基于潜变量增长混合模型的老年共病择期手术患者护理依赖发展轨迹研究

目的 探讨老年共病择期手术患者护理依赖发展轨迹的类别及影响因素.方法 选取江苏省5所综合性三级医院的598例老年共病择期手术患者作为研究对象,采用一般资料调查表、疾病累积评分量表、护理依赖量表分别于术后3 d(T1)、出院时(T2)及出院后1周(T3)进行追踪调查,利用潜变量增长混合模型及无序多分类logistic回归...     

鼻咽癌放化疗患者癌性厌食现状及影响因素分析

目的 探讨鼻咽癌放化疗患者癌性厌食现状并分析其影响因素,为实施针对性护理干预提供参考.方法 采用癌性厌食量表、症状困扰量表、医院焦虑抑郁量表对200例鼻咽癌放化疗患者进行调查.结果 鼻咽癌放化疗患者癌性厌食总分为(20.99±6.70)分,发生率为62.5％;症状困扰条目均分为(6.16士1.29)分,呈中度困扰水平;焦虑、抑郁得分分别为(11.70±3.12)分、(11.18±3.43)分.多元线性回归分析结果显示,患者文化程度、放射性口腔黏膜反应、症状困扰程度、焦虑、抑郁状态是癌性厌食的主要影响因素(P＜0.05,P＜0.01).结论 医务人员应重视评估鼻咽癌放化疗患者癌性厌食状况,并根据患者癌性厌食状况制订针对性饮食管理策略,改善患者生活质量.     

肝胆外科患者出院准备度与出院指导质量的相关性研究

目的了解肝胆外科患者出院准备度及出院指导质量现状及相关性,为针对性干预提供参考。方法选取肝胆外科患者170例,采用出院准备度量表、出院指导质量量表调查,并分析其相关性。结果肝胆外科患者出院准备度得分为7.28±1.64,出院指导质量得分为7.93±1.93。出院准备度和出院指导质量呈正相关(r=0.572,P0.01)。结论肝胆外科患者出院准备度及出院指导质量处于中等水平,出院指导质量正向影响出院准备度。医护人员需加强肝胆外科患者的出院指导,以更好地提高其出院准备度。     

维持性血液透析患者家庭照顾者心理一致感现状及影响因素

目的 探讨维持性血液透析患者家庭照顾者心理一致感现状及影响因素,为制订有效的护理干预方案提供指导.方法 便利抽样选取武汉市2所三甲医院维持性血液透析患者家庭照顾者237名,采用一般资料问卷、心理一致感量表、照顾准备度量表及积极感受量表进行调查.结果 维持性血液透析患者家庭照顾者心理一致感得分为(56.37±11.77)分.家庭照顾者心理一致感与照顾准备度、积极感受呈正相关(均P＜0.01).多元线性回归分析显示,照顾准备度及积极感受是家庭照顾者心理一致感的主要影响因素(均P＜0.01),共可解释其38.0％的总变异量.结论 维持性血液透析患者家庭照顾者心理一致感处于较低水平.医护人员需针对影响因素给予指导干预,提高其心理一致感,促进心理健康.     

预防性肠造口患者出院早期自我管理现状及影响因素分析

目的了解预防性肠造口患者出院早期自我管理现状及影响因素,为制订针对性干预措施提供依据。方法采用一般资料调查表、出院准备度量表对266例预防性肠造口患者于出院前1 d进行调查,出院后60 d使用肠造口患者自我管理问卷进行调查。结果预防性肠造口患者自我管理能力得分(102.22±17.56)分;多元线性回归分析显示,是否进行放化疗、是否有造口相关并发症和出院准备度水平是预防性肠造口患者自我管理能力的主要影响因素(均P<0.01)。结论预防性肠造口患者出院早期自我管理能力处于中等水平。医护人员应关注预防性肠造口患者自我管理的影响因素,为患者制订针对性干预措施,改善患者健康结局。     

