新型冠状病毒肺炎胸部CT影像学特征分析

目的:总结新型冠状病毒肺炎(NCP)患者胸部CT影像学特征表现,探讨其对NCP临床诊治的价值。方法:回顾性分析本院目前收治已确诊NCP的30例患者完整影像学资料,重点观察有无胸部CT异常,并对胸部CT异常阴影的病变分布、形态、密度、位置、分期进行分析。结果:胸部CT扫描发现28例患者均有不同程度的肺部异常阴影。病变分布:单侧单叶(右肺中叶)病变2例(7.14%),单肺多叶病变1例(3.57%),双肺多叶病变20例(71.43%),双下肺病变2例(7.14%),双中下肺3例(10.72%);病变位置:病灶远离肺门,位于周边部位15例(53.47%),同时累及周边和中心13例(46.43%);病变形态:病灶表现为斑片状、部分融合呈大片状12例(42.85%),球形11例(39.29%),两者都有5例(17.86%);病灶密度:磨玻璃样改变11例(39.29%),实变11例(39.29%),两者均有6例(21.42%);病变分期:早期11例(39.29%),进展期13例(46.43%),重症4例(14.28%)。结论:新型冠状病毒肺炎患者具有特征性的胸部CT影像表现;CT扫描及影像分期有助于新冠肺炎的早期诊断及病情动态评估,可用于临床治疗实践。     

肺表面活性蛋白A、D水平监测在间质性肺疾病诊治中的临床价值

目的探讨肺表面活性蛋白A、D(SP-A、SP-D)水平监测在间质性肺疾病诊治中的临床价值。方法选取从2013年6月到2015年7月治疗的118例间质性肺疾病患者作为观察组,另选取同期健康人群115例作为对照组。应用酶联免疫吸附实验(ELISA)法测定观察组患者急性加重期与病情缓解期痰液与血清中SP-A与SP-D的含量,评估其水平变化监测对于临床诊断与治疗的应用价值。结果观察组患者病情急性加重期痰液与血清中SP-A与SP-D水平均高于病情缓解期,观察组患者不同病情进展期血清及痰液中SP-A与SP-D水平均高于对照组患者,差异具有统计学意义(P0.05)。结论临床实时监测间质性肺疾病患者SP-A与SP-D的变化水平,可用于该类疾病的早期诊断、临床监测病情进展情况及评价治疗效果与预后。     

血管外肺水:重症临床应用进展

血管外肺水即肺血管外的液体,能够反映肺水肿的严重程度,指导ICU的危重患者液体管理,可以用来评估患者的治疗及预后。为加深对(extravascular lung water,EVLW)的理解及应用,本文着重介绍EVLW在危重症疾病中的监测、临床应用、进展及局限性。     

进展性肺纤维化表现的结缔组织病相关间质性肺疾病患者临床管理(四川省)专家共识

结缔组织病相关间质性肺疾病(connective tissue diseases associated with interstitial lung disease,CTD ILD)很容易出现进展性肺纤维化（progressive pulmonary fibrosis, PPF）表现而预后不良。然而,如何管理PPF表现的CTD ILD患者的临床认识仍然非常有限;如何规范化治疗这部分患者也是经常面临的临床问题。为此,四川省医疗卫生与健康促进会呼吸与危重症医学专业委员会间质性肺疾病学组邀请了省内ILD相关领域专家组成了共识编写组,根据临床收集问题,组织专家讨论,最终确定纳入了5个方面的内容。相关内容主要包括CTD ILD出现PPF的高危因素、临床表现与诊断、病情评估、随访管理和治疗等方面。基于国内外指南、临床研究数据等循证证据,经过多次讨论和投票表决,形成9条推荐意见,共同制定了《PPF表现的CTD ILD患者临床管理（四川省内）专家共识》,旨在提升出现PPF表现的CTD ILD 的临床认识,为临床决策及管理提供依据,提高临床救治水平。     

肺部超声的临床应用及进展

目前肺部超声已应用于多种肺部疾病的临床诊断,尤其在肺间质综合征、气胸、肺实变、胸腔积液、肺栓塞等疾病诊断中均有较高的敏感性及特异性.近年来肺部超声与心血管超声的联合应用,实现了床旁超声对多种常见危重症疾病的快速排除及诊断,为抢救患者赢得了宝贵的时间.本文就肺部超声的临床应用及进展进行综述.     

