低白蛋白血症对脓毒症患者急性呼吸窘迫综合征发生和预后的预测作用

目的：评价低白蛋白血症对脓毒症患者急性呼吸窘迫综合征（ARDS）发生和预后的预测作用。方法：以302例入住重症监护病房（ICU）并明确诊断脓毒症的患者为观察对象,按血清白蛋白（ALB）水平分为极低蛋白组、低蛋白组和正常蛋白组。收集全部患者诊断脓毒症即刻的血清白蛋白值、一般临床特征、ARDS发病率及28 d预后等相关资料,比较其差异性,用受试者工作曲线（ROC曲线）评价血清白蛋白水平与脓毒症合并ARDS患者预后的关系。结果：极低蛋白组与低蛋白组患者APACHEⅡ评分、血乳酸水平、ARDS发病率均明显高于正常蛋白组（P＜0．05）,3组间28 d病死率比较,差异无统计学意义;合并ARDS的患者中,极低蛋白组与低蛋白组28d病死率明显高于正常蛋白组（P＜0．05）;以血清白蛋白水平＜25 g／L作为ARDS患者死亡预测的界点,敏感性为63％,特异性为86％。结论：低白蛋白血症与脓毒症患者ARDS的发生有关,并可以预测脓毒症合并ARDS患者的预后。     

肝硬化并发缺血性肝炎的临床分析

目的探讨肝硬化患者并发缺血性肝炎的临床特点。方法对2008年1月—2013年6月大连市第六人民医院重症监护病房(ICU)收治的30例肝硬化并发缺血性肝炎患者的临床资料进行回顾性分析。结果发生缺血性肝炎的患者占同期ICU收治患者的1.6%。原发基础疾病包括肝硬化基础上出现的低血容量休克、重度脓毒血症、慢性心力衰竭急性发作、急性呼吸窘迫综合征,监测到患者缺血发生后血清丙氨酸氨基转移酶(ALT)及天冬氨酸氨基转移酶(AST)均急剧升高,并有不同程度的白蛋白(ALB)水平明显下降。治疗针对基础疾病,在护肝治疗的同时,积极纠正休克、抗感染、纠正心力衰竭、呼吸衰竭及加强支持治疗。病死率为66.7%(20/30),其中Child-Pugh C级患者病死率明显高于A、B级。结论发病的主要诱因有低血容量休克、重度脓毒血症、心力衰竭及呼吸衰竭;典型的实验室检查特点主要为血清ALT在发病后急剧升高,经治疗后可短期内降至正常为缺血性肝炎患者典型的实验室表现,本病病死率较高,Child-Pugh C级患者病死率尤其高。     

低蛋白血症对老年人肺炎预后影响的探讨

目的 探讨低蛋白血症对老年人肺炎预后的影响.方法 将2004～2007年老年肺炎病例105例分为死亡组(41例)和治愈组(64例),入院时测定两组患者血清白蛋白,采用χ2检验对结果进行统计学分析.结果 死亡组低蛋血症发生率为56.09%,治愈组低蛋血症发生率为23.44%,两组血清白蛋白比较t检验有统计学意义(P<0.001).结论 低蛋白血症是影响老年肺炎预后的危险因素.     

脑梗死患者并多器官功能障碍综合征118例相关因素分析

目的:调查急性脑梗死伴多器官功能障碍综合征(multipleorgandys-functionsyndrom,MODS)的相关因素及病死率。方法:调查721例脑梗死患者,应用队列研究方法对MODS的相关危险因素及病死率进行分析。结果:721例脑梗死患者中,118例发生MODS,发生率为16.4%。12个因素参与MODS发生的单因素分析,与MODS发生有显著关系的是糖尿病、冠心病、慢性阻塞性肺病、治疗延迟≥4h、甘露醇、高渗性葡萄糖、肺炎。118例MODS患者衰竭器官分布:最高为肺75例(63.4%),依次为胃肠49例(41.5%),肾功能衰竭45例(38.1%),循环系统34例(28.8%)等。118例MODS患者,死亡39例,病死率为33.0%,无MODS组603例中死亡48例(8.0%),两组病死率相比差异有显著性意义(χ2=58.55,P<0.01);MODS累及器官的个数与病死率有关。年龄小于60岁组的发生MODS数量明显少于60岁以上者(P<0.05)。结论:MODS的发生与多因素有关,器官损伤数目越多,预后越差。充分认识MODS发生的危险因素,,治疗中应早期进行有关器官的功能监测,有利于防止MODS的发生。     

