经皮旋转扩张气管切开术与常规气管切开术在危重患者治疗应用的比较

目的比较经皮旋转扩张气管切开术（percutaneous dilational tracheostomy,PDT）与常规气管切开术（surgical tra-cheostomy,ST）在危重患者的应用效果和并发症。方法回顾性分析重症监护病房中实施PDT和ST危重患者（每组均为21例）的临床资料,比较两组患者手术切口大小、手术时间、术中出血量,术后渗血及并发症发生例数。结果 42例患者均顺利完成手术。PDT组和ST组平均手术时间,切口大小,术中出血量分别为15.6±5.2和38.4±15.2min,1.5±0.3和3.5±0.6cm,5.6±2.3和43.6±18.4 ml;术后ST组的渗血量为38.4＋15.2ml,4例皮下气肿,2例切口感染;而PDT组的渗血量为4.5＋3.5 ml,仅1例皮下气肿,无切口感染。结论与ST相比,PDT操作简单、手术时间短、出血少、愈合瘢痕小,术后并发症少等优点,且无需气管镜辅助进行,适合危重患者建立人工气道,值得临床推广。     

经皮旋转扩张气管切开术在ICU中的应用

目的总结经皮旋转扩张气管切开术在ICU中应用的经验和效果。方法对我院ICU自2010年3月至2011年7月采用BRANDEN旋切型经皮气管切开套装行气管切开的24例患者进行回顾性分析。结果 24例患者均手术成功,手术时间6～14 min,仅一例术后少许渗血,无严重并发症。结论 ICU中行经皮旋转扩张气管切开术具有快速、创伤性小、手术操作精确易掌握、成功率高、并发症少等优势,值得推广。     

经皮扩张气管切开术在危重患者中的应用

目的：探究对于危重患者应用经皮扩张气管切开术的效果。方法选择2011年9月-2013年9月在本院进行治疗的危重患者60例,分为对照组、观察组,观察组30例应用经皮扩张气管切开术,对照组30例应用传统气管切开术,对比治疗的效果。结果观察组的手术操作时间、手术切口长度、出血量以及并发症发生率明显的小于对照组, P〈0.05,差异具有统计学意义。结论对于危重患者,应用经皮扩张气管切开术,治疗效果比较理想,在临床上具有推广价值。     

经皮旋转扩张气管切开术的临床应用价值分析

目的研究分析经皮旋转扩张气管切开术在临床上的应用价值。方法选取我院在2013年4月至2014年12月期间收治的60例需行气管切开患者的临床资料作为研究对象,对其进行回顾性分析。对患者进行前瞻性随机分组,每组30例。对照组实施经皮钳扩气管切开术(PDT),观察组采用经皮旋转扩张气管切开术(PRDT),并对两组患者在并发症及手术安全性等方面的情况进行比较。结果调查显示,PRDT组手术时间明显缩短,且出血量少,术后并发症少,较对照组具有显著优势,差异具有统计学意义(P<0.05)。结论经皮旋转扩张气管切开术操作简单,且创伤小,对于患者的术后预后具有重要意义,适合在临床治疗中推广使用。     

经皮扩张气管切开术在危重症患者中的应用

目的探讨经皮扩张气管切开术（percutaneous dialational tracheostomy,PDT）在危重病患者中的应用价值。方法应用PDT技术35例,并与同期传统开放性气管切开术（OT）35例作对照研究。比较两组的手术时间、切口大小、术中出血、切口愈合时间及各种并发症发生率。结果PDT组成功进行手术34例,操作时间为（7．55±2．45）min;切口长度为（1．67±0．35）cm;术中出血（5．75±2．55）ml,及术后并发症发生率明显低于OT组。结论PDT操作安全、简单、快速、组织损伤少、愈合瘢痕小、并发症发生率低,适合危重患者的应用。     

经皮扩张气管切开术在危重患者中的应用体会

经皮扩张气管切开术具有创伤小、出血少、操作时间短等优点,近年来在ICU得到广泛应用[1-3],但在临床实际应用中能否充分体现这种微创手术的优越性,最终取决于术者的操作技巧和经验,因此,及时总结临床应用的经验体会,对提高操作成功率、减少并发症具有重要意义.我科自2005年10月～2007年7月对36例重危患者行经皮扩张气管切开术,现将治疗体会报告如下.     

