血液净化治疗大负荷军事训练所致横纹肌溶解症并急性肾衰竭的多脏器功能障碍综合征

目的观察血液净化治疗大负荷军事训练所致横纹肌溶解并急性肾衰竭的多脏器功能障碍综合征（MODS）的临床效果。方法回顾性分析1988～2010年10例大负荷军事训练所致横纹肌溶解症并急性肾衰竭的MODS患者的临床资料,观察患者血液净化治疗前后尿素、肌酐、肌酸激酶及同工酶、乳酸脱氢酶、丙氨酸转氨酶、电解质、生命体征变化及预后。结果 10例均行血液净化治疗,其中4例采用单纯血液透析治疗,2例采用血液透析、血液透析滤过交替进行的方法,4例采取持续性血液净化疗法。死亡3例,痊愈出院7例。结论对于大负荷军事训练所致横纹肌溶解症并急性肾衰竭的MODS患者应尽早行血液净化治疗,特别是及时行持续性血液净化治疗可改善患者预后。     

连续性血液净化治疗横纹肌溶解症致急性肾功能衰竭的监测和护理

目的探讨连续性血液净化（CBP）治疗横纹肌溶解症（RM）致急性肾功能衰竭（ARF）的监测和护理。方法对23例RM致ARF患者采取CBP治疗,治疗过程中密切观察病情变化,加强血管通路的建立和保护,密切监测各压力值变化及观察治疗前后血肌红蛋白（Mb）、血尿素氮（BUN）、血肌酐（Scr）的变化。结果23例患者中,死亡3例,存活20例,肾功能得到恢复。结论CBP治疗RM致ARF患者可以改善临床症状,改善肾功能,并降低了RM的死亡率,正确的护理方法在其中起到重要的作用。     

酒精中毒合并横纹肌溶解症的诊治体会

目的：探讨酒精中毒合并横纹肌溶解症（RM）的临床特点、病因及诊治方法。方法：总结分析15例酒精中毒合并横纹肌溶解症患者的临床资料及治疗、预后情况。结果：15例患者均为重度酒精中毒,并发急性肾衰竭（ARF）6例,昏迷时间及饮酒至入院时间长,酗酒合并挤压伤、吸入性肺炎、血糖代谢紊乱是主要原因,行连续性肾脏替代治疗（CRRT）2例,血液透析（HD）1例。痊愈14例（93.3%）,死亡1例（6.7%）,为挤压伤并发尿毒症、多器官功能障碍综合征（MODS）。结论：酒精中毒合并横纹肌溶解症常见于酗酒者,早期都为昏迷患者,酗酒合并挤压伤、感染、血糖异常、电解质紊乱是其主要诱因,血肌酸激酶（CK）是反映RM肌肉损害程度和范围最敏感的指标,RM常并发ARF,MODS是其主要死亡原因。早期诊断,及时去除病因、补液、碱化尿液及合理应用血液净化技术是降低病死率的关键。CRRT可清除细胞破坏崩解产物,对预防和减轻肾功能不全疗效确切。     

血液净化技术在过度训练致横纹肌溶解症并发急性肾衰竭救治中的作用

目的探讨血液净化技术在过度训练致横纹肌溶解症并发急性肾衰竭救治中的作用.方法回顾性地研究1993～2003年37例训练致耗竭性横纹肌溶解症患者的临床救治过程,分析其病情变化规律,探讨治疗时机及不同的血液净化方法对预后的影响.结果①患者均在夏、秋季发病,主要表现为呕吐,发热、头昏、肌肉酸痛等非特异性症状,因此有28例(75.67%)患者入院前被误诊为急性胃肠炎或肠型感冒,21例(56.75%)被采用了庆大霉素等氨基甙类肾毒性药物治疗,使急性肾衰竭(ARF)的诊断和治疗变得愈加复杂;②经过连续性肾脏替代治疗(CRRT)、血液透析(HD)及综合治疗,31例渡过少尿期,肾功能得以恢复.死亡6例,死亡原因为多器官功能衰竭.结论①高温高湿环境因素可加重过度训练后肌肉组织损伤和全身反应;②入院时患者器官功能障碍的数目越多,病死率越高,故早期诊断,及时去除病因及合理应用血液净化技术是降低病死率的关键;③CRRT可清除细胞破坏崩解产物,对预防和减轻肾功能不全疗效确切.     

