1例体外膜肺氧合病人俯卧位通气治疗的护理

<正>俯卧位通气指在机械通气过程中协助病人采取俯卧位,以改善病人氧合状态的治疗性体位措施~([1])。研究认为,俯卧位可以改变胸腔压力,进而通过重力影响,减轻对肺组织的压力,同时可以改善胸廓和腹部运动,协调整体胸壁顺应性,增加功能     

1例重症肺炎产妇行体外膜肺氧合联合俯卧位通气治疗的护理

总结1例重症肺炎产妇行跨市体外膜肺氧合驰援联合俯卧位通气治疗成功的护理经验。如何保障患者转运安全,确保ECMO正常运转及后续并发症的预防,是临床治疗和护理过程中需要迫切解决的问题。通过组建专业的体外膜肺氧合团队,安全有效的院间、院内转运,为患者抢救赢得时机。在救治及护理期间,通过准确充分的病情监测及评估,为患者制定完善的抗凝策略、实施精细化的俯卧位通气治疗、序贯性呼吸支持和个体化的肠内营养支持方案。经过精心的治疗及护理,产妇于入院第13天成功撤离ECMO,第20天顺利出院,母子团聚。     

1例急诊重症肺炎患者行体外膜肺氧合治疗的护理

患者男,48岁,因发热、咳嗽3d,后症状加重咳粉红色痰并伴呼吸困难2d到我院急诊就诊。来诊时心率143次／min,呼吸39次／min,指血氧饱和度80％。血气分析为1型呼吸衰竭,外院胸片提示肺部斑片影,我院CT检查提示右肺明显实变,双侧胸腔积液。予以头孢他啶（复达欣）、     

3例危重症型冠状病毒肺炎患者应用体外膜肺氧合联合俯卧位通气的护理

从2019年12月以来,在武汉市出现了多例新型冠状病毒(2019 novel coronavirus,2019-nCoV)感染的肺炎患者,国家将其命名为新型冠状病毒肺炎(novel coronavirus pneumonia,NCP),其具有极强的传染性[1-2]。我院作为武汉市NCP治疗的省级定点综合医院,收治了大量重型和危重型患者。在危重型患者中,部分患者机械通气后仍无法满足基本氧合。     

应用体外膜肺氧合治疗1例儿童重症肺炎的护理

急性呼吸窘迫综合征(acute respiratory distress syn-drome,ARDS)是由感染、创伤等诱发的全身炎症反应综合在肺部的表现,晚期多并发多脏器功能衰竭(MODS)。体外膜肺氧合     

1例溺水心肺复苏术后患者体外膜肺氧合与俯卧位通气的护理

报道1例因溺水心跳骤停实施心肺复苏术后应用体外膜肺氧合与俯卧位通气治疗患者的护理。体外膜肺氧合与俯卧位通气治疗护理专业性强,且该患者入院后症状持续加重,出现多系统器官功能衰竭,加大了护理难度。针对本例患者采取护理措施包括:体外膜肺氧合治疗初始阶段的护理,氧合器管路的管理;团队协作保证俯卧位通气治疗的效果;注重治疗期间心血管功能、呼吸功能、肾功能、凝血与出血的监测。经上述干预本例患者治疗40 d后病情稳定出院。     

1例体外膜肺氧合联合 CRRT 及俯卧位通气治疗 ARDS 病人的护理

体外膜肺氧合(extracorporeal membrane oxygenation,EC-MO)简称膜肺,是近年来开展的一项体外生命支持的新技术,其原理是将体内的静脉血引出体外,经膜肺氧合后再用泵将血灌入体内,替代或部分替代人的心肺功能,有效维持心、肺、脑等脏器的血供和氧合,帮助争取心肺病变的治愈及功能恢复的机会[1]。连续肾脏替代疗法(continous renal replacement ther-apy,CRRT)是采用每天24 h 或接近24 h 的一种连续的体外血液净化方法,以替代受损的肾功能[2]。很多病人在实施 ECMO前由于严重的心、肺功能衰竭常出现血压低、氧合差等情况,需要应用大剂量血管活性药物维持血压,因此常导致肾脏低灌注,加重肾脏缺血缺氧,并发急性肾功能损伤,出现高氮质血症、急性肾衰竭等,病死率高,大多数病人需要 CRRT,但 EC-MO 同期行 CRRT 再加上应用俯卧位通气改善急性呼吸窘迫综合征(ARDS)病人的氧合的方式,治疗管理复杂。2014年8月我科在1例 ARDS 病人的治疗中应用了膜肺串接 CRRT,并配合俯卧位通气治疗,效果满意。现报告如下。     

