儿科急诊危重患儿状况调查及分析

目的 调查分析儿科急诊危重患者状况,以期对诊治提出改进意见.方法 入急诊监护室374例危重患儿,记录来院方式、途中治疗、急诊停留时间,检测血气、生化,评估小儿/新生儿危重病例评分(PCIS/NCIS)、格拉斯哥昏迷评分(GCS),判断是否符合全身炎症反应综合征(SIRS)、脓毒症、感染性休克.结果 在374例患儿中,新生儿占29.9％,其余患儿平均年龄37.4个月.急诊停留时间4.7 h (0.42～96 h),感染性疾病47.6％.出租车、救护车、私家车为主要来院工具,分别占38.3％、28.4％、21.5％.病死率12.3％,住院病死率10.3％,急诊病死率15.6％,差异具有统计学意义(P＜0.01).PCIS/NCIS评分(81.92±9.66),危重评分≤80占44.4％、≤90占81％.172例患儿接受GCS评估,GCS≤8、9～12、13～15分别占35.5％、21.5％、43.0％.病死率为26.23％、10.81％、5.41％,差异具有统计学意义(P＜0.01).GCS≤8与13～15、GCS 9～12与13～15患儿PCIS差异具有统计学意义(P＜0.01);GCS≤8与9～12间PCIS差异无统计学意义(P＞0.05).PCIS与GCS二者正相关(r=0.454,P=0.01),能建立直线回归(R2 =0.183,回归系数t检验P＜0.01).374例,SIRS 41.7％,脓毒症25.7％.262例非新生儿病例,休克占43.5％,61.4％为感染性休克.374例中,低血钠37.2％,高血钾22.0％.新生儿低血糖20.91％,高血糖29.1％;非新生儿低血糖9％,高血糖66.7％.pH ＜7.35的酸中毒67.8％,pH＜7.2的严重酸中毒33.1％.结论 (1)新生儿、婴幼儿占急诊危重患儿绝大部分;(2)急诊停留时间相对较短(4.7 h).急诊病死率高于住院病死率( 15.6％ vs.10.3％,P＜0.01),应积极缩短急诊停留时间,尽早住院;(3)不同交通工具来院,危重评分差异无统计学意义,使用救护车者不到1/3 (28.4％),应提高社会使用院前急救服务的意识并提高院前急救的便利性;(4)急诊PCIS/NCIS可有效评估病情与预后;重度脑功能障碍(GCS≤8)、中度脑功能障碍(GCS 8～12)共57％,非创伤性脑功能损伤在儿科急诊重患中占重要地位;(5) GCS≤8、9～12与13～15患儿的PCIS差异有统计学意义,GCS＜ 13应予重视,患儿可能处于危重状态;(6)SIRS 41.7％,脓毒症25.7％;休克占43.5％,感染性休克为主(61.4％),应重视急诊危重患儿循环、器官组织灌注状态观察与评估,以早期识别休克;(7)电解质紊乱以低血钠(37.2％)、高血钾(22.0％)最常见;高血糖(66.7％)常见,新生儿也应注意低血糖(20.91％);酸碱平衡紊乱以酸中毒为主(67.8％),应注意相关检测及监测.     

严重烧伤早期患者血清可溶性P-选择素及可溶性E-选择素的变化及意义

目的探讨严重烧伤早期患者血清可溶性P-选择素(sP-选择素)、可溶性E-选择素(sE-选择素)的变化及意义。方法采用酶联免疫吸附法定量检测32例严重烧伤患者和20例体检健康者血清sP-选择素、sE-选择素水平。结果严重烧伤早期患者血清sP-选择素、sE-选择素水平高于健康者(P<0.05)。结论严重烧伤早期患者血清sP-选择素、sE-选择素升高与血管内皮细胞损伤及全身非感染性炎性反应有关,血小板可能在烧伤患者凝血功能异常中发挥一定的作用。     

