381. Die operative Therapie beim Thoraxtrauma — eine retrospektive Studie

Zusammenfassung Nach multiplem Trauma sinken intracelluläre Aktivität und Konzentration der Elastase in polymorphkernigen Leukocyten (PMNL), die aus Blut ( = 67 U und 6154 g/10⁹ PMNL) und bronchoalveolärer Lavage (BAL)-Flüssigkeit ( = 44 U und 5957 g/10⁹ PMNL) isoliert wurden im Vergleich zu PMNL Gesunder ( = 106 U und 9962 g/10⁹ PMNL). Gleichzeitig wurde ein Anstieg der extracellulären Elastase-Konzentration in Plasma von = 84 g/1 auf = 399 g/1 und in BAL Flüssigkeit von = 8 g/1 auf = 561 g/1 beobachtet. Die durch Stimulation freigesetzte Elastase wird teilweise von einem spezifischen Receptor auf PMNL erneut gebunden. Die Ergebnisse unterstützen die PMNL-vermittelte ARDS-Pathogenese.     

Symptom Diary–Based Analysis of Disease Course among Patients with Mild Coronavirus Disease,Germany, 2020

Limited information is available on the clinical course of outpatients with mild coronavirus disease (COVID-19). This information is critically important to inform public health prevention strategies and to provide anticipatory guidance to patients, primary care providers, and employers. We retrospectively assessed the daily prevalence of symptoms in 313 COVID-19 outpatients for the first 20 days of illness. Generalized estimating equations were used to assess the probability of symptom occurrence over time. Fatigue (91%), cough (85%), and headache (78%) were the most common symptoms and occurred a median of 1 day from symptom onset. Neurologic symptoms, such as loss of taste (66%) and anosmia (62%), and dyspnea (51%) occurred considerably later (median 3–4 days after symptom onset). Symptoms of COVID-19 are similar to those of other respiratory pathogens, so symptomatic patients should be tested more frequently for severe acute respiratory syndrome coronavirus 2 during influenza season to prevent further spread of COVID-19.     

肾综合征出血热(HFRS)并发ARDS临床特征及抢救

目的　探讨肾综合征出血热 (HFRS)并发急性呼吸窘迫综合征 (ARDS)临床特征及诊断和抢救措施。方法　对 8例HFRS并发ADRS临床特征及血气、X检查进行分析诊断及其抢救措施。结果　 8例中 3例治愈(早期 2例 ,中期 1例 )。 5例死亡 (皆为中晚期 )。治愈率为 37 5% (3/ 8) ;病死率 6 2 5% (5/ 8)。结论　ARDS发病期别与预后关系较大。其发病机理主要是各种致病因素 ,尤其是严重感染和休克 ,使体内产生大量炎性介质、可使毛细血管扩张 ,通透性增加 ,引起间质性肺水肿。由于中性粒细胞和血小板被活化 ,可释放大量自由基 ,使肺微血管损伤和通透性增加 ,使肺含水量增高所致。救治措施 ,积极治疗和纠正原发病 ,迅速纠正缺氧 ,限制液体入量 ,早期使用胶体液 ,减轻肺水肿。早期大量肾上腺皮质激素应用 ;α受体阻滞剂 -酚氨拉明及抗胆碱能药物 -东莨菪碱应用 ,均对改善肺水肿有益。     

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality.The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.     

Septischer Schock und multiples Organversagen in der chirurgischen Intensivmedizin

Zusammenfassung Beschrieben wird ein tierexperimentelles Sepsismodell, das der Problematik chirurgischer Intensivpatienten entspricht. Nach rezidivierender Applikation von E.-coli-Endotoxin W0111:134 unter standardisierten Bedingungen konnten spezifische hämodynamische, biochemische (TNF, TXA₂, PG I₂, IL-6, PAF) und morphologische Veränderungen (pulmonales Endothel) nachgewiesen werden. Die sepsisinduzierten ARDS-Veränderungen werden mit einer Hochfrequenzdruck-und-flowmessung mit 385 Meßpunkten fiber einem Atemzyklus analysiert. Die Rolle des Darms in der Sepsis wurde mit ionenselektivem Kaliummonitoring vergleichend auf der Mukosa and Serosa untersucht. Jede Endotoxingabe wurde vom Dünndarm mit selektiven Anstiegen der Kaliumaktivität als Ausdruck einer Endotoxin-induzierten relativen Ischämie beantwortet. Das Profil der Oberflächenkaliumwerte korreliert sowohl mit dem cardiaco output als auch mit den Prostazyklinspiegeln. Die während der Versuchsdauer kontinuierlich abnehmende Mukosa-Serosa-Kaliumdifferenz kann als Nachweis einer die Sepsis katalysierenden intestinalen Permeabilitätsstörung interpretiert werden.

