早期肌钙蛋白I对危重孕产妇重症监护病房住院时间的预测价值

目的评估入重症监护病房（ICU）早期出现肌钙蛋白I（TnI）升高对重症孕产妇ICU住院时间的预测价值。 方法对2014年1月1日至2019年7月1日入住北京大学人民医院ICU的危重孕产妇的临床资料进行回顾性分析。根据入住ICU住院时间是否大于72 h,分为ICU住院时间延长和ICU住院时间非延长2个组。采用多因素Logistic回归方法分析ICU住院时间延长的独立危险因素。采用受试者工作特征（ROC）曲线评价入ICU早期TnI水平及AKI对ICU住院时间延长的预测价值。 结果本研究纳入转入ICU的危重孕产妇119例;其中ICU住院时间延长组47例（39.5%）,非延长组72例（60.5%）。Logistic回归分析发现,早期TnI升高（优势比6.697,95%CI：1.27~35.332,P=0.025）和急性肾损伤（AKI,优势比6.054,95%CI：1.248~29.368,P=0.025）是危重孕产妇ICU住院时间延长的独立危险因素。ROC曲线分析显示,入ICU早期发生TnI升高及AKI对ICU住院时间延长预测的曲线下面积分别为0.741（95%CI 0.65~0.832,P<0.001）和0.729（95%CI 0.634~0.825,P<0.001）;二者联合对ICU住院时间延长预测的曲线下面积为0.806（95%CI 0.723~0.889,P<0.001）。 结论早期出现TnI升高和AKI是预测危重孕产妇ICU住院时间延长的独立危险因素,对ICU住院时间有预测价值。     

改良早期预警评分在危重孕产妇护理中的应用效果评价

目的探讨改良早期预警评分(Modified Early Warning Scoring,MEWS)在产科危重孕产妇护理中的应用。方法以2013年1—12月上海交通大学附属第六人民医院危重孕产妇抢救中心收治的100例危重孕产妇为对照组,由医师根据辅助检验及临床表现判断来处置患者并给予转诊分流;选取2014年1月—2015年3月100例危重孕产妇为观察组,通过应用MEWS,根据评分分数分诊患者并给予相对应的护理措施。结果观察组平均救治时间、产科急性事件发生率、重症监护室(intensive care unit,ICU)转入率及住院时间均低于对照组(P均0.05)。结论将MEWS系统应用于产科危重分类救治,能有效缩短平均救治时间、降低产科急性事件发生率、缩短住院和治疗时间及ICU转入率。     

