不同胃残余量对重症患者肠内营养的影响

目的:探讨不同胃残余量对重症患者肠内营养的影响。方法:将120例重症患者按胃残余量(GRV)临界值分为对照组和实验组各60例,对照组选择200 ml,实验组选择500 ml,两组均经鼻胃管通过喂养泵持续匀速输注肠内营养液,根据每隔4 h GRV监测的结果,调节输注速度,直到达到目标热卡;胃残余量低于临界值,增加或保持原输注速度;超过临界值,停止肠内营养;一旦恢复到临界值以下,以停止前的速度重新开始。比较两组营养达标率、反流和(或)误吸、吸入性肺炎发生率。结果:实验组营养达标率高于对照组(P0.01)。结论:GRV临界值选择500 ml比选择200 ml更有利于提高肠内营养达标率,不影响胃肠耐受性。     

肠内营养启动时机对重症急性胰腺炎预后影响的Meta分析

目的系统评价早期肠内营养(EEN)和延迟肠内营养(DEN)对重症急性胰腺炎(SAP)患者预后的疗效及安全性。方法截至2014年5月,计算机检索Pub Med、Ovid、Cochrane Library、Embase、Wan Fang、CNKI,收集肠内营养治疗SAP的临床随机对照试验(RCT)。按照Cochrane系统评价方法对纳入文献进行资料提取和质量评价,采用Rev Man 5.2软件对纳入的文献进行Meta分析。结果最终共纳入6个RCT,合计723例患者。Meta分析结果显示,EEN组其SAP患者病死率[OR=0.29,95%CI(0.13,0.65),P=0.003]、多器官功能障碍综合征(MODS)发生率[OR=0.48,95%CI(0.27,0.86),P=0.010]、胰腺感染[OR=0.35,95%CI(0.16,0.77),P=0.009]、胰腺外周感染发生率[OR=0.60,95%CI(0.38,0.95),P=0.030]及呼吸衰竭发生[OR=0.35,95%CI(0.16,0.77),P=0.009]明显优于DEN组患者,但是两组患者间外科手术干预[OR=0.58,95%CI(0.25,1.39),P=0.220]及肺炎发生率[OR=0.86,95%CI(0.54,1.37),P=0.530]比较,差异均无统计学意义。结论与DEN组相比,EEN可以降低病死率,MODS、呼吸衰竭、胰腺及胰腺外周感染的发生率,对SAP患者进行早期营养支持治疗,48 h内启动肠内营养可明显改善临床结局。     

经皮穴位电刺激对肠内营养病人胃肠功能影响的Meta分析

目的:系统评价经皮穴位电刺激对重症肠内营养病人胃肠功能的影响。方法:计算机检索中国知网、万方数据库、中国生物医学文献数据库、维普数据库、PubMed、EMbase、the Cochrane Library、Web of Science数据库中关于经皮穴位电刺激对重症肠内营养病人胃肠功能影响的随机对照试验,检索时限从建库至2023年5月31日,采用RevMan 5.4软件进行Meta分析。结果:共纳入11篇文献,涉及794例病人。Meta分析结果显示,经皮穴位电刺激组腹泻发生率[OR=0.49,95%CI(0.28,0.87),P=0.01]、消化道出血发生率[OR=0.20,95%CI(0.09,0.47),P=0.000 2]、腹胀发生率[OR=0.46,95%CI(0.23,0.90),P=0.02]及重症监护室(ICU)住院时间[MD=-2.56,95%CI(-3.87,-1.26),P=0.000 1]均明显低于对照组(P<0.05)。结论:现有证据表明,经皮穴位电刺激能降低重症肠内营养病人腹泻、消化道出血、腹胀发生率,缩短ICU住院时间。     