行体外膜肺氧合治疗并发症的观察及护理

目的探讨行体外膜肺氧合（ECMO）治疗并发症的观察及护理要点。方法对8例因心肺功能不全而在术中或术后建立ECMO的患者，对治疗过程中出现的并发症进行分析和总结。结果8例患者使用ECMO时间为4～81h，4例患者能顺利脱离ECMO,4例不能脱机，其中2例因心跳停止不能恢复，1例出血不止，1例因怀疑肺栓塞而放弃。结论出血仍是ECMO最主要的并发症，使用肝素涂层的膜肺和管道并合理应用肝素，是减少出血的方法之一。     

Perioperative management of emergent cesarean section in a patient with peripartum cardiomyopathy and orthopnea: a case report

Perioperative management of pregnant women with heart failure is difficult. Management of anesthesia in pregnant women is especially difficult because all of the currently available choices present challenges. We report a patient with peripartum cardiomyopathy (PPCM) who required an emergent cesarean section and discuss the possible tactics for managing anesthesia. A 40-year-old primipara with severe cardiac and respiratory failure required an emergent cesarean section at 39⁺¹ gestational weeks. Her left ventricular ejection fraction was between 10% and 15%, and she had orthopnea. General anesthesia was planned after inserting sheaths for percutaneous cardiopulmonary support from the femoral artery and vein. However, when the patient was asked to lie down on the operation bed, she panicked and resisted because of labor pain and dyspnea. Therefore, anesthesia was induced instead of the initial plan. Finally, we successfully managed the anesthesia and delivered the newborn. There are no alternatives to general anesthesia in patients with PPCM presenting with orthopnea. Anesthesia induction in the supine position is impossible in such patients owing to dyspnea. Anesthesia should be started with light sedation in the sitting position, and ketamine or low-dose remifentanil may be an option to maintain maternal hemodynamics and prevent neonatal asphyxia.     

RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest

There is a growing interest in using point-of-care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno-arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.     

经颅多普勒超声在体外膜肺氧合患者脑血流动力学监测及预后评估中的应用

目的  探讨经颅多普勒超声在体外膜肺氧合患者脑血流动力学监测及预后评估中的应用价值。方法  回顾性分析2015年5月20日~2020年1月3日在本院87例进行体外膜肺氧合治疗患者的临床资料,比较患者治疗前后脑血流动力学指标[收缩峰值血流速度(Vs)、舒张期峰值流速(Vd)、平均血流速度(Vm)、搏动指数(PI)]和心功能指标[左心射血分数(LVEF)、左心室流出道血流速度时间积分(VTI)、平均动脉压(MAP)]。随访1年,统计患者的预后状态。依据其不同的预后状态分为预后良好组(n= 56)和预后不良组(n=31),比较两组性别、年龄、疾病分类、肾功能不全、肝功能异常、多器官衰竭、体外膜肺氧合流量、正性肌力药物评分(IS)、Vs、Vd、Vm、PI、LVEF、MAP水平。结果  治疗前与治疗后Vs、Vd、Vm、PI值差异无统计学意义(P>0.05);体外膜肺氧合患者治疗后LVEF、MAP、VTI升高(P < 0.05);单因素分析结果显示,两组肾功能不全、多器官功能衰竭率及Vs、Vd、Vm、PI、LVEF、VTI、MAP值的差异有统计学意义(P < 0.05),两组性别、年龄、疾病分类、体外膜肺氧合流量及IS评分的差异无统计学意义(P>0.05);Logistics回归分析结果显示,肾功能不全、Vs、Vd、Vm、PI、MAP是影响体外膜肺氧合患者预后不良的独立危险因素(P < 0.05)。结论  脑血流动力学指标(Vs、Vd、Vm、PI)与体外膜肺氧合患者预后有密切联系,临床需加强联合各指标检测,尽早评估体外膜肺氧合患者预后状态。     

早期清醒俯卧位联合经鼻高流量氧疗治疗重型新型冠状病毒肺炎一例

在新型冠状病毒肺炎（简称“新冠肺炎”）疫情防控的早期阶段,由于对疾病的认识不足,重症患者治疗难度大、病死率高,这对ICU医师提出了挑战。皖南医学院弋矶山医院在疫情防控早期阶段收治1例重型新冠肺炎患者,结合既往急性呼吸窘迫综合征（ARDS）的处理经验,采用早期清醒俯卧位联合经鼻高流量氧疗（HFNC）治疗,成功避免气管插管和机械通气,最终患者康复出院。本文报告该病例的综合救治过程,并结合文献,分析清醒俯卧位联合HFNC治疗重型新冠肺炎的循证医学依据、注意事项和及时转为有创机械通气的时机,提出“俯卧位前移”的概念,为重症新冠肺炎患者救治提供有力的医疗决策。     

