支气管镜吸痰及肺泡灌洗在ICU术后继发肺部感染诊治中应用

目的探讨床边纤维支气管镜吸痰及肺泡灌洗在ICU术后的患者继发肺部感染病原学诊断及治疗中的应用意义。方法 166例术后入住ICU患者继发肺部感染后进行床边支气管镜吸痰及肺泡灌洗,对灌洗液行病原学检查,同时对需求镜下治疗的病源分类。结果 166例患者共行支气管镜下吸痰及灌洗液培养394例次,致病菌株检出数96株,检出率24.4%。其中革兰氏阳性球菌10株(10.4%),革兰氏阴性杆菌86株(89.6%),以铜绿假单胞菌32株(33.3%)所占比率最多。病源中重症颅脑损伤56例(33.7%),胸部手术后96例(57.8%),普外科术后12例(7.3%),骨科术后2例(1.2%)。行镜下治疗并根据药敏调整后显效136例(82.2%),有效24例(14.3%),无效6例(3.6%)。结论床边支气管镜吸痰及肺泡灌洗对ICU内外科术后继发肺部感染患者提供了病原学诊断,同时对高危病源应及早采取镜下治疗提供临床证据并提高了治疗成功率。     

纤维支气管镜吸痰在重症肺炎治疗中的作用

目的探讨纤维支气管镜吸痰在重症肺炎治疗中的应用价值。方法通过对10例重症肺炎（7例气管插管）患者在抗感染、营养支持等治疗基础上运用纤维支气管镜吸痰,观察吸痰治疗前后患者呼吸频率、心率、血气分析及胸部X线的变化,以及与8例对照组进行疗效比较。结果经纤维支气管镜吸痰患者呼吸频率、心率、动脉血氧分压（PaO2）及动脉血氧饱和度（SaO2）、均明显改善,P〈0．05：观察组总有效率明显高于对照组,P〈0．05。结论纤维支气管镜吸痰是治疗重症肺炎的一种安全有效手段。     

纤维支气管镜吸痰用于心胸外科术后机械通气并发肺部感染的疗效分析

目的分析纤维支气管镜吸痰用于心胸外科术后机械通气并发肺部感染的临床疗效。方法选取2013年6月至2016年6月期间在我院心胸外科接受手术治疗后行机械通气并发肺部感染的患者86例为研究对象,将患者随机分为对照组和实验组,每组各43例;两组患者术后均给予机械通气及常规抗感染治疗,对照组行密闭式导管吸痰法,实验组行密闭式导管吸痰法联合纤维支气管镜吸痰,监测患者的呼吸、体温、心电图及动脉血氧分压等指标,比较两组患者的临床疗效。结果实验组的临床治疗有效率为83.72%明显高于对照组的62.79%(P0.05);与对照组比较,治疗后实验组的临床病症恢复时间较短,痰培养阳性率较高,动脉血氧分压及氧合指数较高(P0.05)。结论纤维支气管镜吸痰用于心胸外科术后机械通气并发肺部感染的临床疗效肯定,对患者临床症状快速消失和机体康复有积极作用,值得临床推广。     

床边支气管肺泡灌洗治疗术后肺不张

目的探讨床边纤维支气管镜支气管肺泡灌洗治疗术后肺不张的效果及安全性。方法术后肺不张患者25例在床边监护吸氧或机械通气下,表面麻醉后纤维支气管镜插至堵塞部进行支气管肺泡灌洗,观察对比检查前后的胸片、临床表现、经皮血氧饱和度等指标。结果发现22例患者粘稠痰液阻塞一侧主支气管或叶支气管,为阻塞性肺不张,3例在支气管腔内只有少许黏液,为非阻塞性肺不张,治疗后肺完全复张21例(84%),部分肺复张3例(12%),未复张1例(4%);临床表现、血氧饱和度和X线胸片有不同程度改善者24例(94%)。结论术后肺不张均为炎症导致大量痰液堵塞支气管引起,纤维支气管镜床边支气管肺泡灌洗治疗术后肺不张效果确切、安全。     

