基于APP的维持性血液透析患者透析间期体质量管理

目的评价基于APP的体质量管理对维持性血液透析(MHD)患者透析间期体质量和液体摄入依从性的影响。方法将MHD患者随机分为干预组31例和对照组32例。两组均按血液透析常规护理,同时以血液透析患者透析间期体质量管理指导手册进行体质量管理,干预组增加基于APP的体质量管理,于干预前及干预第1、第2、第3个月评价患者体质量增长值(IDWG)、体质量增长率(PIDWG)和液体摄入依从性。结果两组干预后IDWG、PIDWG的时间效应和交互效应差异有统计学意义(均P0.01),PIDWG的组间效应差异有统计学意义(P0.05);随着干预时间延长,干预组液体摄入依从性显著高于对照组(P0.01)。结论基于APP的体质量管理能够有效降低MHD患者的IDWG与PIDWG,提高患者液体摄入依从性。     

阶段变化护理干预对血液透析患者液体摄入依从性的影响

目的探讨阶段变化护理干预模式提高血液透析(HD)患者液体摄入依从性的中期效果.方法将58例液体摄入不依从的HD患者随机分为干预组(30例)和对照组(28例).干预组实施以阶段变化理论为指导的为期3个月的护理干预,对照组仅接受常规护理.干预结束随访3个月,评价干预第6个月HD患者的液体摄入依从性.结果干预后干预组患者透析间期体重增长与干体重的比值、液体摄入量及不依从天数显著低于对照组(均P<0.01);依从程度显著高于对照组(P<0.01);患者的液体摄入依从行为所处阶段显著高于对照组(P<0.01). 结论以阶段变化理论为指导,实施有关HD患者液体摄入控制的教育,可提高患者液体摄入依从性,建立合理的液体控制行为,将透析间期体重增长控制在理想范围.     

腹膜溶质转运特性对腹膜透析患者营养指标的影响

目的 探讨阶段变化护理干预模式提高血液透析（HD）患者液体摄入依从性的中期效果。方法 将58例液体摄入不依从的HD患者随机分为干预组（30例）和对照组（28例）。干预组实施以阶段变化理论为指导的为期3个月的护理干预,对照组仅接受常规护理。干预结束随访3个月,评价干预第6个月HD患者的液体摄入依从性。结果 干预后干预组患者透析间期体重增长与干体重的比值、液体摄入量及不依从天数显著低于对照组（均P〈0．01）;依从程度显著高于对照组（P〈0．01）;患者的液体摄入依从行为所处阶段显著高于对照组（P〈0．01）。结论 以阶段变化理论为指导,实施有关HD患者液体摄入控制的教育,可提高患者液体摄入依从性,建立合理的液体控制行为．将透析间期体重增长控制在理想范围。     

基于行为转变理论的饮食教育对血液透析患者的作用

目的探讨基于行为转变理论的饮食教育对维持性血液透析患者的作用。方法将96例维持性血液透析患者随机分为观察组和对照组各48例。对照组给予门诊血液透析常规的饮食相关健康教育,观察组成立行为转变理论模式健康教育团队,实施以行为改变理论模式为指导的饮食健康教育。结果干预6个月后,观察组饮食依从性得分显著高于对照组(P0.05),血钾、血磷水平显著低于对照组(均P0.05)。结论基于行为转变理论的饮食教育可提高维持性血液透析患者饮食依从性,从而控制血钾、血磷,达到饮食管理的目的。     

持续电话回访对血液透析患者体质量增长的影响

目的 探讨电话回访对控制维持性血液透析患者透析间期体质量增长的效果.方法 选取42例维持性血液透析患者,随机分为对照组22例和观察组20例,对照组管床护士利用透析时间进行床旁教育、赠送透析知识手册供其自行阅读.观察组在此基础上由回访护士实施为期12周的透析间期电话回访.结果 观察组透析间期体质量增加相对值、液体摄入依从性差的比例在整个回访期呈明显下降趋势,并在第8周、第12周显著低于对照组（P＜0.05,P＜0.01）.结论 持续电话回访能控制维持性血液透析患者透析间期体质量增长.     

