17例重症胰腺炎并发成人呼吸窘迫综合征诊治体会

重症胰腺炎可使机体多个器官受到严重损害,其中以肺损伤最常见,主要表现为成人呼吸窘迫综合征（ＡＲＤＳ）,也是多系统器官功能衰竭（ＭＳＯＦ）的始动环节〔１〕。笔者对我院１９９０年至１９９８年收治的１７例重症胰腺炎并发ＡＲＤＳ的患者进行回顾性分析,就其临床表现、诊断及治疗讨论如下。１　临床资料１．１　一般资料１７例中女１１例,男６例,年龄２７～７２岁。ＡＲＤＳ诊断标准为：①发病或手术后出现进行性呼吸困难,急促、气短、紫绀,普通氧疗难以纠正;②在吸氧情况下ＰａＯ２进行性下降（＜８．０ｋＰａ～＜４．６７ｋ…     

高海拔区急性呼吸窘迫综合征的监护

为减少高海拔地区呼吸窘迫综合征（Ｈ－ＡＲＤＳ）的病死率,对收入ＩＣＵ的２５２例创伤、感染、大手术患者进行了心电、呼吸、血气、生化连续动态监护。结果：２５２例中有２８例分别于伤后３￣７２ｈ（平均１９．６ｈ）发生了急性呼吸窘迫综合征（ＡＲＤＳ）。除１例死亡外,２７例抢救成活。提示连续动态监护为Ｈ－ＡＲＤＳ的早期诊断、治疗提供了可靠依据,从而减少了病死率。     

急性呼吸窘迫综合征国内外诊断标准的对比研究

目的：以欧美现行的急性肺损伤（ＡＬＩ）和急性呼吸窘迫综合征（ＡＲＤＳ）诊断标准为准,比较国内现行诊断标准的相似准确度。方法：回顾性地将１９９６年１月至１９９９年１０月瑞金医院外科ＩＣＵ收治的１８９例病人按有无可诱发ＡＲＤＳ的危险因素分为高危组和对照组,收集患者病史中动脉血气分析、胸部Ｘ线、呼吸频率、心功能、诊断时间和ＡＰＡＣＨＥ　Ⅱ评分等临床资料,并据此将我国的广州ＡＲＤＳ诊断标准与欧美的ＡＬＩ、ＡＲＤＳ标准作比较。结果：在高危组中,广州标准的灵敏度为８９％,特异性为８０％,准确度为８４％,但假阳性率为３４％,其主要原因是欧美标准诊断ＡＲＤＳ要求有胸部Ｘ线资料;在对照组中,广州标准的灵敏度为零。凭广州标准确定诊断时,距发病平均为３７．６ｈ±３２．２ｈ,而欧美标准为５２．２ｈ±４４.８ｈ（ＡＲＤＳ）和４９.１ｈ±４２．３ｈ（ＡＬＩ）。结论：广州标准与欧美ＡＬＩ标准近似,但有助于更早地确立诊断。我们认为广州标准不凭胸部Ｘ线资料就可诊断ＡＲＤＳ是恰当的。     

梗阻性黄疸病人术后多器官功能障碍综合征的机理与防治策略

１９９１年美国胸科医师学会（ＡＣＣＰ）和危重病医学会联席会议（ＳＣＣＭ）提出全身炎症反应综合征（ＳＩＲＳ）概念,将炎症反应的认识从实验研究水平推广到临床。ＳＩＲＳ的最严重后果是多器官功能障碍综合征（ＭＯＤＳ）。本文旨在探讨梗阻性黄疸病人手术后ＭＯＤＳ的机理和防治策略。临床资料１．病例资料：１９８３年１月～１９９７年９月共手术治疗恶性肿瘤梗阻性黄疸病人３０８例,男１９９例,女１０９例,平均年龄５５－７８岁。２．诊断标准：参照１９９１年ＡＣＣＰ和ＳＣＣＭ的定义的诊断标准诊断ＳＩＲＳ。ＭＯＤＳ包括早期…     

