胰岛素强化治疗对颅脑外伤后高血糖患者预后的影响及护理

目的观察胰岛素强化治疗对颅脑外伤后高血糖患者预后的影响及总结护理要点。方法将64名颅脑外伤患者根据入院时空腹血糖分为高血糖组(血糖>7.8 mmol/L)和正常血糖组,高血糖组入院后即给予胰岛素强化治疗,控制血糖在4.4~6.1 mmol/L之间,其他治疗两组相同。观察1周后两组死亡率和格拉斯哥昏迷评分(GCS)。结果高血糖组死亡率15.6%,正常血糖组死亡率18.8%,两组比较,差异无统计学意义(P>0.01);两组治疗前后GCS评分比较,差异无统计学意义,但高血糖组胰岛素强化治疗前后GCS评分比较,有统计学意义(均P<0.01)。结论胰岛素强化治疗能改善颅脑外伤后高血糖患者的预后,护理上护士应做好患者血糖动态监测工作,协助医师调整患者血糖,这对提高救治水平、降低死亡率、改善患者预后有重要意义。     

短期胰岛素强化治疗危重症应激性高血糖的临床观察

目的:探讨短期胰岛素强化控制应激性高血糖对危重症临床疗效及预后的影响.方法:将172例合并应激性高血糖危重病患者随机分成胰岛素强化治疗组(治疗组)与常规胰岛素治疗组(对照组),对照组当血糖11.9 mmol/L时,使用胰岛素将血糖控制在10～11.1 mmol/L;治疗组当血糖6.1 mmol/L,使用胰岛素将血糖控制在4.0～6.1 mmol/L.强化治疗期为7天,7天后血糖控制及其处理均同对照组.结果:治疗组院感发生率、MODS发生率、死亡率较对照组明显降低;ICU住院时间较对照组明显缩短.结论:短期胰岛素强化治疗能有效提高危重症的治愈率,减少危重症并发症的发生,降低危重症的死亡率,并能缩短ICU住院时间,降低医疗费用.     

强化胰岛素治疗在危重病应激性高血糖中的应用

目的：观察危重患者强化胰岛素治疗后的疗效。方法：58例危重病伴高血糖患者随机分为治疗组（IT组）给予强化胰岛素治疗,血糖控制在4.4-6.1 mmol/L;对照组（CT组）给予常规胰岛素治疗,血糖控制在9.0-11.9mmol/L。结果：IT组中患者使用胰岛素天数、抗生素天数、住ICU天数、院内感染发生率、病死率均明显低于CT组。结论：强化胰岛素治疗控制危重患者血糖能降低患者的病死率。     

胰岛素强化治疗对急性脑梗死伴高血糖患者预后的影响

目的 观察胰岛素强化治疗对急性脑梗死伴高血糖患者的血清CRP与预后的影响.方法 162例急性脑梗死伴高血糖患者随机分成2组,治疗组81例给予胰岛素强化治疗,使血糖控制在4.4～6.1 mmol/L,对照组81例给予常规胰岛素治疗,血糖控制在10.0-11.7 mmol/L,观察2组患者血清CRP的变化及预后.结果 强化治疗组CRP较正常治疗组明显下降[(14.68±1.36)ms/L与(19.06 ±2.24)mg/L,P＜0.05],感染发生率明显低于常规治疗组(18.71%与33.65%,P＜0.05).神经系统功能恢复好于常规治疗组(第15天CCS评分别为72.16 ±2.31与58.13 ±2.07,第28天CCS评分别为76.42 ±2.14与67.07 ±1.99,P均＜0.05).结论 胰岛素强化治疗可降低急性脑梗死伴高血糖患者血清CRP与感染率,有助于神经系统功能恢复.     

重型颅脑损伤行肠外营养支持患者血糖控制的研究

目的通过控制重型颅脑损伤患者行肠外营养支持时的血糖水平,以减少高血糖、高甘油三酯血症和电解质失衡等并发症的发生。方法采用前瞻性随机对照研究法,把行肠外营养支持的66例重型颅脑损伤患者随机分为治疗组和对照组,各33例。治疗组患者持续输注胰岛素,使血糖水平控制在4.4~6.6mmol/L之间;对照组患者血糖水平高于11.0mmol/L时接受胰岛素治疗。对比两组患者的血糖水平、上臂周径、C反应蛋白、血脂、肝功能和电解质。结果治疗组平均血糖水平低于对照组(P0.05);治疗组甘油三酯和C反应蛋白均低于对照组(P0.05);两组电解质比较有差异,治疗组镁和磷低于对照组(P0.05)。结论重型颅脑损伤患者行肠外营养支持治疗时血糖水平控制在4.4~6.6mmol/L之间有利于改善患者的营养状况,能减少并发症的发生。     

