俯卧位机械通气治疗急性呼吸窘迫综合征的研究

目的评价俯卧位机械通气对急性呼吸窘迫综合征(ARDS)治疗的有效性。方法纳入42例ARDS患者,早期给予俯卧位机械通气治疗,观察仰卧位、俯卧位1h、2h、3h、4h以及治疗后8h的动脉血气分析、呼吸频率(RR)、吸入氧浓度(FiO2)、氧合指数(PaO2/FiO2)、胸肺顺应性(C)、气道阻力(Raw)的变化。结果俯卧位机械通气可显著改善患者的氧合状况,有效率为66.7%。俯卧位1h后FiO2及PaO2/FiO2增加至峰值,其后略有下降,但直至治疗后8h,患者的FiO2及PaO2/FiO2仍高于治疗前(P<0.05);治疗后3h RR下降,低于治疗前(P<0.05),而后又有所回升;治疗后1h Raw显著升高(P<0.05),而后又有所下降,而PaCO2、pH值、C和HR、MAP、CVP在治疗前和治疗后无明显变化。结论俯卧位机械通气可显著改善ARDS患者的氧合。     

PaO_2/(FiO_2×P■)对急性呼吸窘迫综合征患者肺内分流的评估价值

目的探讨新的氧合指数即结合了平均气道压(P■)的[PaO2/(FiO2×P■)]能否较传统氧合指数(PaO2/FiO2)更准确地反映急性呼吸窘迫综合征(ARDS)患者的肺内分流(Qsp/Qt)。方法符合ARDS诊断标准的患者12例,气管插管呼吸机支持,采用肺保护性通气策略(潮气量6 mL/kg,呼吸频率16次/min,FiO260%),留置Swan-Ganz导管,采用低流速法测定准静态肺压力-容积曲线,确定低位转折点压力(Pinf)。调整PEEP水平,观察血流动力学、呼吸力学的变化,分别留取外周及肺动脉血行血气分析,计算Qsp/Qt和PaO2/FiO2。结果递增的呼气末正压(PEEP)不足以显著改变ARDS患者的肺顺应性(Cst)、PaO2/FiO2及PaO2/(FiO2×P■)(P0.05)。递增的PEEP对Qsp/Qt改变不明显(P0.05)。检验Qsp/Qt与PaO2/(FiO2×P■)及Qsp/Qt与PaO2/FiO2的相关系数,Δz=0.571,无显著性差异(P0.05)。影响ARDS患者的Qsp/Qt和PaO2/FiO2的参数不是Paw,而是Cst。结论 PaO2/(FiO2×Paw)与PaO2/FiO2相比,两者对ARDS患者肺内分流的评估价值相当。     

支气管肺泡灌洗治疗吸入性肺炎的疗效观察

目的:探讨支气管肺泡灌洗(BAL)治疗吸入性肺炎的临床治疗效果。方法:选择46例吸入性肺炎(AP),随机分为常规综合治疗组和观察组,观察组加行BAL,临床观察10 d,比较两组治疗前后氧合指数(PaO2/FiO2)、急性呼吸窘迫综合征(ARDS)发生率及死亡率。结果:观察组与常规综合治疗组比较,氧合指数(PaO2/FiO2)明显改善,肺部阴影消失时间明显缩短,ARDS发生率及死亡率有明显下降(P<0.05)。结论:BAL是治疗AP的有效措施。     