住院患者社区获得性与医院获得性急性肾损伤临床特征及预后分析

目的探讨住院患者发生社区获得性急性肾损伤(community-acquired acute kidney injury, CA-AKI)、医院获得性急性肾损伤(hospital-acquired acute kidney injury, HA-AKI)的临床特征及预后的影响因素。方法住院发生急性肾损伤(acute kidney injury, AKI)患者933例,其中510例HA-AKI为HA-AKI组、423例CA-AKI为CA-AKI组,比较2组临床资料,多因素logistic回归分析CA-AKI、HA-AKI患者住院期间死亡的危险因素。结果 HA-AKI组血肌酐峰值[(162.2±119.9)μmol/L]、入院时AKI分期3期比率(43.9%)、转入ICU比率(7.3%)、有高血压史比率(52.4%)、住院期间使用利尿剂比率(48.6%)较CA-AKI组[(145.1±98.4)μmol/L、36.5%、4.0%、41.1%、40.4%]高,住院时间[(15.4±7.3)d]较CA-AKI组[(14.1±7.9)d]长,年龄[(62.3±16.0)岁]较CA-AKI组[(64.5±16.7)岁]小,入院血肌酐[(99.3±59.6)μmol/L]、估算肾小球滤过率(estimated glomerular filtration rate, eGFR)[(80.2±34.6) mL/(min·1.73 m~2)]较CA-AKI组[(137.7±94.9)μmol/L、(93.7±29.3)mL/(min·1.73 m~2)]低(P0.05),住院期间病死率(15.1%)较CA-AKI组高(6.1%)(P0.05);HA-AKI组死亡患者基础血肌酐[(160.4±69.7)μmol/L]、血肌酐峰值[(231.7±170.0)μmol/L]、转入ICU比率(37.7%)、入院时AKI分期1期比率(75.3%)、住院期间使用利尿剂比率(62.3%)高于CA-AKI组死亡患者[(107.6±67.3)μmol/L、(154.0±98.4)μmol/L、15.4%、46.2%、26.9%],eGFR[(77.5±28.4) mL/(min·1.73 m~2)]低于CA-AKI组死亡患者[(95.1±24.4) mL/(min·1.73 m~2)],住院时间[(7.1±6.1)d]较CA-AKI组死亡患者[(13.8±8.5)d]短(P0.05);多因素logistic回归分析结果显示,转入ICU(OR=5.96,95%CI:1.74～20.47,P=0.005)、有脑血管病史(OR=2.48,95%CI:1.07～5.72,P=0.034)是CA-AKI患者住院期间死亡的危险因素,转入ICU(OR=5.84,95%CI:2.73～12.52,P0.001)、有脑血管病史(OR=2.32,95%CI:1.33～4.04,P=0.003)、住院期间使用利尿剂(OR=2.18, 95%CI:1.27～3.75,P=0.005)、入院时AKI分期3期(OR=5.21, 95%CI:1.86～14.59,P=0.002)是HA-AKI患者住院期间死亡的危险因素。结论 HA-AKI、CA-AKI是住院患者常见的并发症,HA-AKI病情相对较重,病死率高,转入ICU、有脑血管病史是二者住院期间死亡的共同危险因素,住院期间使用利尿剂、AKI分期3期与HA-AKI预后不良有关。     

产科联合重症监护室抢救危重孕产妇39例临床分析

目的:探讨产科联合重症监护室(ICU)抢救危重孕产妇的原因、监护及治疗措施.方法:回顾性分析2000年1月～2006年4月两院转入ICU的危重孕产妇39例的临床资料.结果:转入ICU的常见原因是产后出血、DIC、重度子痫前期、产前出血、妊娠合并症、产褥感染、羊水栓塞;产后出血者有17例发生多脏器功能障碍(MODS),重度子痫前期患者均出现MODS;产褥感染可导致多脏器功能衰竭(MOF)甚至死亡;监护和支持重要脏器功能,及时治疗原发病可较快恢复脏器功能.本组抢救成功38例(97.4%).结论:妇产科医生应及时将危重孕产妇转入ICU进行监护和支持重要脏器功能,可提高其抢救成功率,减少死亡率.     

血清镁在重症患者的变化及对预后的影响

目的:探讨血清镁在重症监护病房(ICU)重症患者中的变化水平及对预后的影响。方法:采用单中心观察性研究,选择2018-02—2019-05期间延安大学附属医院ICU的住院患者,排除住院时间48h及入ICU前已有明确的低镁血症或已接受镁补充治疗的患者。所有患者在入ICU后24h内取血标本送检,利用自制表格记录患者的一般资料、实验室检查、机械通气时间、ICU住院时间及28d生存率等,并计录入ICU后24h内的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分;采用Logistic回归分析筛选重症患者死亡的危险因素。结果:共纳入重症患者256例,低镁血症(0.7mmol/L)患者100例(39.06%);正常血镁(0.7～1.2mmol/L)患者128例(50.00%);高镁血症(1.2mmol/L)患者28例(10.94%)。死亡组(患者生存时间28d)61例,其中低镁血症患者38例,占62.30%;存活组(患者生存时间≥28d)195例,其中低镁血症患者62例,占31.79%;与存活组比较,死亡组年龄明显偏大[(62.64±15.35)vs.(53.02±17.69)岁,P=0.000];血镁水平明显偏低[(0.89±0.30)vs.(0.74±0.24)mmol/L,P=0.001],血小板计数(PLT)偏低(P0.05),而血清降钙素原(PCT)、脑钠肽前体(NT-BNP)、APACHEⅡ评分明显偏高,机械通气时间明显延长(P0.05)。通过多因素Logistic回归分析发现重症患者APACHEⅡ评分[优势比(OR)=0.866,95%可信区间(95%CI):0.821～0.913,P=0.000]、年龄(OR=0.971,95%CI:0.949～0.994,P=0.013)和血镁(OR=0.798,95%CI:0.074～1.388,P=0.047)为影响ICU重症患者死亡的独立危险因素。结论:ICU危重患者低镁血症发生率很高,且血镁水平与患者病死率密切相关。     

