成人重症患者深静脉血栓医护一体快速筛查流程的构建

目的 探讨适合我国成人重症患者深静脉血栓快速筛查的流程,为血栓预防护理提供参考。方法 应用循证护理方法,针对成人重症患者深静脉血栓筛查流程提出问题,进行系统检索、证据提取等,形成成人重症患者深静脉血栓医护一体筛查的证据;通过2轮焦点小组访谈确定成人重症患者深静脉血栓医护一体快速筛查流程。结果 形成的成人重症患者深静脉血栓医护一体快速筛查流程包括风险评估、超声筛查、深静脉血栓预防、管理与质控4个步骤。结论 本研究构建的成人重症患者深静脉血栓医护一体快速筛查流程,可用于成人重症患者深静脉血栓风险筛查。     

成人重症患者深静脉血栓医护一体快速筛查流程的构建

目的 探讨适合我国成人重症患者深静脉血栓快速筛查的流程，为血栓预防护理提供参考。方法 应用循证护理方法，针对成人重症患者深静脉血栓筛查流程提出问题，进行系统检索、证据提取 等，形成成人重症患者深静脉血栓医护一体筛查的证据；通过2轮焦点小组访谈确定成人重症患者深静脉血栓医护一体快速筛查流程。结果 形成的成人重症患者深静脉血栓医护一体快速筛查流程包括风险评估、超声筛查、深静脉血栓预防、管理与质控4个步骤。结论 本研究构建的成人重症患者深静脉血栓医护一体快速筛查流程，可用于成人重症患者深静脉血栓风险筛查。     

Sepsis induced changes of adipokines and cytokines - septic patients compared to morbidly obese patients

Background  

Hyperglycemia and insulin resistance frequently occur in critically ill and in morbidly obese (MO) patients. Both conditions are associated with altered serum levels of cytokines and adipokines. In addition, obesity related alterations in adipokine expression contribute to insulin resistance in metabolic syndrome. In this study we examined the serum adipocytokine profile in critically ill patients, MO patients, and healthy blood donors.     

Microcirculatory alterations in critically ill patients

The recent onset of orthogonal polarization spectral (OPS) imaging techniques has allowed the direct visualization of the microcirculation at the bedside of critically ill patients. A systematic review with particular emphasis on recent findings and implications in pathophysiological processes is presented. Using OPS techniques various investigators have observed microcirculatory alterations in critically ill patients, and especially in patients with severe sepsis and septic shock. These alterations include a decrease in vessel density and an increased proportion of non perfused or intermittently perfused capillaries, and these alterations can be fully reversed by the topical application of acetylcholine. Similar alterations are observed in patients with septic and cardiogenic shock. Persistent microvascular alterations are associated with the development of organ failure and death. In addition, the reversal of these alterations during resuscitation procedures is highly predictive of outcome. Unfortunately, the effects of many therapeutic interventions usually performed in critically ill patients are still not well defined, even though evidence coming from animal experiments is sometimes available. In particular, the role of fluid resuscitation, red blood cell transfusions, inotropic, vasoactive and anesthetic agents should be investigated. Microcirculation plays an important role in the pathogenesis of shock and organ dysfunction, especially in sepsis. The microcirculatory effects of various therapeutic interventions have still to be reported. OPS technique may become a valuable tool to monitor patients with circulatory failure.     

危重患者的护理访视管理

目的 探讨危重患者的有效护理访视方法,提高护理安全性.方法 选取符合条件的护理管理者并对其进行培训后,每2人一组对全院危重患者按病情进行基本信息、护理措施落实、存在的风险三方面访视;通过完善访视制度,规范访视内容,反馈访视信息,追踪改进等措施解决访视中发现的问题.结果 访视危重患者856例,与常规护理管理的1 095例危重患者比较,不良事件发生率显著降低,患者满意率显著升高（P＜0.05,P＜0.01）.结论 护理访视管理可提高危重患者的护理安全性和满意度.     