儿童早期预警评分在急诊患儿病情危重程度评估中的应用

目的:探讨儿童早期预警评分(PEWS)在急诊患儿病情严重程度评估中的应用效果。方法:选取2015年6~9月来我院儿科急诊就诊且符合纳入标准的内科患儿800例,根据患儿的去向分为普通组(包括出院、入住普通病房)和PICU组,对两组患儿预检时进行PEWS评分,并分析PEWS分值对评估患儿入住PICU的敏感度、特异度及最佳截断值。结果:PICU组患儿PEWS分值明显高于普通组(P0.05),ROC曲线下面积为0.849(95%CI:0.78~0.92),PEWS对评估患儿入住PICU具有重要意义(P0.05),PEWS对评估患儿入住PICU的敏感度为92.9%,特异度为79.3%,Youden指数为0.722,PEWS最佳截断值为2.5分。结论:PEWS评分系统对评估急诊患儿病情严重程度具有较高的临床应用价值,值得临床推广使用。     

血浆可溶性E-选择素和P-选择素与慢性乙型肝炎的关系

选择素是细胞黏附分子的一种,近年来发现与许多疾病密切相关。选择素与慢性肝病之间的关系也越来越受到人们的重视,为了探讨可溶性E-选择索（sE-selectin）和可溶性P-选择素（sP-seleetin）在各型慢性乙型肝炎患者的含量变化,我们动态检测了慢性乙型肝炎60例患者外周血sE-selectin和sP-seleetin的含量,并分析其与血清乙型肝炎病毒脱氧核糖核酸（HBV-DNA）定量的关系,现报道如下。     

冠心病病情和预后评估指标:E-选择素及C-反应蛋白的检测

目的:探讨不同类型冠心病患者可溶性E-选择素(solubleE-selectin,SES)、C-反应蛋白(C-reactiveprotein,CRP)的变化及其临床意义。方法:81例患者,按临床诊断分为4组:急性心肌梗死组17例、不稳定型心绞痛组24例、稳定型心绞痛组20例和20例对照组患者(阵发性室上速)。分别检测各组患者SES及CRP的水平,对冠心病患者的冠状动脉损害行Gensini评分,并比较各组间的差异。对冠心病患者冠状动脉损害行Gensini评分,并与其SES及CRP水平进行直线相关分析。结果:①急性心肌梗死组、不稳定型心绞痛组及稳定型心绞痛组的SES犤其值分别为(99.29±15.04),(97.46±11.33),(78.48±18.93)μg/L犦及CRP犤其值分别为(6.73±1.44),(5.31±1.08),(4.13±1.11)mg/L犦的水平高于对照组犤SES为(62.76±8.23)μg/L,GRP为(3.28±0.67)mg/L犦。②急性心肌梗死组、不稳定型心绞痛组SES及CRP水平与稳定型心绞痛组相比,其值明显增加;急性心肌梗死组和不稳定型心绞痛组SES水平相近,急性心肌梗死组CRP高于不稳定型心绞痛组。③急性冠状动脉综合征(acutecoronaryinsufficiency,ACS)患者SES水平与冠状动脉Gensini评分呈正相关(r=0.682,P<0.01),CRP水平与冠状动脉Gensini评分不相关。结论:SES,CRP是冠心病病情监测和评价粥样斑块不稳定性的非侵     

冠心病病情和预后评估指标：E-选择素及C-反应蛋白的检测

目的：探讨不同类型冠心病患者可溶性E-选择紊(soluble E-selectin．SES)、C-反应蛋白(C-reactive protein，CRP)的变化及其临床意义。方法：81例患者，按临床诊断分为4组：急性心肌梗死组17例、不稳定型心绞痛组24例、稳定型心绞痛组20例和20例对照组患者(阵发性室上速)。分别检测各组患者SES及CRP的水平，对冠心病患者的冠状动脉损害行Gensilli评分，并比较各组间的差异。对冠心病患者冠状动脉损害行Gensini评分，并与其sEs及cRP水平进行直线相关分析。结果：①急性心肌梗死组、不稳定型心绞痛组及稳定型心绞痛组的SES【其值分别为(99．29&;#177;15．04)，(97．46&;#177;11．33)，(78．48&;#177;18．93)μg／L】及CRP【其值分别为(6．73&;#177;1.44)，(5．31&;#177;1．08)，(4．13&;#177;1．11)mg／L】的水平高于对照组【SES为(62．76&;#177;8．23)μg／L，GRP为(3．28&;#177;0．67)mg／L】。②急性心肌梗死组、不稳定型心绞痛组SES及CRP水平与稳定型心绞痛组相比，其值明显增加；急性心肌梗死组和不稳定型心绞痛组SES水平相近，急性心肌梗死组CRP高于不稳定型心绞痛组。③急性冠状动脉综合征(acute comnary insufficiency，ACS)患者SES水平与冠状动脉Gensilli评分呈正相关(r=0．682。P&;lt;0．01)，CRP水平与冠状动脉Gensilli评分不相关。结论：SES．CRP是冠心病病情监测和评价粥样斑块不稳定性的非侵人性指标；在ACS中，SES水平与冠状动脉病变程度呈正相关。     

