非隧道式导管新型固定方法用于血液透析病人的可行性分析

目的:探究非隧道式导管新型固定方法用于血液透析病人的可行性。方法:选取2019年1月—2021年1月在医院进行血液透析的200例病人作为研究对象,采用随机数字表法分为对照组和试验组各100例,对照组采用传统敷贴胶带固定法对非隧道式导管进行固定,试验组采用新型固定法对非隧道式导管进行固定,比较两组病人导管固定效果、导管意外事件发生率、皮肤情况。结果:试验组导管稳定、颈部舒适病人所占比例高于对照组(P<0.05);试验组病人导管意外事件发生率低于对照组(P<0.05);试验组病人非隧道式导管部位皮肤红肿、渗液、污渍发生率低于对照组(P<0.05)。结论:在血液透析病人非隧道式导管固定方案中应用新型固定方法,相比于传统敷贴胶带固定法可获得更好的固定效果,导管意外事件、皮肤不良反应发生率明显降低,且操作简单,可行性高。     

不同敷料覆盖中心静脉导管与血路管连接端对预防血透导管感染的作用

目的探讨血液透析过程中血透导管与血路管连接端不同敷料覆盖法对血透导管感染的影响。方法收集2015年1月~2016年6月在本中心行血液净化治疗的临时和长期透析患者80例,随机分为观察组和对照组,各40例;观察组上机后血透导管与血路管连接端给予碘伏纱布外加一次性无菌PE手套包裹;对照组则以无菌干纱布包裹;透析治疗结束后,对两组导管连接端均采样做细菌检测,比较病原菌检出的阳性率及其与血透导管感染的相关性。结果共培养细菌3株,观察组0株,对照组3株,差异无统计学意义(P0.05)。结论无论使用无菌纱布还是碘伏纱布,两种敷料覆盖中心静脉导管连接端在预防血透导管感染上无明显差异。预防血透导管感染的最佳方式是医务人员严格执行手卫生规范,同时加强导管连接端的护理,以减少中心静脉导管感染的发生率。     

经锁骨下静脉置入PICC导管加皮下隧道的效果观察

目的探讨锁骨下静脉置入PICC导管加皮下隧道在肿瘤患者中的应用效果。方法将120例肿瘤患者分观察组、对照组各60例。对照组经锁骨下静脉置入PICC导管,观察组经锁骨下静脉置入PICC导管加皮下隧道。观察两组导管留置时间、相关培养标本阳性率及导管问题的差异。结果导管留置时间观察组(259.97±12.81)d、对照组(65.95±10.79)d;皮肤细菌培养阳性率观察组6.67%、对照组20%;导管培养阳性率观察组3.33%、对照组13.33%;血培养阳性率观察组1.67%、对照组11.67%;观察组发生导管阻塞、导管脱出较对照组少。结论经锁骨下静脉置入PICC导管加皮下隧道用于肿瘤患者,使用效果优于经锁骨下静脉置入PICC导管。     

PICC导管维护标准流程降低导管相关性感染的效果

目的减少PICC导管留置期间导管相关性感染的发生率,提高带管安全性,使患者得到长期有效的输液保证。方法将2009年1月至2010年12月各类需长期输液的PICC置管患者406例按就诊时间分为对照组和观察组,对照组采取常规导管维护方法,观察组严格按照PICC导管维护标准流程实施导管维护,比较两组患者导管相关性感染的发生率。结果观察组患者导管相关性感染的发生率(4.7%)低于对照组(17.8%),差异有统计学意义(P<0.01);但两组患者发生导管相关性感染的类型(导管病原菌定植、出口部位感染、隧道感染、导管相关血流感染)差异无统计学意义(P>0.05)。结论实施PICC导管维护标准流程可以规范护士导管维护的操作规程,有效控制导管相关性感染,对保障输液安全起到积极的作用。     

经隧道式中心静脉导管行血液透析导管相关血流感染发病率及危险因素的系统评价与Meta分析CSCD

目的系统评价经隧道式中心静脉导管行血液透析导管相关血流感染(catheter-related blood stream infection,CRBSI)发病率及危险因素。方法检索从建库到2022年9月PubMed、Web of science、Embase、Cochrane Library、中国知网、维普、万方和中国生物医学文献数据库,搜集报道了CRBSI发病率和/或危险因素的临床研究。采用R语言(version 4.1.2)进行单组率和危险因素的Meta分析。结果共纳入21篇文献,6758例经隧道式中心静脉导管行血液透析的患者。Meta分析结果显示:CRBSI总发病率为14.5%,欧洲人群发病率为28.9%(95%CI:16.2%~43.5%),病例对照研究的发病率为26.3%(95%CI:14.1%~40.7%),年龄≥60岁人群发病率为22.2%(95%CI:14.5%~31.0%),导管使用时间>24个月的发病率为28.2%(95%CI:2.5%~67.2%)。年龄≥60岁(OR=1.85,95%CI:1.29~2.64)、白蛋白<30g/L(OR=2.12,95%CI:1.40~3.22)、股静脉置管(OR=2.17,95%CI:1.24~3.80)、合并糖尿病(OR=1.82,95%CI:1.37~2.40)、置管时间≥4周(OR=2.04,95%CI:1.22~3.41)是经隧道式中心静脉导管行血液透析患者发生CRBSI的重要危险因素。结论经隧道式中心静脉导管行血液透析CRBSI发生率较高,年龄≥60岁、白蛋白<30g/L、股静脉置管、合并糖尿病、置管时间≥4周是CRBSI的重要危险因素。     

