重症医学科重度子痫前期产妇围手术期临床路径的应用

Objective To evaluate the effect of implementation of perioperative clinical pathway (CP)for severe preeclampsia patients in intensive care unit (ICU), and to discuss variation factors in order to improve clinical quality. Methods Thirty-six patients treated in ICU in the Second Clinical Hospital of Fujian Medical University were divided into two groups according to time of 1 year before implementation of CP (from January to December in 2009, n = 14) and 1 year after implementation of CP (from January to December in 2010, n = 22). The length of stay in ICU, cost of hospitalization, occurrence of major complications and mortality, as well as the total effective rate of control of blood pressure in the first 3 days after operation were compared. Results Compared with the group of patients of 1 year before implementation of CP, in the group of patients of 1 year after implementation of CP, the length of stay in ICU (hours) was significantly shorter (65. 5 ±24. 9 vs. 86. 3 ±28. 2, t = Z. 321, P＜0. 05), the cost of hospitalization (yuan) was significantly lower (6 463. 6±1 838.2 vs. 8 136. 5±2 142.8, r = 2. 496, P＜ 0. 05), the occurrence rate of major complications was lower (36. 4% vs. 42. 8%, x2 = 0. 100, P＞0. 05), the total effective control rate of blood pressure was significant improved on the 1st and the 2nd postoperative day (1 day: 59. 1 % vs. 14. 3%, 2 days: 86. 4% vs. 50. 0%, both P＜0. 05), but there was no significant change on the 3rd postoperative day (95. 4% vs. 85. 7%, P＞0. 05). One patient died before the application of CP,and none after its application. Conclusion These results suggested that it was beneficial to implement the program in preeclampsia patients to improve medical quality.     

A retrospective analysis of severe multiple trauma with secondary thrombocytosis北大核心CSCD

Objective To estimate the clinic features of severe multiple trauma with secondary thrombocytosis as a factor influencing the prognosis. Methods A retrospective single-center study was carried out in 680 patients with severe multiple trauma survived longer than 72 hours in Chongqing Emergency Medical Center from March 2010 through March 2013. The variables including age, gender, ISS (injury severity score) , APACHE II score, splenectomy and the usages of vasopressors, blood products transfusion, hematopoietic medicines and anticoagulant were analyzed. The prognosis indices including total in-hospital mortality after 72 hours, length of hospital stay and morbidity of thrombo-embolism were explored. The clinic characteristics and prognosis of severe multiple trauma with secondary thrombocytosis ( platelet count more than 450 × 109 L-1 ) were evaluated. T test or rank sum test was used for comparison between measurement data and Chi-square test or Fisher' s exact test was used for comparison between enumeration data. Results Thrombocytosis was identified in 99 (14.56% ) patients and it occurred one week after injury with median time of 27 days ( ranged from 8 days to 304 days) , and maintained for (18. 62 ±4.38) d. The median of platelet count was 584 × 109 L-1(lowest 478 × 109 L-1, highest 1 072 × 109 L-1) in severe multiple trauma patients with thrombocytosis. The proportions of splenectomy, prolonged use of vasopressors and employment of hematopoietic medicines or anticoagulant were significantly higher in patients with thrombocytosis than those in patients without thrombocytosis (14. 14% vs. 7. 06% , P =0. 03; 62. 63% is. 39.07% , P <0. 01; 28.28% vs. 6.71% , P <0. 01; 90. 91% vs. 19.45% , P < 0. 01). The highest D-Dimer level presenting in patients with thrombocytosis during the time of platelet increasing was significantly more common than that in patients of non- thrombocytosis group 7 days after trauma [ (11. 68 ± 11. 90) vs. (5. 05 ±5. 11) , P =0. 004]. However, the mortality, length of hospital stay and morbidity of thrombo-embolism were not significantly increased in patients with thrombocytosis compared with patients without thrombocytosis [8. 08% vs. 8. 78% , P =0. 82; 34 d (28. 5, 54. 5) d vs. 45d(23, 67) d, P = 0.41; 10.10% vs. 10.50%, P=0.91]. Conclusion There was a higher rate of secondary thrombocytosis in severe multiple trauma patients. The factors such as splenectomy, vasopressors, hematopoietic medicines and so on might induce the reactive thrombocytosis in trauma patients. Thrombocytosis might increase the incidence of thromboembolism in severe multiple trauma patients without appropriate prophylactic anticoagulation. For the sake of prophylaxis, employment of anti-platelet agent might be the appropriately therapeutic strategy for patients suffering from severe multiple trauma with secondary thrombocytosis accompanying risk factors of arterial thrombo-embolism.     

单中心医疗机构20年肺栓塞发病的回顾性分析

Objective To evaluate the correlation of pulmonary embolism (PE) and original diseases by retrospectively analysis of the patients for 20 years in single medical center. Methods Five hundred and five patients with PE were admitted and treated in General Hospital of Chinese PLA from January 1989 to January 2009, and their clinical data were retrospectively reviewed to analyze the risk factors of PE and the correlations of PE with the original diseases. Results Of the 505 patients with PE in the past 20 years, the incidence of PE was increased year by year, especially it increased spectacularly after the year of 2004 [61.2% (309) vs. 38.8% (196)]. It was found to be most prevalent in patients of 41 - 60 years old. Its incidence in males was 1.52 folds higher than that of the females [60. 4% (305) vs. 39.6% (200)].Dyspnea, chest pain and hemoptysis were the initial symptoms in the PE patients. Among the 505 patients,40.0% of them complained dyspnea with chest pain and hemoptysis. Among them, dyspnea occurred in 100.0% of patients, hemoptysis in 52.1%, and chest pain in 40.0%. In 31.1% of the patients if was complicated with deep venous thrombosis (DVT), 19. 8% of them suffering from varicosity, 9. 5% of them had the history of surgery less than 30 days before, 22. 0% of them suffering from neoplasm, 3. 6% of them were accompanied with cerebrovascular disease within 4 days, 17.4% of them were accompanied with infection, 10. 1 % of them were accompanied with primary pulmonary hypertension, and 16. 8% of them were accompanied with heart diseases. Multivariate analysis showed that the history of surgery, DVT and neoplasm had significant correlation with the occurrence of PE [odds ratio (95% confidence interval), OR (95%CI) was 4.540 (2.186-9.443), 0.325 (0.155 -0.682), 2.610 (1.020-6.708), P＜0.05 or P＜ 0. 013, while oral contraception, primary pulmonary hypertension and cerebrovascular disease showed a less significant correlation with the occurrence of PE [OR (95%CI) was 0. 297 (0. 078 - 1. 126), 3. 210 (0. 855 -12. 110), 2. 939 (0. 862 - 10. 020), all P＞0. 05]. The age and infection did not show significant correlation with the occurrence of PE [OR (95%CI) was 1. 041 (0. 674 - 1. 607) and 0. 820 (0. 410 - 1. 665), both P＞0.05]. Conclusion The PE is difficult in diagnosis, but with increasing cognizance, the diagnostic rate of PE has been increased. Patients with history of surgical operation, DVT or neoplasm, who complain dyspnea without known cause, chest pain or hemoptysis, should be subjected to further examinations, as to confirm the diagnosis of PE, then the survival rate of the patients with PE may be elevated.     

