存在和不存在基础心脏病的感染性心内膜炎患者临床特点及预后的比较研究

目的:比较有基础心脏病和无基础心脏病感染性心内膜炎(IE)患者的临床特点及预后。方法:回顾性分析2007年1月至2016年12月在浙江大学医学院附属第一医院确诊为IE的402例成人(≥16岁)住院患者的临床资料,比较有基础心脏病和无基础心脏病IE患者的临床特点、影响预后的相关因素。结果:无基础心脏病IE患者占总IE患者的45.5%(183/402);其中,27.3%(50/183)合并慢性疾病,37.1%(68/183)存在易感因素。与有基础心脏病的IE患者相比,无基础心脏病IE患者右心及全心受累比例更低(P=0.001),多瓣膜受累更少见(P0.001),心力衰竭、心律失常、瓣周脓肿等心脏并发症的发生率更低(P均0.05),但住院病死率和1年病死率差异无统计学意义(P均 0.05)。多因素分析显示,年龄≥65岁(OR=14.6,95%CI:1.7～124.0,P=0.014)、长期血液透析(OR=20.0,95%CI:1.4～128.9,P=0.027)和Pitt≥2分(OR=83.9,95%CI:13.9～746.8,P0.001)是无基础心脏病IE患者住院死亡的独立危险因素。无基础心脏病并发栓塞IE患者的1年生存率明显低于非栓塞患者(81.0%vs 95.9%,P=0.002);手术治疗患者的1年生存率明显高于非手术治疗患者(95.3%vs 84.8%,P0.001)。结论:无基础心脏病IE并不少见且多有易感因素,出现心脏并发症的比例相对较低,病死率较低,预后较好。年龄≥65岁、长期血液透析和Pitt评分≥2是住院死亡的独立危险因素。合并栓塞事件的患者1年生存率较低;抗生素联合手术治疗可以提高1年生存率。     

急诊重症监护病房慢性阻塞性肺疾病老年患者下肢深静脉血栓形成的发病特征及危险因素

目的探讨急诊重症监护病房(EICU)慢性阻塞性肺疾病(COPD)老年患者下肢深静脉血栓(DVT)的发病特征及相关危险因素。方法采用回顾性病例对照研究设计,收集2013年1月至2017年12月青岛大学医学院附属青岛市市立医院急诊EICU收治的612例COPD急性加重期(AECOPD)老年患者为研究对象,入住EICU后24～48 h内行床旁双下肢静脉超声检查,统计DVT发病率,分析AECOPD患者DVT的发病特点,按照是否合并DVT分为病例组和对照组,对两组的一般资料、实验室指标及临床特征进行比较,采用多因素Logistic回归模型筛选AECOPD合并DVT的危险因素。结果 AECOPD住院患者中DVT的总体发病率为12.8%(78例),AECOPD住院患者总病死率为2.3%(14例),AECOPD合并DVT患者住院病死率为7.7%(6/78),显著高于单纯AECOPD组病死率[1.5%(8/534),P0.01]。多因素Logistic回归分析显示:卧床时间≥3 d(OR=3.376)、D-二聚体升高(OR=6.345)、下肢不对称肿胀发生(OR=2.213)是AECOPD患者合并DVT发病的独立危险因素。结论在EICU的AECOPD住院患者合并DVT的发病率较高,卧床时间≥3 d、D-二聚体升高和下肢不对称肿胀发生时,需明确是否合并DVT。     

系统性红斑狼疮并发蛛网膜下腔出血的临床特点

目的探讨系统性红斑狼疮(systemic lupus erythematosus,SLE)并发蛛网膜下腔出血(subarachnoid hemorrhage,SAH)患者的临床特点及预后。方法总结分析1983年1月至2012年1月就诊于北京协和医院的12例SLE并发SAH患者的临床资料。结果 SLE并发SAH患者住院期间的病死率高达42%(5/12)。SLE并发SAH的症状以头痛为主(75%)。系统性红斑狼疮疾病活动指数平均为(17.5±4.5)分。死亡患者在SAH发生早期即出现意识障碍者占80%(4/5),合并严重感染者占60%(3/5)。结论 SAH是SLE的少见且致命的并发症。对于出现意识障碍或合并感染的SLE患者,应当提高警惕,积极治疗SLE原发病及SAH,提高生存率。     

