硝酸酯药物临床应用新进展

硝酸酯是治疗心血管疾病历史悠久的一类药物，临床应用已有一百多年历史，其疗效确切，尤其近20年发展迅速，从最初的不同种类硝酸酯（不同化学结构）到不同的给药途径、不同的制剂，而且还扩大了临床用药指征。近20年来从临床治疗到作用机制的研究均有新的进展和突破。单硝酸异山梨醇酯是硝酸酯类发展过程中最后一个化学物质。1972年美国开始对口服二硝酸山梨酯的代谢产物进行一系列的研究，二年后研制出2-单硝酸异山梨酯和5-单硝酸异山梨酯。     

冠心病人合理使用硝酸酯

硝酸酯制剂是防治冠心病常用主要药物之一,可直接扩张冠状动脉,减轻心脏前(主要)和后负荷。常用制剂包括硝酸甘油、硝酸异山梨酯(消心痛)、5-单硝酸异山梨酯、戊四硝酯等。     

单硝酸异山梨酯缓释剂和卡托普利联合治疗心绞痛的疗效观察——附120例报告

目的：观察单硝酸异山梨酯缓释剂和卡托普利联合治疗冠心病心绞痛的疗效，探讨卡托普利增强单硝酸异山梨酯疗效的机制。方法：120例冠心病心绞痛病人随机分为2组，治疗组口单硝酸异山梨酯缓释剂40mg，每晚1次，卡托普利6.25mg，每日2次，对照组仅口服单硝酸异山梨酯缓剂40mg，每晚1次，2组均以4个月为1疗程。观察2组治疗前后每日心绞痛发作次数，胸闷次数，急救硝酸甘油含量，给药前及给药后第四个月静息状态12导联心电图或运动心电图的变化，结果：治疗后治疗组的心绞痛，胸闷症状的改善较对照组明显，有统计学意义（P＜0．01）。心电图改善情况心电图ST段压低的总和（∑T）下降（mm)、∑T波倒置导联数、∑T波倒置深度（mm)，治疗组均较对照组改善（均为P＜0．05）。治疗组的总有效率高于对照组（P＜0．01）。结论：卡托普利能提高单硝酸异山梨酯治疗冠心病心绞痛的疗效。     

单硝酸异山梨酯静脉滴注治疗冠心病心绞痛临床观察

目的:观察单硝酸异山梨酯静脉滴注治疗冠心病心绞痛临床疗效.方法:60例冠心病心绞痛患者随机分为两组,治疗组60例,单硝酸异山梨酯20mg.加入5%葡萄糖250mL中,每天1次,连用12 d.对照组60例用硝酸甘油10mg,加入5%葡萄糖250mL中,每天1次,连用12 d.结果:治疗组疗效与和心电图时照都优于对照组(P＜0.05).结论:单硝酸异山梨酯片治疗冠心痛心绞痛疗效确切,不易耐药,副作用小,使用方便、安全,在长期治疗中明显优于硝酸甘油,值得推广.     

硝酸酯类联合降压降脂治疗对老年单纯收缩期高血压的影响

目的观察硝酸酯类和他汀类药物对老年单纯收缩期高血压（ISH）伴高脂血症患者血压、血脂及大动脉结构的影响.方法 96例老年ISH伴高脂血症患者随机分为单硝酸酯三联组（A组）：给予单硝酸异山梨酯、辛伐他汀和非诺地平治疗;辛伐他汀二联组（B组）：给予辛伐他汀和非诺地平治疗;对照组（C组）：单用非诺地平治疗,疗程均为12周.于试验期间观察血压、血脂及大动脉结构等变化.结果 A组的降压疗效明显优于B组、C组（ P＜0.01）,A组与B组的降脂效果及颈动脉内膜厚度的变化均优于C组（ P＜0.05）.结论硝酸酯类药物能降低老年ISH患者的收缩压,使脉压减小,而对舒张压影响不大;他汀类药物可干预、延迟大动脉内膜中层增厚进程,两药合用,有益于控制老年ISH.     