培美曲塞联合铂类治疗乳腺癌肺转移患者的疗效

目的:回顾性分析培美曲塞联合铂类治疗乳腺癌肺转移患者的疗效以及影响乳腺癌肺转移患者预后的相关因素。方法:回顾性分析2011年7月至2016年7月间44例乳腺癌肺转移的临床资料,比较两类不同解救治疗方案的近期和远期疗效,并采用Cox回归分析以及Cox多因素模型分析44例患者的预后相关因素。结果:44例乳腺癌患者肺转移后解救治疗的总有效率为6 1.4%(27/44),培美曲塞联合铂类化疗组临床有效率[B组,76.0%(19/25)]优于吉西他滨联合化疗组[A组,42.0%(8/19)],差异有统计学意义(P=0.023)。两组均出现血液学毒性以及恶心、呕吐等不良反应,B组患者中贫血、白细胞减少、血小板降低、恶心、呕吐、口腔黏膜炎的发生率明显低于A组,差异有统计学意义(P0.05)。44例患者中位随访期22.5(6~60)个月,中位无疾病进展时间(progression free survival,PFS)为14(95%CI 6.0~22.1)个月,中位生存期(lung metastasesoverall survival,LM-OS)为41(95%CI 30.9~50.1)个月,肺转移后2年PFS为49.2%,肺转移后5年OS为41.4%。两组的PFS和LM-OS差异均无统计学意义(P0.05)。单因素分析和多因素分析结果均表明病理分型、临床分期、解救治疗后的临床缓解情况是预后危险因素。结论:乳腺癌肺转移的预后较差,其中三阴型乳腺癌、初始就发现肺转移的IV期患者以及解救治疗后出现进展预后差。采用培美曲塞联合铂类化疗方案解救治疗仅有肺转移或者肺转移合并骨转移的晚期乳腺癌患者近期疗效较好,不良反应小,但患者的远期预后并没有得到明显改善。     

危重症甲型H1N1流行性感冒病毒肺炎的临床特征——附17例报告

目的:探讨危重症甲型H1N1流行性感冒病毒(甲流)肺炎患者的主要临床特点,分析各临床检验指标与病情严重程度的关系。方法:收集入住呼吸重症监护病房(RICU)的17例危重症甲流肺炎患者的临床资料,归纳分析其临床特征。结果:17例患者以发热、咽痛、咳嗽、肌肉酸痛为主要症状。双肺多发实变影12例(71%)。入院后白细胞为(3.4～25.1)×109/L,中性粒细胞(2.72～21.84)×109/L,中性粒细胞比例58.6%～96.4%,淋巴细胞5.1%～21.6%。CRP 34.6～381.9 mg/L,乳酸脱氢酶(LDH)310～820 U/L,白蛋白<30 g/L10例(59%),ALT升高6例(35%),血清肌酐升高5例(29%),脑钠肽升高4例(24%)。氧合指数<300 mm Hg 13例(76%)。均予奥司他韦治疗,气管插管机械通气支持治疗3例(18%)。死亡2例(12%),均为男性,均为气管插管机械通气者。结论:LDH、CRP升高、炎性细胞增多提示危重症甲流肺炎患者肺部损害加重;机械通气支持治疗对于部分肺内广泛实变者效果不理想,且相关的并发症是部分患者病情加重或死亡的促发因素。     

院内转运时危重症患者血氧饱和度降低原因分析及护理

目的:分析影响危重症患者院内转运时血氧饱和度降低的高危因素及护理要点。方法:回顾性分析2016年6月~2017年7月急诊科抢救的504例危重症患者的临床资料,评估院内转运时血氧饱和度降低(SpO_2下降超过5%)的发生情况,分析高危影响因素,总结护理要点。结果:院内转运的504例危重症患者中,转运过程中出现SpO_2降低140例(27.8%),与供氧装置、转运人员职称、疾病类型、早期改良预警评分、年龄等因素密切相关(P0.05)。结论:供氧装置、转运人员职称、疾病类型、早期改良预警评分、年龄是危重症患者院内转运时SpO_2降低的高危因素,对危重症患者院内转运时进行安全护理,可减低患者不良事件的发生。     