肝癌患者血清P-选择素测定及临床意义

目的：研究肝癌患血清P-selection(P-sel)在肝癌复发和转移中的作用。方法：采用ELISA法分别测定原发性肝癌患和对照组血清P-选择素的含量，同时测定AFP含量。结果：肝癌患P-sel含量显高于正常人，且与AFP含量呈线性正相关，术后2周浓度降低；P-sel含量以Ⅰ、Ⅲ和Ⅳ期肝癌患显高于Ⅰ期患；且大肝癌患显高于小肝癌患，有癌栓组、有肝内转移组明显高于无癌栓组和无转移组。结论：P-选择素测定在原发性肝癌的诊断和检测术后复发方面有重要价值，联合检测AFP和sP-sel可提高诊断敏感性。     

可溶性E-和P-选择素与急性脑梗死的关系

目的　探讨E -和P -选择素与脑梗死的关系。方法　用ELISA方法测定 30例脑梗死、2 5例脑出血患者及2 8例正常人的sE -和sP -选择素血清水平 ,分析它们与WBC、N %、TNF及IL - 6血清水平之间的关系。结果　急性期脑梗死患者sE -和sP -选择素血清水平 [分别为 (6 5 2± 39 4)ng/ml、(399± 134)ng/ml]明显高于脑出血患者 [分别为 (4 4 6± 11 8)ng/ml、(2 43± 112 )ng/ml]及正常人 [分别为 (4 0 5± 12 5 )ng/ml、(2 2 7± 10 6 )ng/ml]。而该组患者恢复期这两种选择素水平无明显升高。急性期脑梗死患者sE -和sP -选择素水平分别与WBC、N %、IL - 6水平呈正相关关系 ,sP -选择素水平还与TNF水平呈正相关关系。结论　sE -和sP -选择素血清水平增高反映脑梗死急性期E -和P -选择素可能在TNF和IL - 6的刺激下 ,参与脑梗死损伤过程     

床旁超声在急危重症中的临床价值

目的探讨床旁超声检查在急危重症诊断中的临床应用价值。方法回顾性分析我院近2年行床旁超声检查的496例患者资料,其中心血管急危重患者172例,腹部急危重患者324例。结果超声诊断与临床诊断相符470例,其中急性心肌梗死76例、主动脉夹层7例、肺栓塞5例、心包积液82例、内脏损伤162例、急性胰腺炎30例、异位妊娠54例、黄体破裂38例及前置胎盘16例,符合率94.8%。漏诊26例,占5.2%。结论床旁超声检查为急危重症患者迅速、方便地提供有价值的诊断信息,具有重要的临床应用价值。     

Distinct determinants of long-term and short-term survival in critical illness

Purpose

To identify the determinants of short-term and long-term survival in adult patients admitted to intensive care units (ICUs).

Methods

This population-based, observational cohort study included all eleven adult ICUs in the Winnipeg Health Region of Manitoba, Canada, analyzing initial ICU admissions during the period 1999–2010 of all Manitobans ≥17 years old. Analysis included Kaplan–Meier survival curves and multivariable regression models of 30-day mortality and post-90-day survival among those who survived to day 90. We used likelihood ratios to compare the predictive power of clusters of variables in these models.

Results

After 33,324 initial ICU admissions, mortality rates within 30 and 90 days were 15.9 and 19.5 %, respectively. The survival curve demonstrated an early phase with a high rate of death, followed by a markedly lower death rate that was only clearly established after several months. 30-day mortality was predominantly determined by characteristics of the acute illness; with its relative contribution set at 1.00, the next largest contributors were age (0.19) and comorbidity (0.16). In contrast, post-90-day mortality was mainly determined by age (relative contribution 1.00) and comorbidity (0.95); the next largest contributor was characteristics of acute illness (0.28).