整体护理干预对血液透析患者营养状况及透析并发症的影响

目的 改善血液透析患者的饮食营养状况,降低透析并发症.方法 应用护理程序对126例血液透析患者(观察组)实施整体护理干预,与105例实施常规护理的血液透析患者(对照组)比较,观察患者饮食营养状况、透析并发症发生率及患者满意率.结果 观察组饮食控制依从性及血浆白蛋白、血红蛋白均显著高于对照组(P＜0.05,P＜0.01),水负荷过高、血压异常及内瘘闭塞发生率显著低于对照组(P＜0.05,P＜0.01),患者满意率显著高于对照组(P＜0.01).结论 应用护理程序实施整体护理干预对提高血液透析患者的饮食营养状况、减少并发症、提高其生活质量有积极意义.     

基于循证的维持性血液透析患者液体摄入依从性管理

目的将与维持性血液透析患者液体摄入依从性管理有关的最佳证据应用于临床护理实践,提高血液透析患者液体摄入控制依从性。方法将JBI临床证据实践应用系统和临床转化系统作为审查工具,基于现有的血液透析患者液体摄入依从性管理的最佳证据,制定5条审查标准。对20名护士、30例患者实施基线审查和证据应用后第2轮审查。结果基线审查时4条标准执行率较差(0~55.0%),第2轮审查时,第3条审查标准(患者自我监测液体摄入)执行率73.3%,其余4条审查标准执行率均100%。护士液体摄入管理知识和技能得分从12.70提高到14.60(P0.01);血液透析患者液体摄入知识和技能得分从11.13分提高到13.47分(P0.01),其液体摄入控制不依从率从53.33%降低至23.33%(P0.05)。结论基于循证的质量审查改善维持性血液透析患者液体摄入依从性管理的临床护理实践,可提高患者液体摄入控制依从性。     

维持性血液透析患者的精准饮食管理

目的 探讨精准饮食管理对血液透析患者营养状况及液体摄入依从性的影响。方法 将慢性肾衰竭血液透析患者120例按照透析单双日分为对照组和研究组各60例,对照组给予常规饮食指导,研究组采取精准饮食管理,包括精准测量、精准评估、精准记录与精准纠偏。比较两组干预前与干预6个月后液体摄入依从性及营养指标。结果 干预6个月后,研究组液体摄入依从性显著高于对照组,白蛋白、血红蛋白值显著高于对照组(P<0.05,P<0.01)。结论 精准饮食管理有利于改善血液透析患者营养状况,提高其液体摄入依从性。     

维持性血液透析患者首次建立内瘘的无缝隙护理

目的探讨无缝隙护理在维持性血液透析首次建立内瘘患者中的应用效果。方法选择2014年首次建立内瘘的维持性血液透析患者56例为观察组,给予无缝隙护理;以2013年实施常规护理的53例患者为对照组。结果观察组术后1年内瘘假性血管瘤和内瘘血栓发生率显著低于对照组,遵医行为依从性显著高于对照组(P0.05,P0.01)。结论无缝隙护理可降低维持性血液透析患者内瘘并发症的发生,提高患者的遵医行为。     

基于行为阶段转变理论对腹膜透析患者实施容量管理的效果

目的探讨基于行为阶段转变理论的容量管理干预对腹膜透析患者水盐控制的影响。方法将110例腹膜透析患者随机分为观察组和对照组各55例。对照组采用常规护理干预,观察组在常规护理基础上实施基于行为阶段转变理论的多阶段容量管理干预,连续6个月后评价效果。结果干预后观察组容量管理行为显著优于对照组,液体摄入量、食盐摄入量显著低于对照组,食欲减退、水肿、气促、胸闷等症状发生率显著低于对照组,口渴评分、体质量显著低于对照组(P0.05,P0.01);两组尿量均逐渐减少;干预前后两组超滤量无明显改变(均P0.05)。结论基于行为阶段转变理论的容量管理干预能够促进患者容量管理行为转变,提高患者的水盐摄入依从性,改善患者容量状况。     

Organization and composition of body fluids

Disorders of fluid balance and electrolyte homeostasis are commonly observed in critically ill patients and in those who require emergency anaesthesia. Consequently, anaesthetists and intensive care physicians must understand the physiological principles that govern fluid balance. This article discusses the compartmentalization of total body water and describes methods by which the volume of the fluid compartments may be measured. The novel concept of the endothelial glycocalyx is discussed in addition to the conventional and contemporary models of capillary filtration dynamics. The core elements of fluid balance and cardiovascular homeostasis are also explored.     