血必净注射液对多器官功能障碍综合征合并低蛋白血症患者血清白蛋白水平的影响

目的 探讨血必净注射液对多器官功能障碍综合征(MODS)合并低蛋白血症患者血清白蛋白水平的影响.方法 采用多中心、随机、对照的试验设计方法,将200例MODS患者分为白蛋白组(A组)、血必净组(B组)、血必净早期联合白蛋白组(C组)、血必净后期联合白蛋白组(D组)4组,每组50例.分别于治疗前及治疗后1、3、5、7 d测定血清白蛋白水平,并计算患者Marshall评分和胃肠功能评分.结果 与治疗前比较,B、C、D组血清白蛋白水平均逐渐升高,Marshall评分和胃肠功能评分逐渐下降;B组7 d时,C组5 d起,D组3 d起差异均有统计学意义(P<0.05或P<0.01);B组7 d时与A组,C组5 d起与A、B组,D组3 d起与A、B、C组比较差异即有统计学意义(P<0.05或P<0.01).结论 血必净注射液后期联合应用白蛋白可显著提高MODS合并低蛋白血症患者的白蛋白水平,并可对患者衰竭器官有保护作用.     

重症脓毒症合并多器官功能障碍综合征的临床特征

目的探讨重症脓毒症合并多器官功能障碍综合征(MODS)的临床特征。方法比较重症脓毒症合并MODS病例与非重症脓毒症合并MODS病例。结果在根据同一入选标准入选的MODS病例中,重症脓毒症合并MODS者较非重症脓毒症合并MODS者的住院病死率与ICU病死率高,平均年龄大,住院时间和住ICU时间长,APACHEII分值高,呼吸机的使用频率高,体温高,呼吸频率快,血压低(包括收缩压、舒张压、平均动脉压),心率快,中性粒细胞百分比高,血红蛋白浓度高,血糖浓度高,白蛋白浓度低,动脉血氧分压低,氧合指数低,肺泡动脉氧分压差高,功能障碍器官个数多,MODS评分分值高,器官功能障碍的发生率高。以上比较,差异均有显著性(P<0.05)。结论重症脓毒症合并MODS者平均年龄大,病情更重,住院病死率和住ICU病死率更高。     

甲状腺癌术后低钙血症探讨

目的:探讨甲状腺癌术后低钙血症的发生情况,分析其原因、预防及处理.方法:对2004年1月至2008年12月54例甲状腺癌手术患者进行动态监测血清钙变化,术后随访.结果54例甲状腺癌手术患者术后出现低钙血症37例(69%),其中无症状低钙血症25例(46%),有症状低钙血症12例(22%).41例甲状腺非全切除术患者出现低钙血症24例(59%),13例甲状腺全切除术患者出现低钙血症13例(100%),差异具有统计学意义(P＜0.05),且3例出现手足搐搦.12例无淋巴结清扫患者出现低钙血症5例(42%),42例加淋巴结清扫患者出现低钙血症32例(76%),差异具有统计学意义(P＜0.05).结论甲状腺癌术后低钙血症发生率高,术后第1、2、3天应常规监测血清钙.行甲状腺全切除或加淋巴结清扫患者,低钙血症发生率明显增加,术中应注意保护甲状旁腺.低钙血症症状多于术后前3天出现,及时补充钙剂后症状多能迅速消失.     

