VAP病原菌分布及耐药性的目标性监测研究

目的探讨机械通气患者呼吸机相关肺炎(VAP)及相关危险因素的微生物定植和常见耐药菌群的耐药情况。方法采用目标性监测方法,每隔24~48 h采集机械通气患者下呼吸道、口咽部、胃液及呼吸机湿化器、冷凝器、螺纹管气管接口端前10 cm内壁标本进行微生物培养、菌种鉴定和药敏试验。结果VAP的发病率为61.02%,且随着机械通气时间的延长发病率逐渐升高;本次研究共送检标本660份,分离菌株249株,下呼吸道、口咽部、胃液的主要定植菌为鲍曼不动杆菌、铜绿假单胞菌和粪肠球菌,对抗菌药物的平均耐药率为56.2%~72.5%;呼吸机装置的主要污染菌为铜绿假单胞菌、鲍曼不动杆菌属、肺炎克雷伯菌。结论VAP的致病菌以GNB为主,且为多重耐药菌。最初经验性抗菌治疗应依据病原学和耐药性监测结果。     

呼吸机相关肺炎的非药物预防及护理

呼吸机相关肺炎（VentilatorassociatedPneumonia，VAP）是指患者受机械通气治疗48h后和停用机械通气、拔除人工气道48h内发生的肺实质炎症，为接受机械通气患者最常见的医院内感染，导致病人住院时间延长、治疗费用增加及院内感染死亡的主要原因。国外报道VAP发病率为9％～70％，病死率可达50％～70％^[1]。国内报道，VAP发病率70％，病死率可达51．6％^[2]。VAP发病机制与口咽部菌群定植以及气道内吸入污染物密切相关，因此VAP的预防主要是预防病原微生物传播以及纠正宿主感染的危险因素。本文将着重讨论ICU（重症监护病房）患者VAP感染的非药物预防及护理。     

加强口咽部护理对预防呼吸机相关性肺炎的临床观察

0 引言 呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)是患者接受机械通气(mechanical ventilation, MV)48 h后所并发的肺实质感染. VAP是机械通气过程中常见而又严重的并发症之一,其发病率高达18%～60%,病死率高达30%～70%[1]. 有研究表明,VAP的发病率与口咽部的革兰阴性菌的定植相关,有效的口咽部护理是预防VAP的重要途径[2]. 2003-09/2005-09,我们通过加强口咽部护理,预防机械通气患者VAP,收到了一定的效果.     

69例呼吸机相关肺炎的危险因素分析及护理对策

目的:研究呼吸机相关肺炎的危险因素分析及护理对策。方法:对69例呼吸机相关肺炎患者进行回顾性分析,并记录其性别、年龄、基础疾病、是否合并慢性阻塞性肺疾病、机械通气时间、感染菌株并进行相应的统计学分析。结果:年龄≥65岁,应用机械通气时间≥7 d,合并慢性阻塞性肺疾病,机械通气治疗3天后心功能Ⅳ级的患者呼吸机相关肺炎(VAP)发病率明显增高,气管切开并不是VAP发生的危险因素。结论:年龄、机械通气时间、合并慢性阻塞性肺疾病及机械通气3天后心功能缓解情况是VAP发生的危险因素,积极纠正心功能衰竭、减少医源性感染、有效排痰、充分的口腔护理和胃肠道护理是预防VAP发生的重要的护理对策。     

新生儿呼吸机相关性肺炎相关因素分析

目的 分析新生儿呼吸机相关性肺炎( ventilator-associated pneumonia,VAP)发病的相关危险因素,指导临床防治工作. 方法 回顾性研究本院新生儿科2012年全年收治机械通气时间≥48h的216例患者及病原学资料,使用检验和Logistic回归进行统计分析. 结果 单因素分析发现早产、低出生体重、机械通气时间、上机次数有统计学意义(P＜0. 05),而多因素分析发现机械通气时间和上机次数与VAP发病相关(P＜0. 05). 结论 早产低体重儿免疫系统发育不成熟,易发生感染. 气管插管将外界及口咽部细菌下移. 气管导管停留时间越长,其表面细菌定殖越多,并以多重耐药菌为主. 临床防治VAP提倡从患者管理、呼吸机管理、病房管理及人员管理各方面加强的集束化管理.     

