死腔分数与早期急性呼吸窘迫综合征患者预后的关系

目的 探讨死腔分数(VD/VT)与早期急性呼吸窘迫综合征(ARDS)患者预后的关系.方法 前瞻性临床研究,纳入2009年6月至2010年5月间东南大学附属中大医院ICU符合早期ARDS诊断标准(发病时间＜3 d)的机械通气患者23例,采用单次呼吸CO2图法测定VD/VT.记录患者一般情况、心率、呼吸、平均动脉压、急性生理和慢性健康( APACHEⅡ)评分、Murray评分、功能残气量(FRC)、PaO2/FiO2、平台压、肺准静态顺应性、住院28 d病死率;根据患者入ICU 28 d预后分为存活组和死亡组,探讨VD/VT对ARDS患者预后的预测判断价值.结果 ARDS患者发病早期VD/VT明显升高,为(0.59 ±0.09),FRC明显下降,为(1643±409)ml;23例患者中存活11例,死亡12例,28 d住院病死率52.2％ (12/23),死亡组VD/VT明显高于存活组[(0.64±0.08) vs.(0.53±0.04),P＜0.05].患者VD/VT与Murray评分之间有显著相关性(相关系数为0.464,P=0.026).VD/VT预测预后的受试者操作曲线(ROC)下面积为0.867 (P＜0.05),以0.57为临界值预测预后的敏感性及特异性分别为:0.83和0.82,显著高于FRC、Murray评分、APACHEⅡ评分.结论 ARDS早期患者死腔分数明显升高,死腔分数对ARDS早期患者预后评估有指导价值.     

限制性液体管理对急性肺损伤患者预后影响的荟萃分析

Objective To evaluate the effect of conservative fluid management on the outcomes in patients with acute lung injury (ALI). Methods Randomized controlled trials (RCTs) and cohort trials on conservative fluid management from January 1, 1990 to May 20, 2010 were retrieved by electronic and manual searching. A meta-analysis of effect of conservative fluid management on the outcomes in ALI patients was conducted by the methods as recommended by the Cochrane Collaboration. Results Four RCTs involving 594 cases in conservative fluid management group and 584 in conventional fluid management group were included into the Meta-analysis. Compared with the conventional fluid management group, there was no beneficial effect of conservative fluid management strategy on mortality in ALI patients (P = 0. 16) .However, the duration of mechanical ventilation was shortened while the incidence of renal failure remained unchanged. Three retrospective cohort trials involving 296 cases in conservative fluid management group and 750 in conventional fluid management group were included into the meta-analysis. As compared with the conventional fluid management strategy, conservative fluid management strategy had improved the patient outcomes (P ＜0.001). Conclusion No beneficial effect of conservative fluid management strategy on the mortality is observed in the ALI patients. And the ventilator-free durations become elongated. However,further trials of a larger sample size and a higher quality are warranted.     

呼吸系统弹性阻力对急性肺损伤患者肺复张后氧合影响的荟萃分析

目的 探讨呼吸系统弹性阻力(respiratory system elasticity resistance,Ers)在急性肺损伤(acute lung injury,ALI)患者肺复张过程中氧合的影响.方法 收集1999年1月1日至2010年6月30日关于在肺复张对不同Ers急性肺损伤患者氧合影响的随机对照研究、前瞻观察性研究和病例对照研究,对于肺复张对Ers≥33.3 cmH2O/L(1 cmH2O=0.098 kPa)和Ers＜33.3 cmH2O/L(1 mmHg=0.133 kPa)的ALI患者氧合影响作Meta评价.结果 共281篇文献符合纳入标准,纳入文献共20篇,共纳人患者共395人,结果提示肺复张对高Ers患者氧合改善为(51.97±8.89)mmHg,血压下降(4.33±1.32)mmHg;对低Ers患者氧合改善为(35.13±10.33)mHg,血压下降(0.22±1.03)mmHg,肺复张对两组患者之间氧合改善和血压的影响差异具有统计学意义(P＜0.01).结论 肺复张能够改善ALI患者的氧合,对高Ers的ALI患者氧合改善更为明显;但对高Ers的患者循环影响更为明显.

