可吸痰式气管切开插管预防呼吸机相关性肺炎的效果观察

目的观察可吸痰式气管切开插管对预防呼吸机相关性肺炎（ventilato rassociated pneumonia,VAP）的临床价值。方法便利选取2010年1月至2012年1月在海军安庆医院ICU治疗的66例经气管切开行机械通气（mechanical ventila—tion,MV）患者为研究对象,按入院先后将其分为对照组（n=34）和观察组（n=32）。对照组患者使用一次性气管切开插管,观察组患者使用可吸痰式气管切开插管,观察两组患者VAP的发生率以及呼吸机停用的时间。结果 4d内,观察组患者VAP的发生率为12．5％,低于对照组的41．1％,差异有统计学意义（P〈0．05）;观察组MV使用时间明显短于对照组,差异有统计学意义（P〈0．05）。4d后,两组患者VAP的发生率分别为28．1％和35．3％,差异无统计学意义（P〉0．05）。结论应用可吸痰式气管切开插管可略低早发性VAP的发生率及MV的使用时间．但并不能隆低VAP的发生率。     

经皮扩张气管造口术引发呼吸机相关性肺炎的临床研究

目的 探讨接受经皮扩张气管造口术（PDT）进行机械通气的患者呼吸机相关性肺炎（VAP）的临床发病率和流行病学特征。方法 对185例危重患者采用PDT进行机械通气，观察VAP患者临床表现与未感染患者的差异。对气管插管前、后的气管吸出物进行病原菌的构成检测，与患者是否患VAP进行相关性分析。结果 48例（25．9％）患者发生VAP，VAP使患者的机械通气时间和ICU时间分别延长16d和21d。机械通气患者病死率为31．9％（59／185）；VAP患者病死率为39．6％（19／48），显著高于对照组（P〈0．01）。VAP病原菌以革兰阴性杆菌为主，其中又以铜绿假单胞菌居多（35．4％，17／48）。48例VAP患者，气管插管前气管吸出物中即有病原菌存在的占64．6％（31／48），显著高于插管前气管吸出物无菌的患者（35．4％，17／48）（P〈0．01）。结论 PDT引发的VAP通常会对患者的临床症状和病死率造成不良影响。导致VAP的主要病原菌是铜绿假单胞菌。     

刷洗负压吸引法在经口气管插管患者口腔护理中的应用

目的探讨刷洗负压吸引法在经口气管插管患者口腔护理中的应用效果。方法选取ICU经口气管插管的患者82例,随机分为观察组42例和对照组40例,观察组采用刷洗负压吸引法进行口腔护理,对照组采用传统口腔护理方法。比较两组患者口腔感染发生率、呼吸机相关性肺炎（VAP）发生率、牙菌斑发生率和口腔黏膜损伤发生率。结果观察组口腔感染发生率、VAP的发生率和牙菌斑发生率分别为7．14％,2．38％,4．76％,均少于对照组的22．50％,15．00％,32．50％,差异均有统计学意义（x。分别为3．88,4．18,10．55;P〈0．05）。两组口腔黏膜损伤发生率比较差异无统计学意义（P〉0．05）。结论与传统口腔护理方法相比,刷洗负压吸引法能有效保持经口气管插管患者口腔清洁,降低口腔感染、VAP和牙菌斑的发生率。     

气管插管和气管切开患者感染病原菌分布及药敏分析

目的分析气管插管和气管切开患者感染的病原菌分布及药敏结果，指导临床用药。方法对2000—2004年医院气管插管及气管切开肺部感染患者下呼吸道送检281份阳性标本分离出的病原菌及药敏进行分析。结果共检出312株致病菌，其中革兰阴性杆菌占68．9％，革兰阳性球菌占18．9％，真菌占12．2％。绝大多数革兰阴性杆菌对亚胺培南耐药率〈30％；葡萄球菌对万古霉素的耐药率为0。结论气管插管和气管切开患者易引起医院内肺部感染，感染的病原菌以铜绿假单胞菌为主。细菌的多重耐药现象严重，应予以重视。     