急诊监护病房危重患者贫血特征分析

目的:探讨危重病患者合并贫血的临床特点及其预后。方法:入选2009年7月至2011年4月急诊重症监护病房(EICU)288例危重病患者,分析其不同性别和年龄段贫血的发生率。按血红蛋白(Hb)水平分为贫血组和对照组,比较其临床特点及预后。住院期间对照组患者Hb低于参考值定义为新发生的贫血,比较住院期间新发生的贫血患者同Hb正常患者的不同临床特点及预后。结果:老年患者占EICU患者的60.8%,不同性别和年龄组之间贫血的发生率无差别。入院时即有贫血的患者占48.3%(男47.0%,女50.0%)。入院贫血组患者所需机械通气和肾脏替代治疗较对照组增加(P<0.01),其病死率高于对照组(P<0.05),2组住院时间无统计学差异。住院期间新出现的贫血患者同对照组相比,机械通气和肾脏替代治疗较对照组增加(P<0.05或P<0.01),2组住院时间和病死率无统计学差异。结论:急诊危重病患者常合并贫血,入院贫血和住院期间新发贫血患者机械通气和肾脏替代治疗者更多。贫血患者的临床预后更差。     

精神障碍伴发肺结核病118例临床分析

目的探讨精神障碍患者伴发肺结核病的临床特征。方法分析118例精神障碍患者伴发肺结核病的临床资料。结果 (1)社会人口学资料:男性111例(占94.1%)。(2)精神科资料:精神分裂症97例(占82.2%),精神分裂症病程≥20年者103例(占87.3%)。(3)结核病资料:病灶范围≥3个肺野103例(占87.3%);痰抗酸杆菌涂片阳性39例(阳性率33.1%,39/118),痰分枝杆菌培养阳性者34例(阳性率28.8%);24例患者的药敏试验结果提示耐药(耐药率20.3%,24/118)。(4)其它资料:躯体合并症以糖尿病为主,19例(发生率16.1%);死亡18例(死亡率15.3%)。结论精神分裂症是最常见的伴发肺结核病的精神障碍,精神障碍伴发肺结核病具有病灶范围大、耐药率高、躯体合并症多、死亡率高等特征。     

重症监护病房老年非心原性危重症患者B型利钠肽水平与预后的关系

目的 探讨急诊重症监护病房(EICU)中B型利钠肽(BNP)对老年非心原性危重症患者28 d病死率的预测价值.方法 连续选取EICU老年非心原性危重症患者70例,收集临床资料,检测BNP水平并随访患者28 d内是否死亡.结果 28 d内共有22例(31.4%)患者死亡,死亡组BNP水平的自然对数值明显高于存活组,分别为(6.4±1.2)ng/L与(5.1±1.5)ng/L(P＜0.05),BNP预测EICU老年危重症患者28 d病死率所得出接收者操作特征曲线下面积为0.759(95%可信区间0.636～0.882,P＜0.05),BNP预测EICU老年危重症患者28 d病死率最佳临界点为342 ng/L,敏感度为77.3%,特异度为68.7%,Youden指数为0.460.结论 BNP可作为预测老年非心原性危重症患者28 d病死率方便快捷的预测指标.     

急性主动脉夹层患者的临床特征及死亡危险因素

目的探讨急性主动脉夹层(AAD)患者的临床特征及其相关死亡危险因素。方法采用回顾性分析方法,收集2010年1月至2014年12月安徽省亳州市人民医院收治的93例AAD患者的相关资料,并分析与死亡相关的危险因素。结果AAD患者93例临床表现各异,首发症状以疼痛为主占89.2%(83/93),高血压占72.0%(67/93),发病年龄为(58.9±12.0)岁,男女性别比约为2.4∶1.0。确诊至术前93例均行内科急诊救治,总体临床病死率为16.1%(15/93),其中De BakeyⅠ型患者临床病死率16.7%(7/42),De BakeyⅡ型为28.6%(6/21),De BakeyⅢ型为6.7%(2/30)。CT、磁共振诊断AAD的准确率为100%,存活组与死亡组血清D-二聚体分别为(0.9±1.0)和(2.1±1.6)mg/L(P0.05)。单因素分析显示,AAD患者死亡的危险因素有高血压、胸痛、心包积液、低血压/休克和肾功能不全。多元Logistic回归分析显示,高血压是AAD患者死亡的独立危险因素(P0.05)。结论高血压是AAD患者院内死亡的危险因素。     

