OEC管理模式在预防重型颅脑损伤患者术后深静脉血栓中的应用

目的 探讨OEC管理模式在预防重型颅脑损伤患者术后深静脉血栓(deep vein thrombosis,DVT)中的应用。 方法 选取2018年1-12月笔者所在医院收治的重型颅脑损伤患者80例,根据患者入院时间将其分为对照组(2018年1-6月)及观察组(2018年7-12月)各40例,2组均采用血栓弹力图进行监测。对照组行常规血栓预防指导,观察组在对照组基础上应用OEC管理模式实施管理,比较2组患者血栓发生率、平均住院时间、患者投诉率及患者满意率。 结果 观察组干预后,血浆D-二聚体(D-D)、凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(FIB)较对照组明显改善(P＜0.05),观察组患者血栓发生率、患者投诉率均低于对照组(χ²=4.507,P=0.034;χ²=5.165,P=0.023),患者满意率高于对照组(χ²=6.274,P=0.012)。 结论 OEC管理模式能有效改善重型颅脑损伤患者术后血液黏稠度,预防血栓形成,缩短患者治疗时间,提高患者治疗满意率。     

Prophylactic tracheal intubation for upper GI bleeding: A meta-analysis

AIM: To evaluate usefulness of prophylactically intubating upper gastrointestinal bleeding (UGIB) patients. METHODS: UGIB results in a significant number of hospital admissions annually with endoscopy being the key intervention. In these patients, risks are associated with the bleeding and the procedure, including pulmonary aspiration. However, very little literature is available assessing the use of prophylactic endotracheal intubation on aspiration in these patients. A comprehensive search was performed in May 2014 in Scopus, CINAHL, Cochrane databases, PubMed/Medline, Embase, and published abstracts from national gastroenterology meetings in the United States (2004-2014). Included studies examined UGIB patients and compared prophylactic intubation to no intubation before endoscopy. Meta-analysis was conducted using RevMan 5.2 by Mantel-Haenszel and DerSimonian and Laird models with results presented as odds ratio for aspiration, pneumonia (within 48 h), and mortality. Funnel plots were utilized for publication bias and I² measure of inconsistency for heterogeneity assessments. RESULTS: Initial search identified 571 articles. Of these articles, 10 relevant peer-reviewed articles in English and two relevant abstracts were selected to review by two independent authors (Almashhrawi AA and Bechtold ML). Of these studies, eight were excluded: Five did not have a control arm, one was a letter the editor, one was a survey study, and one was focused on prevention of UGIB. Therefore, four studies (N = 367) were included. Of the UGIB patients prophylactically intubated before endoscopy, pneumonia (within 48 h) was identified in 20 of 134 (14.9%) patients as compared to 5 of 95 (5.3%) patients that were not intubated prophylactically (P = 0.02). Despite observed trends, no significant differences were found for mortality (P = 0.18) or aspiration (P = 0.11). CONCLUSION: Pneumonia within 48 h is more likely in UGIB patients who received prophylactic endotracheal intubation prior to endoscopy.     

Adjudicating ventilator-associated pneumonia in a randomized trial of critically ill patients

The purpose of this study was to evaluate an adjudication strategy for diagnosing ventilator-associated pneumonia (VAP) in a randomized trial.

In a double-blind trial of sucralfate versus ranitidine, one of four pairs of adjudicators examined each case of clinically suspected VAP Nurse and physician notes and all relevant laboratory data were allocated to each adjudication pair in groups of five patients. Each reader in the pair decided whether the patient had VAP; differences were resolved by consensus discussion.

The overall unadjusted study odds ratio for VAP was 0.82 (P = .21) representing a trend toward less pneumonia with sucralfate compared with ranitidine. The odds ratio adjusted for adjudication pair was 0.85 (P = .27). The proportion of charts adjudicated as VAP positive among pairs ranged from 50% to 92%; crude agreement between readers in each pair varied from 50% to 82%. When adjudicators disagreed, the final consensus was split evenly between the two adjudicators' initial opinions in two pairs; in the other two pairs, the final decision reflected one dominant initial opinion. Personnel time to adjudicate all patients with a suspicion of VAP was 74 days.

Though adjudication of outcomes such as VAP is time-consuming, consistent decision-making rewuires strict criteria, training, and calibration. Patients should be assigned to adjudication teams through random allocation.     

