重症监护病房重症肺炎病人贫血的发生发展及对预后的影响

目的 分析重症肺炎病人在ICU住院期间贫血的发生发展及对临床结局的影响。方法 选择2020年3月1日至2022年3月31日南京市第一医院ICU收治的首要诊断为重症肺炎的老年病人,通过医疗电子信息系统收集病人临床资料,根据临床结局将病人分为生存组与死亡组,比较2组病人基线特征、ICU住院期间Hb变化;采用二分类Logistic回归分析影响病人预后的危险因素。结果 共43例病人纳入研究,其中死亡22例,生存21例。与生存组相比,死亡组病人年龄更大,入ICU时序贯器官衰竭评分(SOFA)和APACHEⅡ评分更高,住院期间平均Hb水平更低。ICU住院期间,2组病人Hb持续下降,平均下降总量达(24.70±23.39)g/L,且第7天起,死亡组Hb较生存组明显下降。年龄、是否合并基础疾病、住院期间Hb平均水平与病人死亡风险相关(OR分别为1.199、0.005、0.815)。结论 贫血与ICU重症肺炎病人不良预后有关,应积极预防与纠正。     

呼吸监护病房老年患者高钠血症的临床分析

目的 探讨老年危重患者高钠血症与病情变化及预后的关系。方法 回顾2002年5月-2003年10月呼吸监护病房所有老年高钠血症患者临床资料．并用统计学方法对上述资料进行分析。结果 189例患者中高钠血症26例，发生率13．76％。高钠血症患者中死亡14例．病死率53．85％。在气管插管病例中高钠血症发生率为70．37％。发生高钠血症时急性生理学和慢性健康状况(APACHE)Ⅱ评分显著高于入监护室24小时的APACHEⅡ评分，同时肾功能也有一定影响，血肌酐值明显升高。高钠血症中死亡组与存活组比较，血钠水平有显著差异。结论 高钠血症是老年危重患者较常见的并发症，在气管插管患者发生率更高，且预后差。因此要重视老年危重患者高钠血症的发生。     

急诊抢救室老年危重患者死亡风险分析

目的分析急诊抢救室老年危重患者死亡风险。方法回顾性分析我院急诊抢救室收治的急危重症患者3174例,根据年龄分为老年组(≥65岁)1839例和非老年组(14~64岁)1335例,记录患者性别、年龄、就诊时间、诊断、转归以及死因等资料,比较2组患者的死亡风险。结果3174例急诊危重患者中老年人占57.94%。与非老年组比较,老年组女性比例、年龄、心血管及呼吸系统发病率明显升高,差异有统计学意义(P<0.05,P<0.01)。老年组前3位病因为心血管疾病(48.2%)、神经疾病(19.7%)及呼吸系统疾病(15.7%)。3174例患者中死亡305例,其中老年组和非老年组分别为204例和101例,老年组病死率明显高于非老年组(66.89%vs 33.11%,P=0.001)。老年组危重症死因前3位的分别为心血管系统、神经系统及呼吸系统疾病。老年组呼吸危重症病死率明显高于非老年组(21.1%vs 3.0%,P=0.000)。结论心血管病、神经疾病及呼吸系统疾病是急诊老年危重患者最常见病因,病死率高,其中呼吸危重症的死亡风险更高。     

重症监护病房老年非心原性危重症患者B型利钠肽水平与预后的关系

目的 探讨急诊重症监护病房(EICU)中B型利钠肽(BNP)对老年非心原性危重症患者28 d病死率的预测价值.方法 连续选取EICU老年非心原性危重症患者70例,收集临床资料,检测BNP水平并随访患者28 d内是否死亡.结果 28 d内共有22例(31.4%)患者死亡,死亡组BNP水平的自然对数值明显高于存活组,分别为(6.4±1.2)ng/L与(5.1±1.5)ng/L(P＜0.05),BNP预测EICU老年危重症患者28 d病死率所得出接收者操作特征曲线下面积为0.759(95%可信区间0.636～0.882,P＜0.05),BNP预测EICU老年危重症患者28 d病死率最佳临界点为342 ng/L,敏感度为77.3%,特异度为68.7%,Youden指数为0.460.结论 BNP可作为预测老年非心原性危重症患者28 d病死率方便快捷的预测指标.     

