可视型双腔支气管导管在胸部创伤急诊手术中的应用效果

目的 探究可视型双腔支气管导管在胸部创伤急诊手术中的应用效果.方法 前瞻性选取2019年7月至2020年8月琼海市人民医院收治的行急诊胸外科手术的102例胸部创伤患者作为本次研究对象,按随机数字表法将患者分为观察组(n=52)和对照组(n=50).观察组手术时采用可视型双腔支气管导管(DLT)插管,对照组手术时采用普通...     

半永久双腔中心静脉导管维持性血液透析患者的微炎症状态

背景：半永久性双腔中心静脉导管作为自体动静脉内瘘的重要补充形式在维持性血液透析患者中应用日益广泛,但有研究发现,将半永久性双腔中心静脉导管作为血液透析血管通路患者的死亡率高于使用自体动静脉内瘘者,原因尚未完全明确。目前不同类型血管通路对微炎症状态的影响还鲜有报道。目的：比较半永久性双腔中心静脉导管与自体动静脉内瘘作为血管通路维持性血液透析患者体内炎性因子的差异,探讨不同类型的血管通路对维持性血液透析患者微炎症状态的影响。方法：选择维持性血液透析患者80例,根据血管通路不同分为自体动静脉内瘘组48例及颈静脉半永久双腔静脉导管组32例,以门诊健康体检者60例作为健康对照。检测2组维持性血液透析患者及健康对照者血清超敏C-反应蛋白、白细胞介素6、肿瘤坏死因子α水平,并行对比分析。结果与结论：维持性血液透析患者血清超敏C-反应蛋白、白细胞介素6、肿瘤坏死因子α水平明显高于健康对照组,差异有显著性意义（P〈0.01）;半永久插管组患者血清超敏C-反应蛋白、白细胞介素6、肿瘤坏死因子α水平高于内瘘组,差异有显著性意义（P〈0.05）。结果提示维持性血液透析患者体内存在微炎症状态,使用半永久性双腔中心静脉导管作为血液透析血管通路较使用自体动-静脉内瘘可进一步加重微炎症状态。     

密闭式静脉留置针在新型医院船重症监护室的应用

目的 探讨密闭式静脉留置针在新型医院船重症监护室应用的优越性.方法 结合近年来新型医院船海上医疗队模拟演练,从护理人力配置、新型医院船重症监护室特殊工作环境、海战伤的复杂伤情,分析密闭式静脉留置针的应用效果.结果 应用密闭式静脉留置针为新型医院船重症监护室伤病员建立静脉通路,穿刺成功率高、脱针/渗漏少、不误伤操作者.结...     

急性呼吸衰竭纤维支气管镜肺段冲洗乌司他丁干预的临床研究

目的 评价纤维支气管镜肺段冲洗联合机械通气乌司他丁干预对控制胸腹部手术后急性呼吸衰竭、防治多脏器功能障碍综合征（MODS）及降低其病死率的作用.方法 56例胸腹部手术后急性呼吸衰竭患者随机分为纤维支气管镜肺段冲洗联合机械通气组（n=30）和纤维支气管镜肺段冲洗联合机械通气乌司他丁干预组（n=26）,比较两组患者呼吸力学、动脉血气及血流动力学的变化.观察两组患者肺及肺外脏器功能改善率、ICU病死率及其死亡原因等.结果 两组患者年龄和APACHE Ⅱ评分比较差异无显著性（P＞0.05）;纤维支气管镜肺段冲洗联合机械通气乌司他丁干预组对患者呼吸力学、动脉血气及血流动力学的影响均优于单纯使用纤维支气管镜肺段冲洗联合机械通气组;乌司他丁治疗组多脏器功能衰竭（MODF）的病死率为15.3%,明显低于对照组（25.6%,P＜0.05）.结论 纤维支气管镜联合机械通气乌司他丁干预能进一步改善胸腹部手术后急性呼吸功能衰竭患者的呼吸力学、动脉血气及血流动力学指标,并在防治MODS及降低急性呼吸衰竭患者病死率上有显著临床效果.     