急性前壁心肌梗死伴心力衰竭患者急诊经皮冠状动脉介入治疗围手术期应用重组人B型钠尿肽的心肾保护效应

目的 评价急性前壁心肌梗死伴心力衰竭(AAMI-HF)患者急诊经皮冠状动脉介入治疗(pPCI)围手术期应用重组人B型钠尿肽(rhBNP)的心肾保护作用.方法 选择发病24 h内AAMI-HF患者126例,按随机数字表法分为rhBNP组(62例)和对照组(64例),均行PPCI治疗,并在常规药物治疗的基础上,分别给予持续静脉滴注rhBNP或硝酸甘油至术后24 h,监测治疗前后心率(HR)、收缩压(SBP)、B型钠尿肽(BNP)、肾小球滤过率(eGFR)、心脏功能改变,观察30 d内主要心脏不良事件(MACE)的发生率.结果 pPCI后rhBNP组HR显著下降,对照组降低不明显;两组SBP均显著下降.与给药前比较,两组pPCI后各时间点血浆BNP水平及左室射血分数(LVEF)、左室舒张期末内径(LVEDD)均明显改善,且rhBNP组优于对照组[BNP(ng/L)pPCI后30 h:303.5±128.4比354.0±133.6,pPCI后14 d:157.8±78.6比201.1±91.7;LVEF pPCI后1 d:0.420±0.052比0.378±0.055,pPCI后14 d:0.444±0.050比0.393±0.055,pPCI后30 d:0.469±0.053比0.413±0.052;LVEDD(mm)pPCI后1 d:53.5±4.4比57.6±4.4,pPCI后14 d:49.6±5.1比53.4±4.6,pPCI后30 d:46.5±4.4比50.2±4.8,P＜0.05或P＜0.01].两组pPCI后1 deGFR均出现下降,rhBNP组pPCI后3 d回升至用药前水平,两组pPCI后7 d、14 d eGFR水平显著高于用药前,但两组间无差异.rhBNP组造影剂肾病发生率较对照组有降低趋势[19.4%(12/62)比29.7%(19/64),P=0.178].pPCI后7 d内rhBNP组室性心律失常发生率显著低于对照组[48.4%(30/62)比75.0%(48/64),P＜0.01].30 d内rhBNP组MACE发生率显著低于对照组[12.9%(8/62)比26.6%(17/64),P＜0.05].结论 rhBNP可有效改善AAMI-HF-pPCI围手术期患者的心脏功能,降低30 d内MACE发生率;减少造影剂肾病的发生趋势.

Abstract：

Objective To evaluate the protective effect of recombinant human B-type natriuretic peptide (rhBNP) on cardiac and renal functions in heart failure (HF) patients as a result of acute anterior myocardial infarction (AAMI) in peri-operative period of primary percutaneous coronary intervention (pPCI).Methods One hundred and twenty-six patients with AAMI-HF were enrolled into this study.All patients undertaken pPCI were randomly assigned to the rhBNP group (n=62) or the control group(n=64).rhBNP or nitroglycerin was intravenously administered on the basis of conventional treatment from first day of admission to 24 hours after pPCI in both groups.Heart rate (HR), systolic blood pressure (SBP), B-type natriuretic peptide (BNP), estimated lomerular filtration rate (eGFR) and heart function were observed.All patients were followed up for 30 days for the observation of main adverse cardiac events (MACE).Results The HR was significantly decreased compared with that at admission in rhBNP group, but such condition was not found in the control group.The SBP was reduced obviously in both groups.The plasma level of BNP, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension (LVEDD) were improved significantly at different time points compared with those before administration in both groups.The improvement of above parameters in rhBNP group was more significant than that in the control group[BNP (ng/L) 30 hours after pPCI: 303.5±128.4 vs.354.0± 133.6, 14 days after pPCI:157.8±78.6 vs.201.1±91.7; LVEF 1dayafter pPCI: 0.420±0.052 vs.0.378±0.055, 14 days after pPCI:0.444±0.050 vs.0.393±0.055, 30 days after pPCI: 0.469±0.053 vs.0.413±0.052; LVEDD (mm) 1 day after pPCI: 53.5±4.4 vs.57.6±4.4, 14 days after pPCI: 49.6±5.1 vs.53.4±4.6, 30 days after pPCI: 46.5±4.4 vs.50.2±4.8, P＜0.05 or P＜0.01].The eGFR was reduced obviously 1 day after pPCI than that at admission in both groups, and eGFR recovered to baseline 3 days after pPCI.The level of eGFR was significantly increased 7 days and 14 days after pPCI than that at admission, but there was no difference between rhBNP group and control group.The incidence of contrast-induced nephropathy showed a lowering tendency in the rhBNP group than that in the control group[19.4% (12/62) vs.29.7% (19/64),P=0.178].The incidence of ventricular arrhythmias was obviously lowered 7 days after pPCI in the rhBNP group than that in the control group[48.4% (30/62) vs.75.0% (48/64), P＜0.01].The rate of MACE was lower in rhBNP group than that in control group in 30 days[12.9% (8/62) vs.26.6% (17/64), P＜0.05].Conclusion Administration of rhBNP can effectively improve the heart function in AAMI-HF patients undergoing pPCI, and it lowered the incidence of MACE in 30 days, without influence on renal function, and it can reduce the incidence of contrast-induced nephropathy.     

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insuffi ciency(CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD).METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit(ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group(n=32) and a control group(n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone(150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers ofinfl ammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value 0.05 was considered statistically signifi cant.RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI(23.8% vs. 8.7%, P0.01). KaplanMeier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group(P0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group(18.2±9.5 vs. 25.8±4.1, P0.05). Treatment with low-dose glucocorticoid obviously decreased the markers ofinfection and inflammation(P0.01), such as C-reactive protein(13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α(26.1±16.2 g/L vs. 17.5±11.7 g/L for the control group; 25.0±14.8 g/L vs. 10.4±7.8 g/L for the treatment group) and procalcitonin(3.88 g/L vs. 2.03 g/L for the control group; 3.77 g/L vs. 1.26 g/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group(P0.01).CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers ofinfection and infl ammation.     