Abstract：

Objective To investigate the effects of elasticity resistance (Ers) in respiratory system on oxygenation in patients with acute lung injury (ALI) after recruitment maneuvers (RM). Method Meta-analysis of data about the effects of recruitment maneuvers on oxygenation in ALI patients with different elasticity resistances in respiratory system carried out with pooling of study-oriented data stored in Pubmed, Embase, Web of Science databases from January 1999 to June 2010. Results A total of 281 articles were taken, and 20 of them included a sample size of 395 ALI patients. In patients treated with RM in different degrees of respiratory system elasticity resistance ( ≥33.3 cmH2O/L and ＜33.3 cmH2O/L), the effect of RM was better in patients with the high respiratory system elasticity resistance than that with the low one [(51.97 + 8.89) mmHg vs. (35.13 ± 10.33 ) mmHg], P ＜ 0. 01 ), but the high respiratory system elasticity resistance was potentially to lower blood pressure [(4. 33 ± 1.32 ) mmHg vs. (0.22 ± 1.03 ) mmHg],P ＜ 0.01 ). Conclusions This study suggests RM could improve oxygenation of ALI patients with high respiratory system elasticity resistance, and caution must be made to avoid hypotension during RM.     

无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后影响的荟萃分析

目的 探讨无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后的影响.方法 通过计算机检索和手工检索中文期刊数据库,Pubmed,Embase,Web of Science数据库,收集1995年1月1日至2010年6月30日关于无创正压通气对急性呼吸衰竭患者拔管后进行呼吸支持和治疗的随机对照研究,按Cochrane协作网推荐的方法对拔管后采用无创正压通气进行呼吸辅助治疗患者的再插管率和病死率行Meta评价.结果 共纳入6篇随机对照研究,其中拔管后无创正压通气组(治疗组)患者381例,拔管后常规氧疗组(对照组)患者379例,治疗组和对照组患者的病死率分别为18.6%(62/334)vs.21.6%(72/333)(P=0.34),再插管率分别为30.2%(115/381)vs.33.5%(127/379)(P=0.27).与常规氧疗相比,拔管后无创正压通气不能降低患者再插管率,也不能改善患者预后.对拔管后即开始进行无创正压通气的患者进行分析,结果提示治疗组患者病死率明显降低[12.2%(22/181)vs.23.9%(44/184),P=0.004],再插管率减少;但与对照组相比,差异无统计学意义[14.0%(32/228)vs.20.4%(47/230),P=0.07].结论 急性呼吸衰竭患者拔管后早期行无创正压通气有助于减少患者再插管率,可显著改善患者预后.

Abstract：

Objective To evaluate the effects of noninvasive positive pressure ventilation (NPPV)used after extubation on mortality and rate of reintubation in patients with acute respiratory failure (ARF).Method Pubmed, Embase, Web of Science databases were searched to collect data from randomized controlled trials (RCT) of the relevant subject from January 1995 to May 2010. Meta analysis of data about NPPV on mortality and rate of reintubation in patients after extubation carried out by using the methods recommended by the Cochrane Collaboration. Results Six RCTs included sample size of 381 NPPV and 379routine medical care. In total, the mortalities of patients in NPPV group and routine medical care group were 18.6% (62/334) vs. 21.6% (72/333), respectively, and the rates of reintubation of the two groups were 30.2% (115/381) vs. 33.5% (127/379), respectively. Compared with routine medical care, NPPV did not significantly reduce the mortality ( OR: 0.83, 95% CI =0.57 ～ 1.21 ,P =0.34) and rate of reintuation( OR: 0.83, 95% CI = 0.59 ～ 1.16, ( P = 0.27). When the analysis was focused to the four studies of them in which patients received NPPV as soon as extubation, the results were quite different. From these four studies, the mortalities of patients in NPPV group and routine medical care group were 12. 2% (22/181) vs.23.9% (44/184),(P=0.004), and the rate of reintubation of the two groups were 14.0% (32/228) vs.20.4% (47/230), (P =0.07). Compared with routine medical care, early application of NPPV to patients after extubation reduced the mortality. Conclusions This study suggests the favorable effects of early application of NPPV to patients after extubation on the mortality of acute respiratory failure.     

