机械通气患者预防呼吸机相关性肺炎的集束化护理

目的探讨集束化护理措施在预防机械通气患者呼吸机相关性肺炎（ventilator-associated pneumonia,VAP）中的效果。方法回顾性分析2012年1—12月在湖州市中心医院重症医学科机械通气≥48h患者的临床资料,所有患者均采取呼吸道管理、抬高床头30°～45°、加强口腔护理、预防消化道溃疡和深静脉血栓等集束化护理措施。结果应用集束化护理措施后,216例患者中,发生VAP40例,发生率为18．52％,较常规护理干预明显降低。结论集柬化护理措施可明显降低机械通气患者VAP发生率,是预防和减少VAP的有效方法。     

Preoxygenation,Reoxygenation, and Delayed Sequence Intubation in the Emergency Department

Background: The goal of preoxygenation is to provide us with a safe buffer of time before desaturation during Emergency Department intubation. For many intubations, the application of an oxygen mask is sufficient to provide us with ample time to safely intubate our patients. However, some patients are unable to achieve adequate saturations by conventional means and are at high risk for immediate desaturation during apnea and laryngoscopy. For these patients, more advanced methods to achieve preoxygenation and prevent desaturation are vital. Discussion: We will review the physiology of hypoxemia and the means to correct it before intubation. Next, we will discuss apneic oxygenation as a means to blunt desaturation and the optimal way to reoxygenate a patient if desaturation does occur. Last, we will discuss the new concept of delayed sequence intubation, a technique to be used when the discomfort and delirium of hypoxia and hypercapnia prevents patient tolerance of conventional preoxygenation. Conclusions: These new concepts in preoxygenation and reoxygenation may allow safer airway management of the high-risk patient.     

大鼠机械通气所致肺损伤时p38丝裂原活化蛋白激酶通路的激活

目的探讨大鼠机械通气所致呼吸机相关性肺损伤(VILI)时p38丝裂原活化蛋白激酶(MAPK)的激活以及致炎因子的表达。方法30只健康SD大鼠随机均分成A、B、C3组,A组:潮气量(VT)8ml/kg,呼吸频率(RR)80次/min;B组:VT20ml/kg,RR80次/min;C组:VT40ml/kg,RR80次/min。各组机械通气时间均为2h。实验结束处死大鼠,收集支气管肺泡灌洗液(BALF)和肺组织标本,光镜下观察肺组织病理学改变。采用蛋白质免疫印迹法(Western blotting)检测各组肺组织中p38、磷酸化p38(p-p38)水平,逆转录-聚合酶链反应(RT-PCR)检测细胞间黏附分子-1(ICAM-1)表达水平,考马斯亮蓝染色法检测肺组织中总蛋白浓度和髓过氧化物酶(MPO)活性,双抗体夹心酶联免疫吸附法检测BALF中肿瘤坏死因子-α(TNF-α)、巨噬细胞炎症蛋白-2(MIP-2)和白细胞计数(WBC)。结果肺组织病理观察显示,A、B、C3组的改变依次加重;与A组相比,B、C两组p-p38和ICAM-1的表达以及总蛋白、WBC、MIP-2、TNF-α及MPO的水平均显著增高(P均<0.01);与B组相比,C组p-p38和ICAM-1的表达以及总蛋白、WBC、MIP-2、TNF-α及MPO的水平均显著增高(P<0.05或P<0.01)。结论大VT机械通气能显著激活p38通路以及致炎因子的表达,这可能是大鼠机械通气所致肺损伤的重要致病机制之一。     

A Comparison of GlideScope Video Laryngoscopy Versus Direct Laryngoscopy Intubation in the Emergency Department

Objectives: The first‐attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED). Methods: A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts. Results: A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first‐attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p < 0.01). Conclusions: Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.     