兰州西北“三会”会议纪要

由中华医学会甘肃省分会、兰州军区卫生部科委会组织,兰州军区总医院、甘肃省急救中心承办的《中国西部急性呼吸窘迫综合征诊断标准专题研讨会》、《西北五省区第二届急救医学学术交流会》暨《兰州军区第三届胸心外科学术交流会》于１９９９年８月２４日至２６日在兰州市联合召开,参会代表１２０余人,收稿３６０篇,会议围绕危重病急救医学、临床极具挑战性的急性呼吸窘迫综合征（ＡＲＤＳ）和多器官功能障碍综合征（ＭＯＤＳ）进行了专题讲座和学术交流。通过近十年,４个海拔高度现场的内毒素／油酸ＣＬＰＡＬＩ动物模型实验和３１０例…     

重症急性胰腺炎伴成人呼吸窘迫综合征的救治

目的：探讨如何降低ＳＡＰ所伴发的ＡＲＤＳ的发病率及救治方案。临床资料：１９９１．１￣１９９８．１２ＳＡＰ病人５４例。手术组３１例,三天内手术１２例,发生ＡＲＤＳ７例,死亡６例;三天后手术１９例,发生ＡＲＤＳ４例,死亡１例。非手术组２３例,早期（三天内）发生ＡＲＤＳ５例,死亡３例,后期发生ＡＲＤＳ２例,死亡１例。一旦明确ＳＡＰ诊断,给予积极抗休克,有计划的手术,控制感染,营养支持。一旦出现难于纠正的     

不同时期胸部创伤的特点及救治经验

目的比较不同时期收治胸部创伤（胸伤）的特点，围绕其院内死亡原因总结救治经验。方法将１６３９例胸伤分为１９９０年前、后两组，比较不同时期病例数、致伤原因、严重胸伤构成比及住院死亡率，并对伤后早期与晚期常见致死原因失血性休克、成人呼吸窘迫综合征（ＡＲＤＳ）和多系统器官衰竭（ＭＳＯＦ）等进行分析。结果９０年代后收治胸伤病例增多，穿透性刃器伤、重症钝性胸伤、连枷胸、肺挫伤和ＡＲＤＳ病例明显增加，住院死亡率从４．３０％降至２．９６％；住院早期死亡原因以失血性休克为主，晚期死亡原因多为ＡＲＤＳ和ＭＳＯＦ。结论应针对９０年代胸伤特点，围绕严重胸伤常见的致死原因，进一步改进急救和后续处理，降低死亡率。     

肾病综合征患儿人类白细胞抗原－DRB1基因分型

为进一步明确人类白细胞抗原（ＨＬＡ）与肾病综合征的关系，应用聚合酶链反应（ＰＣＲ）／顺序特异的寡核苷酸（ＳＳＯ）探针的方法对２３名上海地区激素敏感型肾病综合征患儿进行了ＨＬＡ－ＤＲＢ１等位基因的频率分析，发现ＨＬＡ－ＤＲＢ１０７与该病相关（Ｐ校正Ｐｃｏｒｒ＝９．０２×１０－３，相对危险度，ＲＲ＝８．１５），ＨＬＡ－ＤＲＢ１０９与该病的频复发相关（Ｐｃｏｒｒ＝２．５１×１０－２，ＲＲ＝２０．７７），用ＰＣＲ／ＳＳＯ分型方法可精确分析与肾病综合征相关的ＨＬＡ等位基因。     

心脏瓣膜病巨大左室的外科治疗经验

１９８７年１月至１９９２年３月，我们为６５例心脏瓣膜病巨大左室（ＥＤＤ＞７０ｍｍ）病人施行了瓣膜替换术。术前平均ＥＤＤ７８．８ｍｍ，ＥＳＤ５７．３ｍｍ，ＦＳ０．２６。心功能ＩＩＩ级１６例，ＩＶ级４９例。手术方式：ＭＶＲ１６例，ＭＶＲ＋ＴＶＰ１０例，ＡＶＲ１１例，ＭＶＲ＋ＡＶＲ２１例，ＭＶＲ＋ＡＶＲ＋ＴＶＰ７例。术后早期发生心、肺、肾、肝等重要器官并发症２７例，死亡９例（１３．８％）。ＡＶＲ组（１８     

