综合重症监护病房和重症监护网建设探讨

综合ICU床位数以6～12张病床为宜。医生人数与ICU床位数比例及护士人数与ICU床位数之比至少应该分别接近1:1和2．5:1。管理模式可选封闭式或半封闭式。至少应配备一间单间病房。床旁临时心脏起搏术、持续血液净化、肠外营养支持、疾病危重程度评分、镇静及其评分,所有ICU均应该开展。呼吸机,三级医院应每床1台,二级医院也应尽量接近此要求,且最好是具备呼吸功能监测的呼吸机,同时应配备一定数量的无创呼吸机和便携式呼吸机。纤维支气管镜至少配备1套。持续肾脏替代治疗仪应力求配置。滴注泵和微量注射泵应分别达到每床1台和2台,肠内营养注射泵最好能每床1台。重症监护网应具备有效的纵向与横向联系。     

呼吸内科重症监护病房机械通气患者医院感染的特点与管理

目的了解呼吸重症监护病房机械通气患者医院感染的特点，探讨预防感染的措施。方法采集呼吸重症监护病房57例发生医院感染患者的痰液标本进行细菌培养和药敏试验，分析并比较机械通气患者与同期非机械通气患者下呼吸道分泌物病原菌菌株的分布情况及两组患者常用抗生素对G^-菌的耐药率。结果呼吸重症监护病房57例医院感染患者中，24例机械通气患者感染G^-菌株128株、G^＋菌株26株，33例非机械通气患者感染G^-菌株35株、G^＋菌株16株；铜绿假单胞菌、鲍曼不动杆菌及金黄色葡萄球菌为感染的主要菌种；机械通气组常用抗生素物对G^-菌耐药率均显著高于非机械通气组（P〈0．05）。结论呼吸重症监护病房中的机械通气患者易发生医院感染，且菌株的耐药率高；护理上应重视病房管理、医务人员管理和相应的消毒隔离措施，尤其加强对机械通气患者的护理，以降低医院感染的发生率。     

内科与专科重症监护病房有创机械通气患者常见呼吸机报警原因的比较分析

目的 分析内科重症监护病房(ICU)与专科ICU有创机械通气患者常见呼吸机报警原因及相关处理策略.方法 选择中国医科大学附属第一医院2011年1月至12月内科ICU及专科ICU收治的有创机械通气患者,对需由一线医生、呼吸治疗师及上级医师或由内科ICU会诊处理的呼吸机报警、报警原因进行分析比较.结果 内科ICU 59例患者共发生375次呼吸机报警,前3位报警参数的发生率为气道高压21.87％、高潮气量15.73％、高分钟通气量14.13％；专科ICU 249例患者共发生403次呼吸机报警,前3位报警参数的发生率为气道高压32.51％、气道低压15.38％、高呼吸频率10.42％.内科ICU中气道高压、气道低压报警率明显低于专科ICU(21.87％比32.51％,8.53％比15.38％,均P＜0.01),高分钟通气量、高潮气量报警率高于专科ICU(14.13％比7.20％,15.73％比9.68％,P＜0.01和P＜0.05).内科ICU前3位报警原因为雾化吸入、痰液堵塞、氧电池过期,专科ICU为痰液堵塞、呼吸窘迫、管道漏气和氧电池过期；内科ICU由于痰液堵塞、管道因素(气管插管位置改变、管道积水)、报警参数设置不当为原因的报警率明显低于专科ICU(10.93％比17.12％,1.87％比4.47％,1.33％比3.72％,1.60％比3.97％,均P＜0.05),由于雾化吸入导致的呼出端过滤器严重堵塞、高潮气量、高分钟通气量为原因的报警率明显高于专科ICU(18.93％比3.97％,P＜0.01).结论 内科ICU及专科ICU均应了解各科呼吸机报警特点,有针对性地预防,及时发现问题并进行相关处理.     