结核病危重患者的死亡预后因素初步分析

目的 探讨结核病危重患者死亡预后的影响因素.方法 对2008年6月至2010年2月浙江省中西医结合医院结核科ICU的62例成年结核病危重患者的临床资料进行回顾性分析,其中男48例,女14例,年龄20～91岁,平均(63±4)岁.以入住结核科ICU时间为研究起点,以转出结核科ICU或死亡时间为研究终点,将患者分为存活组(33例)和死亡组(29例),对年龄、性别、呼吸衰竭类型、有无机械通气、合并其他感染、耐多药结核病、抗结核治疗、急性病生理学和长期健康评价Ⅱ(APACHEⅡ)评分及肝损害等变量进行单因素分析.采用Cox回归分析患者死亡预后的独立危险因素,采用Kaplan-Meier生存分析法计算患者的累积生存率.结果 与结核病危重患者死亡预后有关的因素为:真菌感染,风险比(HR值)为3.44,95%CI为1.23～9.62;Ⅱ型呼吸衰竭,HR值为4.03,95%CI为1.56～10.38;肝损害,HR值为3.96,95%CI为1.30～12.10;APACHEⅡ评分＞25分,HR为4.91,95%CI为1.99～12.11.上述4项因素均可使结核病危重患者住院死亡的风险显著增高(x2值为5.53～11.88,均P＜0.05),住院累积生存率显著降低(x2值为4.43～22.68,均P＜0.05).结论 结核病危重患者的病死率高,合并真菌感染、Ⅱ型呼吸衰竭、肝损害和APACHEⅡ评分＞25分是患者死亡预后的危险因素.

Abstract：

Objective The purpose of this study was to investigate the prognostic factors associated with mortality in critically ill tuberculosis patients, and therefore to provide information for the early diagnosis and treatment of the disease. Methods The clinical daza of 62 patients with tuberculosis, who were admitted to the intensive care unit (ICU) of Integrated Chinese and Western Medicine Hospital of Zhejiang Province between June 2008 and Feb 2010, were analyzed retrospectively, with the admission date as a start point and the transferring out of ICU date or death date in the ICU as an end point. Forty-eight patients were males and 14 were females, and the patient' s age ranging from 20 to years (63 ± 4) years. In addition,these patients were divided into the survival (33 cases) and the death groups (29 cases). A total of 19 factors including age, sex, respiratory failure types, mechanical ventilation, infection, anti-tuberculous drug resistance, chemotherapy, clinical complications, critical illness score, liver damage, were analyzed for a single risk factor by the univariate model, and calculated for the independent death risk factors using the Cox logistic regression multivariate model. The cumulative survival rate based on the Kaplan-Meier survival model was calculated. Results The mortality was associated with 4 independent factors: fungal infection ( HR =3.44, 95% CI = 1.23 - 9. 62), type Ⅱ respiratory failure ( HR = 4. 03, 95% CI = 1.56 - 10. 38), liver damage (HR=3.96, 95% CI=1.30 -12. 10) and elevated APACHEⅡ score (＞25) (HR =4.91,95%CI = 1.99 - 12. 11 ). These factors significantly ( x2 =5. 53 - 11.88, all P ＜0. 05) increased the in-hospital mortality and decreased the hospital cumulative survival rate( x2 = 4. 43 -22. 68, all P ＜ 0. 05 ). Conclusion The high mortality of tuberculosis patients admitted to ICU was associated with fungal infection, type Ⅱ respiratory failure, liver damage, and elevated APACHE Ⅱ score ( ＞ 25).     

酒精性肝硬化患者贫血特征分析

目的 探讨酒精性肝硬化患者贫血的实验室及临床特征。方法 对2020年12月—2021年5月于首都医科大学附属北京佑安医院进行网织红细胞及全血细胞分析检测且贫血的住院患者进行研究,筛选出院诊断为酒精性肝硬化且无上消化道出血史及输血史的患者共106例作为研究对象,根据贫血的严重程度、贫血的细胞形态学分类、网织红细胞血红蛋白含量(Ret-He)回顾性分析其临床特征及影响因素。正态分布计量资料两组间比较采用独立样本t检验,多组间比较采用单因素方差分析,进一步两两比较采用SNK-q检验和LSD-t检验。偏态分布计量资料两组间比较采用Mann-Whitney U检验,多组间采用Kruskal-Wallis H检验。计数资料组间比较采用χ²检验。不同贫血分类标准与实验室指标及临床特征相关性采用Spearman相关分析。结果 (1)患者中男性103例(97.2%),平均年龄(55.07±10.18)岁,平均血红蛋白(Hb)(87.16±18.55)g/L,轻度贫血49例(46.2%)、中度贫血49例(46.2%)、重度贫血8例(7.5%);Ret-He为33.65(13.3～46...     

危重患者炎症性贫血的机制和治疗

贫血是重症患者的常见问题。大部分患者入住重症监护病房(ICU)时即有不同程度贫血,在ICU期间诸多因素可造成患者进一步贫血。导致重症患者贫血的原因包括每日静脉采血、营养(如叶酸、维生素B12)缺乏性贫血、出血、消化     

危重患者贫血的发生机制及治疗进展

危重患者发生贫血十分常见.入住加强监护病房(ICU)的患者3d后有95%的患者会出现血红蛋白水平低于正常值[1],从而使血氧含量下降,导致危重患者死亡的风险增加[2].     

