肺心病加重期心脏恶液质综合征治疗近况

<正> 心脏恶液质综合征(Syndromes of Cardiac Cachesia,SCC)系指在慢性充血性心力衰竭的基础上出现体重明显下降、显著消瘦、低蛋白血症及免疫功能低下等恶液质表现的一组综合征。慢性肺源性心脏病(以下简称慢性肺心病)所致的SCC在临床上较多见,而肺心病加重期SCC易并发多器官功能不全甚至多系统器官功能衰竭(MSOF),治疗相当棘手,预后不良,病死率高。作者复习近年来国内     

老年肺心病与多系统器官衰竭

多系统器官衰竭(multiple system organ failure,MSOF)是指肺、心、肾、肝、消化道、中枢神经系统或血液系统等同时或在短时间内发生两个或两个以上的器官衰竭。其病死率高达74％～94％。近年来受到广泛重视。老年肺心病并发MSOF病情复杂,预后更差。我院1985年1月至1992年6月收治老年肺心病470例,就其中并发MSOF的132例(28％)讨论如下。     

慢性肺心病并发多系统器官衰竭45例死亡分析

慢性肺心病(简称肺心病)是呼吸系统中常见病、多发病,病死率高。我院1985年1月～1993年12月收治肺心病并发多系统器官衰竭(MSOF)81例,本文对其中45例死亡病例作如下分析。     

42例新生儿多器官功能衰竭临床分析

目的提高新生儿多器官功能衰竭(MSOF)的早期诊断和防治水平。方法对42例新生儿各种疾病合并MSOF的病因，发生器官衰竭例数，累及器官衰竭顺序和持续时间及与发病日龄、胎龄、出生体重的关系进行分析。结果本组MSOF病例中，原发病以新生儿肺炎占第一位；各种疾病中单个器官衰竭的发生率，以呼吸衰竭最高为92．8％；新生儿MSOF的发生率在日龄≤7d围生儿为73．8％；在早产儿与足月儿相比有显著性差异(P≤0．01)。结论MSOF与预后呈正相关。器官功能衰竭数越多病死率越高，其发生常与感染、缺氧缺血、早产、营养不良等因素有关，因此加强围产期保健，及时控制感染，抢救休克，纠正呼衰，对防治MSOF尤为重要。     

慢性肺心病并发多系统器官功能衰竭：附100例临床分析

多系统器官功能衰竭(Multiple system organ failure,以下简称MSOF)是本世纪七十年代提出的一个新的临床综合征。今将我们近年来收治的慢性肺心病并发MSOF 100例作一简要分析。     

肺心病右心衰竭479例临床分析

本文总结753例肺心病住院患者,并发右心衰竭479例(63.61%),死亡157例(20.85%),较云南省第一医院死亡率(19.2%)高.并对肺心病并发右心衰竭后的病死率、与多系统器官功能衰竭、频繁呼吸道感染、免疫功能异常的关系以及临床特点进行分析如下.     

肺心病并多器官功能衰竭76例临床分析

多系统器官功能衰竭也称多脏器衰竭(MultipleSystem Faiture,MSOF),任何危重病的晚期均可发生MSOF,因其病死率高,近年来临床上受到广泛重视.我院1984～1995年收治肺心病320例,其中并发MSOF76例,现分析如下.1 临床资料1.1一般资料 男49例,女27例,年龄45～80岁,平均65.4岁,所有病例符合1977年全国肺心病会议修     

重型颅脑损伤并多器官功能衰竭45例临床分析

目的探讨重型颅脑损伤并发多系统器官衰竭(MSOF)的主要临床特征和预防治疗的对策。方法对586例单纯性重型颅脑损伤患者各器官功能进行监测。结果全组发生MSOF45例，发生率7．68％，其临床特征①常出现在伤后3～7天，本组37例，占82．2％，病情复杂，容易忽视，本组有7例未能及时发现，占15．6％；②最早最多见的临床表现为呼吸衰竭，本组41例，占91．1％；③既往有疾病的器官发生率高为69％；④颅脑损伤越重．GCS评分越低，MSOF发生率越高，本组GCS6～8分者MSOF发生率为3．4％，3～5分者发生率为8．1％，脑疝者发生率为10．4％；⑤脑实质损伤多见，本组41例占91．1％，预后差、死亡率高，本组死亡31例，病死率为68％。结论早期开颅手术，解除颅内高压，控制肺部感染，密切监测各器官功能，加强对器官功能的支持，可降低MSOF的发生率。     