超高龄老年脑梗死患者血镁水平的临床研究

目的:探讨年龄≥90岁的超高龄老人血镁及脑梗死发生之间的关系.方法:回顾性分析122例超高龄患者的血清镁水平,比较脑梗死及非脑梗死患者血镁水平,并比较不同血镁水平的患者脑梗死发生率.结果:总血清镁浓度为(0.973±0.544)mmol/L,不同年龄、性别组患者组间血镁浓度差异无统计学意义(P＞0.05).脑梗死组、非脑梗死组患者血清镁浓度组间差异无统计学意义(P＞0.05).而低镁血症组、血镁正常组及高镁血症组患者脑梗死患病率分别为81.82%、35.71%、23.08%,低镁血症组脑梗死患病率显著高于其他两组(均p＜0.05).结论:超高龄患者中低镁血症者脑梗死患病率较非低血镁者高.因此,超高龄患者适当补充镁可能对脑梗死的发生有一定预防作用.     

高渗性非酮症昏迷合并多脏器功能障碍的护理

糖尿病合并多器官功能障碍综合征 (MODS)常发生于高渗性非酮症昏迷 (HNKDC) ,发生率约为 2 5 %～ 90 % [1] ,如不及时救治可迅速发展为多器官功能衰竭 (MOPF) ,以至死亡。HNKDC常发生于未经确诊的 2型糖尿病 ,起病隐袭 ,但病情来势凶 ,进展快 ,近年来由于提高了对本病的警惕 ,病死率有所下降 ,但仍高达 2 0 %～ 5 0 % [2 ] 。我们 2所医院在近 3年内收住HNKDC合并MODS患者 11例 ,经过及时、正确的监护 ,救治成功 9例。现将监测与护理措施总结如下。1　对象2 0 0 0年～ 2 0 0 2年我们共收治HNKDC患者 11例 ,其中男5例 ,女 6例 ;…     

持续性不卧床腹膜透析患者并发低蛋白血症30例临床分析

目的 研究腹膜透析患者并发低蛋白血症的发生情况,探讨其与C-反应蛋白(CRP)及其与各种炎性并发症的关系.方法 对2006年1月至2009年6月入院的60例持续性不卧床腹膜透析(CAPD)患者进行血清白蛋白(ALB)含量及其引发的相关并发症进行调查.根据ALB含量分为A组和B组,其中A组为营养良好,ALB含量正常;B组为合并低白蛋白血症患者.比较2组间CRP、转铁蛋白(TF)和主观营养评估法(SGA)的变化及其与临床并发症的关系.采用t检验及Pearson相关分析.结果 60例CAPD患者中,B组患者CRP含量[(8.40±1.32)mg/L]显著高于A组[(2.14±0.87)mg/L](P＜0.01);B组腹膜炎发生率为6.7%,肺炎发生率为13.3%,心血管疾病的发生率为16.7%,均明显高于A组(腹膜炎发生率为0,肺炎发生率为10%,心血管疾病的发生率为6.7%)(P均＜0.05).结论 CAPD合并低白蛋白血症患者并发炎症及心血管疾病的发生率皆高于营养良好者.应重视腹膜透析患者营养不良-炎症-心血管疾病(动脉粥样硬化)综合征的诊治.     

Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score

BACKGROUND: The effect of 5 percent human albumin on multiple organ dysfunction was investigated during the first 14 days of treatment to determine whether albumin resuscitation might benefit adult burn patients. STUDY DESIGN AND METHODS: Multicenter unblinded controlled trial with stratified block (two patients per block) randomization by center and mortality prediction at enrollment (high-risk stratum [predicted mortality, 50%-90%] and low-risk stratum [predicted mortality, <50%]). The primary outcome was the worst multiple organ dysfunction score (MODS), excluding the cardiovascular component, to Day 14. Eligible adults (>15 years) suffering from thermal injury not more than 12 hours before enrollment received fluid resuscitation with Ringer's lactate (n=23) or 5 percent human albumin plus Ringer's lactate (n=19) by protocol to achieve recommended (American Burn Association) resuscitation endpoints. RESULTS: Forty-two patients were randomly assigned. There were no significant differences (median [95% confidence intervals]) in age (36 [24-45] vs. 31 [25-39] years), burn size (39 [32-53] vs. 32 [26-34] total body surface area percentage), inhalation injury (n=12/19 vs. n=11/23), or baseline MODS (3 [1-5] vs. 1.5 [0-2]) between the treatment and control groups. In an intention-to-treat analysis, there was no significant difference between the treatment and control group in the lowest MODS from Day 0 to Day 14 (analysis of covariance, p=0.73). CONCLUSION: Treatment with 5 percent albumin from Day 0 to Day 14 does not decrease the burden of MODS in adult burn patients.     

