3%高渗盐水降低颅内肿瘤患者颅内压的可行性

目的观察3%高渗盐水(HTS)对颅内肿瘤患者脑脊液压力(CSFP)、血液动力学及电解质的影响,探讨3%HTS用于降低颅内肿瘤患者颅内压的可行性。方法择期行大脑半球胶质瘤切除术患者加例,男23例,女17例,ASA Ⅰ或Ⅱ级,随机分为两组(n=20),HTS组和M组,麻醉诱导前行L3,4刺置管监测CSFP。两组均行静吸复合麻醉,异氟醚呼气末浓度达1MAC后,在15 min内输注3%HTS(5.33 ml/kg)和20%甘露醇(1g/kg)。在输注前即刻(T0)、输注后15、30、60、90、120 min(T1-5)记录平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)、尿量,采集5 ml动脉血测定血浆Na 、K 、pH、血浆渗透压;在T0-4监测CSFP,计算脑灌注压(CPP)。结果两组各时点MAP和HR比较差异无统计学意义(P>0.05)。与T0时比较,HTS组CSFP在T2-4时降低,M组在T3、T4时降低,HTS组CVP在T1-4 时升高,M组在T4、T5时降低,两组各时点血浆渗透压均升高,两组不同时点血浆Na 和K 浓度均有改变但仍在正常范围内(P<0.05)。与M组比较,HTS组CSFP在T2时降低,CVP在T5时升高,尿量在T1-2、T2-3、T3-4、T4-5时段减少(P<0.05)。结论3%HTS可安全地用于颅内肿瘤患者,其降低颅内压的作用优于20%甘露醇,且在降低颅内压的同时,不影响血液动力学。     

短期应用高渗盐水对重症蛛网膜下腔出血患者颅内压、脑血流量的影响

目的 探讨23.4%高渗盐水(HTS)对重症蛛网膜下腔出血(SAH)患者颅内压、脑灌注压、脑血流量(CBF)的影响.方法 16例重症SAH患者(GCS≤8分)在颅压升高时接受静脉输注23.4%HTS,监测用药前及用药后30、60、90、120、150、180 min的颅内压(ICP),平均动脉压(MAP),脑灌注压(CPP)及脑血流速度(FV).结果 用药后30 min可见ICP显著降低,同时MAP、CPP及FV显著升高(P<0.05),ICP显著降低可持续180 min,CPP和FV的改善持续约90 min(P<0.05).结论 HTS能显著降低重症SAH患者的ICP,改善脑组织灌注,可用来纠正脑缺血引起的病生理变化.     

Changes in circulating blood volume after infusion of hydroxyethyl starch 6% in critically ill patients

BACKGROUND: The cardiovascular response to a volume challenge with hydroxyethyl starch (HES) (200/0.5) 6% depends on the relation between the volume of HES 6% infused and the expansion of the blood volume in critically ill patients. However, only relatively limited data exist on the plasma expanding effect of infusion of HES 6% in critically ill patients. The purpose of the study was to evaluate the variation in the expansion of the circulating blood volume (CBV) in critically ill patients after infusion of 500 ml of colloid (HES (200/0.5) 6%) using the carbon monoxide method. METHODS: In 20 consecutive patients admitted to the ICU requiring mechanical ventilation and volume expansion, 500 ml of HES (200/0.5) 6% was infused. The CBV was measured immediately before the infusion, 10 min after completing the infusion and then hourly for 8 h. RESULTS: The median volume expansion immediately after infusion was 470 ml (range 270 ml to 840 ml). The corresponding values after 4 h and 8 h were 265 ml (range -30 ml to 460 ml) and 120 ml (range -210 ml to 360 ml), respectively. The increase in CBV was only statistically significant for 4 h. The coefficient of variation of the method for estimation of CBV was 3.6%. CONCLUSIONS: The large interindividual variation of the volume expansion after infusion of HES 6% in critically ill patients illustrates one of the difficulties in optimizing colloid therapy and interpretating the changes in hemodynamic variables after a colloid challenge.     

