老年重症患者骨质流失相关危险因素分析

目的探讨老年重症患者骨质流失的相关危险因素。 方法纳入2020年7月至2021年7月浙江大学医学院附属金华医院收治的老年重症患者,测量其入住ICU前后的骨密度数据,T值下降>10%为存在骨质流失。先采用t检验、秩和检验、χ²检验比较骨质流失组与对照组临床资料的差异,再通过多因素logistic回归分析骨质流失的相关危险因素。 结果共纳入老年重症患者71例,骨质流失组41例,对照组30例。与对照组比较,骨质流失组入院时氧合指数较低、序贯器官衰竭评估评分较高、接受连续性肾脏替代治疗患者的比例较高、机械通气时间及制动时间均较长（t=-3.516,χ²=8.019,Z=-3.990、-3.161、-2.056,P<0.05或0.01）。两组患者入ICU时实验室检查指标中仅白细胞计数、C反应蛋白、白介素-6的差异有统计学意义（t=2.682,Z=-3.108、3.307,P<0.01）。多因素分析结果显示,引起患者骨质流失的相关危险因素包括入ICU时SOFA评分高、白介素-6水平高,住ICU期间行CRRT以及机械通气时间长（OR=1.223、1.080、6.635、1.004,P<0.05）。 结论老年重症患者住ICU期间发生骨质流失的风险较高,引起骨质流失相关的危险因素包括入ICU时SOFA评分高、白介素-6水平高,住ICU期间进行CRRT以及机械通气时间长。     

老年患者经鼻胃镜检查的安全性与耐受性临床研究

目的评价老年患者经鼻胃镜检查的耐受性和心肺功能的影响。方法 849例年龄≥60岁患者分为经鼻胃镜组（TN组）644例和经口胃镜组（TO组）205例,监测检查前至结束时的血氧饱和度、平均动脉压、心率,检查完毕后采用问卷调查方式了解其耐受程度。结果检查中TO组心率增快、血压升高、血氧饱和度降低比TN组更加明显,2组比较有显著性差异（P〈0.05）;TO组插镜时心率增快、血压升高,与检查前比较有统计学差异（P〈0.05）,而TN组检查前后无统计学差异（P〉0.05）。耐受性问卷调查TN组A、B、C三级各为86.0%、11.5%和2.5%,TO组分别为9.3%、33.2%和57.6%,2组比较有显著性差异（P〈0.01）。结论经鼻胃镜插入痛苦小、对心肺功能影响小,具有良好的耐受性和安全性,对高风险的老年患者尤为重要。     

82例老年吸入性肺炎的临床特征及病原学分析

目的 分析82例老年患者吸入性肺炎的临床特征及病原学特点.方法 收集2010年5月至2011年12月期间入住我院呼吸科、神经科、康复科的82例老年吸入性肺炎的临床资料,统计并分析其临床特点及病原学结果.结果 老年吸入性肺炎患者均有基础疾病及易感因素,临床表现不典型,共检出病原菌127株,革兰阴性杆菌82株(64.6％),革兰阳性球菌32株(25.2％),真菌13株(10.2％).混合感染33例,占40.2％;二重感染14例,占17.1％.结论 提高对老年吸入性肺炎的诊断率,根据其病原学特点合理使用抗菌药物,重视预防老年患者吸入性肺炎的发生具有重要意义.     

Aspiration and the elderly

Aspiration is prevalent in the elderly but its association with impairment of oral intake and gastroesophageal reflux is often misunderstood. This paper describes the causes, pathophysiology, and consequences of aspiration and their unique features in aged persons. It also explains how videofluoroscopic evaluation can assess current function while limiting factors that result in misinformation. The management of aspiration is discussed, emphasizing the importance and difficulties in maintaining functional well-being and possible complications of therapy.     

老年内科危重症患者急性肾衰竭的临床分析

目的 了解老年内科危重症患者发生急性肾衰竭(ARF)的致病因素及转归.方法 对我院内科近10年老年(≥60岁)ARF患者的临床资料进行回顾分析,将老年患者分为院外获得性ARF(院外ARF)组和院内获得性ARF(院内ARF)组,并与同期内科非老年ARF患者进行比较.结果 (1)老年内科ARF患者381例,院外获得性ARF为218例(57.2%),医院获得性ARF为163例(42.8%),其中来自内科重症监护室153例(93.9%);(2)与院外ARF组比较,院内ARF组患者年龄较高.慢性基础疾病较多,伴发感染和/或心力衰竭的比率和病死率较高,ARF的程度较重;(3)院内ARF组的致病因素以感染及心力衰竭或心肌缺血为主;(4)院内ARF组死亡147例,死亡组伴慢性基础疾病、合并严重感染及心力衰竭、伴发老年多器官功能障碍综合征(MODS)者均多于存活组,危霞症程度(APACHEⅡ评分)更高,肾衰竭程度更重;(5)与非老年组比较,老年组院内ARF构成比、伴发MODS、APACHEⅡ评分及病死率均显著增高. 结论 老年危重症患者更易发生ARF,医院获得性ARF的主要诱因为感染,心力衰竭或严重心肌缺血,病死率较高.     