Conclusions

We observed two phases of survival related to critical illness. Short-term mortality was mainly determined by the acute illness, but its effect decayed relatively rapidly. Mortality beyond 3 months, among those who survived to that point, was mainly determined by age and comorbidity. Recognition of these findings is relevant to discussions with patients and surrogates about achievable goals of care.     

Hormonal status in protracted critical illness and in-hospital mortality

Introduction

The aim of this study was to determine the relationship between hormonal status and mortality in patients with protracted critical illness.

Methods

We conducted a prospective observational study in four medical and surgical intensive care units (ICUs). ICU patients who regained consciousness after 7 days of mechanical ventilation were included. Plasma levels of insulin-like growth factor 1 (IGF-1), prolactin, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS) and cortisol were measured on the first day patients were awake and cooperative (day 1). Mean blood glucose from admission to day 1 was calculated.

Results

We studied 102 patients: 65 men and 37 women (29 of the women were postmenopausal). Twenty-four patients (24%) died in the hospital. The IGF-1 levels were higher and the cortisol levels were lower in survivors. Mean blood glucose was lower in women who survived, and DHEA and DHEAS were higher in men who survived.

Conclusions

These results suggest that, on the basis of sex, some endocrine or metabolic markers measured in the postacute phase of critical illness might have a prognostic value.     

小剂量促肾上腺皮质激素刺激实验在危重病患儿肾上腺功能评估中的作用

目的 探讨小剂量(1 μg/1.73 m2)促肾上腺皮质激素(ACTH)刺激实验在儿童危重症相关性肾上腺皮质功能障碍(CIRCI)评估中的意义.方法 对收入上海交通大学附属儿童医院儿童重症监护病房(PICU)患儿24 h内测定血液基础皮质醇(T0)后,静脉注射ACTH(1μg/1.73 m2),30 min后测定刺激后血液皮质醇(T1)水平,根据T0和皮质醇增值(Δmax=T1-T0)判断肾上腺功能,以T0＜ 10 μg/dL或Δmax≤9 μg/dL为判断肾上腺功能障碍标准.结果 95例患儿中,严重感染35例,非感染重症患儿30例,大手术患儿30例,总病死率为12.6％ (12/95).CIRCI发生率55.8％ (53/95),其中重症感染组、非感染重症组、大手术组患儿CIRCI发生率分别是60％、53.3％和53.3％,差异无统计学意义(P＞0.05).重症感染组、非感染重症组、大手术组、T0和71分别为(37.17±47.35) μ.g/dL、(31.52±52.78) μg/dL、(28.61±17.45) μg/dL和(50.26±48.21) μg/dL、(58.56±73.21) μg/dL、(42.41±13.56)μg/dL,3组差异无统计学意义(P＞0.05).CIRCI组和正常皮质醇反应组患儿病死率分别是7.5％和19.0％ (P＞0.05).T0和T1水平与儿童危重病例评分(PCIS)有关(P＜0.05).结论 危重症患儿存在肾上腺功能障碍,CIRCI发生率较高,小剂量ACTH刺激实验可以作为肾上腺功能功能判断的依据.本研究未发现危重病患儿CIRCI与病死率的显著相关性.     

B型尿钠肽对危重病患者预后的诊断价值研究

目的探讨B型尿钠肽(BNP)水平判断危重病患者预后的诊断价值。方法选择本院重症监护室患者46例,按慢性健康状况评分Ⅱ(APACHEⅡ)随机分为A、B 2组,各23例,每组分别于入院第1天、第4天、第7天检测血浆BNP水平。结果 A组第1天、第4天、第7天血浆BNP水平明显低于B组(P<0.01);2组患者第4天和第7天血浆BNP水平均明显高于第1天,且第7天血浆BNP水平均明显高于第4天(P<0.01)。结论血浆BNP在诊断心力衰竭的同时,也可作为判断危重病患者预后的指标之一。     