不同类型新冠肺炎临床病例特点分析

目的 通过回顾性分析不同类型新冠肺炎患者的临床资料,探讨新冠肺炎的临床病例特点。方法 收集我院119例非危重症新冠肺炎患者和30例危重症新冠肺炎患者基本人口学特征、基础疾病、临床表现,以及重要检验指标,对两组患者数据进行统计学分析。结果 两组之间不存在性别差异,危重症患者以高龄者居多,临床表现均以单个症状者较少,大多是数个症状共同或先后出现,但危重症患者程度更严重。新冠肺炎常伴有基础疾病,其中最多为高血压病,其次是冠心病及2型糖尿病,而51.3-63.3%的患者往往同时患有高血压病、冠心病及2型糖尿病等多种疾病。另外还发现,危重症患者淋巴细胞计数、淋巴细胞百分比明显低于非危重症患者,而白细胞计数、白细胞百分比、C反应蛋白、降钙素原,肌酸激酶、肌酸激酶同工酶、乳酸脱氢酶及α-羟丁酸脱氢酶等指标,危重症患者则明显高于非危重症患者。结论 和非危重症新冠肺炎患者相比,危重症新冠肺炎患者年龄更大,临床表现和基础疾病更多、程度更重,炎性反应更明显,对肺、心及肝等重要器官功能影响更显著。     

重型甲型H1N1流感患者临床特征分析

[目的]探讨甲型H1N1流感重症和危重症病例的临床特点.[方法]本院EICU收治18例合并重症肺炎或急性呼吸窘迫综合征（ARDS）患者,对其发病特点、治疗方法及转归等资料进行分析.[结果]所有病例表现为发热和呼吸系统症状,主要临床特点为高热持续不退,呼吸困难,白细胞数及炎症反应指标升高,免疫功能紊乱,胸部影像改变特点为进展快,双肺多叶受累,以广泛肺实质浸润为主,部分病例出现肺间质渗出、支气管充气征,甚至ARDS改变.17例康复出院,另一例病情已平稳,康复治疗中.[结论]重型甲型H1N1流感病情进展快,以呼吸困难、低氧血症为突出表现,肺部病变广泛,进展迅速,有呼吸道基础疾病或免疫抑制状态合并细菌感染是甲型H1N1发生重型和死亡的高危因素,早期奥司他韦抗病毒、呼吸支持、控制混合感染及免疫调节等综合治疗是降低病死率的关键.     

Secondary bloodstream infection in critically ill patients with COVID-19

ObjectiveSecondary infection, especially bloodstream infection, is an important cause of death in critically ill patients with COVID-19. We aimed to describe secondary bloodstream infection (SBI) in critically ill adults with COVID-19 in the intensive care unit (ICU) and to explore risk factors related to SBI.MethodsWe reviewed all SBI cases among critically ill patients with COVID-19 from 12 February 2020 to 24 March 2020 in the COVID-19 ICU of Jingmen First People''s Hospital. We compared risk factors associated with bloodstream infection in this study. All SBIs were confirmed by blood culture.ResultsWe identified five cases of SBI among the 32 patients: three with Enterococcus faecium, one mixed septicemia (E. faecium and Candida albicans), and one C. parapsilosis. There were no significant differences between the SBI group and non-SBI group. Significant risk factors for SBI were extracorporeal membrane oxygenation, central venous catheter, indwelling urethral catheter, and nasogastric tube.ConclusionsOur findings confirmed that the incidence of secondary infection, particularly SBI, and mortality are high among critically ill patients with COVID-19. We showed that long-term hospitalization and invasive procedures such as tracheotomy, central venous catheter, indwelling urethral catheter, and nasogastric tube are risk factors for SBI and other complications.     

Nurse led protocols for control of glycaemia in critically ill patients: A systematic review

BackgroundBlood glucose control in critically ill patients is challenging and can affect clinical outcomes. Several manual as well as automated approaches have been proposed over the time, however nursing staff still covers the key-role for optimization of glycemia throughout adjustment of insulin infusion and administration.AimSystematic review to compare the efficacy/the effects of nurse led insulin infusion protocols versus standard approaches in patients admitted in the intensive care unit.MethodsAll relevant studies evaluating nurse directed protocols for insulin administration in critically ill adults. Data was independently extracted and collected through a dedicated electronic form. The following outcomes have been recorded: the number (or percentage) of glycaemia measurements within the target range; the number of hypo- and hyper-glycaemic events, separately; the mean glycaemia; the lowest and highest glycemia values recorded; the time to reach the glycaemia target; the ICU length of stay and the ICU and the long-term (>30 days) mortality. Statistical analysis was conducted on the summary statistics of the selected articles (eg, means, medians, proportions). Unpaired nonparametric continuous data were compared through the Mann-Whitney U-test.ResultsGlycaemic control as well as ICU length of stay and mortality are similar in both patients' groups. Specifically, the group of patients treated with standard modalities include those treated with doctors led protocols, paper charts or software-based approaches.ConclusionOverall, nurse led insulin protocols can effectively control blood glucose level among critically ill patients.     

