重症超声与连续心排血量监测在感染性休克患者液体复苏中应用比较

目的比较重症超声与连续心排血量监测在感染性休克患者液体复苏中的应用效果。方法选择2017年1月～2019年6月我院感染性休克患者226例作为研究对象,参考随机数字表法分为观察组与对照组各113例。对照组采取连续心排血量监测指导液体复苏,观察组采取重症超声指导液体复苏。比较两组复苏相关指标(液体复苏量、氧合指数、中心静脉血氧饱和度)以及不良事件发生情况。结果复苏24h后,观察组液体复苏量低于对照组,氧合指数、中心静脉血氧饱和度高于对照组,机械通气时长、ICU监护时长短于对照组,差异有统计学意义(P<0.05);观察组不良事件发生率7.96%(9/113)低于对照组17.70%(20/113),差异具有统计学意义(P<0.05)。结论相对于连续心排血量监测,重症超声应用于感染性休克患者液体复苏中,更能提升患者的复苏质量,且不良事件发生率更低,安全性能较高。     

Vigileo在感染性休克患者容量管理中的应用

目的探讨Vigileo的动脉脉搏心输出量(arterial pressure-based Cardiac output,APCO)监测技术在指导感染性休克患者液体复苏中的应用价值和护理措施。方法选择急性生理与慢性健康评分(APACHII)16分的感染性休克患者28例。在应用Vigileo监测指导液体复苏前及复苏后6h采集2组患者前后血流动力学数据及24h后的乳酸、碱剩余、APACHII评分的变化。结果 28例患者均达到液体复苏的目的,未发生不良反应及相关并发症。结论 Vigileo的APCO监测技术能及时有效的指导感染性休克患者早期液体复苏,具有其重要的临床应用价值。     

每博量变异、血管外肺水指数在烧伤机械通气患者液体复苏临床指导意义

目的探讨每博量变异(SVV)、血管外肺水指数(EVLWI)在烧伤机械通气患者液体复苏中的临床指导意义。方法选取2015年3月~2017年3月我院收治的68例大面积烧伤急诊气管切开机械通气患者。按其是否采用PiCCO监测分为治疗组30例和对照组38例。其中观察组依据患者有创血压、每博量变异(SVV)、血管外肺水指数(EVLWI)、心率、每小时尿量等监测指标指导液体复苏;对照组依据有创动脉压、中心静脉压(CVP)、心率、每小时尿量等监测指标指导液体复苏;观察两组患者休克期内各个时间点(6h、12h、24h、36h、48h)血流动力学指标、血气分析指标、休克期第1个24h、第2个24h补液总量;两组患者入院72h后肺水肿、胸腔积液发生率。结果观察组第1个24h、第2个24h液体补充总量与对照组比较,差异显著(P0.05);观察组入院72h后肺水肿发生率显著少于对照组,差异有统计学意义(P0.05)。结论每博变异、血管外肺水指数可有效监测烧伤机械通气患者休克期液体复苏过程中心脏及机体液体负荷情况,减少因机械通气液体复苏时胸腔内压对CVP的影响,保证各个脏器有效灌注,减轻肺水肿的发生率。     

PICCO在危重患者容量管理指导中的应用效果

将入住重症医学科56例危重患者随机分为两组,每组各28例。观察组经肺热稀释技术和脉搏波型轮廓分析技术(PICCO)指导容量管理,并进行护理治疗。对照组行中心静脉压(CVP)监测指导容量管理,观察两组患者治疗后1、2、3d的APACHEⅡ评分与血流动力学变化、3d液体总入量、治愈率、死亡率、机械通气时间等情况。结果观察组2d、3d APACHEⅡ评分、HR较第1d降低明显,MAP升高(P<0.05);对照组3d各项指标无明显变化(P>0.05),两组2d、3d各项指标相比有显著差异(P<0.05)。两组机械通气时间差异显著(P<0.05),3d液体总入量、治愈、死亡情况无显著差异(P>0.05)。应用PICCO监测技术对危重患者更有效地监测血流动力学变化和总容量的管理,可准确判断血容量状态,指导恰当补液。     

脓毒性休克早期液体复苏中PICCO的应用价值探讨

选取我院2013年8月~2014年8月50例实施早期液体复苏治疗的脓毒性休克患者,将其分为对照组和观察组各25例。对照组实施常规监测,观察组在PICCO监测下实施治疗。对比分析两组患者的治疗效果。结果血乳酸2mmo L/L以及中心静脉氧饱和度≥70%的例数对比,对照组和观察组患者复苏6h差异不大(P0.05),复苏24h差异明显(P0.05);和对照组相比,观察组患者在复苏6h和24h其输液量较多、多巴胺用量较少,差异显著(P0.05);和对照组相比,观察组患者的多脏器功能障碍综合征(MODS)发生率和病死率明显偏低,差异显著(P0.05)。PICCO在脓毒性早期液体复苏中的应用,能够进一步纠正患者血流动力学和氧代谢异常,从而改善患者复苏效果,值得在临床中推广应用。     