舒适护理在气管插管机械通气患者中的应用

目的总结舒适护理在气管插管机械通气患者中的应用方法和效果。方法回顾性分析舒适护理在45例气管插管机械通气患者中的应用。结果 45例患者在生理、心理、社会方面的不适感减少,舒适感增强,患者满意度为99.0%。结论舒适护理应用于气管插管机械通气患者,可提高机械通气治疗的依从性,并促进患者早日康复,提高患者满意度,体现"以人为本,以患者为中心"的现代护理理念。     

改良集束化策略预防呼吸机相关性肺炎的临床研究

目的研究改良的集束化策略预防呼吸机相关性肺炎的效果。方法本院收治的机械通气≥5 d患者209例,随机分为对照组（94例）和试验组（115例）。对照组应用常规方法预防呼吸机相关性肺炎;试验组在对照组基础上采用改良的集束化策略。比较2组呼吸机相关性肺炎发生率、机械通气时间及ICU住院时间及痰病原学检查结果。结果试验组呼吸机相关性肺炎发生率较对照组明显下降,机械通气时间I、CU住院时间较对照组明显缩短。结论改良集束化策略能有效预防呼吸机相关性肺炎的发生。     

A prospective,randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system

The objective of this study was to verify the incidence of nosocomial pneumonia in intubated and extended mechanically ventilated patients having endotracheal suctioning by an open vs. closed suction method aiming to decrease nosocomial pneumonia. Twenty-four (51.1%) patients received open-tracheal suction and 23 (48.9%) received closed-tracheal suction. The inclusion criteria were: surgical and medical patients older than 13 years, undergoing mechanical ventilation for more than 48 hours. Additional data were gathered using the Acute Physiology and Chronic Health Evaluation II, and details on smoking, alcoholism, diabetes mellitus, renal failure, previous lung disease, and previous use of antibiotics, steroids, H2 antagonists and antacids. Among the 24 patients having open-tracheal suction, 11 developed nosocomial pneumonia while of the 23 patients undergoing closed-tracheal suction, seven developed infection (P = 0.278). Risk factors for nosocomial pneumonia were not significantly different between the two groups. In the final logistical regression model the following variables remained: groups (open and closed) [odds ratio (OR) = 0.014; confidence interval (CI) = 0.001-0.416; P = 0.014] and use of prior antibiotics (OR = 2.297; CI = 1.244-4.242; P = 0.008). Use of a closed suction system did not decrease the incidence of nosocomial pneumonia when compared with the open system. The exogenous risk factors were the most important for acquiring this infection.     

护理干预对老年呼吸机相关性肺炎发生的预防作用分析

目的探讨护理干预对老年呼吸机相关性肺炎发生的预防作用。方法选取本院接诊的80例接受机械通气患者作为研究对象。按照随机抽签法分为观察组和对照组各40例,2组患者进行常规对症治疗,包括气管插管、化痰止咳、纠正酸碱失衡及水电解质紊乱、解痉平喘、抗生素治疗等。对照组采用常规护理,观察组采用护理干预。观察2组患者机械通气时间和住院时间,动脉血气分析,生命体征,肺功能指标,呼吸机相关性肺炎发生率及病死率。结果观察组机械通气时间和住院时间低于对照组;pH值、p(O_2)值均高于对照组,p(CO_2)低于对照组(P0.05);Sa O2显著高于对照组(P0.05),心率、呼吸频率低于对照组(P0.05);2组患者肺功能指标PEF、PEEPi均改善,且观察组改善程度优于对照组(P0.05);呼吸机相关性肺炎发生率及病死率均低于对照组(P0.05)。结论加强护理干预在对老年呼吸机相关性肺炎发生具有显著的预防作用,能够促进患者恢复,缩短机械通气治疗时间,从而减少肺部感染。     

两种卧位对机械通气患者呼吸机相关性肺炎的影响

目的探讨两种卧位对机械通气患者呼吸机相关肺炎（ventilator associated pneumonia,VAP）的影响。方法按患者住院号或就诊卡号单双数将行机械通气〈48h的177例患者分为实验组88例和对照组89例。遵医嘱对两组患者进行治疗并采取相同的护理措施,同时实验组患者采取30～45°半卧位,对照组患者采取≥15°但〈30°的半卧位。比较两组VAP发生率及其死亡率和住院时间。结果实验组VIP发生率较对照组低,住院时间较对照组短,两组比较,差异具有统计学意义（均P〈0.05）;两组VAP患者死亡率比较,差异无统计学意义（P〉0.05）。结论机械通气患者采用床头抬高30～45°的半卧位可以降低VAP的发生,缩短住院时间。     

