲线(DCA)评价模型的有效性。结果 163例(48.66%)ICU患者发生肠内营养相关性腹泻。肠内营养相关性腹泻风险预测模型纳入APACHE-Ⅱ评分、口服钾制剂时间、使用胃肠动力药、禁食时间和白蛋白水平5个预测因子。预测模型的ROC曲线下面积为0.940,灵敏度为81.82%,特异度为91.18%,准确度为86.57%,最大Youden指数0.73所对应的预测临界值为122分。校准曲线为斜率接近于1的直线，准确度良好。临床决策曲线显示模型的净获益值较高。结论 该模型可以有效预测ICU患者肠内营养相关性腹泻的发生，且评价指标在开始行肠内营养时即可获得，可为ICU医护人员及时采取预防性护理干预提供借鉴。     

肿瘤外科患者呼吸机相关性肺炎发生危险因素分析

目的分析肿瘤外科患者呼吸机相关性肺炎(VAP)发生的危险因素。方法选取2017-10-2018-10间收治的88例机械通气超过48 h的肿瘤外科患者,对其临床资料进行回顾性分析。结果 88例患者中34例(38.64%)发生VAP,单因素分析显示,气管切开、胃肠内营养、ICU住院时间、机械通气时间、术前使用抗生素超过48 h等,是VAP发生的危险因素(P<0.05)。多因素分析显示,胃肠内营养是VAP发生的独立危险因素(P<0.05)。结论肿瘤外科患者VAP发生率较高,相关危险因素较多,胃肠内营养是主要的独立危险因素,应加强相关预防措施,降低其发生风险。     

ICU患者肠内营养相关性腹泻分析及护理

目的观察43例ICU患者肠内营养相关性腹泻及护理措施。方法选择2009年1月～2010年1月间笔者所在医院ICU行肠内营养并发腹泻的患者43例,分析肠内营养并发腹泻的发生原因,提出有效的护理干预措施。结果肠内营养相关性腹泻的发生与营养液供给的量和速度、患者并发低蛋白血症以及药物的使用等有关。结论护理干预可以改善患者的低蛋白血症,降低肠内营养患者腹泻的发生率。     

不监测胃残留量对ICU行肠内营养患者影响的系统评价

目的探讨不监测胃残留量对ICU行肠内营养患者的影响,为临床开展肠内营养护理提供循证依据。方法计算机检索有关不监测胃残留量对ICU行肠内营养患者影响的随机对照试验(RCT)文献,按Cochrane协作网的系统评价方法筛选文献、评价纳入文献质量,使用RevMan5.3软件进行统计分析。结果共纳入5篇RCT,878例研究对象。Meta分析结果显示,不监测胃残留量患者呕吐、腹胀发生率显著高于常规监测胃残留量患者,而喂养不耐受发生率显著降低(均P0.01);不监测胃残留量对肺炎、腹泻、误吸发生率及机械通气时间、住院时间等无影响(均P0.05),对营养摄入量有影响。结论ICU行肠内营养患者不监测胃残留量对其肺炎、误吸及腹泻发生率无明显影响,其呕吐和腹胀发生风险增加,喂养不耐受发生率降低,营养摄入量得到保障。受纳入研究数量和质量限制,研究结果尚需进行大样本、高质量、多中心的RCT加以论证。     

ICU患者腹泻的原因分析及对策

目的:探讨ICU患者腹泻的原因及对策。方法:随机抽查我院ICU近2年收住的486例患者,其中临床诊断腹泻患者82例进行回顾性分析。结果:腹泻的发生率16.9%,其发生、发展与多种因素有关,包括肠内营养相关性腹泻、肠道感染、抗生素相关性腹泻(AAD)、机械通气有关等。结论:必须根据腹泻的原因进行基础护理及针对性护理干预,才能有效地预防腹泻及其并发症的发生。     