纤维支气管镜引导下经皮旋转扩张气管切开术在抢救急危重症患者中的应用

目的 探讨纤维支气管镜(纤支镜)引导下经皮旋转扩张气管切开术( PDT)在危重病患者中的临床价值.方法 将118例重症患者分成A、B组,A组在纤维支气管镜(纤支镜)引导下行经皮旋转扩张气管切开术( PDT),B组单纯行经皮旋转扩张气管切开术(PDT).比较两组患者的手术时间、术中出血、相关并发症及安全性 结果 A组手术时间(7.3±2.5) min,B组(6.8±2.2)min,两组手术时间无差异(P＞0.05);A组术中出血(5.8±2.2) ml,B组(9.2±2.3)ml,A组出血量明显减少(P＜ 0.01),而且相关并发症更少.结论 纤维支气管镜(纤支镜)引导下经皮旋转扩张气管切开术( PDT)安全性和准确性高,操作简单、快速,适合急危重患者抢救中应用.     

经皮扩张气管切开术在危重患者中的应用体会

经皮扩张气管切开术具有创伤小、出血少、操作时间短等优点,近年来在ICU得到广泛应用[1-3],但在临床实际应用中能否充分体现这种微创手术的优越性,最终取决于术者的操作技巧和经验,因此,及时总结临床应用的经验体会,对提高操作成功率、减少并发症具有重要意义.我科自2005年10月～2007年7月对36例重危患者行经皮扩张气管切开术,现将治疗体会报告如下.     

经皮扩张气管切开术在危重症患者中的应用

目的 探讨经皮扩张气管切开术(percutaneous dialational tracheostomy,PDT)在危重病患者中的应用价值.方法 应用PDT技术35例,并与同期传统开放性气管切开术(OT)35例作对照研究.比较两组的手术时间、切口大小、术中出血、切口愈合时间及各种并发症发生率.结果 PDT组成功进行手术34例,操作时间为(7.55±2.45)min;切口长度为(1.67±0.35)cm;术中出血(5.75±2.55)ml,及术后并发症发生率明显低于OT组.结论 PDT操作安全、简单、快速、组织损伤少、愈合瘢痕小、并发症发生率低,适合危重患者的应用.     

经皮扩张气管切开术在危重症患者中的应用

目的 探讨经皮扩张气管切开术(percutaneous dialational tracheostomy,PDT)在危重病患者中的应用价值.方法 应用PDT技术35例,并与同期传统开放性气管切开术(OT)35例作对照研究.比较两组的手术时间、切口大小、术中出血、切口愈合时间及各种并发症发生率.结果 PDT组成功进行手术34例,操作时间为(7.55±2.45)min;切口长度为(1.67±0.35)cm;术中出血(5.75±2.55)ml,及术后并发症发生率明显低于OT组.结论 PDT操作安全、简单、快速、组织损伤少、愈合瘢痕小、并发症发生率低,适合危重患者的应用.     

危重症患者应用CRRT的临床和心理护理

目的观察连续性肾脏替代疗法(CRRT)在危重患者中应用的临床效果,总结CRRT用于危重患者治疗中的护理技能和经验。方法对23例行CRRT治疗的危重症患者的观察护理,进行监测生命体征、保持血管通畅、严格无菌操作、预防感染、体液管理和心理干预等护理。结果经CRRT治疗及综合护理,23例患者中16例患者治愈、3例患者病情稳定后转院、4例因多器官功能衰竭死亡,综合性护理措施提高了治疗效果和减少了并发症的发生。结论危重患者在进行CRRT治疗过程中,采取积极有效的护理措施,能保证CRRT的顺利进行,从而达到满意的治疗效果。     