神经外科医院感染的现状及相关因素分析

目的:调查神经外科住院患者医院感染现状,分析发生的危险因素。方法:回顾性分析神经外科的4 716例患者临床资料,运用单因素及多因素Logistic回归分析医院感染发生的相关危险因素。结果:4 716例患者中,发生医院感染216例(4.6%),医院感染253例次(5.4%);感染部位中,呼吸系统感染139例次(55.0%),中枢神经系统感染50例次(19.8%),血液系统感染34例次(13.4%),手术部位感染16例次(6.3%),泌尿系统感染14例次(5.5%)。Logistic回归结果显示,吸烟史(OR=1.734,95%CI 1.073～2.802)、急诊入院(OR=0.520,95%CI 0.341～0.794)、住院时间长(OR=1.114,95%CI 1.090～1.140)、入住ICU(OR=2.256,95%CI 1.319～3.857)、机械通气(OR=2.032,95%CI 1.263～3.270)、人工气道(OR=2.127,95%CI 1.018～4.444)、留置静脉导管(OR=2.391,95%CI 1.490～3.836)及低温治疗(OR=3.334,95%CI 1.732～6.418)为神经外科住院患者医院感染的独立危险因素。结论:神经外科住院患者医院感染发生率较高,感染部位以呼吸系统居首位。     

行肠外营养治疗的ICU重症患者发生抗生素相关性腹泻的影响因素分析

目的分析行肠外营养治疗的ICU重症患者的临床资料,探讨其发生抗生素相关性腹泻(antibiotic-associated diarrhea,AAD)的影响因素。方法行肠外营养治疗的ICU重症患者177例,发生AAD者50例为AAD组,未发生AAD者127例为非AAD组。比较2组年龄,性别比例,合并高血压、糖尿病比率,ICU住院时间,入住ICU时白蛋白水平,急性生理与慢性健康评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)及益生菌、质子泵抑制剂、抗生素使用情况;多因素logistic回归分析行肠外营养治疗的ICU重症患者发生AAD的影响因素。结果177例患者AAD发生率为28.25%。AAD组年龄[(56.80±20.41)岁]大于非AAD组[(47.12±19.30)岁](P<0.05),ICU住院时间[(17.82±12.15)d]、抗生素使用时间[(13.08±8.84)d]长于非AAD组[(9.83±7.11)、(7.92±4.83)d](P<0.05),联合使用抗生素(72.00%)及联合使用3种抗生素比率(46.00%),加酶抑制剂类、抗真菌类、恶唑烷酮类及喹诺酮类抗生素使用比率(80.00%、58.00%、26.00%、28.00%)均高于非AAD组(43.31%、19.69%、62.99%、24.41%、12.60%、11.02%)(P<0.05)。多因素logistic回归分析结果显示,年龄(OR=1.020,95%CI:1.000~1.041,P=0.048)、ICU住院时间(OR=1.058,95%CI:1.007~1.113,P=0.026)、抗生素使用时间(OR=1.124,95%CI:1.062~1.189,P<0.001)、联合使用3种抗生素(OR=3.366,95%CI:1.655~6.848,P=0.001)、使用加酶抑制剂类抗生素(OR=2.350,95%CI:1.076~5.131,P=0.032)是行肠外营养治疗的重症患者发生AAD的影响因素。结论年龄、ICU住院时间、抗生素使用时间、联合使用3种抗生素与行肠外营养治疗的ICU重症患者发生AAD有关。     