综合重症监护病房呼吸机相关性肺炎监测分析

目的了解综合重症监护病房(ICU)呼吸机相关性肺炎(VAP)感染率、危险因素、病原菌分布及其耐药情况,探讨有针对性的预防控制措施。方法 2009年1月-12月综合ICU共收治患者447例,采用主动监测方法,由ICU医务人员和专职人员每日对综合ICU病房住院时间≥48 h且撤停机械通气后48 h内的患者进行VAP监测。结果 447例患者中住院时间≥48 h的患者168例,96例患者使用呼吸机,使用呼吸机时间182 d,ICU住院总日数1 339 d,发生VAP 17例,呼吸机使用率13.59%,VAP感染率93.4例/1 000机械通气日,根据平均病情严重程度(ASIS法)调整后的VAP感染率为2.38%。呼吸机使用方式与VAP发生有关联。检出病原菌18株,全部为Gˉ杆菌,其中鲍曼不动杆菌4株,对包括硫霉素、氨曲南在内的多种抗菌药物耐药。结论综合ICU病房VAP感染率为2.38%,呼吸机使用不当是VAP的危险因素,VAP致病菌为Gˉ杆菌,其中鲍曼不动杆菌耐药率达100%,并呈多重耐药性;抗生素使用时间过长,预防性使用不当是致病菌产生多重耐药的重要原因。     

重症监护病房患者机械通气相关事件监测结果与分析

目的了解重症监护病房（ICU）各类机械通气相关事件（VAE）的发生情况，为研究干预措施提供参考依据。方法采用前瞻性调查方法对2013年4月-7月所有新入院在ICU使用机械通气时间〉2d、年龄≥18岁的49例患者进行留置机械通气所发生的有关事件监测，并对49例患者VAE发生率进行分析比较。结果49例患者中共发生VAE16例，发生率为32．6％，其中包括呼吸机相关并发症3例、与感染有关的呼吸机相关并发症8例、疑诊呼吸机相关肺炎4例和拟诊呼吸机相关肺炎1例。与未发生VAE的患者相比，发生VAE的患者年龄和急性生理学及慢性健康状况Ⅱ评分更高，机械通气时间和住院时间更长，预后更差，抗菌药物使用率更高，差异均有统计学意义（P〈0．05）。结论VAE监测客观、简便，可以为患者制定VAE预防干预措施提供依据。     

重症监护病房内上消化道出血的临床分析

目的探讨重症监护患者上消化道出血的主要因素,以及并发上消化道出血与病死率的关系。方法回顾分析重症监护病房(ICU)并发上消化道出血(急性非静脉曲张性上消化道出血)急危重病患者252例,按发病后上消化道出血发生时间与病死率的关系进行比较分析,并根据治疗超过3 d后继发感染和上消化道出血与病死率的关系进行比较分析。结果发生上消化道出血的主要疾病为脑血管意外和重度颅脑损伤;上消化道出血出现时间愈早(分别为<1 d、1~3 d、>3 d)死亡率愈高(P<0.05);治疗超过3 d后出现继发感染者上消化道出血发生率增加(P<0.05),其中呼吸机相关性肺炎35例,占83.33%,且继发感染伴上消化道出血患者病死率增加(P<0.05)。结论ICU患者出现上消化道出血提示预后不良;及时发现上消化道出血,防治感染尤其是呼吸机相关性肺炎等对ICU患者预后有重要意义。     

早期渐进性活动训练促进重症监护病房机械通气患者神经肌肉功能恢复的效果观察

目的探讨早期渐进性活动训练促进重症监护病房(intensive care unit,ICU)机械通气患者神经肌肉功能恢复的效果。方法将98例ICU机械通气患者随机分为实验组和对照组,每组各49例,实验组患者在镇静中断后每天实施两次早期渐进性活动训练;对照组患者每天两次接受床上被动或主动全范围关节活动。采用功能独立性评分表(functional independence measure,FIM)对两组患者分别在拔除气管插管时、转出ICU时和出院时进行评定,并比较两组患者住院期间并发症发生情况。结果实验组患者在拔除气管插管时FIM总分及自理能力、括约肌控制、转移方面得分明显高于对照组,两组比较,均P<0.05,差异具有统计学意义;实验组患者在转出ICU时和出院时在FIM总分及5个方面得分明显高于对照组,两组比较,均P<0.05,差异具有统计学意义。实验组患者呼吸机相关性肺炎(ventilator associated pneumonia,VAP)、下肢深静脉栓塞(deep vein thrombosis,DVT)的发生率明显低于对照组,两组比较,均P<0.05,差异具有统计学意义。结论早期渐进性活动训练能促进ICU机械通气患者神经肌肉功能恢复,并可降低相关并发症的发生率。     

