医护人员对发热伴血小板减少综合征防护知信行的调查

目的了解收治发热伴血小板减少综合征患者的科室医护人员对本病防护的知信行现状及影响因素,为制定防护对策避免疾病引发的职业暴露提供参考。方法采用自行设计的调查问卷对某三甲医院急诊科、ICU、呼吸科、感染科的186名医护人员进行发热伴血小板减少综合征防护知识、态度、行为的横断面调查。结果医护人员防护知识知晓率为80.86%,防护态度得分(42.93±3.00)分,防护行为得分为(28.86±5.19)分。不同年龄、职称、工作年限、科室和岗位的医护人员防护知识知晓率比较,差异有统计学意义(P0.05,P0.01)。不同年龄、岗位医护人员的防护行为得分比较,差异有统计学意义(P0.05,P0.01)。多重线性回归分析显示,岗位管理和防护态度为防护行为的影响因素(P0.05,P0.01)。结论医护人员对发热伴血小板减少综合征认知不足,影响防护行为的因素较多。需对医护人员适时进行职业防护培训,以提高医护人员对新发生、少见的传染性疾病的防护认知和行为,从而保障医护人员的职业安全。     

基于行为安全的医护人员血源性职业暴露综合干预

目的探讨基于行为安全的综合干预对医护人员血源性职业暴露的影响,为医护人员职业暴露防护管理提供参考。方法将符合纳入标准的178名医护人员作为研究对象,对其进行血源性职业暴露基线调查,并在此基础上实施教育培训、体验式操作、现场督导、管理控制等综合干预措施。结果干预后医护人员锐器伤发生率显著下降;医护人员血源性职业暴露防护知识正确率,防护态度、行为及安全环境得分显著高于干预前(P0.05,P0.01)。结论基于行为安全的综合性干预能提高医护人员安全防护知识、态度、技能,促进安全行为的依从性,降低血源性职业暴露发生率。     

医务人员血源性病原体职业暴露认知及防护行为分析

目的分析某三级甲等传染病医院医护人员血源性职业暴露的情况以及不同医护人员对血源性职业暴露相关知识和防护行为的差异,为探索该院职业防护与安全的全面控制模式提供参考依据。方法通过制定问卷对该院职业暴露防护认知及暴露管理进行调查分析,本阶段采用随机抽样的方法,选取该院210名在院医护人员为问卷的调查对象,共回收有效问卷196份。问卷由医护人员的人口社会学资料、血源性职业暴露认知状况、医院职业暴露管理行为,个人职业暴露状况及职业防护行为等部分组成。结果医护人员对血源性职业暴露认知的平均得分为8.11分;总体认知较好,不同科室、不同职称、不同年龄组、不同性别医护人员对职业暴露管理认知得分差异具有统计学意义(P均0.05),但不同学历和工龄间职业暴露管理认知得分差异无统计学意义。该院医护人员未接种乙肝疫苗的比例仍有10.20%,对患者是否携带病原微生物表示不关心或从未考虑的比例为14.80%。89.00%的医务人员暴露后紧急处理比较规范,97名发生过职业暴露的医护人员中80.41%(78例)的医护人员及时上报,并坚持暴露后的监测与随访。结论该院的职业防护认知和在职业暴露发生后的应急处理和上报情况较好,但仍需继续提高医院感染管理能力和医护人员的防范意识。     

肿瘤相关科室护士化疗药物职业暴露现状调查

目的了解肿瘤相关科室护士化疗药物的职业暴露现状及影响因素,为规范职业防护行为提供参考。方法采用自行设计的化疗药物职业暴露问卷对综合医院肿瘤相关科室的418名护理人员进行调查。结果肿瘤相关科室护理人员接触化疗药物所致的不良反应状况得分为(45.67±9.13)分;接触化疗药物后经常发生的不良反应为角膜炎(66.98%),恶心、呕吐(66.03%),腹泻(64.11%),皮炎、皮肤水疱(63.88%),感觉异常(60.05%)等。护理人员所在的科室、接触化疗药物的频繁程度、配药室的通风情况与其不良反应状况得分有关(P0.05,P0.01)。结论管理部门建立健全职业防护制度,规范职业防护行为,加大职业防护设施的配备,加强对肿瘤相关科室护理人员职业防护方面的相关培训,进而提高其职业防护意识,降低因接触化疗药物所致的不良反应。     

基层医务人员锐器伤分析及防护对策

<正>锐器损伤是导致医护人员发生血源性传播疾病最危险的传播途径之一。受到工作环境的局限性及自身职业防护意识淡薄等因素影响,目前基层医院医务人员出现锐器伤的概率较高。现回顾性分析我院2011-02-2013-02间发生的34例医务人     

