危重病患者的加强胰岛素治疗

目的观察危重病人加强胰岛素治疗后的的疗效。方法将116例危重病人随机分为两组,传统治疗组(CT)和加强胰岛素治疗组(IT)。CT组:当血糖>215mg/dl,诺和R笔芯皮下注射,控制血糖180～200mg/dl;IT组:当血糖>110mg/dl,控制血糖80～110mg/dl。结果CT组死亡率44.83%远远高于IT组的12.07%,病人的ICU住院时间、使用呼吸机日数、每日6:00的平均血糖、每日TISS-28评分均明显高于IT组(P<0.05);CT组每日胰岛素用量、HLA-DR、CD4+/CD8+明显小于IT组(P<0.05)。两组并发症比较,CT组病人发生肾损害、输注红细胞、发热的人数均明显高于IT组(P<0.05)。结论加强胰岛素治疗控制危重病人血糖80～110mg/dl,能降低病人的死亡率。     

胰岛素泵治疗危重患者应激性高血糖的临床观察

目的探讨采用胰岛素泵控制危重伴应激性高血糖的临床疗效。方法将112例危重伴应激性高血糖患者随机分为胰岛素泵（CSII）组和每日多次皮下胰岛素注射（MDII）组各56例。两组患者均给予常规治疗,此外,分别加用CSII和MDII治疗,使血糖维持在6.1～8.3mmol/L。结果两组血糖达标时间、每日胰岛素用量、达标后血糖水平及住院时间比较均差异有统计学意义（P〈0.01）,CSII组优于MDII组。CSII组低血糖发生率和病死率也明显低于MDII组（P〈0.01）。结论对危重伴应激性高血糖患者采用胰岛素泵治疗,能有效控制高血糖,降低病死率,改善预后。     

危重患者液体治疗

液体治疗是重症患者常用的治疗手段,其治疗方案的合理与否对患者预后起着决定性作用。本文对液体治疗的途径、液体种类的优缺点以及液体治疗的并发症及监测进行了论述。     

强化胰岛素治疗危重症患者应激性高血糖的临床研究

目的观察强化胰岛素治疗在危重症患者应激性高血糖中的临床研究。方法截取本院ICU2010年2月～2012年10月100例高血糖危重症患者,按照强化胰岛素治疗方案来控制血糖,随机分为强化治疗组及常规治疗组,其强化治疗组（50例）给予强化胰岛素治疗,强化治疗组血糖维持在4．4～6．1mmol／L;常规治疗组（50例）给予常规胰岛素治疗,常规治疗组血糖控制在10．0—11．1mmol／L。治疗4周后,观察两组患者使用呼吸机的天数、使用抗生素的天数、住院时间、院内感染发生率、病死率。结果强化治疗组中使用呼吸机的天数为（9．4±3．8）d,使用抗生素天数为（13．0±2．5）d,住院时间为（15．0±3．2）d,院内感染率（18．0％）、病死率（15．0％）均明显低于常规治疗组,差异有统计学意义（P〈0．05）。结论当危重症患者出现应激性高血糖时,强化胰岛素治疗可控制高血糖并改善危重症患者的预后,降低感染发生率和病死率,提高临床疗效。     

