老年人肺部感染合并胃潴留的临床分析

目的明确老年人肺部感染患者并发胃潴留的相关危险因素,及胃潴留与患者疾病严重度、预后的火系,以利预防和及时处理,减少老年患者的死亡率。方法用Logistic同归分析方法分析83例不同程度肺部感染患者并发胃潴留的相关危险因素,如感染的病情、脑血管意外、尿毒症、代谢性酸中毒、低血钾、低血钙、MODS、机械通气等情况;分析并发MODS患者器官功能小全数与胃潴留存在是否相关;并分析胃潴留患者的预后。结果病情严重（APACHE Ⅱ评分高者）、尿毒症、代谢性酸中度、低钾血症、脑血管意外、MODS、机械通气等是老年人肺部感染继发胃潴留的危险因素;老年人肺部感染并发MODS患者,脏器功能衰竭的数量与胃潴留的发生成正相关;老年人肺部感染并发胃潴留者预后差,死亡率高。结论提示老年人肺部感染者发生胃潴留与多种因素有关．尤其是并发MODS患者,听且病情越严重,胃潴留发生越多,预后差。     

老年人腹部手术后急性胃轻瘫11例临床分析

目的 探讨老年人腹部手术后胃轻瘫的诊断与治疗方法。方法 总结2002年5～12月11例老年人腹部手术后发生胃轻瘫的临床资料，主要观察患者每天胃肠减压量、腹部体征，分析其诊治情况。结果 11例均符合胃轻瘫的诊断标准，胃肠减压量850～2450ml／d，平均1050ml／d，无腹部压痛，肠鸣音减弱。经禁食、胃肠减压、静脉输注小剂量红霉素及胃管内给予吗叮啉、针灸、中药大承气汤等综合保守治疗，痊愈。胃肠功能恢复时间为16～32d，平均24d。结论 老年人胃轻瘫可以发生在腹部大手术后，主要由于胃功能异常所致，保守治疗为主要治疗方法。     

红霉素对糖尿病患者胃轻瘫的影响

红霉素对糖尿病患者胃轻瘫的影响张传继，丛培喜，毛学忠，曹洪贤，刘学兰糖尿病患者常伴胃轻瘫［１］，其关键病理生理机制是与胃排空延迟有关的胃动力异常或胃－幽门－十二指肠动力异常。近年研究发现红霉素能与胃肠道平滑肌细胞上的胃动素受体结合，产生促胃动力作用［...     

肠内及肠外营养在根治性远端胃大部切除术后胃瘫治疗中的作用

目的:比较肠内营养(enteral nutrition,EN)与肠外营养(parenteral nutrition,PN)在根治性远端胃大部切除术后胃瘫治疗中的作用,探究术后胃瘫治疗中的适当营养方式.方法:52例根治性胃大部切除术后胃瘫患者,按术后营养治疗方式分为EN组(n=36)和PN组(n=16),分别给予EN或PN治疗.比较两组平均胃排空功能恢复时间和血红蛋白、总蛋白、白蛋白的差异.结果:EN组平均胃排空功能恢复时间低于PN组,组间比较差异无显著性(25.3d vs28.2d,P>0.05).治愈后EN组血红蛋白、总蛋白、白蛋白水平与PN组比较差异无显著性(均P>0.05).E N组患者营养支持费用明显低于PN组(398.74元/d±47.68元/d vs512.77元/d±54.31元/d,P<0.05).与治疗前比较,EN组治疗后的血红蛋白、总蛋白、白蛋白均明显升高,差异均有统计学意义(123.25g/L±15.68g/Lvs117.25g/L±13.28g/L;70.34g/L±12.85g/Lvs65.13g/L±10.76g/L;40.65g/L±8.15g/Lvs36.20g/L±9.16g/L,均P<0.05);PN组治疗后血红蛋白(125.14g/L±13.39g/Lvs120.32g/L±14.67g/L)和总蛋白变化较大(67.52g/L±13.09g/Lvs64.23g/L±12.47g/L,P<0.05),而白蛋白仅略升高(P>0.05).治疗前后EN组血红蛋白、总蛋白及白蛋白的变化幅度均明显高于PN组各项指标,且差异均有统计学意义(P<0.05).结论:EN对术后胃瘫的全身支持及减少并发症的发生有着积极的治疗作用,是术后胃瘫的营养治疗中的安全有效措施.     