5-单硝酸异山梨酯治疗心绞痛疗效观察

目的比较 5 -单硝酸异山梨酯与硝酸异山梨酯治疗心绞痛的疗效。方法采用随机、单盲法将 178例心绞痛患者分两组。治疗组90例 ,给予 5 -单硝酸异山梨酯 ;对照组 88例 ,给予硝酸异山梨酯。结果治疗组总有效率 91.6 % ,对照组总有效率 76 .6 % ,组间比较有高度显著性差异 ( P<0 .0 1)。治疗组心电图改善总有效率 6 8.9% ,对照组总有效率 5 2 .7% ,组间比较有显著性差异 ( P<0 .0 5 )。结论 5 -单硝酸异山梨酯治疗心绞痛疗效优于硝酸异山酯     

静脉滴注单硝酸异山梨酯治疗充血性心力衰竭的临床观察

目的：总结静脉滴注单硝酸异山梨酯治疗充血性心力衰竭（CHF）的疗效及副作用。方法：13例心功能Ⅲ～Ⅳ级的CHF患者随机分为治疗组和硝酸甘油组。在CHF常规治疗的基础上，治疗组给予单硝酸异山梨酯40mg 5%葡萄糖注射液250ml，每日静脉滴注，2－10mg/h，1次／d，共2周。硝酸甘油组：给予硝酸甘油40mg 5%葡萄糖注射液250ml，每日静脉滴注，2－10mg/h，共2周。两组均观察1－3个月。结果：单硝酸异山梨酯组治疗1及3个月CHF患者心功能改善显效率及总有效率明显优于硝酸甘油组，左心室射血分数（LVEF），左室短轴缩短率（FS），快速充盈期及心房收缩期二尖瓣血流速度（E／A）均较硝酸甘油组为高。结论：静脉滴注单硝酸异山梨酯治疗CHF患者疗效好，不良反应轻微，可作为治疗CHF患者的有效措施之一。     

复方丹参滴丸治疗稳定型心绞痛临床研究

目的探讨更适合稳定型心绞痛患者长期服用的药物。方法应用随机双盲对照观察复方丹参滴丸和单硝酸异山梨酯治疗稳定型心绞痛的疗效。结果复方丹参滴丸在改善心肌方面优于单硝酸异山梨酯,其运动持续时间、诱发心绞痛发作时间、ST段压低≥1 mm所需时间均显著延长,运动耐力增加;每日心绞痛发作次数及硝酸甘油用量均减少;无症状心肌供血得到了显著改善。结论复方丹参滴丸更适合稳定型心绞痛患者长期服用,疗效显著,不产生耐药性,不良反应少;尤其适用于对硝酸酯类耐药,又需长期服用及不能耐受硝酸酯类药物不良反应如头晕、头痛的患者。     

冠心病心绞痛应用单硝酸异山梨酯静脉泵入治疗的临床效果

目的分析冠心病心绞痛应用单硝酸异山梨酯静脉泵入的治疗效果。方法研究对象为本院2015年8月至2016年7月收治的74例冠心病心绞痛患者,随机分为试验组与对照组,各37例。对照组患者使用硝酸甘油静脉泵入治疗,试验组患者给予注射用单硝酸异山梨酯静脉泵入治疗。观察对比两组患者的临床疗效、血压、心率、用药安全性等指标。结果试验组患者的临床总有效率明显高于对照组,差异具有统计学意义(P<0.05)。试验组患者治疗前、后的血压与心率保持稳定(P>0.05);治疗后,对照组患者的收缩压出现明显下降,与同组治疗前及试验组治疗后比较,差异具有统计学意义(P<0.05)。两组不良反应总发生率比较,差异无统计学意义(P>0.05)。结论冠心病心绞痛应用单硝酸异山梨酯静脉泵入治疗能够显著提高临床疗效,改善患者的临床症状及收缩压,且不良反应少,具有很高的临床应用价值。     

静点单硝酸异山梨酯注射液引起2例脑梗死的护理体会

硝酸酯类制剂作为血管扩张剂，目前被广泛地用于冠心病、心肌梗死、顽固性心力衰竭等心脏疾病的治疗中，属安全有效的新型药品，但用药过程中因用药速度、患者的个体差异及其他因素影响可产生头胀、恶心、头痛、血压低等不良反应。现将2例患者在静点单硝酸异山梨酯药物后引起脑梗死的护理体会介绍如下。     

