围手术期急性肾损伤的预防

围手术期是急性肾损伤(acute kidney injury,AKI)最常见的发病期。外科手术相关的AKI的发生率占医院获得性AKI的18%~47%。如何防治AKI的发生、发展已成为当前肾脏病研究工作中的重点和热点。由于目前没有特异性治疗措施可以逆转AKI,围手术期AKI的预防和早期识别至关重要,故本文重点就围手术期可能对肾功能造成影响的危险因素、术前AKI的风险评估模型以及AKI早期诊断的生物学标记物进行了详细阐述。最后结合2012年KDIGO指南就目前AKI的治疗策略进行了介绍。     

ICU内急性肾损伤患者的预后指标分析

目的 通过分析重症医学科(intensive care uint,ICU)内急性肾损伤(acute kidney injury,AKI)患者高病死率的影响因素.筛选与其相关的临床预后指标.方法 回顾性分析2008年3月至2009年8月在西安交通大学第二附属医院和中南大学湘雅医院ICU内收治的符合急性肾损伤诊断标准患者的临床资料,排除ICU未满24 h死亡患者、既往慢性肾脏病史及资料不完整的患者,按60 d生存状态将患者分为存活组和病死组,统计其性别,年龄、慢性疾病史、24 h内相关临床化验指标(血常规、血气分析、肝肾功能、血清胱抑素C浓度,血电解质等)的最差值,并对其进行急性病理生理学和慢性健康评价(APACHE)Ⅱ评分及确诊后60 d病死率.采用t检验、χ~2检验行两组问变量的差异比较,再应用单因素Logistic回归分析,计算比值比(OR)和95%可信区间(CI),并对筛选出的危险凶素进行多因素Logistic 回归分析各种因素与病死率之间的关系.结果 纳入病例98例,男60例,女38例,年龄19～89岁,(52.4 ±16.1)岁;到确诊后60 d为止,死亡34例,死亡率34.7%.病死组患者A-PACHEU评分(17.4±4.3)分高于存活组(14.2±4.8)分,P＜0.05.血清胱抑素(Cystatin C)＞1.3 ms/L的AKI患者死亡率为50%(24/48),高于血清Cystatin C＜1.3 mg/L的患者(20%,10/50;P＜0.05).单因素分析显示,器官衰竭数目t≥2个,少尿,APACHEⅡ＞15分,Cystatin C＞1.3 mg/L、Cystatin C＞1.3mg/L+APACHEⅡ＞15分与AKI患者死亡率相关,Logistic多因素[口j归分析显示:器官衰竭数目≥2个、少尿、Cystatin C＞1.3 ms/L结合APACHEⅡ＞15分是急性肾损伤患者的独立死亡危险因素.结论 Cystatin C＞1.3 mg/L结合APACHEⅡ＞15分可以作为评价AKI患者预后的指标.     

先天性心脏病患儿围手术期急性肾损伤研究进展

由于低龄、低体质量、肾脏发育未成熟、体外循环时间长以及围术期管理等因素,复杂先天性心脏病患儿发生围术期急性肾损伤风险较高。先天性心脏病围手术期急性肾损伤是病死率增加、机械通气时间延长、ICU留滞时间和住院时间延长、治疗费用增加的主要原因。由于基于血肌酐和尿量的肾损伤诊断标准不易发现早期病变,限制了临床早期预防和干预治疗,肾损伤新型生物标记物的检测为急性肾损伤的早期诊断与治疗提供了极大帮助。先天性心脏病围术期肾损伤的防治主要集中于容量管理、抑制炎症反应、改善缺血等方面。积极有效的干预治疗可以改善预后,促进患者康复。     