The role of thyroid dysfunction in the critically ill: a review of the literature

During critical illness, patients with no known history of thyroid disorders may experience multiple alterations in their serum thyroid hormone levels. Such alterations have been termed sick euthyroid syndrome or, more recently, non-thyroidal illness syndrome (NTIS). The laboratory parameters of NTIS usually include low serum levels of triiodothyronine (T3), normal or low serum levels of thyroxine (T4) and normal or low serum levels of thyroid-stimulating hormone (TSH). The magnitude of the alteration in thyroid function correlates with the severity of the illness and its outcomes in critically ill patients with NTIS. The pathogenetic mechanisms involved in NTIS include a decreased conversion of T4 to T3 in extrathyroidal tissues and alterations in thyroid hormones' binding to serum proteins. In cases of protracted critical illness, a decrease in the pulsatile frequency of TSH secretion, resulting from reduced thyrotropin-re leasing hormone (TRH) release by the hypothalamus, may also occur. Several medications or clinical conditions that are commonly present in critically ill patients may be responsible for lowering serum concentrations of thyroid hormone. Among those who study the condition, the question of whether NTIS is a protective adaptation of the organism to illness or a maladaptive response to a stressful insult remains unanswered. In either case, thyroid hormone abnormalities are likely to play a role in the critically ill patient.However, there is currently no convincing evidence to suggest that restoring physiological thyroid hormone concentrations in unselected patients with NTIS would be beneficial.     

重危患者护理质量跟踪评估表的应用效果评价

目的建立一个系统、动态、有效的重危患者护理质量跟踪评估体系,以提高重危患者的护理质量。方法在实施急危重症患者抢救工作规章制度和重危患者护理质量控制流程的基础上,利用电子信息系统提供的全院重危患者信息选择跟踪评估对象,由护理质控专家及夜查房护士长根据自行设计的重危患者护理质量跟踪评估表对重危患者护理质量进行评估。结果重危患者护理质量跟踪评估表应用后重危护理质控检查评分显著高于应用前(P<0.01),患者对护理服务的满意度有所提升,但差异无统计学意义(P>0.05)。结论重危患者护理质量控制体系的完善、实施,对重危患者的护理工作起到了良好的监管、指导作用,可提高重危患者护理质量,确保护理安全。     

Severe bone marrow necrosis associated with septic shock in the intensive care unit

Unexplained cytopenias can be related to bone marrow necrosis (BMN) in critically ill patients as it can be encountered in several diseases or life-threatening conditions. We present the case of a 39-year-old woman with pancytopenia revealing a BMN in the setting of an acute pyelonephritis with septic shock, multiple organ failure and sickle cell trait. After a short review on the subject, we suggest that various haematological abnormalities occurring in critically ill patients may be related to a mild to severe marrow necrosis.     

Analgesia and sedation in the critically ill--a practical approach

Advancements in intensive care therapy have progressed rapidly over the last two decades. Associated with this have been scientifically unsubstantiated sedation and analgesia practices in the intensive care unit. There is little consensus as to which agents are the most suitable, let alone when and how to use them. There are few, if any, placebo-controlled trials involving sedative drugs in critically ill patients. In an analysis of the literature, we have attempted to present a practical approach to sedation and analgesia practices in the critically ill patient. The aim is to present a framework upon which medical personnel managing critically ill patients can develop a strategy for their own circumstances.     

Anemia and red blood cell transfusion in the critically ill

Critically ill patients are anemic early in their intensive care unit (ICU) course. As a consequence of this anemia they receive a large number of red blood cell (RBC) transfusions. There is little evidence that "routine" transfusion of stored allogeneic RBCs is beneficial to critically ill patients and may in fact be associated with worse clinical outcomes. It is clear that most critically ill patients can tolerate hemoglobin levels as low as 7 g/dl and therefore a more conservative approach to RBC transfusion is warranted. Strategies to minimize loss of blood and increase the production of RBCs are also important in the management of all critically ill patients.     

Recombinant human erythropoietin use in a critically ill Jehovah's witness after cardiac surgery

Complex cardiac surgery often requires blood transfusion. Some patients refuse transfusion, even when it is potentially life-threatening to do so. Although recombinant human erythropoietin (rhEPO) has been used to reduce the need for blood transfusion, it has been considered ineffective in critically ill patients. The time course of hematological responses in a Jehovah's Witness patient with acute renal failure and severe cardiac disease suggests that a trial of rhEPO should be considered for salvage therapy in critically ill patients. IMPLICATIONS: The authors describe successful treatment of life-threatening anemia using recombinant human erythropoietin in a critically ill Jehovah's Witness patient after cardiac surgery.     