血透中心护士职业伤害认知及防护行为的调查

目的 了解血透中心护士对职业伤害的认知和行为,为制订针对性干预对策提供依据.方法 对省、市、区三级医院血透中心的402名护士采用自行设计的职业伤害认知和防护行为问卷进行调查.结果 职业伤害认知14项中11项认知正确率达66.2%～95.0%,3项认知正确率为41.0%～51.5%;防护行为11项中8项经常实行率为75.9%～98.8%,3项经常实行率分别为65.09%、42.0%和44.5%;职业防护认知和防护行为评分,省级医院显著高于市级、区级医院,市级医院显著高于区级医院(均P＜0.01).职业防护认知总分与职业防护行为总分呈正相关(r=0.383,P＜0.05).结论 省、市、区三级医院血透中心护士职业危害认知呈中等水平,防护行为较好,医院级别越高,认知和防护行为越好;认知影响行为.各级卫生管理部门、医院及护理管理者均引起高度重视,需加强血透中心护士职业防护培训和防护设施建设,尤其应特别重视基层医院,以全面提高血透中心职业防护水平.     

临床护士职业防护现状调查

随机选择三所三级甲等教学医院的 176名护士进行问卷调查 ,内容包括一般资料、护理人员工作中的防护性行为、针刺伤情况、经血液传播疾病知识等。结果临床护士各种操作过程中如戴手套、口罩 ,洗手等安全保护意识差 ,内科护士针刺伤发生情况高于外科护士 (P <0 .0 5 ) ,戴防护性手套、掰安瓿时使用砂轮的防护行为低于外科护士 (P <0 .0 5 )。提示临床护士的职业防护意识淡漠 ,应提高其安全防范意识。     

急诊科护士建言行为及核心自我评价对其职业成长的影响研究

目的调查急诊护士的建言行为、核心自我评价和职业成长水平并探讨建言行为、核心自我评价对职业成长的影响。方法采用建言行为量表、核心自我评价量表和职业成长量表对北京市2所三甲医院急诊科的133名护士进行问卷调查。结果急诊护士建言行为得分为(3.76±0.62)分,其中抑制性建言行为得分(3.73±0.63)分,促进性建言行为得分(3.80±0.71)分;核心自我评价得分为(3.22±0.37)分;职业成长得分为(3.45±0.66)分;急诊护士的建言行为与职业成长总得分呈正相关(P0.01),核心自我评价与职业成长总分无相关性(P0.05),但与晋升速度和报酬增长2个维度具有正相关性(均P0.05);建言行为和择业原因是职业成长总水平的影响因素,核心自我评价是职业晋升维度和报酬增长维度的影响因素。结论急诊护士有着中等水平的建言行为、核心自我评价及职业成长水平,护士建言行为和择业原因是影响职业成长总水平的影响因素,核心自我评价是职业成长晋升速度和报酬增长维度的影响因素。急诊护理管理者可以通过鼓励性的措施,提高急诊护士的建言行为和核心自我评价,进而提高职业成长的水平。     

Comprehensive interventions for reducing occupational exposures in medical workers

目的 探讨预防医护人员职业暴露的有效干预措施.方法 对全院医护人员实施防范职业暴露的综合干预措施,包括宣教与培训、硬件配备、监督与反馈3个主要环节.比较实施前后医护人员职业暴露发生情况.结果 实施综合干预措施后,医护人员职业暴露发生率逐年递减(P＜0.01),操作针头所致的职业暴露逐年降低.结论 采取综合干预措施可显著降低护士的职业暴露,但医生的职业防护意识和行为仍有待加强.     

显微外科预防新型冠状病毒肺炎的应急护理管理措施

目的 探讨手足显微外科在新型冠状病毒肺炎(COVID-19)期间的应急护理管理方法,并评价效果. 方法 2020年1月20日至2月20日,采取应急护理管理措施:做好急诊患者的体温及肺部CT筛查,对所有在院患者及家属进行体温及指脉氧监测,高热或肺部CT异常患者的隔离与确诊,疑似及确诊患者病房的消毒与终末处理,医护人员的个人防护与培训,防护用具的规范使用与管理,病房人力资源的调配与管理,加强住院患者COVID-19的知识宣教以缓解焦虑等,确保患者及医务人员的安全.结果 本科室持续发热患者4例,2例排除COVID-19;1例确诊后转诊;1例高度疑似,已居家隔离.医护人员培训完成率100%,合格率100%.支援一线医护人员共48人,后备人员17人.疫情初期1例医生感染,应急管理措施落实之后无人感染;科室防护用具使用得当;在院患者无过激情绪反应,口罩佩戴依从性100%.结论 科室疫情期间所采取应急管理办法有效避免了院内交叉感染的发生,保障了医务人员及患者的安全,科学及时有效.     

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.     

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.     

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.     

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.     

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.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.