呼吸内科重症监护病房机械通气患者医院感染的特点与管理

目的了解呼吸重症监护病房机械通气患者医院感染的特点,探讨预防感染的措施。方法采集呼吸重症监护病房57例发生医院感染患者的痰液标本进行细菌培养和药敏试验,分析并比较机械通气患者与同期非机械通气患者下呼吸道分泌物病原菌菌株的分布情况及两组患者常用抗生素对G-菌的耐药率。结果呼吸重症监护病房57例医院感染患者中,24例机械通气患者感染G-菌株128株、G 菌株26株,33例非机械通气患者感染G-菌株35株、G 菌株16株;铜绿假单胞菌、鲍曼不动杆菌及金黄色葡萄球菌为感染的主要菌种;机械通气组常用抗生素物对G-菌耐药率均显著高于非机械通气组(P<0.05)。结论呼吸重症监护病房中的机械通气患者易发生医院感染,且菌株的耐药率高;护理上应重视病房管理、医务人员管理和相应的消毒隔离措施,尤其加强对机械通气患者的护理,以降低医院感染的发生率。     

呼吸内科重症监护病房机械通气患者医院感染的特点与管理

目的 了解呼吸重症监护病房机械通气患者医院感染的特点,探讨预防感染的措施.方法 采集呼吸重症监护病房57例发生医院感染患者的痰液标本进行细菌培养和药敏试验,分析并比较机械通气患者与同期非机械通气患者下呼吸道分泌物病原菌菌株的分布情况及两组患者常用抗生素对G-菌的耐药率.结果 呼吸重症监护病房57例医院感染患者中,24例机械通气患者感染G-菌株128株、G 菌株26株,33例非机械通气患者感染G-菌株35株、G 菌株16株;铜绿假单胞菌、鲍曼不动杆菌及金黄色葡萄球菌为感染的主要菌种;机械通气组常用抗生素物对G-菌耐药率均显著高于非机械通气组(P＜0.05).结论 呼吸重症监护病房中的机械通气患者易发生医院感染,且菌株的耐药率高;护理上应重视病房管理、医务人员管理和相应的消毒隔离措施,尤其加强对机械通气患者的护理,以降低医院感染的发生率.     

Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses. Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients, with a wide range of variable prevalence rates of up to 50%-60% in some studies. This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit(ICU). The original disease that caused pleural effusion can be the exact caus...     

重症监护病房患者的心理压力分析与护理

目的研究重症监护病房(ICU)患者的心理压力因素及其心理疏导护理。方法采用ICU病人心理护理调查量表对入住ICU的清醒患者进行心理调查,对61例ICU患者的心理压力因素进行了测定,针对患者的不良心理反应进行心理疏导工作。2周后,对其中52例患者进行第2次调查评估。结果ICU患者常见的环境压力因子为:害怕死亡、疼痛、有插管在鼻子或口中、不知道在ICU住多少天、思念配偶或恋人及担心费用问题等。绝大多数ICU患者存在不同程度的抑郁、焦虑等不良心理反应。结论针对ICU患者的心理压力因素及不良心理反应进行心理疏导工作,有助于患者的配合治疗及顺利康复。     

ICU患者在机械通气中应用异丙酚镇静的观察与护理

目的观察异丙酚在ICU机械通气患者的镇静效果及护理.方法选择40例在ICU接受气管插管、机械通气患者按住院号单双分成2组,观察组20例在上机后使用异丙酚,对照组20例给与其它镇静剂,观察2组机械通气时间、在ICU住院的时间.结果观察组的机械通气时间、在ICU住院时间,明显少于对照组（P＜0.01,P＜0.05）.结论异丙酚用于ICU机械通气患者的镇静不仅能安全有效镇静,而且能减少机械通气时间和在ICU住院时间,使用异丙酚应严格无菌技术操作以防止发生医源性感染.     