乌司他丁对全身炎症反应综合征病人无创血流动力学影响的临床研究

目的观察乌司他丁(20万U/d)对危重病人全身炎症反应综合征(SIRS)期无创血流动力学的影响,从血流动力学变化方面探讨乌司他丁在危重病人SIRS期的作用。方法应用动态无创血流动力学监测方法,将62例ICU的危重病人随机分为两组乌司他丁组31例,对照组31例,连续观察两组病人的平均动脉压(MABP)和无创血流动力学值CI(心脏指数)的变化。结果乌司他丁组的CI值明显高于对照组(P<0.05),MABP无显著性差异(P>0.05)。结论乌司他丁能明显改善危重病人SIRS期无创血流动力学值(CI),应用无创血流动力学监测仪能较早发现危重病人的血流动力学异常,在危重病人SIRS期应用乌司他丁能明显降低危重病人死亡率。     

严重烧伤患者休克期血流动力学监测及护理

总结血流动力学监测在５２例大面积烧伤患者休克期补液及休克期切痂中的护理经验。５２例患者均在入院后立即置入Ｓｗａｎ－Ｇａｎｚ漂浮导管,监测烧伤后血流动力学指标变化,指导休克期复苏及手术切痂。在监测指导下实施快速复苏,所有患者在烧伤后２４ｈ各项血流动力学指标恢复正常,无一例出现并发症。烧伤休克期实施有创血流动力学监测对指导复苏具有重要意义。只要进行精心护理,实施Ｓｗａｎ—Ｇａｎｚ导管监测是安全可靠的。     

床旁超声与PICCO指导ICU脓毒症患者液体复苏的效果研究

目的 探讨床旁超声与脉搏连续心排血量监测(PICCO)指导ICU脓毒症患者液体复苏治疗的效果。方法 选择2020年6月至2022年6月驻马店市中心医院收治的120例脓毒症患者为研究对象，以随机数字表法分为对照组与观察组，每组60例，均行液体复苏治疗。治疗过程中对照组使用PICCO监测，观察组使用床旁超声指导。比较两组血流动力学、液体复苏达标率、临床相关指标及终点事件发生情况。结果 两组治疗前、治疗6 h、治疗12 h血流动力学指标比较，差异未见统计学意义(P>0.05);两组治疗后血流动力学指标均较治疗前改善，差异有统计学意义(P<0.05)。观察组治疗6 h、治疗1 d、治疗3 d液体复苏达标率分别为76.67%(46/60)、85.00%(51/60)、91.67%(55/60),均高于对照组[58.33%(35/60)、65.00%(39/60)、71.67%(43/60)],差异有统计学意义(P<0.05)。两组血管活性药物用量、1个月内病死率比较，差异未见统计学意义(P>0.05);观察组液体复苏量低于对照组，3 d内肺水肿发生率低于对照组，差异有统计...     

有创直接动脉压监测法在危重患者中的应用与护理

目的探讨病情危重和需用血管活性药治疗的患者应用有创直接动脉压监测法的重要性，以及在应用中的观察与护理。方法观察36例病情危重患者应用有创血压监测，通过及早发现血压的变化，指导用药治疗，并制定严密的护理方案，预防并发症的发生。结果本组34例患者血压平稳后拔除置管，2例患者死亡后拔除置管，无一例出现并发症。结论对于病情危重，外周血管强列收缩或痉挛者，自动化无创测压非常困难，而且会影响测量结果，而有创直接动脉压监测则更为准确、方便。但由于有创直接动脉压监测为侵入性操作，在置管期间应及时观察、制定严密的护理方案，预防并发症的发生，提高有创直接动脉压监测的准确性和有效使用率。     

脉搏指数持续心输出量监测在感染性休克患者液体复苏中的应用

目的探讨使用脉搏指数连续心输出量监测(PiCCO)中的容量指标指导液体复苏方案在感染性休克患者早期液体复苏中的应用价值。方法选取明确诊断的感染性休克患者36例,PiCCO组根据监测的胸腔内血容积指数(ITBVI)和血管外肺水指数(EVLW)指导液体复苏,对照组以传统的中心静脉压(CVP)为指导的液体复苏目标。比较两组患者液体复苏治疗效果及预后的差异。结果 PiCCO组患者液体复苏治疗72 h后APACHEⅡ评分、血管活性药物评分和乳酸清除率均较对照组明显改善(P<0.05);PiCCO组与对照组相比28天病死率、住院病死率、住ICU天数、机械通气治疗时间无明显差异(P>0.05);PiCCO组的第一次液体复苏成功率较对照组明显提高(P<0.05),血管活性药物使用时间也较短(P<0.05)。结论 PiCCO中的容量指标指导下的早期液体复苏治疗,可以提高液体复苏的成功率;EVLW指导液体复苏治疗,并不能改善患者的预后。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.