Quality of care for patients with indwelling urinary catheter in selected hospitals in Kashan, Iran 2007

A cross-sectional study was conducted on 377 patients with indwelling urinary catheter to evaluate the quality of catheter care in three educational hospitals of Kashan University of Medical Sciences, Kashan, Iran. In this study, 331 patients expressed their views on the quality of care and 46 patients were observed. Indwelling urethral catheters were mostly used for immobile and bedrest patients (36·3%). In total, 45·77 ± 12·24% of the score was reached from the patients' view and 51·08 ± 10·83% from the observer's view. The total quality of care was low. The nurses' in-service education programmes should be reinforced. Strengthening the supervisory system and overcoming the staff shortage can also have beneficial effects on the quality of care for patients with indwelling urethral catheter.     

Evaluation of a triple-lumen central venous heparin-coated catheter versus a catheter coated with chlorhexidine and silver sulfadiazine in critically ill patients

Objective To compare the incidence of catheter colonization and catheter-related bloodstream infections between heparin-coated catheters and those coated with a synergistic combination of chlorhexidine and silver sulfadiazine.Design Randomized, controlled clinical trial.Setting A 20-bed medical-surgical intensive care unit.Patients A total of 180 patients requiring the insertion of a trilumen central venous catheter.Interventions Patients were randomized to receive either a trilumen heparin or chlorhexidine and silver sulfadiazine-coated catheter.Measurements Catheter colonization was defined by a semiquantitative catheter tip culture yielding 15 or more colony-forming units or quantitative culture of 1,000 or more colony-forming units/ml. Catheter-related bloodstream infection as the isolation of the same microorganism from a peripheral blood culture and catheter tip.Results A total of 260 catheters were cultured. Out of 132 heparin-coated catheters, 29 were colonized and out of 128 chlorhexidine and silver sulfadiazine- coated catheters, 13 were colonized (p=0.03), relative risk RR=2.16 (1.18–3.97). This represents an incidence of 23.5 and 11.5 episodes of catheter colonization per 1,000 catheter-days, respectively (p=0.0059), RR=2.04 (1.05–3.84). Microorganisms isolated in catheter colonization from heparin-coated catheters were gram-positive cocci 23, gram-negative bacilli 7, and Candida spp 4. In chlorhexidine and silver sulfadiazine-coated catheters were gram-positive cocci 6 and gram-negative bacilli 11 (p=0.009). The incidence of catheter-related bloodstream infections per 1,000 catheter-days was 3.24 in heparin-coated catheters and 2.6 in chlorhexidine and silver sulfadiazine-coated catheters (p=0.79), RR=1.22 (0.27–5.43).Conclusions In critically ill patients the use of trilumen central venous catheters coated with chlorhexidine and silver sulfadiazine reduced the risk of catheter colonization due to prevention of gram-positive cocci and Candida spp.Presented in part as an abstract (K-1426) at the 41st Annual ICAAC, Chicago, December 2001.     

模拟昼夜节律的镇静在重症监护病房机械通气患者中的应用

目的 观察模拟昼夜节律的镇静方案在重症监护病房(ICU)机械通气患者撤除镇静后昼夜节律的形成、机械通气时间及ICU停留时间等方面是否具有优势.方法 采用前瞻性随机对照方法,将120例收入ICU的机械通气患者用信封法完全随机分为昼夜节律组(CR)、每日中断组(DI)、持续输注组(CS)、按需镇静组(DS)4组,每组30例,因DS组不良反应多,入组10例后去除该组,最终入组患者共90例.记录患者的年龄、性别、体重、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、镇静药物剂量、每日清醒时间、机械通气持续时间、ICU停留时间、并发症(呼吸机相关性肺炎、需置入胸引管的气压伤)和不良反应(患者意外拔管、再次插管、气管切开、死亡),并测定生化指标,10:00和22:00各记录1次在岗护士人数.结果 CR、DI、CS3组患者性别比例、年龄、体重、APACHEⅡ评分、ICU停留时间、机械通气时间差异无统计学意义.CS组镇静药物总剂量(mg:5466.7±620.4)、平均镇静药物剂量(mg·h-1·kg-1:2.19±0.61)均明显高于CR组(4344.5±816.0、1.00±0.51 )、DI组(4154.3±649.4、1.23±0.62),差异均有统计学意义(均P＜0.01);CR组与DI组无差异.CR组每日清醒时间(h:4.40±1.30)较DI组(0.59±0.26)、CS组(0.15±0.02)均明显延长(均P＜0.05).各组并发症的发生未见统计学差异;DI组不良反应的发生(2例次)较CR组(1例)、CS组(0例)明显增加(P=0.0477).撤除镇静后,CR组昼夜节律正常者较CS组明显增加(19比9,P=0.0339).CR、DI、CS 3组间白天在岗护士人数两两比较差异均有统计学意义(1.65、1.41、1.14,均P＜0.01),夜间则无差异.各组生化指标未见差异.结论 模拟昼夜节律的镇静方案有助于ICU机械通气患者脱离镇静后昼夜节律的形成,且不增加不良反应及并发症发生率,不延长机械通气时间及ICU停留时间,具有一定临床适用性.     