纤维气管镜灌洗吸痰治疗老年吸入性肺炎疗效观察

目的:探讨常规治疗以及常规治疗加用纤维支气管镜下支气管灌洗吸痰治疗老年吸入性肺炎(aspiration pneumonia,AP)的临床疗效.方法:选取2015年1月至2016年12月接受治疗的AP患者40例,其中男22例,女18例,随机分为两组,对照组(20例)给予常规治疗(包括普通吸痰管吸痰),观察组(20例)给予常规治疗加用纤维支气管镜下支气管灌洗、吸痰,持续观察至出院,观察两组患者治疗前后白细胞总数(WBC)及氧合指数(PaO2/FiO2)、两组患者的一般情况和治疗1周后胸片肺部阴影面积缩小情况.结果:治疗后,两组PaO2/FiO2上升,WBC下降,两组治疗方法均有效,且观察组疗效明显优于对照组(P<0.05).治疗后患者的一般情况观察组较对照组改善明显(P<0.05)治疗1周后复查胸片,观察组显效率90%(18/20)明显优于对照组50%(10/20)(P<0.05).结论:两组治疗后PaO2/FiO2、WBC以及肺部阴影明显改善.证明在老年AP患者的治疗中纤维支气管镜支气管灌洗的疗效优于普通吸痰管吸痰.     

SARS的X线平片与CT诊断

目的评价平片和CT检查在严重急性呼吸综合征(SARS)的诊断价值.方法回顾性分析29例临床诊断SARS的患者,对发病后的一系列胸片和CT影像进行分析.结果胸片显示SARS患者早期出现肺部局灶性斑片状模糊影,并进行性扩大,有82.8%(24/29)的患者最后病变累及两肺大部分区域.CT显示起病初期以肺实变为主的影像表现.中期表现为肺间质增厚,呈网格状,并肺实变影.恢复期肺间质增厚,呈细网状.部分患者遗留肺纤维化病灶.结论SARS同时存在急性肺炎和急性间质性肺炎的影像改变,在治疗过程中,一系列胸片检查有助于掌握病情的变化,CT检查能较准确的评价肺部病变.     

乌司他丁治疗急性呼吸窘迫综合征的临床研究

目的：探讨蛋白酶抑制剂乌司他丁治疗急性呼吸窘迫综合征（ARDS）对稳定肺毛细血管、减少肺内血管外渗出的临床价值。方法：ARDS患者33例,APACHEⅡ评分10~20分,氧合指数100~200 mmHg。其中对照组16例,根据患者病情决定治疗方案,包括抗生素使用、低蛋白血症纠正以及补液支持等。观察组17例在对照组基础上,加用乌司他丁治疗7天。比较两组肺毛细血管血流量（PCBF）、肺泡通气量（MValv）、氧合指数（PaO2/FiO2）,血管外肺水（EVWL）和肺血管通透性（PVPI）及预后情况。结果：死亡率观察组为5.9%,对照组为25.0%,差异无统计学意义（P=0.126）。观察组于治疗2 d后、对照组于治疗3 d后开始出现不同程度的PCBF减少、MValv增多和PaO2/FiO2升高,7 d时两组PCBF、MValv及PaO2/FiO2均较治疗前改善,差异均有统计学意义（P<0.05）,观察组的改善明显优于对照组,差异均有统计学意义（P<0.05）。治疗开始后两组都出现不同程度EVW和PVPI降低,治疗后7 d与治疗前比较,差异均有统计学意义（P<0.05）,观察组治疗后7 d与对照组比较,差异均有统计学意义（P<0.05）。结论：乌司他丁治疗可以改善ARDS患者肺毛细血管稳定性,减轻肺毛细血管渗漏,提高肺顺应性,增加肺泡通气量,改善肺的氧合能力。     

吸氧浓度改变对肺氧交换指标影响的临床观察

目的 :探讨吸入氧浓度 (FiO2 )改变对肺氧交换指标的影响。方法 :6例 (9例次 )呼吸功能不全和 1例原因不明杵状指患者在病情处于相对稳定状态下 ,在FiO2 改变前后 30min分别取动脉血进行血气分析 ,计算肺泡氧分压 (PAO2 )及肺氧交换指标 ,然后用SPSS9.0软件进行统计分析。结果 :FiO2 改变前后肺泡 动脉氧分压差 (P(A a) O2 )差异有极显著性 (P <0 .0 0 1) ,动脉 肺部氧分压比 (PaO2 /PAO2 )、呼吸指数 (RI)和氧合指数(PaO2 /FiO2 )差异没有显著性 (P >0 .0 5 ) ;FiO2 提高与P(A a) O2 升高在不同个体没有相关性 (r=0 .2 38,P >0 .0 5 )。结论 :P(A a) O2 明显受FiO2 影响 ,PaO2 /PAO2 、RI和PaO2 /FiO2 受FiO2 影响较小 ,因此 ,在不同吸气氧浓度情况下用PaO2 /PAO2 、RI和PaO2 /FiO2 判断氧交换有无异常比P(A a) O2 更可靠。     