Effects of intravenous nitroglycerin combined with dopamine on intracranial pressure and cerebral arteriovenous oxygen difference in patients with acute subarachnoid haemorrhage

Summary The effects of intravenous nitroglycerin (NTG) combined with dopamine on intracranial pressure (ICP) and cerebral arteriovenous oxygen difference (AVDO₂) were studied in 11 patients with acute subarachnoid haemorrhage (SAH). The study was performed on Days 1 to 3 of SAH after aneurysmal clipping. Treatment consisted of an intravenous drip infusion of NTG in increasing incremental doses of 0.5, 1.0, 1.5, 2.0, and 2.5 g/kg/min at one-hour intervals. Dopamine (5 to 10 g/kg/min) was also given concurrently to maintain systemic blood pressure. ICP values before NTG administration ranged from 7 to 24 mmHg (mean, 11.91±5.30 mmHg). ICP began to increase immediately after the adminisration of NTG 0.5 g/kg/min and peaked at 14.64±5.93 mmHg 10 minutes after onset of infusion. Thereafter, ICP gradually returned to pretreatment levels. Increasing the dose of NTG failed to induce further significant rises in ICP. Mean AVDO₂ before NTG administration was 4.69±0.62 ml/dl. This parameter showed no significant change during NTG infusion, although cerebral perfusion pressure decreased to between 75% to 94% of the control value after NTG administration. These results indicate that continuous NTG infusion combined with dopamine does not have adverse effects on ICP (the ICP increase is minimal and transient) and may even have beneficial effects on CBF in patients with acute SAH.     

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study

BackgroundCritically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension.MethodsObstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24 hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure.ResultsOne-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5–7 mmHg in 34%; 7–12 mmHg in 60%; and ≥12 mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12 mmHg following delivery, but in the remaining two it persisted ≥12 mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5 ± 1.1 vs 7.9 ± 1.7 mmHg, P=0.079).ConclusionsThe incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.     

Effects of hypertonic dextran in hypovolaemic shock: a prospective clinical trial

The aim of this paper is to report the results of prospective clinical trials of hypertonic saline dextran (HSD) in the resuscitation of hypovolaemic shock in critically injured patients. There are many types of fluids, which can be administered intravenously. Recent interest in the usage of HSD solution has confirmed that they have a place in resuscitation of a patient in shock. Heart rate and arterial pressure recovered well with HSD solution. The plasma osmolarity, sodium and potassium levels were significantly elevated in patients resuscitated with HSD. Urine output recovered rapidly and was well maintained throughout.     

Erythropoietin in patients with aneurysmal subarachnoid haemorrhage: a double blind randomised clinical trial

Summary Background. Erythropoietin (EPO) is neuroprotective in experimental models of stroke and subarachnoid haemorrhage (SAH) and possibly in patients with thromboembolic stroke. We studied the efficacy and safety of EPO in patients with SAH. Methods. A larger scale clinical trial was planned but preliminarily terminated because of a lower than expected inclusion rate. However, 73 patients were randomised to treatment with EPO (500 IU/kg/day for three days) or placebo. The primary endpoint was Glasgow Outcome Score at six months. We further studied surrogate measures of secondary ischaemia, i.e. transcranial Doppler (TCD) flow velocity, symptomatic vasospasm, cerebral metabolism (microdialysis) and jugular venous oximetry, biochemical markers of brain damage (S-100β and neuron specific enolase) and blood–brain barrier integrity. Findings. The limited sample size precluded our primary hypotheses being verified and refuted. However, data from this study are important for any other study of SAH and as much raw data as possible are presented and can be included in future meta analyses. On admission the proportion of patients in a poor condition was higher in the EPO group compared with the placebo group but the difference was statistically insignificant. In the EPO-treated patients the CSF concentration of EPO increased 600-fold. Except for a higher extracelullar concentration of glycerol in the EPO group probably caused by the poorer clinical condition of these patients, there were no statistically significant group differences in the primary or secondary outcome measures. EPO was well tolerated. Conclusions. Beneficial effects of EPO in patients with SAH cannot be excluded or concluded on the basis of this study and larger scale trials are warranted.     

