失效模式与效应分析在神经内科仪器管理中的应用

目的探讨失效模式与效应分析(FMEA)在神经内科仪器管理中应用效果。方法成立仪器管理团队,对共计8类设备,187台诊疗仪器,进行失效模式与效应分析管理干预,计算优先风险指数,找出失效模式及相关原因,对需优先解决的问题进行改进。结果失效模式的优先风险指数均下降,护理质控反馈护士对仪器操作及理论考核成绩显著提升(均P0.05)。结论 FMEA法应用于科室医疗仪器的管理能够对潜在的风险进行控制,提高仪器管理质量。     

应用失效模式与效应分析预防桥小脑角肿瘤手术患者误吸

目的识别桥小脑角肿瘤手术患者进食过程中潜在的风险,改进围手术期误吸预防策略。方法成立桥小脑角肿瘤误吸预防安全护理管理团队,应用失效模式与效应分析(FMEA)方法,列出桥小脑角肿瘤围手术期预防误吸的各个步骤,以及每个步骤可能发生的失效模式,并计算失效模式的危急值(RPN),查找误吸预防策略中存在的危险因素,针对误吸发生的高危因素,制定改进措施并应用于临床护理。比较实施FMEA前后RPN值及误吸发生率。结果实施FMEA后桥小脑角肿瘤手术患者误吸发生率显著下降(P0.05),失效模式RPN值由实施前的210~448分降低至72~160分。结论 FMEA模式应用于桥小脑角区肿瘤手术患者有利于降低术后误吸风险,提高护理安全性。     

医疗失效模式与效应分析用于降低术后患者床边监护仪报警失效

目的降低术后患者床边监护仪报警失效,保障患者安全。方法根据医疗失效模式与效应分析(HFMEA)方法,成立床边监护仪报警HFMEA小组,对床边监护仪报警流程及规范进行失效模式及潜在风险原因分析,计算优先风险指数(RPN);找出失效模式及相关原因;对需优先解决的问题进行改进。结果实施HFMEA管理后,术后患者床边监护仪报警未开启率及报警参数设置错误率显著低于管理前(均P0.01);80.95%~100%外科护士对HFMEA管理持肯定态度。结论运用HFMEA评估并改进床边监护仪报警流程,可以降低术后患者床边监护仪报警失效,提高术后患者监护安全。     

基于失效模式与效应分析的病区低值耗材智能化管理

目的探讨基于失效模式与效应分析(Failure Mode and Effects Analysis,FMEA)的智能化管理在病区低值耗材管理中的应用效果。方法在病区组织由护士长和资深护士组建6人团队,对科室低值耗材的管理进行风险评估,找出耗材管理中的潜在失效模式,邀请科室全体成员对每个潜在失效模式进行风险优先指数(Risk Priority Number,RPN)评分,并针对性地实施智能化改进措施,比较智能化管理措施实施前后主要失效模式的RPN评分和管理效益相关评价指标。结果管理6个月后,病区低值耗材管理的5项主要失效模式RPN值,以及低值耗材库存量、耗材库存质量合格率和耗材月盘点花费时间与实施前比较,差异有统计学意义(均P<0.01)。结论通过FEMA确定科室低值耗材管理的失效模式,针对性采用智能化管理措施可有效提高病区低值耗材的管理质量。     

追踪方法学联合失效模式与效应分析用于老年患者口腔管理

目的探讨追踪方法学联合失效模式与效应分析在老年患者口腔管理的应用效果。方法成立老年患者口腔管理追踪检查小组,运用资料查阅、现场访谈、实地查看等追踪方法,对老年患者口腔管理进行追踪检查,并应用失效模式与效应分析进行风险评估,完善老年患者口腔管理方法。比较实施前后各100例老年患者(对照组与观察组)风险优先指数值、口腔护理规范率及口腔功能状态。结果观察组风险优先指数值、老年患者口腔护理规范率及患者口腔功能状态显著优于对照组(均P<0.01)。结论运用追踪方法学联合FMEA可降低老年患者口腔疾病风险,提高口腔管理质量。     

综合医院住院患者自杀预防的最佳证据总结

目的总结综合医院住院患者自杀预防的相关证据,为预防住院患者自杀提供参考。方法根据问题开发工具PIPOST确立综合医院住院患者自杀预防的循证问题,检索Cochrane图书馆、JBI循证卫生保健国际合作中心图书馆、BMJ Best Practice、美国国立指南库(NGC)、加拿大安大略注册护士协会(RNAO)循证护理指南、Wiley Online Library、JAMA、Pub Med以及中国生物医学文献库(CBM),进行文献质量评价,并对证据进行总结。结果纳入8篇文献,总结出15项证据,包括自杀风险评估、自杀安全管理、自杀治疗护理、自杀随访及自杀守门人培训5个主题。结论综合医院住院患者自杀预防的证据实证性强,可用于临床。护理人员在应用证据时应评估具体临床情形及障碍因素,结合专业判断形成有效、可行的自杀预防策略,动态评价证据应用效果,切实防范自杀行为。     

