围生期ARDS

1　ARDS的定义、发病诱因及发病率急性呼吸窘迫综合征 (acuterespiratorydistresssyndrome ,ARDS)于 196 7年Ashbough首次报道 ,其定义是指因多种病因所引起的急性呼吸衰竭综合征 ,以非心源性肺水肿、低氧血症和弥漫性肺间质实变为主要特征。近年来研究表明 ,ARDS是急性肺损伤 (acutelunginjury ,ALI)发展到后期的典型表现。ALI和ARDS有相同的定义和内涵 ,区别在于ALI代表早期的阶段 ,ARDS代表晚期的阶段。有关ARDS的命名有史以来大约有 30余种 ,如畸形肺泡衰竭、急性肺损伤、进行性呼吸窘迫呼吸衰竭综合征、白肺综合征、肺挫…     

胎肺发育过程中炎性介质和细胞因子在急性肺损伤中的作用

急性肺损伤(acute lung injury,ALI)指机体遭受严重感染、创伤、休克等打击后发生的急性炎症反应,以弥漫性肺泡、毛细血管膜损伤为主要病理变化,以进行性呼吸困难和缺氧为主要临床表现,是新生儿临床常见的危重症[1-2].促炎因子与抗炎因子之间的动态平衡是影响ALI预后的重要因素[3].新生儿肺发育欠成熟,对内源性细胞因子的变化易感,尤其是低出生体重及小胎龄的早产儿更容易发生炎症介导的ALI[4].炎性介质网络的平衡以及转录因子的调控,目前已经成为ALI发病机制的研究重点.现就炎性介质与新生儿ALI的关系进行综述.     

围产期急性肺损伤四例报告及文献复习

机体遭受严重的感染、创伤、休克、手术打击以及再灌注损伤等均可导致急性肺损伤发生.孕产妇发生急性肺损伤多与产后失血性休克、DIC、全身炎症反应综合征(SIRS)、官内感染、重度子痫前期等因素相关,其临床特点是起病急、治疗困难,且死亡率高.本文报道首都医科大学附属北京妇产医院2009年1-6月收治的4例急性肺损伤,并结合国内外文献复习,探讨围产期发生急性肺损伤的诊治与预防.     

产后失血性休克继发急性肺损伤的早期诊断与治疗——附5例临床分析

因患者大量出血未得到及时、有效的控制,致组织严重缺血、缺氧,持续的低血容量状态极易诱发全身性炎症反应综合征(systermic inflammatory response syndrome,SIRS),并发急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)或多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS),进而导致孕产妇的死亡.为了提高早期诊断和治疗质量,本文对我院2006年1月至2007年6月5例产后出血后并发ARDS的早期阶段急性肺损伤(acute lung injury,ALI)患者的临床资料进行了回顾性分析,旨在探讨产后出血继发急性肺损伤的预防、早期诊治与预后.以凝血功能为首发症状的非典型羊水栓塞,可通过排除其他原因后确定诊断[1].此5例患者均为首发宫缩乏力,继而出现大出血,排除羊水栓塞继发产后出血.     

重症胰腺炎并发急性呼吸窘迫综合征的护理

目的:探讨急性重症胰腺炎(SAP)治疗过程中并发急性呼吸窘迫综合征(ARDS)的护理方法。方法对76例SAP并发ARDS患者的临床资料进行回顾性分析。结果增强CT检查发现胰周积液69例,胰腺坏死26例,出现局部并发症15例(假性囊肿9例、胰尾脓肿6例)。76例SAP中,痊愈53例,明显好转18例,好转4例,死亡1例。结论对SAP并发ARDS患者,应尽早查明原因和机制,早期诊断、早期治疗及早期精心护理是降低其病死率的关键。     