慢性肺心病并发多脏器功能衰竭144例临床分析

目的：回顾总结慢性肺心病并发MOF的临床体会。方法：对144例MOF病历临床资料进行分析讨论。结果：①衰竭器官数与病死率关系是呈正相关(并发一个器官衰竭的是29．2％，两个器官的83．9％，三个器官以上是100％)。②衰竭器官不同病死率相差很大(中枢神经是56．7％，血液是85．7％)。结论：MOF是慢性肺心病死亡的主要原因，积极恰当治疗呼衰、心衰是防止MOF发生的关键。     

肺原性心脏病并发多脏器功能衰竭临床特点

目的：总结肺原性心脏病(简称肺心病)并发多脏器功能衰竭的临床特点。方法：回顾性分析我院1995年1月至2002年12月收治的肺心病并发多脏器功能衰竭86例的临床资料。结果：肺心病并发多脏器功能衰竭的主要诱因是肺部感染，各脏器均可发生功能衰竭，死亡34例，病死率为39．5％，病死率随衰竭脏器数的增多而增加。结论：积极防治肺心病患者的肺部感染，可减少并发多脏器功能衰竭和病死率。     

Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management

Pulmonary hypertension (PH) is common in the critical care setting, and may be a target for specific therapy. Moderate degrees of pulmonary hypertension are most often the consequence of acute or chronic heart failure, hypoxemia, or acute pulmonary embolism, and may be relatively rapidly reversible. The consequences of more severe forms of PH, both acute and chronic, can include hypotension; low cardiac output; right heart failure with congestion of the liver, gut, and kidneys; and varying degrees of hypoxemia, each of which can lead to death or severe disability. We review the physiology, definitions, classification, pathogenesis, diagnostic tools, and algorithms for diagnosis and specific treatments for the various causes of PH as seen in the critical care setting.     

Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension

Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1–5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36?% died overall, 10?% per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5?% change in RAEF: 0.83 [95?% CI 0.73–0.94], p?=?0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.     

紫外线照射充氧自血回输治疗肺心病多器官功能衰竭48例

１９８９年１０月至１９９３年５月，我们对经综合治疗无好转或恶化的４８例慢性肺心病急性发作期并发多器官功能衰竭（ＭＯＦ）患者，加用紫外线照射充氧自血回输疗法，４７例缓解出院，而对照组１６例中仅８例缓解出院，治疗组明显优于对照组。     

急性呼吸窘迫综合征右心改变的认识进展

尽管治疗方案经历了长足的发展，急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)的病死率仍居高不下。随着研究的深入，学者们逐渐发现ARDS患者不仅出现肺损伤，也会出现循环损伤，导致右心功能不全及急性肺源性心脏病。短暂的低氧血症并非ARDS患者预后的独立危险因素，而循环损伤可直接影响其预后。因此，ARDS治疗的核心逐渐从肺保护转向于右心保护。本文对ARDS右心改变的特点及右心保护的策略进行梳理和总结，同时针对循环保护的环节，提出“抢先保护”的理念，为ARDS的治疗提供新的思路。     

先天性心脏病伴重度肺动脉高压术后早期并发症分析

目的 探讨先天性心脏病（CHD）伴重度肺动脉高压（PH）体外循环（CPB）术后早期并发症及处理。方法对本科2003年6月至2009年6月行CPB手术的45例CHD伴重度PH患者进行回顾分析,讨论术后早期主要并发症和死亡原因。结果术后早期主要并发症有严重低氧血症（13．33％）、缺氧发作（11．11％）、低心排（6．67％）。住院死亡率6．67％,死亡原因均为低心排,主要为右心室功能失代偿。多因素分析显示,低温CPB（OR=0．56;95％CI0．35-0．89）是严重低氧血症的一个危险因素。结论术后早期并发症主要由术后PH为基础的心肺功能不全所导致,对术后高危患者动态监测肺动脉压、右心功能和延长呼吸机支持,有助于防治并发症。     

BiPAP呼吸机治疗COPD合并Ⅱ型呼吸衰竭疗效观察

目的 探讨BiPAP(双水平正压通气)呼吸机在治疗慢性阻塞性肺疾病(COPD)合并II型呼吸衰竭中的价值.方法 在给予吸氧、抗感染、呼吸兴奋剂等常规治疗的基础上,加用BiPAP呼吸机通气治疗,观察COPD合并Ⅱ型呼吸衰竭患者治疗前后pH值、PO2、PCO2、呼吸频率、心率等指标的变化.结果 34例COPD合并Ⅱ型呼吸衰竭患者中29例加用BiPAP无创呼吸机通气,治疗后pH值、PO2、PCO2、呼吸频率、心率等指标变化有显著性改善(P<0 01).结论 应用BiPAP呼吸机治疗COPD合并II型呼吸衰竭的疗效满意、并发症少,患者易于接受.     

