外科危重病人院内安全转运的管理

目的:探讨实施外科危重患者院内安全转运管理后的效果。方法:2010年我院外科加强院内安全转运管理的113例危重症患者为实验组,2009年常规院内转运管理的102例为对照组,观察两组的转运时间、转运过程中不良事件和意外事件的发生率。结果:2010年院内转运时间为(30.2±7.9)min,2009年为(39.8±5.5)min,两组比较(P<0.01)统计学有显著性差异,2010年院内转运时间比2009年有明显缩短。2010年不良事件的例数:脱管3例、窒息0例、坠床0例、病情恶化1例,不良事件发生率3.53%;2009年不良事件的例数:脱管5例、窒息3例、坠床2例、病情恶化7例,不良事件发生率16.67%,两组比较(P<0.01)统计学有显著性差异,2010年不良事件的发生比2009年有明显减少。结论:实施外科危重患者院内安全转运管理,可缩短转运时间,提高转运效率,减少转运过程中不良事件及意外事件的发生率。     

Validation of a prognostic score in critically ill patients undergoing transport

Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died subsequently in hospital and 28 survived to return home. The mean score for the non-survivors before resuscitation was 21.7 and for the survivors 12.2 (p less than 0.0005). Among the non-survivors there was a significant fall in score with resuscitation but this did not alter their subsequent outcome. Neither group deteriorated during transport. The sickness score is a powerful method for determining prognosis, and employed longitudinally it may be useful in the assessment of treatment. It has important implications for the administration and organisation of regional intensive care services.     

急诊危重症患者院内转运的风险评估及安全护理

危重症患者病情变化快、病情复杂、并发症多、常因检查、诊断和治疗需要进行院内转运.对危重症患者进行正确的风险评估,是进行院内安全转运的前提.本文从转运前的风险评估及准备,转运途中的监护、观察及应急抢救措施,转运后的交接等方面进行综述,以确保危重症患者院内转运安全,为临床护理工作提供借鉴性意见.     

危重患者院内转运集束化策略应用效果分析

目的 观察集束化干预在院内危重患者转运中的临床效果.方法 以危重患者院内转运的时间段分组,其中2015年1-3月院内转运患者设为对照组,采用传统方法;2015年4-6月的院内转运患者设为观察组,应用集束化转运策略.以5％的比例随机抽样,抽样结果为对照组110例,观察组116例.分别观察比较两组患者转运不良事件发生情况.结果 两组患者转运前状态比较差异无统计学意义(P＞0.05);观察组转运过程中不良事件发生率和等级低于对照组,两组比较差异有统计学意义(P＜0.05);两组患者不良事件原因分析中人员因素、设备因素、病情因素、流程因素比较,差异有统计学意义(P＜0.05).结论 通过集束化干预可以减少重症患者院内转运不良事件的发生,提高转运安全性.     

危重疾病患者的高血糖反应及其处理

近年来,危重疾病当中的高血糖反应受到广泛关注,研究表明通过控制高血糖可以减少并发症并降低死亡率。与单纯糖尿病不同,在危重疾病患者,反应性高血糖的发生机制尚未完全清楚,治疗困难;且常同时伴随水、电解质、酸碱平衡紊乱及多脏器功能损伤,其处理有一定的特殊性。一、反应性高血糖的形成在健康个体中,通过胰岛素、胰高血糖素等激素,神经和肝脏等的自身调节,血糖浓度基本上是恒定的,即使餐后有所升高,但有一定限度,通过调节也可恢复至适当水平。但在危重疾病患者,机体调节异常,高血糖发生的机会显著增加。1.体内因素:创伤和危重病患者常存…     

危重病患者菌血症75例分析

目的了解危重病患者菌血症的流行病学概况和死亡的危险因素,并对抗生素治疗进行评估。方法对１９８９～１９９６年间北京协和医院加强医疗病房７５例危重病患者发生的１１６次菌血症进行回顾性分析。结果菌血症患者的病死率４３％。致病菌多为高度耐药的病原菌,如葡萄球菌（２９％）、肠球菌（１２％）、产Ｉ型诱导酶的肠杆菌（１２％）和产超广谱酶的肠杆菌（１０％）。其中革兰阳性球菌检出率较高。受累脏器按呼吸（７７％）、肝脏（５３％）、循环（５３％）、消化道（５０％）、肾脏（４７％）、中枢神经（３６％）和血液系统（２７％）依次减少。其中多器官功能衰竭为７６％。单因素分析显示原发病严重程度、多器官功能衰竭、感染性休克、肝功能衰竭、肾功能衰竭以及感染灶部位均显著影响患者的死亡（Ｐ＜０．０５）。Ｃｏｘ比例风险模型分析提示中枢神经系统功能衰竭、感染性休克、血液系统功能衰竭、肝功能衰竭和呼吸道操作均显著影响菌血症患者的生存时间。结论革兰阳性球菌是危重病患者菌血症的重要致病菌。抗生素治疗不能预防菌血症,亦不能改变菌血症患者的预后。     

