颅脑损伤气管切开病人气道湿化的效果探讨

目的：探讨持续氧气驱动雾化方法与传统超声雾化方法在颅脑损伤气管切开术后病人气道湿化的效果。方法：将89例颅脑损伤气管切开术后的病人随机分为两组,分别采用持续氧气驱动雾化气道湿化与传统超声雾化气道湿化方法,对其痰液的粘稠度、痰痂形成进行观察。结果：两组病人痰液粘稠度及痰痂形成有显著性差异（P〈0.01）。结论：颅脑损伤气管切开术后病人持续氧气驱动雾化气道湿化方法可预防痰液附着管壁,减少痰痂形成,对改善和保持病人呼吸道通畅有明显效果。     

重型颅脑损伤患者气管切开术后早期应用持续加温湿化吸氧疗法的效果观察

目的探讨持续加温湿化吸氧疗法在重型颅脑损伤患者气管切开术后的早期应用效果。方法将70例重型颅脑损伤气管切开非机械通气患者随机分成对照组和观察组。对照组（35例）采用持续氧气雾化吸入法进行气道湿化；观察组（35例）采用持续加温湿化氧疗进行气道湿化；观察两组患者痰液粘稠度、痰痂、日均吸痰次数、血氧饱和度及肺部感染等并发症的情况。结果观察组患者痰痂、日均吸痰次数、肺部感染发生率均低于对照组。结论重型颅脑损伤气管切开术后早期采用持续加温湿化氧疗进行气道湿化，能有效保持患者的气道通畅，增加氧合，降低肺部感染发生率，值得临床推广使用。     

复方氧氟沙星溶液用于老年气管切开患者预防呼吸道感染的研究

目的 为减少老年气管切开术后患者呼吸道感染，探讨有效的气管内给药途径。方法 将44例老年气管切开患者随机分为3组，给予临床上常用的3种气道湿化法，13例超声雾化组，17例间歇气管内滴药组，14例持续气管内滴药组。分别采用细菌学培养，并定时测量痰液、血液的药物浓度。3组进行效果观察对比。结果 14例持续气管内滴药组痰液的细菌明显少于其他组（P〈0．01），而血液的药物浓度明显高于其他2组（P〈0．05）。结论 采用套管内持续气管内滴药可充分湿化气道，促进患者气管、支气管内痰液稀释并排出，促进气管上皮柱状纤毛有效摆动，预防肺部感染发生，减轻患者的经济负担和痛苦。     

喉癌患者气管切开术后精密持续气道湿化法的效果评价

目的探讨精密持续气道湿化法对喉癌患者气管切开术后的护理效果。方法将96例喉癌行气管切开术的患者随机分为实验组50例和对照组46例。实验组采用精密持续气道湿化法持续湿化气道,对照组采用传统的气管内间断滴药湿化的方法,观察两组的护理效果。结果精密持续气道湿化法在刺激性咳嗽、痰痂形成、痰液粘稠不易吸净、气道黏膜出血、下呼吸道感染等方面的护理效果明显优于传统的气管内间断滴药湿化法,两组比较有显著性差异（P〈0．05,P〈0．01）。结论精密持续气道湿化法效果好,患者感觉舒适,并发症少,方法简单,减轻护理工作量,可应用于临床。     

复方氧氟沙星溶液用于老年气管切开患者预防呼吸道感染的研究

目的 为减少老年气管切开术后患者呼吸道感染,探讨有效的气管内给药途径.方法 将44例老年气管切开患者随机分为3组,给予临床上常用的3种气道湿化法,13例超声雾化组,17例间歇气管内滴药组,14例持续气管内滴药组.分别采用细菌学培养,并定时测量痰液、血液的药物浓度.3组进行效果观察对比.结果 14例持续气管内滴药组痰液的细菌明显少于其他组(P＜0.01),而血液的药物浓度明显高于其他2组(P＜0.05).结论 采用套管内持续气管内滴药可充分湿化气道,促进患者气管、支气管内痰液稀释并排出,促进气管上皮柱状纤毛有效摆动,预防肺部感染发生,减轻患者的经济负担和痛苦.     