动态血糖监测联合胰岛素强化治疗高血糖危重患者的临床研究

目的观察动态血糖监测联合胰岛素强化治疗对重症监护室(ICU)高血糖危重患者的临床疗效。方法我院重症监护室收治的高血糖危重患者135例,随机分为对照组67例和试验组68例。对照组患者每天进行3次指尖血糖监测,用注射泵持续静脉泵入胰岛素2~4 U·h^-1常规治疗。试验组患者进行动态血糖监测(每6 h对血糖变化进行记录),同时联合胰岛素强化治疗(当患者初次血糖>12.1 mmol·L^-1时,静脉输注4 U·h^-1胰岛素,若血糖未能下降,适当增加1.5~2.0 U·h^-1的胰岛素用量)。2组患者均连续治疗2周。观察2组患者在不同时间的FBG值、ICU住院时间、平均机械通气时间、病死情况和低血糖发生情况。结果试验组在治疗后3,5,7 d的FBG分别为(6.34±1.48),(5.73±1.23),(5.24±0.86)mmol·L^-1,对照组分别为(8.76±2.36),(8.46±2.19),(7.59±2.19)mmol·L^-1,差异均有统计学意义(均P<0.05)。试验组ICU住院时间、平均机械通气时间分别为(8.63±5.72),(6.25±4.61)d,对照组分别为(9.78±6.34),(6.75±4.78)d,差异均无统计学意义(均P>0.05)。试验组病死例数7例(10.29%),对照组11例(16.41%),差异无统计学意义(P>0.05)。试验组发生低血糖6例次(8.82%),对照组发生14例(20.89%),差异有统计学意义(P<0.05)。结论对重症监护室高血糖危重患者进行动态血糖监测联合胰岛素强化治疗,能够更精准地掌握高血糖危重患者的血糖变化情况,更科学地制定胰岛素的用量,快速降低患者的血糖并降低低血糖的发生率,具有很好的临床效果。     

Combination antibiotic therapy in critically ill patients

Combination antibiotic therapy may be used for a number of reasons in critically ill patients. The potential benefits of combination therapy include prevention of resistance, treatment of polymicrobial infections, to decrease toxicity, or for synergy. Selected literature is reviewed which examines the use of combination therapy in critically ill patients. Research reports have not uniformly demonstrated the benefits of combination therapy. The situations where combination therapy has been beneficial are discussed.     

危重病人的营养治疗

目前，营养治疗已成为危重病人有效的辅助治疗或主要治疗方法。本文通过查阅1999—2006年部分相关文献，对危重病人营养治疗的目的、适应证、禁忌证、治疗时机、治疗途径，以及肠内与肠外营养选择进行综述。提出正确适时的营养治疗可以改善危重病人的临床症状，减少斤发症．缩短在ICU的时间，改善营养状况。提高危重病人的抢救成功率。     

Clinical pharmacokinetic monitoring of midazolam in critically ill patients

Midazolam is a commonly used sedative in critically ill, mechanically ventilated patients in intensive care unit (ICU) settings worldwide. We used a nine-step decision-making algorithm to determine whether therapeutic monitoring of midazolam in the ICU is warranted. Midazolam has a higher clearance and shorter half-life than other benzodiazepines, and prolonged sedation is achieved with continuous infusion. There appears to be very good correlation between plasma concentrations of both midazolam and its active metabolite, alpha1-hydroxymidazolam, and the degree of sedation. However, due to high interpatient variability, it is not possible to predict the level of sedation in any given individual based on plasma concentration of midazolam or its metabolites. Moreover, no simple and practical assay is available to quantitate midazolam plasma concentrations in the acute ICU setting. Many scales are available to assess the sedative effects of midazolam. Because the plasma concentration of midazolam required to achieve a constant level of sedation is highly variable, it is usually more prudent for the clinician to monitor for sedation with a validated clinical scale than by plasma concentrations alone. Various physiologic parameters, including age-related effects, compromised renal function, and liver dysfunction affect the pharmacokinetics of midazolam and alpha1-hydroxymidazolam. Although routine drug monitoring for all critically ill patients receiving midazolam is not recommended, this practice is likely beneficial in patients with neurologic damage in whom sedation cannot be assessed and in patients who have renal failure with a prolonged time to awakening.     

胰岛素不同给药方式控制危重症应激性高血糖的临床观察

目的探讨胰岛素不同给药方式对危重症应激性高血糖控制的临床疗效。方法将重症监护室(ICU)住院治疗的危重症应激性高血糖患者100例随机分为2组。观察组52例行静脉泵连续皮下输注胰岛素控制血糖,对照组48例予胰岛素多次皮下注射治疗。比较2组血糖控制情况。结果观察组血糖达标时间为(2.3±0.8)d短于对照组的(4.8±1.4)d,差异有统计学意义(P<0.05)。观察组低血糖发生率为5.8%低于对照组的16.7%,差异有统计学意义(P<0.05)。2组治疗后空腹血糖比较差异无统计学意义(P>0.05)。结论微量泵控制血糖安全、稳定,疗效迅速,低血糖发生率低,适合不同个体的生理需要,是控制应激性高血糖较好的方法。     