Unsedated transnasal versus transoral sedated upper gastrointestinal endoscopy: A one-series prospective study on safety and patient acceptability

BACKGROUND: While conventional oesophagogastroduodenoscopy is frequently performed under sedation to improve acceptability, transnasal oesophagogastroduodenoscopy would appear to be less invasive. STUDY AIMS: To compare diagnostic accuracy, feasibility, acceptability and safety of transnasal oesophagogastroduodenoscopy without sedation versus conventional oesophagogastroduodenoscopy under sedation. PATIENTS: Following anxiety assessment, 30 dyspeptic patients underwent transnasal oesophagogastroduodenoscopy under local anaesthesia (lidocaine) and conventional oesophagogastroduodenoscopy under conscious sedation (i.v. midazolam) on two consecutive days. Transnasal oesophagogastroduodenoscopy was performed with an ultrathin and conventional oesophagogastroduodenoscopy with a standard endoscope. METHODS: Safety, evaluated by monitoring cardio-respiratory functions. Acceptability, rated according to discomfort and preference between the two examinations. Diagnostic accuracy evaluated taking into account endoscopic patterns and adequacy of biopsy specimens for histology. Feasibility, defined according to endoscopic performance, quality of images and overall opinion of the endoscopist. Only gastric biopsies were evaluated. RESULTS: All patients but one who refused conventional oesophagogastroduodenoscopy underwent both transnasal oesophagogastroduodenoscopy and conventional oesophagogastroduodenoscopy. No cardiorespiratory complications occurred during either technique. Majority of patients (87%) preferred transnasal oesophagogastroduodenoscopy. Examinations were completed in all cases, with comparable endoscopic patterns. All biopsy specimens were suitable for histology. CONCLUSIONS: Transnasal oesophagogastroduodenoscopy without sedation provides good diagnostic accuracy, is safer and better accepted than conventional oesophagogastroduodenoscopy under sedation and, therefore, represents a valid alternative in routine diagnosis of upper digestive tract diseases.     

动态监测老年吸入性肺炎患者血清超敏C反应蛋白变化的临床意义

目的 探讨动态监测老年吸入性肺炎患者血清超敏C反应蛋白(hs-CRP)水平的临床意义.方法 选择50例老年吸入性肺炎患者,在确诊第1天、第3天和第7天检测患者血清hs-CRP水平,并根据患者的病情及预后进行分析和比较.结果 50例老年吸入性肺炎患者经积极治疗后,治愈或明显缓解37例,死亡13例(26.0％);确诊第3天血清hs-CRP水平较第1天显著升高(P＜0.01),第7天较第3天回落明显(P＜0.01);第3天和第7天患者血清hs-CRP水平在病情危重组均明显高于病情较轻组(P＜0.01);不同时间点死亡组患者血清hs-CRP水平均明显高于治愈或好转组(P＜0.05或P＜0.01).结论 动态监测血清hs-CRP水平的变化可有效反映老年吸入性肺炎患者的病情变化,并对病情及预后判断具有重要意义.     

老年消化道出血414例临床分析及死亡风险评估

目的 分析老年消化道出血(GIB)患者的临床特点,评估其死亡风险因素.方法 回顾分析解放军总医院16年内(1994至2009年)414例老年GIB患者的临床资料,分析其临床特征及导致死亡的相关凶素.结果 入组患者年龄65～96岁,平均83.5岁.老年患者发生GIB的主要原因是消化性溃疡(33.1%,137/414)、胃十二指肠黏膜糜烂(28.5%,118/414)和肿瘤(21.0%,87/414);主要临床症状为黑便(71.0%,294/414);导致老年患者GIB的药物主要为非甾体消炎药(NSAIDs),包括阿司匹林(11.1%,46/414)、对乙酰氨基酚(8.9%,37/414)和吲哚美辛(1.9%,8/414).药物导致GIB的比例以及胃十二指肠黏膜糜烂导致GIB的比例在2004-2009年份段明显增加(P<0.05).有58例患者因GIB在30 d内死亡,30 d病死率为14%.本组老年GIB患者中,死亡患者的年龄、发生GIB时舒张压、心率、出血量及Hb与未死亡者相比差异明显(P<0.001).肝硬化、门静脉高压导致GIB的老年患者,以及合并心力衰竭、肾衰竭是影响30 d病死率的相关因素.结论 老年GIB患者30 d病死率与高龄、合并症及全身状况密切相关.

