心胸外科中心静脉导管感染患者的相关因素分析及预防对策

目的 探讨并分析心胸外科中心静脉导管感染的相关因素及预防对策.方法 2002年1月-2005 12月,随机抽取行中心静脉穿刺患者560例.治疗结束后,取导管尖端进行细菌培养,并对结果进行分析.结果 引起心胸外科深静脉置管相关感染的病原菌中,葡萄球菌占50%,真菌占16.7%;深静脉置管3,4,5周的感染率分别为24.5%、35.6%和65.2%;普胸手术及开放性胸外伤患者导管感染发生率分别为14.8%、18.0%,高于心脏手术及化疗患者;锁骨下静脉穿刺及贵要静脉置管感染发生率(9.6%、9.4%)低于颈内静脉(18.7%).结论 引起心胸外科深静脉置管相关感染的病原菌以葡萄球菌为首位病原菌;深静脉留置时间愈长,则导管感染率越高;普胸手术及开放性胸外伤患者导管感染发生率显著高于心脏手术及化疗患者;锁骨下静脉穿刺及贵要静脉置管感染发生率低于颈内静脉.严格深静脉置管护理和缩短留置时间对防止相关性感染具有重要临床意义.     

基层医院血液透析病人深静脉导管感染相关因素分析及预防对策

目的探讨分析基层医院血液透析病人深静脉置管引起导管感染的相关因素及预防措施。方法 1999年5月至2009年5月,深静脉置管维持性血液透析40例,发生严重感染6例,占15.0%,更换导管时取导管尖端进行细菌培养,并对结果分析。结果引起血液透析深静脉导管感染病原菌为表皮葡萄球菌。置管2、3、6月的感染率分别为16.7%、33.3%、50.0%,锁骨下静脉穿刺置管发生率为0,股静脉置管发生1例,占16.7%,其余5例均为颈内静脉置管,占83.3%。局部护理合理者感染机会少。6例感染者均有护理不得力因素存在。结论引起血液透析深静脉置管感染相关的病原菌为表皮葡萄球菌。导管留置时间越长及护理不得力,则导管感染率越高,锁骨下静脉置管深静脉导管感染发生率低于股静脉和颈内静脉置管。严格深静脉置管护理和缩短留置时间对防止相关性感染具有重要临床意义。     

神经外科患者中心静脉导管感染的相关因素分析及预防护理

目的:探讨并分析神经外科患者中心静脉导管感染的相关因素及预防护理方法.方法:随机抽取560例行深静脉置管患者,于治疗结束后取导管尖端进行细菌培养,并对结果进行分析.结果:引起神经外科患者中心静脉导管感染的病原菌中,葡萄球菌占65.2%,真菌占16.7%;深静脉置管15～21 d、22～28 d、≥29 d患者导管感染发生率分别为24.5%、35.6%和65.3%;深静脉置管时间愈长,导管感染发生率越高(P＜0.01);高血压性脑出血手术及开放性颅脑损伤患者导管感染发生率分别为14.8%、18.0%,均高于颅内肿瘤切除手术及化疗患者(P＜0.01);锁骨下静脉穿刺置管及经贵要静脉穿刺置管患者感染发生率均低于颈内静脉穿刺置管患者(P＜0.01).结论:严格深静脉置管护理和缩短留置时间对防止神经外科患者中心静脉导管感染具有重要临床意义.     

血管内留置导管感染的相关因素分析及预防对策

目的 探讨与静脉导管感染的相关因素以及预防对策.方法 分析598例中心静脉留置导管患者的临床资料,对可疑静脉导管感染者130例行导管留置的时间、部位、细菌学监测.结果 留置导管时间为3～70 d.其中77例占12.88％血培养和导管尖端微生物学培养阳性.共检出病原菌151株:革兰阴性菌48株占31.79％,革兰阳性菌78株占50.65％,真菌25株占16.56％.其中,最常见的病原体是表皮葡萄球菌、金黄色葡萄球菌、念珠菌、不动杆菌;大多数细菌具有高度耐药性.部位的选择:锁骨下静脉和贵要静脉导管相关感染率低于股静脉、锁骨上静脉和颈内静脉,置管时间≤13 d的静脉导管相关感染率低于≥14 d的.结论 选择锁骨下静脉和贵要静脉行静脉置管术,规范穿刺技术、严格置管护理、缩短留置时间和改善患者全身情况可减少导管相关性感染.合理使用抗生素,是降低危重病患者血管内导管感染的重要措施.     