产科联合ICU救治危重孕产妇36例分析

目的分析危重孕产妇在产科和重症监护病房(ICU)联合救治后的母婴结局,以提高危重孕产妇救治成功率。方法回顾性分析2007~2009年36例入住ICU抢救的危重孕产妇的资料。结果36例患者都抢救成功,围产儿死亡9例(24.32%)。其中经产妇21例(58.33%),外来人口35例(97.22%),未做/不正规产前检查者26例(72.22%);子痫、重度子痫前期并发严重并发症15例(41.67%),产科出血11例(30.56%)。结论产科处理与ICU综合监护和救治是确保危重孕产妇抢救成功的关键。加强外来人口孕产妇的保健管理是减少孕产妇重危疾病发生的重要一环。     

重症加强治疗病房妊娠期急性肾衰竭危险因素分析

目的 分析导致重症加强治疗病房(ICU)危重孕产妇妊娠期急性肾衰竭(ARF)的危险因素.方法 采用回顾性分析方法,选择因产后并发症入住ICU的危重孕产妇192例,排除3例因羊水栓塞死亡,7例 因记录不完整者,共182例纳入本研究.将患者根据是否合并ARF分为ARF组(68例)和非ARF组(114例),采集两组患者发生先兆子痫、HELLP综合征(溶血、肝酶升高、血小板减少)、妊娠急性脂肪肝、产后出血、脓毒症等指标;以及产后4 d内使用的主要药物: ① 血浆体积膨胀剂:液体(晶体液、人工胶体、高渗白蛋白、4%白蛋白)和血液制品(浓集红细胞、浓缩血小板、纤维蛋白原、新鲜冷冻血浆、活化因子Ⅶ); ② 抗纤溶药:氨甲环酸; ③ 抗高血压药物:血管紧张素转换酶抑制剂(ACEI),利尿剂; ④ 肾毒性药物:氨基糖苷类,造影剂等.对上述指标先进行单因素分析,将有统计学意义的危险因素进行多因素logistic回归分析,筛选出ICU危重孕产妇妊娠期发生急性肾衰竭的危险因素.结果 单因素分析表明:HELLP综合征、产后4 h使用氨甲环酸和高渗白蛋白是ARF的危险因素(χ2值分别为4.92、4.29、5.53,均P<0.05).多因素logistic回归分析表明:HELLP综合征〔优势比(OR)=10.478,95%可信区间(95%CI)为1.248~17.953,P=0.030〕和产后4 h使用高渗白蛋白(OR=6.632,95%CI为1.211~16.328;P=0.029)是ARF发生的独立危险因素.结论 ICU危重孕产妇ARF是多因素参与的过程,应充分认识各种危险因素对ARF的影响,存在HELLP综合征和产后4 h使用高渗白蛋白是ARF发生的独立危险因素,对存在危险因素的患者实施重点防护以减少ARF的发生.     