连续性血液净化治疗在多脏器功能障碍综合征中的应用

多脏器功能障碍综合征（MODS）治疗是医学界一个难题，连续性血液净化（CBP）治疗技术一出现便受到广泛关注，被广泛应用于MODS的治疗。现将我院应用CBP治疗MODS28例总结如下。     

连续血液净化调节多器官功能障碍免疫失衡的研究进展

多器官功能障碍综合征（MODS）的死亡率在40％-60％，是危重患者死亡的主要原因之一。MODS是临床治疗的难点，它的发病机理、病理生理变化及治疗方法也是国际医学界的研究热点。连续性血液净化（CBP）又称为连续性肾脏替代治疗（CRRT），是一种连续、缓慢清除水分和溶质的治疗方式，其适应证已从急性肾衰竭的治疗推广到MODS的救治，并已成为抢救危重病患者的一项主要措施，作为体外循环生命支持系统（ECLS）的重要组成部分，CBP是近年来重症监护医学治疗最重要的进展之一。     

高容量血液滤过在多器官功能障碍综合征治疗中的应用

连续性血液净化（CBP）被作为“最后的治疗手段”,在重症监护病房危重病患者抢救中的应用越来越广泛。高容量血液滤过（HVHF）为CBP方式之一,能持续缓慢清除体内溶质和过多水分,有利于多器官功能障碍综合征（MODS）患者的救治。2002年5月至2003年7月,我们对9例MODS患者进行HVHF治疗,将治疗前后心、肺、肾功能等进行比较,报告如下。     

连续性血液净化救治多器官功能障碍综合征10例分析

目的观察连续性血液净化(CBP)对多器官功能障碍综合征(MODS)的治疗效果。方法对10例MODS患者给予CBP中最常用的连续性静静脉血液透析滤过方式治疗,分别检测CBP前后血生化指标并进行比较。结果好转7例,死亡3例;血尿素氮及肌酐等水平均较治疗前明显下降(P<0.01)。结论连续性静静脉血液透析滤过方法在危重患者的抢救中是一种行之有效的方法。     

连续性血液净化对内皮细胞组织因子活性的影响及相关因素分析

目的探讨连续性血液净化（CBP）对体外培养内皮细胞组织因子（TF）活性的影响及其相关因素。方法采用脐静脉内皮细胞株培养、一期凝固法检测组织因子活性；酶联免疫吸附法测定血清TNF—α，IL-1β浓度。结果连续性血液净化能有效清除多器官功能障碍（MODS）患者血清TNF-α，IL-1β等细胞因子；体外培养内皮细胞经MODS患者血清刺激后组织因子活性较空白对照组明显升高（P〈0．05）。经CBP治疗后，患者血清对内皮细胞TF活性的影响呈下降趋势，与治疗过程中血清TNF-α，IL-1β变化趋势一致，呈正相关（TNF—α：r=0．655，P〈0．05；IL-1β：r=0．630，P〈0．05）。肿瘤坏死因子呈剂量依赖性增加内皮细胞组织因子活性（r=0．899，P〈0．01），而肝素对TF活性无明显影响。结论连续性血液净化可以部分改善MODS患者内皮细胞功能，降低内皮细胞组织因子活性，其机制可能通过清除TNF-α，IL-1β等细胞因子而实现。     

连续性血液净化在多器官功能障碍综合征病人中的应用及护理

[目的]探讨连续性血液净化（CBP）辅助治疗多脏器功能障碍综合征（MODS）病人的临床应用,总结护理措施。[方法]回顾性分析35例MODS病人行CBP治疗的临床资料,比较治疗前后病人的生化指标、平均动脉压、心率、氧合指数和急性生理学及慢性健康状况评分Ⅱ（APACHEⅡ）的变化。[结果]35例病人好转15例（42.9%）,死亡20例（57.1%）;15例病人治疗后病人的血肌酐、尿素氮、心率和APACHE-Ⅱ评分低于治疗前（P〈0.05）,平均动脉压和氧合指数无明显变化。[结论]MODS病人行CBP治疗,可改善病人的血液生化指标,维持内环境的稳定,为进一步治疗争取了时间,从而提高救治成功率;加强血液净化技术对改善MODS病人的预后有重要作用。     

The clearance of Procalcitonin (PCT) during continuous veno-venous hemodiafiltration (CVVHD)

