急性生理学及慢性健康评估II系统在临床重症监护中的应用

急性生理学及慢性健康评估II(APACHE II)系统是目前临床重症监护病房(ICU)应用广泛且极具权威的危重患者病情评价系统。APACHE II能够正确判断患者疾病严重程度及评估患者预后,分值越高病情越重,且预后越差,病死率越高,已成为世界上应用最为广泛的危重病预后评价系统。追溯APACHE II系统的历史发展以及在重症监护领域的应用现状,对其应用的局限性进行回顾和探讨,提示在临床重症监护中充分利用APACHE II系统的优势,克服其局限性使之更好的为临床服务,使危重病评分系统在重症监护工作中得到更广泛更合理的应用,以提高危重患者的救治水平和重症监护水平。     

肠内联合肠外营养的应用对危重症患者的预后影响

目的:研究肠内联合肠外营养(EN+PN)支持在危重症病人中的临床应用效果. 方法:将60例有部分或全部胃肠功能的危重症病例随机分为肠内联合肠外营养(EN+PN)支持组、完全肠内营养(TEN)支持组和完全肠外营养(TPN)支持组,每组20例,对比观察营养支持前1d及营养支持后d7患者的体重指数、肱三头肌皮褶厚度、血清前白蛋白、白蛋白、总蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数,且每天观察并发症情况. 结果:营养指标比较:经EN+PN支持后,血清前白蛋白明显升高(P<0.01),总蛋白、白蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数亦有升高(P<0.05);而TEN和TPN支持后,各指标结果无显著差异.三组对比,EN+PN支持组血清前白蛋白、白蛋白、总蛋白、血红蛋白、免疫球蛋白、淋巴细胞计数均高于EN组和PN组(P<0.05),体重指数,肱三头肌皮褶厚度无显著差异.并发症比较:EN+PN支持组患者并发症的发生率显著低于EN组和PN组(P<0.05).结论:EN+PN支持更符合生理状态,有更好的代谢效应,能改善危重症病例营养状况提高免疫功能,降低并发症发生率,对有部分或全部胃肠功能的危重症病例,应尽量早期采用.     

Integrating mental health care into residential homes for the elderly: an analysis of six Dutch programs for older people with severe and persistent mental illness

Integrating mental health care into residential homes for the elderly is a potentially effective model to address the complex care needs of older chronically mentally ill people. Because no research was available on the implementation of such integrated care in practice, six programs already operating in the Netherlands were analyzed. At the administrative level, three types of cooperative arrangements existed: a psychiatric hospital renting a unit in a residential home for the elderly, a psychiatric hospital stationing mental health professionals in a residential home on a permanent basis, and a residential home employing its own psychiatrically trained staff. At the operational level, contrasting views emerged on the relation-ship between physical and mental health care; these were delivered separately or in integrated form. In either case, the employees trained as elder care workers or as psychiatric nurses had difficulties understanding each other because they held different ideas about good-quality care. These care visions can be characterized as the care-giving approach (care workers) versus the problem-oriented and the rehabilitation approaches (nurses). At the housing level, two models existed: mentally ill patients having apartments in a separate unit (concentrated housing) or located throughout the facility (dispersed housing). The most promising model appears to be the one in which a psychiatric hospital assigns mental health professionals to work in a residential home, where they remain administratively and operationally distinct from the standard residential services. Whether or not the psychiatric residents should be housed in separate units could not be decided based on this study.     

Nutrition and survival in intensive care

Summary The potential role of nutrition to influence survival in the critically-ill is discussed. Increasing benefits are described to enteral nutrition but there remain some patients who have high mortality in whom only parenteral nutrition is possible. The clinical relevance of glutamine in parenteral nutrition is reviewed in the context of how it might influence survival from severe illness. Received: 7 May 1997 Accepted: 12 August 1997     

Effect of afterload reduction on plasma volume during acute heart failure

Previous investigations in our unit indicated that acute cardiogenic pulmonary edema is associated not only with an increase in left ventricular end-diastolic pressure and pulmonary arterial wedge pressure but also with a relative increase in colloid osmotic (oncotic) pressure and peripheral hemoglobin concentration. This combination of changes suggested that acute congestive heart failure with pulmonary edema, unlike chronic congestive heart failure, is associated with a contraction of intravascular blood volume. In this study, plasma volume changes were measured before and during the treatment of acute cardiogenic pulmonary edema in 14 patients with arteriosclerotic heart disease. The plasma volume measurement in all 14 patients before the initiation of treatment was either normal or decreased. After treatment with the alpha adrenergic blocking agent phentolamine, the plasma volume increased rather than decreased when measured 4 and 12 hours after the initiation of treatment. During this time colloid osmotic pressure and peripheral hemoglobin concentration progressively decreased. These findings suggest that acute cardiogenic pulmonary edema is associated with the extravasation of large quantities of plasma water from the intravascular compartment into the interstitial compartment and contraction of the intravascular plasma volume. The treatment of acute cardiogenic pulmonary edema is associated with the return of hypo-oncotic fluid from the interstitial compartment back into the intravascular compartment with expansion of plasma volume and reduction of colloid osmotic pressure and hemoglobin concentration.     

湖南省2005-2009年违法犯罪精神病人接受强制治疗的现状

目的:探讨湖南省司法精神病学鉴定结果为无/限定刑事责任能力的违法/犯罪精神病人,接受强制治疗的情况及相关因素.方法:利用自编调查问卷,对湖南省2005-2009年间经司法精神病学鉴定为无/限定刑事责任能力的所有1808违法/犯罪精神病人,进行资料收集.结果:1808例病人中,接受强制治疗者为284人(15.7％),未接受强制治疗者1524人(84.3％).多因素logistic回归分析表明,男性(OR=2.35,95％CI=1.51 ～3.67)、患有精神病性障碍(OR=3.44,95％ CI=1.55 ～ 7.62)或器质性精神障碍(OR=3.55,95％CI=1.31～9.64)、犯故意杀人罪(OR =6.56,95％CI =4.05～ 10.62)或故意伤害罪(OR=2.60,95％CI=1.55～4.35)、被鉴定为无刑事责任能力(OR=11.81,95％CI =5.43 ～25.67)的违法/犯罪精神病人接受强制治疗的可能性较大.结论:湖南省违法/犯罪精神病人接受强制治疗的比例较低,司法系统应按现行法律规范违法/犯罪精神病人接受强制治疗的程序.     

Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review

ObjectivesCoronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients.MethodsWe performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection.ResultsFrom 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5–59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5–11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6–13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors.ConclusionsThis systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.     

SBAR沟通模式对老年危重症患者护理质量及家属满意度的影响研究

目的：研究SBAR沟通模式对老年危重症患者护理质量及家属满意度的影响。方法：选取2019年1~3月收治的老年危重症患者42例为对照组,另选取2019年4~6月收治的老年危重症患者42例为观察组。对照组患者在交接班管理中采用传统沟通模式,观察组患者在交接班管理中采用SBAR沟通模式。对比两组交接班管理护理质量、患者家属满意度和护士对交接班效果的评价。结果：观察组护理质量各项内容评分和总分均高于对照组,差异有统计学意义（P＜0.05）;观察组不良事件发生率（2.38%）低于对照组（14.29%）,但差异无统计学意义（P＞0.05）;观察组家属满意度为97.62%,高于对照组的80.95%,差异有统计学意义（P＜0.05）;观察组护士满意度高于对照组,差异有统计学意义（P＜0.05）。结论：老年危重症患者护理服务中采用SBAR沟通模式,可提高护理质量,降低护理期间不良事件发生率,提高患者家属满意度。