纤维支气管镜在外科重症监护室的应用

目的探讨纤维支气管镜对外科重症监护室合并肺部并发症患者的应用价值。方法应用纤支镜对37例外科重症监护室合并肺部并发症的患者进行床边检查、吸痰、支气管灌洗、钳夹痰栓、血凝块、取深部痰标本培养等操作,总结其有效性和安全性来评价临床应用价值。结果37例肺部感染和肺不张患者经纤支镜吸痰、支气管灌洗共58例次,肺部感染均得到不同程度的控制;其中14例肺不张患者经纤支镜钳夹及支气管灌洗后均复张,成功率100％;31例次吸痰前用纤支镜取深部痰标本培养加药敏,共有23例（74．2％）阳性。操作中所有患者无1例死亡。结论在外科重症监护室合并肺部并发症患者中开展床边纤维支气管镜是一种有效、安全的诊断和治疗方法。     

床旁纤维支气管镜在急危重症患者中的应用体会

目的探讨床旁纤维支气管镜在急危重症患者治疗中的临床应用情况。方法选取2010年12月—2011年12月本院收治的急危重症患者48例,均采用床旁纤维支气管镜治疗,观察其临床治疗效果。结果 42例肺部重症感染患者,术前动脉血氧分压(PaO2)为(56.43±5.34)mmHg;经纤维支气管镜吸痰和灌洗治疗后,PaO2为(76.76±6.76)mmHg,治疗前后比较,差异有统计学意义(t=13.3242,P<0.05)。6例呼吸道异物患者,均顺利将异物取出。结论床旁纤维支气管镜在临床急危重症患者的治疗上具有确切的临床效果,值得在临床推广使用。     

支气管镜肺泡灌洗在重症肺部感染应用及灌洗液培养结果分析

目的研究纤维支气管镜下支气管肺泡灌洗在重症肺部感染中的临床应用价值,并分析肺泡灌洗液病原菌及耐药性情况。方法 86例重症肺部感染患者随机分为治疗组和对照组各43例,两组均给予常规治疗,治疗组在其基础上采用经纤维支气管镜吸痰及支气管肺泡灌洗术进行治疗,对照组用普通吸痰机常规吸痰,观察两组临床治疗效果,并对治疗组肺泡灌洗进行细菌培养和药敏试验。结果治疗后两组患者Pa O2和Sp O2水平均升高,而Pa CO2水平均明显降低,两组治疗后比较(P0.05),治疗组患者在咳嗽消失时间、喘息消失时间、体温恢复正常时间、肺部啰音消失时间、胸部X线阴影消失时间和住院时间明显低于对照组(P0.01),重症肺部感染患者以革兰氏阴性杆菌感染最为主要,其中鲍氏不动杆菌、铜绿假单胞菌、肺炎克雷伯菌和大肠埃希菌最为常见,并且对临床上常用的抗生素耐药性均较高。结论支气管镜肺泡灌洗在重症肺部感染应用效果较为理想,灌洗注入抗生素应当选择敏感的药物,以提高临床治疗效果。     

便携式纤维支气管镜治疗合并严重肺部感染的急危重症疗效观察

目的 探讨便携式纤维支气管镜(纤支镜)在合并严重肺部感染的急危重症患者急救中的应用疗效.方法 对本院收住的18例合并严重肺部感染的急危重症患者进行纤支镜引导下气管插管、吸痰及支气管-肺泡灌洗术,术中严密监测患者的血氧饱和度、血压、心率、呼吸及意识变化,术后复查血常规、血气、胸片及肺部CT等.结果 18例合并严重肺部感染的急危重患症患者中,11例进行了纤支镜引导下经口气管插管或经鼻气管插管,成功率100%;18例患者均进行了床边纤支镜吸痰及支气管-肺泡灌洗术,有效率为77.78%;置管时间3～35d,平均5.3～8.5d.结论 纤支镜治疗技术是合并严重肺部感染的急危重患者必要且有效的治疗手段.     