PaO2/（FiO2×Paw）对急性呼吸窘迫综合征患者肺内分流的评估价值

目的探讨新的氧合指数即结合了平均气道压（Paw）的[PaO2/（FiO2×Paw）]能否较传统氧合指数（PaO2/FiO2）更准确地反映急性呼吸窘迫综合征（ARDS）患者的肺内分流（Qsp/Qt）。方法符合ARDS诊断标准的患者12例,气管插管呼吸机支持,采用肺保护性通气策略（潮气量6 mL/kg,呼吸频率16次/min,FiO260%）,留置Swan-Ganz导管,采用低流速法测定准静态肺压力-容积曲线,确定低位转折点压力（Pinf）。调整PEEP水平,观察血流动力学、呼吸力学的变化,分别留取外周及肺动脉血行血气分析,计算Qsp/Qt和PaO2/FiO2。结果递增的呼气末正压（PEEP）不足以显著改变ARDS患者的肺顺应性（Cst）、PaO2/FiO2及PaO2/（FiO2×Paw）（P0.05）。递增的PEEP对Qsp/Qt改变不明显（P0.05）。检验Qsp/Qt与PaO2/（FiO2×Paw）及Qsp/Qt与PaO2/FiO2的相关系数,Δz=0.571,无显著性差异（P0.05）。影响ARDS患者的Qsp/Qt和PaO2/FiO2的参数不是Paw,而是Cst。结论 PaO2/（FiO2×Paw）与PaO2/FiO2相比,两者对ARDS患者肺内分流的评估价值相当。     

无创通气条件下肺复张在早期ARDS的应用分析

目的探讨无创通气条件下肺复张在早期ARDS的应用。方法对45例早期ARDS患者应用大型多功能呼吸机Puritan-bennett840经面罩连接行无创机械通气。在无创通气基础上,采用CPAP法进行肺复张,动态观察复张前后动脉血氧分压、氧合指数(PO2/FiO2)、动脉二氧化碳分压、pH值、心率、平均动脉压(MAP)、血压(BP)等治疗效果。结果肺复张后1h PaO290.76±11.40mmHg,PaO2/FiO2203.25±30.77mmHg肺复张后30min及1h动脉血氧分压和氧合指数明显升高,复张前后比较具有显著性差异(P<0.05)。结论对于早期ARDS患者,应用无创通气进行肺复张短时间内可提高动脉血氧分压和氧合指数;肺复张前后呼吸、血流动力学指标稳定。无创通气肺复张治疗早期ARDS安全有效。大型多功能呼吸机能够提供较高的压力,具有更完善监测功能,使肺复张更加充分完全。     

连续性血液净化对肺外源ARDS患者肺血管外肺水及呼吸功能的影响

目的观察连续性血液净化（CBP）对肺外源急性呼吸窘迫综合征（ARDSexp）患者肺血管外肺水及氧合功能的影响。方
法回顾性分析广州医科大学附属第二医院重症医学科31例ARDSexp患者的临床资料,根据是否行CBP治疗,为血液净化组
（16例）和对照组（15例）;记录治疗后血管外肺水指数（EVLWI)）、肺毛细血管通透指数（PVPI）及呼吸功能的变化。结果血液
净化组死亡率为12.5%,对照组死亡率为33.3%（P<0.05）;血液净化组EVLWI、PVPI、PaO2/FiO2和呼吸功能改善时间明显早于
对照组,效果也优于对照组（P<0.05）。结论早期应用CBP可改善ARDSexp患者肺血管外肺水及通透指数,改善肺氧合功能和
顺应性,从而改善预后。
     