高渗盐复合液在脑外伤并未控制失血性休克中的临床疗效评价

目的:探讨高渗盐复合液(缩写HSH,其中氯化钠的浓度为4.2%,羟乙基淀粉40为7.6%)对重型颅脑外伤,颅内高压并休克的临床疗效评价及其可能的作用机制,及其与传统液体复苏相比的优势。方法:将符合重型颅脑外伤,颅高压并体克的患者80例随机分为高渗盐复合液+甘露醇复苏组(实验组)40例;传统液体+甘露醇复苏组(对照组)40例。对两组患者不同时间点的心率、收缩压、输液量、ARDS、MODS发生率、病死率等进行统计与评价分析。结果:两组的心率、尿量变化和平均动脉压差异T1-T3有显著性(P<0.05),T0、T4无显著性(P>0.05)。高渗盐水组液体总量1205±322ml明显小于对照组,2147±674ml,P<0.01(t=8.839);其ARDS、MODS、病死率均低于对照组(P<0.05)。结论:对于急性颅内高压伴失血性休克的患者,高渗盐复合液能更快更有效的纠正休克时组织低灌注,保护重要脏器的功能和降低颅内压,减少输液量,降低ARDS、MODS的发生率及病死率。     

甲泼尼龙对急性肺损伤早期血管内皮生长因子影响的研究

摘要：目的　研究不同剂量甲泼尼龙（MP）对急性肺损伤（ALI）早期血管内皮生长因子（VEGF）的影响,为临床治疗提供理论依据。方法　选择2005年3月至2008年12月温州医学院附属育英儿童医院收治的符合ALI诊断标准的儿童重症监护病房（PICU）患儿48例,随机分为3组： ALI组 11例,HALI组（大剂量MP干预）22例,LALI组（小剂量MP干预）15例,正常对照组（NC）8例。应用ELISA法检测入院0、24、48、72 h血清VEGF,采用美国NOVA生化血气分析仪检测血气分析,日本血乳酸测定仪（便携式）检测血乳酸。结果　（1） ALI组、HALI组、LALI组各时间血清VEGF、血乳酸高于NC组,氧合指数（PaO2/FiO2）低于NC组,差异均有统计学意义（P < 0.05）;（2）24、48、72 h时HALI组、LALI组血清VEGF、血乳酸低于ALI组,高于ALI组,差异均有统计学意义（P < 0.05）;（3）24、48、72 h HALI组与LALI组血清VEGF、血乳酸及PaO2/FiO2差异均无统计学意义（P > O.05）;（4）72 h内HALI组、LALI组发展为急性呼吸窘迫综合征（ARDS）病例百分率少于ALI组,差异有统计学意义（P < 0.05）,HALI组与LALI组发展为ARDS病例百分率差异无统计学意义（P  > O.05）。结论　ALI早期VEGF表达增加,小剂量MP通过抑制血清VEGF表达,从而抑制ALI病情进展。     

妊娠合并感染性休克

感染性休克是导致孕产妇死亡的重要原因之一,产科感染性休克的原因主要是绒毛膜羊膜炎、无菌操作不严格致产后感染、妊娠合并阑尾炎、血栓性静脉炎等。治疗包括积极的抗感染治疗、有效的容量复苏、血管活性药物的应用及器官功能支持。     

妊娠期急性呼吸窘迫综合征诊治

妊娠期急性呼吸窘迫综合征(ARDS)是一种极其凶险的产科并发症,其发病原因可分为产科因素和非产科因素。ARDS可诱发多器官功能衰竭,病死率高,预后极差。早期识别病情、有效干预以及各学科之间的合作对改善母儿预后有重要意义。本文重点讨论妊娠期ARDS的诊断和治疗。     

98例脓毒性休克患者的临床分析

目的了解孕产妇患脓毒性休克的病因、临床特点及结局。 方法回顾性分析广州医科大学附属第三医院2005年5月至2019年12月发生脓毒性休克的孕产妇临床资料。 结果共纳入98例产科脓毒性休克孕产妇,其中孕产妇存活73例(74.5%),死亡25例(25.5%);75例(76.5%)脓毒性休克发生在孕期,52例(69.3%)因脓毒性休克终止妊娠。肺部感染30例(30.6%),生殖道感染25例(25.5%),泌尿道感染27例(27.6%),腹腔内感染7例(7.1%),其他感染9例(9.2%)。98例脓毒性休克孕产妇的外科干预性感染(46例,46.9%)较非外科干预性感染(52例,53.1%)的存活率高[42例(91.3%) vs 21例(40.4%),P<0.001],平均住院时间长(11 vs 6 d,P<0.001),功能障碍器官数目≥3个者比例低(17.4% vs 55.8%,P<0.001)。75例孕期感染者的83例胎儿中死胎/死产为56.6%(47例),活产30.1%(25例),继续妊娠至足月分娩胎儿为13.3%(11例)。 结论孕产妇脓毒性休克主要为肺部、生殖道以及泌尿道感染;具有手术干预指征的外科干预性感染患者存活率高。孕期严重感染容易导致不良妊娠结局,但脓毒性休克并非终止妊娠的绝对指征,胎儿结局有赖于母亲病情的转归。     

