脓毒性休克规范化液体复苏治疗中的特殊性

脓毒性休克规范化液体复苏具有普遍指导意义,但不同的个体表现出的病理生理特点并非一致,液体复苏要注意具体患儿所表现出的特殊性.本文就脓毒性休克规范化液体复苏治疗中应考虑的特殊性进行讨论.     

无创血流动力学监测对儿童脓毒性休克液体复苏容量反应性的预测价值

目的 探讨无创血流动力学监测对脓毒性休克液体复苏容量反应性的预测价值.方法 选取2018年2月至2020年3月于湖南省儿童医院儿童重症监护病房(PICU)确诊的脓毒性休克患儿92例纳入研究,患儿均给予无创心输出量测量仪床旁监测心脏指数(CI)、每搏输出量指数(SVI)、系统血管阻力指数(SVRI)等指标.根据液体复苏治...     

再谈脓毒性休克液体复苏

液体复苏依然被推荐为脓毒性休克的一线复苏治疗。但目前该疗法被接受的原因,部分是由于其应用历史较长,且其在其他类型休克复苏中的应用为人熟知;部分则在于对脓毒性休克病理生理学改变的不全面、不正确的认识。近来,静脉液体复苏的安全性受到质疑,部分观察性研究和前瞻性研究均提示更少量的液体复苏有可能改善预后。对支持继续将液体复苏作为脓毒性休克复苏措施的证据目前依然存有争议,没有前瞻性研究证据显示液体复苏作为单一治疗措施会带来益处。该文对液体复苏作为脓毒性休克治疗措施的病理生理学基本原理进行了回顾,并基于目前临床证据讨论几个重要问题。     

小儿肠套叠和嵌顿疝致脓毒性休克的临床分析

目的 分析小儿肠套叠和嵌顿疝引起脓毒性休克的临床特征及干预措施.方法 对肠套叠和嵌顿疝患儿的手术方式、休克临床过程、液体复苏、预后等方面进行回顾性分析.结果 7例患儿均出现超高热、惊厥、脓毒性休克,其中3例成活患儿均进行积极的液体复苏;而4例死亡患儿均未进行液体复苏,发生难治性休克,并发多脏器功能不全综合征,从休克至心跳骤停时间平均仅11 h.入院早期仅3例诊断为休克,2例接受液体复苏治疗.7例患儿均发生严重低蛋白血症,C-反应蛋白显著升高,白细胞减低.其中6例发生弥散性血管内凝血.结论 临床医生对小儿肠套叠和嵌顿疝并发脓毒性休克认识不足,且液体复苏常不充分,极易导致肠套叠和嵌顿疝患儿进展为难治性休克,短期内迅速恶化,病死率甚高.     

脓毒性休克定义中加入血乳酸的意义

乳酸是反映休克组织灌注及细胞氧代谢的重要生物学标志物.2012年,"拯救脓毒症运动"国际指南建议将乳酸作为反映脓毒性休克组织灌注的量化指标之一.2016年欧美危重病协会颁布"第三届国际脓毒症及脓毒性休克诊断指南(Sepsis-3)",将脓毒性休克定义为:尽管充分的液体复苏,仍需要用血管升压药维持平均动脉压≥65mmHg(1mmHg=0.133kPa)和血乳酸≥2mmol/L(>18mg/dl),确定了乳酸在脓毒性休克诊断中的重要地位.乳酸≥4mmol/L是评估脓毒性休克患者预后不良的参考指标.以动态乳酸值为靶向指标的液体复苏与血管活性药物使用策略具有重要意义.乳酸清除率与早期乳酸面积可预测脓毒性休克死亡风险.     

