乳酸盐置换液在危重患者CRRT中的应用价值

目的评价乳酸盐置换液在危重患者CRRT治疗中的应用价值。方法选择在ICU行CRRT治疗的63例危重患者(乳酸盐置换液组34人,碳酸氢盐置换液组29人),于治疗前、治疗24h和48h测定血乳酸、PH、BE、HCO3-、平均动脉压(MAP)等参数并进行比较。结果乳酸盐组在CRRT治疗24h、48h后,乳酸呈下降趋势,但未达到统计意义差别(F=2.765,P=0.068)。碳酸氢盐组CRRT治疗24h后乳酸即下降,至48h乳酸较治疗前均达到显著意义差异(F=4.432,P=0.012)。血PH值、BE、HCO3-和FiO2在CRRT治疗后24h、48h两组均显著升高,APACHⅡ评分在治疗48h后两组均显著下降(P均<0.05)。血清肌酐在治疗24h后两组均显著下降,48h下降更为显著(乳酸组F=36.073,P=0.000;碳酸氢盐组F=47.954,P=0.000)而平均动脉压、血清钠离子和谷丙转氨酶在治疗过程中无统计意义差别。除乳酸(F=4.594,P=0.012)、BE(F=1.875,P=0.039)外,CRRT治疗后乳酸盐组和碳酸氢盐组各时间点参数均无统计学差异。结论乳酸盐置换液不升高血乳酸,在纠正酸中毒、维持血压、稳定内环境方面具有优势,乳酸盐置换液可以安全地用于危重患者的CRRT治疗。     

气管插管后机械通气治疗危重支气管哮喘合并呼吸衰竭的疗效观察

目的探讨气管插管后机械通气对危重支气管哮喘合并呼吸衰竭的疗效。方法回顾性分析2002年1月~2008年4月收治的17例危重支气管哮喘合并呼吸衰竭患者,采用气管插管后机械通气。通气模式:同步间歇指令通气(SIMV)加低水平呼气末正压(PEEP)。根据患者病情及时调整呼吸机参数及考虑撤机,观察机械通气治疗前后血气及相关临床资料。结果机械通气治疗后,临床症状、体征改善明显,pH值、PaO2、PaCO2均恢复正常,顺利撤除呼吸机,与治疗前比较差异均有显著性意义(P<0.01)。结论危重支气管哮喘合并呼吸衰竭采用经气管插管后机械通气技术治疗效果确切,能迅速纠正呼吸衰竭,缓解临床症状,改善动脉血氧分压和通气,并能在短期内顺利撤机,值得临床推广。     

气管插管后机械通气治疗危重支气管哮喘合并呼吸衰竭的疗效观察

目的探讨气管插管后机械通气对危重支气管哮喘合并呼吸衰竭的疗效。方法回顾性分析2002年1月2008年4月收治的17例危重支气管哮喘合并呼吸衰竭患者,采用气管插管后机械通气。通气模式：同步间歇指令通气（SIMV）加低水平呼气末正压（PEEP）。根据患者病情及时调整呼吸机参数及考虑撤机,观察机械通气治疗前后血气及相关临床资料。结果机械通气治疗后,临床症状、体征改善明显,pH值、PaO2、PaCO2均恢复正常,顺利撤除呼吸机,与治疗前比较差异均有显著性意义（P〈0.01）。结论危重支气管哮喘合并呼吸衰竭采用经气管插管后机械通气技术治疗效果确切,能迅速纠正呼吸衰竭,缓解临床症状,改善动脉血氧分压和通气,并能在短期内顺利撤机,值得临床推广。     

