心源性死亡的诱发因素分析及干预对策

目的探讨分析心脏病患者心源性死亡的促发因素及干预对策。方法回顾28例住院心源性死亡患者的临床资料,分析其护理措施及死亡原因。结果本组中,心源性死亡多发于70岁左右,男性多于女性,冠心病是其主要病因,电解质紊乱和体力活动是其主要诱发因素。最常见的直接原因是冠心病及其并发症,占71.4%;21例有明确的诱发因素,占75%。结论心源性死亡与心脏基础疾患以及诸多诱发因素相关,应积极治疗心脏基础疾病,加强对患者的健康指导和病情监护,及时去除诱发因素,以尽可能改善预后。     

A Case of Transient Diabetes Insipidus Associated with Poisoning by a Herbicide Containing Glufosinate

Background: The herbicide BASTA® (AgrEvo, Germany), containing glufosinate ammonium (20%) and an anionic surfactant, polyoxyethylene alkylether sulfate (33%), is widely used. In acute oral BASTA poisoning, patients develop a variety of clinical signs, including disturbed consciousness, convulsions, and apnea. These effects are suspected to be due to the effects of glufosinate on the central nervous system. Case Report: A 60-year-old man ingested 500 mL of BASTA herbicide in a suicide attempt. He developed not only unconsciousness, respiratory distress, and convulsions but also an increase in urine output (7885 mL/d), elevated serum sodium (167 mEq/L), elevated plasma osmolality (332 mOsm/kg), and a decrease in both urine osmolality (200 mOsm/kg) and urine specific gravity (1.003), which suggested the development of diabetes insipidus. The plasma level of antidiuretic hormone remained within the normal range (1.3 pg/mL), despite high plasma osmolality. The administration of desmopressin was successful in normalizing urine volume, specific gravity, and osmolality. Serum sodium corrected gradually within 48 hours. The possible mechanisms causing the diabetes insipidus are discussed.     

Osmolality measurements in heart disease

A study of the variations of plasma and urinary osmolality in patients with acute myocardial infarction and heart failure of different origin was made. It was shown that the plasma osmolality may be related to the clinical evolution of heart disease. The effectiveness of monitoring the osmolality in establishing the alterations of water-electrolyte balance is also reported.     

宫腔镜灌流液对患者病理生理学影响的研究

目的研究宫腔镜手术中灌流液(膨宫液)的吸收对患者生化指标的影响及一过性血糖的升高与低钠血症的相关性,检验并揭示5%葡萄糖作为膨宫介质的安全性与可行性.方法选择60例子宫内膜良性病变患者行宫腔镜电切术,以5%葡萄糖作为膨宫介质,于术前、术毕、术后1 h、术后3 h分别采静脉血测定血清钠、氯、钾、CO2-CP、尿素氮、肌酐、血浆渗透压、阴离子间隙及血糖等指标,结果应用SPSS 10.0统计软件进行分析.结果术后血清钠、钾、血浆渗透压、阴离子间隙、尿素氮均较术前明显下降(P＜0.05),血糖于术毕明显升高(P＜0.05);控制灌流液吸收因素后,血钠的降低与血糖的升高之间无明显相关性(P＞0.05).结论宫腔镜电切术中灌流液的吸收可引起一过性血清钠、钾、尿素氮、血糖、血浆渗透压及阴离子间隙的改变;一过性高血糖不会加重低钠血症,使用5%葡萄糖作为灌流液安全可行.     

The effect of acutely reduced plasma osmolality on acute renal failure in rats

The present study was designed to evaluate the effect of acute fall in plasma osmolality in three models of acute tubular necrosis in rats: (a) glycerol, (b) arterial clamping and (c) mercuric chloride. Plasma osmolality was reduced by a water loading during a mild anaesthesia from 305 +/- 7 to 270 +/- 12 mosmol/kg of water (P less than 0.01). In the ischaemic models of acute tubular necrosis (glycerol and arterial clamping), during the first 24 h in rats with reduced plasma osmolality, the respective creatinine clearance rates (CCR), 0.04 +/- 0.02 and 0.06 +/- 0.04 ml/min, were strikingly lower than those in rats with normal osmolality, 0.21 +/- 0.03 and 0.26 +/- 0.06 ml/min (P less than 0.001) respectively. The control CCR were 0.65 +/- 0.07 and 0.62 +/- 0.07 ml/min respectively. During the second day after induction of ischaemic (glycerol and arterial clamping) acute tubular necrosis, rats with reduced plasma osmolality exhibited a similar worsening in CCR as on the first day, when compared with that in rats with normal osmolality. In rats with acute tubular necrosis induced with mercuric chloride reduction in plasma osmolality did not aggravate the severity of renal failure. These results show that acute fall in plasma osmolality worsens the renal failure in the ischaemic but not in the nephrotoxic models of acute tubular necrosis.     

