Transthoracic echocardiography is not cost-effective in critically ill surgical patients

BACKGROUND: Echocardiography has been shown to be valuable in critically ill surgical patients. Transthoracic echocardiography (TTE) often fails to provide adequate imaging in critically ill patients, necessitating subsequent transesophageal echocardiography (TEE). The objective of this study was to determine and quantify factors associated with failure of transthoracic echocardiography (TTE) in critically ill surgical patients, and to define a cost-effective strategy for echocardiography in these patients. METHODS: Demographic and clinical data were collected retrospectively and evaluated to determine which factors were associated with failure of TTE to provide adequate imaging. In addition, models were developed to estimate costs for echocardiography in critically ill surgical patients. RESULTS: TTE has a high failure rate in critically ill surgical patients. This failure rate increases significantly in patients who gain > 10% body weight from admission weight, who are supported with > or = 15 cm H(2)O positive end-expiratory pressure, and in those with chest tubes. As a result, the use of TTE in critically ill surgical patients is not cost-effective. TEE, however, is highly effective in this group of patients, and is more cost-effective than TTE in evaluating those critically ill surgical patients requiring echocardiography. CONCLUSION: The routine use of TTE to initially evaluate all critically ill surgical patients who require echocardiography should be abandoned because it is not cost-effective. TEE appears to be the most cost-effective echocardiographic modality in the surgical intensive care unit.     

重危患者护理质量跟踪评估表的应用效果评价

目的建立一个系统、动态、有效的重危患者护理质量跟踪评估体系,以提高重危患者的护理质量。方法在实施急危重症患者抢救工作规章制度和重危患者护理质量控制流程的基础上,利用电子信息系统提供的全院重危患者信息选择跟踪评估对象,由护理质控专家及夜查房护士长根据自行设计的重危患者护理质量跟踪评估表对重危患者护理质量进行评估。结果重危患者护理质量跟踪评估表应用后重危护理质控检查评分显著高于应用前(P<0.01),患者对护理服务的满意度有所提升,但差异无统计学意义(P>0.05)。结论重危患者护理质量控制体系的完善、实施,对重危患者的护理工作起到了良好的监管、指导作用,可提高重危患者护理质量,确保护理安全。     

成人重症患者深静脉血栓医护一体快速筛查流程的构建

目的 探讨适合我国成人重症患者深静脉血栓快速筛查的流程,为血栓预防护理提供参考。方法 应用循证护理方法,针对成人重症患者深静脉血栓筛查流程提出问题,进行系统检索、证据提取等,形成成人重症患者深静脉血栓医护一体筛查的证据;通过2轮焦点小组访谈确定成人重症患者深静脉血栓医护一体快速筛查流程。结果 形成的成人重症患者深静脉血栓医护一体快速筛查流程包括风险评估、超声筛查、深静脉血栓预防、管理与质控4个步骤。结论 本研究构建的成人重症患者深静脉血栓医护一体快速筛查流程,可用于成人重症患者深静脉血栓风险筛查。     

成人重症患者深静脉血栓医护一体快速筛查流程的构建

目的 探讨适合我国成人重症患者深静脉血栓快速筛查的流程，为血栓预防护理提供参考。方法 应用循证护理方法，针对成人重症患者深静脉血栓筛查流程提出问题，进行系统检索、证据提取 等，形成成人重症患者深静脉血栓医护一体筛查的证据；通过2轮焦点小组访谈确定成人重症患者深静脉血栓医护一体快速筛查流程。结果 形成的成人重症患者深静脉血栓医护一体快速筛查流程包括风险评估、超声筛查、深静脉血栓预防、管理与质控4个步骤。结论 本研究构建的成人重症患者深静脉血栓医护一体快速筛查流程，可用于成人重症患者深静脉血栓风险筛查。     

急诊科院际危重症转运专职护士岗位设立及实践

目的探讨急诊科设立院际危重症转运专职护士岗位的可行性及效果。方法选拔并规范化培训35名转运专职护士,制定转运制度和流程,明确工作内容及岗位职责,实施1年后共转运4 503例危重症患者;以设立转运专职护士岗位前转运的2 378例患者为对照,比较专职岗位设置前后院际危重症患者转运不良事件发生率。结果专职岗位设置后院际转运不良事件发生率显著低于设置前(P0.05,P0.01)。结论危重症转运专职护士岗位的设立可降低转运不良事件发生率,保障危重症患者转运安全。     

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??How to maximize efficacy of nutrition support in the adult critically ill patients WU Guo-hao. Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai200032??China
Abstract Critically ill patients are hypermetabolic and have increased nutrient requirements. Nutritional support is now considered as a standard of care for the critically ill patients. However, many questions about the appropriate substrate, timing, route and amount of nutritional support in critically ill patients remain understudied. Enteral nutrition is favored over parenteral nutrition when the gastrointestinal tract is functional. Early enteral nutrition is recommended for critically ill patients. Parenteral nutrition is indicated for patients who cannot tolerate enteral feedings. Supplemental parenteral nutrition combined with enteral nutrition can be considered to cover the energy and protein targets when enteral nutrition alone fails to achieve the caloric goal. Clinical studies have demonstrated that new formulae enriched with specific nutrients improves the outcomes of critically ill surgical patients.     