The outcome of critically ill Indigenous patients

OBJECTIVE: To investigate the short-term outcome of critically ill Indigenous patients. DESIGN AND PARTICIPANTS: Retrospective cohort study using de-identified audit data from a tertiary intensive care unit (ICU) in Western Australia for the 11-year period 1 January 1993 to 31 December 2003. MAIN OUTCOME MEASURES: Hospital mortality (crude, and adjusted for severity of illness). RESULTS: Of 16 757 ICU patients, 1076 (6.4%) were identified as Indigenous. The Indigenous patients were younger and more commonly had chronic liver and renal diseases. Indigenous people represented 3.2% of the population of Western Australia in 2001, but represented 3.1% and 9.5% of all elective and emergency ICU admissions, respectively. Diagnoses of sepsis, pneumonia, trauma, and cardiopulmonary arrest were common among critically ill Indigenous patients. Following emergency admission, the crude hospital mortality for Indigenous patients was higher (22.7% v 19.2%; crude odds ratio, 1.24; 95% CI, 1.04-1.47) than for non-Indigenous patients. The crude hospital mortality of critically ill Indigenous patients was lower than that predicted by the APACHE II prognostic model and was similar to that of non-Indigenous patients after adjusting for severity of illness and chronic health status. CONCLUSIONS: The pattern of critical illness affecting Indigenous Australians in Western Australia was different from that affecting non-Indigenous patients. The crude hospital mortality was high, but similar to that of non-Indigenous Australians after adjusting for severity of illness and chronic health status.     

白蛋白在危重病人的循证应用

目的 通过对现有医学证据的检索和评价,指导白蛋白在危重病人中的应用。方法 针对合并低蛋白血症和Sepsis状态的危重病人应用白蛋白的利弊提出临床问题,然后用主题词“albumin”和“critically ill or,sepsis”检索Cochrane图书馆(2003年第2期)和MEDLINE寻找相关的证据。结果 通过检索,一共查到4篇系统评价．15篇随机临床研究。大多数研究表明对低蛋白血症的危重病人使用白蛋白不能减少死亡率,反而可能增加死亡风险。结论 通过检索和评价,我们对该患者选择了暂时停用白蛋白。     

血糖监测对危重症患者的作用

目的探讨危重症患者监测血糖的临床作用。方法对我院收治的危重症患者632例进行随机常规血糖监测,其中385例患者血糖升高,对血糖升高患者进行糖化血红蛋白(glycated hemoglobin,GHb)测定,根搌GHb结果,统计分析GHb正常组与GHb升高组患者的临床糖尿病确诊率及病死率。结果危重症血糖正常患者病死率明显低于血糖升高者(P<0.05);GHb正常组患者糖尿病确诊率及病死率显著低于GHb升高组患者(P<0.05);而GHb升高组患者中无糖尿病史较有糖尿病史患者的病死率升高,差异有统计学意义(P<0.05)。结论重视危重症患者血糖的测定及评估,可以为临床诊治提供科学的参考依据,并可以改善患者的预后。     

胃张力测定在内科危重症患者的应用

组织氧合状态监测是近年来对危重病人监测的重要内容.临床和实验研究证明,危重症患者胃肠道是脓毒血症、全身炎症反应综合征(SIRS)和多器官功能障碍综合征(MODS)的重要器官.它既是缺氧、低灌注损伤的"靶"器官,又是损伤的始动因素[1].许多学者认为,胃肠道缺氧发生在其它缺氧监测指标(如动脉血乳酸升高或氧耗量VO2下降)发生之前[2,3].研究也证实胃肠缺血与预后有关,如果纠正胃肠缺血可以改善预后[4].因此,危重症患者胃肠道的监测日益受到重视.胃张力测定的应用和发展使得这一功能监测成为可能[5,6].现将胃张力测定技术进展及其在内科危重症病人监测中的临床应用作一综述.     

Cytomegalovirus reactivation in critically ill immunocompetent patients

Ajit P. Limaye, MD; Katharine A. Kirby, MSc; Gordon D. Rubenfeld, MD; Wendy M. Leisenring, ScD; Eileen M. Bulger, MD; Margaret J. Neff, MD; Nicole S. Gibran, MD; Meei-Li Huang, PhD; Tracy K. Santo Hayes, BSc; Lawrence Corey, MD; Michael Boeckh, MD

JAMA. 2008;300(4):413-422.