Organization and composition of body fluids

Disorders of fluid balance and electrolyte homeostasis are commonly observed in critically ill patients and in those who require emergency anaesthesia. Consequently, anaesthetists and intensive care physicians must understand the physiological principles that govern fluid balance. This article discusses the compartmentalization of total body water and describes methods by which the volume of the fluid compartments may be measured. The novel concept of the endothelial glycocalyx is discussed in addition to the conventional and contemporary models of capillary filtration dynamics. The core elements of fluid balance and cardiovascular homeostasis are also explored.     

Goal-directed fluid removal with furosemide versus placebo in intensive care patients with fluid overload: A randomised,blinded trial (GODIF trial—First version)

Background

Salt and water accumulation leading to fluid overload is associated with increased mortality in intensive care unit (ICU) patients, but diuretics' effects on patient outcomes are uncertain. In this first version of the GODIF trial, we aimed to assess the effects of goal-directed fluid removal with furosemide versus placebo in adult ICU patients with fluid overload.

Methods

We conducted a multicentre, randomised, stratified, parallel-group, blinded, placebo-controlled trial in clinically stable, adult ICU patients with at least 5% fluid overload. Participants were randomised to furosemide versus placebo infusion aiming at achieving neutral cumulative fluid balance as soon as possible. The primary outcome was the number of days alive and out of the hospital at 90 days.

Results

The trial was terminated after the enrolment of 41 of 1000 participants because clinicians had difficulties using cumulative fluid balance as the only estimate of fluid status (32% of participants had their initially registered cumulative fluid balance adjusted and 29% experienced one or more protocol violations). The baseline cumulative fluid balance was 6956 ml in the furosemide group and 6036 ml in the placebo group; on day three, the cumulative fluid balances were 1927 ml and 5139 ml. The median number of days alive and out of hospital at day 90 was 50 days in the furosemide group versus 45 days in the placebo group (mean difference 1 day, 95% CI -19 to 21, p-value .94).

Conclusions

The use of cumulative fluid balance as the only estimate of fluid status appeared too difficult to use in clinical practice. We were unable to provide precise estimates for any outcomes as only 4.1% of the planned sample size was randomised.     

Amniotic fluid embolism during caesarean section

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.     

重症急性胰腺炎体液隔离危害性的临床分析

目的分析重症急性胰腺炎(severe acute pancreatitis,SAP)体液隔离的危害。方法回顾性分析我院1995年1月至2000年1月53例SAP临床资料。按治疗结果分为早期死亡、晚期死亡、治愈3个组;统计3组入院后的前3 d总出入量和体液隔离量以及治疗48 h前后红细胞压积(HCT)的变化;分析早期死亡和后期死亡的原因。结果早期死亡组和晚期死亡组体液隔离持续48 h以上,早期死亡组、晚期死亡组和治愈组在48 h体液隔离量分别为(10 078.3±1 616.2)ml(、6 124.4±1 081.1)ml和(4 719.7±1 397.7)ml,3组相比差异有统计学意义(P<0.05)。早期死亡6例,多与心脏骤停和呼吸衰竭有关;晚期死亡12例,多与感染有关。结论体液隔离的实质是细胞外液病理性再分布和细胞外液增加。体液隔离的危害在早期为组织间隙体液大量急性贮留导致细胞、组织肿胀,心和肺功能受到致命的影响,在晚期增加感染的机会。     

POSTOPERATIVE SEIZURES

Two young patients with extensive ulcerative colitis were treated with oral steroids and developed seizures between 36 and 72 h after emergency colectomy. These cases highlight the problem of postoperative seizures, related to previous steroid administration, fluid overload, postoperative hypertension and biochemical abnormalities.     