持续气道湿化在气管切开中的应用及护理

颅脑损伤、高血压脑出血术后患者因昏迷、呼吸道梗阻、呼吸不畅、痰多且粘稠、严重缺氧等原因，需行气管切开术。气管切开术后气体失去正常呼吸道黏膜加温、滤过、湿化等作用，又因频繁吸痰使气道黏膜和纤毛运动受损导致气道干燥，痰液干涸，呼吸道粘稠分泌物增多，咳嗽及排痰机制障碍而影响通气功能，容易并发肺部感染叫。采用微量注射泵持续气管内给药与传统方法相比有利于呼吸道湿化，稀释痰液，降低呼吸道感染率。2005-01～2007—06我科采用微量注射泵持续气管内给药方法，报告如下。     

气管内滴药与雾化吸入在颅脑损伤患者气管切开中的应用效果

目的 观察气管内滴药与雾化吸入在不同程度脑损伤患者中应用的效果。方法 对120例中度（60例）、重度（60例）颅脑损伤气管切开患者,随机分为气管滴药组（60例）和雾化吸入组（60例）,观察在气管切开后7、14和21d患者的平均痰量和痰细菌培养情况。结果 在中度颅脑损伤气管切开患者中,雾化吸入组痰细菌培养阳性率明显低于气管内滴药组,痰量也较后者显著减少;重度颅脑损伤组气管切开患者中,气管滴药组痰细菌培养阳性率及痰量明显低于雾化吸入组。结论 在颅脑损伤气管切开患者中,中度损伤患者雾化吸入法在稀释痰液防止下呼吸道感染方面效果优于气管滴药法;在重度脑损伤患者中应用气管内滴药效果优于雾化吸入法。     

气管插管后雾化法与滴药法给药的效果比较

正常人鼻腔内含有丰富的血管,对吸入空气的温度和湿度起调节作用,气管插管经人工气道机械通气者,由于上呼吸道的湿化和温热功能完全丧失,减弱了呼吸系统的防御功能,使肺部感染发生率升高[1],充分排痰与气管内给药是预防呼吸道感染的重要护理措施。为预防呼吸道感染一般采用气道内滴药,但滴药量小时,药物不易到达肺内,只能在气管内起抑菌和湿润痰液的作用;用药量较大则有稀释肺表面活性物质的弊端[2],并易诱发气道痉挛而引起患者剧烈呛咳,造成人机对抗。随着呼吸机改进,气管插管患者可以通过雾化疗法湿化呼吸道。因此对雾化法和滴药法给药的…     

重型颅脑损伤气管切开患者气道湿化研究进展

重型颅脑损伤常伴有不同程度的呼吸障碍,致使患者缺氧窒息,颅内压升高,病情进一步恶化。因此行气管切开术,建立人工气道,保持呼吸道通畅,是对重型颅脑损伤患者早期救治的关键。气管切开后患者自主湿化及排痰能力减弱,易导致人工气道内痰痂形成,甚至堵塞,且由于气道湿化不足及机体抗感染能力下降等因素易导致肺部感染等并发症的发生。合理的气道湿化可保持气道湿润、稀释痰液、保持呼吸道通畅、预防肺部感染。临床上采用的湿化方法多种多样,现就重型颅脑损伤气管切开患者气道湿化的护理综述如下。     

气管内滴药对预防气管切开患者呼吸道感染的效果观察

目的：预防气管切开术后呼吸道感染,选择有效的气管内给药方式。方法：将气管切开术后的患随机分为36例持续气管内滴药组和30例间断气管滴药组,分别进行痰液的细菌学培养,同时动态监测痰液和血液的药物浓度。结果：持续气管内滴药组的痰液检出细菌明显少于间断滴药组（P＜0．05）;其血液药物浓度亦高于间断滴药组（P＜0．01）。结论：对气管切开术后患行持续气管内滴药,有利于湿化气道,稀释痰液,抑制细菌生长,对预防呼吸道感染效果明显。     

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.