连续性肾脏替代疗法对重症脓毒症患者免疫功能的影响

目的：分析连续性肾脏替代疗法对重症脓毒症患者机体免疫功能及血清炎症介质水平的影响。方法：随机选取2017年4月~2019年1月收治的重症脓毒症患者150例,根据治疗方案不同分为常规组及治疗组,每组75例。常规组患者接受常规治疗,治疗组患者在常规治疗基础上接受连续性肾脏替代疗法治疗。比较两组患者免疫功能、炎症介质水平、临床疗效、细胞增殖。结果：治疗组患者CD3+、CD4+、CD4+/CD8+值均高于常规组（P＜0.05）。治疗组患者降钙素、C反应蛋白、白细胞介素-6水平均低于常规组（P＜0.05）。治疗组患者临床疗效优于常规组,差异有统计学意义（P＜0.05）。治疗后,治疗组患者细胞增殖率高于常规组（P＜0.05）。结论：连续性肾脏替代疗法能明显提升重症脓毒症患者机体免疫功能,降低炎症介质水平,提升免疫功能。     

老年重症脓毒症患者树突状细胞的功能变化

目的 初步探讨老年脓毒症患者树突状细胞(DC)的功能变化.方法取广州军区广州总医院干部内科及内科重症监护病房(NICU)同一时间收治的老年患者共20例,排除既往有恶性肿瘤、血液系统疾病、免疫性疾病、干扰免疫功能药物治疗史的患者,按美国胸科医师协会/危重病医学会的定义分为非脓毒症组(A组)、脓毒症组(B组)、严重脓毒症组(C组)、脓毒症休克组(D组);分别分离每例患者的外周血单个核细胞(PBMC),在体外用人重组粒一巨噬细胞集落刺激因子(GM-CSF)及白细胞介素4(IL-4)培养10 d后,倒置显微镜、扫描电镜以及流式细胞仪鉴定,采用配对t检验比较培养前后各组细胞表面标志物的变化,并使用MTT比色法观察各组患者树突状细胞在体外刺激同种异体T淋巴细胞反应的能力.结果 四组患者的外周血单个核细胞在体外经组合细胞因子培养后均可分化为具有典型树突状形态的细胞,培养后细胞表面CD40,CD80,CD86及HLA-DR的表达较培养前明显增高,分别为(43.2±12.5)%/(27.3±9.3)%、(31.4±10.1)%/(22.5±8.7)%、(39.3±15.7)%/(21.9±7.7)%及(75.4±25.6)%/(58.7±16.7)%;四组患者培养后获得的树突状细胞体外刺激同种异体T淋巴细胞反应的能力(刺激指数)分别为(23.3±7.9)、(18.9±8.3)、(11.4±5.1)、(5.5±3.7),随患者脓毒症严重程度的增加而减低,其中D组树突状细胞体外刺激同种异体T淋巴细胞反应的能力最低.结论老年脓毒症患者随着脓毒症严重程度的增加,其树突状细胞的免疫功能逐渐减退.     

蛋白酶抑制剂对重症脓毒症患者的疗效及作用机制

细胞因子在脓毒症的病理生理过程中起决定性作用。本研究通过观察乌司他丁对重症脓毒症患者的疗效和安全性及其对细胞因子的影响,以探讨其作用机制。     

老年脓毒症患者甲状腺激素水平变化与临床意义

目的 探讨老年脓毒症患者甲状腺激素水平的变化及其与预后的关系.方法140例老年脓毒症患者,分别进行APACHE Ⅱ评分与SIRS评分,根据患者是否发生多器官功能不全综合征(MODS)及预后分为2组,比较其甲状腺激素的水平.结果老年脓毒症患者病情严重者,血清游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)下降明显,APACHE Ⅱ评分和SIRS评分升高明显(P<0.05或0.01),死亡组FT3、FT4水平明显低于存活组(均P<0.05).结论炎症反应和细胞因子对甲状腺轴具有一定影响,甲状腺激素水平可以反映老年脓毒症患者的病情,病情越重,甲状腺激素水平越低,越易发生MODS而死亡.     

重症监护病房脓毒症患者降钙素原的临床研究

目的　探讨血浆降钙素原 (PCT)在重症监护病房 (ICU)脓毒症患者发病过程中的变化及其诊断价值。方法　采用双抗夹心免疫荧光发光法定量分析 36例脓毒症患者血浆中PCT含量和动态变化 ,并与 2 4例非脓毒症患者及 2 0例健康人对照分析。结果　脓毒症患者中首次测定PCT含量显著高于非脓毒症组和对照组 (P <0 0 1)。动态观察发现PCT随着病情好转逐渐降至正常 ,而 11例死亡患者的PCT因病情恶化呈上升趋势。结论　PCT定量分析是一种快速、灵敏的检测手段 ,对于尽早发现脓毒症、判断其病情及预后具有重要价值。     

mNUTRIC评分对老年脓毒症患者发生慢重症的预测价值

目的:探讨改良版危重症营养风险（the modified NUTrition Risk in the Critically ill, mNUTRIC）评分对老年脓毒症患者发生慢重症（chronic critical illness, CCI）的预测价值。方法:前瞻性观察性研究2019年8月至2021年1月南部战区总医院...     