3种途径深静脉置管在血液净化中的应用比较

目的 总结3个不同部位深静脉置管在血液净化中的应用,本文通过对不同部位深静脉置管出现的并发症、穿刺成功率、导管留置时间进行分析,以寻找最佳的深静脉置管的血管通路.方法 分析2005年3月至2007年3月我院血液净化室对90例需要行血液净化治疗病人先后采用锁骨下静脉置管30例,颈内静脉置管30例,股静脉置管60例.结果 导管留置时间:锁骨下静脉13-116(30±9)d,颈内静脉16-103(26±11)d,股静脉2-60(15±8)d;穿刺成功率:锁骨下静脉90%,颈内静脉93%,股静脉98%;感染的发生率:锁骨下静脉10%,颈内静脉6.7%,股静脉16.7%.结论 深静脉置管有快捷、方便、安全的优点,导管留置时间锁骨下和颈内静脉差异无显著性,但比股静脉明显延长;穿刺成功率股静脉优于颈内静脉及锁骨下静脉;感染率股静脉高于颈内静脉及锁骨下静脉.     

深静脉置管行血液净化治疗患者出血的原因分析及护理

总结留置临时性深静脉导管行血液净化治疗患者出血的护理经验。行临时性单针双腔静脉导管留置术血液净化治疗患者223例,其中颈内静脉置管193例,右锁骨下静脉置管21例,股静脉置管9例。颈内静脉置管患者误穿颈总动脉并发出血发生率为3．1％（6／193）,股静脉置管患者误穿股动脉发生率为22．2％（2／9）,穿刺部位渗血发生率为7．1％（16／223）,导管意外脱落发生率为1．3％（3／223）。误穿动脉,穿刺部位渗血,导管意外脱落为深静脉置管并发出血的主要原因。临床实践经验和技术熟练程度对防止置管术中出血至关重要;根据患者情况选择不同的穿刺点置管可以减少出血并发症;对患者的卫生宣教也是防止导管脱落并发出血必不可少的措施。     

血液透析患者中心静脉置管感染相关因素分析及对策

目的分析血液透析患者留置导管感染的相关因素,并探讨其对策。方法回顾311例中心静脉置管患者,分析置管部位、留置时间与感染的关系,并对细菌药敏进行测定。结果股静脉感染率为34.97%,颈内静脉感染率为18.56%,锁骨下静脉感染率为14.08%,留置1周感染率为8.39%,2周感染率为17.53%,3周感染率为29.58%,病原菌以葡萄球菌为主。结论选取非股静脉置管方式,缩短留置时间可降低感染率,需早期发现积极治疗。     

两种深静脉置管术在危重症患者治疗中的比较

目的 对锁骨下静脉穿刺置管术和股静脉穿刺置管术的优缺点进行比较.方法 对我科2006～2007年240例行深静脉穿刺置管术的重症监护病房(ICU)患者进行回顾性分析,对两种静脉置管术的一针穿刺成功率、插管完成时间、误穿动脉率、导管留置时间、导管相关感染率和深静脉血栓形成率进行比较.结果 股静脉穿刺置管术的一针穿刺成功率较锁骨下静脉穿刺置管术高,插管完成时间短,误穿动脉率低,但导管留置时间较锁骨下静脉穿刺置管短,导管相关感染率,深静脉血栓形成率高.结论 ICU患者如果需要留置导管较长时间,宜选择锁骨下静脉穿刺置管方法,而对于急性中毒患者,宜选择股静脉穿刺置管.     

血液透析颈内静脉置管并发感染的预防

目的 预防血液透析颈内静脉置管并发感染，延长颈内静脉导管留置的时间。方法 加强颈内静脉置管患者的置管后护理，严格执行无菌操作，并采取有效的干预措施，预防穿刺口和皮下隧道感染的发生。结果 留置时间最短21天，最长1例置管347天（中途换管1次，拔管后选择另一侧颈内静脉再次置管）。局部及皮下隧道感染率情况：留置时间〈20天为4例（2．82％），20—30天14例（9．86％），30—150天18例（12．68％），留置时间在150—347天血培养阳性者5例（3．52％）。结论 加强颈内静脉留置双腔导管的护理，可以延长颈内静脉留置的时间，缩短住院天数，减轻患者的痛苦和经济负担。     

经皮下隧道贵要静脉穿刺置管预防危重病患者静脉营养导管相关性感染的效果观察

目的探讨经皮下隧道贵要静脉穿刺置管用于危重病患者静脉营养对防止导管性感染以及延长导管留置时间的作用。方法选择136例需行静脉营养的危重病患者,随机分为观察组和对照组各68例。观察组采用经皮下隧道右侧贵要静脉穿刺置管,对照组采用直接右侧贵要静脉穿刺置管。观察1次穿刺成功率、导管留置时间,静脉营养期间穿刺部位血肿、导管阻塞、导管脱出以及导管相关性感染情况。结果观察组导管留置时间明显延长,且发生导管相关性感染的病例明显减少,导管相关性感染多以金黄色葡萄球菌为主,其次为铜绿假单胞菌和白色念珠菌。结论经皮下隧道贵要静脉置管可有效延长深静脉导管留置时间,有效预防导管相关性感染。     

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.     

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.     

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.     

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.