急性前壁心肌梗死伴心力衰竭患者急诊经皮冠状动脉介入治疗围手术期应用重组人B型钠尿肽的心肾保护效应

Objective To evaluate the protective effect of recombinant human B-type natriuretic peptide (rhBNP) on cardiac and renal functions in heart failure (HF) patients as a result of acute anterior myocardial infarction (AAMI) in peri-operative period of primary percutaneous coronary intervention (pPCI).Methods One hundred and twenty-six patients with AAMI-HF were enrolled into this study.All patients undertaken pPCI were randomly assigned to the rhBNP group (n=62) or the control group(n=64).rhBNP or nitroglycerin was intravenously administered on the basis of conventional treatment from first day of admission to 24 hours after pPCI in both groups.Heart rate (HR), systolic blood pressure (SBP), B-type natriuretic peptide (BNP), estimated lomerular filtration rate (eGFR) and heart function were observed.All patients were followed up for 30 days for the observation of main adverse cardiac events (MACE).Results The HR was significantly decreased compared with that at admission in rhBNP group, but such condition was not found in the control group.The SBP was reduced obviously in both groups.The plasma level of BNP, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension (LVEDD) were improved significantly at different time points compared with those before administration in both groups.The improvement of above parameters in rhBNP group was more significant than that in the control group[BNP (ng/L) 30 hours after pPCI: 303.5±128.4 vs.354.0± 133.6, 14 days after pPCI:157.8±78.6 vs.201.1±91.7; LVEF 1dayafter pPCI: 0.420±0.052 vs.0.378±0.055, 14 days after pPCI:0.444±0.050 vs.0.393±0.055, 30 days after pPCI: 0.469±0.053 vs.0.413±0.052; LVEDD (mm) 1 day after pPCI: 53.5±4.4 vs.57.6±4.4, 14 days after pPCI: 49.6±5.1 vs.53.4±4.6, 30 days after pPCI: 46.5±4.4 vs.50.2±4.8, P＜0.05 or P＜0.01].The eGFR was reduced obviously 1 day after pPCI than that at admission in both groups, and eGFR recovered to baseline 3 days after pPCI.The level of eGFR was significantly increased 7 days and 14 days after pPCI than that at admission, but there was no difference between rhBNP group and control group.The incidence of contrast-induced nephropathy showed a lowering tendency in the rhBNP group than that in the control group[19.4% (12/62) vs.29.7% (19/64),P=0.178].The incidence of ventricular arrhythmias was obviously lowered 7 days after pPCI in the rhBNP group than that in the control group[48.4% (30/62) vs.75.0% (48/64), P＜0.01].The rate of MACE was lower in rhBNP group than that in control group in 30 days[12.9% (8/62) vs.26.6% (17/64), P＜0.05].Conclusion Administration of rhBNP can effectively improve the heart function in AAMI-HF patients undergoing pPCI, and it lowered the incidence of MACE in 30 days, without influence on renal function, and it can reduce the incidence of contrast-induced nephropathy.     

腹腔镜与开腹脾切除术治疗特发性血小板减少性紫癜的护理

Objective To compare the similarities and the differences of nursing care on patients with idiopathic thrombocytopenic purpura. Underwent laparoscope splenectomy and open splenectomy. Methods A total of 122 cases admitted from October 1996 to September 2008 were selected and investigated prospectively.Among them, 72 cases were underwent laparoscope spleneetomy, the other 50 cases were accepted open splenectomy. Indexes of the recovery after operation were compared. Results The mean operation time was longer in the laparoscopic splenectomy group than that in the open group ( 135.3 min vs 108.5 min,P ＜0. 05).The laparoscopic group decreased more significantly than the open group in blood loss ( 110 ml vs 185 ml),abdominal drainage volume ( 100 ml vs 230 ml), the off-bed ambulation time(26. 2 h vs 46.9 h), the anal aerofluxus time(28.9 h vs 68. 1 h) ,food intake time(32. 2 h vs 72.3 h), and post operative hospitalization (8.5 d vs 15. 1 d). Postoperative pain was significantly less in LS group ( P ＜ 0. 05 ). There were no differences in postoperative complication, treatment effectiveness and temperature between two groups (P ＞ 0. 05 ).Conclusions Laparoscope splenectomy, whereas of less traumatic and low morbidity, results in comparable effects as open splenectomy for the treatment of idiopathic thrombocytopenic purpura.. It has important significance to know both similarities and differences of clinical nursing care for patients undergoing the two ways of splenectomy, in order to enhance the nursing quality for peri-operative patients with splenectomy via laparoscope and promote their postoperative rehabilitation.     

Evaluation of diaphragmatic dysfunction after surgical treatment of type A aortic dissection by ultrasound: Incidence,risk factors and influence on outcomes北大核心CSCD

Objective: To study the incidence, possible risk factors, and influence on patient outcomes of diaphragmatic dysfunction in patients after surgical treatment of type A aortic dissection using ultrasound. Methods: Patients who received replacement of hemiarch or total arch with concomitant procedures concerning aortic pathology, and an elephant trunk procedure for the descending aorta were prospectively enrolled in this study from February to May 2017. After surgery, they were transferred to the cardiac surgical intensive care unit. They were divided into two groups based on diaphragmatic excursion: diaphragmatic dysfunction (DD) group and diaphragmatic function normal (DN) grouBilateral diaphragmatic excursions were evaluated using ultrasound during spontaneous breathing trial by T-tube. The differences in demographic characteristics, operation-related variables and outcomes were compared between the two groups. Results: A total of 42 patients were enrolled in this study, and 32 of them suffered from diaphragmatic dysfunctions. Compared with DN group, the excursion of the influenced diaphragm in DD group was significantly reduced[(0.450 ± 0.331)cm vs. (1.801 ± 0.616)cm, P<0.01], while the excursion of the non-influenced diaphragm was not reduced[(2.013±0.655)cm vs. (1.801±0.616) cm, P=0.254]. Diaphragmatic thickness was comparable [(0.184±0.028)cm vs. (0.189±0.028)cm, P=0.559] between the two groups while thickening fraction was significantly reduced in DD group[(4.67%±3.63)% vs. (23.58%±10.69)%, P<0.01]. Meanwhile, respiratory rate was significantly higher in DD group as compared to DN group [(24.13 ± 4.98)times/min vs. (20.50 ± 3.17)times/min, P=0.037]. Patients in DD group showed longer cross-clamp duration[(121.78±27.75)min vs. (93.10±18.84)min, P=0.004] and longer cardiopulmonary bypass duration [(208.09±32.78)min vs. (182.70±24.38)min, P=0.03] than patients in DN grouFurthermore, binary logistic analysis indicated that longer cross-clamp duration was the potential risk factor for diaphragmatic dysfunction after type A aortic dissection surgery. Mechanical ventilation duration was longer in DD group than in DN group (88 h vs. 37 h, P=0.194) but without statistical significance. The usage of noninvasive ventilation was significantly increased in DD group as compared to DN group (46.88% vs. 10%, P=0.036). Other outcomes such as post-operative complications, mortality, ICU length of stay were comparable between the two groups. Conclusions: Diaphragmatic dysfunction was very common after surgical treatment of type A aortic dissection. Longer duration of cross-clamp was considered as a potential risk factor of diaphragmatic dysfunction. A sequential management of noninvasive ventilation after extubation was feasible for diaphragmatic dysfunction after surgical treatment of type A aortic dissection. © 2018 Chinese Medical Association. All rights reserved.     