Acute lung injury in preterm fetuses and neonates: mechanisms and molecular pathways

Abstract

Acute lung injury (ALI) results in high morbidity and mortality among preterm neonates and efforts have therefore been devoted to both antenatal and postnatal prevention of the disease. ALI is the result of an inflammatory response which is triggered by a variety of different mechanisms. It mostly affects the fetal lung and, in particular, causes damage to the integrity of the lung’s alveolar-capillary unit while weakening its cellular linings. Chemotactic activity and inflammatory products, such as proinflammatory cytokines TNF-α, IL-1, IL-6, IL-11, VEGF,TGF-α and TGF-β, provoke serious damage to the capillary endothelium and the alveolar epithelium, resulting in hyaline membrane formation and leakage of protein-rich edema fluid into the alveoli. Chorioamnionitis plays a major part in triggering fetal lung inflammation, while mechanical ventilation, the application of which is frequently necessary in preterm neonates, also causes ALI by inducing proinflammatory cytokines. Many different ventilation-strategies have been developed in order to reduce potential lung injury. Furthermore, tissue injury may occur as a result of injurious oxygen by-products (Reactive Oxygen Species, ROS), secondary to hyperoxia. Knowledge of the inflammatory pathways that connect intra-amniotic inflammation and ALI can lead to the formulation of novel interventional procedures. Future research should concentrate on the pathophysiology of ALI in preterm neonates and οn possible pharmaceutical interventions targeting prevention and/or resolution of ALI.     

新生儿肺部疾病支气管肺泡灌洗液肺表面活性蛋白A的检测及意义

目的 探讨新生儿常见肺部疾病支气管肺泡灌洗液肺表面活性蛋白A(BAL SP-A)水平及其与临床的关系。方法 收集2000年1月至2003年2月在广州市儿童医院新生儿重症监护室住院的需行机械通气治疗的新生儿重症肺炎、胎粪吸入综合征(MAS)、急性呼吸窘迫综合征(ARDS)以及新生儿呼吸窘迫综合征(RDS)患儿共57例。测定其BAL SP-A水平，监测血气、PaO2/FiO2水平。结果重症肺炎组与MAS组患儿BAL SP-A水平无明显差异，但MAS组患儿PaO2、PaCO2及PaO2/FiO2水平较重症肺炎组明显降低(P值<0.01,<0.05,<0.05)；ARDS及RDS组患儿BAL SP-A水平均较上述两组低(P值均<0.001)，而RDS组患儿BAL SP-A水平较ARDS组低(P<0.001)，但ARDS组患儿PaO2水平较RDS组患儿低(P<0.05)。PS治疗组患儿的病死率较非PS治疗组明显降低(P=0.049)，其PaO2/FiO2与BAL SP-A水平密切相关(r=0.741,P=0.000)。结论 与重症肺炎患儿比较胎粪吸入综合征患儿BAL SP-A水平无明显降低；ARDS及RDS患儿BAL SP-A水平明显降低；BAL SP-A水平能反映新生儿肺损伤的严重程度，对于新生儿肺部疾病预后的判断有一定意义。 Abstract ObjectiveTo investigate the bronchoalveolar lavage (BAL) SP-A concentrations from newborn infants with lung disease,and to study the relationship between BAL SP-A and clinical outcome.Methods 57 cases of newborn infants with lung disease were admitted in our NICU between Jan.2000 and Feb.2003.BAL SP-A concentrations,PO2 value,PCO2 value,and PaO2/FiO2 ratio were measured.ResultsBAL SP-A concentrations did not differ between severe pneumonia group and MAS group,but the value of PaO2、PaCO2 and PaO2/FiO2 ratio in MAS group were significantly lower than that in severe pneumonia group (p respectively<0.001,<0.05,<0.05).BAL SP-A concentrations in RDS and ARDS groups were significantly lower than that in aforesaid groups ( all P<0.05).BAL SP-A concentrations in RDS group were significantly lower than that in ARDS group,but PaO2 value in ARDS group was lower significantly than that in RDS group( P<0.05).The mortality of infants treated with PS was significantly lower than that of infants treated without PS (P=0.049).PaO2/FiO2 ratio for the cohort was related to their BAL SP A concentrations ( r=0.741,P=0.000).Conclusion Surfactant protein A content in MAS is not different from that of severe pneumonia.BAL SP-A concentrations of neonates with ARDS or RDS decrease significantly.BAL SP-A concentrations can evaluate the severity of lung injury and the prognosis of neonatal lung disease. Key wordsInfant,newbornLung disease;Bronchoalveolar lavae;Surfactant protein A     