合并基础疾病的严重急性呼吸综合征患者临床特征分析

目的　探讨合并基础疾病的严重急性呼吸综合征(SARS)患者临床特征和实验室指标变化特点。方法　回顾性分析2003-03~06北京地区1 291例SARS患者的病历资料,对基础疾病的分布和有、无基础疾病两组患者的年龄、性别、临床症状和体征、实验室指标以及病情严重程度进行分析。结果　伴有基础疾病的患者(A组)占27 .5% (355 /1 291),其中40岁以上的患者占65. 6%;而无基础疾病的患者(B组)占72. 5% (936 /1 291),其中40岁以下的患者占74. 6%。本组基础疾病以高血压、糖尿病和冠心病最常见。A组患者的临床症状和体征的发生率明显高于B组(P<0 .05)。在病程中A组患者的淋巴细胞和血小板以及血生化等指标异常率明显高于B组患者(P<0. 05)。A组SARS患者的重症发生率为52. 7% (187 /355)。结论　合并基础疾病的SARS患者其临床表现较重,易出现实验室指标的异常,重症发生率高。     

老年急性白血病患者50例临床特征分析

目的:探讨老年急性白血病(AL)的临床特点,以利于有效治疗。方法:回顾分析50例60岁以上的老年AL患者的临床资料,包括年龄分布、基础疾病、主要症状、临床特征、骨髓(BM)象、染色体、免疫分型、化疗的完全缓解(CR)率、BM抑制程度、病程及病死率。并与同期住院的66例中青年患者进行比较。结果:老年AL发病率占同期成人AL的27%(50/185)。AML的CR率35.7%(15/42),ALL的CR率33%(2/6)。其基础疾病的发病率86%、MDS转化为AML占20%、病程(35.5±16.5)d、BM抑制时间(18.5±6.5)d、病死率20%、染色体核型为-5、-7、+8、+21,以上均高于同期的中青年组(均为P<0.01)。结论:老年AL患者并存基础疾病和染色体核型异常是其病死率高的主要原因,目前尚无早期诊断和有效治疗老年AL的满意策略,呼吁重视此方面的研究。     

2型糖尿病合并慢性阻塞性肺疾病急性加重期血糖控制与预后的关系

目的:分析2型糖尿病合并慢性阻塞性肺疾病急性加重期(AECOPD)患者住院期间的平均血糖水平与患者预后的相关性。方法:查阅2009年1月至2010年12月,在我院呼吸科及急诊重症监护室(EICU),以糖尿病合并慢性阻塞性肺疾病急性加重期入院的患者135例,且住院时间不少于5 d。住院期间每日监测血糖不少于4次的患者的病例资料,根据住院期间不同的平均血糖值(MBG)分组,观察MBG与不良事件发生数、病死率的相关性。结果:3组患者住院期间MBG为7.8～11.1 mmol/L的患者,主要不良事件发生率及病死率显著低于平均血糖<7.8 mmol/L和>1.1 mmol/L组,差异有统计学意义。结论:在2型糖尿病合并慢性阻塞性肺疾病急性加重期患者,平均血糖水平控制在(7.8～11.1mmol/L)范围内时安全性好,病死率低。     

Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial

RATIONALE: Respiratory failure after extubation and reintubation is associated with increased morbidity and mortality. OBJECTIVES: To assess the efficacy of noninvasive ventilation in averting respiratory failure after extubation in patients at increased risk. METHODS: A prospective randomized controlled trial was conducted in 162 mechanically ventilated patients who tolerated a spontaneous breathing trial after recovery from the acute episode but had increased risk for respiratory failure after extubation. Patients were randomly allocated after extubation to receive noninvasive ventilation for 24 h (n = 79), or conventional management with oxygen therapy (control group, n = 83). MEASUREMENTS AND MAIN RESULTS: The primary end-point variable was the decrease in respiratory failure after extubation. In the noninvasive ventilation group, respiratory failure after extubation was less frequent (13, 16 vs. 27, 33%; p = 0.029) and the intensive care unit mortality was lower (2, 3 versus 12, 14%; p = 0.015). However, 90-d survival did not change significantly between groups. Separate analyses of patients without and with hypercapnia (arterial CO(2) tension greater than 45 mm Hg) during the spontaneous breathing trial showed that noninvasive ventilation improved intensive care unit mortality (0 vs. 4, 18%; p = 0.035) and 90-d survival (p = 0.006) in hypercapnic patients only; of them, 98% had chronic respiratory disorders. CONCLUSIONS: The early use of noninvasive ventilation averted respiratory failure after extubation and decreased intensive care unit mortality among patients at increased risk. The beneficial effect of noninvasive ventilation in improving survival of hypercapnic patients with chronic respiratory disorders warrants a new prospective clinical trial.     

COPD als wichtiger Risikofaktor in der herzchirurgischen Intensivmedizin

Background

Chronic obstructive pulmonary disease (COPD) is a common comorbidity in patients undergoing cardiac surgery. Our objective was to analyze its prognostic relevance in a cardiac surgery intensive care unit.

Patients and methods

From January 2006 to December 2008, 121?patients with a preoperative history of COPD underwent cardiac surgery and were compared to an age-, sex-, and operation-matched control group without COPD. The primary endpoint was 30-day mortality.

Results

The logistic EuroSCORE was significantly higher in the COPD group (7.8 vs 5.0; p<0.001). There was a higher prevalence of smoking history in the COPD patients (74 vs 36%; p<0.001) and 43% of patients were on beta-agonist treatment preoperatively. Preoperative pulmonary function was significantly impaired and consequently postoperative respiratory failure was more frequent in patients with COPD (9.9 vs 2.5%; p=0.02). Left ventricular function was significantly lower in COPD patients (57 vs 66%; p=0.001). Intensive care stay (p=0.04) and 30-day mortality (5.8 vs 0.8%; p=0.03) were significantly increased in COPD patients.

Conclusion

Patients with COPD and concomitant left ventricular impairment are at high risk for early mortality, postoperative respiratory failure, and prolonged intensive care unit stay.     

Characteristics of In-Hospital Patients with Congenital Heart Disease Requiring Rapid Response System Activations: A Japanese Database Study

Objectives: This study aimed to study the characteristics of in-hospital deterioration in patients with congenital heart disease who required rapid response system activation and identify risk factors associated with 1-month mortality. Methods: We retrospectively analysed data from a Japanese rapid response system registry with 35 participating hospitals. We included consecutive patients with congenital heart disease who required rapid response system activation between January 2014 and March 2018. Logistic regression analyses were performed to examine the associations between 1-month mortality and other patient-specific variables. Results: Among 9,607 patients for whom the rapid response system was activated, only 82 (0.9%) had congenital heart disease. Only few patients with congenital heart disease were being treated at the cardiology and cardiovascular surgery departments (12.3% and 9.9%, respectively). Moreover, the incidences of rapid-response events after intensive care unit discharge or surgery were low (6.8% and 12.2%, respectively). The most common reason for rapid response system activation was respiratory dysfunction (desaturation: 35.4%, tachypnoea: 25.6%, and new dyspnoea: 19.5%). Rapid response system interventions and intensive care unit transfers were required for 65.9% and 20.7% of patients, respectively. The mortality rate was 1.2% at the end of the rapid response system intervention and 11.0% after 1 month. Moreover, decreased respiratory rate and decreased heart rate at rapid response system activation were associated with increased 1-month mortality. The adjusted odds ratio was 1.10 (95% confidence interval 1.02–1.19) and 1.02 (95% confidence interval, 1.00–1.04 for respiratory rate and heart rate, respectively. Conclusions: Rapid response systems were rarely activated after cardiac surgery and intensive care unit discharge, which were situations with a high risk of sudden deterioration in patients with congenital heart disease. Therefore, encouraging the use of the rapid response system in these departments will enable intervention by a third, specialised team for in-hospital emergencies and help provide comprehensive medical care to patients. Furthermore, 1-month mortality was associated with vital signs at rapid response system activation. These findings may guide treatment selection for patients with congenital heart disease showing deterioration.     