腹腔镜与开腹脾切除术治疗特发性血小板减少性紫癜的护理

Objective To compare the similarities and the differences of nursing care on patients with idiopathic thrombocytopenic purpura. Underwent laparoscope splenectomy and open splenectomy. Methods A total of 122 cases admitted from October 1996 to September 2008 were selected and investigated prospectively.Among them, 72 cases were underwent laparoscope spleneetomy, the other 50 cases were accepted open splenectomy. Indexes of the recovery after operation were compared. Results The mean operation time was longer in the laparoscopic splenectomy group than that in the open group ( 135.3 min vs 108.5 min,P ＜0. 05).The laparoscopic group decreased more significantly than the open group in blood loss ( 110 ml vs 185 ml),abdominal drainage volume ( 100 ml vs 230 ml), the off-bed ambulation time(26. 2 h vs 46.9 h), the anal aerofluxus time(28.9 h vs 68. 1 h) ,food intake time(32. 2 h vs 72.3 h), and post operative hospitalization (8.5 d vs 15. 1 d). Postoperative pain was significantly less in LS group ( P ＜ 0. 05 ). There were no differences in postoperative complication, treatment effectiveness and temperature between two groups (P ＞ 0. 05 ).Conclusions Laparoscope splenectomy, whereas of less traumatic and low morbidity, results in comparable effects as open splenectomy for the treatment of idiopathic thrombocytopenic purpura.. It has important significance to know both similarities and differences of clinical nursing care for patients undergoing the two ways of splenectomy, in order to enhance the nursing quality for peri-operative patients with splenectomy via laparoscope and promote their postoperative rehabilitation.     

脓毒症患者血清可溶性髓系细胞表达的触发受体-1水平及与预后的关系

目的 探讨脓毒症患者血清可溶性髓系细胞表达的触发受体-1(sTREM-1)水平与疾病预后的关系.方法 采用前瞻性对照研究方法.选择2009年3月至12月天津医科大学第二医院重症监护病房(ICU)收治的50例脓毒症患者,按病情分为普通脓毒症组(28例)、严重脓毒症组(22例),按28 d转归分为生存组(34例)、死亡组(16例).于发病1、3、7 d检测血常规、血生化、血气分析、C-反应蛋白(CRP)、降钙素原(PCT),并进行急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分,采用酶联免疫吸附法(ELISA)检测血清sTREM-1浓度.对sTREM-1与APACHE Ⅱ评分、血白细胞计数(WBC)、CRP进行相关性分析,并进行Logistic回归分析.以同期30例健康体检者作为健康对照组.结果 50例脓毒症患者发病1 d血清sTREM-1浓度(ng/L)明显高于健康对照组(52.80±9.30比23.29±6.22,P＜0.01).严重脓毒症组发病1、3、7 d血清sTREM-1浓度(ng/L:58.25±10.59、65.75±13.57、50.18±21.73)均明显高于普通脓毒症组(48.55±5.20、42.85±8.54、34.02±12.86,P＜0.05或P＜0.01).生存组发病1、3、7 d sTREM-1浓度(ng/L)逐渐下降(53.07±10.47、45.04±9.89、32.84±8.42),7 d时接近正常水平;死亡组发病1、3、7 dsTREM-1浓度(ng/L)逐渐上升(52.27±6.42、69.67±12:12.83、75.705±10.55),3 d、7 d时明显高于生存组(均P＜0.01).血清sTREM-1浓度与APACHE Ⅱ评分呈显著正相关(r=0.657,P＜0.01),与血WBC无相关性(r=0.023,P＞0.05),与CRP有一定相关性(r=0.150,P＜0.10).Logistic回归分析显示sTREM-1[相对比值比(OR)=0.893,P=0.000]、APACHE Ⅱ评分(OR=0.771,P=0.000)为影响预后的死亡危险因素,受试者工作特征曲线下面积(AUC)分别为0.868、0.930;以sTREM-1为50 ng/L评价预后的敏感性为81.1%,特异性为74.5%APACHE Ⅱ评分20分的敏感性为83.8%,特异性为86.3%.结论 在脓毒症发病早期血清sTREM-1浓度升高,其变化趋势可能与疾病严重程度有关,与APACHE Ⅱ评分有显著的相关性,是影响预后的死亡危险因素之一.