1例重症感染患者强化胰岛素治疗的药学监护

1例56岁老年男性患者,因"左眼失明2个月余,确诊肺脓肿、肝脓肿2个月"入院。入院后,给予抗感染、控制血糖、祛痰、增强免疫等综合治疗。针对患者糖尿病多年,肝脓肿、肺脓肿、左眼眶蜂窝组织炎多处感染灶的存在,我们复习了感染与应激性高血糖发生时强化胰岛素治疗的相关文献,探讨了临床药师在实际工作中应该如何对糖尿病伴发感梁的患者进行个体化药学监护。     

Dosing of antibiotics in critically ill patients undergoing renal replacement therapy

On September 11, 1945 Maria Schafstaat was the first patient who successfully underwent a dialysis treatment for acute kidney injury (AKI), formerly known as acute renal failure. Since then, the number of patients with AKI is increasing worldwide. Today AKI is generally one feature of a multiple organ dysfunction syndrome (MODS), which develops in response to major surgery, cardiogenic shock or sepsis. Several clinical studies have shown that early and appropriate antibiotic therapy in those patients is of utter importance, yet it remains one of the most difficult challenges to meet. Even in critically ill patients with conserved renal function a myriad of pathophysiological changes, resulting in increased volume of distribution, decreased protein binding and altered hepatic drug clearance, makes appropriate antibiotic dosin difficult. Adequate pharmacotherapy, i.e. dose of anti-infective agens is becoming even more complicated if it has to be tailored to counteract their removal by different modes and intensities of renal replacement therapy. This review summarizes our sparse knowledge about pharmacokinetic studies and dosing recommendations of drugs in patients with AKI undergoing continuous renal replacement therapies (CRRTs) such as continuous venovenous hemofiltration (CVVH) as well as extended dialysis (ED), an increasingly used method to treat patients with AKI in the intensive care setting. We reflect on failure of several large prospective controlled studies to show a survival benefit of higher doses of renal replacement therapy, a finding that might be caused by the fact that we still adhere to dosing guidelines for antibiotics which are at best ineffectual but might also lead to potentially dangerous underdosing of these life saving drugs. Lastly we address possible strategies to overcome the lack of knowledge, the lack of data and the lack of interest in this important area of critical care medicine. Improvement of clinical outcomes and reduction of antibiotic resistance in this patient population will require nephrologist, intensivists and pharmacists to work together.     

Implementation of the glucommander method of adjusting insulin infusions in critically ill patients

Background:

Intensive glycemic control has been associated with reduced morbidity and mortality in critically ill patients. Web-based, patient-specific insulin nomograms may facilitate improved glucose control.

Objective:

To compare 2 algorithms for individualizing insulin infusion therapy (a web-based system [Glucommander method] and a standard paper-based nomogram) in a cardiovascular surgery intensive care unit (ICU).

Methods:

In this prospective, before–after cohort study, measures of glycemic control for 50 patients receiving insulin according to the Glucommander system were compared with a control group (n = 50) who received insulin according to the standard paper-based nomogram used in the cardiovascular surgery ICU.

Results:

There was no significant difference between the 2 groups with respect to time to target blood glucose (5.1–8.0 mmol/L), percentage of time within the target range, or mean amplitude of glucose excursion. Patients in the intervention group spent less time above the target range (p = 0.007) and more time below the target range (p < 0.001), and the mean glucose was lower in this group compared with the control group (7.9 versus 8.6 mmol/L, p = 0.002). The percentage of blood glucose measurements below 4 mmol/L was higher in the intervention group than in the control group (3.7% versus 1.4%, p = 0.003). Satisfaction surveys revealed that the program was well accepted by the nursing staff in the cardiovascular surgery ICU.

Conclusions:

A web-based insulin nomogram was an easy-to-use instrument for achieving tighter glucose control for patients in the cardiovascular surgery ICU. Use of the Glucommander system led to lower mean blood glucose but an increase in episodes of hypoglycemia.     

