ALI/ARDS患者俯卧位通气的研究进展

阐述了急性肺损伤(ALI)及急性呼吸窘迫综合征(ARDS)患者俯卧位通气的理论基础、俯卧位通气的优越性和改善ALI/ARDS患者氧合状况的机制,分析了俯卧位通气治疗的适应证、应用时机、禁忌证、并发症及治疗时间,提出俯卧位通气治疗的实施方法和护理,以期为临床俯卧位通气治疗提供参考。     

ALI/ARDS患者俯卧位通气的研究进展

阐述了急性肺损伤（ALI）及急性呼吸窘迫综合征（ARDS）患者俯卧位通气的理论基础、俯卧位通气的优越性和改善ALI/ARDS患者氧合状况的机制,分析了俯卧位通气治疗的适应证、应用时机、禁忌证、并发症及治疗时间,提出俯卧位通气治疗的实施方法和护理,以期为临床俯卧位通气治疗提供参考。     

老年急性呼吸窘迫综合征患者俯卧位机械通气的临床监护

目的探讨老年急性呼吸窘迫综合征患者俯卧位机械通气的临床监护要点。方法选择ICU、呼吸内科住院治疗的30例老年急性呼吸窘迫综合征患者,予俯卧位机械通气,并实施密切的循环、呼吸、并发症及生命体征监护。结果俯卧位通气治疗后1h、2h患者的SpO2、PaO2显著升高(均P0.01),心率、呼吸显著减慢(均P0.01),而平均动脉压、PaCO2、pH值的变化无显著差异(均P0.05)。结论俯卧位机械通气可提高急性呼吸窘迫综合征患者的氧合状态,改善临床症状,而对患者呼吸循环及并发症等的密切监护是其护理的关键。     

俯卧位通气在急性Stanford A型主动脉夹层术后急性呼吸窘迫综合征中的疗效

目的 探讨俯卧位通气在急性Stanford A型主动脉夹层（acute Stanford type A aortic dissection,STAAD）术后急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）中的疗效。方法 收集2019年11月—2021年9月厦门大学附属心血管病医院STAAD术后并发ARDS且行俯卧位通气患者的临床资料,整理俯卧位前后血气分析、呼吸力学和血流动力学指标,对预后和不良事件等数据进行统计学分析。结果 共264例STAAD患者行外科手术治疗,术后并发ARDS并行俯卧位通气患者40例,其中男37例、女3岁,平均年龄（49.88±11.46）岁。与俯卧位通气前相比,俯卧位通气开始后4 h、12 h,俯卧位通气结束后2 h、6 h氧分压、氧合指数及末梢血氧饱和度均明显改善（P<0.05）。俯卧位通气结束后2 h,氧合指数<131.42 mm Hg提示患者可能需要二次或多次俯卧位通气。结论 STAAD术后中重度ARDS患者采用俯卧位通气是一种安全有效的改善患者氧合的方法。     

甲型H1N1流感危重症机械通气患者不同卧位氧合效果比较

目的探讨不同卧位机械通气对甲型H1N1流感危重症患者氧合的影响。方法对23例甲型H1N1流感危重症急性呼吸窘迫综合征(ARDS)患者,入院即经气管插管术行呼气末正压通气(PEEP)呼吸机辅助呼吸,采取自身对照法行平卧位、半卧位、侧卧位、侧俯卧位、俯卧位各1h,循环6次;观察HR、MAP、潮气量(VT)、平均气道压(Pmean)、PaO2、静态顺应性(Cst)、氧合指数(OI)的变化。结果不同卧位患者各项指标比较,差异有统计学意义(均P0.01),其中VT、PaO2、Cst、OI值俯卧位显著高于其他卧位,Pmean值显著低于其他卧位(均P0.05)。结论俯卧位通气能有效改善甲型H1N1流感危重症患者的氧合状况,对血流动力学和呼吸力学无明显影响,侧俯卧位次之。     

急性呼吸窘迫综合征患者侧俯卧位机械通气的效果

急性呼吸窘迫综合征(ARDS)患者的病死率高达30%～加%[1].俯卧位及侧卧位可改善ARDS患者的机械通气效果[2-5].本研究拟评价 ARDS患者侧俯卧位机械通气的效果,为临床提供参考.     

