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目的分析重症加强治疗病房呼吸机相关性肺炎(VAP)的病原菌分布特点及变迁。方法对中国医科大学附属第一医院重症加强治疗病房(ICU)2003年1月至2006年12月间VAP病人的痰培养病原菌及药敏结果进行回顾性分析。结果4年中ICU中VAP发生率为19.1%。铜绿假单胞菌为最常见菌,洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌4年中均排在前6位。金黄色葡萄球菌在2003-2005年间逐年增加,2006年有所下降;脑膜败血黄杆菌在2005、2006年分离率明显下降;近两年肺炎克雷伯杆菌的分离率增加。2004年铜绿假单胞菌对多种抗生素耐药率高(均在75%以上)。4年中对亚胺培南的耐药率均超过40%。鲍曼不动杆菌对亚胺培南和左氧氟沙星耐药率较低,嗜麦芽窄食单胞菌对复方磺胺甲恶唑、环丙沙星和左氧氟沙星耐药率较低。分离出的金黄色葡萄球菌中,耐甲氧西林金黄色葡萄球菌(MRSA)所占比例高。结论铜绿假单胞菌、洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌等非发酵菌仍为VAP主要致病菌。4年中VAP致病菌的分布特点和耐药性发生了改变。     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

呼吸重症监护病房机械通气患者下呼吸道感染的病原学动态变化

目的了解呼吸重症监护病房(RICU)机械通气患者下呼吸道感染的病原学分布及动态变化.方法采用回顾性的调查方法,对1995年10月～2001年3月收治的76例88例次接受机械通气的下呼吸道感染患者的下呼吸道分泌物中的致病菌及其药敏结果进行分析.用无菌吸痰管从下呼吸道采集分泌物,按常规方法培养、鉴定.定量培养液浓度≥107 CFU/ml的病原体为气道内致病菌.结果 88例次共培养阳性菌95株,其中10例有混合感染,阳性率76%,阳性率逐年增加(1995年～1997年阳性率为52%,1999年～2001年阳性率为91%);铜绿假单胞菌仍为常见菌(31株,36%);不动杆菌显著增长(由0株增加到8株);G-杆菌对三代头孢菌素,如头孢噻肟、头孢曲松、头孢哌酮等有较高的耐药性;6年间铜绿假单胞菌耐药率有动态变化.结论随着年代的变迁,机械通气患者下呼吸道感染发生率增加,细菌的耐药率明显增加,细菌谱亦有明显改变.积极地进行病原学诊断,合理地应用抗生素及辅助药物,对提高RICU病人的治愈率十分重要.     

危重症患者内分泌变化的临床意义

机体在大手术、重症感染等所致的严重应激状态下，不仅会发生肺脏、肾脏等脏器功能障碍，也会发生内分泌代谢紊乱，从而影响患者的临床过程和预后。本文通过动态监测45例不同病因的危重症患者血糖、血清甲状腺激素、皮质醇等改变，了解应激状态下内分泌激素的变化规律，探讨各项指标与疾病预后的相关性，为是否需要干预治疗提供依据。     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

脓毒症糖尿病大鼠肺组织DDAH2表达变化及意义

目的：观察二甲基精氨酸二甲胺水解酶2（dimethylarginine dimethylaminohydrolase 2,DDAH2）在糖尿病脓毒症机体中的表达变化,探讨血管内皮功能损害的发生机制。方法：64只Wistar大鼠随机分为正常对照组、单纯脓毒症组、糖尿病组、糖尿病脓毒症组,每组16只。免疫组织化学方法观察肺组织结构变化及DDAH2表达的分布变化。Griess法测定血清及肺组织一氧化氮（nitrite oxide,NO）含量,real-time PCR测定肺组织DDAH2 mRNA水平。结果：免疫组织化学显示糖尿病组大鼠肺组织平均光密度值（average optical density value,AOV）无明显变化,RT-PCR显示DDAH2 mRNA表达水平低于正常对照组（P〈0.05）;脂多糖（lipopolysaccharides,LPS）腹腔注射后,单独脓毒症组和糖尿病脓毒症组肺组织DDAH2 AOV值及mRNA表达较正常对照组均明显降低（均P〈0.01）;且糖尿病脓毒症组AOV值低于单纯脓毒症组（P〈0.01）,DDAH2 mRNA表达亦低于单纯脓毒症组（P〈0.05）。糖尿病脓毒症组及单纯脓毒症组血清及肺组织中NO水平均增高,血清测定前者低于后者（P〈0.05）,但肺组织中前者高于后者近2倍（P〈0.05）。结论：脓毒症肺表现为DDAH2表达下调,糖尿病脓毒症肺组织表现为DDAH2表达更为明显下调,提示存在更为严重的血管内皮细胞损害,因此DDAH2表达下调可能参与脓毒症糖尿病机体肺损伤的发生。     

严重肝功能障碍的出凝血问题

严重肝功能障碍常见出凝血异常,包括血小板减少、促凝因子和抗凝因子水平降低、纤溶蛋白水平降低,以及内 皮细胞来源的促凝因子水平增高等,共同构成出凝血系统的“再平衡”状态。在感染等诱发因素作用下,严重肝功能 障碍患者既可发生低凝出血,又可发生高凝血栓形成的并发症。全面评估严重肝功能障碍患者出凝血系统改变非常 重要。全血黏弹性检测的临床评估效能可能优于常规出凝血检测。临床医生应采用目标指导性治疗策略对严重肝 功能障碍患者出血和血栓形成进行恰当的预防和治疗。     

急性胃肠损伤分级对疾病严重程度及预后评估价值研究（附296例报告）

目的 探讨急性胃肠损伤（AGI）分级与疾病严重程度及病人预后的关系。方法 回顾性分析2013年1-9月中国医科大学附属第一医院重症医学科（ICU）收治的296例重症病人资料,对不同AGI分级病人的发病原因、APACHE Ⅱ评分、SOFA评分、并发症发生及预后情况等进行统计分析。结果 296例病人中共289例（97.6%）发生AGI,其中以AGI Ⅰ、 Ⅱ级为主;原发AGI占67.8 %,继发AGI占32.2%;原发AGI分级高于继发AGI,差异有统计学意义（P<0.05）。不同AGI分级病人APACHE Ⅱ及SOFA评分差异有统计学意义（P=0.015、0.003）,AGI Ⅲ、Ⅳ级病人APACHEⅡ评分高于AGIⅠ、Ⅱ级,AGI Ⅳ级SOFA评分高于其他（P<0.05）。不同AGI分级病人28 d病死率及多器官功能障碍综合征发生率差异有统计学意义（P<0.05）;两两比较结果显示,除AGIⅠ、Ⅱ级间比较外,其余组间差异均有统计学意义（P<0.05）。发生严重AGI时间多在入ICU早期,AGI Ⅲ、Ⅳ级病人常见临床病因为严重腹腔感染。结论 重症病人AGI发生率较高,多数以轻度（Ⅰ、Ⅱ级）AGI为主,且轻度与重度（Ⅲ、Ⅳ级）AGI病人的病情严重程度及预后存在明显差异。