重症监护病房气管切开置管后病人肺部感染预防的护理

气管切开置管是重症监护病房（ICU）危重病人救治过程中的重要手段,置管后病人呼吸道梗阻得以解除,可保证病人呼吸道通畅,同时可以对病人下呼吸道分泌物进行抽吸,并进行有效的辅助呼吸。但作为一种有创的人工气道,肺部感染一直是其常见的并发症之一。国内报道,气管切开后下呼吸道医院感染率达86％～100％,病死率高达48％～76％;ICU单纯气管切开继发下呼吸道感染率为11．1％～39．2％,呼吸机相关性肺炎（VAP）发生率达69％;     

气管插管和气管切开患者感染病原菌分布及药敏分析

目的 分析气管插管和气管切开患者感染病原菌分布及药敏结果。方法 对2005年11月至2006年11月本院气管插管和气管切开患者下呼吸道送检的253份阳性标本分离出的病原菌及药敏进行分析。结果 在送检的301份标本中，阳性标本253份，阳性率为84％，检出312株致病菌，其中59份标本同时培养出两种细菌（另一种菌以真菌为主），占23．3％，其中革兰阴性杆菌占74．7％、革兰阳性球菌占6．4％、真菌占18．9％。绝大多数革兰阴性杆菌对亚胺培南耐药率〈20％；葡萄球菌对万古霉素的耐药率为0，真菌对氟胞嘧啶、制霉菌素的耐药率为0。结论 气管插管和气管切开易引起医院内肺部感染。     

ICU呼吸机相关性肺炎的预防护理

目的：探讨重症监护室（ICU）患者呼吸机相关肺炎（VAP）的预防护理。方法：对我院2007年5月～2008年9月ICU收治的40例经1：3插管或气管切开机械通气（MV）患者采取针对性护理措施,了解VAP的发生情况。结果：40例机械通气患者在ICU住院期间发生VAP7例,发生率17．5％;因VAP死亡3例,死亡率7．5％。结论：做好环境的消毒管理,严格无菌操作,掌握吸痰方法,加强呼吸道管理等是降低VAP发生率和死亡率的有效护理方法。     

早期气管切开在急危重病人中的应用

目的 探讨早期气管切开在急、危重病人的临床作用.方法 对近5年217例ICU急、危重症需气管切开和机械通气的病人进行回顾性分析,分别对早期气管切开(ET,手术在发病3 d内施行)与延期气管切开(LI,手术在发病7 d后施行)病人的APACHE Ⅱ评分、机械通气天数、住ICU和总住院时间、呼吸机相关肺炎(VAP)发生率、死亡率和手术早期并发症发生率进行分析比较.结果 在LT组VAP发生率显著升高,机械通气时间明显延长;在ET组病人住ICU和总住院时间明显缩短.结论 早期气管切开对急、危重病人有较高的临床价值,如能在3 d内施行气管切开能够显著降低病人VAP发生率,减少机械通气时间,缩短住ICU和总住院时间.     

经口与经鼻气管插管呼吸机相关肺炎发生的比较

呼吸机相关性肺炎(VAP)是患者接受机械通气48h后所并发的肺实质感染[1]。国外报道:VAP发生率为9%~70%,病死率达50%~69%[2],国内有医院调查:VAP发生率为43.1%,病死率为51.6%[3]。在人工气道的选择上有经口、经鼻插管等途径,本文旨在阐明患者急性生理和慢性健康评分系统Ⅲ(APACHEⅢ)评分相似的情况下,在插管48h~5 d和≥5 d时,经口与经鼻不同途径气管插管对VAP发生情况的影响。1资料和方法1.1研究对象本院2000年3月~2005年12月重症监护室收治的危重病经口、经鼻人工气道呼吸机治疗患者85例,呼吸机治疗时间平均13±27.24 d;其中男性52例…     

ICU患者经口气管插管与经鼻气管插管后行气管切开的比较

目的探讨经口气管插管与经鼻气管插管在ICU留置时间,比较两组气管插管后行气管切开的比例。方法将42例气管插管患者随机分为经口气管插管组24例和纤维支气管镜引导下经鼻气管插管组18例,比较两组患者插管留置时间及插管后再行气管切开率。结果经鼻气管插管留置时间明显长于经口气管插管,经鼻气管插管后行气管切开的比例明显低于经口气管插管。结论纤维支气管镜引导经鼻气管插管在ICU是有效的,插管留置时间更长,部分经鼻气管插管患者避免行气管切开。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.