ICU危重症患者并发上消化道出血的临床观察

目的 研究分析ICU危重症患者并发上消化道出血的临床治疗效果.方法 选取本院2011年11月～2012年10月收治的58例ICU危重症并发上消化道出血患者的临床资料进行研究分析.结果 经过治疗后,患者治疗的总有效率为94.83％.其中,无效3例、占5.17％,有效10例、占17.24％,显效45例、占77.59％.治疗无效的3例患者全部因抢救无效而死亡.结论 对ICU危重症并发上消化道出血患者采取积极正确的治疗措施,可以显著减少患者出现死亡的现象,延长患者的生命周期.     

降钙素原对重症患者抗感染治疗指导价值的临床研究

目的 研究重症患者抗感染治疗前及过程中血清降钙素原(PCT)、C反应蛋白(CRP)及白细胞计数(WBC)的变化对指导抗菌药物的选择和疗效判断的价值。方法 选取2013年1月至2014年12月收治的200例住院患者,在明确感染的前提下结合细菌培养结果分为细菌感染组130例和非感染组70例,对其进行血清PCT、CRP和WBC检测,比较两组患者治疗前和治疗过程中PCT、CRP及WBC计数之间的差别,并计算PCT、CRP和WBC诊断细菌感染的敏感度和特异度。结果 细菌感染组患者PCT和CRP检测值高于非感染组患者(P < 0.05),而WBC两组间差异无统计学意义(P > 0.05);PCT升高诊断细菌感染的敏感性(95.4%)和特异性(91.4%)要高于CRP和WBC(P < 0.05);在使用抗菌药物治疗前,革兰阴性菌(G^-菌)感染组患者的PCT高于革兰阳性菌(G⁺菌)感染组(P < 0.05)。抗菌药物治疗后,PCT水平下降幅度较CRP大(P < 0.05),WBC变化幅度较小(P < 0.05)。结论 PCT可作为感染性疾病初步诊断的指标之一,并可用于初步判断病原体及指导判断抗菌药物的疗效。     

阿米卡星在严重败血症患者体内的药代动力学研究

目的：初步探讨25 mg·kg －1的阿米卡星在重症监护室（ICU）患者体内的药代动力学。方法纳入符合条件的30例革兰阴性（G －）败血症患者进行阿米卡星药物治疗研究,通过非房室模型计算每名患者的阿米卡星的药代动力学。结果阿米卡星在 G －败血症患者体内平均药物分布为（0．36±0．07）L·kg －1,平均血液清除率为（3．88±0．97）mL·min －1·kg －1。肌酐清除率与血清肌酸酐（SCr）相关性具有统计学意义。结论对 ICU 患者应用高剂量阿米卡星（≥25 mg·kg －1）需要考虑败血症对血液动力学的影响,需要密切监测败血症血液药物浓度变化,关键要考虑到重症患者体内药代动力学与普通人群是不同的。     

Safety and efficacy of transitioning from intravenous to subcutaneous insulin in critically ill patients

Background Intravenous (IV) insulin is commonly used for the management of hyperglycemia in critically ill patients. However, an assessment of real-world practices for the transition process from IV to Subcutaneous (SC) is lacking. Objective The objective of this study was to describe the real-world practice during insulin transition from IV to SC in intensive care unit (ICU) patients. Setting ICUs at a tertiary medical center. Methods This was a retrospective cohort study. Data were obtained from electronic medical records for all ICU patients for whom insulin infusions were ordered between Nov 2017–2018. Adult ICU patients were included if they were transitioned to a SC insulin regimen after spending at least 6 h on IV insulin infusion. Data collected include blood glucose readings, transition percentage, and the type of insulin regimen used after transition. Main outcome measure Assessment of the transition percentage and dysglycemic events during the insulin transition process from IV to SC. Results Two hundred patients with 4702 blood glucose checks were included. Of the included patients, 65% (130/200) were transitioned to a basal insulin-containing regimen. The median transition percentage in those patients was 45% [IQR: 28 – 69]. In the overall cohort, the number of patients who developed moderate and severe hypoglycemia was significantly higher prior to transition, while hyperglycemia was significantly higher after insulin transition. Conclusion We observed that patients were converted to SC therapy using a lower transition percentage than previously described. More data are needed to optimize the transition process in critically ill patients.