严重脓毒症患者红细胞免疫粘附功能变化及其临床意义

目的：了解严重脓毒症患者红细胞免疫粘附功能的变化，探讨红细胞免疫粘附功能在严重脓毒症向多脏器功能失常综合征（ＭＯＤＳ）转变中的意义。方法：采用酵母菌致敏法测定２０例严重脓毒症患者和２０例正常人的红细胞免疫粘附功能，以红细胞Ｃ３ｂ（ＲＢＣＣ３ｂ）受体花环率和红细胞免疫复合物（ＲＢＣＩＣ）花环率作判断指标。结果：严重脓毒症患者ＲＢＣＣ３ｂ受体花环率明显低于正常对照组（０．１０５±０．０３２比０．１７４±０．０６５，Ｐ＜０．０１），ＲＢＣＩＣ花环率明显高于正常对照组（０．０９１±０．０３１比０．０４１±０．０２５，Ｐ＜０．０１）；严重脓毒症患者发生ＭＯＤＳ组ＲＢＣＣ３ｂ受体花环率明显低于病情好转组（０．０６８±０．０２３比０．１４２±０．０３２，Ｐ＜０．０１），ＲＢＣＩＣ花环率明显高于病情好转组（０．１３４±０．０３２比０．０６４±０．０３２，Ｐ＜０．０１）。结论：严重脓毒症患者红细胞免疫粘附功能明显下降，并与病情的转归有密切关系     

大剂量联合应用免疫球蛋白和抗生素提高严重脓毒症患者术后存活率

最近西班牙和阿根廷学者选取7所教学医院中的外科重症监护治疗病房(SICU)患者进行了一项前瞻、随机、双盲的对照研究,评价大剂量静脉注射浓缩IgM抗体(IVIG)对腹部脓毒症辅助治疗的效果。纳入对象包括发病后24h内进入SICU的严重脓毒症和由腹腔器官感染所致的脓毒性休克患者。按随机原则分组,实验组给予抗生素+7ml·kg-1·d-1IVIG进行治疗,对照组给予抗生素+相同剂量的人血白蛋白。在入选的56例患者中,总体病死率为37.5%,其中20例休克患者的病死率为     

血糖变化对ICU脓毒症患者预后的影响

目的:探讨血糖变化对ICU脓毒症患者预后的影响。方法:回顾性分析2017年1月—2019年12月期间收治的脓毒症患者480例。收集患者的APACHEⅡ,SOFA,SIRS,GCS评分及临床实验室检查指标。根据离开ICU时的预后分为存活组及死亡组。采用受试者工作特征曲线分析各指标在预测脓毒症死亡的敏感度、特异度以及最大约登指数下的界值。对不同血糖波动的患者进行生存分析。结果:存活组和死亡组的临床指标[APACHEⅡ、SOFA、SIRS、GCS、PCT、IL-6、BNP、CRP、PLT、ALB、BUN、CREA、P、PT、APTT、INR、DD、FDP、心率、呼吸、收缩压、Δ血糖(最高血糖与最低血糖差值)、pH、PaO_(2)/FiO_(2)(校正后)、Lac]进行比较,差异有统计学意义(P<0.05)。运用受试者工作特征曲线对脓毒症死亡的预测价值进行分析发现APACHEⅡ,SOFA,Lac及Δ血糖四个指标的曲线下面积接近或超过0.7。以Δ血糖的3.275 mmol/L对患者分组,两组生存率不同(P<0.001)。结论:血糖波动大于3.275 mmol/L时的患者的病死率明显升高;疾病严重程度越高,血糖波动越大。     

集束化护理干预对严重脓毒症患者早期脱机及睡眠质量的影响

目的:探讨严重脓毒症患者予以集束化护理干预对早期脱机及睡眠质量的影响.方法:选取2016 年12月12日至2018年11月19日遵义医科大学第五附属(珠海)医院重症医学科收治的严重脓毒症患者63 例作为研究对象,按照抓阄法分为对照组(n=31)和观察组(n=32).对照组采用常规护理,观察组在常规护理的基础上联合集束化护理.比较2组的护理效果.结果:1)对照组的脱机失败率为19.35%,比观察组的3.43%高,差异有统计学意义(P<0.05);2)对照组的机械通气时间和ICU入住时间,均较观察组长,差异有统计学意义(P<0.05);3)观察组的睡眠质量评分比对照组低,差异有统计学意义(P<0.05).结论:严重脓毒症患者予以集束化护理干预,有助于其尽早脱机,改善睡眠质量.     

