连续性血液净化治疗患儿静脉留置导管感染风险预测体系的构建及应用

目的:探讨连续性血液净化治疗患儿静脉留置导管感染风险因素,据此构建风险预测体系,并检验其实际应用效果,以期为临床预防护理提供依据。方法:选取医院2018年4月—2020年4月收治的400例连续性血液净化治疗患儿,按两组基础资料具有匹配性原则将其分为构建组300例、验证组100例,统计构建组中静脉留置导管感染患儿例数,通过单因素分析、多因素Logistic回归分析筛选静脉留置导管感染的独立危险因素,据此构建风险预测体系,并检验其在验证组中的应用效果。结果:经统计得到,构建组中静脉留置导管感染患儿共66例,感染发生率为22.00%;单因素分析得到,连续性血液净化治疗患儿静脉留置导管感染风险因素有穿刺部位、导管留置时间、插管次数、血流速度、血红蛋白、遵医依从性、抗生素使用时间、操作人员手卫生(P<0.05);多因素Logistic回归分析得到,连续性血液净化治疗患儿静脉留置导管感染独立风险因素有股静脉置管、导管留置时间>7 d、血流速度>180 mL/min、血红蛋白<100 g/L、遵医依从性差、抗生素使用时间>7 d(P<0.05);构建得到连续性血液净化治疗患儿静脉留置导管感染风险预测体系为P=1/[1+e^(-(-1.935+1.635×股静脉置管+1.740×导管留置时间>7 d+1.725×血流速度>180 mL/min+2.241×血红蛋白<100 g/L+2.089×遵医依从性差+1.331×抗生素使用时间>7 d))],ROC曲线分析显示,曲线下面积AUC=0.881,灵敏度为86.67%,特异性为97.14%,准确率为94.00%。结论:连续性血液净化治疗患儿静脉留置导管感染风险大,且风险因素复杂,研究构建的静脉留置导管感染风险预测体系灵敏度高、特异性强,评估准确率高。     

超声及应变式弹性成像预测超声引导下腘静脉置入血管鞘用于治疗下肢深静脉血栓形成成功与否

目的 分析超声及应变式弹性成像预测超声引导下置入腘静脉血管鞘治疗下肢深静脉血栓形成(DVT)成功与否的价值。方法 回顾性分析103例接受超声引导下置入患侧腘静脉血管鞘的DVT患者的术前超声资料,比较置入血管鞘失败与成功病例腘静脉超声及应变式弹性成像表现差异;绘制差异有统计学意义超声参数的受试者工作特征曲线,获得其预测血管鞘置入失败的阈值,对每个参数阈值赋值1分,得到联合超声评分,以实际置入结果为标准,评价超声单一参数及联合评分的预测效能。结果 103例中,对100例行单侧、3例行双侧腘静脉置入血管鞘,包括左侧腘静脉71支、右侧35支,共106支腘静脉;对其中95支腘静脉置入血管鞘成功(成功组),11支失败(失败组)。相比成功组,失败组腘静脉内径及腘静脉与腘动脉内径比值均较小,血栓为等或高回声,与血管壁边界模糊,腘静脉应变式弹性评分为硬。以超声单一参数及联合评分预测置入血管鞘成功与否的曲线下面积分别为0.909、0.926、0.865、0.899、0.958及0.940(P均＜0.001)。结论 患侧腘静脉超声及应变式弹性成像能有效预测对下肢DVT患者行超声引导下置入腘静脉血管鞘成功与否。     

Patients' expectations,experience and acceptability of postoperative analgesia: a nested qualitative study within a randomised controlled trial comparing rectus sheath catheter and thoracic epidural analgesia

Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.     

猪尾巴导管在单孔胸腔镜肺肿瘤手术中应用的有效性评估:基于倾向性评分匹配法的研究

目的评估猪尾巴导管在单孔胸腔镜肺肿瘤手术中应用的有效性。方法回顾性分析2020年1月至12月上海交通大学医学院附属仁济医院东院接受单孔胸腔镜肺肿瘤手术的患者共441例,根据是否放置猪尾巴导管分为胸管组和猪尾巴管组,通过倾向性评分匹配法进行1∶1匹配,对比两组患者围手术期的各项指标。结果匹配后每组143例配对成功,匹配后两组间基线特征无统计学差异。对比两组围手术期指标发现,猪尾巴管组患者术后3天胸腔引流总量显著多于胸管组(375.49 ml对285.03 ml,P<0.001),术后两周复查CT示胸腔积液量显著少于胸管组(131.77 ml对178.84 ml,P=0.032),两组术后疼痛评分、引流天数及住院天数无明显统计学差异。结论加放猪尾巴导管可有效改善单孔胸腔镜肺肿瘤术后胸腔引流情况,且不增加患者术后疼痛,不延长胸腔引流及住院天数。     

Comparative Measurement of Biophysical Parameters in Consideration of Skin Graft Donor Site for Nasal Defects

BackgroundIn planning a skin graft, the texture, color, and size of the recipient and donor site tissues should be considered.ObjectiveWe determined the optimal donor sites for nasal full-thickness skin grafting based on biophysical parameters.MethodsThirty women over the age of 60 were selected for this study. Four recipient sites (nasal root, dorsum, tip, ala) and three donor sites (preauricle, postauricle, forehead) were considered. Biophysical parameters such as transepidermal water loss (TEWL), capacitance, sebum output, erythema/melanin value, and skin replica technique were tested.ResultsThe nasal root was correlated with the forehead in terms of TEWL and sebum output. The nasal dorsum was correlated with the preauricle in terms of TEWL, erythema/melanin value, and skin replica measurements. The nasal tip was correlated with the preauricle in terms of TEWL, sebum output, erythema/melanin value, and skin replica measurements. The ala was correlated with the forehead in terms of TEWL and skin replica measurements.ConclusionThe preauricule is the optimal donor site for resurfacing of the nasal dorsum and tip. The forehead is a good donor site for alar defects. For resurfacing of the nasal root, the forehead and postauricle are good choices.     