Critically ill patients with COVID-19 in Tokyo,Japan: A single-center case series

IntroductionWe reported, in our previous study, a patient with coronavirus disease 2019 (COVID-19) who was successfully treated with extracorporeal membrane oxygenation. Data on clinical courses and outcomes of critically ill patients with COVID-19 in Japan are limited in the literature. This study aimed to describe the clinical courses and outcomes of critically ill patients with COVID-19 in Tokyo, Japan.MethodsThis is a single-center case series study. Patients with COVID-19 treated with mechanical ventilation (MV) were reviewed retrospectively. Data on baseline characteristics, in-hospital treatment, and outcomes were collected.ResultsBetween February 2, 2020, and June 30, 2020, 14 critically ill patients with COVID-19 were treated with MV. Most patients were male and had comorbidities, especially hypertension or diabetes; 35.7% were overweight and 21.4% were obese. The majority of the patients had dyspnea on admission. The median duration of MV was 10.5 days, and the 28-day mortality rate was 35.7%. In the four patients with COVID-19 who died, the cause of death was respiratory failure.ConclusionsAs in previous reports from other countries, the mortality rate of patients with COVID-19 requiring intensive care remains high in Tokyo. Further study on the appropriate timing of MV initiation and specific treatments for critically ill patients with COVID-19 is needed.     

Angiotensin (1−7) peptide replacement therapy with plasma transfusion in COVID-19

AimTo determine whether convalescent angiotensin (1?7) peptide replacement therapy with plasma (peptide plasma) transfusion can be beneficial in the treatment of critically ill patients with severe coronavirus 2 (SARS-CoV-2) infection.Study designCase series of 9 critically ill patients with laboratory-confirmed COVID-19 who met the following criteria: severe pneumonia with rapid progression and continuously high viral load despite antiviral treatment.Peptide plasma: Plasma with angiotensin (1?7) content 8–10 times higher than healthy plasma donors was obtained from suitable donors. Peptide plasma transfusion was applied to 9 patients whose clinical status and/or laboratory profile deteriorated and who needed intensive care for 2 days.ResultsIn our COVID-19 cases, favipiravir, low molecular weight heparin treatment, which is included in the treatment protocol of the ministry of health, was started. Nine patients with oxygen saturation of 93% and below despite nasal oxygen support, whose clinical and/or laboratory deteriorated, were identified. The youngest of the cases was 36 years old, and the oldest patient was 85 years old. 6 of the 9 cases had male gender. 3 cases had been smoking for more than 10 years. 4 cases had at least one chronic disease.In all of our cases, SARS CoV2 lung involvement was bilateral and peptide plasma therapy was administered in cases when oxygen saturation was 93% and below despite nasal oxygen support of 5 liters/minute and above, and intensive care was required. Although it was not reflected in the laboratory parameters in the early period, 8 patients whose saturations improved with treatment were discharged without the need for intensive care. However, a similar response was not obtained in one case. Oxygen requirement increased gradually and, he died in intensive care process. An increase of the platelet count was observed in all cases following the peptide plasma treatment.ConclusionIn this preliminary case series of 9 critically ill patients with COVID-19, administration of plasma containing angiotensin (1?7) was followed by improvement in their clinical status. The limited sample size and study design preclude a definitive statement about the potential effectiveness of this treatment, and these observations require evaluation in clinical trials.     

