隧道式PICC在肿瘤晚期患者置管中的应用效果观察

目的 探讨隧道式PICC在肿瘤晚期患者置管中的应用.方法 采用数字随机法将某院106例行PICC置管的肿瘤晚期患者分为观察组和对照组,对照组采用B超引导下置管,观察组采用隧道式置管,两组均置入三向瓣膜式4FrPICC(美国巴德公司).比较两组患者置管时间、一针穿刺成功率、置管后出血、滑管、静脉炎等方面的差异.结果 观察组与对照组在置管时间、导管异位、皮疹、穿刺口渗液、置管48 h穿刺口渗血量差异无统计学意义(P＞0.05);一针穿刺成功观察组为98.08％,对照组为81.48％,观察组明显高于对照组,两组比较差异有统计学意义(P＜0.05);置管后24 h穿刺口出血、导管滑管、静脉炎等发生数观察组明显少于对照组,两组比较差异有统计学意义(P＜0.05).结论 采用隧道式PICC,大大提高了置管的成功率及延长了使用时间,提高了患者舒适性,降低了滑管的概率,减轻了局部渗血、静脉炎相关并发症的发生.     

肝素盐水有效降低PICC插管后静脉炎发生的临床研究

目的探讨三向瓣膜式PICC管经肝素盐水浸泡后再置管,对静脉炎发生的影响.方法将60例需要置管的患者,随机分为实验组和对照组各30例,实验组采用肝素盐水完全浸泡的PICC导管;对照组采用不经肝素盐水完全浸泡的PICC导管.分别观察2组患者静脉炎发生情况.结果实验组和对照组静脉炎发生例数经统计学分析,χ2=4.32 >3.84,P<0.05.结论经肝素盐水浸泡后的PICC导管静脉炎的发生率有所下降.从而延长导管保留时间,减少患者痛苦,降低患者住院费用.     

肝素盐水有效降低PICC插管后静脉炎发生的临床研究

目的　探讨三向瓣膜式PICC管经肝素盐水浸泡后再置管 ,对静脉炎发生的影响。方法　将 6 0例需要置管的患者 ,随机分为实验组和对照组各 30例 ,实验组采用肝素盐水完全浸泡的PICC导管 ;对照组采用不经肝素盐水完全浸泡的PICC导管。分别观察 2组患者静脉炎发生情况。结果　实验组和对照组静脉炎发生例数经统计学分析 ,χ2 =4 .32 >3.84 ,P <0 .0 5。结论　经肝素盐水浸泡后的PICC导管静脉炎的发生率有所下降。从而延长导管保留时间 ,减少患者痛苦 ,降低患者住院费用     

地塞米松肝素盐水预防PICC静脉炎的临床研究

目的探讨单腔三向瓣膜式PICC导管经地塞米松肝素盐水浸泡后再置管,对静脉炎发生的影响。方法将120例需置管的患者,随机分为实验组和对照组各60例,实验组采用地塞米松肝素盐水将PICC导管完全浸泡,对照组采用无菌生理盐水将PICC导管完全浸泡,分别观察2组患者静脉炎发生情况。结果实验组静脉炎发生率为3.34%,对照组静脉炎发生率为18.33%,两组例数经统计学分析,差异有统计学意义(P<0.05)。结论经地塞米松肝素盐水浸泡后的PICC导管置管后静脉炎的发生率明显下降,延长了导管的留置时间,减少了患者的痛苦,降低了医疗费用,提高了患者的满意度及生存质量。     

肝素钠生理盐水浸泡导管预防 PICC 置管后机械性静脉炎的效果分析

目的：探讨肝素钠生理盐水浸泡导管预防 PICC置管所致机械性静脉炎的效果。方法选择拟置入PICC的住院患者共计78例，按置管时间分为实验组39例、对照组39例。两组均按PICC操作规程置入导管。在置管前，对照组常规先采用生理盐水20 ml预冲导管，然后将PICC导管浸泡其中5～10 min后置入导管；而实验组先采用肝素钠生理盐水20 ml预冲导管，然后将PICC导管浸泡其中5～10 min后置入导管。结果对照组机械性静脉炎发生率为23．2％，实验组为5．2％，两组差异有显著意义（ P＜0．05）。结论肝素钠生理盐水浸泡导管，对预防PICC置管后机械性静脉炎效果良好。     

