监测乳酸清除率对早期脓毒性休克患儿的临床意义

目的:探讨血乳酸清除率对早期脓毒性休克患儿组织缺氧情况和预后判断的临床价值.方法:应用液体复苏治疗48例早期脓毒性休克患儿,在液体复苏治疗前、24 h后分别测定血乳酸水平,计算乳酸清除率,并与小儿危重病例评分法(PCIS)作比较.结果:治疗成功组乳酸水平在液体复苏前后差异有非常显著意义(P<0.01),而MODS组则无显著意义(P<0.05).成功组的乳酸清除率为55.2%±32.4%,MODS组为(25.1±38.7)%(P<0.01).乳酸清除率与小儿危重病例评分PCIS存在明显相关.结论:早期乳酸清除率可作为判断脓毒症患儿预后的-个指标.     

脓毒症EGDT后早期血乳酸清除率与器官功能障碍评分及预后的关系

[目的]探讨严重脓毒症及脓毒症休克患者经早期目标导向治疗(EGDT)后,早期(6 h内)乳酸清除率与器官功能障碍评分的变化与病死率的关系.[方法]选择2008年5月至2010年3月本院急诊科严重脓毒症和脓毒症休克患者64例,应用EGDT,计算早期(6 h)血乳酸清除率,按乳酸清除率四分位数由低到高分为四组,统计治疗至 72 h患者各种器官功能障碍评分:①急性生理和慢性健康评分(APACHEⅡ),②简化急性生理评分(SAPSⅡ),③多器官功能障碍评分(MODS),④序贯器官衰竭评分(SOFA).并统计住院30 d、60 d死亡率.[结果]治疗最初6 h,乳酸清除率较高组在72 h各器官功能障碍评分均较低,差异有统计学意义(P<0.01);乳酸清除率较高组住院d30、d60的病死率也显著低于乳酸清除率较低组,差异有统计学意义(P<0.01).[结论]早期乳酸清除率与严重脓毒症和脓毒性休克患者各器官功能障碍程度以及住院死亡率存在相关.这可能为临床医师判断严重脓毒症及脓毒症休克治疗效果、预后提供参考.     

早期连续性血液净化治疗多器官功能障碍综合征的临床疗效

目的 探讨早期应用连续性血液净化技术(continuous blood purification, CBP)治疗多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS)的临床疗效.方法 98例MODS患者,其中治疗组(MODS发生48 h内行CBP治疗)46例,对照组(MODS发生48 h后行CBP治疗)52例,分别行CBP治疗48～276 h.观察并比较两组CBP治疗24、48 h急性生理和慢性健康状况评分Ⅱ(APACHEⅡ)、MODS评分及ICU住院时间、ICU病死率.结果 两组年龄、性别及发生MODS时APACHEⅡ评分、MODS评分比较差异均无统计学意义(P>0.05);治疗24、48 h 两组APACHEⅡ评分、MODS评分比较差异均有统计学意义(P<0.05).两组ICU住院时间及病死率比较差异均有统计学意义(P<0.05).结论 尽可能早期开展CBP治疗,能提高MODS患者的救治成功率.     

早期应用柴芩承气汤治疗重症急性胰腺炎伴多器官功能障碍综合征临床研究

目的：探讨早期应用柴芩承气汤治疗重症急性胰腺炎（severe acute pancreatitis,SAP）伴多器官功能障碍综合征（multiple organ dysfunction syndrome,MODS）的临床疗效。方法：88例符合病例选择标准并接受柴芩承气汤治疗的SAP伴MODS住院患者,按院外病程长短分为早期组（48 h内入院接受治疗,44例）和晚期组（48~72 h内入院接受治疗,44例）,比较治疗过程中两组患者器官功能障碍持续时间、住院时间、感染率、中转手术率及病死率。结果：早期组急性呼吸窘迫综合征、肾功能衰竭、心功能衰竭、肝功能不全、脑病、凝血系统损害的持续时间低于晚期组（P〈0.05）;早期组住院时间、感染率、中转ICU率、中转手术率及病死率低于晚期组（P〈0.05）。结论：早期应用柴芩承气汤治疗SAP伴MODS能减少器官损害持续时间,减轻器官损害,从而缩短病程,减少后期感染率及中转手术率,降低病死率。     

小儿危重病评分法在护理中的应用研究

目的探讨小儿危重病评分法(草案)在护理中的临床应用.方法对109例ICU的患儿于入院时、24 h、48 h、72 h各进行危重病评分一次,并于第7天及出院前再次评分.同时进行器官功能衰竭的评估及护理判断分析.按评分值分组:I组为≤70分,Ⅱ组71～80分,Ⅲ组81～100分,分别代表病情极危重、危重和非危重,并相应采取特别护理、重点护理和一级护理措施,尤其对评分≤80分的患儿及时应用以设备为主的加强监护.结果首次评分值越低、多脏器功能衰竭(MSOF)发生率越高,发生器官功能衰竭次数越多,预后越差.随着病情好转,评分值逐渐升高.本组有37例(34.2%)不属于危重病例住入ICU,第二天搬出ICU.结论应用小儿危重评分法能帮助判断病情及预后,对指导儿科临床护理有重要意义,在ICU和非ICU均有推广应用价值.     