肿瘤外科ICU室上性心律失常的发生率及危险因素分析

目的 探讨肿瘤外科ICU室上性心律失常(SVAs)的发生率及危险因素.方法 回顾分析我院ICU 2008年11月至2009年10月间收治570例患者的临床资料,对SVAs可能的影响因素进行单因素和多因素Logistic分析.结果 13例有心房颤动病史的患者被除外,入选557例.SVAs发生率为12.93%(72/557).多因素分析显示年龄(OR=1.066,95%CI:I.034～1.099,P＜0.001)、冠心病病史(OR=2.644,95%CI:1.459～4.790,P＜0.05)、转入时确诊为脓毒症(OR=2.374,95%CI:1.098～5.135,P＜0.05)和胸部外科手术操作(OR=2.322,95%CI:1.061～5.084,P＜0.05)是SVAs发生的独立危险因素.SVAs患者与非SVAs组住ICU时间[2(1～77)、3(1～40)d,Z=-3.505,P＜0.001]和APACHEⅡ评分[9(0～37)、11(3～38)分,Z=-3.332,P=0.001],差异有统计学意义.SVAs组死亡9例(12.5%),非SVAs组死亡19例(3.9%),病死率差异有统计学意义(x2=9.673,P=0.002).结论 肿瘤外科ICU患者术后SVAs的发生率较高,年龄、冠心病病史、转入ICU时确诊有脓毒症和胸部外科手术操作是术后SVAs发生的独立危险因素.SVAs增加患者住ICU时间,是反映患者病情严重性的一种标志.

Abstract：

Objective To evaluate the incidence and to investigate risk factors of supraventricular arrhythmia (SVAs) in postoperative cancer patients in intensive care unit ( ICU ). Methods Data of 570 patients consecutively admitted to oncologic surgical ICU of Cancer Hospital of Chinese Academy of Medical Sciences from Nov. 2008 to Oct. 2009 were retrospectively collected. Univariate and multivariate logistic analysis were conducted for potential factors that influenced SAVs. Results Thirteen patients with a history of atrial fibrillation (AF) were excluded and 557 patients were eligible for the study. SVAs occurred in 72 patients ( 12. 93% ). Multivariate analysis showed four independent predictors of SVAs including age ( OR = 1. 066,95%CI: 1. 034 - 1. 099,P ＜0. 001 ) ,a history of coronary heart diseases ( OR = 2. 644,95% CI: 1. 459 - 4. 790,P ＜ 0. 05), sepsis ( OR = 2. 374,95% CI: 1. 098 - 5. 135, P ＜ 0. 05 ) and intra-thoracic procedure ( OR =2. 322,95 % CI: 1.061 - 5.084, P ＜ 0. 05 ) . ICU length of stay, severity ( APACHE Ⅱ scores in SVAs patients) were significantly greater in patients who were not affected by SVAs ( ICU stay: [2 ( 1 ～ 77 )]vs [3 ( 1 ～ 40 )]days,P ＜ 0. 001; APACHE Ⅱ score: [9 (0 ～ 37 )] vs [11 (3 ～ 38 )], P = 0. 001 ). Nine cases died in SVAs patients ( 12. 5% ) and 19 died in the non-SVAs patients (3.9%), with significant difference between the two groups( x2 = 9. 673, P = 0. 002). Conclusion In oncologic surgical ICU, the incidence of SVAs is high. Age,history of coronary heart diseases, sepsis and intra-thoracic procedure were independent rsik factors of SVAs. SVAs prolong ICU length of stay. SVAs is a marker of critical illness severity.     

ICU系统性红斑狼疮患者的临床特征与预后分析

目的探讨ICU系统性红斑狼疮（SLE）患者的临床特征和预后的影响因素。 方法回顾性分析2013年1月至2019年6月入住我院内科ICU的SLE患者的临床数据,主要包括：年龄、性别、患病年限、主要器官受累情况、SLE疾病活动指数（SLEDAI）、急性生理学与慢性健康状况（APACHEⅡ）评分、ICU住院时间及转归、入住ICU的直接原因、ICU住院期间治疗（包括糖皮质激素、免疫抑制剂、大剂量免疫球蛋白、有创机械通气、血液透析、血管活性药物）以及主要的实验室检查数据。 结果共纳入61例患者,以女性为主（68.85%）,APACHEⅡ评分（18.93±7.62）分。感染和急性心力衰竭是转入ICU最常见的原因。多因素Logistic回归分析提示APACHEⅡ评分≥20分、血管活性药物应用、脓毒症与预后相关（OR=23.326,95%CI：2.307~235.896,P=0.008;OR=26.218,95%CI：1.641~418.897,P=0.021;OR=17.194,95%CI：1.332~221.945,P=0.029）。 结论ICU的SLE患者预后较差,APACHEⅡ评分≥20分、血管活性药物应用、脓毒症是其死亡的危险因素。     

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

Patients and methods

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

Results

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n = 89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P = .744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P = .003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P = .007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P = .002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P = .0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P = .014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P = .035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P = .008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P = .001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P = .028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P = .0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P = .004) were the independent risk factors in patients with solid tumors.