高渗氯化钠羟乙基淀粉溶液对脑动脉瘤出血介入术后脑血管痉挛的影响及机制

目的 探讨术中及术后输注高渗氯化钠羟乙基淀粉溶液(hypertonic sodium chloride hydroxyethyl starch solution,HSH)对脑动脉瘤破裂出血介入术后脑血管痉挛(cerebral vasospasm,CVS)的影响及其机制. 方法 发病后3d内拟行颅内动脉瘤介入栓塞术的动脉瘤破裂蛛网膜下腔出血(aneurysm subarachnoid hemorrhage,aSAH)患者30例.ASA分级Ⅱ、Ⅲ级,Hunt和Hess(原发性蛛网膜下腔出血的临床状态)分级Ⅱ、Ⅲ级,改良Fisher分级1、2级,格拉斯哥昏迷评分(Glasgow ComaScale,GCS) 13～15分,年龄18～80岁.按随机数字表法分为两组(每组15例):实验组(H组),输注4.2％ HSH 4 ml/kg;对照组(N组),输注等量生理盐水.两组均于术前(T0),输注HSH或生理盐水结束时(T1),手术结束时(T9及术后第1天(T3)、第2天(T4)、第3天(T5)、第4天(T6)、第5天(T7)的上午8点,分别记录MAP、CVP、血浆渗透压(plasma osmotic pressure,POP)、HR、Na+、K+、C1-等数值;采用经颅多普勒超声(transcranial doppler,TCD)监测T0及T3～T7时右侧大脑中动脉血流速度,ELISA检测上述时间点血浆中IL-6、TNF-α、内皮素-1(endothelin-1,ET-1)及一氧化氮(nitric oxide,NO)等因子浓度,同时记录患者GCS得分、神经功能缺损评分(china stroke scale,CSS)及24 h出入量. 结果 H组CVP在T1～T7时分别高于N组(P＜0.05);POP在T2～T7时高于N组(P＜0.05).两组患者大脑中动脉血流速度术后呈上升趋势,H组患者在T5～T7时低于N组(P＜0.05);H组患者在T7时血浆IL-6、TNF-α浓度低于N组(P＜0.05);T5～T7时,H组ET-1浓度低于N组(P＜0.05);T4～T7时,H组NO浓度高于N组(P＜0.05);上述指标其他时间点及两组间GCS得分、CSS评分、24h出入量比较,差异无统计学意义(P＞0.05). 结论 脑动脉瘤破裂出血患者围手术期小量输注HSH能有效减轻脑血管介入手术后CVS发生程度,其机制可能与抑制炎症介质及血管舒缩因子平衡紊乱有关.     

高渗氯化钠羟乙基淀粉40注射液对外伤性颅内血肿伴失血性休克患者术中颅内压的影响

目的 探讨高渗氯化钠羟乙基淀粉40注射液(HH40)对外伤性颅内血肿伴失血性休克患者术中颅内压(ICP)的影响.方法 外伤性颅内血肿伴失血性休克患者40例,急诊行颅内血肿清除术,随机均分为HH40组(H组)和4.2%高渗盐水组(C组).麻醉诱导后,分别在15 min内快速静脉输入HH40 5ml/kg或4.2%高渗盐水5 ml/kg.在输注HH40或4.2%高渗盐水前即刻(T0)、输注后15 min(T1)、30 min(T2)、60 min(T3)、90 min(T4)、120 min(T5)记录MAP、HR、CVP、尿量,采集桡动脉血测定血浆Na+、K+浓度进行血气分析,并计算各时点脑灌注压(CPP):CPP=MAP-ICP.结果 与T0时比较,T1～T5时两组MAP、CVP、CPP升高,HR减慢,T2～T5时ICP降低(P＜0.05).与C组比较,T4、T5时H组HR减慢和T5时MAP升高(P＜0.05);H组降低ICP幅度与其相似,而降ICP作用维持时间较长(P＜0.05).结论 HH40可安全地用于外伤性颅内血肿伴失血性休克手术患者,能有效地纠正其休克,降低其ICP.     

