急性重症胆管炎患者血小板活性的研究

作者动态现察了23例急性重症胆管炎(ACST)患者手术前后2周内血小板活性的变化。结果显示：血小板在ACST发病过程中明显活化，并与病情轻重和胆道梗阻程度成正比，而且血小板结构和功能均有显著变化。血小板活化持续不恢复静息状态则提示病情更严重和预后不良，有助于进一步了解ACST复杂的病理生理过程，也有利于了解多器官功能衰竭的发病机理。     

集束化诊治策略防治肿瘤重症患者医院获得性肺炎的效果研究

目的 探讨集束化诊治策略在预防肿瘤重症患者医院获得性肺炎中的作用.方法 采用病例对照研究,对265例对照组患者采用常规预防措施,对292例观察组采用集束化干预策略,包括控制抗生素应用、手卫生、口腔护理、多重耐药菌的隔离、持续床头抬高、呼吸道管理、恰当的镇痛镇静等.比较实施前后两组患者医院获得性肺炎的发病率、归因病死率、机械通气时间、ICU停留时间、医院获得性肺炎抗生素应用频度、多重耐药病原菌感染阳性率.结果 观察组患者的医院获得性肺炎的发病率(13.70％)、机械通气时间(7.10±3.75)d、ICU停留时间(12.92±9.93)d和抗生素应用频度(49.66 ±11.34)均小于对照组,差异具有统计学意义(P＜0.01),观察组和对照组患者医院获得性肺炎的归因病死率(6.51％ vs6.79％)及多重耐药病原菌感染阳性率(47.26％vs53.21％),差异无统计学意义(P＞0.05).结论 集束化诊治策略可有效降低肿瘤重症患者医院获得性肺炎的发病率,缩短住院时间.     

重症急性胆管炎并发多器官功能衰竭患者的死亡原因分析

近年的研究表明,在重症急性胆管炎(ACST)的各个时期,MOF均是其主要死亡原因。ACST后MOF这一难题已成为进一步降低此症病死率的主要限制性因素。我们对70例ACST并发MOF的发生率、病     

63例重症急性胆管炎的救治体会

作者报道15年间由胆石症导致的重症急性胆管炎（ACST）63例的救治，指出胆石症导致的重症急性胆管炎（ACST）并发多器官功能衰竭（MSOF）是良性胆道疾病最重要、最直接的死亡原因，强调一旦发生多器官功能衰竭，要给予强有力的“四大一支持”综合疗法。该疗法有助于ACST病人渡过手术关，在致死性的触发病因去除后，促进器官功能发生逆转，最终使患者获得痊愈。     

及时应用经胸超声心动图评估可改善重症监护室患者急性肾损伤发生后的临床预后

目的:探讨经胸超声心动图（transthoracic echocardiography,TTE）评估对重症监护室（intensive care unit,ICU）患者发生急性肾损伤（acute kidney injury,AKI）后住院预后的影响。方法:回顾性收集美国重症监护医学信息数据库（MIMIC-Ⅲ v1.4）中...     

术后重症患者在重症监护病房发生医院感染的危险因素分析

WHO的有关调查和其他研究均表明,医院感染发生率最高的是重症监护病房（ICU）,而在ICU中,术后患者往往因其手术过程中创伤大、时间长、侵入性操作多、病情危重等特点,成为医院感染的高危人群。为了解ICU术后患者医院感染的相关因素,为医院感染目标性监测及对医院感染防控提供可靠依据,     

单乙基甘氨酰二甲苯胺试验预测重症监护病人发生多器官功能衰？…

目的 比较单乙基甘氨酰二甲苯胺（ＭＥＧＸ）肝功能试验和其余肝功能试验在预测外科重危监护（ＩＣＵ）病人发生多器官功能衰竭（ＭＯＦ）及预后方面的作用。方法 １７例ＩＣＵ重危监护病人均于术后转入ＩＣＵ病房，术后经３ｄ行ＭＥＧＸ肝功能试验及其它肝功能试验。结果 比较ＭＯＦ组和未发生ＭＯＦ组ＭＥＧＸ值有显著差异，其余肝功能试验比较未见明显差异。     