体位护理对机械通气患者胃食管返流后误吸的影响

目的 探讨RICU机械通气患者半坐卧位护理(45°)是否减少误吸。方法 对20例RICU机械通气患者随机取水平仰卧位或半坐卧位,间隔2d交换2种体位做自我对照实验,用Tc-99m硫胶体标记患者胃内容物,5h内每隔30min测定气管、支气管内分泌物的放射计数,并对患者胃液、咽拭子和支气管内分泌标本微生物学检查。结果 患者在仰卧位和半坐卧位护理时,支气管内分泌物5h的总放射计数均数分别是4169±1957cpm和972±211cpm(P<0.05);仰卧位30min和300min的放射计数分别是301±153cpm和2601±1904cpm(P<0.05);半坐卧位30min和300min的放射计数分别是110±44cpm和217±61cpm(P<0.05)。患者胃液、咽拭子和支气管内分泌同种细菌检出率,半坐卧位为35％,仰卧位达70％。结论 RICU患者持续水平仰卧位护理是胃内容物返流后误吸入气道的潜在高危因素。     

系统护理在预防呼吸机相关性肺炎中的作用

目的从系统护理角度探讨预防呼吸机相关性肺炎(VAP)的方法。方法将98例机械通气患者随机分为对照组和实验组各49例,对照组行常规护理,实验组在常规护理的基础上强化系统护理干预,观察2组的VAP发生率。结果实施系统护理干预后,实验组VAP发生率显著低于对照组,差异有统计学意义(P<0.05)。结论对机械通气患者实施系统护理干预能有效预防VAP的发生。     

急诊内科危重病人气管插管时机与方法的探讨

目的:总结急诊内科病人气管插管的特点,分析其治疗效果,并探讨其插管时机、方法与转归。方法:根据病人在急诊科治疗情况,将病人分成三组。第Ⅰ组23例,系到医院前已临床死亡;第Ⅱ组30例,经抢救无效在急诊科死亡;第Ⅲ组30例,经抢救病人在急诊科存活,后转入病房或急诊留观。结果:第Ⅰ组病人经口气管插管,抢救平均30分钟,无一例心跳呼吸恢复;第Ⅱ组虽经急诊CPR,但呼吸功能不能恢复正常,或因其原发病未能控制,最终在急诊科死亡;第Ⅲ组病人经口插管13例,经鼻插管17例,6例病人在急诊留观治疗后出院,12例病人经ICU或病房住院治疗后基本痊愈出院,另12例最终死亡。结论:急诊科所遇垂危病人,多数需气管插管者是由内科医师首诊实施。正确的插管方法和较高的成功率是直接影响病人转归的重要因素。     

集束化护理干预策略预防新生儿呼吸机相关性肺炎

目的探讨新生儿呼吸机相关性肺炎(VAP)集束化护理干预策略的制定与实施。方法对2010年7月—2012年6月NICU收治的机械通气>48 h的31例患儿实施集束化护理干预策略,观察其体温、血常规、胸片及下呼吸道细菌学检查,并选取2008年7月—2010年6月机械通气患儿30例作为对照。结果实施集束化护理干预前VAP的发病率为26.7%,干预后则为16.1%,差异有统计学意义(P<0.05)。结论集束化护理干预策略能减少机械通气患儿VAP的发生。     

预防呼吸机相关性肺炎的护理进展

结合美国疾病预防控制中心(CDC)的预防医院感染指南制订的护理措施包括病情允许的病人采取半卧位、声门下持续吸引、及时更换被污染的呼吸机管道、接触病人前后洗手等,从呼吸机相关性肺炎(VAP)的高危因素及预防VAP的一般护理及与机械通气机关的护理措施方面阐述了近年来预防VAP的护理研究进展.     