     

Validation of an insulin infusion nomogram for intensive glucose control in critically ill patients

STUDY OBJECTIVE: To evaluate the effectiveness, safety, and associated patient outcomes of a simplified, nurse-directed insulin nomogram designed to achieve intensive blood glucose level control (target range 90-144 mg/dl). DESIGN: Prospective study with a retrospective control group. SETTING: A medical-surgical intensive care unit (ICU) in a quaternary care, university-affiliated hospital in an urban center. PATIENTS: Eighty-six critically ill adult patients (aged>or=18 yrs) requiring blood glucose control, with 42 in the retrospective control group and 44 in the prospective nomogram group. INTERVENTION: Control patients received insulin subcutaneously or intravenously based on ad hoc insulin sliding scales; nomogram patients received intravenous insulin at a rate specified by the nomogram, based on capillary blood glucose levels measured at the bedside. MEASUREMENTS AND MAIN RESULTS: Insulin infusion in the prospective patient group was titrated by the bedside nurse based on a predefined nomogram to attain the target blood glucose level. The retrospective control group was used as a comparison to assess the safety and effectiveness of the nomogram. Fewer patients in the nomogram (32%) than control (67%) group had a diagnosis of diabetes mellitus on admission. Overall, blood glucose levels in the nomogram group were within the target range 52% of the time versus 20% in the control group (p<0.001). Morning blood glucose levels were significantly lower compared with the control group (mean+/-SD 128+/-32 vs 176+/-50 mg/dl, p<0.001). Nomogram patients achieved target blood glucose levels faster than control patients (median 15 vs 66 hrs, p<0.0001). This improved blood glucose control remained statistically significant after adjusting for baseline differences in diabetes status. Hyperglycemia occurred less often in the nomogram than the control group (14% vs 53%, p<0.0001), and hypoglycemia occurred more often (3.8% vs 2.2%, p=0.004). The frequency of severe hypoglycemia was similar in both groups (0.2% vs 0.4%, p=NS). Such control required slightly more blood glucose checks/day in the nomogram group (7.1+/-1.5 vs 5.8+/-1.1, p<0.001). No significant reduction was observed in duration of vasopressor or antibiotic therapy or in length of stay in the ICU. CONCLUSION: This study demonstrated that intensive blood glucose control is achievable using a nurse-directed nomogram. This improved control was achieved, regardless of diabetes status of the patient, without substantially compromising safety or increasing resource use.     

机械通气治疗120例危重症患者临床分析

目的 探讨120例机械通气治疗危重症患者的临床效果。方法 选取我院自2009年1月-2011年1月收治120例的机械通气治疗危重症患者,对其上机前后的PH值、PaCO2、PaO2等动脉血气指标变化进行观察,记录相关数据,进行统计学分析。结果 120例患者均抢救成功,机械通气后PH值明显改善,PaCO2明显降低,PaO...     

替加环素在重症患者经验性抗感染治疗中的临床疗效

目的观察替加环素对重症患者经验性抗感染治疗的效果,为临床合理使用替加环素防治多重耐药菌感染及改善患者预后提供依据。方法选择2013年7月至2014年12月在我院ICU给予替加环素治疗的重症患者30例,比较替加环素治疗前后患者的体温、白细胞(WBC)及降钙素原(PCT)等临床感染指标及临床预后和并发症的发生率的变化。结果患者应用替加环素的总疗程为8.5(6~12)d,临床成功(感染症状和体征部分或完全改善)21例,临床失败(感染症状和体征无改善或恶化)9例,替加环素治疗28 d后的死亡率为20%(6/30),并发转氨酶升高2例。替加环素治疗临床成功患者用药前后APACHEⅡ和SOFA评分分别为(16.05±8.18 vs.8.61±5.50,P<0.001)和(6.76±5.18 vs.2.67±2.52,P<0.001),WBC(×109/L)和PCT(ng/m L)分别为(15.46±5.73 vs.8.81±3.44,P<0.001)和(4.88±5.73 vs.0.37±0.35,P<0.01),患者体温完全恢复正常时间为7(5~10)d。结论对可疑MDR病原菌感染的重症患者使用替加环素经验性治疗能够提高临床抗感染的成功率,进而可能改善重症患者的预后。