Resultados a largo plazo de cirugía antirreflujo vesicoureteral con técnica de Lich-Gregoir sin drenaje vesical

ObjectiveTo describe our long-term experience with patients with vesicoureteral reflux (VUR) who underwent conventional surgery without postoperative bladder drainage.Material and methodsRetrospective review of 45 patients surgically treated by extravesical Lich-Gregoir's ureterovesical reimplantation without postoperative bladder drainage between 2010 and 2013.Results37 women (82.2%) and 8 men (17.8%). 28 patients with unilateral reflux, and 17 patients with bilateral reflux with a total of 62 operated kidneys. The mean age at surgery was 6 years (2 to 11 years).The main cause of surgical indication was the persistence of reflux in patients older than 6 years (73.3%); with grade III VUR (75.6%) being the most frequent. The mean surgical time was 44 minutes (35-70) for unilateral reimplantation, and 70 minutes (53-98) for bilateral ones.All patients presented spontaneous urination in the immediate postoperative period, without pain, no hematuria, full incontinence, and without a bladder balloon. None required bladder catheter placement, and hospital discharge was indicated between 7 and 36 hours postoperatively (mean 11 h).All continued with spontaneous micturitions, without postvoid residual or voiding dysfunction during the 5-year follow-up.ConclusionThe thorough selection of the patients, the detailed surgical gestures, the bladder emptying without instrumentation of the urethra, together with a correct use of analgesics and early ambulation allowed excellent outcomes obtained in these patients managed with a short hospital stay and without bladder drainage, also demonstrating the safety of the procedure at 5 years of follow-up.     

PICC延续性照护服务现状及制约因素分析

目的从患者和社区医疗机构层面了解PICC延续性照护服务现状并分析制约因素,为PICC维护技术在社区医疗机构的推广提供参考。方法对在株洲市3所三级医院进行PICC置管维护的196例患者采用自行设计的问卷进行调查,对10家社区医疗机构负责人进行半结构式深入访谈。结果 88.8%的PICC带管者平时的维护地点为三级医院,31.1%的患者愿意到社区医院进行导管维护,61.2%的患者因社区诊疗技术不足而不到社区医疗机构进行导管维护。访谈共提取6个主题:人力资源不足,相关知识及技术缺乏,担心风险,收费标准缺乏文件依据,缺乏国家政策支持,建议提高医疗风险的保额。结论社区医院PICC维护情况不容乐观,推进PICC维护进社区存在较多的制约因素,政府、三级医院及社区医疗机构应积极采取对策加以改进,以发挥社区医疗机构初级医疗保健作用。     

Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week

Patients with active cancer are at an increased risk of arterial and venous thromboembolism (VTE) and bleeding events. Historically, in patients with cancer, low molecular weight heparins have been preferred for treatment of VTE, whereas warfarin has been the standard anticoagulant for stroke prevention in patients with atrial fibrillation (AF). More recently, direct oral anticoagulants (DOACs) have been demonstrated to reduce the risk of venous and arterial thromboembolism in large randomized clinical trials of patients with VTE and AF, respectively, thus providing an attractive oral dosing option that does not require routine laboratory monitoring. In this review, we summarize available clinical trial data and guideline recommendations, and outline a practical approach to anticoagulation management of VTE and AF in cancer.     

预置硬膜外导管对分娩镇痛效果和母婴安全的影响

目的观察预置硬膜外导管实施分娩镇痛的效果及对母婴安全的影响。方法选择单胎、头位、足月、有镇痛需求的初产妇364例,年龄22～30岁,BMI 25～30 kg/m~2,随机分为两组:预置管组(n=180)在出现规律宫缩、宫颈接近消失后硬膜外穿刺置管,产妇自觉疼痛剧烈要求镇痛时开始镇痛;常规组(n=184)在出现规律宫缩、宫口开大1 cm后开始硬膜外穿刺置管镇痛。两组镇痛液配方均为0.075%罗哌卡因+舒芬太尼0.5μg/ml。记录分娩镇痛的有效性评分,包括镇痛开始时的VAS评分、镇痛起效时间(从产妇要求镇痛到疼痛缓解的时间)和镇痛期间最高VAS评分;分娩期间补救镇痛情况,以及产程时间、新生儿1 min和5 min Apgar评分,产间发热情况等。结果与常规组比较,预置管组镇痛开始时的VAS评分明显降低[3(2～4)分vs 5(4～5)分,P0.05],镇痛起效时间明显缩短[(18.45±7.05)min vs (33.2±10.51)min,P0.05],但镇痛期间最高VAS评分差异无统计学意义[4(2～6)分vs 4(2～6)分],预置管组的有效性评分明显较高[4(3～5)分vs 3(2～4)分,P0.05]。两组产妇产程时间、出血量、镇痛泵按压次数、补救次数、产妇发热比例及新生儿Apgar评分差异无统计学意义。结论硬膜外预置管可以提高分娩镇痛的有效性,且不影响产程和母婴安全,是一种值得推广的分娩镇痛模式。