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C‐collar) device in situ and are subsequently exposed to device‐related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C‐collar‐related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C‐collar were retrieved over a 9‐year period. Chi square and t‐tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine‐year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C‐collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024‐1.723, P = .033). Time in the C‐collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C‐collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.     

Factors associated with time to defecate and outcomes in critically ill patients: a prospective,multicentre, observational study

Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days’ invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1–18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05–1.66), p = 0.02; laxatives before admission, 2.35 (1.79–3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36–0.82), p = 0.004; duration of ventilation, 0.78 (0.74–0.82), p < 0.001; laxatives after admission, 1.67 (1.23–2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07–1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.     

参照点的选择对重症患者腹内压测定的影响

目的 探讨不同参照点的选择对重症患者腹内压(IAP)测定结果的影响.方法 以2008年7月至2010年6月间入住ICU的9例具有腹腔高压危险因素并同时放置有腹腔引流管和导尿管的患者为研究对象.采用经膀胱测量法(间接法)及经腹腔引流管测量法(直接法),并分别选取耻骨联合、右心房对应点及腋中线与髂嵴交点为参照点测定患者IAP,记录不同参照点测得的IAP,结果分别标记为IAPS、IAPP、IAPI.应用Bland Altman分析直接法和间接法测量的一致性;配对t检验比较不同参照点下IAP测量结果的差异,计算各参照点下直接法和间接法测量的直线相关系数.结果 从9例患者获得60组测量结果.直接法测量的IAPI为(13.8±3.9)mmHg(1 mmHg=0.133 kPa),高于同法测量的IAPP(12.8±3.6)mmHg和IAPS(9.1±3.6)mmHg的水平(P＜0.05);间接法测得IAPI为(12.7±3.2)mmHg,也高于同法测量的IAPP(11.7±2.9)mmHg和IAPS(7.9±3.0)mmHg的水平(P＜0.05).两种测量方法中IAPP均高于IAPS(P＜0.05).不同参照点直接法和间接法测量结果具有良好的相关性,直接法和间接法测量结果之间的相关系数RS、RP及RI分别为0.791,0.755,0.759.结论 间接法测得的膀胱压能较好地反映IAP.耻骨联合和右心房对应点不能代替腋中线与髂嵴交点作为IAP监测的参照点.

Abstract：

Objective To investigate the effects of different reference point on intra-abdominal pressure (IAP) measurement. Methods Nine critically ill patients with risk of intra-abdominal hypertension (IAH) were studied from July 2008 to June 2010, all of the patients were equipped with abdominal cavity drain and urinary drainage tube. By which IAP was measured using direct and indirect methods respectively. The symphysis pubis, phlebostatic axis and the midaxillary line at the level of the iliac crest were defined as reference points. According to the different reference point, three sets of IAP measurements were obtained in the supine position with each method and kept as IAPS, IAPP, IAPI. Bland-Altman method analysis and Pearson's correlation were performed to evaluate the relationships between results from different reference points with direct and indirect methods. Paired t-test was performed to evaluate the differences among different reference points. Results Sixty measurements of IAPS, IAPP and IAPI were obtained. In direct measurement through abdominal cavity drain, IAPI ( 13. 8 ± 3.9) mmHg ( 1mmHg =0. 133 kPa) was significantly higher than IAPP( 12. 8 ±3.6) mmHg and IAPs(9.1 ±3.6) mmHg,P ＜ 0. 05; while in indirect measurement through urinary drainage tube, IAPI ( 12. 7 ± 3. 2 ) mmHg was significantly higher than IAPP ( 11.7 ± 2. 9) mmHg and IAPS (7. 9 ± 3.0) mmHg too, P ＜ 0. 05. In either direct or indirect method, IAPP was higher than IAPAS, P ＜ 0. 05. And good correlations were found among IAPS, IAPP and IAPI. Conclusions In the supine position, pressure obtained via the bladder could reflect authentic IAP. But selection of reference point has great impact on IAP measurement.     