BNP与急诊危重患者28d死亡率的关系

目的探讨B型利尿钠肽（BNP）对预测急诊危重患者28d病死率的作用。方法选取1075例急诊室危重患者,测量血BNP浓度,并记录各项化验指标和临床生理指标。随访28d后记录患者是否存活,分析BNP水平与28d病死率的关系。结果死亡325例,死亡组患者血BNP浓度中位数水平明显高于存活组;BNP〉113．5ng/L是预测患者28d死亡率的独立危险因素,其预测死亡率的敏感度为84％、特异度为56．3％,判断死亡总符合率为64．7％。结论检测BNP能够预测危重患者死亡率。     

重症监护病房耐碳青霉烯肺炎克雷伯菌感染情况的临床分析

目的了解我院重症医监护病房耐碳青霉烯类肺炎克雷伯(carbapenem-resistant Klebsiella pneumonia,CRKP)感染患者的临床特点及抗生素耐药情况,为CRKP防控提供依据,指导临床用药。方法收集我院2015年10月至2015年12月期间重症监护病房患者临床资料,回顾性分析其临床基本情况、临床表现、治疗方案及预后情况。结果我科CRKP发生率为27.42%,CRKP患者多为高龄男性(平均年龄64.14±14.45岁,男性占78.57%),发热(肺克组85.71%vs.非肺克组51.35%、非感染组9.09%,χ~2=14.484,P=0.001)、白细胞总数(肺克组15.70±6.92 vs.非肺克组10.09±4.33、非感染组9.41±4.48×109/L,χ~2=9.980,P=0.007)、C反应蛋白(肺克组142.00(50.50,240.00)vs.非肺克组71.10(27.00,107.50)、非感染组14.10(5.00,53.30)mg/L,χ~2=9.387,P=0.009)及降钙素原(肺克组3.50(1.07,27.05)vs.非肺克组0.71(0.20,3.14)、非感染组0.20(0.20,0.30)μg/L,χ~2=16.236,P0.001)升高为主要表现,经替加环素联合碳青霉烯治疗后病死率(肺克组35.71%vs.非肺克组45.95%、非感染组36.36%,χ~2=0.607,P=0.738)无明显增高,但会延长住院时间(肺克组33.00(18.75,44.50)vs.非肺克组7.00(4.00,11.50)、非感染组9.00(4.00,13.00)天,χ~2=15.398,P0.001)、增加住院费用(肺克组23.92(10.14,36.08)vs.非肺克组4.41(2.64,11.22)、非感染组2.80(1.94,3.19)万元,χ~2=21.370,P0.001)。结论重症监护病房易出现CRKP流行,减少广谱抗生素的不规范使用和不必要的侵入性操作,及时调整抗感染方案,是控制CRPK流行、减轻临床负担的重要措施。     

急诊重症监护病房患者精神障碍的监测

目的:探讨急诊重症监护病房(emergency intensive care unit,EICU)患者精神障碍的临床特征。方法:收集2010年1月至2012年1月2年间,于北京安贞医院EICU住院患者的临床资料,进行总结分析。结果:患者住EICU出现精神障碍的年龄段集中在76～85岁,占57.1%(P<0.05),发生率7.5%(42/563),男女病死率相同11.9%(5/42)。患者基础病多为呼吸系统、心血管系统疾病、营养和代谢疾病,常合并呼吸衰竭、心力衰竭、电解质紊乱及肾功能不全等。EICU患者精神障碍的临床表现多为行为异常和定向力障碍。出现EICU精神障碍的患者精神症状大多持续1～10 d;由疾病因素为主导致精神障碍占61.9%(26/42),由非疾病因素为主导致的精神障碍占38.1%(16/42)。结论:EICU患者精神障碍的发生率以及病死率高。出现精神障碍多数与基础疾病有关。应重视病因治疗减少精神障碍持续时间。     

Feasibility study of unattended polysomnography in medical intensive care unit patients

Objectives

To evaluate the feasibility of using unattended, portable polysomnography (PSG) to measure sleep among patients in the medical intensive care unit (MICU).

Background

Accurate measurement of sleep is critical to studies of MICU sleep deprivation. Although PSG is the gold standard, there is limited data regarding the feasibility of utilizing unattended, portable PSG modalities in the MICU.

Methods

MICU based observational pilot study. We conducted unattended, 24-h PSG studies in 29 patients. Indicators of feasibility included attainment of electroencephalography data sufficient to determine sleep stage, sleep efficiency, and arousal indices.