Abstract：

Objective To approach the relationship between the contents of soluble form of triggering receptor expressed on myeloid cells-1 (sTREM-1) and prognosis in patients with sepsis. Methods Using prospective, control study design, a total of 50 patients with sepsis who were admitted in intensive care unit (ICU) of the Second Hospital of Tianjin Medical University from March to December in the year of 2009 were enrolled. Firstly, the patients were divided into sepsis (n=28) and severe sepsis (n=22) groups according to the patients' condition. Then the patients were divided into survival group (n = 34) and death group (n = 16)according to the clinical outcome at 28 days after onset of sepsis. Clinical and laboratory data including blood routine tests, blood chemistry, blood gas analysis, C-reactive protein (CRP) and procalcitonin (PCT) were collected on the 1st, 3rd and 7th day after onset. Acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ ) score was determined. sTREM-1 levels were determined using enzyme linked immunosorbent assay (ELISA) method. Correlation analysis of the sTREM-1, APACHE I score, white blood cell count (WBC) and CRP, using Logistic regression analysis. A total of 30 healthy persons were enrolled into the control group. Results The sTREM-1 levels (ng/L) in 50 septic patients on the 1st day were higher than those of the healthy persons (52. 80±9. 30 vs. 23. 29±6. 22, P＜0. 01). The sTREM-1 levels (ng/L) in severe sepsis group on the 1st, 3rd and 7th day (58. 25±10. 59, 65. 75±13. 57, 50.18±21. 73) were higher than those of the sepsis group (48.55±5.20, 42.85±8.54, 34.02±12.86, P＜0.05 or P＜0.01). The sTREM-1 levels (ng/L) of the survival group on the 1st, 3rd and 7th day (53. 07± 10. 47, 45. 04±9. 89,32. 84 ±8. 42) were decreased with the progression of the ailment. The sTREM-1 levels did not differ significantly between the control group and survival group on the 7th day (P＞0. 05). The sTREM-1 levels (ng/L) in the death group on the 1st, 3rd and 7th day were increased with the progression of the ailment (52.27±6.42, 69.67±12.83, 75. 70± 10. 55), and the level was significantly higher than that in survival group on the 3rd and 7th day (both P＜0. 01). The contents of sTREM-1 were positive correlated with APACHE Ⅱ score (r= 0.657, P＜0. 01), but not correlated with WBC (r= 0.023, P＞0. 05), whilesomewhat correlated with CRP (r=0. 150, P＜0.10). Logistic regression analysis showed that sTREM-1 [odds ratio (OR) = 0. 893,P = 0. 000] and APACHE I score (OR = 0.771, P = 0.000) might be potential prognostic factors for septic patients. The area under the receiver operator characteristic curve was 0. 868 and 0.930. The sensitivity of prognostic evaluation was 81.1% and specificity was 74.5% with sTREM-1 50 ng/L, and the sensitivity was 83. 8% and specificity was 86. 3% with APACHE Ⅱ score 20 to estimate the outcome. Conclusion The serum sTREM-1 are elevated at early stage in sepsis patients. It can reflect the severity of the condition. The sTREM-1 level, which might be considered as a potential prognostic factor for septic patients, is significantly correlated with APACHE Ⅱ score.     

性激素对腹部外科疾病伴全身炎症反应综合征患者预后的影响

目的 评价血清性激素水平在腹部外科疾病伴全身炎症反应综合征(SIRS)患者病情预后评估中的应用价值.方法采用前瞻性、单中心、观察研究方法.选择2009年7月10日至2010年2月9日天津市南开医院外科重症监护病房(SICU)收治的39例腹部外科疾病伴SIRS患者,根据患者入院72 h内的血清雌二醇、泌乳素及睾酮水平(用放射免疫法检测)分为雌二醇升高组(20例)和未升高组(19例)、泌乳素升高组(16例)和未升高组(23例)、睾酮降低组(14例)和未降低组(25例),分别观察各组患者急性生理学与慢性健康状况评分系统Ⅱ (APACHE Ⅰ)评分、总住院时间、住ICU时间、总住院费用及28 d转归.结果 与雌二醇未升高组比较,雌二醇升高组APACHEⅡ评分(分)有所降低,但差异无统计学意义(11.6±7.8比15.2±8.8,P＞0.05),住ICU时间(d)明显缩短(8.5±4.0比12.1±7.9,P＜0.05),28d病死率明显降低(10.0％比35.7％,P＜0.05).与泌乳素未升高组比较,泌乳素升高组住ICU时间(d)明显缩短(8.7±3.1比12.9±2.1,P＜0.01),总住院费用(万元)明显降低(6.70±3.50比13.20±8.20,P＜0.05).与睾酮未降低组比较,睾酮降低组APACHEⅡ评分(分)明显降低(10.4±5.4比15.2±9.4,P＜0.05),住ICU时间(d)明显缩短(26.6±12.2比28.1±17.0,P＜0.01),28 d病死率明显降低(0比31.8％,P＜0.01).结论 腹部外科疾病伴SIRS患者早期血清雌激素、泌乳素及睾酮水平对患者的预后有显著影响.     

胸腔内血容量指数在感染性休克患者液体管理中的应用

目的 探讨胸腔内血容量指数(ITBVI)在感染性休克患者液体管理中的应用价值.方法 采用前瞻性临床观察研究方法,将入住重症监护病房(ICU)的33例感染性休克患者分为两组.ITBVI组17例患者接受脉搏指示连续心排血量(PiCCO)监测,以ITBVI作为液体管理的指导指标;对照组16例患者以中心静脉压(CVP)作为液体管理的指导指标.对比两组患者治疗1 d和3 d时的急性生理学与慢性健康状况评分系统I(APACHE I)评分、感染相关器官功能衰竭评分系统(SOFA)评分、血管活性药物评分,以及补液72 h内两组患者的液体管理数据.结果 ①ITBVI组3 d时APACHE I、SOFA和血管活性药物评分(分)均较1 d时显著下降[21.3±6.2比25.4±7.2,6.1±3.4比9.0±3.5,5.0(0,8.0)比20.0(8.0,35.0),均P＜0.01];而对照组则均无显著变化.②虽然ITBVI组48～72 h液体出量(ml)大于对照组(2 421±868比1 721±934,P=0.039),但ITBVI组与对照组0～72 h的液体出入量和平衡量(ml)比较差异均无统计学意义(入量:9 918±137比10 529±1 331,出量:6 035±1 739比5 827±2 897,平衡量:3 882±1 889比4 703±2 813,均P＞0.05).③在快速补液试验中,ITBVI组与对照组患者除0～6 h胶体液入量[ml:250(125,500)比250(69,250)]差异无统计学意义(P＞0.05)外,其余时段液体入量(ml)ITBVI组均比对照组高[0～6 h晶体液:250(150,250)比125(105,125),6～72 h晶体液:125(125,250)比100(56,125),0～72 h晶体液:250(125,250)比125(75,125),6～72 h胶体液:125(106,250)比75(50,125),0～72 h胶体液:200(125,250)比100(50,125),均P＜0.01].结论 与以CVP指导相比,用ITBVI指导感染性休克患者的液体管理显示,3 d时患者病情较1 d改善,这种改善可能得益于对血容量状态的准确判断和适当的快速补液速度.     