ICU患者急性肾损伤流行病学分析

目的:分析重症监护病房(ICU)患者急性肾损伤(AKI)的发病率、病死率和病因等,筛选出与AKI相关的影响因素。方法:采用急性肾损伤网络(acute kidney injury network,AKIN)诊断标准进行分期回顾性研究。结果:观察期间入选的ICU患者共222例,AKI发病率为32%,其中1期、2期、3期分别占12.2%、5.9%、14.0%。ICU患者病死率为13.1%,AKI患者病死率为36.6%,非AKI患者病死率为2.0%。引起AKI的主要原因为肾性,包括脓毒症、呼吸心跳骤停、恶性肿瘤等。多元Logistic回归分析显示年龄、患者类型、AKI第1天分期及循环衰竭是AKI分期的影响因素,年龄、患者类型、AKI第1天分期、肝功能衰竭及血糖最低值是AKI预后的影响因素,肾上腺素、脓毒性休克是ICU患者病死率的影响因素。结论:ICU患者中,发生AKI的患者病死率更高。年龄、患者来源、AKI第1天分期及循环衰竭是AKI分期的影响因素,年龄、患者来源、AKI第1天分期、肝功能衰竭及血糖最低值是AKI预后的影响因素。     

围术期管理进展

作者就重症监护，肿瘤，免疫低下，肥胖及老龄病人的围术期处理及护理进行讨论。重点介绍了对术后肺不张，气管拔管，停用呼吸机，预防血栓栓塞的护理注意事项。     

围术期管理进展

作者就重症监护、肿瘤、免疫低下、肥胖及老龄病人的围术用处理及护理进行讨论。重点介绍对术后肺不张、气管拔管、停用呼吸机、预防血栓栓塞的护理注意事项。     

输血与围术期血液管理

输血是围术期有效的治疗措施,但也存在很多风险。围术期血液管理以患者为中心,应用多学科技术,避免或减少异体血输注,改善患者临床转归。本文论述了输血治疗的相关风险及围术期血液管理的具体措施和实施方案。     

ICU急性肾损伤的高危因素分析

目的：探讨ICU住院患者急性肾损伤的危险因素。方法：回顾性分析重症监护病房2008-03-2013-03住院治疗的840例患者临床资料,应用多因素回归分析方法探讨发生急性肾损伤的高危因素。结果：840例患者中284例发生AKI,发病率为33.8%。284例AKI患者死亡68例,死亡率23.9%。年龄、APACHEⅡ分值、脓毒症、糖尿病、使用肾毒性药物、基线血肌酐值、休克是AKI发生的危险因素。结论：AKI是ICU中常见并发症,死亡率高。年龄、APACHEⅡ分值、脓毒症、糖尿病、使用肾毒性药物、基线血肌酐值、休克是AKI发生的独立危险因素,应采取多种综合措施减少AKI发生。     

围术期用药安全:临床现状与指南解读

麻醉学正在经历向围术期医学的转型,围术期用药差错所导致的不良后果已经向每一位麻醉医生敲响了警钟。如何查找围术期用药的薄弱环节,减少或避免围术期用药差错,是我们从麻醉学到围术期医学发展过程中必须重视和突破的关键问题。围术期用药差错最常见的类型包括药物选择不当、药物过量或不足、给药途径错误、没有给药等。其原因既包括药物包装相似等客观因素,也与麻醉医生注意力不集中等主观因素密切相关。2017年欧洲麻醉学委员会发布《安全用药指南(更新版)》,从注射器准备和标示,药品包装和标签,麻醉医生注意力等6个方面出发,为围术期用药安全的临床操作提供指导依据。作为中国麻醉医生,如何将指南与实际情况结合,切实提高围术期用药安全,则是我们应该深刻探讨的问题。     

儿童急性鼻窦炎合并眶内并发症围术期的护理

总结6例儿童急性鼻窦炎合并眶内并发症围术期风险控制的护理安全管理经验。围术期风险控制的护理安全管理主要包括应激性心理障碍的风险护理、降低疾病风险的安全护理、继发颅内感染风险护理、眼部症状观察及护理、长期使用抗生素并发症的预防及病人意外风险安全防范。通过实施有效的护理观察及疾病风险安全管理措施,术后患儿眼部症状明显改善,眼睑及眶周红肿逐渐消退,未再出现眼痛、鼻塞及发热症状,患儿住院期间未发生护理不良事件,患儿均顺利出院。     