应用肺复张法治疗肺内源性和肺外源性急性呼吸窘迫综合征的比较

目的探讨应用肺复张法(RM)治疗肺内源性和肺外源性急性呼吸窘迫综合征(ARDS)对氧合、呼吸力学参数及预后影响的差异。方法53例ARDS患者,依其病因分为肺内源性ARDS组(n=25)和肺外源性ARDS组(n=28)。采用持续气道正压(CPAP)40cmH2O,40s完成肺复张法。分别观察2组患者动脉血气分析、呼吸力学参数和预后指标,比较2组上述参数的差异。结果RM第1,2天后2h的氧合指数显著高于RM前,但2组间氧合差异无统计学意义。2组呼吸力学改变及预后指标差异均未见统计学意义。结论RM可以显著改善ARDS患者的氧合。RM对肺内源性ARDS和肺外源性ARDS患者氧合、呼吸力学参数变化和预后影响的差异无统计学意义。     

Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome

Context  Severe acute respiratory syndrome (SARS) is an emerging infectious disease with a 25% incidence of progression to acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and mortality exceeding 10%. Objective  To describe the clinical spectrum and outcomes of ALI/ARDS in patients with SARS-related critical illness. Design, Setting, and Patients  Retrospective case series of adult patients with probable SARS admitted to the intensive care unit (ICU) of a hospital in Singapore between March 6 and June 6, 2003. Main Outcome Measures  The primary outcome measure was 28-day mortality after symptom onset. Results  Of 199 patients hospitalized with SARS, 46 (23%) were admitted to the ICU, including 45 who fulfilled criteria for ALI/ARDS. Mortality at 28 days for the entire cohort was 20 (10.1%) of 199 and for ICU patients was 17 (37%) of 46. Intensive care unit mortality at 13 weeks was 24 (52.2%) of 46. Nineteen of 24 ICU deaths occurred late (=" BORDER="0">7 days after ICU admission) and were attributed to complications related to severe ARDS, multiorgan failure, thromboembolic complications, or septicemic shock. ARDS was characterized by ease of derecruitment of alveoli and paucity of airway secretion, bronchospasm, or dynamic hyperinflation. Lower Acute Physiology and Chronic Health Evaluation II scores and higher baseline ratios of PaO₂ to fraction of inspired oxygen were associated with earlier recovery. Conclusions  Critically ill patients with SARS and ALI/ARDS had characteristic clinical findings, high rates of complications; and high mortality. These findings may provide useful information for optimizing supportive care for SARS-related critical illness.      

Low-dose inhaled nitric oxide in patients with acute lung injury: a randomized controlled trial

Context  Inhaled nitric oxide has been shown to improve oxygenation in acute lung injury. Objective  To evaluate the clinical efficacy of low-dose (5-ppm) inhaled nitric oxide in patients with acute lung injury. Design and Setting  Multicenter, randomized, placebo-controlled study, with blinding of patients, caregivers, data collectors, assessors of outcomes, and data analysts (triple blind), conducted in the intensive care units of 46 hospitals in the United States. Patients were enrolled between March 1996 and September 1999. Patients  Patients (n = 385) with moderately severe acute lung injury, a modification of the American-European Consensus Conference definition of acute respiratory distress syndrome (ARDS) using a ratio of PaO₂ to FiO₂ of 250, were enrolled if the onset was within 72 hours of randomization, sepsis was not the cause of the lung injury, and the patient had no significant nonpulmonary organ system dysfunction at randomization. Interventions  Patients were randomly assigned to placebo (nitrogen gas) or inhaled nitric oxide at 5 ppm until 28 days, discontinuation of assisted breathing, or death. Main Outcome Measures  The primary end point was days alive and off assisted breathing. Secondary outcomes included mortality, days alive and meeting oxygenation criteria for extubation, and days patients were alive following a successful unassisted ventilation test. Results  An intent-to-treat analysis revealed that inhaled nitric oxide at 5 ppm did not increase the number of days patients were alive and off assisted breathing (mean [SD], 10.6 [9.8] days in the placebo group and 10.7 [9.7] days in the inhaled nitric oxide group; P = .97; difference, –0.1 day [95% confidence interval, –2.0 to 1.9 days]). This lack of effect on clinical outcomes was seen despite a statistically significant increase in PaO₂ that resolved by 48 hours. Mortality was similar between groups (20% placebo vs 23% nitric oxide; P = .54). Days patients were alive following a successful 2-hour unassisted ventilation trial were a mean (SD) of 11.9 (9.9) for placebo and 11.4 (9.8) for nitric oxide patients (P = .54). Days alive and meeting criteria for extubation were also similar: 17.0 placebo vs 16.7 nitric oxide (P = .89). Conclusion  Inhaled nitric oxide at a dose of 5 ppm in patients with acute lung injury not due to sepsis and without evidence of nonpulmonary organ system dysfunction results in short-term oxygenation improvements but has no substantial impact on the duration of ventilatory support or mortality.      