多器官功能障碍综合征患者高级氧化蛋白产物的表达及其临床意义

目的 探讨高级氧化蛋白产物(AOPP)在多器官功能障碍综合征(MODS)发病中的作用及临床意义.方法 选择全身炎症反应综合征(SIRS)和MODS患者各90例.采用分光光度计法测定患者静脉血中C-反应蛋白(CRP)和AOPP的浓度;同时对MODS患者进行急性生理学与慢性健康状况评分系统Ⅲ(APACHE Ⅲ)评分,追踪患者1个月内的生存或死亡情况;分析CRP和AOPP浓度与器官功能障碍程度和病情转归的关系.以同期90例与患者年龄、性别相匹配的健康体检者作为健康对照组.结果 MODS组患者血CRP[(22.22±4.32)mg/L3和AOPP[(130.66±18.08)μmol/L]浓度均显著高于健康对照组[(2.38±0.89)mg/L和(33.20±5.32)μmol/L3和SIRS组[(5.32±1.22)mg/L和(48.58±6.03)μmol/L],差异均有统计学意义(P均<0.05),健康对照组与SIRS组间差异无统计学意义.MODS组中死亡患者(47例)血CRP和AOPP浓度显著高于存活患者(43例,P均<0.05);MODS患者血CRP、AOPP浓度与APACHE Ⅲ评分E(98.66±20.87)分]均呈高度正相关(rl=0.469,r2=0.528,P均<0.01).血CRP、AOPP浓度随衰竭器官数增加而明显升高(P均<0.05),AOPP浓度与CRP呈高度正相关(r=0.448,P<0.01).结论 AOPP可能参与了MODS的发病过程,AOPP浓度异常增高反映MODS患者体内存在严重氧化应激状态,可作为判断MODS患者器官功能障碍程度和预后的重要指标.     

Effect of protein binding of daptomycin on MIC and antibacterial activity.

A higher rate of clinical failures in patients treated with daptomycin (2 mg/kg of body weight, given once daily) compared with rates in patients treated with conventional regimens caused early termination of this comparative clinical trial. One explanation for these failures could be that daptomycin is highly protein bound and that the concentration of the unbound active drug is too low for antibacterial activity. To assess this explanation, we studied the binding of daptomycin to proteins by using an ultrafiltration method. pH (7.0 to 7.4), temperature (25 or 37 degrees C), or daily freezing and thawing over 2 months had no effect on binding of daptomycin to proteins. We found that daptomycin was bound to albumin (90%) at 4 g/100 ml. Binding of daptomycin was not concentration dependent (2.5 to 80 micrograms/ml). In human serum samples spiked with daptomycin, average binding was 94% +/- 2.4%. In 6 subjects given an intravenous infusion of daptomycin (3 mg/kg), average binding was 90% +/- 2.1%. Susceptibility studies showed that a concentration in serum 20 times the unbound concentration was needed to equal the MIC of the total drug. These results indicate that daptomycin is highly bound (90 to 94%) to albumin and that clinical failure to daptomycin can in part be explained by the low concentration of the unbound drug.     