Abstract：

Objective To analyze clinical characteristics of patients with gastrointestinal bleeding (GIB)and the death-related risk factors.Methods A retrospective analysis Was conducted in 414 patients hospitalized for GIB during a 16-year period of 1994 to 2009.Logistic regression analysis identified predictors of mortality.Results The mean age of the 414 patients is 83.5 years old,ranging from 65 to 96years old.The main causes of GIB were peptic ulcer(33.1%,137/414),gastroduodenal mucosal erosion (28.5%,118/414)and tumor(21.0%,87/414).The main symptom was melena(71.0%,294/414).Drugs that induced GIB were mainly non-steroidal anti-inflammatory drugs,including aspirin(11.1%,46/414),acetaminophen(8.9%,37/414)and indomethacin(1.9%,8/414).14%of patients(58/414) died of GIB in 30 days.The proportion of drug-induced GIB and gastroduodenal mucosal erosion caused GIB had increased significantly during the period of 2004 to 2009(P<0.05).Analysis of 30-day mortality risk showed advanced age,low diastolic blood pressure,high heart rate,low hemoglobin levels at presentation and hemorrhage volume in dead GIB elderly patients were significantly different compared with GIB elderly patients alive.Presence of severe comorbidity(heart failure and renal failure)and caused by cirrhosis and portal hypertension in GIB elderly patients were the only independent predictors of 30-day mortality (P<0.001).Conclusion Death of GIB patients occurred predominantly in elderly patients with severe comorbidities and systemic conditions at presentation.     

老年危重症患者血浆D-乳酸及内毒素的检测及临床意义

目的探讨血浆D-乳酸和内毒素水平在老年危重症中的变化及临床意义。方法分别采用改良酶学分光光度法和微量鲎试剂酶反应显色法检测血浆D-乳酸和内毒素活性,分析老年危重症不同疾病血浆D-乳酸和内毒素的变化及其与APACHEⅡ评分、胃肠功能评分的关系。结果老年危重症患者起病后血浆D-乳酸和内毒素水平均升高,尤以重症肺炎、急性心梗、恶性心律失常升高显著;各疾病组与健康体检组比较差异有统计学意义(P0.05);危重症组患者血浆D-乳酸、内毒素活性与APACHEⅡ评分呈显著正相关(D-乳酸/APACHEⅡ评分:r=0.895,P=0.0027,内毒素/APACHEⅡ评分:r=0.562,P=0.0089);胃肠功能障碍组与非胃肠功能障碍组的血浆D-乳酸水平分别为(19.1389±8.10902)mg/L、(14.5738±6.20032)mg/L,两组比较,差异有统计学意义(P0.05),内毒素水平分别为(0.9031±0.26207)EU/ml、(0.7692±0.20677)EU/ml,两组比较,差异有统计学意义(P0.05)。结论老年危重症患者血浆D-乳酸和内毒素水平显著升高,联合监测血浆D-乳酸和内毒素活性可作为评估老年危重症胃肠功能障碍的指标之一。     

胶囊内镜对老年不明原因消化道出血的诊断及再出血因素分析

目的 评估胶囊内镜对老年不明原因消化道出血的诊断价值,并通过长期随访结果分析其再出血率及其影响因素。方法入选2002年5月至2008年2月间因不明原因消化道出血在本院行胶囊内镜检查的老年患者127例,评估受检患者的耐受性和诊断率,并随访根据诊断结果实施的治疗效果、再出血率及其影响因素。结果127例受检者中阳性诊断率为66．1％,其中以血管病变为最主要诊断,其次为肿瘤和克罗恩病,分别为59．5％、16．7％和11．9％。剔除10例失访者后,经随访发现117例中再出血率为41％,其中阳性诊断组为48-8％（38／78）,阴性诊断组为25．7％（10／39）,两组具有统计学差异（P〈0．05）;而阳性诊断组中非血管病变者再出血率为24．2％（8／33）,血管病变者为66．7％（30／45）,同样具统计学差异（P〈0．01）。结论胶囊内镜对于老年不明原因消化道出血患者是一项安全有效的检查手段。胶囊内镜诊断中以非血管性病变及阴性者再出血率低,而血管病变者再出血率高。     