脑电双频指数与镇静-躁动评分指导短期机械通气患者镇静治疗的随机对照研究

目的 比较脑电双频指数(BIS)实时监测和镇静-躁动评分(SAS)在重症监护病房(ICU)短期机械通气患者镇静治疗实施过程中的可行性.方法 选择ICU中18～60岁外科手术后需持续机械通气(＞12 h)患者105例,按信封法随机分为BIS组(42例)和SAS组(63例),分别依据BIS和SAS评估镇静深度.两组均给予芬太尼镇痛,丙泊酚和咪唑安定联合镇静,每小时根据镇静深度评估调节镇静药物泵入剂量(BIS组目标值为50～70,SAS组目标为3～4级).入ICU后次日晨6时停用镇静及镇痛药物,每小时记录镇静深度(BIS值或SAS分级)、镇静持续时间、觉醒时间、机械通气时间、单位时间内咪唑安定和丙泊酚用量及累计总量,以及吸痰后躁动发生率、镇静期间气管导管耐受率和疼痛耐受率、拔管后谵妄发生率.结果 BIS组单位时间内眯唑安定和丙泊酚用量均高于SAS组[咪唑安定(mg·kg-1·h-1):0.10±0.02比0.09±0.02,丙泊酚(mg·kg-1·h-1):0.95±0.23比0.86±0.20,均P＜0.05],总体镇静达标时段(Dt,以1 h为1个时段)以及前3个时段(D1、D2、D3)的镇静达标率均明显高于SAS组[Dt:75.2%(507)比52.8%(421),D1:78.6%(33)比22.2%(14),D2:88.1%(37)比20.6%(13),D3:81.0%(34)比31.7%(20),均P＜0.01],觉醒时间(min)明显短于SAS组[0(0,20)比15(0,47),P＜0.05];BIS组和SAS组患者急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分(分:3.57±2.60比4.19±2.30)、机械通气时间[h:16.5(14.5,19.0)比17.0(15.0,19.0)]、镇静持续时间[h:14.0(12.9,17.1)比16.0(13.0,18.0)]及吸痰后躁动发生率(81.0%比79.4%)、镇静期间气管导管耐受率(71.4%比74.6%)和疼痛耐受率(92.8%比93.6%)、拔管后谵妄发生率(4.8%比1.6%)等差异均无统计学意义(均P＞0.05).结论 与SAS比较,BIS在指导ICU短期机械通气患者的镇静治疗中,对镇静深度调控具有更好的可操作性.

Abstract：

Objective To compare the value of bispectral index (BIS) monitoring and sedationagitation scale (SAS) in guiding intensive care unit (ICU) sedation therapy for the patients undergoing shortterm mechanical ventilation. Methods One hundred and five patients aged 18 - 60 years after operation receiving mechanical ventilation for longer than 12 hours in ICU were enrolled in this study. The patients were randomly divided into two groups: BIS-guided group (n=42) and SAS-guided group (n=63). All of them received protocolized continuous sedation and analgesia by using fentanyl for analgesia and propofol plus midazolam to sedate intravenously. The effect of sedation was assessed every hour till BIS reaching 50 - 70 or SAS reaching grade 3 - 4. Sedatives and analgesics were suspended st 6: 00 am on next day after ICU admission, and BIS and the SAS were recorded every hour, sedation time, time to wake up, duration of mechanical ventilation, daily dosage of midazolam and propoful, and the incidence of adverse events including restlessness after suction, endotracheal tube resistance, pain tolerance during sedation, and delirium after extubation were all recorded accordingly. Results Dosages of midazolam and propofol were found higher in BIS-guided group than the SAS-guided group [midazolam (mg · kg-1 · h-1) : 0. 10±0. 02 vs. 0. 09±0. 02,propofol (mg · kg-1 · h-1): 0. 95±0. 23 vs. 0. 86±0. 20, both P＜0.05＝. The total time (Dt) of patients under sedative control was significantly longer in BIS-guided group compared with SAS-guided group, and also in first three hours [D1, D2, D3, D,: 75.2% (507) vs. 52.8% (421), D1: 78.6% (33) vs. 22.2%(14), D2: 88. 1% (37) vs. 20. 6% (13), D3: 81.0% (34) vs. 31.7% (20), all P＜0. 01＝. The time to wake up (minutes) was significantly shorter in BIS-guided group compared with SAS-guided group [0 (0, 20) vs.15 (0, 47), P＜0.05＝. No significant difference in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score (3. 57± 2. 60 vs. 4. 19 ± 2. 30), duration of mechanical ventilation [hours: 16. 5 (14.5, 19.0) vs. 17.0 (15.0, 19.0)], sedation time [hours: 14.0 (12.9, 17.1) vs. 16.0 (13.0, 18.0)]and incidence of adverse events including restlessness after suction (81.0% vs. 79. 4%), endotracheal tube resistance (71.4% vs. 74.6%), pain tolerance during sedation (92.8% vs. 93.6%) and delirium after extubation (4. 8% vs. 1.6%) was found between BIS-guided group and SAS-guided group (all P＞0. 05).Conclusion BIS monitoring is better in sedative control than SAS assessment for ICU patients undergoing short-term mechanical ventilation.     

超微补阳还五汤对脑梗死恢复期患者神经功能/生活质量及血清血管内皮生长因子的影响

目的 观察补阳还五汤对脑梗死恢复期患者神经功能、生活质量和血清血管内皮生长因子(VEGF)的影响,评价超微粉化对补阳还五汤效应的作用.方法 选择251例脑梗死恢复期患者,按进入研究的时间顺序,采用简单随机化方法按1∶1∶1分为传统补阳还五汤组(83例)、超微补阳还五汤组(85例)和对照组(83例).对照组给予康复训练;传统补阳还五汤组和超微补阳还五汤组除康复训练外,分别给予传统补阳还五汤颗粒剂,每次15 g、每日2次和补阳还五汤超微颗粒,每次5 g、每日2次,疗程均为12周.评价各组临床疗效和中医证候疗效,观察治疗前后患者的神经功能、生活质量,并测定血清VEGF水平;同时测定23例健康成人的VEGF水平作为健康对照.结果 与对照组比较,超微组、传统组临床总有效率(83.5%、85.5%比77.1%)和中医证候疗效总有效率(87.0%、89.2%比77.1%)均显著升高(均P＜0.05).3组患者治疗后神经功能和生活质量均有明显改善,超微组、传统组与对照组比较差异有统计学意义[神经功能缺损程度评分(分):11.95±5.03、12.68±4.67比15.23±5.12,生活质量评分(分):64.71±6.73、63.56±6.53比59.09±6.81,均P＜0.05].对照组、传统组、超微组患者治疗前血清VEGF水平(ng/L)较健康者明显增加(79.87±2.81、80.19±3.23、80.23±3.18比68.13±3.39,均P＜0.05);治疗后超微组、传统组血清VEGF水平(ng/L)明显高于对照组(76.38±3.02、76.84±3.18比70.26±3.15,均P＜0.05).超微组与传统组间各指标比较差异无统计学意义(均P＞0.05).结论 补阳还五汤能改善脑梗死恢复期患者神经功能和生活质量,提高血清VEGF水平,超微粉化能减少药物的用量.     