Effect of Prolonged Methylprednisolone Therapy in Unresolving Acute Respiratory Distress Syndrome: A Randomized Controlled Trial

Context.— No pharmacological therapeutic protocol has been found effective in modifying the clinical course of acute respiratory distress syndrome (ARDS) and mortality remains greater than 50%. Objective.— To determine the effects of prolonged methylprednisolone therapy on lung function and mortality in patients with unresolving ARDS. Design.— Randomized, double-blind, placebo-controlled trial. Setting.— Medical intensive care units of 4 medical centers. Participants.— Twenty-four patients with severe ARDS who had failed to improve lung injury score (LIS) by the seventh day of respiratory failure. Interventions.— Sixteen patients received methylprednisolone and 8 received placebo. Methylprednisolone dose was initially 2 mg/kg per day and the duration of treatment was 32 days. Four patients whose LIS failed to improve by at least 1 point after 10 days of treatment were blindly crossed over to the alternative treatment. Main Outcome Measures.— Primary outcome measures were improvement in lung function and mortality. Secondary outcome measures were improvement in multiple organ dysfunction syndrome (MODS) and development of nosocomial infections. Results.— Physiological characteristics at the onset of ARDS were similar in both groups. At study entry (day 9 [SD, 3] of ARDS), the 2 groups had similar LIS, ratios of PaO₂ to fraction of inspired oxygen (FIO₂), and MODS scores. Changes observed by study day 10 for methylprednisolone vs placebo were as follows: reduced LIS (mean [SEM], 1.7 [0.1] vs 3.0 [0.2]; P<.001); improved ratio of PaO₂ to FIO₂ (mean [SEM], 262 [19] vs 148 [35]; P<.001); decreased MODS score (mean [SEM], 0.7 [0.2] vs 1.8 [0.3]; P<.001); and successful extubation (7 vs 0; P=.05). For the treatment group vs the placebo group, mortality associated with the intensive care unit was 0 (0%) of 16 vs 5 (62%) of 8 (P=.002) and hospital-associated mortality was 2 (12%) of 16 vs 5 (62%) of 8 (P=.03). The rate of infections per day of treatment was similar in both groups, and pneumonia was frequently detected in the absence of fever. Conclusions.— In this study, prolonged administration of methylprednisolone in patients with unresolving ARDS was associated with improvement in lung injury and MODS scores and reduced mortality.      