老年危重症患者心力衰竭特征及其危险因素分析

目的探讨老年危重症患者心力衰竭特征并分析其相关危险因素。 方法回顾性分析2016年1月至2017年7月在徐州医科大学附属医院急诊重症医学科治疗的100例老年危重症患者的临床资料,将所有患者分为未合并心力衰竭组65例,合并心力衰竭组35例,分析心力衰竭特征及相关危险因素。 结果合并心力衰竭组患者年龄和冠心病、糖尿病、呼吸衰竭、肾功能不全、瓣膜性心脏病占比均高于未合并心力衰竭组,差异有统计学意义(P<0.05);Logistic回归分析显示,冠心病、糖尿病、呼吸衰竭、肾功能不全、瓣膜性心脏病均为导致老年危重症患者心力衰竭的危险因素。 结论冠心病、糖尿病、呼吸衰竭等为导致老年危重症患者心力衰竭的危险因素,在救治该疾病患者时应综合考虑其相关基础疾病。     

重症监护病房老年非心原性危重症患者B型利钠肽水平与预后的关系

目的 探讨急诊重症监护病房(EICU)中B型利钠肽(BNP)对老年非心原性危重症患者28 d病死率的预测价值.方法 连续选取EICU老年非心原性危重症患者70例,收集临床资料,检测BNP水平并随访患者28 d内是否死亡.结果 28 d内共有22例(31.4%)患者死亡,死亡组BNP水平的自然对数值明显高于存活组,分别为(6.4±1.2)ng/L与(5.1±1.5)ng/L(P＜0.05),BNP预测EICU老年危重症患者28 d病死率所得出接收者操作特征曲线下面积为0.759(95%可信区间0.636～0.882,P＜0.05),BNP预测EICU老年危重症患者28 d病死率最佳临界点为342 ng/L,敏感度为77.3%,特异度为68.7%,Youden指数为0.460.结论 BNP可作为预测老年非心原性危重症患者28 d病死率方便快捷的预测指标.     

老年人上消化道出血154例临床分析

目的探讨老年人上消化道出血的临床特点。方法回顾性分析我院2003年1月～2007年12月间收治的154例以上消化道出血为主要表现的老年病人的临床特点,并与同期中青年病例比较。结果与中青年人相比,老年人上消化道出血存在明显诱因者较少见（39．6％）,出血方式表现为呕血者较少见（21．6％）,其伴随疾病（49．4％）和并发症（21.4％）较多,再出血率（16．9％）和死亡率（11．7％）较高。出血病因中,老年人以胃溃疡最多见（27．9％）,其次为十二指肠溃疡（18．8％）及胃癌（18．2％）;而中青人以十二指肠溃疡（34．3％）最多见,其次为胃溃疡（16．3％）及胃癌（10．6％）。老年人胃溃疡及胃癌出血的发生率均高于中青年人,而十二指肠溃疡出血的发生率则低于中青年人（P〈O．05）。结论老年人上消化道出血以消化性溃疡多见,胃溃疡及胃癌出血的发生率较高,伴随疾病和并发症多,再出血率和死亡率高。     

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. METHODS: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). RESULTS: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. CONCLUSION: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.     

Unsedated transnasal endoscopy: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients

OBJECTIVES: Endoscopic screening of cirrhotics for large esophageal varices (EV) is advocated before initiation of prophylactic therapy for variceal bleeding. Conscious sedation for conventional endoscopy is problematic in cirrhotic patients because of risk of prolonged encephalopathy. Unsedated transnasal endoscopy (T-EGD) is a new technique, which allows for unsedated examination because it is well tolerated. The aims of this study were to determine whether T-EGD is feasible for screening of cirrhotic patients for presence of EV and to compare the diagnostic yield of T-EGD with conventional endoscopy for detecting and grading of EV. METHODS: Fifteen cirrhotics with no history of variceal bleeding, known EV, severe thrombocytopenia, or recurrent epistaxis were evaluated by unsedated T-EGD using a 5.3-mm outer diameter endoscope. Immediately afterward, a different endoscopist, blinded to T-EGD findings, performed sedated conventional endoscopy in standard fashion. The presence and size of EV, gastric varices, and other findings were recorded. Patient tolerance was also evaluated. RESULTS: Both modalities detected EV in the same 10 and gastric varices in the same two patients and completely agreed on size of EV. No stigmata of recent variceal bleeding were noted. Average time for unsedated T-EGD was 5 min 6 s. All patients found both procedures acceptable overall, with no significant difference in choking, discomfort, and sore throat. One patient developed self-limited epistaxis after T-EGD. CONCLUSIONS: 1) EV are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly screening alternative for EV in cirrhotic patients.     