Protocol-driven care in the intensive care unit: a tool for quality

Advances in organization and patient management in the intensive care unit (ICU) have led to reductions in the morbidity and mortality suffered by critically ill patients. Two such advances include multidisciplinary teams (MDTs) and the development of clinical protocols. The use of protocols and MDTs does not necessarily guarantee instant improvement in the quality of care, but it does offer useful tools for the pursuit of such objectives. As ICU physicians increasingly assume leadership roles in the pursuit of higher quality ICU care, their knowledge and skills in the discipline of quality improvement will become essential.     

中心静脉导管在癌性腹水患者治疗中的应用及护理

目的:探讨中心静脉置管在治疗癌性腹水中的应用及护理方法。方法:对9例癌性腹水患者给予中心静脉导管作持续腹腔引流及行腹腔内灌注化疗。结果:9例置管均成功,导管留置时间5~29d,平均17d,腹胀均明显减轻。结论:中心静脉置管治疗癌性腹水操作简单、安全,效果好,患者活动方便,易于接受,提高了生活质量。     

ICU患者在机械通气中应用异丙酚镇静的观察与护理

目的观察异丙酚在ICU机械通气患者的镇静效果及护理.方法选择40例在ICU接受气管插管、机械通气患者按住院号单双分成2组,观察组20例在上机后使用异丙酚,对照组20例给与其它镇静剂,观察2组机械通气时间、在ICU住院的时间.结果观察组的机械通气时间、在ICU住院时间,明显少于对照组（P＜0.01,P＜0.05）.结论异丙酚用于ICU机械通气患者的镇静不仅能安全有效镇静,而且能减少机械通气时间和在ICU住院时间,使用异丙酚应严格无菌技术操作以防止发生医源性感染.     

综合重症监护病房患者胸腔积液的临床分析

目的研究综合重症监护病房(ICU)患者胸腔积液的临床特点。方法选择2005-01～2006-06入住ICU的患者632例,依据住ICU期间有无胸腔积液分为胸腔积液组和非胸腔积液组。分析原因并比较两组患者呼吸衰竭的发生率、机械通气时间及预后。结果632例患者胸腔积液的发生率是58%,基础疾病以创伤、病理产科、急性胰腺炎和外科手术后为主,发生胸腔积液的相关因素以低蛋白血症及多脏器功能障碍综合征最常见。胸腔积液组呼吸衰竭的发生率高于非胸腔积液组(P<0.01),机械通气时间长于非胸腔积液组(P<0.05);胸腔积液组的死亡率明显高于非胸腔积液组(P<0.05)。结论综合ICU患者胸腔积液的发生率高,合并胸腔积液较无胸腔积液的患者在呼吸衰竭的发生率、机械通气平均时间方面差异均有统计学意义,且与预后相关;ICU患者发生胸腔积液的原因明显区别于普通病房。     

综合ICU机械通气患者气道感染监测结果分析与对策

目的分析综合ICU有刨机械通气患者气道病原菌分布规律,提出解决及预防气道感染发生的对策。方法采用前瞻性研究与回顾性调查相结合的方法,对入住综合ICU的25例有创机械通气患者的气道进行感染监测,并对其临床资料进行分析。结果呼吸机相关性肺炎发生率为64．00％;下呼吸道与呼吸机管路存在多重菌感染,二者病原菌一致;呼吸机管路的污染率随通气时间延长而升高。结论加强气道管理与感染监控,缩短呼吸机管道更换周期,是预防呼吸机相关性肺炎的重要措施。     

Nursing diagnoses in patients having mechanical ventilation support in a respiratory intensive care unit in Turkey