防止恶病质患者PICC导管置入过程中移位的方法

目的探讨减少消化系统疾病所致恶病质患者置入三向瓣膜式PICC导管移位至颈内静脉的方法。方法便利选取2010年1月至2012年7月在长海医院消化科行PICC置管的恶病质患者188例,均为消化系统疾病所致,BMI〈18．5。将188例患者随机分为对照组90例和观察组98例：对照组采取PICC常规置管法,即当导管头端到达肩部后协助患者将下颌靠近穿刺侧肩部,防止导管进入颈内静脉;观察组当导管到达锁骨下静脉中段时,助手在同侧锁骨上窝靠近胸锁关节处以四指并拢向内下方用力按压颈内静脉,防止导管进入颈内静脉。结果对照组与观察组的置管成功率分别为91．1％（81／90）及97．9％（95／98）,差异有统计学意义（X^2=5．395,P〈0．05）。结论恶病质患者置人PICC过程中,通过指压法可以有效减少PICC置管移位的发生,提高置管的成功率和工作效率。     

微波联合喜疗妥乳膏治疗PICC致机械性静脉炎的临床观察

机械性静脉炎是PICC置管后常见的并发症之一,发生率达20％～25％.我科2009年7月至2012年9月,应用微波照射联合喜疗妥乳膏外涂治疗PICC置管引起的机械性静脉炎30例,取得良好的效果,现报道如下. 资料与方法 1.一般资料.2009年7月至2012年9月共行PICC置管约500例,均为肿瘤放疗和(或)化疗患者,出现机械性静脉炎60例,其中使用美国巴德三向瓣膜式经PICC导管45例,有2012年5月本科才开始使用的山东白多安“康新”侧壁式PICC导管15例,男40例,女20例,年龄18～75岁.按随机抽号分为微波照射联合喜疗妥乳膏治疗组30例,50％硫酸镁湿敷30例,2组患者的性别、年龄、病种、治疗方式等比较,差异无统计学意义,具有可比性.     

三向瓣膜式PICC置管在肿瘤化疗患者中的应用及护理

目的：探讨三向瓣膜式PICC穿刺置管在肿瘤化疗患者中的应用效果与护理对策。方法：将本院2010年1月～2011年12月收治的170例住院首次化疗患者随机分成观察组86例与对照组84例,观察组患者实施三向瓣膜式PICC穿刺术,对照组患者应用ARROW抗感染单腔中心静脉导管实施深静脉置管术,比较两组患者穿刺成功率、留置时间、治疗费用以及感染率方面的差异,并总结护理要点。结果：观察组穿刺成功率高于对照组（P〈0.05）,留置时间长于对照组（P〈0.05）,感染发生率低于对照组（P〈0.05）,治疗费用少于对照组（P〈0.05）。结论：三向瓣膜式PICC置管的效果优于深静脉置管,能提高肿瘤患者对化疗的依从性,可在临床上推广应用。     

心内心电图特异性Q波辅助PICC尖端定位的效果观察

目的 探讨心内心电图特异性Q波引导三向瓣膜式PICC置管的应用效果。方法 2017年4月—2018年5月选取我院肿瘤科经上肢置入PICC的患者371例,按入组顺序进行抽签,A为观察组179例,B为对照组192例。观察组采用心内心电图定位法联合B超引导下改良塞丁格技术进行置管,并观察特异性Q波确定导管尖端的位置。对照组采用B超引导下改良塞丁格技术进行置管。观察比较2组患者导管尖端异位发生率。结果 观察组置入PICC导管尖端异位发生率低于对照组（P<0.05）。结论 采用心内心电图特异性Q波辅助三向瓣膜式PICC尖端定位能减少导管异位的发生,提高导管尖端到达上腔静脉与右心房交界处的准确率,值得临床借鉴使用。     

循证护理预防肿瘤患者PICC术后机械性静脉炎的效果

目的 探讨循证护理在肿瘤患者中预防PICC导管相关性静脉炎的临床效果.方法 将123例采用PICC导管行化疗的肿瘤患者随机分为观察组和对照组,对照组仅行常规护理,观察组给予循证护理,观察并比较两组患者置管后静脉炎的发生率、发生时间及平均置管时间.结果 观察组患者导管相关性静脉炎的发生率为6.2％,明显低于对照组的20.7％,且差异有统计学意义（x2 =5.23,P＜0.05）.而且,观察组患者静脉炎发生的时间（7.1±2.1）d明显晚于对照组（3.3±1.4）d,平均置管时间（103.6±10.2）d明显长于对照组（72.3±11.5）d,差异均有统计学意义（t分别为3.26,4.65;P＜0.05）.结论 对行PICC置管的肿瘤患者进行循证护理能显著降低导管相关性静脉炎的发生率,延长置管时间,值得临床推广和进一步深入研究.     

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.     

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.     

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.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.