Objective. To evaluate the Procalcitonin (PCT) clearance during continuous veno-venous hemodiafiltration (CVVHD).?Design. Case report?Setting. Surgical intensive care unit?Patient. 51-year-old man, who had undergone total thyroidectomy about ten years before owing to multiple endocrine neoplasia 2 (MEN 2), suffering from multiple organ dysfunction syndrome (MODS) with acute renal failure after severe trauma caused by a traffic accident.?Measurements and main result. The samplings of prefilter (afferent) and post-filter (efferent) blood and of ultradiafiltrate were 6 times performed during 24 h of CVVHD to calculate the PCT clearance of hemdiafiltration.?During the first half period of CVVHD the serum PCT concentration did not decrease, though PCT had been eliminated from serum. On the other hand during the latter half period of it the serum PCT value decreased (from 46.8 ng/ml to 29.4 ng/ml) and the amount of the eliminated PCT from serum was about 100 ng per minute and its clearance was 2.3 ∼ 3.4 ml/min.?Conclusion. The CVVHD could eliminate PCT from serum. First it was brought about by the adsorption by the filter menbrane and then by ultradiafiltration. Received: 25 February 1999/Final revision received: 31 May 1999/Accepted: 9 June 1999     

人工通气在非心脏疾患致心搏呼吸骤停心肺脑复苏中价值的探讨

目的　评价人工气道建立和有效通气在非心脏疾患引起心搏骤停患者心肺脑复苏 (CPCR)中的真正价值 ,分析与总结有效人工通气与Ⅰ、Ⅱ、Ⅲ期复苏成功率之间关系 ,探讨对这类患者采取CPCR的抢救步骤和时机 ,为临床采取切实有效CPCR步骤提供依据。方法　选择非单纯心脏疾患致心搏呼吸停止行CPCR患者 2 6例作为分析对象。按照心肺复苏(CPR)实际操作过程中所采取的方法不同 ,将患者分为CAB组 (12例 / 12例次 )和ABC组 (14例 / 18例次 )。CAB组中 ,按照C与AB步骤采取的间隔时间不同 ,分为 <5min、5～ 10min、>10min组 ;ABC组中 ,部分患者在发生心搏骤停以前 ,已经建立人工气道和接受有效通气治疗 ,一旦心搏骤停发生后 ,在AB措施已经存在条件下进行心脏复苏。统计与计算各组复苏成功率(% ) ,χ2 检验各组差异显著性。结果　CAB组患者接受C -AB间隔时间不等 ,Ⅰ、Ⅱ期复苏成功率无显著差异 ,但Ⅲ期复苏成功率差异显著 (P <0 0 5 )。ABC组Ⅲ期复苏成功率分别为 83 3% (15 / 18)、77 7% (14 / 18)、6 6 7% (12 / 18) ,与CAB组总体比较无显著差异 (P >0 0 5 )。结论　虽然CAB对非单纯心脏疾患致心搏呼吸骤停的患者也是可取的CPCR抢救步骤 ,但及时建立人工气道进行有效通气仍是不可忽视的重要步骤 ,尤其当 5min内     

动脉瘤性蛛网膜下腔出血病人血清FSH LH PRL GH的浓度变化

目的　研究动脉瘤性蛛网膜下腔出血 (SAH)病人血清卵泡刺激素 (FSH)、黄体生成素 (LH)、泌乳素 (PRL)、生长激素 (GH)的浓度变化规律。方法　对 35例动脉瘤性SAH病人发病后 1～ 3、7～ 9、13～ 15d血清FSH、LH、PRL、GH的浓度进行动态观察 ,用TCD检测大脑中动脉血流速度 (VMCA)。结果　动脉瘤性SAH病人血清FSH、LH、PRL、GH浓度在发病后 1～3、7～ 9d各均值明显高于对照组 ,尤以发病后 7～ 9d变化最明显 ;术前、术后有脑血管痉挛 (CVS)组和非CVS组也有明显差异。结论　动脉瘤性SAH病人血清FSH、LH、GH、PRL含量与SAH的病情演变、CVS程度有关 ,并可判断预后。     

Creatine kinase and myoglobin determination in myocardial infarction

Summary In order to evaluate the diagnostic and prognostic impertance of serum myoglobin (Mb) determination during acute myocardial infarction (AMI) we determined the time of first rise of both CK and Mb, that is the time in hours between the onset of pain and the last normal myoglobin and enzyme determination (TFR for Mb=2.2±1.5 h; TFR for CK=4.0±2.5 h). We also attempted to evaluate infarct size by mathematical analysis of the serum concentrations of Mb. The average percentage difference between the infarct size calculated from the CK concentrations and Mb concentrations was 35.8±35.2%. The results show that the determination of serum myoglobin is a useful and sensitive test for the early diagnosis of AMI. On the other hand, the serum myoglobin cannot be utilized to evaluate infarct size. The main limitation in the determination of infarct size from the serum Mb concentrations lies in the extreme variability of the disappearance rate (Kd), mainly resulting from the renal elimination of the substance.     