出院准备计划方案在老年肠造口患者中的应用研究

目的 探讨出院准备计划用于老年肠造口患者的效果，为临床护理提供参考。 方法 将170例老年肠造口患者根据整群随机法分为两组各85例，对照组实施常规护理，干预组制定和实施出院准备计划方案。 结果 对照组75例和干预组77例完成全程研究。干预组出院准备度得分显著高于对照组；3个月随访期内造口门诊就诊率、非计划入院率及造口周围潮湿相关性皮肤损伤发生率显著低于对照组，自护能力得分及护理依赖得分显著高于对照组（均P＜0.05）。 结论 出院准备计划方案的实施可提高老年肠造口患者出院准备度，增强自护能力，减轻护理依赖，从而一定程度上减少造口并发症的发生，降低患者非计划再入院率及造口门诊就诊率，节约医疗资源。     

腹膜透析置管患者出院准备度现状及影响因素分析

目的调查腹膜透析置管患者出院准备度现状并分析其影响因素,以指导出院准备服务。方法采用一般情况调查表、出院准备度量表对62例腹膜透析置管患者出院前进行问卷调查。结果腹膜透析置管患者出院准备度总分(155.05±21.36)分,条目均分为(7.05±1.26)分,各维度得分从高到低依次为出院后应对能力、可获得的社会支持、自身状况、疾病知识;多元线性回归分析显示,性别、教育程度、居住方式、疾病知识知晓程度是患者出院准备度的重要影响因素(均P0.05)。结论患者出院准备度处于中等水平。医护人员应高度关注腹膜透析置管患者出院准备度水平及其影响因素,根据具体情况给予针对性的干预措施,确保患者出院后的安全。     

老年前列腺增生症患者主观幸福感与自我护理能力及社会支持的相关性

目的 了解老年前列腺增生症(BPH)患者主观幸福感与自我护理能力、社会支持的相关性,为实施针对性措施提高其幸福感提供依据.方法 采用纽芬兰纪念大学幸福度量表(MUNSH)、自我护理能力问卷、社会支持量表对157例老年BPH患者进行调查.结果 患者MUNSH得分(18.62±11.24)分;不同自我护理能力、社会支持患者...     

宫颈癌根治术后居家清洁间歇导尿患者出院准备度及影响因素调查

目的调查宫颈癌根治术后居家清洁间歇导尿患者出院准备度及影响因素,为实施针对性护理干预提供参考。方法采用一般资料调查表、出院准备度量表、出院指导质量量表对132例宫颈癌根治术后需要居家清洁间歇导尿患者进行调查。结果患者出院准备度总分为92.45±12.34;多元线性回归分析显示,居住地、主要照顾者、出院指导质量是宫颈癌根治术后居家清洁间歇导尿患者出院准备度的主要影响因素(P0.05,P0.01)。结论宫颈癌根治术后居家清洁间歇导尿患者出院准备度处于中等水平,临床医护人员应加强出院指导,根据患者情况给予针对性的干预措施,确保患者出院后的安全。     

早产儿母亲出院准备度现状及影响因素分析

目的 探讨早产儿母亲出院准备度现状,并分析影响因素,为提高产妇出院准备水平提供参考.方法 选取青岛市3所三级甲等医院NICU早产儿母亲257名,住院期间实施三阶段干预培训母亲照护技能;采用出院准备度量表、领悟社会支持量表、儿科护士与患儿父母伙伴关系量表进行调查,分析影响因素.结果 257名早产儿母亲出院准备度总分83.31±9.44,社会支持总分48.38±5.42,早产儿母亲与护士的伙伴关系总分146.55±15.65.是否具有育儿经验、不同受教育程度的早产儿母亲出院准备度得分差异有统计学意义(P＜0.05,P＜0.01);出院准备度总分与早产儿母亲和护士的伙伴关系、社会支持总分呈正相关(均P＜0.01);育几经验、社会支持水平、伙伴关系水平是早产儿母亲出院准备的主要影响因素(均P＜0.01).结论 医护人员可从影响早产儿母亲出院准备度的主要因素着手,给予早产儿母亲足够的社会支持同时制定策略加强其与护士的伙伴关系,从而提高其出院准备水平.     

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.