Contemporary management of chronic obstructive pulmonary disease: scientific review

Context  The care of patients with chronic obstructive pulmonary disease (COPD) has changed radically over the past 2 decades, and novel therapies can not only improve the health status of patients with COPD but also modify its natural course. Objective  To systematically review the impact of long-acting bronchodilators, inhaled corticosteroids, nocturnal noninvasive mechanical ventilation, pulmonary rehabilitation, domiciliary oxygen therapy, and disease management programs on clinical outcomes in patients with COPD. Data Sources  MEDLINE and Cochrane databases were searched to identify all randomized controlled trials and systematic reviews from 1980 to May 2002 evaluating interventions in patients with COPD. We also hand searched bibliographies of relevant articles and contacted experts in the field. Study Selection and Data Extraction  We included randomized controlled trials that had follow-up of at least 3 months and contained data on at least 1 of these clinical outcomes: health-related quality of life, exacerbations associated with COPD, or death. For pulmonary rehabilitation, we included studies that had a follow-up of at least 6 weeks. Using standard meta-analytic techniques, the effects of interventions were compared with placebo or with usual care. In secondary analyses, the effects of interventions were compared against each other, where possible. Data Synthesis  Long-acting ₂-agonists and anticholinergics (tiotropium) reduced exacerbation rates by approximately 20% to 25% (relative risk [RR] for long-acting ₂-agonists, 0.79; 95% CI, 0.69-0.90; RR for tiotropium, 0.74; 95% CI, 0.62-0.89) in patients with moderate to severe COPD. Inhaled corticosteroids also reduced exacerbation rates by a similar amount (RR, 0.76; 95% CI, 0.72-0.80). The beneficial effects were most pronounced in trials enrolling patients with FEV₁ between 1 L and 2 L. Combining a long-acting ₂-agonist with an inhaled corticosteroid resulted in an approximate 30% (RR, 0.70; 95% CI, 0.62-0.78) reduction in exacerbations. Pulmonary rehabilitation improved the health status of patients with moderate to severe disease, but no material effect was observed on long-term survival or hospitalization rates. Domiciliary oxygen therapy improved survival by approximately 40% in patients with PaO₂ lower than 60 mm Hg, but not in those without hypoxia at rest. The data on disease management programs were heterogeneous, but overall no effect was observed on survival or risk of hospitalization. Noninvasive mechanical ventilation was not associated with improved outcomes. Conclusions  A significant body of evidence supports the use of long-acting bronchodilators and inhaled corticosteroids in reducing exacerbations in patients with moderate to severe COPD. Domiciliary oxygen therapy is the only intervention that has been demonstrated to prolong survival, but only in patients with resting hypoxia.      

Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial

Context  A recent trial showed that placing patients with acute lung injury in the prone position did not increase survival; however, whether those results hold true for patients with hypoxemic acute respiratory failure (ARF) is unclear. Objective  To determine whether prone positioning improves mortality in ARF patients. Design, Setting, and Patients  Prospective, unblinded, multicenter controlled trial of 791 ARF patients in 21 general intensive care units in France using concealed randomization conducted from December 14, 1998, through December 31, 2002. To be included, patients had to be at least 18 years, hemodynamically stable, receiving mechanical ventilation, and intubated and had to have a partial pressure of arterial oxygen (PaO₂) to fraction of inspired oxygen (FIO₂) ratio of 300 or less and no contraindications to lying prone. Interventions  Patients were randomly assigned to prone position placement (n = 413), applied as early as possible for at least 8 hours per day on standard beds, or to supine position placement (n = 378). Main Outcome Measures  The primary end point was 28-day mortality; secondary end points were 90-day mortality, duration of mechanical ventilation, incidence of ventilator-associated pneumonia (VAP), and oxygenation. Results  The 2 groups were comparable at randomization. The 28-day mortality rate was 32.4% for the prone group and 31.5% for the supine group (relative risk [RR], 0.97; 95% confidence interval [CI], 0.79-1.19; P = .77). Ninety-day mortality for the prone group was 43.3% vs 42.2% for the supine group (RR, 0.98; 95% CI, 0.84-1.13; P = .74). The mean (SD) duration of mechanical ventilation was 13.7 (7.8) days for the prone group vs 14.1 (8.6) days for the supine group (P = .93) and the VAP incidence was 1.66 vs 2.14 episodes per 100-patients days of intubation, respectively (P = .045). The PaO₂/FIO₂ ratio was significantly higher in the prone group during the 28-day follow-up. However, pressure sores, selective intubation, and endotracheal tube obstruction incidences were higher in the prone group. Conclusions  This trial demonstrated no beneficial outcomes and some safety concerns associated with prone positioning. For patients with hypoxemic ARF, prone position placement may lower the incidence of VAP.      