LEARNS模式在妊娠期糖尿病患者健康教育中的应用

目的 探讨LEARNS模式在妊娠期糖尿病患者健康教育中的应用效果。方法 选取产科门诊收治的120例妊娠期糖尿病患者为研究对象,采用随机数字表法将其分为对照组和观察组,每组各60例。对照组给予常规健康教育,观察组采用LEARNS模式开展健康教育。比较2组血糖水平及体质量控制情况、患者自我管理能力、妊娠并发症及妊娠结局。结果 观察组空腹血糖、餐后2 h血糖、糖化血红蛋白及体质量控制的达标率均高于对照组(χ² =6.171,P=0.013;χ² =9.219,P=0.002;χ² =9.259,P=0.002;χ² =9.412,P=0.002),观察组自我管理能力评分高于对照组(t=12.972,P<0.001),羊水过多、巨大儿及早产发生率均低于对照组(χ² =6.982,P=0.008;χ² =7.688,P=0.006;χ² =4.904,P=0.027);2组妊娠期高血压、胎膜早破及新生儿低血糖发生率比较,差异均无统计学意义(P＞0.05)。结论 LEARNS模式可明显提高妊娠期糖尿病患者自我管理能力,改善其血糖及体质量控制水平,降低妊娠并发症的发生风险。     

机械通气患儿实施改良口腔护理方案预防呼吸机相关性肺炎的效果观察

目的 探讨改良口腔护理方案在预防机械通气患儿呼吸机相关性肺炎(ventilator associated pneumonia,VAP)中的临床效果。 方法 选取笔者所在医院重症监护室2018年1月—2019年12月收治的接受有创机械通气患儿140例为研究对象,按随机数字表法将其分为观察组与对照组,各70例。对照组采取棉球沾取0.9%氯化钠溶液进行口腔擦拭护理,观察组采取儿童牙刷结合3%过氧化氢与金银花水煎剂进行口腔护理。比较2组口腔清洁度、口腔分泌物与肺泡灌洗液微生物检查情况、呼吸机相关性肺炎发生率、机械通气时间、ICU住院时间。 结果 观察组口腔清洁度优于对照组(Z=-3.052,P=0.002),口腔分泌物微生物与肺泡灌洗液微生物检出率低于对照组(P<0.05),呼吸机相关性肺炎发生率低于对照组(χ²=4.538,P=0.033),机械通气时间与ICU住院时间均短于对照组(t=9.155,P<0.001;t=10.113,P<0.001)。 结论 使用以儿童牙刷蘸取过氧化氢溶液刷洗法结合金银花水煎剂负压吸引冲洗法能够提高机械通气患儿口腔清洁度,增强口腔护理抑菌效果,降低呼吸机相关性肺炎风险,促进患儿康复。     

Predisposing factors,clinical assessment,management and outcomes of agitation in the trauma intensive care unit

BACKGROUND: Agitation occurs frequently among critically ill patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU.METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status.RESULTS: A total of 102 intubated patients were enrolled; of which 46 (45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95% CI=1.35-18.27), subarachnoid hemorrhage (OR=5.11; 95% CI=1.38-18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95% CI=1.16-15.35) were independent predictors for agitation (P<0.01).CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.     

签约式饮食管理在糖尿病专科护理门诊中的应用效果

目的 探讨签约式饮食管理模式在糖尿病专科护理门诊中的应用效果。方法 选取2019年4月-2021年4月就诊于糖尿病专科护理门诊的200例2型糖尿病患者为研究对象,采用随机数字表法将其分成常规随访组和签约管理组。常规随访组采用门诊常规饮食教育进行干预;签约管理组采用签约式饮食管理的方式进行干预,比较2组规范复诊率、血糖控制水平、饮食自我管理水平及患者满意度。结果 干预后,签约管理组规范复诊率和患者满意度均高于常规随访组(χ²=47.994,P<0.001;t=2.729,P<0.001);空腹血糖、餐后2h血糖、糖化血红蛋白均低于常规随访组(t=7.532,P<0.001;t=5.404,P<0.001;t=9.040,P<0.001);饮食自我管理水平优于常规随访组(t=10.090,P<0.001)。结论 糖尿病专科护理门诊运用签约式饮食管理,可以提高糖尿病患者饮食自我管理水平,有助于控制血糖水平,患者认可度高。     

Subclinical hypothyroidism and the metabolic syndrome: A meta-analysis of cross-sectional studies