Acute kidney injury and renal replacement therapy in the intensive care unit

Background:  Renal replacement therapy (RRT) is now offered as a routine treatment in most intensive care units (ICU) in the UK for patients suffering from acute kidney injury (AKI). It is important for all ICU staff to understand the underlying principles of the available therapeutic options and the possible complications thereof.
Aims and objectives:  The objective of this review was to provide an accessible theoretical and practical update on the management of RRT. In addition to a detailed discussion of the underlying principles and indications for the various modes of RRT, we will discuss the assessment of kidney function, possible complications and anticoagulation during RRT, following a review of the current literature.
Search strategies:  Pubmed, Medline and the Cumulative Index to Nursing and Allied Health Literature were searched using the keywords renal function, RRT, dialysis, renal failure kidney injury, together with intensive care, intensive therapy and critical care. We included only studies published in English from 1998 to 2008 and from these identified and included additional publications. The 12 most relevant publications are referenced in this review.
Conclusion:  AKI is associated with increased mortality in ICU, and RRT should be considered early in the disease process. Continuous haemofiltration is the most common modality of treatment in this group of patients, and a detailed knowledge of the management of such patients is required.     

重症患者之急性肾损伤

重症监护病房中,急性肾损伤的发生率逐年增加,台湾地区全民健康保险研究数据库显示ICU的患者约有10%需要肾脏替代治疗。造成肾损伤主要的原因为脓毒症及低血容积休克,静脉输液补充血管内容积及维持稳定血压及肾灌注为最基本的治疗。由于利尿剂在防止或治疗肾损伤中的角色已淡出,肾脏替代疗法应在无尿期时尽早实施。连续性肾脏替代治疗（CRRT）,可以避免洗肾时的低血压发生,持续性低效率每日透析（SLEDD）是一种复合型治疗,结合了CRRT血流动力状态稳定的优点,也具备间歇性肾脏替代治疗节省人力与治疗时间的好处。一个多专科团队能及时矫正即有的疾病,充分的血流动力及营养支持,早期的肾脏替代治疗,可防止多重器官衰竭发生,改善患者的结果。     

Acute kidney injury in Indigenous intensive care patients

BackgroundPatients presenting to intensive care units (ICUs) report high rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT). Globally, Indigenous populations report higher rates of renal disease than their non-Indigenous counterparts.ObjectivesThis study reports the prevalence, presenting features, and outcomes of Indigenous ICU admissions with AKI (who require RRT) within an Australian ICU setting and compares these with those of Indigenous patients without AKI.MethodA retrospective database review examined all Indigenous patients older than 18 years admitted to a regional Australian ICU between June 2013 and June 2016, excluding patients with chronic kidney disease requiring dialysis. We report patient demography, presenting clinical and physiological characteristics, ICU length of stay, hospital outcome, and renal requirements at three months after discharge, on Indigenous patients with AKI requiring RRT.ResultsAKI requiring RRT was identified in 15.9% of ICU Indigenous patients. On univariate analysis, it was found that these patients were older and had a higher body mass index, lower urine output, and higher levels of creatinine and urea upon presentation than patients who did not have AKI. Patients with AKI reported longer ICU stays and a higher mortality rate (30%, p < 0.05), and 10% of these required ongoing RRT at 3 months. Multivariate analysis found significant associations with AKI were only found for presenting urine outputs, urea and creatinine levels.ConclusionsThis study reports higher rates of AKI requiring RRT for Indigenous adults than non-Indigenous adults, as has been previously published. Benefits arising from this study are as follows: these reported findings may initiate early targeted clinical management and can assist managing expectations, as some patients may require ongoing RRT after discharge.     

Acute severe asthma: differences in therapies and outcomes among pediatric intensive care units