甘露醇与血糖对脑卒中急性期血浆晶体渗透浓度的影响

目的 :研究脑中风急性期甘露醇用量和血糖浓度对血浆晶体渗透浓度的影响。方法 :测定 34例脑卒中急性期病人血浆电解质和葡萄糖的渗透浓度 ,计算同期甘露醇用量总数。设立HBSS、NBSS实验组和对照组。结果 :仅电解质形成的渗透浓度 ,三组间无明显差异 ,由葡萄糖形成的渗透浓度及总血浆晶体渗透浓度 ,HBSS明显高于NBSS和对照组。 2 0 %甘露醇用量与HBSS的渗透浓度呈高度的直线正相关关系 (r=0 72 7,P <0 0 0 1)。结论 :对脑卒中急性期运用 2 0 %甘露醇降颅压时 ,除适当补充水和电解质外 ,需积极有效地控制高血糖 ,不盲目大量使用甘露醇。     

重症急性胰腺炎预后的早期相关因素分析

目的探讨重症急性胰腺炎(severe acute pancreatitis,SAP)患者入院24 h内与预后的相关因素.方法 对193例SAP患者临床资料作回顾性分析.按预后分为死亡组和存活组,先以单因素分析筛选有统计学意义的影响因素,再通过Logistic回归分析筛选与预后有关的影响因素.结果 SAP死亡组患者年龄、血钙、阴离子间隙、血浆总蛋白、血清白蛋白、肌酐、尿素氮与存活组患者比较差异有统计学意义(P<0.05),SAP死亡组患者性别、病因、红细胞比积、白细胞计数、血小板计数、氧分压、谷草转氨酶、谷丙转氨酶、乳酸脱氢酶与存活组患者比较差异无统计学意义(P>0.05).Logistic回归分析显示早期血肌酐、血清总蛋白浓度与SAP预后存在相关性(P<0.05).结论 入院24h内的血肌酐、血清总蛋白浓度是影响SAP预后的早期因素.     

颅脑创伤患者血浆和脑脊液血管升压素的动态变化及意义

目的 探讨颅脑创伤患者血浆和脑脊液血管升压素(AVP)的动态变化及其临床意义。方法 将36例中重度颅脑创伤患者按GCS和GOS评分分组，采用放射免疫RIA方法和渗透压测定仪对患者血浆和脑脊液中AVP、血浆和脑脊液渗透压和电解质进行动态检测，同时选择30例外科手术患者作为对照。结果 颅脑创伤组血浆和脑脊液AVP明显高于对照组并与GCS评分有关。对照组血浆AVP术前与术后有显著性差异，GOS各分组间脑脊液AVP有显著性差异，AVP水平与脑脊液渗透压和颅内压相关；血浆AVP与血浆渗透压相关；Spearman相关性检验提示，相对低钠血症，血浆AVP变化较脑脊液AVP敏感；相对颅内压变化血浆渗透压较脑脊液渗透压敏感。结论 血浆和脑脊液中AVP可以通过不同环节和不同因素参与继发性脑损害的过程。脑脊液或血浆中的AVP可以通过不同环节和不同因素参与继发性脑损害的过程，脑脊液或血浆中的AVP与颅脑创伤损伤严重程度密切相关，可以作为判断伤情程度的客观指标；创伤患者预后越差，脑脊液中AVP浓度越高，测定颅脑创伤患者CSF中AVP水平比血浆中AVP更合适作为预后的判断指标，用来评估脑水肿严重程度和颅内压也较血浆中AVP敏感、准确。     