Mortality Rates and Predictors of Mortality Among Late-Middle-Aged and Older Substance Abuse Patients

This study describes mortality rates and predictors of mortality among late-middle-aged and older (55+) substance abuse inpatients ( n = 21, 139) in Department of Veterans Affairs (VA) Medical Centers in the 4 years after an index episode of care. A total of 24% of the patients died; this mortality rate was 2.64 times higher than expected. Predictors of earlier mortality included older age and nonmarried status, alcohol psychosis and organic brain disorder diagnoses, and several medical diagnoses, including neoplasms, liver cirrhosis, respiratory, endocrine and metabolic, and blood system disorders. Three proxy indicators of illness severity also predicted mortality: more prior inpatient and outpatient medical care and an index episode in an extended care unit. In contrast, more prior outpatient mental health care and remitted status predicted lower mortality. These diagnostic and treatment indicators can be used to identify patients at heightened risk for premature mortality. Moreover, they show that intensive mental health aftercare and remission of substance abuse may delay mortality, even among older patients who have longstanding substance abuse problems.     

自主呼吸试验通过后拔管失败原因分析

目的:分析通过自主呼吸试验(SBT)后拔管失败的原因,提高撤机拔管的成功率。方法:回顾性分析重症监护病房(ICU)接受机械通气并通过SBT后拔管的126例患者的临床资料及其拔管失败原因。结果:拔管失败28例(22.22%),因呼吸系统原因导致拔管失败15例,其中气道分泌物过多且喘憋加重14例,呼吸骤停1例;低氧血症7例;呼吸性酸中毒3例,其中喉水肿1例,支气管狭窄1例;意识障碍加重3例,其中脑出血1例。拔管失败患者中,血白蛋白水平是拔管失败后患者病死率的保护因素。结论:仅通过SBT来指导撤机拔管可能有一定的局限性,除了呼吸系统原因外,氧合状态、中枢神经系统、营养状态等都可能对拔管结局产生影响,因此对于通过SBT进行脱机拔管的患者,仍应该充分评估呼吸道、中枢神经、心功能以及营养状态等多方面因素。     

Incidence of readmission to the ICU after cardiac surgery: a systematic review and meta-analysis

BackgroundDue to the complexity of cardiac surgery, almost all patients need to be admitted to the intensive care unit (ICU) for postoperative care after surgery. After being discharged from the ICU, some patients need to be readmitted due to disease deterioration during hospitalization. We conducted a meta-analysis of the literature to investigate the incidence of readmission to the ICU in patients undergoing cardiac surgery.MethodsThe PubMed, Medline, and Elsevier databases were searched using the keywords “cardiac surgery,” “readmission,” “intensive care unit,” and “ICU” to retrieve English-language articles published from January 2000 to January 2021. The articles were screened, and their quality was evaluated. A meta-analysis was performed on the outcomes of patients after readmission to the ICU using Stata16.0 software.ResultsUltimately, 9 articles were included in the meta-analysis, comprising 32,825 cardiac surgery cases, of whom 1,302 were readmitted to the ICU. The incidence of readmission to the ICU was 3.97%. Among the direct reasons for readmission to the ICU, respiratory failure accounted for 13.6–48.6%, while hemodynamic instability accounted for 21.6–51.9%. The results of the meta-analysis showed that the mortality rate of patients readmitted to the ICU was significantly higher than that of patients not readmitted to the ICU [risk difference (RD) =8.05, 95% confidence interval (CI): 5.10–12.69, Z=8.965; P<0.0001], as was the length of hospital stay [standard mean difference (SMD) =3.17, 95% CI: 1.40–4.94, Z=3.504; P<0.001], and the incidence of complications (odds ratio =1.97, 95% CI: 1.35–2.87, Z=3.507; P<0.001).ConclusionsNine articles were included in this meta-analysis on the incidence rate of readmission to the ICU of patients undergoing cardiac surgery. The results showed that the proportion of readmission to the ICU was 3.97%. Patients readmitted to the ICU had a higher rate of complications, longer hospital stay, and higher mortality rate than those not readmitted.     