A comparative study of the cardiorespiratory effects of continuous positive airway pressure breathing and continuous positive pressure ventilation in acute respiratory failure

Positive end expiratory pressure (PEEP) produces cardiopulmonary effects whether administered by controlled positive pressure ventilation (CPPV) or continuous positive airway pressure (CPAP). In eight patients with acute respiratory failure, the effects of 20 cm PEEP administered via CPPV and CPAP were compared. An esophageal balloon was used to calculate the transmural vascular pressures. The control values under mechanical ventilation with no PEEP (IPPV) for PaO₂ and QS/QT (FiO₂ being 1.0) were respectively 132±15 mmHg and 31±3%; CPPV gave a PaO₂ of 369±27 mmHg and QS/QT fo 14±1.6%, CPAP 365±18 mmHg and 18±1.3% respectively. The two different modes of ventilation (CPPV and CPAP) gave identical blood gas improvement through the same level of end expiratory transpulmonary pressure despite marked differences between absolute mean airway and esophageal pressures. Conversely, hemodynamic tolerance was very different from one technique to the other: CPPV depressed cardiac index from 3.4±0.3 to 2.4±0.2 l/min/m² as well as decreasing transmural filling pressures, suggesting a reduction in venous return. Conversely, filling pressures maintained at control values during CPAP and cardiac indexes were unchanged.Abbreviations IPPV intermittent positive pressure ventilation; mechanical ventilation (controlled mode) with zero end expiratory pressure (ZEEP) - CPPV continuous positive pressure ventilation: mechanical ventilation (controlled mode) with a positive pressure during expiration - CPAP continuous positive airway pressure; spontaneous ventilation with a positive pressure maintained during expiration - PEEP positive end expiratory pressure, whatever the ventilatory mode; spontaneous (CPAP) or mechanical (CPPV) Presented in part at the 44 th annual meeting of American College of Chest Physicians, Washington DC, October 1978     

Intervention studies to reduce the prevalence and incidence of pressure sores: a literature review

Much has been written about the prevention of pressure sores. However, electronic and manual searches located only 10 studies within the literature in the UK that described interventions able to reduce either their incidence or prevalence. All the studies located contained serious methodological flaws. Apparent success in reducing the number or severity of pressure sores could have resulted because staff involved in data collection were aware that the study was being undertaken and thus took more interest in pressure area care. From the review findings it is apparent that there is a dearth of research evidence upon which to base practice in the sphere of pressure sore prevention and further research is urgently required.     

Influence of tissue pressure on central venous pressure/peripheral venous pressure correlation: An experimental report

BACKGROUND: Peripheral venous pressure (PVP) has been shown to correlate with central venous pressure (CVP) in a number of reports. Few studies, however, have explored the relationship between tissue pressure (TP) and PVP/CVP correlation.METHODS: PVP and CVP were simultaneously recorded in a bench-top model of the venous circulation of the upper limb and in a single human volunteer after undergoing graded manipulation of tissue pressure surrounding the intervening venous conduit. Measures of correlation were determined below and above a point wherein absolute CVP exceeded TP.RESULTS: Greater correlation was observed between PVP and CVP when CVP exceeded TP in both models. Linear regression slope was 0.975 (95% CI: 0.959-0.990); r² 0.998 above tissue pressure 10 cmH₂O vs. 0.393 (95% CI: 0.360-0.426); and r² 0.972 below 10 cmH₂O at a flow rate of 2000 mL/h in the in vitro model. Linear regression slope was 0.839 (95% CI: 0.754-0.925); r² 0.933 above tissue pressure 10 mmHg vs. slope 0.238 (95% CI: -0.052-0.528); and r²0.276 in the en vivo model.CONCLUSION: PVP more accurately reflects CVP when absolute CVP values exceed tissue pressure.     