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??Stress response characteristics of surgical critically ill patients DONG Qi. Department of General Surgery, the People’s Hospital of Liaoning Province, Shenyang 110016, China
Abstract Stress responses of surgical critically ill patients involved in the functional change of multiple system and organs of body. In this status, stress responses are characterized as disorder of metabolic balance, endocrine system, water and electrolyte balance, inflammation and immune response??et al. The paper introduces basic knowledge of stress responses of surgical critically ill patients and aims at improving efficacy and reducing mortality of the patients.     

Cardiorespiratory responses to dextran 40. Hemodynamic and oxygen transport changes in normal subjects and critically ill patients.

Hemodynamic and oxygen transport were observed in 190 studies before and after administration of 500 ml dextran 40 in 12 normal, healthy subjects and 147 critically ill patients who were, or recently had been, in various degrees of shock. The major influence of dextran 40 was plasma expansion and hemodilution, which resulted in increased blood flow and blood volume. In general, the pressure-flow responses were greater in the ill patients than in the normal subjects. After dextran 40 infusion, oxygen transport increased in the critically ill patients, but not in the normal volunteers. Some of the effects of dextran 40 on oxygen transport in critically ill patients may be attributed to increased tissue perfusion from expansion of plasma volume, as well as to improved flow properties of blood in the microcirculation.     

Sleep disturbances in critically ill patients in ICU: how much do we know?

Sleep disturbances in the intensive care unit (ICU) seem to lead to development of delirium, prolonged ICU stay, and increased mortality. That is why sufficient sleep is important for good outcome and recovery in critically ill patients. A variety of small studies reveal pathological sleep patterns in critically ill patients including abnormal circadian rhythm, high arousal and awakening index, reduced Slow Wave Sleep, and Rapid Eye Movement sleep. The purpose of this study is to summarise different aspects of sleep-awake disturbances, causes and handling methods in critically ill patients by reviewing the underlying literature. There are no studies of level 1 evidence proving the positive impact of the tested interventions on the critically ill patients' sleep pattern. Thus, disturbed sleep in critically ill patients with all the severe consequences remains an unresolved problem and needs further investigation.     

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??Metabolic changes and nutrition support management in surgical critically ill patients WANG Xin-ying.Department of General Surgery, Jinling Hospital, Medical School, Nanjing University, Nanjing 210002, China
Abstract Surgical critically ill patients are hypermetabolic, accompanying with the system inflammation response and increased nutrient requirement. Nutrition support is now considered as an important part of therapy for critically ill patients. Rational nutrition support implement should be based on the overall consideration of organ function and enteral nutrition tolerability in surgical critically ill patients, including the appropriate substrate, timing, route and monitoring. Clinical studies also demonstrate that some new formulae enriched with specific nutrients may improve the organ and immune function, decrease the incidence of morbidity and mortality, and shorten the hospital stay in critically ill patients.     

如何提高外科危重病人的营养支持疗效

外科危重病人高分解代谢、营养物质需求增加,营养支持是危重病人治疗的重要措施之一。合理、有效的营养支持包括提供合适的营养底物,选择正确的喂养途径和时机。早期肠内营养、改善肠内营养的安全性和耐受性、联合应用肠外肠内营养以满足机体对热量的需求、有效控制高血糖以及提供一些药理营养素均可降低应激状况下机体的分解代谢反应,改善机体重要脏器和免疫功能,降低并发症发生率,缩短入住ICU和住院时间,提高危重病人救治成功率。     

Propofol and Intralipid cause creaming of serum from critically ill patients

The aim of this in-vitro study was to investigate the incidence of propofol agglutination with serum from critically ill patients. Serum (400 μl) from 58 critically ill patients and 30 healthy volunteers was incubated with 10 μl of either propofol, Intralipid 10% or Intralipid 20%. Control incubations contained serum only. At 24 h, the serum was examined macroscopically and microscopically for agglutination. Agglutination was seen with Intralipid 20% in serum from all critically ill patients and 13.3% of volunteers. Serum from 91.4% of critically ill patients was agglutinated with Intralipid 10% and only 3.3% of the healthy volunteers. In comparison, propofol produced agglutination in 74.1% of critically ill patients and in none of the serum from healthy volunteers (p < 0.05 propofol versus Intralipid 10%, p < 0.0001 propofol versus Intralipid 20%). No correlation was seen between agglutination and age, sex, APACHE II score or plasma concentration of acute phase proteins. However, agglutination of propofol and Intralipid 10% was more frequent (p < 0.001) in serum from patients with pulmonary disease, than in patients with normal lungs. The clinical implications of these in-vitro findings are unclear and need further investigation.     