母鼠人巨细胞病毒感染致胎鼠脑、肺和肝脏的损害

目的 探讨母鼠人巨细胞病毒(HCMV)感染对胎鼠脑、肺和肝脏的损害情况.方法 将30只10周龄健康昆明鼠按雌雄比1:1配对,分为感染组(20只)和对照组(10只),均雌雄各半.感染组雌鼠妊娠前3 d腹腔内接种1×106半数组织培养感染量病毒悬液0.5 ml,对照组雌鼠分别接种等量的人胚成纤维细胞培养上清液.然后交配受孕并于孕19 d剖宫取出胎鼠.感染组共获胎鼠15只;对照组获得健康胎鼠36只,随机抽取15只纳入本研究.检测胎鼠脑、肺、肝脏组织HC-MV DNA和病理改变并进行病毒分离.两组间计数资料比较用χ2检验.结果 感染组胎鼠病毒分离阳性率分别为:脑73.3%(11/15)、肝脏53.3%(8/15)、肺脏60.0%(9/15);对照组3种组织病毒分离阳性率均为0(P<0.05).感染组胎鼠HCMV DNA阳性率分别为:脑93.3%(14/15)、肝脏93.3%(14/15)、肺脏86.7%(13/15);对照组HCMV DNA阳性率均为0(P<0.05).病理检测结果显示感染组胎鼠的脑、肺、肝脏组织结构损伤严重,可见病毒颗粒.结论 母鼠HCMV感染可以发生垂直传播,导致子鼠脑、肺、肝脏等易感器官损伤.     

血管生成素2在脓毒症及肺损伤儿童中的应用研究

目的 研究探讨血管生成素2在脓毒症及肺损伤儿童血清中的变化情况及临床意义.方法 选择我院2019年7～12月的脓毒症患儿90例,按病情严重程度分为脓毒症组63例和脓毒性休克组27例,同期选取健康体检儿童30例为对照组.90例脓毒症患儿中有肺损伤25例.观察各组研究对象血管生成素2水平情况以及脓毒症及肺损伤患儿血管生成素...     

Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes

Objective: To report maternal and perinatal outcomes in obstetric patients with severe sepsis and septic shock. Methods: We performed a retrospective study of obstetric patients admitted to an intensive care unit (ICU) for severe sepsis/septic shock. Maternal clinical characteristics, hemodynamic profiles, laboratory findings, and perinatal outcomes were evaluated. Patients with severe sepsis (N = 20) and septic shock (N = 10) were compared using Fisher’s Exact and Mann–Whitney U tests. Results: Pyelonephritis was the most common etiology overall (37%) and acute respiratory distress syndrome (ARDS) was the most common organ injury in both severe sepsis (50%) and septic shock (80%). Liver dysfunction was present in cases with increased morbidity as a late finding and was the least frequent organ injury. Patients with septic shock had significantly higher rates of disseminated intravascular coagulation (DIC) (p = 0.01), altered mental status (p ≤ 0.001), total bilirubin >4?mg/dl (p = 0.04), failure in ≥3 organ systems (70% vs. 15%, p = 0.005), and maternal death (30% vs. 0%, p = 0.03). All patients with septic shock were delivered during hospitalization vs. 40% with severe sepsis. 71% of viable pregnancies required emergent cesarean delivery, and 50% of these for worsening respiratory function. Conclusions: ARDS is frequently found in critically ill obstetric patients with severe sepsis/septic shock and is associated with a high risk of emergent cesarean delivery.     