卡维地洛治疗肾病患者难治性高血压的前瞻性多中心临床研究

目的评价卡维地洛治疗各种肾脏病患者中难治性高血压的安全性、降压疗效和其对心肾功能的影响。方法采用前瞻性、多中心、开放、自身对照试验,入选患者共2171例,观察期限为8周。结果与用药前相比,所有患者治疗4周后平均收缩压(SBP)和舒张压(DBP)均明显下降(P＜0．01)。卡维地洛治疗4周降压有效率达57．1%,显效率为11．5%;至用药8周时有效率达79．7%,显效率为26．7%。治疗后平均心率有所下降,由治疗前(79．3±10．2)次/min下降为4周时(75．9±7．6)次/min和8周时的(75．0±8．5)次/min(P＜0．05),但仍处于正常范同。血浆中去甲肾上腺素平均水平由治疗前38．7ng/L降至17．6ng/L(P＜0．05)。卡维地洛治疗后患者肝肾功能、心电图均无明显改变,不良反应轻微。结论卡维地洛治疗肾病患者难治性高血压安全有效。     

卡维地洛治疗肾病患者难治性高血压的前瞻性多中心临床研究

目的 评价卡维地洛治疗各种肾脏病患者中难治性高血压的安全性、降压疗效和其对心肾功能的影响。方法 采用前瞻性、多中心、开放、自身对照试验，入选患者共217例，观察期限为8周。结果与用药前相比，所有患者治疗4周后平均收缩压（SBP）和舒张压（DBP）均明显下降（P〈0．01）。卡维地洛治疗4周降压有效率达57．1％，显效率为11．5％；至用药8周时有效率达79．7％，显效率为26．7％。治疗后平均心率有所下降，由治疗前（79．3±10．2）次／min下降为4周时（75．9±7．6）次／min和8周时的（75．0±8．5）次／min（P〈0．05），但仍处于正常范围。血浆中去甲肾上腺素平均水平由治疗前38．7ng／L降至17．6ng／L（P〈0．05）。卡维地洛治疗后患者肝肾功能、心电图均无明显改变，不良反应轻微。结论 卡维地洛治疗肾病患者难治性高血压安全有效。     

伊马替尼术后辅助治疗胃肠间质瘤的多中心前瞻性临床试验中期报告

目的评价具复发转移高风险的胃肠间质瘤(GIST)患者术后予以伊马替尼(imatinib,IM)辅助治疗的安全性和疗效。方法2004年8月16日至2005年12月15日期间,国内16家医院共同参加的多中心前瞻性临床研究。选择18岁以上、肿瘤最大径在5 cm及以上、病理核分裂相在5/50个高倍视野及以上、CD117阳性、肿瘤能作完整切除的GIST患者,手术后4周内开始服用IM,每天400 mg；疗程持续12个月或以上。主要终点观察指标为术后1、3年的肿瘤复发或转移率；次要终点指标为无病生存期、总生存期、不良事件和生活质量。按方案完成12个月或以上的IM治疗,且至少有1次主要终点指标评估者归入符合方案(PP)分析,至少服用过1次研究药物者归入意向治疗(ITT)分析。结果符合入选标准者57例,其中男34例,年龄(50．6±12．2)岁；女23例,年龄(50．0±10．8)岁。肿瘤部位：胃50．9%,小肠38．6%,结直肠10．5%；全部接受根治性手术切除。归入PP分析者12例,归入ITT分析者57例。至中期报告随访期间,所有受试者均未发现肿瘤复发、转移和死亡；无病生存期ITT分析为(268．3±120．2)d,PP分析为(396．7±38．2)d；不良事件发生率44．4%。患者的生活质量与基线评估指标相比,差异无统计学意义(P＞0．05)。结论对于有高度恶性倾向的胃肠间质瘤完整切除术后患者,每天口服400 mg的IM可降低肿瘤的转移率和复发率；其不良反应是可以接受的。