Lack of a Hyperkalemic Response in Emergency Department Patients Receiving Succinylcholine

Objective: To determine whether serum potassium (K) levels increase significantly following succinylcholine (SCh)-assisted intubation in ED patients.
Methods: A prospective. noncontrolled, consecutive case series design was used to evaluate the change in serum K levels in ED patients who received SCh for emergency intubation. The study was performed at an academic medical center staffed by board-certified emergency physicians. The subjects were 100 consecutive prescreened ED patients with various diagnoses who received SCh for intubation. The eligible subjects had serum K levels determined prior to and 5 minutes after administration of a 1.0–1.5-mg/kg IV dose of SCh. Serum K levels were measured by the ionselective electrode assay method.
Results: The mean change in serum K levels was -0.04 mmol/L (95% CI -0.14 to 0.06). The maximum increase was 1.10 mmol/L. The serum K level rose in 46 cases, decreased in 46 cases, and was unchanged in eight cases. No instance of SCh-induced cardiac arrest was identified.
Conclusion: Changes in serum K levels following SCh administration in prescreened ED patients were minimal. A hyperkalemic response is uncommon in ED patients who undergo SCh-assisted intubation.     

改进吸痰法在气管插管机械通气患者中的应用效果观察

目的探讨改进吸痰法在气管插管机械通气患者中的应用效果观察。方法将行气管插管机械通气的120例患者,按照随机数字表法分为试验组和对照组,每组各60例,试验组采用改进吸痰法,包括气管导管内（浅部）吸痰、气管导管外（深部）及气囊上方吸痰3部分;对照组采用常规吸痰法。两周后观察两组患者气道黏膜损伤及呼吸机相关性肺炎（ventilator-associated pneumonia,VAP）的发生情况。结果试验组和对照组患者气道黏膜损伤发生率比较,差异具有统计学意义（1.7%vs16.7%,χ2=8.107,P〈0.01）;试验组和对照组患者VAP的发生率比较,差异具有统计学意义（3.3%vs18.3%,χ2=6.988,P〈0.01）。结论改进吸痰法在气管插管机械通气患者中的应用,不仅降低了患者气道黏膜的损伤,同时还降低了VAP的发生,值得临床推广应用。     

住院危重患者发生呼吸机相关肺炎的影响因素

目的探讨住院危重患者发生呼吸机相关肺炎(VAP)的影响因素。方法选取2013年10月到2014年12月德阳市人民医院收治的重症监护患者140例进行研究,将患者按照是否发生VAP分为VAP组与非VAP组,分析VAP发病的相关因素。结果根据数据统计,VAP组患者和非VAP组患者的年龄和性别差异均无统计学意义(P0.05)。VAP组患者和非VAP组患者的住院时间、气管留置时间、血清蛋白、吸痰次数、吸烟史、呼吸系统史和慢性健康状况(APACHEⅡ)评分,差异有统计学意义(P0.05)。经过VAP发生的多因素分析,与VAP发生的相关因素包括住院时间、气管留置时间、吸痰次数、呼吸系统史和APACHEⅡ评分,经概率型非线性(Logistic)回归分析,差异有统计学意义(P0.05)。结论住院危重患者发生VAP的影响因素很多,其中,最主要的影响因素包括住院时间、气管留置时间、血清蛋白、吸痰次数、吸烟史、呼吸系统史和APACHEⅡ评分。     

机械通气患者呼吸机相关肺炎的危险因素分析

目的探讨机械通气患者呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)的危险因素,以期为制定相应的防治对策、降低VAP的发生率提供临床依据。方法便利抽样法选取2010-2012年在上海市第七人民医院重症监护室(intensive care unit,ICU)及呼吸内科行机械通气的65例患者为研究对象,分析其临床资料和治疗经过。结果 65例患者中有20位患者出现呼吸机相关性肺炎,发生率为30.8%,其中患者合并肺功能减退(OR=43.19,P=0.007)、使用抑酸药物(OR=46.52,P=0.004)、年龄60岁(OR=26.47,P=0.034)是导致VAP发生的3个独立危险因素。结论在ICU及呼吸内科重症监护病房中VAP的发生率仍较高,患者合并有肺功能减退、使用抑酸药物及年龄大于60岁是VAP发生的3个独立危险因素,应加强对此类患者的重视,及时采取预防防治措施。