Bispectral Index Monitoring in Helicopter Emergency Medical Services Patients

Background. Many critically ill patients are given sedatives andparalytics to facilitate aeromedical transport. Bispectral index (BIS) monitoring is a computer-derived electroencephalography (EEG) analog currently used to monitor the level of awareness of sedated patients. It gives a score of 1–100, with 1 representing no brain function and100 representing a completely alert patient. Objective. To evaluate whether critically ill patients are adequately sedated during aeromedical transport. Methods. This was a prospective, observational study of a convenience sample of critically ill patients transported by helicopter. All intubated patients who received sedatives and/or paralytics to facilitate transport were eligible for enrollment by the attending clinician. Prior to liftoff, a BIS sensor was applied to the patient's forehead. Minimum, maximum, andmean BIS index scores were recorded every minute during transport. Results. Forty-seven patients (57% male) were enrolled, with a median age of 60 years (interquartile range [IQR] 18–81, range 14 to 86 years). The median duration of monitoring was 15.0– minutes (IQR 6.0–26.0, range 2 to 33). The median BIS score was 54.6 (IQR 38.6–67.3, range 28 to 89.5). Only two patients (4.3%, 95% confidence interval [CI] 0.5% to 14.8%) had at least one BIS score greater than 85, the accepted threshold for recall. Conclusion. These results suggest that patients are adequately sedated during air medical transport.     

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care on the Duration of Mechanical Ventilator for Critically Ill Patients

PurposeEarly enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical outcomes.MethodsThis study compares a pretest-posttest design for the two groups, which was done before and after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit (ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG started within the first 48 hours of admission to the ICU, and for the control group, they received standard nursing care.ResultsAfter the implementation, it showed significant associations between the duration of mechanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter starting time of EN and a reduced duration of mechanical ventilator than those in the control group (p < .001).ConclusionA CNPG for EN care reduced the duration of mechanical ventilator. This could possibly improve the delivery of target calories when compared with current standard practice and improve the outcome of critically ill patients.     

The sieving coefficient and clearance of vasopressin during continuous renal replacement therapy in critically ill children

HypothesisAs vasopressin is a small peptide, its sieving coefficient (SC) and clearance (CL) during continuous renal replacement therapy may be intermediate to those for urea and β2 microglobulin (commonly used markers for small– and middle–molecular weight solutes, respectively).MethodsA prospective, minimal-risk study was undertaken of the SC and CL of vasopressin in critically ill children on the first day of continuous renal replacement therapy using AN69 membrane filters and prefilter replacement fluid. All prefilter plasma (vasopressin) samples were drawn from the arterial port after predilution.ResultsNine patients with fluid overload, renal failure, or both were recruited (median age, 14 years) during the first day of either continuous venovenous hemofiltration (n = 3) or hemodiafiltration (n = 6). Multiorgan dysfunction syndrome was present in 8 patients, and 3 were in shock (2 were receiving a vasopressin infusion). Median prefilter plasma (vasopressin) was 1.7 pg/mL, although data points were skewed: 5 patients had a low prefilter plasma (vasopressin) (<2 pg/mL), and 4 patients (including 2 receiving a continuous vasopressin infusion) had a prefilter plasma (vasopressin) between 4.2 and 56.4 pg/mL. All those with low prefilter plasma (vasopressin) had an effluent (vasopressin) less than the detection limit (0.6 pg/mL). The median SC was 1 in the 4 patients with a measurable effluent (vasopressin), and their median filter CL was 48 mL/min or 39 mL/(min 1.73 m²).ConclusionsThe SC and CL of vasopressin by continuous venovenous hemofiltration or hemodiafiltration in these critically ill children were similar to values for urea.     

COVID-19 in critically ill patients in North Brabant,the Netherlands: Patient characteristics and outcomes

PurposeSince the SARS-CoV-2 pandemic, countries are overwhelmed by critically ill Coronavirus disease 2019 (COVID-19) patients. As ICU capacity becomes limited we characterized critically ill COVID-19 patients in the Netherlands.MethodsIn this case series, COVID-19 patients admitted to the ICU of the Jeroen Bosch Hospital were included from March 9 to April 7, 2020. COVID-19 was confirmed by a positive result by a RT-PCR of a specimen collected by nasopharyngeal swab. Clinical data were extracted from medical records.ResultsThe mean age of the 50 consecutively included critically ill COVID-19 patients was 65 ± 10 years, the mean BMI was 29 ± 4.7 and 66% were men. Seventy-eight percent of patients had ≥1 comorbidity, 34% had hypertension. Ninety-six percent of patients required mechanical ventilation and 80% were ventilated in prone position. Venous thromboembolism was recognized in 36% of patients. Seventy-four percent of patients survived and were successfully discharged from the ICU, the remaining 26% died (median follow up 86 days). The length of invasive ventilation in survivors was 15 days (IQR 12–31).ConclusionsThe survival rate of COVID-19 critically ill patients in our population is considerably better than previously reported. Thrombotic complications are commonly found and merit clinical attention.Trial registration number: NL2020.07.04.01