Characteristics and evolutive data of chronic respiratory diseases after respiratory intensive care. Evaluation of the Pneumology Department of the Pavillon Saint-Fran?ois in Strasbourg between 1980 and 1985

Between 1980 and 1985, 66 patients with chronic obstructive lung disease (respiratory deficit of the restrictive type) were admitted to our department after an episode of acute respiratory failure treated with assisted ventilation in an intensive care unit. These patients were in a particularly poor clinical condition, due to their previous long stay in the intensive care unit (mean 43 days), the high percentage of tracheotomies (mean 44%), the loss of autonomy of movement in 30% of the cases and the presence of an associated pathology in 45% of the patients. These data explain the high mortality observed in this group: 40% of the patients died within one year of the acute respiratory failure episode. Other prognostic factors, notably the patients' nutritional status, must also be taken into account.     

Prevalence and prognostic role of cardiovascular complications in patients with exacerbation of chronic obstructive pulmonary disease admitted to Italian respiratory intensive care units.

BACKGROUND: Cardiovascular complications are frequently observed in patients with chronic obstructive pulmonary disease (COPD) admitted to respiratory intensive care units and may affect the prognosis. The aims of this study were to evaluate a) the prevalence of cardiovascular complications in patients with COPD exacerbation admitted to respiratory intensive care units, b) which parameters detected at admission were predictive of cardiovascular complications, and c) the prognostic role of cardiovascular complications. METHODS: A series of 278 consecutive patients with COPD admitted to 11 Italian respiratory intensive care units between November 1997 and January 1998 has been retrospectively analyzed. All cardiovascular complications were recorded. RESULTS: One hundred and ten patients (39.6%) developed cardiovascular complications: congestive heart failure 49 (17.6%), arrhythmias 40 (14.4%), shock 13 (4.7%), and hypotension 11 (4%). Multivariate analysis showed that the APACHE II score, ECG abnormalities (supraventricular ectopic beats, right and/or left ventricular hypertrophy) and digoxin therapy were independent predictors of cardiovascular complications. The overall mortality was 9% being 4.7% in patients without and 15.5% in patients with cardiovascular complications (p = 0.0044). Multivariate analysis showed that the APACHE II score, respiratory rate, pneumonia and end-stage respiratory diseases were independent predictors of mortality. CONCLUSIONS: Cardiovascular complications occurred in many patients with COPD exacerbation admitted to respiratory intensive care units, and identify a subset of patients with higher mortality.     

体外循环不停跳冠状动脉搭桥在心功能低下患者手术中的应用

目的:探讨危重冠心病患者进行体外循环下,心脏不停跳冠状动脉搭桥术的可行性。方法:2008年1月至2011年1月间1 030例冠状动脉搭桥术(CABG)中,选择64例(6.2%)进行体外循环下心脏不停跳CABG的患者进行回顾性分析。其中,常规手术组36例,19例为急诊行CABG,9例为非体外不停跳CABG紧急改为体外下不停跳CABG。术前观察其一般情况、心肌缺血情况、左心室射血分数(LVEF)及是否患有3支冠状动脉病变、左主干病变、术前是否放置主动脉内球囊反搏(IABP)等。结果:64例患者术前LVEF为(32±5)%,均进行了体外循环下不停跳CABG。平均体外循环(CPB)时间为(72±14)min,移植桥血管平均数为(2.8±0.7)根,其中53例(82.8%)使用了左乳内动脉。住院期间死亡3例(4.7%),均为紧急建立体外循环者,原因为严重心律失常或心力衰竭。其余患者无围术期心肌梗死发生,5例患者(7.8%)发生肾功能不全,3例(4.7%)发生肺部感染。平均住院时间为(14±6)d。61例患者全部随访,平均随访时间为(12±2)个月。随访期内1例患者死于严重心律失常,其余患者无心绞痛主诉或心衰表现。术后1年行超声心动图检查,平均LVEF为(38±8)%。结论:对于危重冠心病患者,CABG有较高的风险。体外循环下心脏不停跳CABG,是一种更安全可靠的方法。