经鼻留置吸痰管用于重症支气管扩张症患者效果评价

目的探讨经鼻留置吸痰管于气管内按需吸痰辅助治疗重症支气管扩张症患者的临床疗效。方法将符合条件的61例患者随机分为对照组30例和观察组31例,对照组按常规给予抗生素、对症支持、雾化吸入、体位引流,观察组在此基础上给予气管内留置吸痰管,通过留置吸痰管向气管内注入气道湿化液,根据需要从留置吸痰管内按需吸痰。以动脉血氧分压、动脉血二氧化碳分压、咳嗽、咳痰、呼吸困难、住院天数、行机械通气例数为观察指标。结果经治疗后,对照组患者入院96 h氧分压(75.1±3.3)mm Hg(1 mm Hg=0.133 k Pa),入院96 h二氧化碳分压(52.4±3.4)mm Hg,入院120 h氧分压(78.6±4.7)mm Hg,入院120 h二氧化碳分压(51.8±3.9)mm Hg;与观察组的入院96 h氧分压[(79.8±5.4)mm Hg]、入院96 h二氧化碳分压[(49.1±2.8)mm Hg]、入院120 h氧分压[(84.9±4.4)mm Hg]、入院120 h二氧化碳分压[(48.3±2.2)mm Hg]比较差异有统计学意义(P0.01);对照组呼吸困难(2.78±0.47)分,与观察组的(2.43±0.39)分比较,差异有统计学意义(P0.01);对照组患者住院天数为(21.93±4.87)d,行机械通气5例;观察组患者住院天数(16.55±3.71)d,机械通气0例,两组比较差异有统计学意义(P0.01或0.05)。结论重症支气管扩张症患者经鼻留置吸痰管按需吸痰对患者有辅助治疗作用,能及时解除痰液滞留,保持呼吸道通畅,改善患者的缺氧状态,缩短病程。     

胆碱能抗炎通路对大鼠呼吸机相关性肺损伤的影响

目的 研究胆碱能抗炎通路对呼吸机相关性肺损伤(VILI)的影响.方法 36只SD大鼠按随机数字表法分为自主呼吸对照组、机械通气组、烟碱治疗组,每组12只.采用大潮气量(VT)通气制作大鼠VILI模型.于机械通气前10 min腹腔注射烟碱生理盐水2 mg/kg,其余两组注射等量生理盐水.各组大鼠均行血流动力学和动脉血气监测;通气2 h处死大鼠取肺组织,测定肺湿/干重(W/D)比值和髓过氧化物酶(MPO)活性,采用酶联免疫吸附法(ELISA)测定支气管肺泡灌洗液(BALF)中白细胞介素-8(IL-8)含量及肺组织匀浆细胞间黏附分子-1(ICAM-1)含量;苏木素-伊红(HE)染色观察肺组织病理改变,按修改后弥漫性肺泡损伤评分系统(DAD)进行评分.结果 机械通气期间,机械通气组和烟碱治疗组动脉血pH值呈升高趋势,动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、平均动脉压(MAP)均呈下降趋势.机械通气2 h,烟碱治疗组PaO2(mm Hg,1 mm Hg=0.133 kPa)显著高于机械通气组(85±4比76±3,P<0.05).机械通气组肺W/D比值和MPO活性显著高于对照组[W/D比值:5.66±0.33比4.53±0.21,P<0.01;MPO(U/g):1.73±0.50比0.89±0.17,P<0.05];烟碱治疗组肺W/D比值(5.02±0.37)和MPO活性(1.11±0.33)显著低于机械通气组(均P<0.05).与对照组比较,机械通气组和烟碱治疗组DAD评分(分:10.40±1.85、7.90±1.67比1.60±1.20)、IL-8(ng/L:1 625.3±271.7、965.5±310.5比428.5±120.6)及ICAM-1(μg/L:589.4±87.5、452.5±89.3比247.5±73.7)显著升高(均P<0.01),但烟碱治疗组各指标明显低于机械通气组(P<0.05或P<0.01).结论 胆碱能抗炎通路可抑制VILI大鼠肺组织中IL-8、ICAM-1的表达,减少中性粒细胞在肺内的黏附与渗出,从而减轻肺损伤.     

无创正压通气治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭

目的 探讨无创正压通气在慢性阻塞性肺疾病（COPD）合并Ⅱ型呼吸衰竭的治疗作用。方法 2005年10月—2009年10月对COPD合并Ⅱ型呼吸衰竭患者40例,随机分为对照组和治疗组（各20例）。在行常规抗感染、对症治疗的同时,分别予以持续静脉滴注尼可刹米或无创正压通气治疗6 h,比较两组治疗前后生命体征及血气分析变化。结果 治疗6 h后,治疗组在收缩压、呼吸频率及心率方面改善均显著优于对照组（P＜005）。pH值对照组无改善,治疗组显著改善,两组比较有统计学意义（P＜005）。治疗后治疗组动脉血氧分压由（51.2±3.7） mm Hg上升至（82.3±5.7） mm Hg,对照组由（51.4±4.6） mm Hg上升至（66.7±8.3） mm Hg,治疗组动脉血二氧化碳分压由（78.9±10.0） mm Hg降低至（46.9±7.2） mm Hg,对照组由（78.6±6.5） mm Hg降低至（61.2±5.7） mm Hg,治疗组改善明显（P＜0.01）。结论 无创正压通气治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭效果明显。     