外科手术后全身性炎性反应综合征和严重脓毒症患者血浆血管加压素浓度及其相关因素分析

目的：研究外科手术后全身性炎性反应综合征（SIRS）、严重脓毒症患者血浆血管加压素（AVP）浓度的变化,及其与动脉血气、血电解质、血流动力学参数的关系。方法：将2009年3月—2010年3月间收入外科监护病房（SICU）的患者,依据收入SICU24h内临床过程分为对照组、SIRS组、严重脓毒症组3组,每组10例。分别记录各组人口统计学资料、临床信息,测定动脉血气,入SICU24h内血浆AVP浓度及相应的血流动力学指标、中心静脉压、血生物化学检查数据。结果：严重脓毒症组患者的血浆AVP浓度显著高于对照组和SIRS组（1 300.59±87.49pg.mL-1比266.33±12.03pg.mL-1,397.59±18.32pg.mL-1）（P〈0.001）。血浆AVP浓度与对照组患者血Na＋值、Ca2＋值呈正相关（r=0.742,P=0.014;r=0.821,P=0.004）,仅与SIRS组患者血Na＋值呈正相关（r=0.727,P=0.017）,而与严重脓毒症组患者血Na＋值、Ca2＋值无相关（r=0.409,P=0.241）。血浆AVP浓度与严重脓毒症组患者平均动脉压（MAP）呈正相关（r=0.544,P=0.015）,与心率（HR）呈负相关（r=-0.706,P=0.023）,而与对照组及SIRS组患者的MAP及HR均无相关性（r=0.363,P=0.302;r=0.454,P=0.188）。结论：对照组与SIRS组患者血浆AVP浓度变化与血Na＋变化相关,而在严重脓毒症患者中AVP浓度仅与MAP相关,提示血流动力学的不稳定刺激了血浆AVP的分泌而发挥升压作用。     

Severe Sepsis in Do-not-resuscitate Patients: Intervention and Mortality Rates

Background

Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis.

Objective

Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality.

Methods

Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009–2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status.

Results

In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9–44.9%; 64.0% vs. 24.9%, 95% CI 25.1–53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48–6.17; OR 3.80, 95% CI 1.88–7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45–3.15).

Conclusion

In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.     

脓毒症患者凝血功能的改变及其意义

目的研究脓毒症患者凝血功能的变化及其意义。方法按照脓毒症诊断标准,将76例患者分为生存组50例和死亡组26例,一经确诊即抽血检查凝血四项、D-二聚体浓度、血小板及白细胞计数。结果与生存组比较,死亡组的APTT、PT显著延长,D-二聚体浓度、白细胞计数显著增高,纤维蛋白原浓度、血小板计数显著降低（P〈0．05）。结论脓毒症患者存在凝血系统功能紊乱,其中D-二聚体浓度、血小板计数与脓毒症的严重程度有显著相关性,对判断患者的预后及评估病情、严重程度有重要意义。     

集束化治疗对严重脓毒症患者循环灌注和乳酸清除率的影响

目的:研究集束化治疗对综合ICU严重脓毒症患者循环灌注和乳酸清除率的影响.方法:将2007年10月至2009年12月我科收治的18岁以上严重脓毒症患者63例随机分配入集束化治疗组和对照组,观察两组患者心率(HR)、血压(BP)、中心静脉压(CVP)、中心静脉血氧饱和度(ScvO2)、动脉血乳酸(LAC)及乳酸清除率的变化.结果:集束化治疗组HR、SBP和DBP与对照组同期比较差异无统计学意义,但集束化治疗组入选后6 h CVP和ScvO2明显高于对照组同期,LAC明显低于对照组同期(P＜0.05),入选后24 h CVP和ScvO2仍高于对照组同期,LAC仍低于对照组同期,但仅LAC的变化差异具有统计学意义(P ＜ 0.05),集束化治疗组6 h和24 h乳酸清除率均明显高于对照组同期,差异具有统计学意义(P＜0.01).结论:集束化治疗可以明显改善严重脓毒症患者早期的循环灌注.     