Osmole gap in neurologic-neurosurgical intensive care unit: Its normal value, calculation, and relationship with mannitol serum concentrations

OBJECTIVE: To determine a) if the admission osmole gap, the difference between osmolality and osmolarity, is the same in the neurologic-neurosurgical intensive care unit (NNICU) population as in healthy controls; b) which of 11 osmole gap formulas, or osmolality, correlates best with mannitol serum concentrations; c) whether osmole gap correction for plasma water content improves this correlation; and d) whether the osmole gap can predict mannitol serum concentrations. DESIGN: Prospectively collected data. SETTINGS: NNICU of a tertiary teaching hospital. SUBJECTS: Ten NNICU patients on mannitol and eight not on mannitol, and 95 healthy controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the admission osmole gap between all 18 NNICU patients and healthy controls and the correlation between osmole gap or osmolality and mannitol serum concentrations in ten NNICU patients while receiving mannitol. The osmole gap was calculated using 11 osmolarity formulas (six corrected for plasma water content). Student's t-test was used to compare the mean osmole gap between control and patient groups.We found that the mean osmole gap in healthy subjects and NNICU patients was not different. There were no statistically significant differences between any of the 11 osmole gap formulas and the correlation of osmole gap with serum mannitol concentrations; the highest R =.80, with formula 4, 1.86 (sodium + potassium) + (blood urea nitrogen/2.8) + (glucose/18) + 10, requires the least laboratory measurements. Osmolality had the lowest correlation with mannitol concentration (R =.60), significantly lower than any of the osmole gap calculations. Plasma water content correction did not improve this correlation. The osmole gap-mannitol serum concentrations relationship is 1 to 0.81, not accurate enough to predict specific mannitol serum concentrations. CONCLUSIONS: The osmole gap correlates better with mannitol serum concentrations than osmolality, and although it cannot predict a specific mannitol serum concentration, a normal osmole gap concentration, as we find at trough times, indicates sufficient clearance for a new mannitol dose.     

Biochemical changes in extracorporeal circulation in patients.

The effect of priming extracorporeal perfusion pumps with 50% and 80% diluted homologous blood on the serum electrolytes, acid-base status and plasma osmolality has been investigated in 103 patients undergoing open-heart surgery for congenital and acquired heart disease. The value in prognosis of plasma osmolality is discussed.     

血浆脑钠肽水平与急性缺血性脑卒中预后的相关性研究

目的:探讨血浆脑钠肽(BNP)与急性缺血性脑卒中预后的相关性。方法:急性缺血性脑卒中患者212例,依据住院期间是否死亡分为存活组和死亡组,比较2组相关临床资料,并分析血浆BNP和美国国立卫生研究院卒中量表(NIHSS)评分与预后的相关性。结果:急性缺血性脑卒中患者住院期间的预后死亡率为15.09%(32/212);多因素分析结果显示房颤(OR=3.819)、大面积脑梗死(OR=6.228)、血浆BNP浓度≥280 ng/L(OR=5.191)、NIHSS评分≥13分(OR=3.536)为脑卒中预后死亡的独立危险因素;NIHSS评分≥13分筛查预后的灵敏度、特异度、准确度分别为89.1%、75.0%、87.0%;血浆BNP≥280 ng/L筛查预后的灵敏度、特异度、准确度分别为85.0%、81.3%、84.4%。结论:房颤、大面积脑梗死、血浆BNP水平及NIHSS评分为急性缺血性脑卒中预后死亡的高危因素,其中血浆BNP水平和NIHSS评分可能可作为预后死亡的预测指标。     

Acute respiratory infections in persons with spinal cord injury

Respiratory disorders are the leading cause of death for persons with both acute and chronic spinal cord injury (SCI), and much of the morbidity and mortality associated with respiratory disorders is related to acute respiratory infections. Pneumonia is the best recognized respiratory infection associated with mortality in this population. Recent evidence supports some management strategies that differ from those recommended for the general population. Upper respiratory tract infections and acute bronchitis may be precipitating factors in the development of pneumonia or ventilatory failure in patients with chronic SCI. This review emphasizes management principles for treatment and prevention of respiratory infections in persons with SCI.     