机械通气患者胸腔积液分布形态与精确定量的研究

目的了解机械通气患者胸腔内积液分布的形态特征,为利用超声对胸腔积液进行精确定量建立一个新的方法。方法37例合并胸腔积液的机械通气患者于呼气末进行胸部CT扫描,利用软件定量分析CT图像,获取胸腔积液量(V)、积液高度(H)、中间积液层的液体厚度(T)及面积(S);建立V与H、T、S的一元和二元回归方程,比较它们估算积液量的精确度。结果机械通气患者胸腔内积液的体积分布形态近似呈线性,左右侧相似;以S和H建立的二元线性回归方程估算积液量与实际值的相关性最好(r=0.958,P<0.001),精确度最好[与实际值误差的95%分布范围为(-3±137)mL]。结论利用机械通气患者胸腔积液的高度和中间积液层的面积可以非常精确地估算积液量,为临床应用超声对胸腔积液进行精确定量提供了新方法。     

Inspiratory muscle training in intensive care unit patients: An international cross-sectional survey of physiotherapist practice

BackgroundInspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated.ObjectivesThe objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education.MethodOnline cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU.ResultsOf 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules.ConclusionIn this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice.     

ICU机械通气相关下呼吸道感染患者的病原菌分析

目的　分析ICU机械通气引发下呼吸道院内感染病原体的构成及其耐药情况。方法　对 1998年 1月～ 2 0 0 1年 12月间ICU收住的 177例机械通气引发下呼吸道院内感染患者的感染菌及耐药情况进行回顾性调查分析。结果　检出感染菌 383株 ,其中革兰阴性细菌 (G-菌 ) 2 16株 (5 6 .4 % ) ,革兰阳性细菌 (G 菌 ) 117株(30 .5 % ) ,真菌 5 0株 (13.1% )。不少菌株的药敏结果显示多重耐药。结论　ICU机械通气引发下呼吸道院内感染病原体以G-菌为主 ,其药敏试验呈多重耐药 ,临床应重视病菌的准确鉴定 ,合理使用抗生素     

Predicting mortality in intensive care unit patients infected with Klebsiella pneumoniae: A retrospective cohort study

IntroductionAlthough several models to predict intensive care unit (ICU) mortality are available, their performance decreases in certain subpopulations because specific factors are not included. Moreover, these models often involve complex techniques and are not applicable in low-resource settings. We developed a prediction model and simplified risk score to predict 14-day mortality in ICU patients infected with Klebsiella pneumoniae.MethodologyA retrospective cohort study was conducted using data of ICU patients infected with Klebsiella pneumoniae at the largest tertiary hospital in Northern Vietnam during 2016–2018. Logistic regression was used to develop our prediction model. Model performance was assessed by calibration (area under the receiver operating characteristic curve-AUC) and discrimination (Hosmer-Lemeshow goodness-of-fit test). A simplified risk score was also constructed.ResultsTwo hundred forty-nine patients were included, with an overall 14-day mortality of 28.9%. The final prediction model comprised six predictors: age, referral route, SOFA score, central venous catheter, intracerebral haemorrhage surgery and absence of adjunctive therapy. The model showed high predictive accuracy (AUC = 0.83; p-value Hosmer-Lemeshow test = 0.92). The risk score has a range of 0–12 corresponding to mortality risk 0–100%, which produced similar predictive performance as the original model.ConclusionsThe developed prediction model and risk score provide an objective quantitative estimation of individual 14-day mortality in ICU patients infected with Klebsiella pneumoniae. The tool is highly applicable in practice to help facilitate patient stratification and management, evaluation of further interventions and allocation of resources and care, especially in low-resource settings where electronic systems to support complex models are missing.     