两针式皮下隧道法在PICC置管病人中的临床应用效果

目的:探讨两针式皮下隧道法在行经外周静脉置入中心静脉导管(PICC)病人中临床应用效果。方法:选取2020年7月—2021年7月在广西某三级甲等综合医院住院需要进行PICC置管的病人92例,采用掷硬币法随机将病人分为两组。对照组采用常规静脉穿刺法行PICC,试验组采用两针式皮下隧道法行PICC,观察两组病人的并发症发生率(导管相关性感染、导管移位、静脉炎)、渗血、一次性穿刺成功率及导管留置时间。结果:两组病人导管相关性感染发生率、导管移位、静脉炎、渗血发生率比较,差异均有统计学意义(P<0.05);两组病人一次性穿刺成功率比较差异无统计学意义(P>0.05);两组病人导管留置时间3～6个月的导管留置率、6～9个月的导管留置率、9～12个月的导管留置率对比,差异均有统计学意义(P<0.05)。结论:两针式皮下隧道法可有效降低PICC置管病人的导管相关性感染、导管移位、静脉炎、渗血的发生率,同时可以延长导管的留置时间,有利于减轻病人的痛苦和降低医疗费用。     

带隧道和涤纶套透析导管功能不良的治疗策略

目的 探讨带隧道和涤纶套透析导管功能不良患者的评估和治疗策略。方法 回顾分析上海中医药大学附属龙华医院血管外科2016年1月～2020年12月因带隧道和涤纶套透析导管功能不良收治的80例病例的病例特点、治疗方法及疗效。结果本研究共纳入80例患者92次治疗,男31例,女49例,平均年龄(63.45±13.7)岁,造影显示75例合并中心静脉病变。建立上肢自体动静脉瘘8例,建立上肢人工血管动静脉瘘4例,建立下肢人工血管动静脉瘘3例,均正常使用。单纯溶栓治疗14例22次,平均通畅时间(10.22±9.62)月,其中2例短期内再度导管功能不良而行原位换管。总计原位换管52例,异位换管3例,平均随访时间(49.5±3.8)月,导管12个月、24个月、36个月通畅率分别为93.2%、82.7%、74.0%。结论对于带隧道和涤纶套透析导管功能不良的患者应在全面评估的基础上采用个体化的治疗方案,以延长患者的透析生命。     

经皮下隧道静脉置管与直接静脉置管对导管留置时间的影响

目的观察经皮下隧道静脉置管与直接静脉置管对导管留置时间的影响.方法将60例危重病病人随机分为试验组(30例)和对照组(30例),试验组采取经皮下隧道右贵要静脉穿刺置管,对照组采取直接右贵要静脉穿刺置管,观察导管性感染和导管留置时间.结果试验组的导管留置时间比对照组明显延长,具有显著性差异.试验组在穿刺处局部感染率、导管尖端培养和血培养阳性率以及感染相对危险性等方面均比对照组低,有显著性差异(均为P＜0.05).结论经皮下隧道贵要静脉置管能有效地防止导管性感染,延长导管留置时间,值得推广.     

经皮下隧道右贵要静脉穿刺置管用于开颅手术病人围术期输液的效果观察

[目的]观察经皮下隧道右贵要静脉穿刺置管和传统股静脉穿刺置管用于开颅手术病人输液的效果。[方法]将80例需行开颅手术的病人随机分为实验组(n=40)和对照组(n=40),实验组采取经皮下隧道右贵要静脉穿刺置管,对照组采用传统股静脉穿刺置管,观察两组导管留置时间、置管滑脱或堵塞以及导管相关性感染方面的差异。[结果]实验组导管留置时间比对照组长(P<0.01),导管脱出发生率较低(P<0.05),导管尖端培养和血培养阳性率均较对照组低(P<0.05),但两组穿刺部位血肿、血栓性静脉炎、导管阻塞等方面无统计学差异。[结论]经皮下隧道右贵要静脉置管用于开颅手术病人可有效地防止导管相关性感染,显著延长导管留置时间。     

硝酸甘油注射液再通中心静脉导管脂质沉积性堵管

目的观察硝酸甘油注射液应用于胃肠外营养液中脂质成分沉积导致中心静脉导管堵管的再通效果及其安全性。方法硝酸甘油注射液0.25 m l(经颈内静脉非隧道式置管)或0.45 m l(经外周静脉置管)注入中心静脉导管,2 h后抽出导管内液体,用生理盐水反复冲管。结果18例患者21例次中心静脉导管部分堵管,经硝酸甘油注射液处置,输液滴速由处置前(32.3±9.1)滴/m in增加到(67.6±4.1)滴/m in,导管再通成功率为100%,留置时间延长(2.2±1.3)个月。处置前后的血压、脉搏无明显变化(P>0.05)。结论长期经中心静脉导管输入胃肠外营养液,脂质成分沉积在管壁可引起中心静脉导管部分堵管,应用硝酸甘油注射液能有效疏通导管,延长导管留置时间,并且安全、无不良反应。     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.