Analysis of Pain Management in Critically Ill Patients

We analyzed the adequacy of pain control for 17 trauma patients during the initial part of their stay in the intensive care unit, and assessed reasons for inadequate analgesia, if it occurred. Patients, and physicians, and nurses were interviewed. A verbal pain intensity scale was used to determine whether patients received adequate analgesia. Patients were asked if the pain hindered their activities, and whether they requested pain medication from their caregivers. Caregivers were questioned whether patients received adequate analgesia. Prescribed morphine regimens and the amount of narcotic administered were analyzed. Twenty-seven percent of patients rated pain intensity as moderate and 47% as severe. Ninety-five percent of housestaff and 81% of nurses reported the patients received adequate pain control. Forty-seven percent of the patients who had moderate or severe pain asked their physician for more pain medication, and 65% asked the nurse. Thirteen residents did not order a larger dose of morphine due to concern about respiratory depression or hypotension. Morphine dosages ranged from 1–8 mg intravenously every 1–2 hours as necessary. Nurses administered less than the maximum amount ordered 58% of the time. The mean dosing interval was 2.3 hours. Barriers to adequate pain management were disparity in the perception of pain between patients and caregivers; patients not requesting more analgesia despite despite the presence of moderate to severe pain; and physician and nurse concerns about patients' adverse physiologic response to increased dosages.     

临床药师在危重症患者药品不良反应监测中的作用

临床药师通过收集本院ICU、急诊科的药品不良反应、参与临床查房、关注危重症患者的转归等,从药学角度协助医生分析药品不良反应,并在众多使用药物中判断出可疑药物,进而提出相应处理措施.保障了危重症患者的用药安全,提高了合理用药水平.     

Clinical Pharmacology Studies in Critically Ill Children

Developmental and physiological changes in children contribute to variation in drug disposition with age. Additionally, critically ill children suffer from various life-threatening conditions that can lead to pathophysiological alterations that further affect pharmacokinetics (PK). Some factors that can alter PK in this patient population include variability in tissue distribution caused by protein binding changes and fluid shifts, altered drug elimination due to organ dysfunction, and use of medical interventions that can affect drug disposition (e.g., extracorporeal membrane oxygenation and continuous renal replacement therapy). Performing clinical studies in critically ill children is challenging because there is large inter-subject variability in the severity and time course of organ dysfunction; some critical illnesses are rare, which can affect subject enrollment; and critically ill children usually have multiple organ failure, necessitating careful selection of a study design. As a result, drug dosing in critically ill children is often based on extrapolations from adults or non-critically ill children. Dedicated clinical studies in critically ill children are urgently needed to identify optimal dosing of drugs in this vulnerable population. This review will summarize the effect of critical illness on pediatric PK, the challenges associated with performing studies in this vulnerable subpopulation, and the clinical PK studies performed to date for commonly used drugs.     

Hemodynamic Effects of Intravenous Famotidine in Critically Ill Patients

Study Objective : To study the hemodynamic effects of famotidine administered undiluted intravenously over 2 minutes. Design : Nonblinded, nonrandomized. Setting : Medical/surgical intensive care unit in a university-affiliated, tertiary care, teaching hospital. Patients : Eleven consecutive critically ill patients receiving famotidine for stress ulcer prophylaxis. Seven of these patients were also receiving vasopressors or inotropes. Interventions : Famotidine 20 mg/2 ml was administered intravenously undiluted through a peripheral line over 2 minutes. All other medications, including vasopressors and inotropes, were held constant. Measurements and Main Results : No clinically important (> 20 variations from baseline) or statistically significant (p<0.05) changes were seen in heart rate, mean pulmonary arterial pressure, cardiac output, systolic/diastolic blood pressure, systemic vascular resistance, or central venous pressure. Mean arterial pressure (MAP) was elevated at 8 minutes following famotidine (91.2 mm Hg [22.4 SD]) versus baseline (86.7 mm Hg [19.6 SD]). Pulmonary capillary wedge pressure (PCWP) was elevated at 8 minutes (17.2 mm Hg [6 SD]), 12 minutes (17.9 mm Hg [5.68 SD]), and 16 minutes (17.8 mm Hg [6.08 SD]), versus baseline (14.8 mm Hg [7.14 SD]). These changes in MAP and PCWP achieved statistical significance, but were not thought to be of clinical significance. Conclusions : Famotidine given undiluted intravenously over 2 minutes produced no adverse hemodynamic effects in critically ill patients. Administration in this manner should be safe even in patients requiring supportive cardiovascular drug therapy.     