Conclusion

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.     

Serum bicarbonate may independently predict acute kidney injury in critically ill patients:An observational study

AIM: To explore whether serum bicarbonate at admission to intensive care unit(ICU) predicted development of acute kidney injury(AKI).METHODS:We studied all patients admitted to our ICU over a 2 year period(February 2010 to 2012).The ICU has a case mix of medical and surgical patients excluding cardiac surgical,trauma and neurosurgical patients.We analysed 2035 consecutive patients admitted to ICU during the study period.Data were collected by two investigators independently and in duplicate using a standardised spread sheet to ensure accuracy.Ambiguous data were checked for accuracy where indicated.AKI was defined using the Kidney Disease Improving Global Outcomes criteria.Patients were divided into two groups;patients who developed AKI or those who did not,in order to compare the baseline characteristics,and laboratory and physiologic data of the two cohorts.Regression analysis was used to identify if serum bicarbonate on admission predicted the development of AKI.RESULTS:Of 2036 patients 152(7.5%)were excluded due to missing data.AKI developed in 43.1%of the patients.The AKI group,compared to the nonAKI group,was sicker based on their lower systolic,diastolic and mean arterial pressures and a higher acutephysiology and chronic health evaluation(APACHE)Ⅲand SAPSⅡscores.Moreover,patients who developed AKI had more co-morbidities and a higher proportion of patients who developed AKI required mechanical ventilation.The multi-regression analysis of independent variables showed that serum bicarbonate on admission(OR=0.821;95%CI:0.796-0.846;P0.0001),APACHEⅢ(OR=1.011;95%CI:1.007-1.015;P0.0001),age(OR=1.016;95%CI:1.008-1.024;P0.0001)and presence of sepsis at ICU admission(OR=2.819;95%CI:2.122-23.744;P=0.004)were each significant independent predictors of AKI.The area under the ROC curve was 0.8(95%CI:0.78-0.83),thereby demonstrating that the predictive model has relatively good discriminating power for predicting AKI.CONCLUSION:Serum bicarbonate on admission may independently be used to make a diagnosis of AKI.     

中重度颅脑外伤患者合并阵发性交感神经过度兴奋综合征的危险因素及对预后的影响

目的 分析在中重度颅脑外伤患者中与阵发性交感神经过度兴奋综合征（paroxysmal sympathetic hyperactivity,PSH）相关的危险因素,并分析PSH对此类患者预后的影响。方法 选择在我院收治的中重度颅脑外伤患者为研究对象。收集所有患者的人口学信息和临床诊治信息。按照是否合并PSH将患者分为PSH组（n=27）和对照组（n=99）,对相关变量进行回归分析,并分析PSH对中重度颅脑损伤预后［住院时间,住ICU时间,格拉斯哥预后评分(Glasgow Outcome Scale,GOS)］的相关性。结果 共纳入患者126 例（男性 82 例,女性 44例）,共有27例发生了PSH（21.4%）。与PSH发生相关的危险因素包括入院时收缩压>140 mmHg(1 mmHg=0.133 kPa)（OR=3.21,95%CI=1.31~7.87,P=0.011）,GCS<8分(OR=4.34,95%CI=1.73~10.93,P=0.002),创伤后急诊CT提示存在脑挫裂伤（OR=4.29,95%CI=2.55~8.26,P<0.001）,颅内出血量≥50 ml（OR=2.33,95%CI=1.42~5.13,P=0.003）以及后期出现脑积水(OR=3.57,95%CI=1.36~9.37,P=0.010)。而PSH又与住院时间>1个月（OR=5.21,95%CI=2.88~7.42,P=0.002）和GOS 1~3分有关（OR=1.75,95%CI=1.24~3.78,P=0.009）。结论 PSH是中重度颅脑外伤患者的一种常见并发症。PSH的发生与入院时收缩压较高、GCS较低、合并脑挫伤以及后期合并脑积水等因素密切相关,而合并PSH的患者住院时间更长,预后更差。     