俯卧位通气下急性呼吸窘迫综合征患者氧合的变化

目的探讨俯卧位通气下急性呼吸窘迫综合征(ARDS)患者氧合的变化及其机制。方法23例早期ARDS患者(病程<72 h),在镇静、肌松下持续俯卧位通气2 h。呼吸机参数设定为潮气量6-8 ml/kg,吸气时间1.0-1.2 s,吸气流速40 L/min,呼吸频率12-20次/min。吸入氧浓度0.4- 1.0,呼气末正压6-18 cm H2O。观察俯卧位前即刻、俯卧位0.5、2 h及恢复仰卧位2 h的氧合指数(PaO2/FiO2)、呼吸系统静态顺应性(Cst)、心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、平均肺动脉压(MPAP)。肺动脉楔压(PAWP)、心脏指数(CI)、气道峰压(PIP)及气道阻力(Paw)。俯卧位后PaO2/FiO2比俯卧位前上升超过20%作为氧合改善的判断标准。结果与俯卧位前比较,87%患者俯卧位0.5、2 h、恢复仰卧位2 h时PaO2/FiO2和PaO2升高(P<0.01);Cst HR、MAP、CVP、MPAP、PAWP、CI、Raw、PaCO2、PIP差异无统计学意义;87%氧合改善的患者在俯卧位0.5、2 h时Cst差异无统计学意义, 恢复仰卧位2 h时Cst升高(P<0.05)。结论俯卧位通气可改善早期ARDS患者的氧合,且恢复仰卧位后氧合改善持续存在。     

ARDS与俯卧位通气

俯卧位通气能有效改善大部分病人的氧合状况,对呼吸力学、血流动力学无明显影响,且实施比较方便,不会造成严重的副作用,因而可用于ARDS的辅助治疗。本文就俯卧位通气对ARDS病人的作用、机制及临床应用情况作一综述。     

机械通气治疗ARDS的护理进展

对机械通气治疗急性呼吸窘迫综合征的护理进展进行综述,说明选择合适的保护性通气策略、肺复张策略以及适当俯卧位通气,加强呼吸道管理能提高机械通气效果,减少并发症发生.     

重度急性呼吸窘迫综合征患者俯卧位通气前后胃内压的变化

目的 探讨重度急性呼吸窘迫综合征患者俯卧位通气前后胃内压的变化.万法回顾Z01b年6月至2020年9月行胃内压监测的重度ARDS患者,每次采用俯卧位通气前后自身对照,记录吸气相胃内压与呼气相胃内压.根据俯卧位通气期间肠内营养是否减速分为减速组与非减速组.结果 16例患者共监测46例次俯卧位通气治疗前后数据,俯卧位后吸气...     

An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK Transplant Registry study

Transplant options for patients with type 1 diabetes and end‐stage renal disease (ESRD) include deceased donor kidney, live donor kidney (LDK) and simultaneous pancreas‐kidney (SPK) transplantation. The aim of this study was to compare outcomes between LDK and SPK for patients with type 1 diabetes and ESRD in the UK. Data on all SPK (n = 1739) and LDK (n = 385) transplants performed between January 2001 and December 2014 were obtained from the UK Transplant Registry. Unadjusted patient and kidney graft survival were calculated using the Kaplan–Meier method. Multivariate analysis of kidney graft and patient survival was performed using Cox proportional hazards regression. There was no significant difference in patient (P = 0.435) or kidney graft survival (P = 0.204) on univariate analysis. On multivariate analysis there was no association between LDK/SPK and patient survival [HR 0.71 (0.47–1.06), P = 0.095]. However, LDK was associated with an overall lower risk for kidney graft failure [HR 0.60 (0.38–0.94), P = 0.025]. SPK recipients with a functioning pancreas graft had significantly better kidney graft and patient survival than LDK recipients or those with a failed pancreas graft. SPK transplantation does not confer an overall survival advantage compared to LDK. However, those SPK recipients with a functioning pancreas have significantly better outcomes.     

Defining outcomes for β‐cell replacement therapy in the treatment of diabetes: a consensus report on the Igls criteria from the IPITA/EPITA opinion leaders workshop

β‐cell replacement therapy, available currently as pancreas or islet transplantation, has developed without a clear definition of graft functional and clinical outcomes. The International Pancreas & Islet Transplant Association (IPITA) and European Pancreas & Islet Transplantation Association (EPITA) held a workshop to develop consensus for an IPITA/EPITA Statement on the definition of function and failure of current and future forms of β‐cell replacement therapy. There was consensus that β‐cell replacement therapy could be considered as a treatment for β‐cell failure, regardless of etiology and without requiring undetectable C‐peptide, accompanied by glycemic instability with either problematic hypoglycemia or hyperglycemia. Glycemic control should be assessed at a minimum by glycated hemoglobin (HbA_1c) and the occurrence of severe hypoglycemia. Optimal β‐cell graft function is defined by near‐normal glycemic control [HbA_1c ≤ 6.5% (48 mmol/mol)] without severe hypoglycemia or requirement for insulin or other antihyperglycemic therapy, and with an increase over pretransplant measurement of C‐peptide. Good β‐cell graft function requires HbA_1c < 7.0% (53 mmol/mol) without severe hypoglycemia and with a significant (>50%) reduction in insulin requirements and restoration of clinically significant C‐peptide production. Marginal β‐cell graft function is defined by failure to achieve HbA_1c < 7.0% (53 mmol/mol), the occurrence of any severe hypoglycemia, or less than 50% reduction in insulin requirements when there is restoration of clinically significant C‐peptide production documented by improvement in hypoglycemia awareness/severity, or glycemic variability/lability. A failed β‐cell graft is defined by the absence of any evidence for clinically significant C‐peptide production. Optimal and good functional outcomes are considered successful clinical outcomes.     