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Septic shock and multiple organ failure during surgical intensive care. Evaluation of pulmonary and intestinal dysfunction assessment in a porcine model

The study deals with an animal model for the problems of surgical intensive care patients. Following repeated applications of E. coli endotoxin W0111:134 under standard conditions, specific hemodynamic and biochemical (TNF, TXA₂, PGI₂, IL-6, PAF) and morphological (endothelium of the lung) alterations were detected. ARDS patterns induced by the sepsis were analyzed by high-frequency measurement of pressure and flow (385 measurements per breathing cycle). The role of the intestine in sepsis was investigated by ion-selective monitoring of surface potassium activity comparing mucosa and serosa. Every injection of endotoxin was followed by a selective increase of the potassium activity revealing relative ischemia induced by the endotoxin. The profile of the potassium levels on the surface correlates both with the cardiac output and with the prostacyclin levels. The continuous narrowing of the difference between mucosa and serosa, potassium during the period of investigation can be regarded as evidence for pathologic change in permeability fostering the septic course.

     

利用压力-容积曲线选择呼气末正压治疗急性呼吸窘迫综合征

目的探讨利用压力-容积曲线选择呼气末正压(PEEP)对急性呼吸窘迫综合征(ARDS)患者肺力学、血流动力学及动脉血气参数的影响,并选择最佳PEEP范围.方法选择16例确诊为ARDS患者,根据压力-容积曲线,设下拐点压力为PLIP,设上拐点压力为PUIP.分别选择PEEP为0、PLIP/2、PLIP、(PLIP+PUIP)/2和PUIP,测量肺力学、血流动力学及动脉血气参数的变化.结果当PEEP为PLIP/2时,动脉血氧分压与吸入氧浓度比(PaO2/FiO2)及Cst虽然较未加用PEEP时有改善(P<0.05及P<0.01),但尚未达到正常水平;当PEEP为PLIP时,PaO2/FiO2及Cst较PLIP/2时有显著提高(P<0.01),接近正常范围;当PEEP为PUIP时,PaO2/FiO2较(PLIP+PUIP)/2时显著增高(P<0.01),但Cst较PLIP时反而有所降低(P<0.01),MAP下降(P<0.01),CVP升高(P<0.01),同时Pip增高(P<0.01).结论ARDS患者行呼吸机治疗时,在PLIP～PUIP之间可有效纠正低氧血症,而对血流动力学影响较小,可获得满意疗效.     

防治SARS中药的筛选

SARS在世界范围内流行 ,在紧急阶段 ,由于临床处治方案颇有争议 ,迅速的筛选出有效的中成药供临床急用尤为重要和迫切。利用 9个药理筛选模型交叉验证的方法 ,综合评价了 30个中成药的有效性。 19个药物作为有效的药物筛选出来 ,其中 8个最有效作为控制SARS不同阶段症状的药物由全国防治非典指挥部科技攻关组在 2003年5月22日对全国进行发布。本文就筛选的策略 ,顶层设计和主要研究思路做一介绍 ,具体试验结果将陆续发表。     

外源性肺表面活性物质在ARDS中的治疗作用

Several studies have demonstrated that alterations of pulmonary surfactant system contribute to the lung dysfunction associated with acute respiratory distress syndrome (ARDS). There have been many animal experiments and clinical investigations evaluating exogenous surfactant in ARDS models or patients. Exogenous surfactant administration has proven inconsistent as a therapeutic modality for patients with ARDS. Various factors that may influence a host response to exogenous surfactant, these factots include: the nature and severity of the underlying injury,the surfactant preparation utilized, the amount, frequency, and method of surfactant administration, the mode of ventilation used during and after surfactant delivery, and the timing or surfactant administration over the course of the illness     

ARDS机械通气肺保护性策略的研究进展

急性呼吸窘迫综合征(ARDS)是重症监护病房最常见的致死性并发症,治疗困难,机械通气仍是ARDS最重要的治疗手段之一。随着近年对ARDS病理生理学的新认识及ARDS机械通气治疗的临床研究的进展,肺通气保护性策路也发生改变,现概述如下。