危重病患者应激性高血糖的胰岛素强化治疗

目的:观察ICU危重病患者应激性高血糖胰岛素强化治疗的临床疗效.方法:110例ICU病房的危重病患者随机分为胰岛素强化治疗组(n=55)和对照组(n=55),强化治疗组血糖控制在4.4～6.1 mmol/L,对照组血糖控制在10.0～11.1 mmol/L,观察两组患者ICU住院天数、需机械通气例数、机械通气天数、院内感染发生率、抗生素应用天数、ICU最后1 d APACHEⅡ评分、低血糖发生率、多器官功能衰竭发生率、病死率等.结果:治疗组ICU住院天数、需机械通气例数,机械通气天数、院内感染发生率、抗生素应用天数、ICU最后1 d APACHEⅡ评分、多器官功能衰竭发生率、病死率均明显低于对照组(P<0.05或P<0.01),低血糖发生率则高于对照组(P<0.05).结论:危重病患者应激性高血糖胰岛素强化治疗,控制血糖在4.4～6.1 mmol/L水平,可改善临床疗效、降低病死率.     

中重度颅脑损伤合并应激性高血糖患者的护理体会

目的：探讨中重度颅脑损伤合并应激性高血糖患者使用胰岛素强化治疗的护理问题。方法：对2005年1月～2009年1月我科收治的中重度颅脑损伤合并应激性高血糖患者采用回顾性分析,将符合纳入/排除标准的97例患者分为观察组和对照组,观察组给予胰岛素强化治疗方案,对照组按常规控制血糖。结果：观察组预后为良好（GOSⅤ级）的患者多于对照组,而重残、中残（GOSⅢ级、Ⅳ级）的患者少于对照组。观察组患者使用胰岛素天数及住院天数明显低于对照组（P〈0.05）,观察组院内感染率低于对照组,低血糖、高渗性昏迷、低钾血症的发生都明显低于对照组。结论：在中重度颅脑损伤合并应激性高血糖患者中应用胰岛素强化治疗安全有效。     

严重创伤患者早期强化胰岛素治疗的临床护理研究

目的研究强化胰岛素治疗对严重创伤患者血糖控制水平及预后的影响。方法采用前瞻性研究方法,将200例严重创伤患者随机分为试验组和对照组,试验组100例给予强化胰岛素治疗,血糖控制在4.4~6.1 mmol/L;对照组100例按常规控制血糖在10.0~11.1 mmol/L,观察2组使用机械通气时间、脓毒血症发生率、应激性溃疡发生率、多功能脏器衰竭发生率、院内感染发生率、低血糖发生率和死亡发生率的情况。结果强化胰岛素治疗组中上述数据均明显低于传统治疗组,差异有统计学意义(P0.05)。结论对于严重创伤患者既往无糖尿病,当出现血糖水平持续升高时,强化胰岛素治疗可改善患者的病情,降低死亡率,减少感染性并发症的发生,但实施过程中需要严密监测,进行动态观察和护理,减少低血糖事件的发生,保证治疗效果。     

胰岛素泵强化治疗对重型颅脑损伤高血糖反应患者的控制效果及护理

将60例颅脑损伤后高血糖反应患者分为胰岛素泵治疗组(胰岛素泵连续皮下输注组,即CSⅡ组)和对照组(每日多次注射胰岛素组,即MSⅡ组)各30例,并实施有效护理.比较观察两组患者治疗前后血糖水平、血糖达标时闻、胰岛素用量及低血糖发生率.结果CSⅡ组血糖控制效果明显优于MSⅡ组,CSⅡ组能明显缩短血糖达标时间,胰岛素用量及低血糖发生率均少于MSⅡ组.提示应在重型颅脑损伤早期,对高血糖反应患者及早应用胰岛素泵治疗并强化胰岛素泵护理措施.     

目标血糖干预对急性重症胰腺炎并发高血糖患者的影响

目的：探讨目标血糖干预在急性重症胰腺炎患者中的应用价值,归纳总结护理措施。方法选取2015年2月至2016年1月本院消化内科重症急性胰腺炎并发高血糖患者118例为研究对象,按照随机数字表法分为实验组和对照组各59例,两组患者均使用微量泵静脉注射胰岛素,实验组血糖控制目标为6.1~10.0mmol/L,对照组血糖控制目标为4.4~6.1mmol/L,比较两组患者达到目标血糖时间、胰岛素用量、重症监护时间、APACHEⅡ评分、低血糖发生率、院内感染发生率、院内死亡率。结果实验组达到目标血糖时间、血糖监测次数、每日胰岛素用量明显少于对照组,差异具有统计学意义(χ2=4.6644、χ2=9.6074、χ2=10.0030, P<0.01);实验组重症监护时间、APACHEⅡ评分低于对照组,差异具有统计学意义(χ2=2.0257、χ2=1.9993, P<0.05);实验组低血糖发生率低于对照组,差异具有统计学意义(t=4.33,P<0.05);两组院内感染率、院内死亡率比较,差异无统计学意义(t=0.05,P>0.05)。结论目标血糖干预策略合理控制血糖范围6.1~10.0 mmol/L,减少了低血糖的发生,降低了胰岛素的用量,缩短了控制目标血糖时间、血糖监测次数和重症监护时间,安全可行,值得临床推广应用。     

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.