Role of systemic inflammatory response syndrome and infection in the occurrence of early multiple organ dysfunction syndrome following severe trauma

Objective To evaluate the role of infection and systemic inflammatory response syndrome (SIRS) on the occurrence of early posttraumatic MODS.Design Retrospective study.Setting University Teaching Hospital ICU.Patients 163 consecutive patients hospitalized for more than 48 hours following severe trauma.Measurements and main results The patients were classified into two groups in respect to the existence of MODS at day 2. There was 27 patients in the MODS group and 136 patients in the no MODS group. The two groups were similar with respect to age, sex ratio and Simplified Acute Physiology Score. The MODS group had a higher mortality (52 versus 7%), Injury Severity Score (45±14 versus 31±13), hypovolemic shock rate (74 versus 30%), massive volume replacement rate (59 versus 6%) and SIRS rate (81 versus 54%) than the no MODS group (p<0.05). The rate of infection was similarly low in the MODS and no MODS group (4 versus 6% respectively).Conclusion Early MODS is often associated with hypotension and massive volume administration but very rarely with infection, despite the high rate of SIRS.     

大面积烧伤患者血清透明质酸浓度检测的临床意义

目的 :探讨大面积烧伤患者血清透明质酸 (HA)浓度变化与肝细胞损伤的关系。方法 :采用放射免疫和酶联免疫吸附等技术 ,比较分析烧伤严重程度不同及其并发全身炎症反应综合征 (SIRS)、多脏器功能障碍综合征 (MODS)、多器官衰竭 (MOF)和死亡患者各组血清 HA、肿瘤坏死因子α(TNFα)和临床常规肝肾功能指标。结果 :烧伤后 2周内血清 HA浓度一直维持高水平 ,并随烧伤严重程度增加和 SIRS、MODS的产生 ,其数值逐步升高、相差显著 (P<0 .0 0 1 ) ,但在 MODS向 MOF发展直至死亡前后 ,血清 HA值又由高限急剧降低。直线相关分析显示 ,血清 HA浓度变化与烧伤严重程度和 SIRS等并发症的发生发展密切相关 (P<0 .0 1 ) ,与血清 TNFα和天冬氨酸转氨酶、总胆红素值呈正相关 (P<0 .0 5或 P<0 .0 1 ) ,而与血浆白蛋白、白蛋白 /球蛋白比值呈负相关 (P均 <0 .0 5 )。结论 :血清 HA浓度中、重度升高可能与 TNFα等持续损伤肝内皮细胞功能有关 ,可将其作为临床大面积烧伤患者肝损伤、病情严重程度和预后判断的敏感指标     

Peritoneal transport characteristics, comorbid diseases and survival in CAPD patients.

OBJECTIVE: To evaluate the influence of initial peritoneal transport rate, serum albumin concentration, and comorbid diseases on continuous ambulatory peritoneal dialysis (CAPD) patient survival. DESIGN: A prospective single-center study with a long-term follow-up. PATIENTS: A total of 213 consecutive CAPD patients, who underwent a peritoneal equilibration test (PET) at a mean of 7 days (range 3 - 30 days) after beginning CAPD, were included in this study. One hundred twenty patients were male, 116 patients had comorbid diseases, and mean age was 49.5 years (range 18 - 76 years). METHODS: A modified PET was performed using 4.25% glucose dialysis solution. Based on the dialysate-to-plasma creatinine concentration ratio at 4 hours' dwell (D4/P4 Cr, 0.62 +/- 0.14), patients were divided into high (H), high-average (HA), low-average (LA), or low (L) transporters. RESULTS: Of 213 patients, 16.9% were classified as H transporters, 30.5% as HA, 36.6% as LA, and 16.0% as L transporters. The H transporter group had a higher proportion of men, higher proportion of patients with comorbid diseases, lower initial serum albumin concentration, lower D4/D0 glucose, and lower drained volume. The initial D4/P4 Cr correlated with initial serum albumin (r= -0.35, p < 0.001). The patients with comorbid diseases had lower initial serum albumin and higher initial D4/P4 Cr. On Kaplan-Meier analysis, 2-year patient survival of group H was significantly lower compared to the other groups combined (57.1% vs 79.5%, p = 0.009). On Cox proportional hazards analysis, age, comorbid diseases, initial serum albumin concentration, and initial D4/P4 Cr were found to be independent risk factors for mortality. However, in the patients without comorbid diseases, patient survival was not different between group H and the other transport groups combined (p > 0.05), and only age was found to be an independent risk factor for mortality. CONCLUSION: These data suggest that a high peritoneal transport rate at initial PET is associated with high mortality, and that this is in part due to an increased prevalence of comorbid disease in H transporters. These H transporters with comorbid diseases represent a subset of patients with an especially poor prognosis. In patients without comorbid diseases, high transport status or low serum albumin concentration was not an independent risk factor for mortality.     