38例呼吸机相关性肺炎临床分析

目的:了解呼吸内科重症监护病房(RICU)机械通气患者并发呼吸机相关性肺炎(VAP)的临床相关因素和细菌学特点。方法:回顾性分析呼吸机相关性肺炎患者38例发病时间和病原学特点。结果:RICU重症患者机械通气≥48 h 87例,并发VAP 38例,发病率为43.7%。重症患者并发VAP时病死率39.5%。VAP机械通气平均发生在(5.1±2.2)d,与机械通气时间、意识障碍相关;VAP致病菌以革兰氏阴性杆菌感染为主,占81.1%,药敏试验显示对多种常用抗生素耐药。结论:RICU呼吸机相关性肺炎发生率、病死率高,革兰氏阴性杆菌仍为主要病原菌,尽可能缩短呼吸机使用时间、合理使用抗生素、严格无菌操作,有利于呼吸机相关性肺炎控制。     

呼吸机相关性肺炎危险因素分析

目的:分析重症监护病房(ICU)呼吸机相关性肺炎(VAP)发生的相关危险因素,探讨VAP的防治措施。方法:对55例行人工机械通气的ICU住院患者的临床资料进行回顾性分析,对VAP发生的相关危险因素进行单因素及多因素Logistic回归分析。结果:单因素分析结果显示,机械通气时间、非感染性慢性肺疾病、气管切开、意识状态、联合使用抗生素在VAP组及非VAP组之间差异有统计学意义(P<0.05);多因素Logistic回归法分析表明,机械通气时间、意识状态、抗生素联合应用是VAP发生的独立相关因素危险因素。结论:机械通气时间≥3 d、意识状态、抗生素联合应用≥2种是VAP发生的独立危险因素,对这些危险因素加以重点评估和合理控制可以预防VAP的发生。     

重症监护病房呼吸机相关性肺炎的相关危险因素分析

目的:分析重症监护病房(ICU)呼吸机相关性肺炎(VAP)发生的相关危险因素,为探讨VAP的预防提供参考。方法:对80例行人工机械通气的ICU住院患者的临床资料进行回顾性分析,对VAP发生的相关危险因素进行Logistic回归分析,筛选VAP发生的相关危险因素。结果:单因素分析结果显示,机械通气时间、意识状态、误吸、H2-受体拮抗剂或酸剂、激素、抗菌素联合应用与VAP发生有关;多因素Logistic回归法分析表明,抗菌素联合应用≥2种、机械通气时间≥3d、误吸是VAP发生的危险因素。结论:抗菌素联合应用≥2种、机械通气时间≥3d、误吸是VAP发生的危险因素,对这些危险因素加以重点评估和合理控制可以预防VAP的发生。     

内科ICU呼吸机相关肺炎危险因素研究

目的 探讨在内科ICU影响呼吸机相关肺炎(VAP)的危险因素.方法 对2003年8月～2006年8月入住内科重症监护病房(ICU)采用机械通气治疗的220例患者进行回顾性分析,将患者按相关危险因素自然分组,采用χ2检验比较VAP发病率.结果 220例行机械通气治疗患者中有147例发生VAP,发病率为66.8%.机械通气≥5 d、仰卧位、应用抑制胃酸分泌药、进行侵入性操作、应用糖皮质激素、白蛋白＜30 g/L、多器官功能障碍综合征(MODS)与各自对照组比较,其相对比分别是2.73、1.82、2.45、5.67、2.76、3.49、2.06倍,P值均＜0.05,有统计学意义.结论 机械通气≥5 d、仰卧位、应用抑制胃酸分泌药、进行侵入性操作、应用糖皮质激素、白蛋白＜30 g/L、多器官功能障碍综合征(MODS)是影响VAP发生的主要危险因素.     

呼吸机相关性肺炎危险因素病例对照分析与护理策略

目的分析呼吸机相关性肺炎(ventilator associated pneumonia,VAP)的危险因素,为临床预防治疗VAP提供参考依据。方法回顾2010年1月～2011年12月我院864例机械通气时间≥48 h患者的相关住院资料,以同期726例非VAP为对照组,分析VAP发病的危险因素。结果 VAP发病率为15.9%。单因素分析发现,机械通气>5 d、侵入性操作、留置胃管、APACHEⅡ评分>15分、意识障碍、口腔护理、抬高床头、每日唤醒排痰与发生VAP有关(P<0.01或P<0.05);Logistic回归分析发现APACHEⅡ评分>15分、意识障碍、留置胃管、机械通气>5 d和神经损伤为VAP发生的独立危险因素,而口腔护理、患者抬高30°、每日唤醒排痰是VAP的保护性因素。结论机械通气具有较高的VAP发病率,合理的护理策略与尽早撤机缩短机械通气有利于防止VAP的发生。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.