心电技术精准定位结合超声引导头皮针穿刺技术在极低体重儿PICC置管中应用

目的探讨心电P波变化结合超声引导下头皮钢针穿刺技术判断极低体重儿PICC置管尖端定位的安全性、精准性和一次穿刺成功率。方法选择2017年10月至2019年3月行PICC置管的极低体重患儿60例为研究对象,随机等分为对照组和观察组,对照组采用常规穿刺方法置管,观察组采用超声引导下头皮针穿刺结合心电定位技术进行实时监控,根据心电图P波形态变化调整PICC导管置入深度,观察穿刺及送管一次成功率及导管尖端到位精准率。结果观察组患儿一次穿刺成功率、导管到位率均高于对照组(P<0.05),置管操作时间短于对照组(P<0.05),并发症发生率低于对照组(P<0.05)。结论心电技术精准定位结合超声引导头皮针穿刺技术在极低体重儿PICC导管置入过程中应用,可提高一次穿刺成功率和送管成功率,降低导管异位风险,P波形态变化对导管尖端定位精准、安全可行。     

心电精准定位结合超声引导在极低体重儿PICC置管中应用

目的 探讨心电P波变化结合超声引导下头皮钢针穿刺技术判断极低体重儿PICC置管尖端定位的安全性、精准性和一次穿刺成功率。方法 选择行PICC置管的极低体重患儿60例,采用超声引导下头皮针穿刺结合心电定位技术进行实时监控,根据心电图P波型态变化调整PICC导管置入深度,观察穿刺及送管一次成功率及导管尖端到位精准率。结果 60例患儿一次穿刺成功率93.33%,送管一次成功率100%,心电P波型态变化定位极低体重儿PICC导管尖端位置,可行性100%,安全性100%,精准性96.66%。结论 心电技术精准定位结合超声引导头皮针穿刺技术在极低体重儿PICC导管置入过程中,可提高一次穿刺成功率和送管成功率,降低导管异位风险,P波型态变化对导管尖端定位精准、安全可行。     

心电定位在极低体重儿PICC置管中的应用探讨

目的探讨心电定位技术对极低体重儿PICC置管中精准定位导管尖端位置的意义。方法选取2015年7月-2016年6月在本院住院且符合PICC置管指征的116例极低体重儿,将其随机分为对照组和心电定位组各58例,分别采用单一置管完成后的X线定位和心电定位技术置入PICC,比较两组一次穿刺尖端到位率及导管相关性并发症发生率。结果心电定位组一次穿刺尖端到位率为96.55%,明显高于对照组的62.06%,且差异具有统计学意义(P0.05);两组在导管相关性并发症发生率方面差异无统计学意义(P0.05)。结论心电定位技术将置管操作和定位这两项操作集中在床旁一次完成,无需X线检查判断导管位置,对提高极低体重儿PICC置管成功率、减少并发症发生及尖端位置的动态监测有非常重要的作用。     

集束化干预在极低出生体重儿PICC置管中的应用

[目的]观察集束化干预应用于极低出生体重儿经外周静脉置入中心静脉导管(PICC)置管中的效果。[方法]将85例行PICC置管的极低出生体重儿随机分为观察组43例和对照组42例,对照组患儿行常规置管护理,观察组在对照组的基础上行集束化干预,对比分析两组患儿一次性置管成功率、并发症、置管时间、住院时间的差异。[结果]观察组患儿一次性置管成功率高于对照组,导管异位率、堵管、机械性静脉炎发生率、导管感染率低于对照组,经比较差异有统计学意义(P0.05)。观察组置管时间长于对照组、住院时间少于对照组,经比较差异有统计学意义(P0.05)。[结论]集束化干预能有效提高极低出生体重儿一次性置管成功率、延长患儿置管时间、减少置管相关并发症、缩短住院时间。     

极低出生体重儿静脉输液通路的建立与效果观察

目的探讨极低出生体重儿静脉输液通路的建立和管理方法。方法选择2015年9月~2016年12月在本院NICU住院治疗的110例极低出生体重儿为研究对象,分为观察组和对照组。观察组入院时予以脐静脉置管后续PICC置管(60例);对照组入院时予以外周静脉置管后续PICC置管(50例)。观察两组患儿首次置管成功率、平均置管总穿刺次数、PICC一次性置管成功率、置管并发症及恢复出生体重时间。结果观察组首次置管成功率、PICC一次性置管成功率高于对照组,差异有统计学意义(P0.05);观察组平均置管总次数、恢复出生体重时间低于对照组,差异有统计学意义(P0.05);观察组发生腹胀、坏死性小肠结肠炎、导管相关血流感染等并发症的例数与对照组比较,差异无统计学意义(P0.05)。结论极低出生体重儿入院时脐静脉置管后续PICC置管能快速有效建立静脉通道,减少置管总穿刺次数,有利于恢复患儿出生体重。     