组织压监测下治疗小腿骨筋膜室综合征30例报告

目的：探讨测定组织压与血压的差值在诊治小腿骨筋膜室综合征的临床意义。方法：应用穿刺法,通过测量30例筋膜室综合征患者组织压、血压,明确减压手术的客观指标。结果：30例中10例行保守治疗,20例行减压治疗,随访均未发生骨筋膜室后遗症。结论：组织压、收缩压、舒张压的结合测量对指导何时行减压术有重要临床意义。当差值为20mmHg时,需即刻减压。     

持续气道正压-比例压力支持-自动管道补偿与双水平气道正压-压力支持通气两种模式撤机方法的比较

目的 :比较持续气道正压比例压力支持自动管道补偿 (CPAP PPS ATC)与双水平气道正压压力支持通气 (BIPAP PSV)两种模式撤机方法的结果。方法 :CPAP PPS ATC组 42例 ,BIPAP PSV组 40例 ,采用对照研究方法 ,比较两种通气模式、起始参数的调节、解决通气机依赖特点及撤机成功率。结果 :两种模式的撤机成功率无明显差异 (P>0 .0 5 ) ,两种模式均无人机对抗 ,CPAP PPS ATC模式较 BIPAP PSV模式对通气机依赖患者有更大的自主性 ,更容易实现撤机。结论 :BIPAP PSV为压力控制与自主呼吸相结合模式 ,CPAP PPS ATC为自主模式 ,CPAP PPS ATC是一种更好的机械通气撤机模式     

有创血压监测值与无创血压监测值相关性分析

目的 探讨有创血压监测值与无创血压监测值之间的线性关系,为临床血压监测提供参考.方法 选取ICU监测无创血压与有创血压的患者32例,采取自身对照的方法,同时监测患者有创血压及无创血压值,采集数据资料进行比较,并进行线性关系分析.结果 采集有效数据98对,所得数据有创血压收缩压及舒张压值分别为(146.93±21.426),(71.32±13.152) mm Hg,均高于无创血压值的(124.02±19.417),(68.86±15.251)mmHg,差异均有统计学意义(t分别为15.301,3.363;P＜0.05);有创血压与无创血压存在线性关系(r =0.880,P＜0.05).结论 有创血压与无创血压所得监测值之间有差异,不可相互替代,可使用无创血压监测值推导计算有创血压监测值.     

Preventing heel pressure sores: a comparison of heel pressure relieving devices

• ? It has been widely recognized that elderly patients with an orthopaedic problem are predisposed to developing heel pressure sores.
• ? In this study four pressure-reducing devices, commonly used in the prevention of heel ulcers, were objectively compared for their ability to decrease or remove pressure on the heels of patients with fractured necks of femurs and fractured femurs.
• ? Forty-one patients were randomly allocated a pressure relieving device. The efficacy of the device was evaluated by continuously assessing the skin integrity of both heels on a daily basis over a period of 12 days. Data were collected over a 30 month period.
• ? The four devices were foam splints, eggshell foam, duoderm and heel protector boots. Foam splints and eggshell foam proved to be more effective devices in relieving pressure exerted on the heel.
• ? This study recognizes that meticulous nursing care remains the critical clement in prevention of heel ulcers; however, the use of eggshell foam and foam splints in conjuction with this enhances the maintenance of skin integrity.

     

A comparison of extradural and intraparenchymatous intracranial pressures in head injured patients

The reliability of extradural pressure measurements for the measure of intracranial pressure (ICP) is still controversial. This study was undertaken to assess the limits of agreement between extradural and intraparenchymatous pressures using respectively the Plastimed extradural sensor and the Camino fiberoptic system. The study took place in a neurosurgical intensive care unit. Ten head injured patients were included in the study, leading to the comparison of 1032 pairs of hourly ICP values. Although the measures were significantly correlated, there was no agreement between the two methods of ICP monitoring. Extradural pressure was higher than intraparenchymatous pressure (bias 9 mmHg; 95% confidence interval of bias-9.8 to 27.8 mmHg). The lack of agreement between the two methods is probably due to the unreliability of extradural pressure for the measurement of ICP.     