重症急性肾损伤中肾脏替代治疗的新进展

急性肾损伤（AKI）临床常见,是许多疾病的严重并发症之一,具有发病率高,过程凶险,治疗手段缺乏,预后差等特点。肾脏替代治疗（RRT）,是一种清除体内潴留的水分和溶质,对脏器起支持作用的血液净化技术,已被认为是AKI治疗中唯一有效的治疗措施,成为重症AKI患者救治的重要手段。     

重症患者免疫调理治疗的进展

许多重症患者出现了显著的免疫功能异常及炎症反应。重症患者的免疫疗法越来越受到关注。因此．能够改变脓毒症病人的免疫反应和降低其死亡率的药物疗法应运而生。在过去的20年里．人们试用过各种手段：类固醇;抗内毒素或抗细胞因子抗体;细胞困子受体掊抗剂以及其他有免疫调理作用的制剂。但是从某些方面讲,针对这些思路的研究都不是很成功．仍存在争议和挑战。     

全身炎症反应综合征与多器官功能障碍综合征的临床研究

作者前瞻性调查了２３０例危重病患者,根据危重病患者全身性炎症反应综合征（ＳＩＲＳ）和多器官功能障碍综合征（ＭＯＤＳ）的症状,分析ＳＩＲＳ到ＭＯＤＳ的渐进发展过程,探讨治疗策略。结果显示：患者转入加强医疗病房（ＩＣＵ）时,ＳＩＲＳ患病率７１．３％,病死率１８．９％。２３０例患者中,６５例发生ＭＯＤＳ（２８．３％）,死亡３３例（５０．８％）。非感染性ＳＩＲＳ、全身性感染及感染性休克患者的ＭＯＤＳ患病率依次为２２．８％,６１．１％和８５．７％,而病死率依次为１１．４％,３０．６％和５０．０％。作者认为,早期诊断ＳＩＲＳ,并积极调控机体炎症反应,可能是改善危重患者预后的关键。     

床边间歇性血液透析治疗危重症患者的疗效分析

目的 探讨我院自行研发的床边透析技术为不能移动的合并肾衰竭的危重症患者进行有效肾脏替代治疗的效果.方法 回顾性分析我院重症监护病房(ICU)行床边间歇性血液透析(IHD)患者121例,分别统计治疗前、后急性生理学和慢性健康状况评分Ⅱ(APACHEⅡ)、Boston心力衰竭积分、心率、平均动脉压(MAP)、血肌酐(SCr...     

动态监测尿微量蛋白对危重患者预后的价值

目的 探讨尿微量蛋白作为危重患者预后指标的可行性。 方法 前瞻性动态监测ICU危重患者尿微量白蛋白(MA)、α1-微球蛋白(α1-MG)、N-乙酰-β-D-氨基葡萄糖苷酶(NAG)、视黄醇结合蛋白(RBP)，并与目前临床常用的预后评估系统APACHEⅡ、SOFA进行比较。结果 相关分析结果显示尿MA、α1-MG、NAG、住ICU时间、机械通气时间、APACHEⅡ评分、SOFA与死亡呈正相关。尿MA、α1-MG、住ICU时间、机械通气时间、APACHEⅡ评分、SOFA升高与多器官功能不全综合征(MODS)发生呈正相关。尿MA(r=0.397)、α1-MG(r=0.448)和RBP(r=0.465)与APACHEⅡ评分显著相关。APACHEⅡ评分、SOFA评分、MA、α1-MG、RBP、NAG预测死亡的ROC曲线下面积分别是0.875﹙P < 0.05﹚、0.825﹙P < 0.05﹚、0.820﹙P < 0.05﹚、0.730、0.530、0.620。结论 动态监测尿MA、α1-MG、RBP可作为危重患者预后的临床指标。     

Acute kidney injury and the critically ill

Acute renal failure is commonly encountered in the intensive care unit. It is associated with considerable morbidity and mortality. There are many possible aetiologies in the critically ill, including nephrotoxic agents, hypovolaemia and sepsis. While many classification systems for acute renal failure exist, the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria and the Acute Kidney Injury Network (AKIN) criteria are the most commonly utilized. Many supportive therapies are employed to minimize the degree of renal injury once recognized, such as fluid resuscitation, maintenance of an adequate mean arterial pressure (with the use of vasopressors in persistent hypotension despite fluid and treatment of the underlying aetiology). However, if renal failure becomes established, then renal replacement therapy (RRT) may be needed to maintain homeostasis. While there are no clear guidelines with respect to the ideal mode or timing of RRT, we will discuss pros and cons of the various options.     