多器官功能不全综合征患者 Marshall心脏评分与CK/CK-MB 水平关系的研究

目的探讨多器官功能不全综合征(MODS)患者Marshall心功能评分与血清肌酸磷酸激酶/血清肌酸磷酸激酶混合型同工酶(CK/CK-MB)水平之间的关系。方法收集30例MODS患者进行Marshall心功能评分,同时检测CK/CK-MB水平,结果进行相关性分析。结果PAR值(压力调整后心率=心率×中心静脉压/平均动脉压)与CK/CK-MB水平之间无相关关系(P>0·05)。以Marshall心功能评分计算的心脏损伤发生率为46·7%,以CK/CK-MB水平计算的心脏损伤发生率也为46·7%,二者之间无显著差异(P>0·05)。结论Marshall心功能评分及CK/CK-MB水平均可作为评价心脏损伤的指标,二者从不同侧面反映心脏损害情况。     

多器官功能障碍综合征患者外周血白三烯B4与p38丝裂原活化蛋白激酶的变化

目的　探讨多器官功能障碍综合征( MODS)患者外周血白三烯B4( LTB4)与p3 8丝裂原活化蛋白激酶( p3 8MAPK)含量的变化及与MODS病情的关系。方法　对2 6例MODS患者进行病情评分,采用酶联免疫吸附法( ELISA)检测血中LTB4与p3 8MAPK含量,并与1 2例健康体检者进行对照。比较MODS患者MODS评分与外周血L TB4和p3 8MAPK的相互关系,及MODS组死亡与存活患者的MODS评分、外周血LTB4与p3 8MAPK含量。结果　MODS患者血清LTB4含量为( 92 3 .96±3 0 8.65) ng/L,明显低于健康对照组( 2 453 .3 1±40 0 .93 ) ng/L( P<0 .0 5) ;MODS患者血清中p3 8MAPK含量为( 1 93 .83±1 0 6.3 2 ) ng/L,与健康对照组( 1 2 4.3 6±84.50 ) ng/L比较差异无显著性( P>0 .0 5)。MODS组中死亡患者的血清L TB4含量为( 4 44 .98±2 0 6.3 0 ) ng/L,明显低于存活患者的( 1 3 3 4 .51±53 0 .3 5) ng/L( P<0 .0 5) ;p3 8MAPK含量为( 2 72 .0 8±2 0 7.3 7) ng/L ,明显高于存活患者( 1 1 5.59±57.99) ng/L ( P<0 .0 5)。结论　MODS晚期病理生理变化与一般炎症反应有所不同。外周血L TB4与p3 8MAPK可作为MODS病情严重程度及预后判断指标。     

分子吸附再循环系统治疗多器官功能障碍的临床研究

目的　评价分子吸附再循环系统 ( MARS)对各种原因导致的多器官功能障碍患者的临床治疗效果。方法　对 6 1例因各种原因导致的多器官功能障碍患者进行了 198次 6～ 2 4 h的 MARS治疗。用序惯性脏器衰竭评分 ( SOFA)方法、生化指标及炎症细胞因子水平等评价疗效。结果　用 MARS治疗后可使患者一氧化氮、肿瘤坏死因子 α、白细胞介素 2、6、8及脂多糖结合蛋白水平均明显下降 ,同时大量水溶性和非水溶性毒素被明显清除 ,患者血流动力学、肝性脑病及呼吸、心、肾功能等临床症状明显改善 ,总体 SOFA评分明显下降 ,总体预后改善 ( 2 5例痊愈出院 ,其中 6例成功接受肝移植 ,总体生存率 4 1.0 % )。结论　 MARS可安全有效地用于各种原因导致的多器官功能障碍患者 ,有效清除一氧化氮和炎症细胞因子 ,改善临床预后