外科重症患者早期肠内营养误吸状况及影响因素研究

目的探讨重症患者早期肠内营养误吸发生现况及影响因素,为临床护理干预提供参考。方法采用便利抽样法,选取实施早期肠内营养的外科重症患者,动态监测并记录患者从实施肠内营养开始7 d内误吸情况,采用Logistic回归分析误吸发生的影响因素。结果共纳入126例患者,发生误吸30例(23.81%)。误吸组第7天目标热量达标率显著低于无误吸组,住院时间、住院费用显著高于无误吸组(均P<0.01)。APACHEⅡ评分、意识状况、营养风险、鼻饲管置入长度是外科重症患者误吸的危险因素(P<0.05,P<0.01)。结论重症患者早期肠内营养误吸发生率较高,与患者意识、营养状态、疾病程度和鼻饲管置入长度相关。应针对误吸危险因素采取针对性措施防范重症患者肠内营养误吸。     

ICU患者肠内营养加入少量食醋预防腹泻

目的预防ICU患者早期肠内营养腹泻并发症。方法将ICU 100例实施早期肠内营养的患者随机分为观察组和对照组各50例,对照组常规肠内营养,观察组常规肠内营养后鼻饲食醋20mL,连续10d后评价效果。结果观察组并发腹泻11例,对照组34例,两组比较,差异有统计学意义(P<0.01)。结论肠内营养加入少量食醋可降低腹泻发生率。     

益生菌预防机械通气患者肠内营养相关性腹泻

目的观察益生菌对机械通气患者肠内营养相关性腹泻的预防作用。方法将120例机械通气患者随机分为观察组与对照组各60例。观察组在胃肠内注入瑞能肠内营养剂加益力多,对照组常规加入瑞能肠内营养剂,观察两组患者7d内腹泻的发生率及粪便球杆比值。结果观察组患者腹泻发生率为10.0%,对照组为36.7%,两组比较,差异有统计学意义(P0.01);粪便细菌油镜观察两组球杆比值比较,差异有统计学意义(P0.01)。结论益生菌可以帮助恢复失衡的肠道微生态,有效预防机械通气患者胃肠内营养过程中腹泻的发生,有利于肠内营养治疗的顺利进行。     

重症监护室患者肺部感染危险因素与预防对策研究

目的探讨重症监护室住院患者肺部感染发生相关影响因素,并提出合理的防治对策。方法选取2016年1月至2018年6月重症监护室收治的322例患者作为此次研究对象,分析重症监护室治疗患者发生肺部感染的相关因素。结果 322例患者中肺部感染发生率为22.05%(71/322);经单因素分析发现,ICU入住时间15天、基础疾病、单纯气管切开、气管插管/气管切开机械通气、留置中心静脉导管、雾化吸入、使用抗菌药物2种和抗菌药物使用时间2周为重症监护室患者肺部感染发生危险因素,P0.05。多因素分析发现,气管插管/气管切开机械通气、ICU入住时间15天、使用抗菌药物2种和抗菌药物使用时间2周及单纯气管切开为重症监护室患者发生肺部感染的独立性危险因素,P0.05。结论重症监护室患者发生肺部感染影响因素较多,因此可针对高危因素采取合理的防控措施以降低肺部感染发生率,促进其康复。     

多模式培训对ICU护士肠内营养知信行的影响

目的提高ICU护士肠内营养的知识、信念及行为,降低ICU肠内营养患者喂养不耐受发生率。方法选择青岛市12所医院的690名ICU护理人员为对象,进行肠内营养相关知识培训,培训方式包括理论授课、在线授课、角色扮演、情景再现式教学、教学查房以及实践操作。培训前及培训后使用自行设计的肠内营养知信行问卷对培训对象进行调查,同时比较培训前后患者的肠内营养不耐受发生率。结果培训后护理人员肠内营养理论知识、态度信念、行为能力显著高于培训前,ICU肠内营养患者喂养不耐受发生率显著低于培训前(均P0.01)。结论多模式培训有利于提高ICU护理人员肠内营养理论知识、态度信念及行为能力,降低ICU肠内营养患者喂养不耐受发生率。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

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.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

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.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

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.