不同胃残余量对ICU肠内营养患者喂养达标率的影响及危险因素分析

目的 比较ICU持续肠内营养的不同胃残余量患者喂养达标率的差异并分析喂养达标率相关影响因素。方法 选择2021年1月-2022年5月上海市第一人民医院ICU收治持续肠内营养518例患者资料回顾性分析,按照入住ICU第7天不同胃残余量进行分组,其中57例患者胃残余量≥200 mL作为达标组,另461例患者胃残余量<200 mL作为未达标组,比较2组患者ICU入住第7天喂养达标率,同时应用logistic回归模型分析影响喂养达标率的相关因素。结果 达标组患者喂养达标率为14.0%(8/57),较未达标组的27.1%(125/461)明显降低,差异有统计学意义(χ²=4.548,P=0.039)。经多因素logistic回归模型分析显示,影响喂养达标的危险因素为超重(OR=0.496,P<0.001,95%CI:0.317～0.775)、肥胖(OR=0.351,P=0.020,95%CI:0.145～0.851)以及序贯器官衰竭评分(OR=0.931,P=0.023,95%CI:0.876～0.990),而保护性因素为偏瘦(OR=2.462,P=0.005,...     

间断喂养与持续喂养对危重症病人肠内营养耐受性影响的Meta分析

[目的]系统评价间断喂养、持续喂养对危重症病人肠内营养耐受性的影响。[方法]计算机检索Cochrane Library、PubMed、Ovid Medline、EMbase、中国生物医学文献服务系统(CBM)、维普数据库(VIP)、中国期刊全文数据库(CNKI)以及万方数据库,搜索建库至2019年4月1日所有关于采用间断喂养及持续喂养对危重症病人肠内营养耐受性影响的临床对照研究,筛选纳入研究的参考文献。由2名研究生对文献质量进行严格评价及资料提取,使用RevMan 5. 5软件进行Meta分析。[结果]共纳入7篇文献,3篇为随机对照试验研究,4篇为临床对照试验。Meta分析结果显示:间断喂养与持续喂养对危重症病人肠内营养并发症腹胀[OR=1.43,95%CI(0.68,3.04)]、腹泻[OR=1.15,95%CI(0.69,1.92)]的发生率比较差异无统计学意义(P0.05);重症病人肠内营养目标供给量达标情况[OR=2.67,95%CI(1.69,4.23)]比较差异有统计学意义(P0.05)。[结论]现有证据表明,间断喂养更符合正常人的生理,不会增加腹泻、腹胀发生率;且可提高危重症病人肠内营养目标供给量达标率。     

超声监测胃残余量在重症患者肠内营养中应用的Meta分析

目的通过评估超声监测胃残余量的应用效果,为指导重症患者肠内营养方案提供证据。方法系统检索CNKI、中国生物医学文献数据库、万方、维普、中国临床试验注册中心、PubMed、Embase、Cochrane Library、ClinicalTrials.gov等数据库,收集超声监测胃残余量在重症患者肠内营养中应用的RCT,检索时限为建库至2019年12月31日。由2名研究者独立检索文献、筛选文献、提取资料、评价质量,采用RevMan 5.3软件进行Meta分析。结果共纳入10篇文献,共897例患者。与注射器回抽法相比,超声监测胃残余量可以降低反流/呕吐发生率(RR=0.53,95%CI为0.38~0.75)、误吸发生率(RR=0.48,95%CI为0.30~0.77),提高白蛋白水平(MD=1.53,95%CI为0.71~2.35),减少护士操作时间(MD=-5.62,95%CI为-7.59~-3.65),合并效应量有统计学意义(P<0.05);但不改变腹泻发生率(RR=0.77,95%CI为0.53~1.11)与住院病死率(RR=0.73,95%CI为0.41~1.28),合并效应量无统计学意义(P>0.05)。结论超声监测胃残余量在重症患者肠内营养中应用可能有助于减少并发症的发生,改善患者的营养状况。     

超声监测胃残余量对重症患者肠内营养效果的Meta分析

目的系统评价超声与注射器回抽两种监测方法在评估重症患者胃残余量的安全性和有效性。方法计算机检索Cochrane Library、PubMed、Web of Science、Embase、中国知网、万方数据库、中国生物医学文献数据库中关于重症肠内营养支持患者胃残余量监测方法的随机对照试验和类试验研究,并进行Meta分析。结果共纳入15篇文献,包含1138例研究对象。Meta分析显示,超声监测胃残余量能明显降低腹泻、反流、胃潴留、误吸发生率(P0.05);且患者血清白蛋白水平的改善效果更为明显(P0.05)、监测操作时间更短(P0.05)、喂养达标时间更早(P0.05)、喂养中断次数更少(P0.05)。结论超声监测胃残余量具有更好的安全性和有效性,值得在重症肠内营养患者中推广应用。     