Who bounces back? Physiologic and other predictors of intensive care unit readmission

OBJECTIVE: To determine the influence of changes in acute physiology scores (APS) and other patient characteristics on predicting intensive care unit (ICU) readmission. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Single large university medical intensive care unit. PATIENTS: A total of 4,684 consecutive admissions from January 1, 1994, to April 1, 1998, to the medical ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The independent influence of patient characteristics, including daily APS, admission diagnosis, treatment status, and admission location, on ICU readmission was evaluated using logistic regression. After accounting for first ICU admission deaths, 3,310 patients were "at-risk" for ICU readmission and 317 were readmitted (9.6%). Hospital mortality was five times higher (43% vs. 8%; p < .0001), and length of stay was two times longer (16 +/- 16 vs. 32 +/- 28 days; p < .001) in readmitted patients. Mean discharge APS was significantly higher in the readmitted group compared with the not readmitted group (43 +/- 19 vs. 34 +/- 18; p > .01). Significant independent predictors of ICU readmission included discharge APS >40 (odds ratio [OR] 2.1; 95% confidence interval [CI] 1.6-2.7; p < .0001), admission to the ICU from a general medicine ward (Floor) (OR 1.9; 95% CI 1.4-2.6; p < .0001), and transfer to the ICU from other hospital (Transfer) (OR 1.7; 95% CI 1.3-2.3; p < .01). The overall model calibration and discrimination were (H-L chi2 = 3.8, df = 8; p = .85) and (receiver operating characteristic 0.67), respectively. CONCLUSIONS: Patients readmitted to medical ICUs have significantly higher hospital lengths of stay and mortality. ICU readmissions may be more common among patients who respond poorly to treatment as measured by increased severity of illness at first ICU discharge and failure of prior therapy at another hospital or on a general medicine unit. Tertiary care ICUs may have higher than expected readmission rates and mortalities, even when accounting for severity of illness, if they care for significant numbers of transferred patients.     

血管升压素治疗心脏外科术后血管扩张性休克效果的Meta分析

目的探讨血管升压素对心脏外科术后血管扩张性休克患者的治疗价值。 方法检索中国知网、万方医学数据库、PubMed数据库、Embase数据库、Springer Link数据库、Cochrane图书馆等关于应用血管升压素治疗心脏外科术后血管扩张性休克患者的随机对照临床试验（RCT）。检索时限为1980年1月至2018年12月。主要结局指标：病死率;次要观察指标为ICU住院时间、平均动脉压（MAP）、严重不良事件发生率、心房颤动发生率。由2名研究者分别进行文献筛选、数据提取和质量评价。应用RevMan 5.3软件进行Meta分析,绘制漏斗图分析各研究间的发表偏倚。 结果共检索出相关文献458篇,根据纳入和排除标准,最终纳入4项RCT研究,共计458例患者;其中1项研究被认为偏倚风险较低,3项研究存在中度偏倚风险。Meta分析结果显示：与对照组相比,血管升压素不能显著改善心脏外科术后血管扩张性休克患者的病死率[伏势比（OR）=0.95,95%CI：0.55~1.64,P=0.85]及ICU住院时间[均数差（MD）=-0.41,95% CI：-1.40~0.57,P=0.41];可以提升患者的平均动脉压（MAP）（MD=7.77,95% CI：2.59~12.94,P=0.003）;不增加患者严重不良事件的发生率（OR=0.89,95% CI：0.49~1.60,P=0.69）;有降低患者心房颤动发生率的趋势,但差异无统计学意义（OR=0.19,95% CI：0.03~1.04,P=0.06）。 结论现有证据表明,血管升压素不能显著改善心脏外科术后血管扩张性休克患者的病死率和ICU住院时间,但有助于改善患者的MAP且可能会降低其心房颤动的发生率。     