中青年脑出血60例临床分析

目的 分析中青年脑出血的临床特点.方法 回顾性分析60例中青年脑出血患者危险因素、诱发因素、始发症状、并发症、住院期间病死率和死亡原因等,并与同期住院的126例老年脑出血患者比较.结果 中青年脑出血患者男性明显多于女性;吸烟、酗酒比例高于老年脑出血组;发病前多有明显的诱因;头痛症状典型;并发症少但急性期病死率高于老年患者.结论 中青年脑出血患者发病多有明显的诱因,头痛症状典型,出血部位多为单发,并有一定的好发部位,并发症少低于老年患者,急性期病死率高于老年患者.     

Peak expiratory flow rate as predictor of inpatient death in patients with chronic obstructive pulmonary disease

OBJECTIVES: Few studies analyze hospital deaths and related factors in patients with acute exacerbation of chronic obstructive pulmonary disease who require hospitalization. METHODS: A cross-sectional study was done with 284 patients who had been admitted consecutively to the Short Stay Medical Unit at the Juan Canalejo Hospital in A Coru?a. RESULTS: Eleven patients (3.9%) died. The independent variables for predicting death were the peak expiratory flow (OR, 0.96; 95% CI, 0.94 to 0.98), long-term oxygen therapy (OR, 12.46; 95% CI, 2.1 to 72.4), and body mass index (OR, 0.73; 95% CI, 0.59 to 0.90). A peak expiratory flow < 150 L/min showed the best specificity and positive predictive value with maximum sensitivity for predicting death. The results of the arterial blood gasses and the functional tests did not predict hospital death. CONCLUSIONS: Peak expiratory flow was the most important predictive value for determining the risk of death in patients who required hospitalization for acute exacerbation of chronic obstructive pulmonary disease. Additional studies are required to validate these findings.     

脓毒症心肌损伤患者的预后影响因素分析

目的探讨影响脓毒症心肌损伤患者预后的相关危险因素。方法回顾性分析2013年1月至2018年12月首都医科大学附属北京友谊医院收治的147例脓毒症心肌损伤患者的病例资料,研究终点为患者28 d死亡,按照预后将患者分为生存组和死亡组,采用多元Logistic回归分析法分析两组患者的临床资料,分析影响患者死亡预后的危险因素。结果147例患者中,其中66例死亡,死亡率为44.89%,单因素分析显示,与生存组相比,死亡组(n=66,44.89%)患者高血压比率高,以肺部感染为感染源比率高,血糖、血肌酐、血清钾离子水平高,7 d累积液体正平衡多,急性生理与慢性健康评分II(APACHEⅡ评分)、全身感染相关性序贯器官衰竭评分(SOFA评分)高,使用机械通气、血管活性药物、合并急性肾损伤比率大;而生存组24 h乳酸清除率高于死亡组。根据单因素分析筛选指标,进行多元logistic回归分析显示,24 h乳酸清除率(OR=0.348,95%CI:0.155~0.786,P=0.011)、APACHE II评分(OR=2.037,95%CI:1.970~2.109,P=0.028)、肺部感染(OR=4.556,95%CI:1.527~13.593,P=0.007)、合并急性肾损伤(OR=21.443,95%CI:4.119~43.879,P<0.01)是影响脓毒症心肌损伤患者预后的独立危险因素。结论脓毒症心肌损伤患者病死率高,24 h乳酸清除率、APACHEⅡ评分、肺部感染和合并急性肾损伤是影响其预后的危险因素。     

中重型颅脑损伤后血浆渗透压监测的意义及其护理

目的探讨中、重型颅脑外伤患者血浆渗透压水平变化的临床意义及其护理措施。方法136例中重型颅脑损伤患者入院后立即检测患者血浆渗透压,并对患者进行格拉斯哥昏迷评分（GCS）,出院后3个月给予格拉斯哥预后评分（GOS）。结果患者入院时颅脑伤越重,血浆渗透压越高;血浆渗透压水平与血钠、血糖、血尿素氮相关;住院期间死亡及随访植物生存患者入院时血浆渗透压水平高于其他患者。结论血浆渗透压监测既能反映患者的病情变化和判断预后,又是指导治疗的可靠指标之一;加强中重型颅脑损伤后高血浆渗透压患者的护理,可以改善患者的预后。     