This research was carried out to find out the nursing diagnoses in patients who have mechanical ventilation support in a respiratory intensive care unit. The study was conducted with 51 evaluations of critically ill adult patients who underwent invasive and non-invasive mechanical ventilation therapy in 2008. Data collection was based on Gordon's 11 Functional Health Patterns, and nursing diagnoses were determined according to North American Nursing Diagnosis Association-International (NANDA-I) Taxonomy II. The nursing diagnoses were determined by two researchers separately. The consistency between the nursing diagnoses defined by the two researchers was evaluated by using Cohen's kappa (κ). Forty men (78.4%) and 11 women (21.6%) whose mean ages were 70.19 (SD = 8.96) years were included in the study. Nineteen subgroups of nursing diagnoses about safety/protection domain, and 15 subgroups about activity/rest domain were seen at different rates in the patients. There was a statistically significant difference between mechanical ventilation via tracheostomy or endotracheal tube and decreased cardiac output (d.f. = 1, χ(2) = 4.760, P = 0.029). The relationship between the length of time under mechanical ventilation and impaired physical mobility was considerably significant (d.f. = 3, χ(2) = 24.459, P = 0.000). It was found out that there was a high degree of agreement (96.8%) between the nursing diagnoses defined by the two researchers separately (κ = 0.936, SE = 0.08).     

Prospective evaluation of a decision support system for setting inspired oxygen in intensive care patients

Purpose

The aim of the study was to prospectively evaluate a decision support system for its ability to provide appropriate suggestions of inspired oxygen fraction in intensive care patients comparing with levels used by clinicians in attendance.

Materials and Methods

Thirteen mechanically ventilated patients were studied in an intensive care unit where up to 4 experiments were performed during 2 consecutive days. Inspired oxygen fraction was selected in each experiment by both the decision support system and attending clinicians, and each selection was evaluated by measuring arterial oxygen saturation.

Results

Median (interquartile range [range]) changes in inspired oxygen fraction from baseline level by attending clinicians and the decision support system were 0.00 (−0.05 to 0.00 [−0.10 to 0.05]) and −0.03 (−0.07 to 0.01 [−0.16 to 0.12]), respectively. Clinician ranges of inspired oxygen fraction and arterial oxygen saturation were 0.25 to 0.70 and 0.92 to 0.99, respectively. Decision support system ranges of inspired oxygen fraction and arterial oxygen saturation were 0.26 to 0.54 and 0.94 to 0.99, respectively.

Conclusions

The decision support system selects appropriate levels of inspired oxygen fraction in intensive care patients and could be used for automatic frequent assessment of patients, freeing the focus of clinicians to concentrate on more challenging therapy.     

重症监护病房人工气道患者胃液真菌鉴定及意义

目的 通过分析与鉴定重症监护病房(ICU)建立人工气道的重症患者胃液pH值与真菌类型及耐药情况,探讨ICU患者胃液pH值与真菌的直接关系及临床意义.方法 采用前瞻性研究方法,选择160例深圳大学第一附属医院ICU 2008年12月至201 1年10月收治的建立人工气道＞48 h的重症患者.通过鼻胃管收集其胃液样本,用精密pH试纸测定胃液pH值;依胃液酸度将样本分为pH值≤2.0、pH值2.1～3.0、pH值3.1～ 4.0、pH值4.1～5.0、pH值5.1～6.0、pH值6.1～7.0组;同时进行胃液真菌培养及常用抗真菌药物敏感试验,分析胃液酸度对胃液真菌培养阳性率的影响;再按照患者28 d存活情况分成存活组(102例)和死亡组(58例),分析组间胃液真菌分布及临床意义.结果 ①胃液pH值＜4.0时,几乎无真菌生长;随着胃液pH值的增大,真菌培养阳性率明显升高.②胃液总样本真菌培养阳性率为27.9％(55/197),其中白色念珠菌与非白色念珠菌培养阳性率分别为38.2％(21/55)和61.8％( 34/55),差异有统计学意义(x2=4.16,P＜0.05).③存活组与死亡组真菌培养检出率分别为40.0％( 22/55)和60.0％( 33/55),其中存活组白色念珠菌与非白色念珠菌分别为54.5％(12/22)和45.5％( 10/22),死亡组白色念珠菌与非白色念珠菌分别为27.3％( 9/33)和72.7％(24/33).白色念珠菌与非白色念珠菌耐药率分别在4.7％～14.3％(平均10.1％)和0～ 60.0％(平均28.5％).结论 建立人工气道的重症患者胃液真菌培养阳性率随着胃液pH值的增大而明显升高;非白色念珠菌是胃液培养的主要真菌,其耐药率高于白色念珠菌,数量增加提示患者预后较差.     

Toward less sedation in the intensive care unit: a prospective observational study

Purpose

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

Methods

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

Results

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15?240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

Conclusions

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.