AIM: To determine the relationship between subclinical hypothyroidism (SCH) and the metabolic syndrome (MS). METHODS: We performed a systematic search of databases [MEDLINE (July 1950 to July 2012), EMBASE (July 1966 to July 2012)] and the references of identified studies. Completely published cross-sectional studies of a general population involving SCH and the MS were included. The pooled odds ratio and weighted mean difference (WMD) for the outcomes were calculated using random-effects models. RESULTS: Six cross-sectional studies with 19546 participants were included. In total, 398 of 1324 participants (30.06%) in the SCH group had the MS compared with 4975 of 18222 participants (27.30%) in the euthyroid group [OR = 1.20; 95%CI: 1.05-1.36; P = 0.004; χ² = 2.53 (P = 0.773); I² = 0%]. Further analysis of the components of the MS showed that SCH was associated with increased body mass index (WMD, 0.32 kg/m²; 95%CI: 0.04-0.61; P = 0.026), systolic blood pressure (WMD, 2.62 mmHg; 95%CI: 1.35-3.89; P < 0.001) and triglyceride (WMD, 0.25 mmol/L; 95%CI: 0.23-0.28; P < 0.001). CONCLUSION: Based on the cross-sectional data, SCH may be associated with an increased risk of the MS, which could be attributed to the increased risk of metabolic components.     

Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia

Purpose

Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP.

Materials and Methods

Single-center retrospective cohort study of all intubated adult (age ≥ 18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n = 860).

Results

Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP.

Conclusions

Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.     

Analysis of trauma intubations

The timing of trauma patient intubation is dependent on clinical presentation and clinician judgment. We sought to correlate the timing of intubation with the presenting of physiologic parameters and clinical outcome to identify potential quality assurance audit filters. Patients (n = 82) were grouped by timing of intubation: PREHOSPITAL, paramedic intubation; IMMEDIATE, within 10 minutes of arrival; DELAYED, beyond 10 minutes but within 2 hours of arrival; and NONURGENT, beyond 2 hours or at the time of surgery. While mean revised trauma scores and Glasgow Coma Scale (GCS) scores differed for the groups, the mean length of hospital stay and the incidence of aspiration pneumonia were not significantly different. In the DELAYED group, 80% of those who developed aspiration pneumonia had a GCS < or = 13. Patients in the NONURGENT group were older and commonly presented with tachypnea. The survival rate for the NONURGENT group was lower than predicted by the TRISS method (P = .004). A GCS < or = 13 and age greater than 50 years with presenting respiratory rates of more than 25 breaths/min represent potential trauma intubation audit filters.     

智能化疼痛管理决策与质量监测系统在跟骨骨折内固定手术患者中应用

目的 探讨智能化疼痛管理决策与质量监测系统在跟骨骨折内固定手术患者中的应用效果。方法 选取2019年1-6月收治的跟骨骨折内固定术患者40例为对照组,行常规性疼痛干预,选取2019年7-12月骨科收治的跟骨骨折内固定术患者42例为研究组,应用智能化疼痛管理决策与质量检测系统对患者实施疼痛管理,比较2组干预前后疼痛评分、睡眠质量、术后锻炼依从率、并发症发生率、足踝功能恢复情况及患者满意率。结果 研究组干预后数字疼痛评分量表(numerical rating scale, NRS)评分、匹兹堡睡眠质量指数(Pittsburgh sleep quality index, PSQI)、并发症发生率均低于对照组(t=5.464,P<0.001;t=16.940,P<0.001;χ²=5.550,P=0.018),术后锻炼依从率、Morrey评分、MaryLand评分及满意率均高于对照组(χ²=9.217,P=0.002;t=12.906,P<0.001;t=10.687,P<0.001;χ²=6.717,P<0.001)。结论 智能化疼痛管理决策与质量监测系统能有效减轻患者跟骨骨折内固定术后的疼痛感,提高锻炼的依从性,降低并发症的发生率,有利于患者术后的康复,提高患者的满意度。     

综合ICU多发伤呼吸机相关性肺炎的危险因素研究

目的 探讨多发伤患者呼吸机相关性肺炎(VAP)发生的危险因素。 方法 回顾分析综合ICU 2013年1~12月收治的多发伤患者的病历资料,分析VAP相关危险因素。 结果 98例患者中,发生VAP 35例,发病率为35.7％。单因素分析显示,患者住ICU天数、连续应用抗生素时间、气管插管天数、呼吸机使用时间、鼻饲、头颈部和胸部创伤严重程度等级(ISS)等是VAP发生的危险因素。Logistic回归分析显示,气管插管天数、头颈部和胸部损伤的严重程度是多发伤患者VAP发生的独立危险因素。 结论 多发伤患者VAP的发生率高,对头颈部和胸部创伤严重、气管插管时间长的患者应采取有效的VAP防控措施。     