丹参多酚酸盐联合米力农治疗慢性肺心病心力衰竭临床疗效分析

目的观察丹参多酚酸盐联合米力农治疗慢性肺心病心力衰竭的临床疗效。方法选择2010年12月至2013年5月56例慢性肺源性心脏病心力衰竭病例。然后随机分为两组（治疗组与对照组）,两组皆给予积极控制感染、持续低流量吸氧、强心、利尿、解痉、平喘等常规基础治疗。治疗组在常规基础治疗上给予丹参多酚酸盐联合米力农治疗。观察两组的临床疗效及治疗后PaCO2、PaO2变化情况。结果治疗组的总有效率（92．30％）高于对照组（70．00％）,差异具有统计学意义（P〈0．05）。治疗前后两组PaCO2、PaO2水平都具有显著差异,差异具有统计学意义（P〈0．05）,治疗后治疗组的PaCO2水平明显低于对照组（P〈0．05）,PaO2水平明显高于对照组（P〈0．05）。结论丹参多酚酸盐联合米力农治疗慢性肺心病心力衰竭效果显著,值得进一步的临床证实和推广。     

老年急性心肌梗死合并多器官功能衰竭的临床特点与护理

目的总结老年急性心肌梗死（AMI）合并老年多器官功能衰竭（MOFE）的临床特点及护理,以改善护理方法。方法分析22例老年AMI合并MOFE患者的临床特点及护理要点。结果经给予注意心、肺、肾功能的早期监测、早期护理干预减少肺部感染及心衰的发生等护理措施,22例老年AMI患者仍有10例患者合并心、肺及肾功能衰竭,6个以上器官衰竭者病死率100％。结论老年AMI合并MOFE的病死率较高,临床表现不典型,需掌握多学科知识,综合评价监测数据,及时发现器官衰竭早期改变,减少衰竭器官数目。     

Why there is a need to discuss pulmonary hypertension other than pulmonary arterial hypertension?

Pulmonary hypertension(PH) is a condition characterized by the elevation of the mean pulmonary artery pressure above 25 mm Hg and the pulmonary vascular resistance above 3 wood units. Pulmonary arterial hypertension(PAH) is an uncommon conditionwith severe morbidity and mortality, needing early recognition and appropriate and specific treatment. PH is frequently associated with hypoxemia, mainly chronic obstructive pulmonary disease and DPLD and/or left heart diseases(LHD), mainly heart failure with reduced or preserved ejection fraction. Although in the majority of patients with PH the cause is not PAH, a significant number of published studies are still in regard to group Ⅰ PH, leading to a logical assumption that PH due to other causes is not such an important issue. So, is there a reason to discuss PH other than PAH? Chronic lung diseases, mainly chronic obstructive lung disease and DPLD, are associated with a high incidence of PH which is linked to exercise limitations and a worse prognosis. Although pathophysiological studies suggest that specific PAH therapy may benefit such patients, the results presented from small studies in regard to the safety and effectiveness of the specific PAH therapy are discouraging. PH is a common complication of left heart disease and is related to disease severity, especially in patients with reduced ejection fraction. There are two types of PH related to LHD based on diastolic pressure difference(DPD, defined as diastolic pulmonary artery pressure- mean PAWP): Isolated post-capillary PH, defined as PAWP 15 mm Hg and DPD 7 mm Hg, and combined post-capillary PH and pre-capillary PH, defined as PAWP 15 mm Hg and DPD ≥ 7 mm Hg. The potential use of PAH therapies in patients with PH related to left heart disease is based on a logical pathobiological rationale. In patients with heart failure, endothelial dysfunction has been proposed as a cause of PH and hence as a target for treatment, supported by the presence of increased endothelin-1 activity and impaired nitric oxide-dependent vasodilation. Unfortunately, so far, there is no evidence supporting the use of specific PAH therapies in patients with PH related to left heart disease. In conclusion, the presence of PH in patients with conditions other than PAH contributes to the severity of the disease, affecting the outcome and quality of life. The disappointing results regarding the effectiveness of specific PAH therapies in patients withchronic lung diseases and LHD underline the need for seeking new underlying mechanisms and thus novel therapies targeting PH due to left heart disease and/or lung diseases.     

机械通气治疗急性重症左心衰竭的临床应用

目的:探讨机械通气在抢救急性重症左心衰竭患者中的临床应用。方法:对20例急性重症左心衰竭患者在常规治疗的同时,应用机械通气辅助治疗,观察通气前后血液动力学的变化。结果:通气治疗后,17例患者症状明显改善,血气分析等参数与治疗前比较有显著性差异(P<0.01),顺利脱机。结论:机械通气治疗急性重症左心衰竭能迅速改善患者的临床症状,纠正低氧血症,大大降低死亡率,是一种积极有效的辅助治疗措施。