脓毒症早期检测血乳酸清除率的临床意义

目的:探讨脓毒症早期血乳酸清除率检测的临床意义。方法:对2011年10月至2013年6月ICU收治的脓毒症患者63例分为存活组和死亡组,高、低乳酸清除率组,测定入组时(0 h)及入组后6 h、24 h的动脉血乳酸水平及6 h、24 h乳酸清除率,入住ICU后24 h的APACHEⅡ评分、48 h的器官衰竭数目及28 d内死亡率,比较存活组和死亡组,高、低乳酸清除率组间的差异。结果:存活组的6 h乳酸清除率高于死亡组(P0.05);高乳酸清除率组的24 h APACHEⅡ评分、48 h器官衰竭数目及28 d内死亡率均明显低于低乳酸清除率组(P0.05)。结论:早期血乳酸清除率可指导脓毒症的治疗及评估其预后。     

血乳酸水平及清除率和升高时间与重症监护病房危重患者预后的关系

目的 探讨乳酸动态监测指标与重症监护病房(ICU)危重患者预后的相关关系,并对这种关系进行量化评价.方法 收集101例乳酸升高的危重患者,分为死亡组(50例)和存活组(51例),比较两组的乳酸监测指标(乳酸水平、乳酸升高时间、乳酸清除率)、急性生理学与慢性健康状况评分系统Ⅰ(APACHE Ⅰ)评分及其他反映器官功能的指标,使用logistic回归分析找出与预后显著相关的指标.以相应的乳酸指标进行量化分组,分别比较各组休克和多器官功能障碍综合征(MODS)发生率、APACHE Ⅰ评分和病死率.结果 死亡组入ICU乳酸值、乳酸峰值、APACHE Ⅰ评分高于存活组,12 h和24 h乳酸清除率、pH值低于存活组(P<0.05或P<0.01).乳酸峰值、12 h乳酸清除率、APACHE Ⅰ评分和pH值与患者的预后明显相关,相对比值比(OR)分别为1.466、0.922、1.208、0.032.乳酸峰值≥10 mmol/L、12 h乳酸清除率≤10%的患者病死率明显升高,分别为77.8%和70.6%(P<0.05和P<0.01),乳酸升高时间>24 h时病死率虽升高,但无统计学意义.结论 乳酸峰值、12 h乳酸清除率、APACHE Ⅰ评分和pH值是评价患者预后的良好指标.乳酸峰值≥10 mmol/L、12 h乳酸清除率≤10%时应警惕患者较差的预后,而乳酸升高时间评价预后的价值有限.     

早期血液净化对复苏后综合征防治效果的临床观察

目的 观察早期行血液净化(CBP)治疗对复苏后多器官功能障碍综合征(PR-MODS)的防治效果.方法 采用回顾性方法对40例心脏骤停成功复苏患者进行分析,比较CBP组与对照组患者生命体征、脏器功能受累水平、血清炎症因子浓度、PR-MODS发生率.结果 CBP组24、48及72 h上述指标明显优于对照组,且PR-MODS发生率明显下降,差异有统计学意义(P<0.05).结论 早期CBP能稳定内环境,降低炎症因子及脏器功能受累水平差异,降低心肺复苏(CPR)后综合征患者MODS发生率.     

连续性血液净化对多脏器功能障碍综合征患者血管内皮功能的影响

[目的]探讨连续性血液净化(CBP)在多器官功能障碍综合征(MODS)患者应用中对血管内皮细胞(VEC)功能的影响.[方法]MODS患者39例入治疗组,于CBP前、CBP开始后4 h、12 h、24 h、48 h、72 h测定心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心排血量指数(CI),于CBP前、C...     

应用动脉血乳酸评价连续性肾脏替代治疗的效果

目的：探讨进行CRRT治疗的伴急性肾功能不全的多脏器功能衰竭患者治疗前后动脉血乳酸的变化,评估CRRT对高乳酸血症的危重患者的治疗效果。方法：对25例CRRT治疗危重的患者,于治疗开始前、治疗后24h、48h、72h监测患者动脉血乳酸含量,同时检测动脉血pH值,氧合指数,血肌酐等,计算出危重患者APACHEⅡ评分进行分析比较。结果：成活组患者CRRT治疗前后动脉血乳酸含量,动脉血pH值和APACHEⅡ评分进行比较,动脉血乳酸含量和APACHEⅡ评分于治疗后24h有显著性改变。成活组和死亡组患者首次动脉血乳酸和APACHEⅡ评分进行比较,死亡组患者动脉血乳酸和APACHEⅡ评分均有统计学差异。结论：用血乳酸评估应用CRRT治疗患者病情的严重性和预后等同于APACHEⅡ评分,并且更方便快捷。     

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.