床边纤维支气管镜肺泡灌洗在重症监护室机械通气患者中的临床应用

目的探讨床边纤维支气管镜肺泡灌洗在重症监护室(ICU)机械通气患者中的应用效果,为此类患者的气道管理及临床治疗提供参考。方法收集我院40例机械通气患者的临床资料,比较灌洗前后患者动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)以及气道峰压(PIP)、肺动态顺应性(Cdyn)、吸气阻力(RAW)3项呼吸力学指标的变化。结果灌洗后患者PaO2、Cdyn升高,PaCO2、PIP、RAW降低,与灌洗前比较,差异均有统计学意义(P<0.05)。结论在ICU内对机械通气患者给予床边纤维支气管镜肺泡灌洗,可使患者临床症状明显改善,为临床机械通气患者的气道管理提供了一条新途径。     

纤维支气管镜在老年吸入性肺炎中的临床应用分析

目的:研究纤维支气管镜在老年吸入性肺炎治疗中的临床应用价值.方法:将164例老年吸入性肺炎患者随机分为观察组和对照组各82例,均给予呼吸内科常规治疗,观察组加用纤维支气管镜吸痰及支气管肺泡灌洗,观察吸痰前后动脉血气、心率及呼吸频率的变化,对照组给予普通吸痰管吸痰,比较两组临床疗效的差异.结果:纤维支气管镜治疗后观察组动脉血气、心率及呼吸频率均明显改善(P＜0.05);观察组总有效率92.7％,与对照组70.7％比较,差异有统计学意义(P＜0.05).结论:纤维支气管镜吸痰及支气管肺泡灌洗治疗老年吸入性肺炎,临床疗效明显优于常规治疗,且安全性高,值得在临床中推广应用.     

平板运动试验在胸外科手术前的评估价值

目的 研究胸外科术前常规进行平板运动试验评估心血管风险的有效性。方法 回顾性入选2016.1~2016.6期间我院273例拟接受胸外科手术的的患者,常规进行运动平板评估,并随访至围手术期结束。结果 273名患者中,231名患者平板运动阴性,35人阳性,7人可疑阳性,阳性及可疑阳性患者均接受冠脉造影检查。其中8人接受预防性PCI手术,1人放弃后续治疗,14人存在冠脉非显著病变,19人完全正常。共有264名患者接受了胸外科手术,围术期心梗1人。平板运动试验的敏感性为95.8%,特异性为92.4%,阳性预测价值54.8%,阴性预测价值99.6%,准确率92.7%。 结论 胸外科手术是一种高危或中高危手术,术前常规平板运动试验敏感性较高,能识别绝大多数潜在心血管风险的患者,而且临床应用简便经济,可以得到进一步推广。     

Application of Joanna Briggs Institute physical restraint standards to critical emergency department patients following CONSORT guidelines

To explore the effect of Joanna Briggs Institute (JBI) physical restraint standards in improving physical restraint in critical and emergency department patients.Enrolled 300 critical patients admitted in our hospital''s emergency department from January to December 2019: 150 patients admitted January to June 2019 as control group and 150 patients admitted July to December 2019 as observation group. Routine restraints were applied in control group. Emergency department nurses in the observation group received thematic and practical JBI standardized training. This included pre-restraint assessment, principles of physical restraint, informed consent, using a restraint decision-making wheel, and alternatives to physical restraint. The incidence of restraint-associated adverse events (e.g., skin bruising, swelling) and restraint utilization rate were examined between 2 groups.The incidence of adverse events and the restraint utilization rate were significantly lower in the observation group (P < .05).The application of JBI physical restraint standards for emergency department patients can effectively reduce the incidence of adverse events and the restraint utilization rate.     

胺碘酮静脉治疗危重患者并快速房性心律失常30例分析

目的评价胺碘酮静脉治疗临床各科危重患者并发快速房性心律失常的疗效与安全性。方法对来自各科的30例危重症患者，给予胺碘酮5mg／kg负荷剂量静脉注射，如无效，则将胺碘酮加入输液泵中以1mg/min静脉持续治疗6小时。结果30例危重患者中有26例心律失常被及时有效终止，有效率为86．7％。无一例患者发生严重的不良反应。结论胺碘酮静脉治疗临床疗效显著，安全性高，可作为临床各科危重患者并发快速房性心律失常的首选用药。     

The emerging role of echocardiography in the emergency department

Cardiac ultrasound quickly provides both anatomic and physiologic assessment of the heart at the bedside, permitting rapid diagnosis and triage of patients presenting to the emergency department with chest pain, hypotension, or dyspnea. The identification and quantification of left ventricular dysfunction by ultrasound allows effective determination of prognosis and, thus, may supplant the ECG in patient triage. Transesophageal echocardiography definitively identifies the presence of thoracic aortic dissections, and this information may be obtained more immediately than by other imaging methods. Emergency physicians should have, at a minimum, sufficient knowledge of echocardiography to know when it is applicable to a patient problem. It may be feasible for noncardiologists to gain sufficient proficiency in echocardiography to use the technique as a screening procedure in the emergency department setting.     