脐静脉置管联合PICC在极低出生体重儿中的应用研究

目的:探讨脐静脉置管联合经外周穿刺中心静脉置管(PICC)在极低出生体重儿中的应用价值。方法:选择我院2016年1月~2017年2月收治的极低出生体重儿共97例为研究对象。按照患儿是否适用脐静脉置管分为观察组53例和对照组44例。对照组采用PICC置管,观察组采用脐静脉置管联合PICC置管。比较两组PICC置管1次穿刺成功率、计划性拔管率、体质量增长情况、住院时间以及并发症发生率等。结果:观察组一次置管成功率和计划性拔管率均显著高于对照组。观察组体质量增长和住院时间与对照组差异有统计学意义(P0.05)。观察组并发症发生情况明显低于对照组(P0.05)。结论:相比于PICC置管,脐静脉联合PICC置管在极低出生体重儿中具有更好的应用价值。     

不同送管方法对极低出生体重儿经外周静脉置入中心静脉导管颈内导管异位发生的影响

目的探讨不同送管方法对极低出生体重儿经外周静脉置入中心静脉导管(peripherally insertedcentral catheter,PICC)颈内导管异位发生的影响。方法将2013年10月~2014年9月经贵要静脉行PICC置管的80例极低出生体重儿设为对照组;将2014年10月~2015年9月经贵要静脉行PICC置管的80例极低出生体重儿设为观察组,两组在PICC置管过程中,均采用传统的转颈法预防颈内导管异位发生,观察组当导管头端到达肩部时将穿刺侧上肢向头部上举与操作平台形成30°,送入导管至所需长度。观察两组颈内导管异位发生情况。结果观察组PICC颈内导管异位发生率低于对照组,两组比较,差异有统计学意义(P0.05)。结论行PICC置管中,在传统的转颈法基础上,当导管头端到达肩部时将极低出生体重儿上肢向头部上举与操作平台形成30°,可降低颈内导管异位发生率,从而提高PICC置管成功率。     

适于胎龄与小于胎龄的极低出生体重儿身长增长对PICC尖端移位的影响及比较

目的 探讨极低出生体重儿(very low birth weight,VLBW)中适于胎龄儿(appropriate for gestational age,AGA)和小于胎龄儿(small for gestational age,SGA)身长增长对经外周中心静脉置管(peripherally inserted central catheter,PICC)尖端移位的影响,并横向比较影响程度,帮助医护人员更好地把握导管尖端位置监测的时机。方法 回顾性分析2021年1月—2022年6月在医院NICU住院并使用PICC的VLBW,按出生体质量和胎龄关系分为AGA组45例和SGA组19例,记录首次置管当日身长(Ht₁)以及PICC尖端位置、置管期间胸片检查当日身长(Ht_n)以及PICC尖端位置,并计算相应的身长增长率。身长增长率与PICC尖端移位的相关性用Spearman秩相关分析。将AGA和SGA的身长增长率分别与PICC尖端移位进行简单线性回归分析,构建回归模型,用协方差分析比较两组回归直线。结果 VLBW中AGA组97.8%患儿出现移位,SGA...     

分时段中心静脉置管在极低出生体质量儿中的应用

目的探讨分时段脐静脉置管和经外周静脉置入中心静脉导管(peripherally inserted central catheter,PICC)置管在极低出生体质量儿中的应用效果。方法选取2010年1月—2011年12月入院的极低出生体质量儿111例,分为分时段应用脐静脉置管、PICC组（观察组）51例和外周静脉置管加PICC组（对照组）60例,监测两组住院期间的静脉置管情况、患儿身体指征反应及导管感染情况。结果观察组PICC 1次置管成功率高于对照组,输液外渗发生率低（P<0.01）;两组患儿纠正低血糖所需时间差异无统计学意义;呼吸暂停次数、体质量增长至2 kg时间经比较差异有统计学意义（P<0.01）。结论采用分时段中心静脉置管具有穿刺成功率高,留置时间长,输液外渗发生率低,且不增加感染的优点,能最大限度发挥中心静脉置管的优势,为极低出生体质量儿提供了安全有效的静脉治疗通道,值得在临床中推广应用。     

极低出生体重儿PICC导管异位的相关因素分析与护理防护对策

目的探讨极低出生体重儿PICC导管异位的相关因素,并就此提出相应的护理防护措施。方法回顾性分析我院2016年8月至2018年8月收治的88例极低出生体重PICC置管患儿资料,其中有11例(12. 50%)患儿发生PICC导管异位,命名为发生组,其余77例患者命名为未发生组,分别收集两组患儿一般资料和检查结果,分析影响极低出生体重儿PICC导管异位的因素。结果经单因素分析发现,胎龄、出生体重、置管前机械通气、置管时间、置管静脉、操作者层级为影响极低出生体重儿PICC导管异位的相关危险因素;经多因素logistic回归分析发现,胎龄、出生体重、置管静脉为影响极低出生体重儿PICC导管异位的独立危险因素。结论极低出生体重儿PICC导管异位的独立危险因素包括胎龄、出生体重及置管静脉,因此,应通过恢复标准体重、评估血管、测量置管长度等预防和矫正置管位置。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.