乌司他丁治疗老年吸入性肺炎的临床分析

目的 观察乌司他丁对吸入性肺炎的治疗作用.方法 分析我院2007年1月至2011年6月确诊为吸入性肺炎的住院病例60例,分成对照组和治疗组,治疗组加用乌司他丁,观察两组治疗前后临床症状及临床生化指标改变,以及患者预后情况.结果 各组用药前C-反应蛋白(CRP)、白细胞(WBC)、体温、血气分析差异无统计学意义,分组后各组处理结果如下:治疗组与对照组死亡率、治愈率、平均住院时间、CRP、WBC、SaO2、PaO2差异均具有统计学意义(P＜0.05).尤其CRP指标迅速下降.结论 吸入性肺炎需尽早诊断、积极治疗、减少或者消除病因、合理用药,降低发病率及病死率.     

Risk factors for nasal bleeding in patients undergoing transnasal gastrointestinal endoscopy

Transnasal endoscopy is widely used in screening for upper gastrointestinal lesions because of less associated pain. Nasal bleeding is the most severe adverse effect, but specific risk factors have not been identified. The aim of this study is to identify risk factors for nasal bleeding during transnasal endoscopy. Nasal bleeding occurred in 160/3035 (5.3%) of patients undergoing transnasal endoscopy as part of health checkups. Patient data were retrospectively evaluated including anthropometric, medical, and life-style parameters with multiple logistic regression analysis. Multiple logistic regression revealed that nasal bleeding was significantly associated with age in decades [odds ratio/10 years 0.78, 95% confidence interval (CI) 0.63–0.97, p = 0.027], female gender (2.15, 95% CI 1.48–3.12, p < 0.001), a history of previous upper gastrointestinal endoscopy (0.55, 95% CI 0.36–0.82, p = 0.004), and chronic/allergic rhinitis (0.60, 95% CI 0.36–0.98, p = 0.043). Other factors including the use of antiplatelet and/or anticoagulant drugs were not significantly associated with nasal bleeding. Female and young patients are significantly associated with an increased risk of bleeding from transnasal endoscopy, but antiplatelet and/or anticoagulant medications and a history of chronic/allergic rhinitis may not be associated.     

Prandial aspiration and pneumonia in an elderly population followed over 3 years

The purpose of our study was to prospectively determine pneumonia frequency and correlate it with prandial liquid aspiration and feeding status in frail elderly nursing home residents. Initially, 152 patients had video swallowing examinations (81 oropharyngeal dysphagia, 19 thoracic dysphagia, 52 without dysphagia). Those diagnosed with oropharyngeal impairment were subsequently managed with swallowing therapy or artificial feeding modalities. Patients were followed for 3 years (unless they expired earlier) and clinical courses were categorized according to the degree of prandial aspiration and feeding (PAF) status. Subjects with new lung infiltrates persisting for at least 5 days with appropriate clinical findings were diagnosed as having pneumonia and were classified according to the PAF status months in which these findings occurred. Fifty-six pneumonias were diagnosed during 4,280 months with the following frequencies: no aspiration months 0.6%; minor aspiration months 0.9%; major aspiration/oral feeding months 1,3%; major aspiration/artificial feeding months 4.4%, p<0.001. Our results indicate that there is not a simple and obvious relation between prandial liquid aspiration and pneumonia. Artificial feeding does not seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators.     

老年重症新型冠状病毒肺炎患者护理专家共识

目的新型冠状病毒(2019-nCoV)因2019年12月发生在武汉的不明原因病毒性肺炎病例而被发现,由该病原感染所致的肺炎称为新型冠状病毒肺炎(COVID-19)。虽然2019-nCoV对于人群普遍易感,但老年人由于免疫力低下且合并基础疾病较多,使得该组人群感染后病情进展更快、严重程度更高,重症及危重症患者较多。为进一步提高老年重症COVID-19患者的护理质量、减少并发症、降低死亡率,我们组织国内老年重症护理专家在文献回顾和专家研讨的基础上编写该共识,该共识涵盖老年重症COVID-19患者的评估、临床护理、出院护理等相关内容,以期为临床实践提供借鉴与指导。