临床学习环境对护理本科生临床实习表现的影响

目的探讨临床学习环境(CLE)对护理本科生(护生)临床实习表现(CPs)的影响。方法按比例分层从全国142所医药高校中抽取22所的毕业实习护生923名,采用护理临床学习环境评价量表、护理本科生毕业实习临床实践行为表现自评量表进行问卷调查。结果护生CLE总评分为3.39±0.62,CPs总评分为3.68±0.47;护生对CLE评价与其CPs相关系数是0.520(P<0.01);个性化、学生参与性、任务定位是影响护生CPs的主要因素(均P<0.01)。结论 CLE可影响护生的CPs。在临床实习中,护理管理者和临床带教老师应给护生一定的自主性,并进行因人而异的个性化施教,为护生创造更多的动手机会,对护生的实习活动指示明确,让护生清楚自己的实习角色和实习任务,以提高临床实习质量。     

Reliability and usefulness of clinical encounter cards for a third-year surgical clerkship

BACKGROUND: Third-year medical students (MS3) were given clinical encounter cards (CECs) to stimulate feedback during their surgery clerkship. This study analyzes the feedback given on their clinical performance using CECs. METHODS: Two hundred one students enrolled in the 12-week surgery clerkship were given CECs. Each card contained the chief focus of the encounter, which was rated on a six-point Likert scale. The CECs were analyzed to determine if they provided reliable formative information, identified marginal performances, and identified differences between raters, settings, rotations, and aspects of clinical performance evaluated. RESULTS: Seven thousand three hundred eight CECs were submitted from 201 students. The CECs were completed most often (65%) in the inpatient setting. Technical skills were evaluated on 49% of CECs, history/physical examinations on 40%, and case presentations on 30%. There were comments written on half of the CECs and 89% of these were strictly positive. Women (52.8%) and faculty (63.3%) were more likely to provide written comments. The students were most likely to seek feedback from the interns and faculty who gave significantly higher ratings. The Cronbach-alpha reliability coefficient was 0.69, based on 12 raters per student. There was a significant positive correlation (P < 0.05) between the CEC composite rating and the clinical performance rating (r = 0.356), NBME score (r = 0.258), and the final grade (r = 0.250). CONCLUSIONS: The implementation of CECs in a surgery clerkship provided a large quantity of positive feedback. The quality was limited because there were minimal recommendations for improvement and they were a poor predictor of overall clinical performance.     

Clinical research and good clinical practice

Clinical research is one of the important missions of an academic Albert Einstein medical centre and forms the cornerstone for improvement of healthcare. Funding for clinical research has increased steadily over the past few decades, both from the US government and the pharmaceutical industry. In this chapter we will explore how clinical research contributes to improvements in patient care and medical education and describe the process of clinical research. Whereas there can be deficiencies in the process of conducting research, as evidenced by recent media reports, research involving human subjects is a necessary and crucial step in the mechanism of translating scientific discovery and technological advancement into procedures and products that offer the prospect of better lives for all of us. Guidelines on good clinical practice should be followed and, above all, trust between research subjects and investigators should always be upheld and respected.     

Review of the Australian incident monitoring system

BACKGROUND: A survey was conducted to assess the benefits and limitations of the Australian Incident Monitoring System (AIMS) as a programme to improve patient safety. METHODS: A 12-point questionnaire was sent to 12 current users of AIMS in November 2002. RESULTS: The AIMS provides a consistent system of coding, trending and monitoring of incident data. It promotes a patient safety culture and an awareness of system error. Other benefits include the building of teamwork and the implementation of strategies to reduce the prevalence and severity of incidents. The majority of respondents (83%) reported that AIMS investigations resulted in significant changes to equipment usage, medication prescribing or administration, clinical protocols, training programmes and falls risk assessment tools. Although 75% of users reported improvements in patient outcomes, these were difficult to measure. A major limitation of AIMS was the low rate of incident reporting by medical staff. Voluntary reporting systems did not capture all incident data and the information was often too generic for root cause analysis. There were difficulties benchmarking data and concerns were raised regarding the ownership of information. The programme requires ongoing resources to implement change strategies and to maintain incident reporting levels. On a scale of 1 (poor rating) to 10 (excellent rating) the mean benefit rating was 7.6. CONCLUSION: The Australian Incident Monitoring System is beneficial as a component of a clinical risk management strategy. Usefulness could be improved by increased participation by medical staff. The level of resources required should not be underestimated if the programme is to demonstrate improvements to patient outcomes. More recent versions of AIMS promise improved capabilities and will require similar evaluation.