提高复杂性急性肾功能衰竭的防治水平

复杂性急性肾功能衰竭是多脏器功能障碍综合征（ＭＯＤＳ）的一个组成部分,不论急性肾功能衰竭（ＡＲＦ）是初发的衰竭器官抑或其他器官衰竭后的后果,患者的病死率均明显增高,治疗也更趋复杂。因此,研究复杂性ＡＲＦ的治疗是肾脏科和ＩＣＵ医生的重要任务。 败血症是导致ＭＯＤＳ的重要原因,在我院住院的败血症患者中,８７．９％并发ＭＯＤＳ。败血症一旦并发ＡＲＦ后病死率明显增高,从２１．３％升至６９．７％,文献报道亦在５７％～８９％之间。 自１９８５年Ｇｏｒｉｓ提出全身性炎症反应综合征（ＳＩＲＳ）的概念后,人们投入了…     

Nephrogenic acute respiratory distress syndrome: A narrative review on pathophysiology and treatment on pathophysiology and treatment

The kidneys have a close functional relationship with other organs especially the lungs. This connection makes the kidney and the lungs as the most organs involved in the multi-organ failure syndrome. The combination of acute lung injury (ALI) and renal failure results a great clinical significance of 80% mortality rate. Acute kidney injury (AKI) leads to an increase in circulating cytokines, chemokines, activated innate immune cells and diffuse of these agents to other organs such as the lungs. These factors initiate pathological cascade that ultimately leads to ALI and acute respiratory distress syndrome (ARDS). We comprehensively searched the English medical literature focusing on AKI, ALI, organs cross talk, renal failure, multi organ failure and ARDS using the databases of PubMed, Embase, Scopus and directory of open access journals. In this narrative review, we summarized the pathophysiology and treatment of respiratory distress syndrome following AKI. This review promotes knowledge of the link between kidney and lung with mechanisms, diagnostic biomarkers, and treatment involved ARDS induced by AKI.     

Retrospective analysis on acute respiratory distress yndrome in ICU

OBJECTIVE: To assess the incidence, etiology, physiological and clinical features, mortality, and predictors of acute respiratory distress syndrome (ARDS) in intensive care unit (ICU). METHODS: A retrospective analysis of 5 314 patients admitted to the ICU of our hospital from April 1994 to December 2003 was performed in this study. The ARDS patients were identified with the criteria of the American-European Consensus Conference (AECC). Acute physiology and chronic health evaluation III (APACHE III), multiple organ dysfunction syndrome score (MODS score), and lung injury score (LIS) were determined on the onset day of ARDS for all the patients. Other recorded variables included age, sex, biochemical indicators, blood gas analysis, length of stay in ICU, length of ventilation, presence or absence of tracheostomy, ventilation variables, elective operation or emergency operation. RESULTS: Totally, 131 patients (2.5%) developed ARDS, among whom, 12 patients were excluded from this study because they died within 24 hours and other 4 patients were also excluded for their incomplete information. Therefore, there were only 115 cases (62 males and 53 females, aged 22-75 years, 58 years on average) left, accounting for 2.2% of the total admitted patients. Their average ICU stay was (11.27+/-7.24) days and APACHE III score was 17.23+/-7.21. Pneumonia and sepsis were the main cause of ARDS. The non-survivors were obviously older and showed significant difference in the ICU length of stay and length of ventilation as compared with the survivors. On admission, the non-survivors had significantly higher MODS and lower BE (base excess). The hospital mortality was 55.7%. The main cause of death was multiple organ failure. Predictors of death at the onset of ARDS were advanced age, MODS > or = to 8, and LIS > or = 2.76. CONCLUSIONS: ARDS is a frequent syndrome in this cohort. Sepsis and pneumonia are the most common risk factors. The main cause of death is multiple organ failure. The mortality is high but similar to most recent series including severe comorbidities. Based on this patient population, advanced age, MODS score, and LIS may be the important prognostic indicators for ARDS.     