危重神经系统疾病患者肠内营养与胃内营养对预后影响的Meta分析

目的系统评价肠内营养和胃内营养对危重神经系统疾病患者预后的影响。方法计算机检索Pubmed、Embase、Cochrane Library、万方数据库、中国期刊全文数据库,纳入以肠内营养和胃内营养对危重神经系统疾病患者预后影响的随机对照研究。按Cochrane系统评价方法,由2位评价员根据纳入研究标准独立对数据进行Meta分析。结果共纳入7项研究,总样本量为619例,肠内营养组310例,胃内营养组309例。Meta分析显示,肠内营养组能的吸入性肺炎发生率[RR=0.59,95%CI(0.43,0.81)]及呕吐发生率[RR=0.43,95%CI(0.24,0.80)]明显低于胃内营养组患者,而两组患者的每日获得的能量[WMD=0.55,95%CI(-0.19,1.29)],腹泻[RR=1.01,95%CI(0.69,1.48)]、消化道出血的发生率[RR=0.95,95%CI(0.45,2.06)]、ICU住院时间[WMD=-1.15,95%CI(-4.37,2.07)]及病死率[RR=0.99,95%CI(0.73,1.36)]的比较,差异均无统计学意义。结论肠内营养可降低危重神经系统疾病患者吸入性肺炎及呕吐发生率,但尚需要大样本高质量的循证医学证据。     

肠外应用谷氨酰胺治疗重症急性胰腺炎的Meta分析

目的 评价肠外应用谷氨酰胺治疗重症急性胰腺炎的有效性。方法 计算机检索中国生物医学文献数据库、中国知网、Pubmed、Embase及Cochrane图书馆临床对照试验数据库等,查找符合纳入标准的随机对照试验,文献检索时间均从建库截至2013年1月。通过使用由Cochrane协作网推荐的方法,对谷氨酰胺治疗重症急性胰腺炎的随机对照试验进行Meta分析。结果 共纳入4篇随机对照试验,190例患者,这些试验均存在统计同质性。谷氨酰胺组比对照组病死率低[OR=0.26,95%CI（0.09,0.73）,P=0.01],并发症发生率低[OR=0.41,95%CI（0.22,0.78）,P=0.006],住院时间短[WMD=4.85d,95%CI（6.67,3.03）d,P〈0.00001]。结论 据目前的证据,谷氨酰胺对于重症急性胰腺炎有效。     

早期肠内营养对ICU机械通气患者相关并发症影响的Meta分析

目的系统评价早期肠内营养(early enteral nutrition,EEN)应用于ICU机械通气患者的效果,为重症患者营养支持提供循证依据。方法应用计算机检索PubMed数据库、Cochrane Library、Web of Knowledge、中国知网(CNKI)、万方数据库和维普中文科技期刊数据库(VIP)中关于比较EEN与肠外营养(parenteral nutrition,PN)对ICU机械通气患者的随机对照试验。两名研究者对满足纳入标准的文献采用RevMan5.3统计软件进行Meta分析。结果共纳入11篇文献,其中4篇英文文献,7篇中文文献,共5 574例患者。经Meta分析结果显示,与PN相比,EEN能够降低患者肺部感染发生率[OR=0.74,95%CI=0.59～0.92,P0.01];消化道出血发生率[OR=0.33,95%CI=0.18～0.60,P0.01],但EEN在降低血流感染[OR=0.80,95%CI=0.59～1.08,P=0.14]、腹泻发生率[OR=0.43,95%CI=0.17～1.06,P=0.07]及病死率[OR=0.94,95%CI=0.84～1.06,P=0.3]方面并未显示明显优势,合并效应无统计学意义(P0.05)。结论 ICU患者行EEN对其血流感染、腹泻发生率及病死率无明显影响,其肺部感染及消化道出血发生率降低。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.