55例艾滋病合并结核病临床分析

目的探讨艾滋病(AIDS)合并结核病的临床特点、诊断和治疗。方法对1995—2005年期间在北京佑安医院诊治的55例艾滋病合并结核病的患者进行临床资料分析。结果最常见临床表现为发热55例(100%),咳嗽34例(61.8%)、盗汗29例(52.7%)、体质量下降28例(50.9%)、呼吸困难13例(23.6%)、胸痛11例(20%)。临床类型:单纯肺结核8例,结核性胸膜炎3例,单部位淋巴结核12例,播散型肺结核25例,其他部位结核7例。常见影像表现:肺中下叶的局灶性或弥散性渗出病变、淋巴结肿大、胸膜炎、弥散性粟粒或结节影。免疫功能:CD4+0.002×109~0.164×109/L,平均(0.049±0.043)×109/L。治疗:23例未同时抗结核和抗病毒治疗组中,2年后因结核死亡12例;27例同时抗结核和抗病毒治疗组中,2年后因结核死亡5例。结论艾滋病合并结核病的患者中播散型结核多、临床和影像表现复杂多样、诊断困难,及时抗结核治疗和联合高效抗逆转录病毒治疗能缩短病程,改善预后。     

感染性休克患者的负液体平衡与预后的关系

目的探究感染性休克治疗的前3天患者的液体平衡状态与预后的关系。方法采用回顾性对照研究。查看1999年1月至2003年12月收入首都医科大学附属复兴医院ICU的感染性休克患者病例记录,入选病例必须严格符合感染性休克的诊断标准,且既往无肾功能不全病史。采集病例相关数据以及诊断后第1、2、3天的液体平衡值。比较不同组别患者的急性生理和慢性健康评分(APACHEⅡ)、继发器官衰竭评分(SOFA)、液体平衡和病死率等数据。对影响患者预后的独立危险因素进行Logistic回归分析,确定和描述感染性休克患者的预后与在前3天的液体复苏治疗中出现的负平衡((0mL)相关因素的关系。结果负液体平衡患者与未出现负液体平衡患者2组的病死率差异有统计学意义(52.4%vs87.5%,χ2=5.303,P=0.021)。通过对入组时患者年龄、APACHEⅡ评分、第1天和第3天SOFA评分和正负平衡等影响患者预后的独立危险因素Logistic回归分析,表明前3天的治疗中,若有1d出现负液体平衡即可成为影响患者预后的独立危险因素(P=0.035)。结论在感染性休克前3天的治疗中,若有1d出现液体平衡负值即可成为影响感染性休克患者预后的独立因素,对感染性休克的28d生存预后有较强的预测性。在前3天的治疗中出现液体平衡为负值((0mL)的感染性休克患者的生存率比液体平衡为正值的患者的28d生存率高。     

Glycemic Control With Diet, Sulfonylurea, Metformin, or Insulin in Patients With Type 2 Diabetes Mellitus: Progressive Requirement for Multiple Therapies (UKPDS 49)