Complement Activation in Emergency Department Patients With Severe Sepsis

Objectives: This study assessed the extent and mechanism of complement activation in community‐acquired sepsis at presentation to the emergency department (ED) and following 24 hours of quantitative resuscitation. Methods: A prospective pilot study of patients with severe sepsis and healthy controls was conducted among individuals presenting to a tertiary care ED. Resuscitation, including antibiotics and therapies to normalize central venous and mean arterial pressure (MAP) and central venous oxygenation, was performed on all patients. Serum levels of Factor Bb (alternative pathway), C4d (classical and mannose‐binding lectin [MBL] pathway), C3, C3a, and C5a were determined at presentation and 24 hours later among patients. Results: Twenty patients and 10 healthy volunteer controls were enrolled. Compared to volunteers, all proteins measured were abnormally higher among septic patients (C4d 3.5‐fold; Factor Bb 6.1‐fold; C3 0.8‐fold; C3a 11.6‐fold; C5a 1.8‐fold). Elevations in C5a were most strongly correlated with alternative pathway activation. Surprisingly, a slight but significant inverse relationship between illness severity (by sequential organ failure assessment [SOFA] score) and C5a levels at presentation was noted. Twenty‐four hours of structured resuscitation did not, on average, affect any of the mediators studied. Conclusions: Patients with community‐acquired sepsis have extensive complement activation, particularly of the alternative pathway, at the time of presentation that was not significantly reversed by 24 hours of aggressive resuscitation. ACADEMIC EMERGENCY MEDICINE 2010; 17:353–359 © 2010 by the Society for Academic Emergency Medicine     

Impact of Sepsis Bundle Strategy on Outcomes of Patients Suffering from Severe Sepsis and Septic Shock in China

Background

It is well known that poor sepsis outcomes are related to delays in diagnosis and treatment.

Objectives

The aim of this study was to compare the mortality rate between two groups of patients, one group presenting before and one group presenting after implementation of the Surviving Sepsis Campaign (SSC) sepsis performance improvement bundles in the Emergency Department (ED).

Methods

This was a prospective study. The studied population included severe sepsis and septic shock patients entered in the SSC database who were admitted to the ED between June 2008 and December 2009. Patients were divided into two groups based on when they presented to the ED. Key treatment interventions, admission to the intensive care unit, and in-hospital mortality were compared. In addition, a survey was completed by the treating physicians to identify reasons for failures to comply with indicators.

Results

One hundred ninety-five (195) patients with severe sepsis and septic shock were enrolled in the study. Mortality was significantly higher at 44.8% in the baseline group (Group 1) compared to 31.6% in the group studied after the SSC protocol was instituted (Group 2) (p < 0.05). Compliance with all elements of the sepsis resuscitation bundle was 1% in Group 1 and 9% in Group 2 (p < 0.05). Compliance with all elements of the management bundle was 1% in Group 1 and 12.8% in Group 2. The most frequently reported reasons by physicians for failure to comply with the bundles were: “did not think it was needed” and “unsure of reason.”

Conclusion

The results revealed a significant drop in mortality after implementing the SSC protocol and sepsis performance improvement bundles in the ED. The barriers to implementing sepsis guidelines are knowledge, attitude, and behavioral barriers.     

Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Background

Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel.

Objective

This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated.

Methods

We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study.

Results

Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14–8.88; p = 0.040).

Conclusions

This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality.     

中性粒细胞膜表面与胞内热休克蛋白70含量比值和严重脓毒症患者预后的相关分析

目的:探讨外周血中性粒细胞膜表面与胞内热休克蛋白70(heat shock protein 70,HSP70)含量的比值对严重脓毒症患者病情及预后的影响.方法:采用前瞻性随机对照的临床试验设计,选择上海市浦东新区公利医院急诊科确诊的严重脓毒症患者60例作为研究组,同期40例健康人群作为健康对照组.采用流式细胞术检测入急诊科24 h内研究对象外周血中性粒细胞膜表面与胞内HSP70表达水平,同时在进入急诊室24 h内进行简化急性生理学评分Ⅱ(simplified acute physiology score Ⅱ,SAPSⅡ),采用集束化治疗策略治疗,治疗28 d后判定患者的预后,比较研究组内存活患者(存活亚组)与病死患者(病死亚组)的中性粒细胞膜表面与胞内HSP70含量的比值和SAPSⅡ,并对2组中性粒细胞膜表面与胞内HSP70含量的比值和SAPSⅡ进行相关分析.结果:研究组患者中性粒细胞膜表面与胞内HSP70含量的比值显著高于对照组[(0.76±0.53)比(0.08±0.10)],P＜0.01.研究组60例患者中存活42例,病死18例,存活亚组中性粒细胞膜表面与胞内HSP70含量的比值显著低于病死亚组[(0.68±0.13)比(0.83±0.18)],P＜0.05;存活亚组SAPSⅡ显著低于病死亚组[(48.30±8.15)比(68.30±18.58)],P＜0.05.相关性分析显示,中性粒细胞膜表面与胞内HSP70含量的比值与SAPSⅡ呈显著正相关(r=0.295,P=0.01).结论:外周血中性粒细胞膜表面与胞内热休克蛋白HSP70含量的比值可反映严重脓毒症患者病情及预后.