Acute kidney injury and the critically ill

Acute renal failure is commonly encountered in the intensive care unit. It is associated with considerable morbidity and mortality. There are many possible aetiologies in the critically ill, including nephrotoxic agents, hypovolaemia and sepsis. While many classification systems for acute renal failure exist, the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria and the Acute Kidney Injury Network (AKIN) criteria are the most commonly utilized. Many supportive therapies are employed to minimize the degree of renal injury once recognized, such as fluid resuscitation and maintenance of an adequate mean arterial pressure (with the use of inotropes in persistent hypotension despite fluid and treatment of the underlying aetiology). However, if renal failure becomes established, then renal replacement therapy (RRT) may be needed to maintain homoeostasis. While there are no clear guidelines with respect to the ideal mode or timing of RRT, we will discuss pros and cons of the various bedside options.     

Outcomes of critically ill patients with acute kidney injury in COVID-19 infection: an observational study

BackgroundEarly reports indicate that AKI is common during COVID-19 infection. Different mortality rates of AKI due to SARS-CoV-2 have been reported, based on the degree of organic dysfunction and varying from public to private hospitals. However, there is a lack of data about AKI among critically ill patients with COVID-19.MethodsWe conducted a multicenter cohort study of 424 critically ill adults with severe acute respiratory syndrome (SARS) and AKI, both associated with SARS-CoV-2, admitted to six public ICUs in Brazil. We used multivariable logistic regression to identify risk factors for AKI severity and in-hospital mortality.ResultsThe average age was 66.42 ± 13.79 years, 90.3% were on mechanical ventilation (MV), 76.6% were at KDIGO stage 3, and 79% underwent hemodialysis. The overall mortality was 90.1%. We found a higher frequency of dialysis (82.7% versus 45.2%), MV (95% versus 47.6%), vasopressors (81.2% versus 35.7%) (p < 0.001) and severe AKI (79.3% versus 52.4%; p = 0.002) in nonsurvivors. MV, vasopressors, dialysis, sepsis-associated AKI, and death (p < 0.001) were more frequent in KDIGO 3. Logistic regression for death demonstrated an association with MV (OR = 8.44; CI 3.43–20.74) and vasopressors (OR = 2.93; CI 1.28–6.71; p < 0.001). Severe AKI and dialysis need were not independent risk factors for death. MV (OR = 2.60; CI 1.23–5.45) and vasopressors (OR = 1.95; CI 1.12–3.99) were also independent risk factors for KDIGO 3 (p < 0.001).ConclusionCritically ill patients with SARS and AKI due to COVID-19 had high mortality in this cohort. Mortality was largely determined by the need for mechanical ventilation and vasopressors rather than AKI severity.     

Acute acalculous cholecystitis in critically ill patients

BACKGROUND: Acute acalculous cholecystitis (AAC) is a serious complication of critical illness. We evaluated the underlying diseases, clinical and diagnostic features, severity of associated organ failures, and outcome of operatively treated AAC in a mixed ICU patient population. METHODS: The data of all ICU patients who had operatively confirmed AAC during their ICU stay between 1 January 2000 and 31 December 2001 were collected from the hospital records and the intensive care unit's data management system for predetermined variables. RESULTS: Thirty-nine (1%) out of 3984 patients underwent open cholecystectomy for AAC during the two-year period. Infection was the most common admission diagnosis, followed by cardiovascular surgery. The mean APACHE II score on admission was 25, and 64% of the patients had three or more failing organs on the day of cholecystectomy. The mean length of ICU stay before cholecystectomy was 8 days, and the mean total length of ICU stay was 19 days. Most patients (85%) received norepinephrine infusion, and 90% suffered respiratory failure before cholecystectomy. Hospital mortality was 44%. The non-survivors had higher Sequential Organ Failure Assessment (SOFA) scores on the day of cholecystectomy compared to the survivors (12.9 vs. 9.5, P = 0.007). CONCLUSION: Acute acalculous cholecystitis was associated with severe illness, infection, long ICU stay, and multiple organ failure. Mortality was related to the degree of organ failure. Prompt diagnosis and active treatment of AAC can be life-saving in these patients.     