危重症手足口病患儿淋巴细胞亚群的检测

目的研究危重症手足口病患儿外周血淋巴细胞亚群的变化,以探讨其免疫功能改变。方法以临床确诊并入住ICU的40例危重症手足口病患儿为研究对象,并与30例正常儿童进行比对研究,应用流式细胞仪检测外周抗凝全血的淋巴细胞亚群：T淋巴细胞（CD3＋CD19-）、辅助T细胞Th（CD3＋CD4＋）、抑制T细胞Ts（CD3＋CD8＋）、B细胞（CD3-CD19＋）和NK细胞（CD3-CD56＋）的相对计数,并计算Th/Ts值。结果危重症手足口病患儿外周血T淋巴细胞、Th细胞、Ts细胞的百分率下降,均明显低于对照组（P〈0.05）;B细胞的百分率则显著增高（P〈0.05）;而两组间NK细胞百分率及Th/Ts细胞比值的变化不存在明显差异（P〉0.05）。结论危重症手足口病患儿出现细胞免疫及体液免疫功能紊乱。     

Veno-arterial carbon dioxide and pH gradients and survival in critical illness

Abstract. Recent studies have shown that the veno-arterial gradient for carbon dioxide (dVVApCO₂) is increased in the case of low cardiac index (CI). In order to further investigate this matter 220 haemody-namic measurements from 34 patients with septic shock and from 28 patients in the post-operative state without sepsis were evaluated. The arterio-venous gradient for pH (dAVVpH) was also evaluated. CI was found to be inversely correlated to both dVVApCO₂ and dAVVpH when the two groups of patients were analysed separately ( r = -0.76 and r = -0.78, P < 0.001 for the relationship between CI and dVVApCO₂, r = -0.58 and r = -0.69 P <0.001 for the relationship between CI and dAVVpH). When volume loading over 2 h was used to increase CI, 58–66% of_the patients in the two groups showed a decline in dVVApCO₂ > 10% when CI was increased by > 10%. The corresponding values for a reduction in dAVVpH> 10% during volume loading was 36–52%. While dAVVpH was found to be increased in non-survivors ( n = 27) when compared to survivors (0.32 ± 0.01 vs. 0.24±0.1, P <0.05) at the second day in the IUC, dVVApCO₂ was not a significant predictor of mortality despite the fact that CI was found to be decreased in the non-survivors (3.5 ±0.94 vs. 4.3±1.0 L min^-1 m^-2, P <0.01). In conclusion, the veno-arterial carbon dioxide gradient was found to be inversely correlated to cardiac performance in patients both in patients with septic shock and in non-septic post-operative patients. The arterio-venous gradient for pH was increased in low flow states, but this association was weaker. However of these two indices evaluated, only a raised dAVVpH was a significant predictor of later mortality.     

冠心病患者E-选择素血清水平检测的临床意义

目的 探讨血清可溶性E-选择素水平在监测冠心病病情及与冠状动脉病变程度的关系。方法 138例冠心病患者按临床诊断分为急性心肌梗死（AMI）组（50例）、不稳定性心绞痛（UAP）组（48例）、稳定性心绞痛（SAP）组（40例）,对照组为45名。用酶联免疫吸附试验（ELISA）检测各组血清可溶性E-选择素的水平,并比较各组间的差异。对冠心病患者的外周血白细胞总数与血清可溶性E-选择素水平进行直线相关分析。结果 AMI组、UAP组及SAP组的血清可溶性E-选择素水平明显高于对照组（P〈0．05）;AMI组、UAP组可溶性E-选择素水平和SAP组相比,其值增加明显;AMI组与UAP组差异无显著性;冠心病患者血清可溶性E-选择素水平与外周血白细胞总数变化呈正相关。结论 血清可溶性E-选择素可能是冠状动脉粥样硬化的标志之一,其水平与冠状动脉病变程度密切相关。     

危重症患儿连续性血液净化的护理

目的:探讨床旁连续性血液净化(CBP)技术在危重症患儿中的应用。方法:对我科2011年1月～2012年3月运用CBP治疗的40例危重症患儿的护理进行回顾性总结。结果:通过CBP技术及优质的护理,痊愈、好转35例,占87.50%;合并其他并发症死亡3例,占7.50%;放弃治疗2例,占5.00%。结论:成立CBP护理小组,对CBP护士进行专业技能培训,是保证CBP顺利实施的关键。