Intensive care nurse-led point of care ultrasound in the assessment and management of the critically ill COVID-19 patient: A single centre case series

Focused ultrasound can be used to rapidly diagnose COVID-19 disease, assess disease severity, and inform management of COVID-19 and associated pathologies, reducing radiation exposure from other imaging modalities and minimizing spread of infection. Ultrasound examinations performed by trained nurses in the intensive care unit (ICU) enable more patients to receive these assessments. This case series evaluates the use of nurse-led focused cardiac and lung ultrasound for clinical management of ICU patients with COVID-19. We describe common pathophysiological findings and how findings were used to inform clinical decision-making. An ultrasound trained ICU nurse performed Focused Ultrasound in Intensive Care (FUSIC) cardiac and lung scans enabling calculation of a lung severity score on adult ICU patients with a confirmed COVID-19 diagnosis in a single-centre setting. Fifteen scans were performed on 15 patients. Thirteen (87%) patients had normal left ventricular function; 12 (80%) normal right ventricular function. All 15 (100%) scans identified abnormal lung findings including irregular thickened pleura, B-lines, sub-pleural consolidation and hepatization. Worse lung severity scores were correlated with higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores (r = 0.70; p = .003). Of the 15 scans, 10 (67%) identified abnormal pathology contributing to a change in clinical management. This included targeted fluid removal (4, 27%), change in respiratory management (3, 20%) and need for formal echocardiographic assessment (3, 20%). Findings from five (33%) scans required no intervention. This case series demonstrates nurse-led ultrasound could be a useful adjunct in the management of the COVID-19 patient.     

Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta‐analysis of the literature

Summary. Venous thromboembolism (VTE) is one of the most relevant causes of maternal death in industrialized countries. Low molecular weight heparin (LMWH), continued throughout the entire pregnancy and puerperium, is currently the preferred treatment for patients with acute VTE occurring during pregnancy. However, information on the efficacy and safety of anticoagulant drugs in this setting is extremely limited. We carried out a systematic review and a meta‐analysis of the literature to provide an estimate of the risk of bleeding complications and VTE recurrence in patients with acute VTE during pregnancy treated with antithrombotic therapy. The weight mean incidence (WMI) of bleeding and thromboembolic events and the corresponding 95% confidence interval (CI) were calculated. Eighteen studies, giving a total of 981 pregnant patients with acute VTE, were included. LMWH was prescribed to 822 patients; the remainder were treated with unfractionated heparin. Anticoagulant therapy was associated with WMIs of major bleeding of 1.41% (95% CI 0.60–2.41%; I) antenatally and 1.90% (95% CI 0.80–3.60%) during the first 24 h after delivery. The estimated WMI of recurrent VTE during pregnancy was 1.97% (95% CI 0.88–3.49%; I² 39.5%). Anticoagulant therapy appears to be safe and effective for the treatment of pregnancy‐related VTE, but the optimal dosing regimens remain uncertain.     

A ruptured cornual pregnancy successfully managed in a patient with a history of oophorectomy and salpingectomy: A rare case report

Cornual pregnancy is a rare condition that accounts for approximately 2–4% of ectopic pregnancies worldwide. Herein, we report an unstable case of a 32‐year‐old woman with a history of oophorectomy and salpingectomy who was admitted for a ruptured cornual pregnancy in the left cornu, which was successfully managed by laparotomy.     

Therapeutic plasma exchange and pregnancy: A case report and guidelines for performing plasma exchange in a pregnant patient

Therapeutic plasma exchange (TPE) has been demonstrated to be of significant clinical value in a number of diseases and conditions, with well‐established guidelines and recommendations. However, technical support in providing this procedure for pregnant patients is largely absent from these recommendations, leaving therapeutic apheresis practitioners without guidance to safely and adequately treat appropriate conditions in this important patient population. Here, we describe our experience in treating a 35‐year‐old pregnant patient with relapsing‐remitting multiple sclerosis with TPE. Additionally, we outline the principle considerations when developing her treatment plan, and we provide recommendations for apheresis practitioners when performing TPE in pregnant patients. J. Clin. Apheresis 32:191–195, 2017. © 2016 Wiley Periodicals, Inc.