Insulin therapy and acute kidney injury in critically ill patients a systematic review.

BACKGROUND: Intensive insulin therapy has been found to reduce mortality in some critically ill patients. We performed a systematic review and meta-analysis to ascertain the effect of intensive insulin therapy on the incidence of acute kidney injury (AKI) in adult critically ill patients. METHODS: We searched MEDLINE, SCOPUS and the Cochrane Central Register of Controlled Trials for studies that compared 'conventional' vs 'intensive' insulin therapy in critically ill patients. Studies were combined with random effects model meta-analyses. RESULTS: Five studies, three of which were randomized controlled trials, reported AKI as a secondary outcome. Two of the studies were non-concurrent prospective cohort studies. All were single-centre studies conducted in intensive care unit settings. By meta-analysis across all studies, intensive insulin therapy reduced the incidence of AKI by 38% [risk ratio (RR) 0.62; 95% confidence interval (CI) 0.47, 0.83; P = 0.001]. The findings of the randomized and cohort studies were similar and the studies were not statistically heterogeneous. Three studies reported the effect of insulin therapy on dialysis requirement. Overall, intensive insulin therapy reduced the incidence of dialysis requirement by 35%, however, this was not statistically significant (RR 0.65; 95% CI 0.40, 1.05; P = 0.08). The overall rate of hypoglycaemia in the conventional insulin therapy group was 1.3% (range 0.3-3.4%). Intensive insulin therapy was associated with a >4-fold increase in the risk of hypoglycaemia (RR 4.5; 95% CI 2.4, 8.5; P < 0.00001) CONCLUSION: There is evidence that intensive insulin therapy initiated in critically ill adult patients is associated with a reduction in the incidence of AKI in medical and surgical settings. A large trial primarily designed to examine the effect of insulin on the prevention of AKI is needed to confirm this finding.     

Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients

BACKGROUND: Acute acalculous cholecystitis (AAC) refers to cholecystitis without gallstones and is a serious complication of critical illness. We describe the time course of organ system dysfunction associated with cholecystectomy in critically ill patients with AAC. METHODS: The data of all intensive care unit (ICU) patients who had operatively confirmed AAC during their ICU stay between 2003 and 2004 were analyzed. Patients who also had other intra-abdominal pathologies were excluded. The Sequential Organ Failure Assessment (SOFA) scores were recorded 3 days before, on the day of operation and on the first, second, third and seventh post-operative day after cholecystectomy. The impact of open cholecystectomy on organ dysfunction was evaluated on the basis of the change in the total and individual organ SOFA scores. RESULTS: Twenty-four patients underwent open cholecystectomy for AAC with no other intra-abdominal pathology. Sepsis was the most common admission diagnosis, followed by cardiovascular surgery. The mean (standard deviation, SD) Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS) II and SOFA scores on admission were 24.7 (5.8), 44.3 (12.3) and 9.4 (3.2), respectively. The median (25th, 75th percentiles) total SOFA score 3 days before cholecystectomy was 7.5 (1.3, 8.0), which increased to 10.5 (8.3, 13.0) (P < 0.0001) by the day of cholecystectomy, indicating developing multiorgan dysfunction. After the operation, the score decreased to 5.5 (3.3, 10.8) (P = 0.004) by the seventh post-operative day. The change was most obvious in cardiovascular and respiratory SOFA scores. CONCLUSIONS: AAC is associated with multiorgan dysfunction in critically ill patients. Open cholecystectomy seems to alter the course of multiorgan dysfunction in these patients.     

Prognosis of critically ill patients with multiple organ failure

The purpose of this study was to determine the mortality rate in 527 critically ill patients with multiple organ failure (MOF), treated in our ICU between August, 1986 and January, 1992, and to compare it with the results obtained in a group of patients studied who had been treated between October, 1978 and July, 1986. The relationship between the mortality rate and each type of organ failure and the extent of organ system involvement was also investigated. The overall mortality rate was 25%, and the rate increased with the number of failed organs. Sepsis and disseminated intravascular coagulation were closely associated with the development of MOF. The mortality rate of patients with the failure of two organs in the present study was significantly lower than that found in those in the previous study. Although artificial organ mechanical life support technology other than that for patients with renal failure is still unsatisfactory, these results suggest that the prognosis of patients with MOF is improving.