不同负压值吸痰对气管粘膜损伤的实验研究

负压吸引吸痰法是一项侵入性操作,为了减少其对气管粘膜的损伤,探索适宜的负压值,我们对不同负压值吸痰所致气管粘膜损伤的程度,进行了动物实验。作者将实验组36只犬随机分为1～6组,吸痰负压值分别定于5、10、15、20、25、30Kpa,按常规吸痰法吸痰10次后分别处死。切取损伤的全层气管组织两块,做普通光学及电子显微镜检查。结果表明:负压吸引吸痰的负压值与气管粘膜损伤程度成正比,其负压值应控制在5～20Kpa之间,吸痰器计量表应采用低负压Kpa负压表。以便于控制、调节负压值,减少由于吸痰所致气管粘膜损伤。     

102例危重病患者有创血压和无创血压的对比

目的比较102例危重病患者有创血压（IBP）和无创血压（NBP）测量结果的一致性。 方法收集2016年3~9月在西安交通大学第二附属医院重症医学科住院治疗的102例危重病患者的尺/桡动脉IBP和同侧上臂NBP数据1072对,先对所有数据分别按收缩压、舒张压、脉压（PP）和平均动脉压（MAP）进行配对t检验;再将数据分为高血压组（MAP≥107 mmHg）（1 mmHg=0.133 kPa）、正常血压组（70 mmHg≤MAP<107 mmHg）和低血压组（MAP<70 mmHg）三个亚组,分别进行IBP和NBP的收缩压、舒张压、PP以及MAP间的配对t检验。以P<0.05为差异具有统计学意义。 结果有创收缩压和无创收缩压之间比较,差异具有统计学意义［（128.08±35.48）mmHg vs（122.56±24.84）mmHg,t=7.896,P<0.001）］;有创舒张压和无创舒张压之间比较,差异具有统计学意义［（65.66±13.69）mmHg vs（67.98±13.31）mmHg,t=-8.294,P<0.001］;有创PP和无创PP之间比较,差异具有统计学意义［（62.42±28.93）mmHg vs（54.58±20.00）mmHg,t=11.697,P<0.001］;有创MAP和无创MAP之间比较,差异无统计学意义［（86.47±18.94）mmHg vs（86.17±15.33）mmHg,t=0.867,P=0.386］。亚组分析显示高血压组（n=254）：有创收缩压和无创收缩压之间比较,差异具有统计学意义［（163.75±33.93）mmHg vs（152.16±16.78）mmHg,t=6.52,P<0.001］,有创舒张压和无创舒张压之间比较,差异具有统计学意义［（79.17±11.03）mmHg vs（83.69±9.50）mmHg,t=-6.85,P<0.001）］,有创PP和无创PP之间比较,差异具有统计学意义［（84.57±31.50）mmHg vs （68.47±20.72）mmHg,t=9.76,P<0.001］;正常血压组（n=687）：有创收缩压和无创收缩压之间比较,差异具有统计学意义［（122.66±24.74）mmHg vs（118.70±15.14）mmHg,t=5.071,P<0.001）］,有创舒张压和无创舒张压之间比较,差异具有统计学意义［（63.97±10.34）mmHg vs（65.60±8.49）mmHg,t=-5.049,P<0.001）］,有创PP和无创PP之间比较,差异具有统计学意义［（58.69±23.05）mmHg vs （53.10±11.90）mmHg,t=7.682,P<0.001］;低血压组（n=131）：有创收缩压和无创收缩压之间比较,差异无统计学意义［（87.35±24.33）mmHg vs（85.41±11.99）mmHg,t=1.109,P=0.269］,有创舒张压和无创舒张压之间比较,差异具有统计学意义［（48.32±8.27）mmHg vs（49.98±8.06）mmHg,t=-2.073,P=0.040］,有创PP和无创PP之间比较,差异具有统计学意义［（39.03±24.00）mmHg vs（35.43±13.97）mmHg,t=1.806,P<0.001］。 结论有创收缩压大于无创收缩压、有创舒张压小于无创舒张压、有创PP大于无创PP,而有创MAP等于无创MAP。采用MAP数值较采用收缩压和（或）舒张压数值可以消除IBP和NBP测量之间的差异。