目标导向治疗还要遵守吗？

早期目标导向治疗（ early goal-directed therapy,EGDT）通过采用有创监测措施,介导脓毒性休克患者的液体复苏,曾经被认为是降低病死率的重要手段,并获得“拯救脓毒症战役”等国际指南的推荐。近年来大规模多中心研究提示EGDT策略并不能降低严重脓毒症与脓毒性休克患者病死率,并可能带来一些不利的影响。然而,液体复苏与监测仍然是现阶段脓毒性休克救治的重要手段,因此,EGDT仍然有参考价值。今后仍然需要探索实用的监测与评估方法,用于脓毒性休克精准的液体管理。     

液体复苏在脓毒性休克患儿救治中的价值

目的探讨液体复苏在脓毒性休克患儿救治中的价值。方法对27例脓毒性休克患儿进行临床分析,测定复苏前后血pH值、氧合指数[pa（O2）/FiO2]、凝血酶原时间（PT）、部分凝血活酶时间（APTT）、收缩压、脉压差等指标。结果液体复苏后患儿pH值pa（O2）/FiO2显著提高（Pa〈0.01）,PT和APTT显著缩短（Pa〈0.01）,收缩压和脉压差显著升高（Pa〈0.01）。结论尽早在短期达到液体复苏目标,可改善脓毒性休克患儿氧的运输、组织灌注,改善凝血功能和预后。     

危重情况的急救处理

080672川芎嗪注射液佐治小儿感染性休克疗效观察/蔡美英…∥中华妇幼临床医学杂志(电子版).-2007,3(6).-335～337080673液体复苏在脓毒性休克患儿救治中的价值/唐冬梅…∥实用儿科临床杂志.-2007,22(18).-1432～1433对27例脓毒性休克患儿进行临床分析,测定复苏前后血pH值、氧合     

小儿脓毒性休克液体治疗时需要注意的问题

20世纪60年代,血流动力学监测技术的使用使休克患者的液体治疗有了原则可循.然而,如何对脓毒性休克患者进行容量复苏和液体治疗,仍然有许多问题需要进一步探讨. 1 液体治疗一般原则     

液体复苏是与非

第一篇 陈述观点 正方观点 正方一辩（崔云） 脓毒性休克患儿主要病理生理变化是有效循环容量绝对或相对不足,组织灌注不足及氧利用障碍。因此,我方观点是,脓毒性休克早期需快速大量液体复苏,尽快恢复血流动力学稳定,对降低脓毒性休克患儿病死率至关重要。     

Allergic factors associated with the development of asthma and the influence of cetirizine in a double-blind, randomised, placebo-controlled trial: First results of ETA®

There is a common progression known as the allergic march from atopic dermatitis to allergic asthma. Cetirizine has several antiallergic properties that suggest a potential effect on the development of airway inflammation and asthma in infants with atopic dermatitis. Methods. Over a two year period, 817 infants aged one to two years who suffered from atopic dermatitis and with a history of atopic disease in a parent or sibling were included in the ETAC^® (Early Treatment of the Atopic Child) trial, a multi-country, double-blind, randomised, placebo-controlled trial. The infants were treated for 18 months with either cetirizine (0.25mg/ kg b.i.d.) or placebo. The number of infants who developed asthma was compared between the two groups. Clinical and biological assessments including analysis of total and specific IgE antibodies were performed. Results. In the placebo group, the relative risk (RR) for developing asthma was elevated in patients with a raised level of total IgE (≥ 30 kU/I) or specific IgE (≥ 0.35 kUA/I) for grass pollen, house dust mite or cat dander (RR between 1.4 and 1.7). Compared to placebo, cetirizine significantly reduced the incidence of asthma for patients sensitised to grass pollen (RR = 0.5) or to house dust mite (RR = 0.6). However, in the population that included all infants with normal and elevated total or specific IgE (intention-to-treat - ITT), there was no difference between the numbers of infants developing asthma while receiving cetirizine or placebo. The adverse events profile was similar in the two treatment groups. Discussion. Raised total IgE level and raised specific IgE levels to grass pollen, house dust mite or cat dander were predictive of subsequent asthma. Cetirizine halved the number of patients developing asthma in the subgroups sensitised to grass pollen or house dust mite (i.e. 20% of the study population). In view of the proven safety of the drug, we propose this treatment as a primary pharmacological intervention strategy to prevent the development of asthma in specifically sensitised infants with atopic dermatitis.     