Context  Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in critically ill persons lacking evidence of immunosuppression have not been well defined.

Objective  To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically ill immunocompetent persons.

Design, Setting, and Participants  We prospectively assessed CMV plasma DNAemia by thrice-weekly real-time polymerase chain reaction (PCR) and clinical outcomes in a cohort of 120 CMV-seropositive, immunocompetent adults admitted to 1 of 6 ICUs at 2 separate hospitals at a large US tertiary care academic medical center between 2004 and 2006. Clinical measurements were assessed by personnel blinded to CMV PCR results. Risk factors for CMV reactivation and association with hospital and ICU length of stay were assessed by multivariable logistic regression and proportional odds models.

Main Outcome Measures  Association of CMV reactivation with prolonged hospital length of stay or death.

Results  The primary composite end point of continued hospitalization (n = 35) or death (n = 10) by 30 days occurred in 45 (35%) of the 120 patients. Cytomegalovirus viremia at any level occurred in 33% (39/120; 95% confidence interval [CI], 24%-41%) at a median of 12 days (range, 3-57 days) and CMV viremia greater than 1000 copies/mL occurred in 20% (24/120; 95% CI, 13%-28%) at a median of 26 days (range, 9-56 days). By logistic regression, CMV infection at any level (adjusted odds ratio [OR], 4.3; 95% CI, 1.6-11.9; P = .005) and at greater than 1000 copies/mL (adjusted OR, 13.9; 95% CI, 3.2-60; P < .001) and the average CMV area under the curve (AUC) in log₁₀ copies per milliliter (adjusted OR, 2.1; 95% CI, 1.3-3.2; P < .001) were independently associated with hospitalization or death by 30 days. In multivariable partial proportional odds models, both CMV 7-day moving average (OR, 5.1; 95% CI, 2.9-9.1; P < .001) and CMV AUC (OR, 3.2; 95% CI, 2.1-4.7; P < .001) were independently associated with a hospital length of stay of at least 14 days.

Conclusions  These preliminary findings suggest that reactivation of CMV occurs frequently in critically ill immunocompetent patients and is associated with prolonged hospitalization or death. A controlled trial of CMV prophylaxis in this setting is warranted.

     

Emergency transport of critically ill children: stabilisation before departure.

OBJECTIVE: To provide up-to-date practical information, relevant to Australian conditions and practice, on stabilising the condition of critically ill children who need transport to a paediatric hospital. DATA SOURCES AND SELECTION: Information on current resuscitation practice was sought from relevant original articles and reviews in the recent medical literature, from textbooks and monographs published in the last 10 years. DATA SYNTHESIS AND CONCLUSIONS: A recent study found that 47% of 100 children who needed emergency interhospital transfer experienced problems which should have been preventable by greater availability to referring doctors of information on pretransport stabilisation of critically ill children. Hypoventilation, hypoxaemia and hypotension are commonly found in critically ill children before transport, as are difficulties with endotracheal tube care, sedation and analgesia. Mild physiological disturbances are likely to become severe and life-threatening during transfer unless they are corrected before departure. Early discussion of the child's problems and the transfer plan with senior staff at the nearest paediatric intensive care unit may be helpful in planning the pre-transfer resuscitation.     

Outcome of critically ill patients undergoing interhospital transfer

OBJECTIVE: To quantify the morbidity and mortality associated with acute interhospital transfer of critically ill patients requiring intensive care (ICU) services. DESIGN: Three-year (1 July 1996-30 June 1999) retrospective case-control study based on review of patients' medical records. SETTING: Metropolitan hospitals in Melbourne, Victoria. PARTICIPANTS: 73 (of 75) consecutive, critically ill patients from one metropolitan teaching hospital who were transferred to other hospitals because ICU services were not available. OUTCOME MEASURES: Primary endpoints included inhospital mortality and length of stay in ICU and hospital. Secondary endpoints included time from study entry to ICU admission and the change in predicted mortality risk after resuscitation and transfer to ICU (inter- or intrahospital transfer). RESULTS: The Transfer Group experienced a significant delay in admission to ICU (5.0 [4.0-6.0] v 3.0 [2.0-5.5] hours; P=0.001), and a longer stay in ICU (48 [33-111] v 44 [25-78] hours; P=0.04), and hospital (10 [3-14] v 6 [3-13] days; P=0.02). Hospital mortality in the Transfer Group (24.7%) was not statistically different from that in the Control Group (17.8%; P= 0.41; OR, 1.5; 95% CI, 0.68-3.4). CONCLUSION: Acute interhospital transfer is associated with a delay in ICU admission and a longer stay in ICU and hospital, but no statistically significant difference in mortality. A study of over 300 patient transfers would be required to clarify the morbidity and mortality risk of acute interhospital transfer.