ICU患者发生获得性衰弱的危险因素分析

目的分析ICU患者发生获得性衰弱的危险因素。 方法选择2015年6月至2018年9月南充市中心医院ICU收治的280例患者作为研究对象,其中63例患者发生ICU获得性衰弱,217例患者未发生ICU获得性衰弱。根据临床工作经验,将与ICU获得性衰弱有直接或间接尚待求证的因素如性别、年龄、体质量指数（BMI）、入ICU时简化急性生理学评分（SAPS）Ⅱ、急性病生理学和长期健康评价（APACHE）Ⅱ评分、意识障碍、高血压、高血糖、来源科室、弥散性血管内凝血（DIC）、脓毒症、脓毒性休克、多器官功能障碍综合征（MODS）、长期卧床制动、低蛋白血症、机械通气时间、应用糖皮质激素、应用神经肌肉阻滞剂、应用去甲肾上腺素、实施早期康复干预等因素纳入Logistic回归分析,筛选出ICU获得性衰弱的影响因素。 结果单因素Logistic回归分析结果显示,女性[比值比（OR）= 1.514,95%置信区间（CI）（1.074,1.328）,P = 0.042]、年龄≥ 60岁[OR = 1.613,95% CI（1.142,2.002）,P = 0.042]、SAPSⅡ评分≥ 25分[OR = 1.982,95% CI（1.003,2.925）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.770,95%CI（1.192,2.742）,P = 0.014]、高血糖[OR = 1.853,95%CI（1.035,2.214）,P = 0.015]、脓毒症[OR = 2.309,95%CI（1.013,3.063）,P = 0.021]、脓毒性休克[OR = 2.106,95%CI（1.995,4.947）,P = 0.025]、MODS [OR = 3.721,95%CI（1.001,4.980）,P = 0.007]、长期卧床制动[OR = 4.641,95%CI（1.932,5.253）,P < 0.001]、机械通气时间≥ 72 h [OR = 3.367,95%CI（1.635,4.254）,P = 0.005]、应用糖皮质激素[OR = 1.709,95%CI（1.424,2.757）,P = 0.021]、应用神经肌肉阻滞剂[OR = 2.042,95%CI（1.331,4.953）,P = 0.011]以及实施早期康复干预[OR = 0.586,95%CI（0.953,1.472）,P = 0.037]与ICU获得性衰弱相关。将其纳入多因素Logistic回归分析后发现,年龄≥ 60岁[OR =1.576,95%CI（1.095,1.753）,P = 0.038]、SAPSⅡ评分≥ 25分[OR = 1.988,95%CI（1.115,1.803）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.768,95%CI（1.189,2.364）,P = 0.014]、高血糖[OR = 1.680,95%CI（1.033,1.689）,P = 0.015]、脓毒症[OR = 1.842,95%CI（1.011,1.976）,P = 0.010]、长期卧床制动[OR = 4.745,95%CI（1.931,3.470）,P < 0.001]、机械通气时间≥ 72 h[OR = 3.353,95%CI（1.722,4.314）,P = 0.003]、应用神经肌肉阻滞剂[OR = 1.931,95%CI（1.247,2.573）,P = 0.005]是ICU患者发生获得性衰弱的独立危险因素,而实施早期康复干预[OR = 0.598,95%CI（0.978,1.674）,P = 0.037]是其保护因素。 结论ICU获得性衰弱的危险因素复杂,应加强高危患者的早期干预,积极控制好血糖,减少制动时间和机械通气时间,预防ICU获得性衰弱的发生。