糖尿病胃动力障碍和促胃动力药的作用

目的 研究2型糖尿病(DM)胃动力变化和观察西沙必利对DM胃轻瘫的疗效。方法 对74例2型DM患者以SPECT显像技术用核素标记~(113)In液体试餐、~(99m)Tc固体试餐测定胃半排空时间(GET_(1/2))和进行胃电图(EGG)检查,同时检测空腹血糖(FBG)。结果 (1)22例FBG≤7.8mmol/L的糖尿病患者,未见GET_(1/2)延迟;52例FBG>7.8mmol/L的糖尿病患者,36例(69.2％)固相GET_(1/2)延迟,其中14例伴液相GET_(1/2)延迟(P<0.01)。(2)正常对照组和DM组的空腹和餐后胃电图主频、平均过零频率差异均无显著性,两组餐后振幅均显著高于空腹(P<0.05)。DM组的胃电节律紊乱率较对照组显著增高(P<0.05)。(3)FBG>7.8mmol/L的DM患者,核素胃排空(RGE)与EGG相关。(4)36例DM胃轻瘫分两组:A组降糖药加西沙必利和B组单用降糖药用药4周。A组对胃轻瘫有效率85％,B组无效。结论FBG与DM患者胃排空呈负相关;血糖控制不良的DM患者,RGE与EGG相关;西沙必利对DM胃轻瘫有一定疗效。     

胃起搏对胃动力紊乱犬胃排空及胃肌电活动的影响

目的　研究胃起搏对胃动力紊乱犬胃排空及胃电参数的影响。方法　采用双侧迷走神经干切断术联合应用胰高血糖素建立胃动力紊乱犬模型 ;采用 4导联胃肠电系统微机分析仪记录胃肠浆膜肌电活动 ;99mTc 植酸钠标记的半固体试餐 ,单光子计算机断层显像技术 (SPECT)检测胃半排空时间(GEt1/ 2 ) ;采用适宜起搏参数从胃体、胃窦在腹部投影部位输入起搏信号驱动胃电节律。结果　迷走神经干切断术后犬的GEt1/ 2 为 (79.4 2± 1.91)min ,较术前 (5 6 .35± 2 .99)min明显延迟 (P <0 .0 0 1) ,但行胃起搏治疗后GEt1/ 2 为 (6 4 .94± 1.75 )min ,较治疗前明显加快 (P <0 .0 0 1) ;胃起搏治疗前迷走神经干切断犬餐后的胃电频率为 (0 .0 81± 0 .0 0 7)Hz、胃电幅度为 (2 .32± 0 .35 )mV、慢波的传播速度为 (4 .0 6± 0 .4 0 )cm/s ,均较正常对照犬显著降低 [(0 .0 90± 0 .0 0 6 )Hz ,(4 .2 5± 0 .12 )mV ,(6 .92± 0 .2 4 )cm/s,(P <0 .0 5 ) ],治疗后其餐后胃电频率 (0 .0 92± 0 .0 0 5 )Hz、胃电幅度 (3.97± 0 .19)mV和慢波的传播速度 (5 .5 7± 0 .4 8)cm/s均明显高于治疗前 (P <0 .0 5 )。结论　采用适宜起搏参数输入起搏信号可完全触发胃电慢波 ,改善胃电参数 ,纠正药物导致的异常胃电节律 ,加速胃排空 ,恢     

早期滋养型肠内营养在神经外科中老年重症患者中的临床效果

目的 探究早期滋养型肠内营养支持对神经外科中老年重症患者的影响.方法 选择术后或伤后24 h内入住神经外科NICU救治的中老年重症患者48例,采用随机数字表法随机分为早期滋养组与足量喂养组,早期滋养组给予早期滋养型喂养,足量喂养组给予早期足量喂养;观察对比两组胃肠耐受性、血糖代谢指标、生化指标、临床相关指标、新发感染情...     