法洛四联症根治术后急性肺损伤的治疗

目的 分析法洛四联症(TOF)根治术后急性肺损伤(ALI)的原因，总结治疗体会。 方法 2003年7月至2004年6月，上海第二医科大学附属新华医院上海儿童医学中心心胸外科共行TOF根治术161例，发生ALI 5例。记录5例ALI患儿术前经皮氧饱和度(SpO2)、红细胞压积比(HCT)、McGoon比值、肺动脉指数(PAI)和手术、体外循环(CPB)资料，以及ALI发生时间、ALI发生后各项治疗措施、各治疗阶段肺功能指标、计算其肺损伤分数。 结果 5例ALI患儿，年龄7~24(13.8±3.1)个月，体重7.0~9.5(8.2±0.5)kg，均在静吸复合麻醉CPB下进行，术毕给予改良超滤，平均CPB时间(67.2±5.9)min，主动脉阻断时间(43.6±2.4)min，ALI发生率为3.1%，发生时间为术后8~60h，死亡2例。5例均施行腹膜透析术(PD)，2例给予一氧化氮吸入，1例给予肺表面活性物质替代治疗。各治疗阶段肺功能指标逐步改善，至治疗后期，肺功能指标在统计学上有显著性差异(P<0.05)。 结论 TOF术后ALI治疗困难，合理机械通气、尽早维持体液平衡、改善肺通气和氧合功能有利于及时阻断低氧酸中毒导致的恶性循环。 Abstract Objective To analyse the reasons of acute lung injury (ALI) after the surgical correction of tetralogy of Fallot (TOF) and summarize the postoperative treatment skill.Methods There were 161 cases of patients with TOF who underwent corrective repair operation in the Department of Cardiovascular Surgery of Xinhua Hospital/ Shanghai Children’s Medical Center from Jul.2003 to Jun.2004,in which there were 5 patients who developed ALI after the surgical correction of TOF.The mean age was 13.8±3.06 months (7~24 months) and the mean body weight was (8.20±0.46)kg (7~9.5kg).Before operation,their mean SpO2 was (72.8±2.2)% (67%~80%),mean HCT was (49.0±5.5)%,mean McGoon ratio was (1.27±0.05) and mean PAI was (136.0±16.8)mm2/m2.The total cardiopulmonary bypass (CPB) time and aortic clamp time were (67.2±3.9) min and (43.6±2.4) min,respectively.The modified ultrafiltration was used throughout the CPB.The treatment and the blood analysis were recorded when the ALI developed.The parameters of pulmonary function and lung injury score were calculated.Results ALI developed (30.0±9.7) hrs after the operation and the incidence of ALI after the surgical correction of TOF was 3.1%.Two cases died within 48 hrs.Peritoneal dialysis (PD) was performed on all the cases.Meanwhile,2 cases were given inhaled nitric oxide (NO) and 1 case was given pulmonary surfactant (PS).The parameters of pulmonary function were improved step by step and the differences were statistically significant at the latest stage of treatment (P<0.05).Conclusion The treatment of ALI after surgical correction of TOF includes reasonable mechanical ventilation and maintaining the balance of fluid.Inhaling NO and using PS will be benefitial to improve the pulmonary function and to stop the vicious circle which results in the hypoxemia and refractory acidosis. Key wordsTetralogy of Fallot;Acute lung injury;Cardiopulmonary bypass     

剖宫产术后呼吸窘迫综合征19例临床分析

目的:分析剖宫产术后发生呼吸窘迫综合征(ARDS)的发病原因及临床特点。方法:回顾性分析2005年1月至2015年12月第三军医大学附属西南医院收治的剖宫产后诊断为ARDS的产妇19例的临床资料。结果:只有6例(31.6%)被诊断为上呼吸道感染或肺炎,其中剖宫产术前有上呼吸道感染或肺炎临床表现的仅3例。剖宫产手术指征为:重度子痫前期10例(合并部分性前置胎盘1例、中央性前置胎盘1例),轻度子痫前期1例,绒毛膜羊膜炎2例,瘢痕子宫合并边缘性前置胎盘1例,羊水过少1例,相对头盆不称2例,妊娠期急性脂肪肝1例,血小板减少合并重度贫血1例。剖宫产后发生ARDS的时间24~56小时2例,术后24小时内发生8例,术中及术后即刻发生9例。需要呼吸机治疗9例(47.4%),所有患者均好转出院。结论:应警惕妊娠期特有加重肺水肿及肺部感染的疾病,严格控制剖宫产手术指征并加强围手术期管理。