声门下吸引对呼吸机相关肺炎发病率的影响:Meta分析

目的 评估声门下吸引对降低呼吸机相关肺炎(ventilator associated pheumonia,VAP)发病率及患者病死率有效性的影响.方法 收集1991年至2010年20年的随机对照研究(randomized controlled trials,RCT),将其中需要机械通气的患者分为两组,一组为声门下引流组,即患者的人工气道带有声门下吸引；另一组则为非声门下引流组,即应用标准气管插管者,观察两组患者呼吸机相关肺炎的发病率及病死率.所得研究数据通过RevMan4.3软件进行统计、分析.结果 共7篇RCT研究符合纳入标准,共搜集1647例,声门下引流组(796例)VAP发病率较非声门下引流组(851例)低,提示声门下吸引能明显降低呼吸机相关肺炎的发病率(OR =0.45,95％置信区间:0.32 ～0.63),尤其能降低早发型VAP的发病率,但对患者病死率的影响则不明显(OR=1.03,95％置信区间:0.75～1.41).结论 对于预期机械通气时间超过48 h的患者,声门下吸引能有效降低呼吸机相关肺炎的发病率,但并不改善患者病死率.     

外伤性昏迷患者的急诊护理分析

目的 探讨外伤性昏迷患者的急诊护理要点.方法 采用回顾性分析方法对2008年1月～2011年9月在我院急诊科抢救室治疗的的109例外伤性昏迷患者从入我院急诊抢救室至外伤性昏迷患者各项生命体征平稳后转送期间的抢救方法及护理措施进行整理和分析.结果 109例外伤性昏迷患者均我院急诊抢救室积极有效的抢救措施后,在各项生命体征平稳后98例外伤性昏迷患者转送至相关科室,11例外伤性昏迷患者因并发多器官衰竭而死亡,死亡率为10.01%.结论 对外伤性昏迷患者进行快速及时的诊断和救治,完善和细致的急诊护理是抢救成功的关键之一,为外伤性昏迷患者的进一步治疗争取宝贵的时间.     

临床科研比翼 重症医学腾飞

重症医学的临床研究是重症医学不断发展和进步的动力.2014年,重症医学在急性呼吸窘迫综合征（ARDS）、机械通气、重症感染诊治、急性肾损伤（AKI）、镇痛镇静等方面均获得不同程度的进展,本文对此进行总结,供临床同道参考. ARDS诊治进展 1.发病率及病死率的变化ARDS发病率及病死率高,严重威胁患者生命.2014年Villar等对ARDS发病率及病死率情况进行的研究结果显示,1967-1979年ARDS平均病死率约为70％,1980-1989年约为60％,1990-1997年约为50％,1998-2013年约为40％.     

股骨头置换术后早期功能锻炼的效果分析

股骨头置换术是股骨颈骨折的基本治疗方式.资料显示,股骨头置换术后加强早期功能锻炼对于病人下肢功能的恢复非常重要.     

控制性肺膨胀治疗重度急性呼吸窘迫综合征家兔的屏气时间选择

控制性肺膨胀 (ＳＩ)是在机械通气时给予足够的气道压力 ,让塌陷的肺泡充分开放 ,并通过屏气增加复张肺泡的稳定性 ,改善急性呼吸窘迫综合征 (ＡＲＤＳ)的氧合和呼吸力学[1] 。氧合改善程度与ＳＩ屏气时间密切相关 ,我们的研究探讨重度ＡＲＤＳ家兔实施ＳＩ的最佳屏气时间。材料与方法　新西兰家兔 2 8只 ,体重 (2 6± 0 4)ｋｇ。生理盐水肺泡灌洗法建立重度ＡＲＤＳ家兔模型[1] 。 (1)模型组(4只 ) :容量控制通气。潮气量 8ｍｌ/ｋｇ,呼气末正压 0ｃｍＨ2 Ｏ (1ｃｍＨ2 Ｏ =0 0 98ｋＰａ) ,吸气流速 2 0Ｌ/ｍｉｎ ,呼吸频率3 0次 /ｍｉ…