Ultrasonic study of venous patterns in the right hypochondrium: An anatomical approach to differential diagnosis of obstructive jaundice

Through real time ultrasonography, it is possible to display the splenic vein, the superior mesenteric vein, the vena porta, and the intrahepatic portal and systemic veins. In jaundice, it is of the utmost importance to carefully identify the vena porta before making a diagnosis of common bile duct enlargement. It is also necessary, when confronted with a pattern of apparently enlarged intrahepatic ducts, to conduct a thorough study of possible confluences of the ducts with the vena porta or vena cava to be certain that the ducts are not part of the portal or systemic venous network. Without such differentiation, portal enlargement caused portal hypertension, systemic venous enlargement caused cardiac insufficiency, or even nonpathological wide veins may lead to an erroneous diagnosis of obstructive jaundice.     

Quality management of potential chemotherapy-induced neutropenic complications: evaluation of practice in an academic medical center

Goals

Management of the risk of potential chemotherapy-induced neutropenic complications such as febrile neutropenia (FN) and severe neutropenia (SN) is a quality of care priority. How frequently does care at our institution conform to established guidelines?

Materials and methods

This retrospective chart review study included a random sample of 305 cancer patients receiving care at a single US academic medical center. Abstracted data included demographics, risk factors, and outcome variables (e.g., development of FN/SN, administration of myeloid growth factors). To evaluate quality of care, we assessed conformance between actual practice and established clinical practice guidelines for the use of myeloid growth factors from the National Comprehensive Cancer Network (NCCN).

Main results

Of the 305 cases reviewed, 8% were classified as low risk (<10%), 48% as intermediate risk (10–20%), and 44% as high risk (>20%), using the risk classifications in the NCCN guidelines modified to accommodate illness and other risk factors. Thirty-four percent received prophylactic administration of myeloid growth factors. Half of the cases had adequate documentation of mid-cycle absolute neutrophil count to determine whether FN/SN developed. Among these cases with adequate documentation, 21% developed FN/SN. Use of growth factors did not conform to established quality guidelines. Overall, 77 of 133 (58%) high-risk cases received myeloid growth factors, whereas six of 25 (24%) low-risk cases received myeloid growth factors.

Conclusions

Routine clinical practice in this academic oncology setting was poorly aligned with established guidelines; there is substantial opportunity to standardize clinical strategies and increase conformance with evidence-based guidelines.     

颅脑外伤急性期血清镁离子浓度的变化

目的 探讨急性颅脑外伤（ACI）患者血清镁离子浓度变化特点及其对脑细胞功能代谢的影响.方法 85例ACI患者,GCS＞8分35例,GCS≤8分50例,测定血清镁离子浓度、钙离子浓度、脑血管痉挛发生率、脑血氧饱和度.观察低镁血症患者一个月后GOS预后评分及外源性硫酸镁的临床疗效.结果 85例ACI患者血清镁离子浓度明显低于30例正常对照组患者,且降低程度与脑伤程度呈正相关;GCS≤8分者低镁血症发生率明显高于GCS＞8分者;低镁血症患者其脑血管痉挛发生率明显高于对照组,脑血氧饱和度明显低于对照组,GOS评分≤3分者明显多于对照组;24 h内给予硫酸镁能明显提高GOS评分.结论 镁离子浓度的降低直接参与了ACI时继发性脑损害,与伤情及预后密切相关.早期给予硫酸镁对脑组织有明确的保护作用,且它价廉、安全,来源丰富,故有广泛应用前景.     

Low-Intensity Ultrasound Reduces High Glucose-Induced Nitric Oxide Generation in Retinal Pigment Epithelial Cells

Diabetic retinopathy (DR) is a severe micro-vascular complication of diabetes. High glucose (HG)-evoked nitric oxide (NO) production mediated by increased oxidative stress is a key factor in DR pathogenesis. In this study, we examined whether low-intensity ultrasound (LIUS) stimulation can reduce HG-induced NO generation. We determined that LIUS stimulation decreased the HG-induced NO generation possibly via inhibition of reactive oxygen species (ROS) and subsequently diminished the associated pro-inflammatory pathway involving the induced expression of inducible nitric oxide synthase, cyclooxygenase-2 and vascular endothelial growth factor. In addition, we determined that LIUS stimulation reduced the quantity of NO produced by N-acetylcysteine, which was not mediated by ROS. These results indicate that LIUS can inhibit both ROS-dependent and -independent NO generation processes in ARPE-19 cells. We envision LIUS as a potential therapeutic alternative to treat DR. Further studies are required to understand the underlying mechanism of the LIUS-induced reduction of NO generation for DR therapy.