Diagnosis of acute respiratory distress syndrome in nosocomial pneumonia

Acute respiratory distress syndrome (ARDS) complicates nosocomial pneumonias (NPn) in 12% to 33% of patients with associated increases in mortality of up to 80%. A timely diagnosis of ARDS with NPn is, however, problematic. The aim of this investigation was to improve the diagnosis and treatment of the early stages of ARDS with NPn. A total of 82 cancer and multiple trauma patients were enrolled in the investigation. Patients were split into 3 groups according to standard ARDS and NPn diagnostic criteria: group 1 ("ARDS + NPn"), group 2 ("NPn"), group 3 ("no ARDS, no NPn"). ARDS was diagnosed using 3 methods: the Murray score, the American-European Consensus Conference criteria, and the V. A. Negovsky Research Institute of General Reanimatology criteria. Elevation of extravascular lung water index along with other ARDS diagnostic criteria (oxygenation index, central hemodynamic indices) was predictive of early stage of ARDS in patients with NPn. The standard diagnostic criteria for ARDS, including the Murray score, oxygenation index, and radiographic data only predicted the later stages of ARDS in NPn. Early diagnosis of ARDS with concomitant NPn in the current study was associated with improved treatment results with decreased duration of artificial ventilation and intensive care unit stay.     

A prospective cohort study of ALI/ARDS in the Tohoku district of Japan (second report)

Purpose  

We previously reported a study of systemic inflammatory response syndrome (SIRS) cases in the Tohoku district of Japan in which the patients showed a 30-day mortality from acute lung injury/acute respiratory distress syndrome (ALI/ARDS) of about 20%. Cases in which chest X-ray findings did not meet ALI/ARDS criteria were diagnosed as acute hypoxemic respiratory failure (AHRF), but about 50% of these patients progressed to ALI/ARDS. The objective of this study was to verify the findings obtained in the earlier study and to gain further insights into the pathognomonic symptoms of AHRF associated with SIRS.     

Deceased organ donation in Brazil: how can we improve?

METHODS: We retrospectively analyzed the registry data from one organ procurement organization obtained between January 1 and December 31, 2005. RESULTS: Among the 378 potential deceased donors, 182 (48.2%) were lost, mainly due to clinical conditions (27%) or cardiac arrest (19.3%). Of the remaining 196 (51.8%) potential donors, family consent was obtained in 94 cases (48%). Family refusal was higher for potential donors aged between 18 and 59 years (70%). Of the 94 donors, 72 (77%) had their organs harvested. Cardiac arrest before harvesting (56.5%) and positive viral serology (26%) were the main reasons for further losses. The mean donor age was 40 years and 51% were men. Causes of death were cerebral vascular accidents (55.5%), cranium encephalic traumas (29%), and gun shot wounds (8%). The rate of organ donation was 100% for kidneys and livers, 96% for hearts, 86% for pancreatas, 76% for lungs, and 74% for corneas. After assessment of organ viability, 94% of corneas, 91% of kidneys, and 88% of livers were transplanted, but only 52% of pancreata and 42% of hearts. The most frequent causes of discarded organs were age and concomitant donor infection. CONCLUSION: Areas for potential improvements are: (1) earlier identification and adequate maintenance of potential donors; (2) campaigns for organ donation; and (3) careful evaluation of donated organs and selection of a suitable population to increase utilization of expanded criteria organs.     

The evolutionary characteristics of the hypereosinophilic syndrome

The case here described is a young male aged 21 years who met all diagnostic criteria for HES: (1) persistent eosinophilia of over 1500/cubic millimeter (19.904-26.070/cubic millimeter) for longer than 6 month (12 month in our patient); (2) lack of evidence of other known causes of secondary hypereosinophilia (SH); (3) multiple organ involvement. The peculiar aspects found in our case are related to organ involvement: occurrence 2 months after HES onset of chronic myocardial infarction in four locations (apical, anteroseptal and posteroseptal, inferior, left ventricular) demonstrated by electrocardiographic and scintigraphic studies; early global cardiac insufficiency (6 months after the onset); acute renal failure (since HES onset) followed by chronic renal failure. The multiple and severe involvement of the nervous system (up to coma) were not a life threat. It is suggested that a possible explanation for the multiple organ involvement could be the chronic disseminated intravascular coagulation.     