危重患者股动脉与足背动脉采血血气分析临床效果的比较

目的 比较采集危重患者血气标本股动脉与足背动脉两个不同部位的临床效果.方法 对ICU112例APACHEⅡ评分在27～43分的危重患者,分别选用5号针头1 ml注射器行足背动脉采血法与7号针头5 ml注射器行股动脉采血法,对两种采血方法的临床效果进行比较.结果 两种采血方法的血气分析的结果差异无统计学意义（P＞0.05）;股动脉一针穿刺成功例数大于足背动脉（110 vs100,χ2=14.23,P＜0.05）,两个采血部位在误穿静脉、血肿形成、血栓形成、按压时间方面比较差异均有统计学意义（12 vs 1,7 vs 0,6 vs 0,5.5±0.7 vs 2.5±0.5;χ2=9.32,5.99,4.85,t=38.06,P＜0.05）.结论 应根据患者的病情采取个体化的采血方案,经股动脉采血时需加强并发症的预防,提高临床护理质量.     

肿瘤外科ICU室上性心律失常的发生率及危险因素分析

目的 探讨肿瘤外科ICU室上性心律失常(SVAs)的发生率及危险因素.方法 回顾分析我院ICU 2008年11月至2009年10月间收治570例患者的临床资料,对SVAs可能的影响因素进行单因素和多因素Logistic分析.结果 13例有心房颤动病史的患者被除外,入选557例.SVAs发生率为12.93%(72/557).多因素分析显示年龄(OR=1.066,95%CI:I.034～1.099,P＜0.001)、冠心病病史(OR=2.644,95%CI:1.459～4.790,P＜0.05)、转入时确诊为脓毒症(OR=2.374,95%CI:1.098～5.135,P＜0.05)和胸部外科手术操作(OR=2.322,95%CI:1.061～5.084,P＜0.05)是SVAs发生的独立危险因素.SVAs患者与非SVAs组住ICU时间[2(1～77)、3(1～40)d,Z=-3.505,P＜0.001]和APACHEⅡ评分[9(0～37)、11(3～38)分,Z=-3.332,P=0.001],差异有统计学意义.SVAs组死亡9例(12.5%),非SVAs组死亡19例(3.9%),病死率差异有统计学意义(x2=9.673,P=0.002).结论 肿瘤外科ICU患者术后SVAs的发生率较高,年龄、冠心病病史、转入ICU时确诊有脓毒症和胸部外科手术操作是术后SVAs发生的独立危险因素.SVAs增加患者住ICU时间,是反映患者病情严重性的一种标志.

Abstract：

Objective To evaluate the incidence and to investigate risk factors of supraventricular arrhythmia (SVAs) in postoperative cancer patients in intensive care unit ( ICU ). Methods Data of 570 patients consecutively admitted to oncologic surgical ICU of Cancer Hospital of Chinese Academy of Medical Sciences from Nov. 2008 to Oct. 2009 were retrospectively collected. Univariate and multivariate logistic analysis were conducted for potential factors that influenced SAVs. Results Thirteen patients with a history of atrial fibrillation (AF) were excluded and 557 patients were eligible for the study. SVAs occurred in 72 patients ( 12. 93% ). Multivariate analysis showed four independent predictors of SVAs including age ( OR = 1. 066,95%CI: 1. 034 - 1. 099,P ＜0. 001 ) ,a history of coronary heart diseases ( OR = 2. 644,95% CI: 1. 459 - 4. 790,P ＜ 0. 05), sepsis ( OR = 2. 374,95% CI: 1. 098 - 5. 135, P ＜ 0. 05 ) and intra-thoracic procedure ( OR =2. 322,95 % CI: 1.061 - 5.084, P ＜ 0. 05 ) . ICU length of stay, severity ( APACHE Ⅱ scores in SVAs patients) were significantly greater in patients who were not affected by SVAs ( ICU stay: [2 ( 1 ～ 77 )]vs [3 ( 1 ～ 40 )]days,P ＜ 0. 001; APACHE Ⅱ score: [9 (0 ～ 37 )] vs [11 (3 ～ 38 )], P = 0. 001 ). Nine cases died in SVAs patients ( 12. 5% ) and 19 died in the non-SVAs patients (3.9%), with significant difference between the two groups( x2 = 9. 673, P = 0. 002). Conclusion In oncologic surgical ICU, the incidence of SVAs is high. Age,history of coronary heart diseases, sepsis and intra-thoracic procedure were independent rsik factors of SVAs. SVAs prolong ICU length of stay. SVAs is a marker of critical illness severity.     

超负荷量氯吡格雷对急诊冠状动脉介入治疗患者心肌微循环再灌注的影响

目的 观察急性ST段抬高心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)术前应用超负荷量氯吡格雷时术后心肌微循环灌注及心脏功能的影响.方法 2008年1月至2009年10月,64例成功接受急诊PCI治疗的STEMI患者随机分为氯吡格雷300 mg组和600 mg组,2组各32例.比较2组间的基础临床状况和造影情况、介入治疗结果以及术后心肌呈色显像分级(MBG)3级获得率、ST抬高总和回落百分比(sumSTR%)、心功能以及胎盘生长因子(PIGF)、可溶性CD40配体(8CD40L)的变化.结果 2组一般情况、基础临床情况和造影、介入治疗资料差异均无统计学意义(P均＞0.05).术后氯吡格雷600 mg组的MBG分级3级获得率明显高于300 mg组(21.88%和50.00%,P＜0.05),ST段抬高总和回落百分比显著下降[(70.90±9.51)%和(60.70±15.06)%,P＜0.05],左室射血分数(LVEF)明显增加[(70.96±9.51)%和(65.27±9.85)%,P＜0.05],PIGF较300 mg组显著下降[(14.37±1.32)ng/L和(15.85±1.71)ng/L,P＜0.05],sCD40L较300 mg组显著下降[(4.93±0.71)μg/L和(5.68±0.77)μg/L,P＜0.05].结论 急性ST段抬高心肌梗死患者急诊PCI术前给予超负荷量氯吡格雷可以改善PCI术后的心肌微循环灌注,改善心功能状况.     