Results

Electroencephalography data were not affected by electrical interference and were of interpretable quality in 27/29 (93%) of patients. Overnight sleep efficiency was 48% reflecting a mean overnight sleep duration of 3.7 h.

Conclusions

Unattended, portable PSG produces high quality sleep data in the MICU and can facilitate investigation of sleep deprivation among critically ill patients. Patient sleep was short and highly fragmented.     

重症监护病房56例胸腔积液相关情况的回顾性分析

目的:回顾性分析安贞医院急诊重症监护病房(EICU)中56例胸腔积液患者的特点及预后,评价对危重患者进行胸腔穿刺的必要性和安全性。方法:对比胸腔积液患者和无胸腔积液患者住院时间,住院费用及转归的差异;观察胸腔穿刺对诊断的影响及并发症。结果:2004年1月至2005年4月EICU收治患者328例,合并胸腔积液者56例,其中双侧积液30例,主要原因是心力衰竭和低蛋白血症,水负荷过重;单侧胸水26例,主要原因是肺癌和炎性胸腔积液。胸腔积液患者与无胸腔积液患者比较住院时间较长(P<0.05),住院费用较高(P<0.05),病死率无差异。34例行胸腔穿刺,其中10例与初步诊断不一致,误诊率29.4%。胸腔穿刺并发症少。结论:EICU中胸腔积液的发生率较高,出现胸腔积液延长住院时间,增加住院费用,但不影响病死率。     

呼吸重症监护室吸入性肺炎的病原学及预后因素分析

目的：观察呼吸重症监护室（RICU）医院获得吸入性肺炎和社区获得吸入性肺炎的微生物学特点及影响预后的因素。方法回顾性分析符合吸入性肺炎诊断标准且收入 RICU 的重症患者112例,根据感染来源分为医院获得吸入性肺炎和社区获得吸入性肺炎两组,通过纤维支气管镜吸取液培养观察病原学情况,并分析影响预后的因素,其中包括一般情况、血液生化检查、初始治疗、抗生素治疗及最终结果。结果RICU 中医院获得和社区获得吸入性肺炎患者年龄＞65岁者分别占80％和89％。RICU 吸入性肺炎最主要的危险因素是脑出血和脑梗塞（34％）。所有患者均至少伴随有一种基础疾病,53％的患者伴随有4种或4种以上基础疾病。从94例患者中共分离到病原菌128株,其中 G －菌最多（75株）,真菌（36株）次之,混合感染比率高。整体病死率为43．8％,其中社区获得性和医院获得性肺炎死亡率分别为40．0％和50．0％。多因素 Logistic分析显示,年龄＞65岁（P ＜0．05）、使用强心剂（P ＜0．01）以及无效初始治疗（P ＜0．01）是导致治疗效果不佳的独立危险因素。结论RICU 中医院获得和社区获得吸入性肺炎多见于老年人,合并症多;易发生混合感染,需重视真菌感染;老年、心功能不全、无效初始治疗是导致预后差的主要危险因素。     

State of the art: percutaneous tracheostomy in the intensive care unit

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.     

重症监护病房系统性红斑狼疮患者预后因素分析

目的 了解重症监护病房(ICU)危重症系统性红斑狼疮(SLE)患者的预后及其影响因素.方法 1993年6月至2007年6月所有第1次入住ICU的SLE患者纳入组,除外入住ICU后确诊为SLE患者.对在单蹦素相关分析中提示对SLE患者死亡有明显相关性的临床指标进一步采用多因素回归模型分析.结果 符合SLE分类标准的患者共101例,总体病死率为48.6%.入住ICU最常见原因是肺部病变并发急性呼吸窘迫综合征(ARDS).多因素回归分析提示SLE疾病慢性损伤指数(SLICC/ACR DI)>7.7、急性生理和慢性健康评估指数(APACHE Ⅲ)≥21、肺部病变并发ARDS、败血症休克、颅内出血、血细胞减少、近1个月平均等效泼尼松剂量>25 mg/d和气管插管时间>4 d与ICU危重症SLE患者死亡明显相关.而性别、年龄、SLE疾病活动指数(SLEDAI)>27、上消化道出血、甲泼尼龙冲击和末月使用环磷酰胺>1.0 g与死亡结果无明显相关性.结论 人住ICU危重症SLE患者病死率很高,死亡第1位原因是感染.与其死亡明显相关的因素主要有SLICC/ACR DI>7.7、APACHE Ⅲ>121、肺部病变并发ARDS、败血症休克、颅内出血、血细胞减少、近1个月平均等效泼尼松剂量>25 mg/a和气管插管时间>4 d.     

Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.