Triage patients with suspected pulmonary embolism in the emergency department using a portable ultrasound device

The diagnosis of pulmonary embolism (PE) is difficult, despite validated diagnostic models. We sought to determine the value of a portable ultrasound device for triage of patients with suspected PE referred to the emergency department, using simplified echo criteria. We prospectively studied 103 consecutive patients with suspected PE, referred to our emergency department. After D-dimer screening, 76 patients were prospectively enrolled in this ultrasound study and underwent helical chest tomography, transthoracic echocardiography, and venous ultrasonography. Among patients with PE (n = 31), a right ventricular dilation was detected in 17 patients (55%), a direct visualization of clot in the lower limbs was present in 18 patients (58%), and 8 patients (26%) had both right ventricular dilation and deep venous thrombosis. The sensitivity and specificity of a combined ultrasound strategy using echocardiography and venous ultrasonography were respectively 87% (95% confidence interval 74% to 96%), and 69% (95% confidence interval 53% to 82%). The sensitivity of this combined strategy was significantly improved as compared to venous ultrasonography alone (P = 0.01) or echocardiography alone (P = 0.005). In patients with dyspnea or with high clinical probability of PE, this combined strategy was particularly relevant with high sensitivities (respectively 94% and 100%). Echocardiography combined with venous ultrasonography using a portable ultrasound device is a reliable method for screening patients with suspected PE referred to an emergency department, especially in patients with dyspnea or with high clinical probability.     

胸外科肺癌1695例临床资料分析

目的通过对胸外科收治的原发性肺癌患者临床资料的分析,为肺癌的早期诊断、早期治疗提供经验。方法本研究对1695例本院胸外科肺癌患者的临床资料进行回顾性分析,分析目前胸外科收治患者的高发年龄、危险因素、诊断分期和治疗状况等。结果在胸外科肺癌患者中,男女构成比为2．4：1;患者平均吸烟指数39．80包年,其中男性平均40．62包年,女性平均29．52包年;病理类型分布：腺癌692例（50．47％）,鳞癌452例（32．97％）,小细胞癌86例（6．27％）;在腺癌中,男性占54．34％,女性占45．66％;在鳞癌中,男性占92．26％,女性占7．74％。肺癌合并COPD者167例（9．85％）,其中可行手术者105例,病理诊断鳞癌者最多（45例）;肺癌合并COPD术后并发症发生率为22．86％,30d内死亡率为2．86％,均高于一般患者（15．96％,1．82％）;术后30d内死亡患者26例,约70％为Ⅲ期及以上中晚期患者,影像学分期中央型17例,周围型9例,病理示鳞癌14例,腺癌8例。结论肺癌男性发病率高于女性,这与男性中的高吸烟指数相关,近年肺癌的构成已转变,腺癌目前发生最多,这可能与环境污染相关。COPD合并肺癌患者中,鳞癌居多,且COPD致使术后的高并发症及死亡率。周围型腺癌患者术后死亡率较低,早期的手术治疗对延长肺癌患者生存期至关重要。     

医用多功能胸带在胸腹腔镜联合食管癌围术期的临床应用

目的对胸腹腔镜联合食管癌切除术患者围术期使用带有呼吸功能训练装置的医用多功能胸带,探讨该胸带对患者术后肺部并发症的影响。 方法选取2019年3月至2021年1月在我院行胸腹腔镜联合食管癌根治术患者62例,随机分为对照组34例和观察组28例,对照组术后使用传统多头胸带,观察组术后使用我院研发的医用多功能胸带,观察两组患者术前1 d和术后第7 d的血氧饱和度、肺功能指标,以及术后首次下床时间、日活动总量、排气排便、肺部并发症(肺不张、肺部感染、皮下气肿)的情况。 结果观察组患者术前肺功能指标略高于对照组(P<0.05),术后第7 d患者肺功能最大通气量(MVV)、用力肺活量(FVC),1秒用力呼气量(FEV₁)指标显著优于对照组(P<0.01),活动后末梢血氧饱和度高于对照组(P<0.05);观察组患者首次下床时间和排气排便时间均早于对照组(P<0.05),日活动总量显著高于对照组(P<0.01),术后肺部并发症低于对照组(P<0.05)。 结论胸腹腔镜联合食管癌切除术患者围术期使用医用多功能胸带可改善患者肺功能,促进患者早期下床活动,增加活动总量,并降低肺部并发症的发生。     