血浆N末端B型钠尿肽前体对重症患者预后的预测价值研究

目的 探讨入重症监护病房(ICU)时血浆N末端B型钠尿肽前体(NT-pro-BNP)水平是否是预测重症患者预后的独立因子.方法 采用前瞻性、单中心、观察性研究方法.选择6个月内入本院ICU＞18岁的120例患者,最终有88例患者符合试验要求.血浆NT-pro-BNP样本在进入ICU时收集;计算进入ICU后24 h内急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)的最差值;入ICU后28 d患者生存状态为预测终点.结果 入ICU 28 d死亡35例,病死率为39.8%.88例患者血浆NT-pro-BNP水平(ng/L)为1221.7(78.7～5 500.0),生存组明显低于死亡组[781.8(78.7～5 066.6)比2 774.5(166.8～5 500.0),P＜0.01].男性NT-pro-BNP水平(ng/L)高于女性[1 585.5(103.7～5 100.0)比794.5(78.7～5 500.0),P＜0.05];性别与NT-pro-BNP水平有相关性(r=-0.224,P＜0.05).进入ICU时重度感染患者NT-pro-BNP水平(ng/L)较其他患者更高[3 416.1(103.7～5 100.0)比883.4(78.7～5 500.0),P＜0.01];入ICU时是否存在重度感染与NT-pro-BNP水平有相关性(r=0.285,P＜0.01).NT-pro-BNP和APACHE Ⅱ评分的受试者工作特征曲线(ROC曲线)下面积分别为0.734[95%可信区间(95%CI)0.628～0.840]和0.747(95%CI0.637～0.858).Logistic回归分析显示:入ICU时NT-pro-BNP水平＞1 418 ng/L和APACHE Ⅱ评分均可作为28 d生存状态预测的独立因子[相对比值比(OR)5.235,95%CI 1.819～15.071;OR 1.105,95%CI1.819～15.071].以入ICU时NT-pro-BNP最佳临界值1 418 ng/L为分界点进行生存分析,高于此值者生存率比低于此值者低(x2=16.9,P＜0.01).结论 入ICU时血浆NT-pro-BNP＞1 418 ng/L和APACHE Ⅱ评分可作为重症患者短期生存状态的预测因子;NT-pro-BNP值可能用来诊断或者鉴别重度感染患者.

Abstract：

Objective To investigate whether plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP)as measured at admission to intensive care unit(ICU)is an independent predictor of mortality in critically ill patients. Methods A prospective observational study of patients in ICU was conducted. One hundred and twenty patients aged＞18 years were included during a 6-month period. Among them 88 patients were enrolled for the study. Plasma NT-pro-BNP samples were obtained at admission to ICU. The acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score was calculated within 24hours after admission based on the worst values up to that point. The final evaluation was 28-day mortality.Results Thirty-five patients died within 28 days of ICU admission, the mortality was 39. 8%. In 88 patients, the mean plasma NT-pro-BNP levels(ng/L)were 1 221.7(78.7- 5 500.0), and that in survivor group was significantly lower than non-survivor group[781.8(78. 7 - 5 066. 6)vs. 2 774. 5(166.8 - 5 500.0), P＜0.01]. The mean NT-pro-BNP level(ng/L)in male patients was higher than that in females[1 585. 5(103.7 - 5 100. 0)vs. 794. 5(78. 7 - 5 500. 0), P＜0. 05]. There was correlation between gender and NT-pro-BNP levels(r=-0. 224, P＜0. 05). Patients admitted to the ICU because of a severe infection had higher levels of NT-pro-BNP(ng/L)compared with the rest of the cohorts[3 416.1(103. 7 -5 100.0)vs. 883. 4(78. 7 - 5 500. 0), P＜0.01]. There was correlation between severe infection at admission to ICU and NT-pro-BNP levels(r=0. 285, P＜0. 01). Areas under the receiver operating characteristic curves(ROC curves)of NT-pro-BNP and APACHE I score were 0. 734[95% confidence interval(95%CI)0. 628 - 0. 840]and 0. 747(95%CI 0. 637 - 0. 858), respectively. Logistic regression analysis showed that the NT-pro-BNP level ＞ 1 418 ng/L and the APACHE I score were independently associated with 28-day mortality[odds ratio(OR)5.235, 95%CI 1.819- 15.071; OR 1.105, 95%CI 1.819- 15.071]. WithI 418 ng/L of NT-pro-BNP as the cutoff value, survival rate was significantly lower in the patients with higher NT-pro-BNP level as compared with those with lower values at admission(x2= 16.9, P＜0. 01).Conclusion The ICU NT-pro-BNP level higher than 1 418 ng/L and APACHE Ⅱ score at admission are independent prognosis markers of early mortality. NT-pro-BNP might serve as a potent early diagnostic and prognostic marker in critically ill patients.     

血循环中Tie2 mRNA含量对脓毒症患者全身病情变化评价作用的研究

目的 探讨血循环中Tie2 mRNA含量是否与脓毒症全身病情变化存在相关关系.方法 选取重症监护病房(ICU)创伤患者,按是否为脓毒症分为脓毒症组(13例)和非脓毒症组(19例).患者进入ICU当日进行急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分;1、3、7 d采集肘静脉血检测白细胞总数(WBC)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、尿素氮(BUN)、肌酐(Cr)含量;采用实时定量聚合酶链反应(PCR)检测血中Tie2 mRNA含量;用酶联免疫吸附法检测血浆血管性血友病因子(vWF)含量.结果 脓毒症组与非脓毒症组间ALT、AST、vWF含量比较差异均无统计学意义[ALT(U/L):53.30(199.58)比80.65(202.62),AST(U/L):316.53(49.90)比66.10(285.03),vWF:(272.47±114.61)%比(246.66±128.77)%,均P＞0.05].脓毒症组WBC、BUN、Cr及血中Tie2 mRNA水平均显著高于非脓毒症组[WBC(×109/L):18.26(21.82)比10.11(4.72),BUN(mmol/L):20.70(11.20)比7.70(5.45),Cr(μmol/L):252.00(364.55)比68.00(23.20),Tie2 mRNA:1.86±0.67比0.91±0.42,均P＜0.01].所有患者APACHE Ⅱ评分与血Tie2 mRNA水平呈显著正相关(r=0.532,P＜0.01),其线形拟合方程为Y=12.66+4.922X(R2=0.283)vWF与Tie2 mRNA水平呈正相关(r=0.334,P＜0.05),其线形拟合方程为Y=180.932+57.93X(R2=0.112).结论 脓毒症患者血循环中Tie2 mRNA水平能及时反映内皮细胞损伤程度和病情轻重,可作为一个相对敏感的病情预测候选指标.