糖尿病大鼠胃排空功能与胃组织瘦素的关系

大量文献已证实瘦素可抑制胃排空，胃排空延迟是糖尿病常见的并发症。目的：探讨不同病期糖尿病胃排空延迟与胃组织瘦素的关系。方法：40只Wistar大鼠分为对照1周组（NC1组）、对照4周组（NC2组）、糖尿病病期1周组（DM1组）和糖尿病病期4周组（DM2组）。分别于注射链佐霉素或柠檬酸缓冲液1、4周后检测大鼠胃排空、胃组织瘦素和瘦索受体OB—RbmRNA的表达。结果：与NC1组相比，DM1组大鼠胃排空明显加快（P〈0．01），胃组织瘦素表达显著增加（P〈0．01），OB—RbmRNA的表达无显著差异。与NC2组相比，DM2组大鼠胃排空明显减缓（P〈0．01），瘦素表达显著降低（P〈0．01），OB—RbmRNA的表达无显著差异。结论：随着糖尿病病期的持续，大鼠胃排空由加速转为延迟．胃组织瘦素表达反馈性由增加转为减少。     

不同阶段糖尿病胃运动障碍诊治对策

糖尿病患者常见胃运动障碍,表现为上腹胀、早饱、上腹不适、恶心、呕吐等症状以及胃排空延迟,胃排空延迟影响降血糖药的药代动力学,造成餐后血糖升高与降血糖药或胰岛素的血浓度高峰不匹配,进而影响血糖的控制与稳定。糖尿病不同阶段胃运动障碍表现形式不同。核素法是最常用的胃排空诊断方法。糖尿病胃运动障碍的处理包括饮食调节、促动力药以减轻症状、控制血糖,针对胃轻瘫的治疗包括胃电刺激、内镜下幽门注射肉毒杆菌毒素A、内镜下放置鼻胃空肠营养管或经皮内镜下胃（空肠）造瘘、外科手术等。     

埋置胃肌电起搏电极后胃肌电活动演变的研究

目的探讨胃埋置电起搏电极后胃肌电活动演变过程。方法7条纯种比格犬,每1条犬通过开腹手术沿胃大弯浆膜层埋置4对心脏起搏电极。术后第1天开始记录进食固体食物(200g/只)前后30min胃慢波,连续记录7d后,间隔3周再次用同样方法记录胃肌电活动1次。结果(1)与术后第1天相比,术后第2天的空腹正常胃慢波百分率无明显改变(P>0.05)。而术后第3、4、5、6、7天明显降低(P<0.05)。(2)从术后第1天至第7天,与相应天数的空腹胃慢波相比,进食后正常胃慢波百分率增加(P<0.05),主功增高(P<0.05)。(3)手术后第3周,所有犬的进食前后正常胃慢波百分率均>70%。与空腹胃慢波相比,进食后主功增加(P<0.05)。结论犬胃埋置胃肌电起搏电极后胃肌电紊乱在术后第3天出现,之后逐步恢复。进食后胃肌电紊乱改善的特征是否预示胃肌电紊乱能够恢复正常尚待明确。     