�¶�֢��ϵ�ϰ���ע��ȱ�ݶද�ϰ������ڵ�ת��

孤独症谱系障碍(autistic-spectrum disorders,ASDs)近年来患病率逐年攀升至1%左右,其症状往往伴随终生,成为严重威胁儿童健康和发展的神经发育性疾患;注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD)是儿童期最常见的精神障碍,国内报道患病率为4.13%～5.83%,其症状可延续至青少年期,甚至到成年期[1]。这两类精神障碍在成年期的临床表现、共患病、治疗策略和预后与儿童期有哪些不同呢?本文通过回顾相     

EXCITING NEW TREATMENT APPROACHES FOR PATHYPHYSIOLOGIC MECHANISMS OF SICKLE CELL DISEASE

During the past several decades, our understanding of the complex pathophysiology of vasoocclusion associated with sickle cell disease has improved greatly. Interaction of genes, hemoglobin molecules, red cell membrane and metabolic changes, cell-cell interactions and cell-plasma interactions, red cell adhesion to vascular endothelium, activation of coagulation, and vascular reactivity play a role in vaso occlusion. Penicillin prophylaxis of pneumococcal infections and appropriate use of blood transfusions and other supportive measures improved survival of sickle cell patients. Hydroxyurea made a major impact on sickle cell therapy when it was shown to decrease acute painful episodes, acute chest syndrome, and the need for blood transfusion in adults. Significant experience in the use of hydroxyurea has been accumulated in older children. The benefits and risks of hydroxyurea for younger children and long-term risks in all patients will be evaluated in future investigations. Other promising therapies include butyrate compounds, clotrimazole, magnesium supplementation, poloxamer 188, antiadhesion agents, anticoagulant approaches, and nitric oxide. Hemopoietic transplantation remains the only curative therapy. However, several transgenic mouse models are available for studies of gene therapy or other treatment approaches on biochemical, cellular, and pathologic effects of mutant genes.     

Infiltrations of Epstein-Barr virus-carrying cells in granular lymphocyte-proliferative disorders corresponding to chronic active Epstein-Barr virus infection

A 21-year-old man with granular lymphocyte-proliferative disorders (GLPD) associated with chronic active Epstein-Barr virus (EBV) infection is described. Chromosomal analyses revealed several clonal abnormalities and two of them were mainly repetitious. High copy numbers of monoclonal EBV genome were also detected in the proliferative large granular lymphocytes (LGLs), indicating the monoclonal expansion of EBV-infected LGLs. The patient had an indolent course for several years, and there was no evidence of infiltrations of his bone marrow until the end stage. At autopsy, microscopic studies revealed marked infiltrations of LGL in the liver and spleen, and the infiltrating cells were NK-cell immunophenotype. The infiltrated LGLs showed latency I.     

LUTEINIZING HORMONE RECEPTOR MUTATIONS IN DISORDERS OF SEXUAL DEVELOPMENT AND CANCER

Human male sexual development is regulated by chorionic gonadotropin (CG) and luteinizing hormone (LH). Aberrant sexual development caused by both activating and inactivating mutations of the human luteinizing hormone receptor (LHR) have been described. All known activating mutations of the LHR are missense mutations caused by single base substitution. The most common activating mutation is the replacement of Asp-578 by Gly due to the substitution of A by G at nucleotide position 1733. All activating mutations are present in exon 11 which encodes the transmembrane domain of the receptor. Constitutive activity of the LHR causes LH releasing hormone-independent precocious puberty in boys and the autosomal dominant disorder familial male-limited precocious puberty (FMPP). Both germline and somatic activating mutations of the LHR have been found in patients with testicular tumors. Activating mutations have no effect on females. The molecular genetics of the inactivating mutations of the LHR are more variable and include single base substitution, partial gene deletion, and insertion. These mutations are not localized and are present in both the extracellular and transmembrane domain of the receptor. Inactivation of the LHR gives rise to the autosomal recessive disorder Leydig cell hypoplasia (LCH) and male hypogonadism or male pseudohermaphroditism. Severity of the clinical phenotype in LCH patients correlates with the amount of residual activity of the mutated receptor. Females are less affected by inactivating mutation of the LHR. Symptoms caused by homozygous inactivating mutation of the LHR include polycystic ovaries and primary amenorrhea.     