The heterogeneity of the microcirculation in critical illness

Microcirculation, a complex and specialized facet of organ architecture, has characteristics that vary according to the function of the tissue it supplies. Bedside technology that can directly observe microcirculation in patients, such as orthogonal polarization spectral imaging and sidestream dark field imaging, has opened the way to investigating this network and its components, especially in critical illness and surgery. These investigations have underscored the central role of microcirculation in perioperative disease states. They have also highlighted variations in the nature of microcirculation, both among organ systems and within specific organs. Supported by experimental studies, current investigations are better defining the nature of microcirculatory alterations in critical illness and how these alterations respond to therapy. This review focuses on studies conducted to date on the microcirculatory beds of critically ill patients. The functional anatomy of microcirculation networks and the role of these networks in the pathogenesis of critical illness are discussed. The morphology of microvascular beds that have been visualized during surgery and intensive care at the bedside are also described, including those of the brain, sublingual region, skin, intestine, and eyes.     

Novel emergency department registration kiosk for HIV screening is cost-effective

High operating costs challenge sustainability of successful US emergency department (ED) HIV screening programs. Free-standing registration kiosks could potentially reduce the marginal costs of ED HIV screening. We investigated incremental cost-effectiveness ratio (CER) per new HIV diagnosis for a kiosk-based approach for offering screening at ED registration versus a testing staff-based approach to offer testing at the bedside. A rapid oral-fluid HIV screening program, instituted in a US ED since 2005, had a rate of new HIV diagnosis 0.16% in 2012. A two-phase quasi experimental design, including a testing staff-based approach to offer testing at the bedside (Phase I, August and September 2011) and a kiosk-based approach to offer testing at ED registration (Phase II, December 2011 and January 2012), was performed. CER per new HIV diagnosis was defined as total cost of the screening program divided by number of newly diagnosed cases. Costs included screening program personnel (study coordinator, testing staff, and kiosk helpers), diagnostic assays (rapid and confirmatory tests), and kiosks (2 kiosks, software, and IT consulting fees). Sensitivity analyses were performed. Data from our dedicated testing staff (DTS) program (Phase I) resulted in an estimated 5434 patients tested in one year and 9 newly diagnosed HIV-infected patients (95% CI: 3, 18). Data from the kiosk program (Phase II), resulted in a projected 4571 ED patients tested in one year and 21 newly diagnosed HIV-infected patients (95% CI: 4, 70). The overall cost was $ 201,433 for the DTS program, versus $292,008 for the kiosk program. Incremental CER per new HIV diagnosis for kiosk-based approach was $7523 (range: $1780–90,025 by sensitivity analysis). Our pilot data demonstrated that the use of kiosks for HIV screening was potentially more cost-effective than a testing staff-based bedside approach.     

京津三级甲等医院普外科术后患者液体治疗现状初步调查

目的 调查京津三家三级甲等医院普外科术后患者液体治疗现状. 方法 回顾性调查接受普外科手术的住院且术后禁食3 d以上的患者600例,不限年龄和性别、所患疾病种类和接受的手术类型.统计指标包括患者的一般资料、手术前后实验室检查、术后3 d液体治疗内容和部分临床指标(术后并发症、输液反应等). 结果 588例有效病例术后每天平均补液总量为(3030±638)ml;平均每天给予葡萄糖(142±67)g、氯化钾(59.9±23.9)mmol、氯化钠(179.5±66.7)mmol;85.2%的患者接受营养支持,肠外营养与肠内营养比为28:1;术前体质指数(BMI)≥18.5 kg/m2的患者有549例,其中接受肠外营养和肠内营养支持共有470例(85.6%);BMI<18.5 kg/m2共39例,给予规范的肠外营养支持27例(69.2%).均未给予肠内营养.术后3 d液体治疗中未给予氯化钾36例次. 结论 京津三级甲等医院普外科术后患者接受营养支持和肠外营养的比例均过高;即用型复合糖电解质制剂可减少差错和有益于大多数术后患者.