Effects of nosocomial candidemia on outcomes of critically ill patients

PURPOSE: To determine whether nosocomial candidemia is associated with increased mortality in intensive care unit (ICU) patients. SUBJECTS AND METHODS: We performed a retrospective (1992 to 2000) cohort study of 73 ICU patients with candidemia and 146 matched controls. Controls were matched based on disease severity as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/- 1 point), diagnostic category, and length of ICU stay before onset of candidemia. RESULTS: In comparison with the control group, patients with candidemia developed more acute respiratory failure (97% [n = 71] vs. 88% [n = 129], P = 0.03) during their ICU stay. They were mechanically ventilated for a longer period (29 +/- 26 days vs. 19 +/- 19 days, P<0.01) and had a longer stay in the ICU (36 +/- 33 days vs. 25 +/- 23 days, P = 0.02) as well as in the hospital (77 +/- 81 days vs. 64 +/- 69 days, P = 0.04). There was no difference in in-hospital mortality between the groups (48% [n = 35] vs. 43% [n = 62], P = 0.44), a difference of 5% (95% confidence interval [CI]: -8% to 19%). In a multivariate analysis, older age (hazard ratio [HR] = 1.13 per 10 years; 95% CI: 1.04 to 1.23; P = 0.004), acute renal failure (HR = 1.4; 95% CI: 1.1 to 2.0; P = 0.02), and unfavorable APACHE II scores (HR = 1.10 per 5 points; 95% CI: 1.00 to 1.20; P = 0.05) were independent predictors of mortality. Candidemia was not associated with mortality in a model that adjusted for these factors (HR = 0.9; 95% CI: 0.7 to 1.2; P = 0.53). CONCLUSION: Nosocomial candidemia does not adversely affect the outcome in ICU patients in whom mortality is attributable to age, the severity of underlying disease, and acute illness.     

危重患者血糖波动与血清炎症因子水平及病情预后的相关性

目的探讨重症监护病房（ICU）危重患者的血糖波动与血清炎症因子c反应蛋白（CRP）、肿瘤坏死因子-α．（TNF-d）、白细胞介素-6（IL-6）和患者病情及预后的相关性。方法选择2010年1月至2011年1月入住北京军区总医院ICU病房的非糖尿病危重患者共60例,其中男38例、女22例,平均年龄（55±9）岁,急性生理学及慢性健康状况评估Ⅱ（APACHEII）评分〉10分,符合应激性高血糖诊断且糖化血红蛋白为4％-6％。患者入科12h内佩戴动态血糖监测系统（CGMS）,监测平均血糖波动幅度（MAGE）,测定空腹血清CRP、TNF．0l和IL-6水平,分析MAGE与炎症因子水平变化及与APACHEⅡ评分的关系;追踪观察患者28d预后。组间比较采用t检验。结果Pearson相关分析显示危重患者入科24h内MAGE与炎症因子CRP、TNF-d、IL-6及APACHERⅡ评分显著相关（r=0．622、0．505、0．509、0．597,均P〈0．01）。多元线性回归分析结果显示,MAGE和IL-6及性别对ICU患者APACHERlI评分的影响作用较大（β=0．155、0．768、-0．209,t=2．879、8．375、-3．170,均P〈0．05）。死亡病例MAGE及APACHEII评分均明显高于存活病例[MAGE分别为（3．34-1．0）、（5．1±2．0）mmol／L,APACHEⅡ分别为（21±3）、（26±5）分,均P〈0．01）]。多元logistic回归分析显示,MAGE可影响患者预后（OR=4．401,95％CI：2．185-6．618,P〈0．05）。结论危重患者血糖波动幅度与血清炎症因子水平及病重程度密切相关;血糖变异度高可作为ICU危重患者预后的独立预测因子。     

重症监护室患者并发急性肾功能衰竭的临床特点及预后评估

目的 探讨重症监护室(ICU)患者并发急性肾功能衰竭(ARF)的特点及对其预后的评估.方法 回顾性收集2004年12月至2005年4月广东省人民医院ARF患者的临床资料,并对每例患者入住ICU 24 h内进行APACHEⅡ、SAPSⅡ、SOFA和ATN-ISI评分,分析影响患者预后的危险因素.结果 ICU患者并发ARF 41例,占同期ICU患者的19.1%,其中死亡21例(51.2%),机械通气比例65.9%,血管活性药物使用率46.3%,少尿发生率41.5%,平均器官衰竭数目2.16个.APACHEⅡ积分17.3分、SAPSⅡ积分52.0分、SOFA积分9.26分、ATN-ISI积分0.54分.Cox回归分析显示,器官衰竭数目和机械通气是ARF患者ICU 28 d死亡的危险因素,RR值分别为2.54[95%可信区间1.316～4.913)(P=0.006)]和6.0[95%可信区间1.102～32.600(P=0.038)].ROC曲线分析显示,APACHEⅡ、SAPSⅡ、SOFA和ATN-ISI 4个积分系统在预测ARF患者病死率时均有意义,曲线下的面积分别为0.848[95%可信区间0.722～0.974(P＜0.001)]、0.880[95%可信区间0.767～0.994(P＜0.001)]、0.851[95%可信区间0.726～0.976(P＜0.001)]和0.956[95%可信区间0.896～1.026(P＜0.001)].结论 重症监护室患者并发ARF时预后差;器官衰竭数目和机械通气是ARF患者死亡的独立危险因素;APACHEⅡ、SAPSⅡ、SOFA和ATN-ISI 4种积分模型对ARF患者的病死率均有较好的预示作用,ATN-ISI的预测效果可能最优.     