Renal function in tetanus

In twenty-eight patients suffering from tetanus, renal function was evaluated from admission for a period of 2 weeks. Investigations included daily blood urea, osmolality and creatinine and urinary osmolality and sodium. Free water clearance (CH₂O) was calculated. The patients were divided into those requiring tracheostomy and sedation alone (Group I) and those with more severe tetanus requiring total muscle paralysis and IPPV (Group II). The latter group also had evidence of sympathetic nervous overactivity (SOA). Daily blood urea, serum creatinine and osmolality showed no significant difference between the two groups except during the phase of uremia. Mean urinary sodium was significantly different between the two groups (p<0.001). Four patients in Group II developed an abnormal plasma urea (Group IIb). In one patient the rise in urea followed resuscitation from cardiac arrest and the remaining three patients had in common severe cardiovascular instability associated with SOA. All four patients were non-oliguric during the phase of uremia. Only one patient with renal failure survived, compared with a 75% survival in the patients with SOA without renal failure and a 100% survival in Group I. Tetanus complicated by renal failure has a poor prognosis.     

Diagnostic potential of circulating cell-free DNA in patients needing mechanical ventilation: promises and challenges

Circulating cell-free DNA (cf-DNA) mainly comes from apoptotic cells and can reflect the extent of cellular damage. Increased plasma levels of cf-DNA have been found in many acute disorders, including septic and clinically ill patients, and usually correlate well with clinical outcome. Acute respiratory failure, the most frequent organ failure in ICU patients, can be related to various acute diseases that may cause cell death and release of DNA into the bloodstream. In a recent issue of Critical Care, Okkonen and colleagues evaluate levels of cf-DNA in plasma as a prognostic marker in patients needing mechanical ventilation. They report that plasma cf-DNA was higher than normal in patients with mechanical ventilation, and even higher in patients who eventually died compared to survivors. However, its usefulness as a death predictor may be limited in the heterogeneous group of mechanically ventilated patients, probably due to confounding effects of co-morbidities, among other factors.     

特发性间质性肺炎急性加重期患者血清核心蛋白多糖、血管生成素-2的表达及临床意义

目的探讨特发性间质性肺炎(IIP)急性加重期患者血清核心蛋白多糖(DCN)、血管生成素-2(Ang-2)的表达及临床意义。方法选取2017年1月至2018年1月该院诊治的86例IIP患者的临床资料,根据病情分为稳定期组(38例)和急性加重期组(48例),根据生存预后情况将急性加重期组分为生存组(28例)和死亡组(20例)。以40例体检健康者作为对照组。统计学分析各组血清DCN、Ang-2、实验室指标的表达差异及不同预后的急性加重期IIP患者血清DCN、Ang-2水平的表达差异。采用Pearson相关分析IIP急性加重期患者血清DCN、Ang-2水平与实验室指标的相关性。多因素Cox回归分析影响IIP急性加重期患者生存预后的因素。结果与对照组及稳定期组相比,急性加重期组患者血清DCN水平明显较低,而Ang-2水平明显较高(P<0.05)。Pearson相关分析显示,IIP急性加重期患者血清DCN水平与肺泡表面活性蛋白A(SP-A)、肺泡表面活性蛋白D(SP-D)、C反应蛋白(CRP)、红细胞沉降率(ESR)水平呈负相关(P<0.05);血清Ang-2水平与SP-A、SP-D、CRP、ESR水平呈正相关(P<0.05)。与生存组相比,死亡组患者血清DCN水平较低,而Ang-2水平较高(P<0.05)。Cox回归分析结果显示,急性加重期IIP患者血清DCN、Ang-2水平是影响患者生存预后的因素(P<0.05)。结论IIP急性加重期患者血清DCN水平降低,而Ang-2水平升高,两者是影响患者的生存预后的因素,可作为判断IIP急性加重期患者预后的标志物。     

Precipitating factors of heart failure decompensation,short-term morbidity and mortality in patients attended in primary care

Objective To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death.Setting Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema).Main outcome measures Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation.Results Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4–3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5–3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14–1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10–1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15–1.29); previous hospitalisation (OR 1.15, 95% CI 1.11–1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09–1.19).Conclusions In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation.

Key points

• Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease.
• So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes.
• We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death.
• Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.