自制红外线高度测量仪在颅脑术后患者脑室引流护理中的应用

目的 探讨自制红外线高度测量仪在颅脑术后患者脑室引流护理中的应用效果。方法 选取2019年1月-2020年12月收治的颅脑手术患者116例作为研究对象,将2019年收治的患者设为对照组(n=58),2020年收治的患者设为观察组(n=58),对照组行常规引流及护理,观察组采用自制红外线高度测量仪辅助进行脑室引流,比较2组引流袋入口高度准确率、引流管阻塞及并发症发生率。结果 观察组引流袋入口高度准确率高于对照组(χ² =6.576,P=0.010),引流管阻塞、脑疝、脑出血发生率均低于对照组(χ²=5.949,P=0.015;χ² =7.004,P=0.008;χ² =7.017,P=0.008)。结论 自制红外线高度测量仪有助于临床护士精确调整脑室引流袋高度,降低患者脑室引流相关并发症及引流管阻塞发生率。     

重点患者风险管理模块的设计与应用

目的 探讨重点患者风险管理模块在提高临床护士风险意识和风险管理能力,降低护理不良事件发生率中的应用效果。 方法 运用文献回顾、专家小组会议和现况调查等方法设计重点患者风险管理模块,比较应用前后临床护士风险意识和风险管理能力及护理不良事件发生率。 结果 该模块的应用,提高了临床护士对重点患者的风险管理意识和能力(t=-5.816,P<0.001),降低护理不良事件的发生率(χ²=4.763,P=0.029)。 结论 重点患者风险管理模块的设计和应用对构建重点患者风险管理体系,规避住院患者护理风险,减少不良事件的发生,保障住院患者的安全具有重要意义。     

患者参与的饮食管理模式对肝移植术后患者胃肠功能恢复的影响

目的 探讨患者参与的饮食管理对肝移植术后患者胃肠功能恢复的影响.方法 选取2018年1月-2019年1月在郑州某三级甲等医院行肝移植的84例患者为研究对象,将其随机分为对照组和观察组,对照组给予常规饮食指导,观察组给予患者参与的饮食管理模式,比较2组患者术后的胃肠功能恢复情况、相关并发症发生率,并采用患者营养主观评估量...     

基于胰岛素泵治疗的院内血糖管理现状调查分析

目的 调查广州市某三级甲等综合医院基于胰岛素泵治疗的院内血糖管理现状。方法 分析286例实施胰岛素泵治疗患者餐前、餐后2 h血糖(2 hour postprandial blood glucose,2h PBG)检测率,高血糖、低血糖及严重低血糖发生情况,对比非内分泌科与内分泌科的差异。 结果 非内分泌科胰岛素泵治疗的患者餐后2 h血糖检测率为33.12%,糖基化血红蛋白检测率为75.16%,均明显低于内分泌科患者(χ²=94.272,P<0.001; χ²=37.104,P<0.001)。非内分泌科低血糖与严重低血糖密度明显高于内分泌科,其中外科低血糖密度最高。非内分泌科与内分泌科使用胰岛素泵患者血糖总达标率比较,差异无统计学意义(χ²=2.697,P=0.101),非内分泌科不同科室患者血糖总达标率比较,差异有统计学意义(χ²=18.900,P=0.002)。结论 非内分泌科应加强对胰岛素泵治疗患者的血糖监测,结合科室特点积极预防低血糖的发生,降低院内血糖管理风险,提升血糖达标率。     

Operative vs nonoperative treatment of displaced intra-articular calcaneal fracture: A meta-analysis of randomized controlled trials