Context  Treatment with diet alone, insulin, sulfonylurea, or metformin is known to improve glycemia in patients with type 2 diabetes mellitus, but which treatment most frequently attains target fasting plasma glucose (FPG) concentration of less than 7.8 mmol/L (140 mg/dL) or glycosylated hemoglobin A_1c(HbA_1c) below 7% is unknown. Objective  To assess how often each therapy can achieve the glycemic control target levels set by the American Diabetes Association. Design  Randomized controlled trial conducted between 1977 and 1997. Patients were recruited between 1977 and 1991 and were followed up every 3 months for 3, 6, and 9 years after enrollment. Setting  Outpatient diabetes clinics in 15 UK hospitals. Patients  A total of 4075 patients newly diagnosed as having type 2 diabetes ranged in age between 25 and 65 years and had a median (interquartile range) FPG concentration of 11.5 (9.0-14.4) mmol/L [207 (162-259) mg/dL], HbA_1c levels of 9.1% (7.5%-10.7%), and a mean (SD) body mass index of 29 (6) kg/m². Interventions  After 3 months on a low-fat, high-carbohydrate, high-fiber diet, patients were randomized to therapy with diet alone, insulin, sulfonylurea, or metformin. Main Outcome Measures  Fasting plasma glucose and HbA_1c levels, and the proportion of patients who achieved target levels below 7% HbA_1c or less than 7.8 mmol/L (140 mg/dL) FPG at 3, 6, or 9 years following diagnosis. Results  The proportion of patients who maintained target glycemic levels declined markedly over 9 years of follow-up. After 9 years of monotherapy with diet, insulin, or sulfonylurea, 8%, 42%, and 24%, respectively, achieved FPG levels of less than 7.8 mmol/L (140 mg/dL) and 9%, 28%, and 24% achieved HbA_1c levels below 7%. In obese patients randomized to metformin, 18% attained FPG levels of less than 7.8 mmol/L (140 mg/dL) and 13% attained HbA_1c levels below 7%. Patients less likely to achieve target levels were younger, more obese, or more hyperglycemic than other patients. Conclusions  Each therapeutic agent, as monotherapy, increased 2- to 3-fold the proportion of patients who attained HbA_1c below 7% compared with diet alone. However, the progressive deterioration of diabetes control was such that after 3 years approximately 50% of patients could attain this goal with monotherapy, and by 9 years this declined to approximately 25%. The majority of patients need multiple therapies to attain these glycemic target levels in the longer term.      

Ketoconazole for early treatment of acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. The ARDS Network

Context  Three clinical studies have suggested that ketoconazole, a synthetic imidazole with anti-inflammatory activity, may prevent the development of acute respiratory distress syndrome (ARDS) in critically ill patients. However, the use of ketoconazole as treatment for acute lung injury (ALI) and ARDS has not been previously studied. Objective  To test the efficacy of ketoconazole in reducing mortality and morbidity in patients with ALI or ARDS. Design  Randomized, double-blind, placebo-controlled trial conducted from March 1996 to January 1997. Setting  Twenty-four hospitals associated with 10 network centers in the United States, constituting the ARDS Network. Patients  A total of 234 patients with ALI or ARDS. Intervention  Patients were randomly assigned to receive ketoconazole, 400 mg/d (n=117), or placebo (n=117), initiated within 36 hours of fulfilling study entry criteria and given enterally for up to 21 days. Main Outcome Measures  Primary outcome measures were the proportion of patients alive with unassisted breathing at hospital discharge and the number of days of unassisted breathing (ventilator-free days) during 28 days of follow-up. Secondary outcome measures included the proportion of patients achieving unassisted breathing for 48 hours or more, the number of organ failure–free days, and changes in plasma interleukin 6 (IL-6) and urinary thromboxane A₂ metabolites (thromboxane B₂ [TXB₂] and 11-dehydro-TXB₂). Results  In-hospital mortality (SE) was 34.1% (4.3%) for the placebo group and 35.2% (4.3%) for the ketoconazole group (P=.85). The median number of ventilator-free days within 28 days of randomization was 9 in the placebo group and 10 in the ketoconazole group (P=.89). There were no statistically significant differences in the number of organ failure–free days, pulmonary physiology, or adverse events between treatment groups. The median serum ketoconazole level was 1.25 µg/mL and serum levels greater than 0.5 µg/mL were detected in 96% of patients assayed. Plasma IL-6, urinary TXB₂, and 11-dehydro-TXB₂ levels were unaffected by ketoconazole. Conclusions  In these patients with ALI or ARDS, ketoconazole was safe and bioavailable but did not reduce mortality or duration of mechanical ventilation or improve lung function. These data do not support the use of ketoconazole for the early treatment of ALI or ARDS.