危重患者的护理访视管理

目的 探讨危重患者的有效护理访视方法,提高护理安全性.方法 选取符合条件的护理管理者并对其进行培训后,每2人一组对全院危重患者按病情进行基本信息、护理措施落实、存在的风险三方面访视;通过完善访视制度,规范访视内容,反馈访视信息,追踪改进等措施解决访视中发现的问题.结果 访视危重患者856例,与常规护理管理的1 095例危重患者比较,不良事件发生率显著降低,患者满意率显著升高（P＜0.05,P＜0.01）.结论 护理访视管理可提高危重患者的护理安全性和满意度.     

Gastrointestinal dysfunction

Gastrointestinal dysfunction is common in critically ill patients and it is important to try to prevent or manage its manifestations. In this article we discuss the aetiology, management and prevention of: stress ulceration, ileus, bacterial translocation, intra-abdominal hypertension, abdominal compartment syndrome, diarrhoea and constipation in the context of critically ill patients. We also discuss feeding strategies for intensive care patients who cannot be fed normally.     

Analgesia and sedation in the critically ill--a practical approach

Advancements in intensive care therapy have progressed rapidly over the last two decades. Associated with this have been scientifically unsubstantiated sedation and analgesia practices in the intensive care unit. There is little consensus as to which agents are the most suitable, let alone when and how to use them. There are few, if any, placebo-controlled trials involving sedative drugs in critically ill patients. In an analysis of the literature, we have attempted to present a practical approach to sedation and analgesia practices in the critically ill patient. The aim is to present a framework upon which medical personnel managing critically ill patients can develop a strategy for their own circumstances.     

Cholescintigraphy in the critically ill

Critical review of cholescintigraphy in critically ill patients suggests the examination will not conclusively prove or disprove the diagnosis of acute cholecystitis. Of 17 scans performed in critically ill patients with clinical evidence of acute cholecystitis, 7 were true-negative, 1 was false-negative, 6 were false-positive, and 3 were nondiagnostic. Cholestasis and hepatocyte dysfunction, common in the critically ill, result in abnormal clearance of hepatobiliary radionuclide imaging agents, decreasing the usefulness of cholescintigraphy in this patient population. Diagnosing acute cholecystitis in a critically ill patient remains difficult.     

外科重症患者早期肠内营养误吸状况及影响因素研究

目的探讨重症患者早期肠内营养误吸发生现况及影响因素,为临床护理干预提供参考。方法采用便利抽样法,选取实施早期肠内营养的外科重症患者,动态监测并记录患者从实施肠内营养开始7 d内误吸情况,采用Logistic回归分析误吸发生的影响因素。结果共纳入126例患者,发生误吸30例(23.81%)。误吸组第7天目标热量达标率显著低于无误吸组,住院时间、住院费用显著高于无误吸组(均P<0.01)。APACHEⅡ评分、意识状况、营养风险、鼻饲管置入长度是外科重症患者误吸的危险因素(P<0.05,P<0.01)。结论重症患者早期肠内营养误吸发生率较高,与患者意识、营养状态、疾病程度和鼻饲管置入长度相关。应针对误吸危险因素采取针对性措施防范重症患者肠内营养误吸。     

Sepsis induced changes of adipokines and cytokines - septic patients compared to morbidly obese patients

Background  

Hyperglycemia and insulin resistance frequently occur in critically ill and in morbidly obese (MO) patients. Both conditions are associated with altered serum levels of cytokines and adipokines. In addition, obesity related alterations in adipokine expression contribute to insulin resistance in metabolic syndrome. In this study we examined the serum adipocytokine profile in critically ill patients, MO patients, and healthy blood donors.     

外科危重病人的应激反应特点

外科危重病人的应激反应涉及机体多个系统或脏器的功能改变。在应激状态下机体出现的代谢改变主要包括代谢失平衡、内分泌系统紊乱、水和电解质紊乱、炎性反应以及免疫反应等。充分认识外科危重病人的代谢特点,是管理危重病人的重要环节,对进一步选择其他辅助治疗具有重要意义。