急性重症胰腺炎合并ARDS的治疗

本文回顾性报告３例急性重症胰腺炎合并ＡＲＤＳ的成功治疗。证明传统的机械通气是治疗ＡＲＤＳ的有效手段。     

Mortality predictors in recipients developing acute respiratory distress syndrome due to pneumonia after kidney transplantation

Background: The aim of the present study was to investigate the risk factors related to hospital mortality due to infection in kidney recipients with ARDS meeting the Berlin definition.

Methods: Univariate and multivariate logistic regression analysis were used to confirm the independent risk factors related to infection-associated mortality.

Results: From January 2001 to August 2014, a total of 94 recipients with acute respiratory dress syndrome (ARDS) caused by pneumonia following kidney transplantation were enrolled in the present study. The most common type of infection was bacterial (52/94; 55.3%), viral (25/94; 26.6%), and polymicrobial (14/94; 14.9%). The most common ARDS was diagnosed within 6 months after transplantation (76/94; 80.9%). There were 39 deaths in these recipients (39/94; 41.5%). Eleven (11.7%) patients had mild, 47 (50.0%) moderate, and 36 (38.3%) severe ARDS; mortality was 27.3, 27.7, and 63.9%, respectively. The independent predictors of infection-related mortality were serum creatinine level >1.5?mg/dL at ARDS onset (OR 3.5 (95%CI 1.2–10.1), p?=?0.018) and severe ARDS (OR 3.6 (95%CI 1.4–9.7), p?=?0.009) in the multivariate analysis.

Conclusion: Infection-related mortality in kidney transplant patients with ARDS was associated with high serum creatinine level and severe ARDS.     

Report of Sata Clinical Fellowship; brain death and organ donation in hospital for sick children, Toronto, Canada

I have experienced two cases of pediatric organ donation from the brain dead patients in Hospital for Sick Children in three months. First case was a 9-year-old boy after a traffic accident. Second case was an 11-year-old boy with intracranial hemorrhage. Brain death is diagnosed by clinical criteria alone in Canada, as in many of developed countries. EEG or brain flow studies are not mandatory. In the first case, brain death was confirmed after additional brain flow study, EEG, and SSEP because of cervical spinal injury. Second case was diagnosed as brain death by clinical criteria alone, and cardiopulmonary resuscitation was performed after brain death diagnosis. MORE (multiple organ receival and exchange program of Ontario), Organ Donation Team (critical care physicians, nurses, organ donation coordinators, social workers and chaplains) in HSC, and volunteers play the important role to help the family and to make the organ transplantation successful. In Canada, pediatric brain death and organ donation are widely accepted, but there remains an imbalance between the demand for transplantation and the number of organs available.     

暴发性急性胰腺炎22例临床分析

目的探讨暴发性急性胰腺炎(FAP)的临床特点和治疗。方法回顾性总结分析发病72小时内出现严重器官功能障碍综合征的FAP22例的临床资料。对照分析死亡组12例和治愈组10例的临床特点和治疗体会。结果全组均有早期严重炎症反应综合征。发生器官功能障碍平均39小时、受损器官人均3个器官功能不全。非手术综合措施治愈3例,入院及时或经12～24小时非手术治疗无好转或短时缓解又加重,分别在入院12小时至1周内手术19例。全组死亡12例,死亡率54．5％(12／22)。其中75％(9／12)死于发病2周内的全身炎症反应期。死亡原因均为器官衰竭。发生器官功能障碍的时间迟早、数目多少、与治疗结果显著相关。结论FAP的临床特点为发病急、全身反应重、发生器官功能障碍早、受损器官多、死亡率高。救治关键在于早期及时减轻全身炎症反应综合征、努力加强监护和防治早期器官功能障碍。主要措施为充分供氧,防止低氧血症、保持循环、呼吸、肾功能稳定,大量腹水和感染应及时引流。