OBJECTIVE: To determine differences in therapies and outcomes among pediatric intensive care units for patients with acute severe asthma. DESIGN: Retrospective cohort study. SETTING: Eleven pediatric intensive care units participating in the Pediatric Intensive Care Evaluations. PATIENTS: Patients were 1528 children with a primary diagnosis of asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied severity of illness, length of stay, and use of invasive interventions. The patients at the centers had similar median physiologic measures of illness and Pediatric Risk of Mortality III scores. The patients received a wide range of invasive interventions depending on institution, including mechanical ventilation (3% to 47%), arterial catheter placement (4% to 46%), central venous catheter (2% to 51%), and determination of a blood gas (24% to 70%). At institutions where mechanical ventilation was used more commonly (>20%, high use), intensive care and hospital stays were longer for asthmatic patients regardless of mechanical ventilation requirement compared with centers with lower use of mechanical ventilation. The status of "high-use center" was an independent predictor for intensive care stay (p = .005) and hospital length of stay (p = .017) as well as duration of mechanical ventilation (p = .014) after adjustment for age, degree of hypercarbia, maximal respiratory rate, use of an arterial catheter, and Pediatric Risk of Mortality III scores among ventilated children. CONCLUSIONS: We found that use of invasive interventions including mechanical ventilation and vascular monitoring varied greatly by institution. Centers with higher use of mechanical ventilation had longer median intensive care stay and hospital stays. Pediatric asthma management for acute severe asthma may be improved by clear elucidation of the institutional practices where fewer invasive interventions were used to achieve better outcomes.     

Acute kidney injury in the intensive care unit according to RIFLE

OBJECTIVES: To apply the RIFLE criteria "risk," "injury," and "failure" for severity of acute kidney injury to patients admitted to the intensive care unit and to evaluate the significance of other prognostic factors. DESIGN: Retrospective analysis of the Riyadh Intensive Care Program database. SETTING: Riyadh Intensive Care Unit Program database of 41,972 patients admitted to 22 intensive care units in the United Kingdom and Germany between 1989 and 1999. PATIENTS: Acute kidney injury as defined by the RIFLE classification occurred in 15,019 (35.8%) patients; 7,207 (17.2%) patients were at risk, 4,613 (11%) had injury, and 3,199 (7.6%) had failure. It was found that 797 (2.3%) patients had end-stage dialysis-dependent renal failure when admitted to an intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:: Patients with risk, injury, and failure classifications had hospital mortality rates of 20.9%, 45.6%, and 56.8%, respectively, compared with 8.4% among patients without acute kidney injury. Independent risk factors for hospital mortality were age (odds ratio 1.02); Acute Physiology and Chronic Health Evaluation II score on admission to intensive care unit (odds ratio 1.10); presence of preexisting end-stage disease (odds ratio 1.17); mechanical ventilation (odds ratio 1.52); RIFLE categories risk (odds ratio 1.40), injury (odds ratio 1.96), and failure (odds ratio 1.59); maximum number of failed organs (odds ratio 2.13); admission after emergency surgery (odds ratio 3.08); and nonsurgical admission (odds ratio 3.92). Renal replacement therapy for acute kidney injury was not an independent risk factor for hospital mortality. CONCLUSIONS: The RIFLE classification was suitable for the definition of acute kidney injury in intensive care units. There was an association between acute kidney injury and hospital outcome, but associated organ failure, nonsurgical admission, and admission after emergency surgery had a greater impact on prognosis than severity of acute kidney injury.     

Acute kidney injury in elderly intensive care patients: a review

The elderly are at high risk for acute kidney injury (AKI). With the aging of the population, the demand for intensive care unit (ICU) admission from older patients will continue to rise, and this clinical entity will likely become increasingly common. In this article we review the relevant literature, discuss the age-related changes that render older people prone to AKI development, and examine the most frequent etiologies for renal impairment in these patients. We also consider the difficulties in achieving an early diagnosis in the elderly ICU patient, the particularities related to AKI treatment in this age group, and the data available on differences in renal recovery and mortality between the young and the old with renal injury. More importantly, we highlight the methods for prevention of AKI development or worsening in the elderly critically ill patient.     

Acute kidney injury in the intensive care unit: current trends in incidence and outcome

Acute kidney injury (AKI) is a common clinical problem with significant clinical and economic consequences. A number of studies point to a rising incidence of AKI in the hospital and in the intensive care unit over the past several years, and an increase in the degree of co-morbidity associated with it. Recent evidence suggests that there has been some improvement in outcomes over time. Nevertheless, the mortality associated with AKI remains unacceptably high, and further work is needed. Recently developed consensus definitions will be useful in this regard.