New-onset atrial fibrillation in critically ill patients

New-onset atrial fibrillation is a common problem in critically ill patients, with reported incidence ranging from 5% to 46%. It is associated with significant morbidity and mortality. The present review summarizes studies investigating new-onset atrial fibrillation conducted in the critical care setting, focusing on the etiology, management of the hemodynamically unstable patient, rate versus rhythm control, ischemic stroke risk and anticoagulation. Recommendations for an approach to management in the intensive care unit are drawn from the results of these studies.     

早期肠内营养联合益生菌对呼吸科危重症患者营养状况的影响

目的探讨早期肠内营养联合益生菌对呼吸内科ICU患者营养状况改善的临床效果。方法 80例患者随机分为研究组和对照组各40例,两组患者均采用肠内营养支持,经鼻饲泵入瑞素,研究组患者在此基础上,每日于患者肠内营养支持前半小时,经鼻饲给予合生元益生菌。结果研究组患者不良反应率明显低于对照组(P<0.05),研究组患者达到肠内营养目标供给量所需的平均时间明显快于对照组(P<0.05)。结论联合益生菌的治疗方法可加强患者胃肠道对营养的接受程度和吸收速度,提高治疗效果。     

Macrolide use in the treatment of critically ill patients with pneumonia: Incidence,correlates, timing and outcomes

BACKGROUND:

Macrolide antibiotics are commonly used to treat pneumonia despite increasing antimicrobial resistance. Evidence suggests that macrolides may also decrease mortality in severe sepsis via immunomodulatory properties.

OBJECTIVE:

To evaluate the incidence, correlates, timing and mortality associated with macrolide-based treatment.

METHODS:

A population-based cohort of critically ill adults with pneumonia at five intensive care units in Edmonton, Alberta, was prospectively followed over two years. Data collected included disease severity (Acute Physiology and Chronic Health Evaluation [APACHE] II score), pneumonia severity (Pneumonia Severity Index score), comorbidities, antibiotic treatments at presentation and time to effective antibiotic. The independent association between macrolide-based treatment and 30-day all-cause mortality was examined using multivariable Cox regression. A secondary exploratory analysis examined time to effective antimicrobial therapy.

RESULTS:

The cohort included 328 patients with a mean Pneumonia Severity Index score of 116 and a mean APACHE II score of 17; 84% required invasive mechanical ventilation. Ninety-one (28%) patients received macrolide-based treatments, with no significant correlates of treatment except nursing home residence (15% versus 30% for nonresidents [P=0.02]). Overall mortality was 54 of 328 (16%) at 30 days: 14 of 91 (15%) among patients treated with macrolides versus 40 of 237 (17%) for nonmacrolides (adjusted HR 0.93 [95% CI 0.50 to 1.74]; P=0.8). Patients who received effective antibiotics within 4 h of presentation were less likely to die than those whose treatment was delayed (14% versus 17%; adjusted HR 0.50 [95% CI 0.27 to 0.94]; P=0.03).

CONCLUSIONS:

Macrolide-based treatment was not associated with lower 30-day mortality among critically ill patients with pneumonia, although receipt of effective antibiotic within 4 h was strongly predictive of survival. Based on these results, timely effective treatment may be more important than choice of antibiotics.     