Screening and Management of Delirium in Critically Ill Patients

Delirium is highly prevalent in the critically ill population and has been associated with numerous negative outcomes including increased mortality. The presentation of a delirious patient in the intensive care unit (ICU) is characterized by a fluctuating cognitive status and inattention that varies dramatically among patients. Delirium can present in 3 different motoric subtypes: hyperactive, hypoactive, and mixed. Two tools, the Intensive Care Delirium Screening Checklist and Confusion Assessment ICU, are validated and recommended for the detection of delirium in critically ill patients. The identification of delirium in a critically ill patient should be facilitated using one of these tools. An intermediate form of delirium known as subsyndromal delirium also exists, although the significance of this syndrome is largely unknown. Another phenomenon known as sedation-related delirium has been recently described, although more research is needed to understand its significance. Patients in the ICU are exposed to many risk factors for developing delirium; controlling these risk factors is essential for preventing delirium development in critically ill patients. Nonpharmacologic interventions have been shown to prevent patients from developing delirium. Prevention is crucial because once delirium develops pharmacologic therapy is limited.Delirium is highly prevalent in critically ill patients and has been reported to occur in over 80% of mechanically ventilated patients.^1–3 A host of negative outcomes have been associated with delirium including increased intensive care unit (ICU) mortality, increased inpatient mortality, increased ICU length of stay, increased inpatient length of stay, and long-term cognitive impairment.^2,4–8 Unfortunately, the pathophysiology of this syndrome is not well understood. Proposed mechanisms for pathogenesis include neuroinflammation and neurotransmitter imbalances.⁹ The limited knowledge of delirium pathogenesis contributes to the difficulties encountered in managing this common, burdensome syndrome.     

认知训练对ICU危重症患者谵妄的临床效果分析

目的:分析认知训练对ICU危重症患者谵妄的临床效果。方法:将2016年1月~2017年2月80例ICU危重症患者作为研究对象并根据随机数字表分为认知训练组与对照组各40例。对照组采取常规治疗和护理方案,认知训练组在对照组基础上加以认知训练,比较两组家属满意度;谵妄发生率、谵妄发生时间、平均住院时间;干预前后患者APACHEII评分、生存质量评分。结果:认知训练组家属满意度高于对照组,P0.05;认知训练组谵妄发生率低于对照组,谵妄发生时间晚于对照组,平均住院时间短于对照组,P0.05;干预前两组APACHEII评分、生存质量评分相近,P0.05;干预后认知训练组APACHEII评分、生存质量评分优于对照组,P0.05。结论:认知训练对ICU危重症患者谵妄的临床效果确切,可有效降低谵妄发生率,延迟谵妄发生时间,缩短住院时间,改善患者预后和生存质量,患者家属满意度高,值得推广和应用。     

Appropriate Antibiotic Administration in Critically Ill Patients with Pneumonia

Inappropriate initial antibiotics for pneumonia infection are usually linked to extended intensive care unit stay and are associated with an increased risk of mortality. This study evaluates the impact of inappropriate initial antibiotics on the length of intensive care unit stay, risk of mortality and the co-predictors that influences these outcomes. This retrospective study was conducted in an intensive care unit of a teaching hospital. The types of pneumonia investigated were hospital-acquired pneumonia and ventilator-associated pneumonia. Three different time points were defined as the initiation of appropriate antibiotics at 24 h, between 24 to 48 h and at more than 48 h after obtaining a culture. Patients had either hospital-acquired pneumonia (59.1%) or ventilator-associated pneumonia (40.9%). The length of intensive care unit stay ranged from 1 to 52 days (mean; 9.78±10.02 days). Patients who received appropriate antibiotic agent at 24 h had a significantly shorter length of intensive care unit stay (5.62 d, P<0.001). The co-predictors that contributed to an extended intensive care unit stay were the time of availability of susceptibility results and concomitant diseases, namely cancer and sepsis. The only predictor of intensive care unit death was cancer. The results support the need for early appropriate initial antibiotic therapy in hospital-acquired pneumonia and ventilator-associated pneumonia infections.     

纤维支气管镜在ICU危重患者中的应用及护理

纤维支气管镜(纤支镜)在ICU患者应用的优点;并总结了应用纤维支气管镜的准备、配合工作以及纤维支气管镜的清洁、消毒、保养、维护。认为良好的护理是纤维支气管镜应用成功的保障。     

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients

Approximately 16–31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol‐related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom‐triggered treatment of AWS with γ‐aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first‐line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD‐resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD‐resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD‐resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.