血液透析超滤脱水对细胞内外液的影响

目的了解血液透析对细胞内液(intracellular water,ICW)和细胞外液(extracellular water,ECW)的影响。方法选择2012年3月1日至2014年12月31日解放军空军总医院血液净化中心行维持性血液透析(maintenance hemodialysis,MHD)治疗的患者68例,应用整体多频生物电阻抗仪测定透析前和透析后1min内的ICW和ECW,比较血液透析后ICW和ECW的减少量(△ICW和△ECW),观察透析超滤脱水对ICW和ECW变化率(ⅤICW/ICW和△ECW/ECW)的影响。结果血液透析患者68例中,男性37例(占54.41%),平均身高(1.62±0.09)m,体质量指数(bodymnas8 index,BMI)为(23.43±3.13),透析前体质量为(64.72±10.65)kg,干体质量为(61.37±10.74)kg,超滤量为(2.78士0.97)L,透析后ICW/ECW值为(1.99:1)。MHD患者透析前后,ICW从(23.34±4.53)kg下降到(21.64±4.18)kg,差异有统计学意义(t=9.518,P0.01),ICW变化量△ICW=(1.70±1.47)kg;ECW从(12.02±2.41)kg下降到(10.91±2.20)kg,差异有统计学意义(t=10.726,P0.01),ECW变化量△ECW=(1.11±0.85)kg,两种体液变化率分别为△ICW/ICW(7.07%±5。16%)和@ECW/ECW(9.02%±5.80%)。该研究中透析后ICW/ECW=1.99:1,与应用同位素标记的金标准测得的结果 2.0:1高度一致,优于其他多数研究中的1.11:1。结论血液透析超滤脱水同时来源于ICW和ECW变化,并非主要来源于ECW;本方法可能是最为接近金标准的方法。     

The organization and composition of body fluids

The water contained in the body is divided amongst compartments of differing sizes and compositions. The dynamic balance across these compartments is an essential component of normal physiology. Here, the calculation of these volumes by measuring the dilution of markers able to permeate specific compartments is considered. Furthermore, the potential disadvantages to the approach are discussed. The differences in ionic concentration between intracellular and extracellular fluid are quantified and the effects of greater relative protein concentration within cells are also considered. To illustrate daily fluid balance in a healthy individual, a typical intake and output over 24 hours is quantified before consideration of iatrogenic contributions to this equilibrium. The way in which clinically administered fluids of varying compositions affect the fluid compartments is subsequently discussed. The endogenous processes contributing to volume homeostasis are then deliberated including the detection of fluid imbalance through intracellular and extracellular systems as well as the hypothalamic and renal effector mechanisms. Finally, the regulation of sodium is discussed with examination of the mechanisms controlling natriuresis and the reciprocity with potassium balance.     

The surgical treatment of Chiari I malformation

Summary A retrospective study was undertaken on 133 patients with a Chiari I malformation treated within the last 16 years at the Departments of Neurosurgery at the Nordstadt Hospital Hannover, Germany, and the University of California, Los Angeles, U.S.A. Ninety-seven patients presented with symptoms related to accompanying syringomyelia and 4 with associated syringobulbia. They underwent 149 surgical procedures and were followed for a mean of 39±52 months. A decompression at the foramen magnum was performed in 124 patients, while 22 of those with syringomyelia were treated by shunting (7 syringosubarachnoid shunts, 15 syringoperitoneal or -pleural shunts), and 3 by ventriculoperitoneal shunts for hydrocephalus.Except for ventriculoperitoneal shunting, at least a short-term decrease in size of an associated syrinx was observed for all procedures in the majority of cases. However, no long-term benefit was observed for syrinx shunting operations. The best clinical longterm results were obtained with decompression of the foramen magnum in patients with (86% free of a clinical recurrence) and without syringomyelia (77% free of a clinical recurrence). We advise against syrinx shunting, a large craniectomy, and obex plugging which are associated with higher recurrence rates. Instead, surgery should consist of a small craniectomy, opening of the dura, archnoid dissection to establish normal cerebrospinal fluid (CSF) outflow from the 4th ventricle, and a fascia lata durai graft.