儿童重症监护病房呼吸机相关性肺炎病原菌分布及耐药性分析

目的 分析儿童重症监护病房(PICU)呼吸机相关性肺炎(VAP)病原菌及耐药情况,为临床合理选用抗菌药物提供依据.方法 回顾性分析2008年1月至2010年6月武汉市儿童医院PICU收治的46例合并VAP患儿下呼吸道分泌物所分离出的细菌、真菌及其耐药性情况.结果 共分离出病原菌119株,革兰氏阴性(G-)杆菌、革兰氏阳性(G+)球菌和真菌分别占65.55%、13.45%和21.01%;前5位病原菌分别为鲍氏不动杆菌、大肠埃希氏菌、肺炎克雷伯氏菌、白色念珠菌及凝固酶阴性葡萄球菌.药敏结果显示,G-杆菌和G+球菌对临床常用抗菌药物均存在不同程度耐药性,多重耐药现象严重.G-杆菌对阿米卡星、环丙沙星、亚胺培南、美罗培南、头孢哌酮/舒巴坦、派拉西林/他唑巴坦较为敏感;G+球菌均对万古霉素、替考拉宁和利奈唑胺敏感;真菌普遍敏感.结论 VAP病原菌以G-杆菌为主且呈多重耐药性.临床上应对VAP进行规范性、连续性耐药性监测,并依据细菌病原学及耐药性合理选择抗菌药物,同时加强机械通气管理以及医院环境消毒,降低VAP发生率.

Abstract：

Objective To study the pathogenic bacteria strains with drug-resistance prevailing in patients with ventilator-associated pneumonia(VAP)in Pediatric Intensive Care Unit(PICU)in order to provide a reasonable guidance to the clinical use of suitable antibiotics.Method A retrospective clinical study in 46 patients with VAP was carried out in PICU of Wuhan Children's Hospital between January 2008 and June 2010.The prevalent strains of the pathogenic bacteria with drug-resistance isolated from lower respiratory tract by aspiration were analyzed.Results In total,119 pathogenic microbial strains were isolated including Gram-negative bacilli(G-,65.55%),fungi(21.01%)and Gram-positive cocci(G+,13.45%).Among pathogens,the most common pathogenic strains were Acinetobacter baummannii, Escherichia coli,Klebsiella pneumoniae,candida albicans and coagulase-negative staphylococci.Antibiotic susceptibility tests indicated that the situation of the multiple drug-resistances to antibiotics found in G- and G+ Was serious. Most of G- were sensitive to ciprofloxacin, amikacin, imipenem, meropenem,cefoperazone-sulbaetam and piperacillin-tazobactam.The G+ cocci were 100% susceptibility to vancomycin, teicoplanin and linezolid.Fungi were almost sensitive to all the anti-funaus agents. Conclusions The oredominant oathogens of VAP were G- bacilli,and their multiple drug-resistances to antibiotics were the serious problems.The monitoring of the drugresistance should be emphasized, and the option of antibiotics should depend on the antibiotic sensitivity test.     

Experiences with severe P. falciparum malaria in the intensive care unit

Objective: To review the clinical profiles and therapies instituted for patients with severe malaria admitted to an ICU.¶Design: Retrospective study.¶Setting: Internal ICU of a tertiary care centre.¶Patients and participants: Between January, 1992, and February, 1999, 104 patients with malaria were admitted to the General Hospital of Vienna. Sixty-nine patients suffered from Plasmodium falciparum malaria (66 %), seven of these were admitted to the ICU.¶Measurement and results: Seven patients were admitted to the ICU, of whom three died (4 % in hospital case-fatality rate). Four patients required mechanical ventilation because of respiratory insufficiency and adult respiratory distress syndrome (ARDS), of whom three died. Three patients were treated with inhaled nitric oxide (NO) and kinetic therapy; one patient required extracorporeal veno-venous oxygenation. All patients who died required haemofiltration because of acute renal failure.¶Conclusion: As P. falciparum is a potentially life-threatening disease, reliable criteria for ICU admission should be defined and risk factors identified. Early ICU monitoring should be attempted, especially under the following conditions: (1) lack of clinical response to anti-malarial treatment within 48 h and/or (2) any signs of neurological disturbance (hypoglycaemia excluded). Prospective multicentre trials and guidelines for supportive intensive care are urgently needed.