AIM: To investigate clinical efficacy of displaced intra-articular calcaneal fracture (DIACF) following operation and nonoperation. METHODS: Literature search was performed of PubMed and Cochrane Library by two independent authors to identify randomized controlled trials (RCTs) comparing operative vs nonoperative treatment of DIACF from inception to December 31^st, 2013. RCT quality was evaluated by the modified Jadad scale. Dichotomous variables were pooled using risk ratios by review manager 5.3 software. Fixed-effects or random-effects models were adopted with P > 0.05 or P≤ 0.05 for heterogeneity tests, respectively. RESULTS: Eight RCTs comprising 767 cases met inclusion criteria. Results revealed that more surgically treated patients could resume pre-injury job (P = 0.006). No statistical differences were found between the two groups in residual pain (P = 0.33), shoe fitting problems (P = 0.07), limited walking distance (P = 0.56) or secondary late arthrodesis (P = 0.38). However, operative treatment was associated with a higher complication rate (P = 0.003). Subgroup analyses of specific complications revealed that except for a higher risk of superficial wound problems (P < 0.0001) in operative group, the two groups had similar complication rate in deep wound infection (P = 0.34), compartment syndrome (P = 0.46), thromboembolism (P = 0.32), reflex sympathetic dystrophy (P = 0.51) or traumatic arthritis secondary to DIACF (P = 0.43). CONCLUSION: Current evidence demonstrates that compared with operative treatment, conservative treatment of DIACF lead to similar clinical outcomes regarding residual pain, shoe fitting, walking distance and secondary subtalar arthrodesis but a significantly lower complication rate.     

Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

AIM: To compare the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) of colorectal lesions. METHODS: An electronic systematic literature search of four computerized databases was performed in July 2014 identifying studies reporting the outcomes of colorectal ESD and EMR. The primary outcome measures were en-bloc resection rate, endoscopic clearance rate and lesion recurrence rate of the patients followed up. The secondary outcome was the complication rate (including bleeding, perforation and surgery post EMR or ESD rate). Statistical pooling and random effects modelling of the studies calculating risk difference, heterogeneity and assessment of bias and quality were performed. RESULTS: Six observational studies reporting the outcomes of 1324 procedures were included. The en-bloc resection rate was 50% higher in the ESD group than in the EMR group (95%CI: 0.17-0.83, P < 0.0001, I² = 99.7%). Endoscopic clearance rates were also significantly higher in the ESD group (95%CI: -0.06-0.02, P < 0.0001, I² = 92.5%). The perforation rate was 7% higher in the ESD group than the EMR group (95%CI: 0.05-0.09, P > 0.05, I² = 41.1%) and the rate of recurrence was 50% higher in the EMR group than in the ESD group (95%CI: 0.20-0.79, P < 0.001, I² = 99.5%). Heterogeneity remained consistent when subgroup analysis of high quality studies was performed (with the exception of piecemeal resection rate), and overall effect sizes remained unchanged for all outcomes. CONCLUSION: ESD demonstrates higher en-bloc resection rates and lower recurrence rates compared to colorectal EMR. Differences in outcomes may benefit from increased assessment through well-designed comparative studies.     

协同式早期运动干预在腹腔镜结直肠癌手术患者中的应用

目的 探讨协同式早期运动干预在腹腔镜结直肠癌手术患者中的应用效果。方法 使用随机数字表法将2020年5月-2021年5月于笔者所在医院进行腹腔镜结直肠癌手术的84例患者分为对照组和干预组,各42例。对照组术后采用常规运动干预,干预组术后采用协同式早期运动干预。比较2组术后恢复情况、身体状况、术后并发症发生情况。结果 干预组首次下床活动时间、术后排气时间、术后排便时间均早于对照组(χ²=11.823,P=0.001;χ²=4.687,P=0.001;χ²=7.611,P=0.001),术后7d干预组的多维度疲劳量表评分低于对照组(t=2.000,P=0.049),杜克活动指数高于对照组(t=2.256,P=0.027),2组术后并发症发生率比较,差异无统计学意义(χ²=0.343,P=0.558)。结论 协同式早期运动干预能够促进腹腔镜结直肠癌手术患者术后恢复,改善身体状况,值得推广应用。     

多学科护理团队协作模式在老年患者围手术期的应用

目的 探讨多学科护理团队协作模式在老年围手术期患者中的应用效果。方法 选取笔者所在科室2018年1—12月就诊并行手术治疗的65岁以上老年患者50例为对照组,选取2019年1—12月就诊行手术治疗的65岁以上老年患者50例为观察组。对照组给予老年科常规围手术期护理,观察组在对照组基础上给予多学科护理团队协作模式进行干预,比较2组患者术后并发症、护理不良事件发生率及平均住院天数。结果 观察组术后并发症及护理不良事件发生率均低于对照组(χ² =5.086,P=0.024;χ² =4.396,P=0.036);平均住院天数短于对照组(t=5.913,P=0.016)。结论 多学科护理团队协作模式可以降低老年患者术后并发症的发生率,缩短平均住院时间。