脊髓肿瘤患者住院期间疼痛管理方案的构建与应用

【摘要】 目的：构建脊髓肿瘤患者术后疼痛管理方案,为疼痛管理提供科学化、精确化依据。方法：通过循证护理,形成脊髓肿瘤患者住院期间疼痛管理方案初稿,并选取10例患者实施方案初稿,依据实施结果修改完善,形成最终方案。在此基础上,选取2021年1月～2021年7月南京大学医学院附属鼓楼医院神经外科收治的71例脊髓肿瘤患者,采用Excel随机数字生成器随机分为对照组和观察组。对照组采用常规护理干预;观察组在对照组基础上予以疼痛管理方案。比较两组患者术后24h和72h的视觉疼痛模拟评分（visual analog scale,VAS）,术后2周的睡眠质量评分（采用匹兹堡睡眠质量评分量表）和心理弹性水平评分（釆用2007年肖楠等翻译修订的中文版心理弹性量表）。结果：术后24h观察组VAS为5.13±2.08分,对照组为5.67±2.22分,差异无统计学意义（P=0.294）;术后72h观察组VAS为3.62±0.92分,对照组为5.12±1.13分,差异有统计学意义（P＜0.001）。术后2周观察组睡眠质量评分为8.80±4.07分,对照组为11.86±4.73分,差异有统计学意义（P=0.005）。术后2周观察组心理弹性水平评分为19.97±11.16分,对照组为17.57±10.21分,差异无统计学意义（P=0.104）。结论：脊髓肿瘤患者疼痛管理方案的应用能够降低患者术后疼痛水平,提高患者的睡眠质量。     

基于失效模式与效应分析的手术患者术前交接流程管理

目的探讨失效模式与效应分析在手术患者术前交接流程管理中的应用效果。方法对344例手术患者术前交接流程进行梳理,分析交接中的失效模式及原因,计算优先风险数值,找出前5位的失效模式,并针对造成失效模式的主要原因,制订改进措施。实施3个月后,抽取342例手术患者,对术前交接情况进行调查。结果实施后术前准备完善率、患者关键信息规范率、手术部位标记正确率、病历资料齐全率、患者评估齐全率显著高于实施前(P<0.05,P<0.01)。结论失效模式与效应分析能够纠正手术患者术前交接失效模式,使术前交接更加顺畅、规范,保障患者手术安全。     

不同治疗时机的连续性肾脏替代治疗对重症急性胰腺炎疗效的影响

目的 探讨在不同治疗时机进行的连续性肾脏替代治疗(CRRT)对重症急性胰腺炎(SAP)疗效的影响.方法 回顾性分析2006年7月至2009年11月解放军第一八一中心医院收治的44例SAP患者的临床资料.按每位患者开始CRRT治疗的时机分为3组:A组(发病72 h以内)15例,B组(发病72～120 h)18例,C组(发病120 h以后)11例.观察患者的APACHEⅡ评分、ICU住院时间、28 d病死率.计量资料采用t检验和SNK-q检验,率的比较采用x2检验.结果 进行CRRT治疗48 h后,A组患者的APACHEⅡ评分下降最快,由(20±7)分下降至(12±5)分(t=2.06,P＜0.05);其次是B组患者,由(20±6)分下降至(18±6)分(t=2.15,P＜0.05);C组患者的下降最慢,由(24±7)分下降至(20±6)分(t=0.52,P＞0.05).A、B、C组患者ICU住院时间分别为(5.2±2.1)、(8.9±4.8)、(13.4±6.7)d,A组患者ICU住院时间明显短于B组和C组(q=3.52,5.36,P＜0.05),且B组患者ICU住院时间短于C组(q=4.81,P＜0.05).A、B、C组患者28 d病死率分别为1/15、2/18、4/11,3组比较,差异有统计学意义(x2=8.96,P＜0.05).结论 SAP患者发病72 h以内是进行CRRT治疗的最佳时机,发病72～120 h进行CRRT治疗是可以接受的时机,超过120 h以后才开始进行CRRT则为时较晚.     

综合医院住院患者自杀人文环境影响因素及干预措施研究进展

从医护方、患者家属方、组织管理方3个方面对综合医院住院患者自杀的人文环境影响因素,预防住院患者自杀人文环境干预措施进行综述,旨在为建立综合医院住院患者自杀预防干预体系提供参考,降低住院患者自杀发生率。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.