胰岛素强化治疗对危重病患者预后的影响

在创伤、感染、重大手术后和其它危重患者病程中,高血糖和胰岛素抵抗普遍存在,且危害性大、预后不良。在众多预防与治疗措施中,胰岛素强化治疗(IIT)可以改善危重患者的高血糖及其毒性状态,减少其并发症与死亡率,疗效优于传统治疗方案。但IIT也存在一些争议之处。适应证的选择、最佳血糖控制目标、个体化方案和治疗时间等是治疗成功的关键。     

Variability in the use of thromboprophylaxis and outcomes in critically ill medical patients

Purpose

To describe practices for preventing venous thromboembolism in critically ill medical patients and to identify associations between prophylactic measures and survival.

Methods

We reviewed the records of all medical admissions to the intensive care units of a university hospital and an affiliated Veterans Affairs hospital over a 1-year period. We recorded patients’ demographic characteristics, risk factors for venous thromboembolism, methods of prophylaxis, and in-hospital deaths.

Results

We identified 272 critically ill medical patients who received intensive care for at least 24 hours. Some form of prophylaxis was used in 205 patients (75%), including pharmacologic prophylaxis alone in 55 (20%), mechanical prophylaxis alone in 102 (38%), and both methods in 48 (18%). In-hospital mortality rates were 23% (24/103) for patients who received pharmacologic prophylaxis, and 36% (61/169) for those who received mechanical prophylaxis alone or no prophylaxis (P = .03). After adjusting for demographic characteristics, risk factors for thrombosis and severity of illness, the odds of death were 55% lower in patients who received pharmacologic prophylaxis (odds ratio [OR] = 0.45; 95% confidence interval (CI): 0.22 to 0.93; P = .03). Similar results were obtained in propensity-adjusted and propensity-stratified analyses. Use of mechanical prophylaxis was not associated with survival (OR = 0.88; 95% CI 0.44 to 1.77; P = .73).

Conclusion

In this cohort of critically ill medical patients, pharmacologic but not mechanical thromboprophylaxis was associated with reduced risk of in-hospital death. This hypothesis must be tested in randomized trials.     

危重症患者早期动态血糖时间窗对患者疾病转归的影响

目的 探讨重症监护病房(ICU)危重症患者早期(24 h内)血糖情况对患者转归的影响.方法 选择2012年3月至2013年3月入住我院ICU的104例患者,入科24 h内进行急性生理学及慢性健康状况评分系统(APACHEⅡ)评分和动态血糖监测.对死亡组和存活组低血糖总时间、正常血糖总时间、高血糖总时间及APACHEⅡ评分进行比较,将有统计学差异的血糖指标按四分位数间距将患者分为G1(P0-P25) 、G2(P25-P50)、G3(P50-P75)、G4(P75-P100)四个亚组,采用方差分析和卡方检验的方法来评估随着血糖情况、APACHEⅡ评分、死亡率的变化.结果 死亡组中APACHEⅡ值[(32.5±7.6)分]、低血糖时间窗[2.29(0～ 7.68)分]、高血糖时间窗[14.3(3.36～ 24.00)分]均明显高于存活组[(19.9±6.5)分、0.41(0～ 2.88)、3.8(0～12.96)h],两组差异均有统计学意义(t=5.65、Z=-2.01,-3.01,均P＜0.05),死亡组的正常血糖时间窗[7.41(0.24～ 17.52)h]明显低于存活组[19.79(11.28～ 24.00)h],两组差异有统计学意义(Z=-3.95,P＜0.01).亚组分析显示,随着正常血糖时间窗的增加,危重症患者APACHEⅡ分值呈逐渐下降趋势(F=32.20,P＜0.01);随着高血糖时间窗的增加,危重症患者APACHEⅡ分值呈逐渐升高趋势(F=18.71,P＜0.01);低血糖时间窗的比较分析显示,是否发生低血糖,患者APACHEⅡ评分差异无统计学意义(t=-l.3,P＞0.05).结论 危重症患者早期正常血糖时间窗越长,危重症患者的转归越好,高血糖时间窗越长则患者预后出现变差趋势.