无创通气治疗妊娠期重度哮喘临床观察

目的：研究无创通气在妊娠期重度哮喘治疗中对胎儿、动脉血气中酸碱度、动脉血氧分压、动脉血二氧化碳分压的影响。方法：将23例重度支气管哮喘患者随机分为无创通气＋药物治疗组（无创通气组13例）和对照组（10例）。比较治疗后两组动脉血气中酸碱度、动脉血氧分压、动脉血二氧化碳分压变化以及对胎儿发育的影响，观察患者临床症状、心率和呼吸频率。结果：无创通气组在治疗后动脉血气中酸碱度、动脉血氧分压值升高和动脉血二氧化碳分压、心率和呼吸频率下降，对胎儿发育的不利影响明显降低，与对照组比较差异有统计学意义（P〈0．01）。结论：无创通气在妊娠期重度哮喘治疗中可改善血气状况，减少对胎儿的不良影响。     

高频震荡通气在新生儿呼吸窘迫综合征中的应用效果

目的探讨高频震荡通气在新生儿呼吸窘迫综合征中的应用效果。方法回顾性分析2015年1月至2017年1月227例新生儿呼吸窘迫综合征患儿的临床资料,根据治疗方法的不同,将患儿分为高频震荡通气组(122例)与常频机械通气组(105例),比较两组患儿治疗前后肺氧合功能变化情况与血气分析情况。结果治疗后常频机械通气组患儿氧合指数(OI)为(7.92±4.27)mm Hg、动脉/肺泡氧分压比值(a/APO_2)为(0.26±0.12)、血氧分压(PaO_2)为(54.29±14.39)mm Hg,高频震荡通气组患儿以上指标分别为(4.23±2.51)mm Hg、(0.37±0.21)、(63.29±15.21)mm Hg。两组患儿治疗后肺氧合功能变化情况比较,差异有统计学意义(P0.05)。治疗后常频机械通气组患儿PaCO_2为(39.39±5.92)mm Hg、pH值为(7.38±0.37)、PaO_2为(79.67±7.62)mm Hg,高频震荡通气组患儿以上指标分别为(32.15±6.42)mm Hg、(7.37±0.32)、(88.92±6.36)mm Hg。两组患儿PaCO_2与PaO_2比较,差异有统计学意义(P0.05)。结论对于新生儿呼吸窘迫综合征的治疗,高频震荡通气的效果优于常频机械通气,对于患儿的肺氧合功能以及血氧有着良性的作用。     

肺保护性通气与序贯性通气在COPD合并Ⅱ型呼吸衰竭治疗中的应用效果分析

目的:分析肺保护性通气与序贯性通气在慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭治疗中的应用效果。方法:选择2018年6月~2020年6月收治的慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭患者102例,采用随机数字表法分为对照组和观察组,各51例。对照组行有创-无创序贯性通气,观察组行肺保护性通气。比较两组通气时间、血气指标及呼吸机相关性肺炎发生率。结果:观察组有创通气时间(5.18±0.97)d、机械通气总时间(8.22±2.35)d,均短于对照组的(5.91±1.79)d、(10.46±3.17)d,氧分压(75.13±6.48)mmHg、pH7.39±0.09,均高于对照组的(71.36±5.17)mm Hg、7.31±0.06,二氧化碳分压(42.79±3.48)mm Hg、呼吸机相关性肺炎发生率1.96%,均低于对照组的(49.24±5.74)mm Hg,15.69%,差异有统计学意义(P<0.05)。结论:与序贯性通气相比,慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭患者应用肺保护性通气更利于改善患者血气指标,缩短机械通气时间,降低呼吸机相关性肺炎发生率。     

联机自制连续肾脏替代治疗置换液的临床研究

目的探讨联机自制置换液行连续肾脏替代治疗（CRRT）的安全性和有效性。方法将60例行CRRT治疗的患者随机分为2组，观察组使用on-line滤过机制备的碳酸氢盐置换液；对照组用市售乳酸盐溶液，观察其临床表现，检测自制置换液的电解质浓度、pH、渗透压、细菌内毒素水平及2组治疗前后肌酐、尿素氮及电解质浓度。结果观察组不良反应明显低于对照组（P〈0.01），其电解质浓度、pH、渗透压、细菌内毒素检测符合标准；2组对肌酐、尿素氮的清除比较无显著差异性（P〉0.05）。结论联机自制碳酸氢盐置换液行CRRT是一种安全、快捷、经济、有效的方法。     

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.     

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.