Resurgence of measles in Singapore: profile of hospital cases

OBJECTIVE: To ascertain the profile of cases of measles seen at a general hospital during a recent outbreak that occurred despite a measles vaccination program. METHODOLOGY: A retrospective study from January 1991 to March 1998. All patients with measles (ICD code 055. 9) seen at the emergency unit or as inpatients were included. RESULTS: There were 87 cases identified. The diagnosis was clinical in all and proven serologically in 71%. Eighty-five per cent of the cases occurred between January 1997 and March 1998. There was a bi-modal age distribution with peaks in the very young (相似文献   

Personality profiles and heart rate variability (vagal tone) in children with recurrent abdominal pain

The aim of the study was to explore psychological factors and autonomic activity in children with recurrent abdominal pain and to compare them with those in a control group of healthy children. The Personality Inventory for Children was used for assessment of developmental, emotional and psychosocial factors in 25 children with recurrent abdominal pain (age, 7-15 y). Parasympathetic and sympathetic functions in these children and in 23 healthy control subjects (age, 7-13 y) were also investigated, non-invasively using a computerized polygraph. Vagal tone (parasympathetic function) was indexed by calculation of respiratory sinus arrhythmia in beats/min. Skin conductance (sympathetic function) was recorded by the constant current method. On the Personality Inventory for Children, 16 patients had high scores on somatic concern. Several patients had scores in the clinical range for depression, withdrawal and anxiety, but the mean scores for these personality profile scales were well within the normal range of healthy children. Interestingly, there was a spike on the L (Lie)-scale for most of the patients and 15 patients had scores above or close to the clinical cut-off value. As compared with the scores in healthy children, vagal tone and sympathetic tone were normal. Conclusion: Many children with recurrent abdominal pain have scores in the clinical range for depression, withdrawal, anxiety and L-scale indicating coping problems, denial and a trend towards somatic concern that may contribute to the evolution of abdominal pain. Autonomic nerve activity was not disturbed in these children.     

Overcoming surfactant inhibition with polymers

Inhibition of the function of pulmonary surfactant in the alveolar space is an important element of the pathophysiology of many lung diseases, including meconium aspiration syndrome, pneumonia and acute respiratory distress syndrome. The known mechanisms by which surfactant dysfunction occurs are (a) competitive inhibition of phospholipid entry into the surface monolayer (e.g. by plasma proteins), and (b) infiltration and destabilization of the surface film by extraneous lipids (e.g. meconium-derived free fatty acids). Recent data suggest that addition of non-ionic polymers such as dextran and polyethylene glycol to surfactant mixtures may significantly improve resistance to inhibition. Polymers have been found to neutralize the effects of several different inhibitors, and can produce near-complete restoration of surfactant function. The anti-inhibitory properties of polymers, and their possible role as an adjunct to surfactant therapy, deserve further exploration.     

Understanding infant formula

The World Health organisation recommends breast feeding infants for the first six months of life. When this breast feeding does not occur either through parental choice or medical need, infant formulas will be required. There is a bewildering array of formulas on the UK market for many different requirements. When faced with an unsettled infant many parents (and healthcare professionals) will experiment with the infant formula available and then attend the paediatric clinic looking for help and advice. It is therefore essential that paediatricians understand what milks are available and what the key differences between different products are. This review attempts to provide a simple guide through many of the formulations currently available in the UK; and offers advice for the dietary management of the child with extra calorie requirements, infants with cow's milk protein allergy, gastro oesophageal reflux disease, apparent unresolved hunger and infantile colic. Whatever the underlying condition, there is likely to be an infant formula that is suitable in this generation of ever expanding formulations.