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??How to maximize efficacy of nutrition support in the adult critically ill patients WU Guo-hao. Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai200032??China
Abstract Critically ill patients are hypermetabolic and have increased nutrient requirements. Nutritional support is now considered as a standard of care for the critically ill patients. However, many questions about the appropriate substrate, timing, route and amount of nutritional support in critically ill patients remain understudied. Enteral nutrition is favored over parenteral nutrition when the gastrointestinal tract is functional. Early enteral nutrition is recommended for critically ill patients. Parenteral nutrition is indicated for patients who cannot tolerate enteral feedings. Supplemental parenteral nutrition combined with enteral nutrition can be considered to cover the energy and protein targets when enteral nutrition alone fails to achieve the caloric goal. Clinical studies have demonstrated that new formulae enriched with specific nutrients improves the outcomes of critically ill surgical patients.     

Nutrition in Trauma and Critically Ill Patients

Despite significant improvements in the practice of metabolic support of critically ill patients in recent years, malnutrition continues to be common among surgical patients, adding significantly to complications, infections, length of stay, costs, and increased mortality. Furthermore, hypercatabolism is the major metabolic response after major trauma and emergency surgery, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. Many questions have already been answered, such as whether critically ill patients should be fed, when they should be fed, and how nutrients should be delivered. What is not entirely clear is what we should feed critically ill patients at different phases of specific diseases and disorders, as well as whether or not we should enhance and/or modulate patients’ immunity.     

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.     

Computers in the care of the critically ill patient

The use of computer-based care-oriented physiologic evaluation is still in its developmental stage. However, it seems likely that the capability of computer-based applications to critically ill patients are such that quality and cost-effective intensive care can be delivered in a timely and expeditious fashion. This application has a high promise of helping to reduce the mortality and morbidity of the critically ill or injured surgical patient, now and in the future.     

如何提高外科危重病人的营养支持疗效

外科危重病人高分解代谢、营养物质需求增加,营养支持是危重病人治疗的重要措施之一。合理、有效的营养支持包括提供合适的营养底物,选择正确的喂养途径和时机。早期肠内营养、改善肠内营养的安全性和耐受性、联合应用肠外肠内营养以满足机体对热量的需求、有效控制高血糖以及提供一些药理营养素均可降低应激状况下机体的分解代谢反应,改善机体重要脏器和免疫功能,降低并发症发生率,缩短入住ICU和住院时间,提高危重病人救治成功率。     

The impact of Acinetobacter baumannii in the intensive care unit

Acinetobacter baumannii is a significant problem in critically ill patients. It is widespread, can colonise patients quickly and causes virulent infections. However, its overall impact on morbidity and mortality in the critically ill remains unmeasured. This study was designed to investigate A. baumannii colonisation and infection rates in a critically ill population over an 18-month period. Twenty-seven patients from a population of 347 were identified as having A. baumannii. Sixteen were colonised, whereas 11 were infected. Eleven of the 27 patients with A. baumannii died (41%). Of these, eight were colonised and three were infected. In the same period, 320 patients did not have A. baumannii and their mortality rate was 20% (n = 64). The mortality rate of patients with A. baumannii was significantly higher than that of patients without infection.     

New-onset atrial fibrillation in critically ill adult patients—an SSAI clinical practice guideline

Background

Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes.

Methods

We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel.

Results

The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197 .

Conclusions

The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.     

急诊科院际危重症转运专职护士岗位设立及实践

目的探讨急诊科设立院际危重症转运专职护士岗位的可行性及效果。方法选拔并规范化培训35名转运专职护士,制定转运制度和流程,明确工作内容及岗位职责,实施1年后共转运4 503例危重症患者;以设立转运专职护士岗位前转运的2 378例患者为对照,比较专职岗位设置前后院际危重症患者转运不良事件发生率。结果专职岗位设置后院际转运不良事件发生率显著低于设置前(P0.05,P0.01)。结论危重症转运专职护士岗位的设立可降低转运不良事件发生率,保障危重症患者转运安全。     

体外膜肺氧合支持危重患者院内转运核查单的编制及应用

目的降低体外膜肺氧合支持危重患者院内转运不良事件发生率。方法成立研究小组,编制体外膜肺氧合支持危重患者院内转运核查单,采用行动研究方法,通过计划、行动、观察及反思2个循环过程,找出核查单在临床应用过程中的问题,不断完善核查单,并比较行动研究前后不良事件发生率。结果临床应用2个循环后,体外膜肺氧合支持危重患者院内转院运不良事件发生率由45.00%下降至18.75%。结论基于行动研究的体外膜肺氧合支持危重患者院内转运核查单的编制及应用能够降低不良事件发生率,保障患者安全。