7kg以下婴儿先天性心脏病术后机械通气的呼吸道优化管理

目的探讨7 kg以下婴儿先天性心脏病术后机械通气的呼吸道管理策略。方法将我科143例体质量小于7 kg先心病患儿随机分为两组,优化组74例患儿,术后给予机械通气呼吸道优化管理;对照组69例患儿术后给予机械通气常规护理。观察两组患儿使用呼吸机时间、呼吸机相关性肺炎及肺部并发症的发生情况。结果两组呼吸机相关性肺炎、肺部并发症发生情况比较差异有统计学意义(P0.05)。结论低体重先天性心脏病婴儿术后给予机械通气呼吸道优化管理,可以降低呼吸机相关性肺炎和肺部并发症的发生率,获得满意疗效。     

强化式呼吸道管理在先天性心脏病患儿术后护理中的应用

[目的]探讨强化式呼吸道管理在先天性心脏病患儿术后护理中的应用效果。[方法]将160例先天性心脏病患儿根据随机数字表法分为观察组及对照组,每组80例,对照组患儿术后行常规呼吸道护理,观察组患儿术后行强化式呼吸道护理,比较两组患儿术后呼吸系统相关并发症及预后情况。[结果]观察组患儿呼吸机使用时间、入住ICU时间及总住院时间均短于对照组(P0.05),观察组患儿干预后呼吸困难评分、急性生理与慢性健康评分Ⅱ(APACHEⅡ)评分低于对照组(P0.05);观察组呼吸机相关性肺炎、气胸、肺不张等并发症发生率低于对照组(P0.05)。[结论]术后强化式呼吸道管理能有效减少先天性心脏病患儿术后呼吸道相关并发症,有利于改善患儿预后。     

气道护理量化评估模式在先天性心脏病术后呼吸道管理中的应用

[目的]探讨气道护理量化评估模式在小儿先天性心脏病术后呼吸道管理中的应用。[方法]选取2015年1月—12月在我院住院手术治疗的小儿先天性心脏病患儿45例,按住院号单双号分为对照组和观察组,观察组应用量化评估模式进行呼吸道护理,对照组给予常规的呼吸道护理,比较两组患儿术后监护时间、使用呼吸机时间、呼吸系统相关并发症(主要包括肺不张、呼吸机相关性肺炎、气胸等)发生情况。[结果]观察组平均监护时间及使用呼吸机时间均较对照组缩短,但两组间差异无统计学意义(P0.05);术后总并发症、呼吸机相关性肺炎、肺不张、气胸发生率有所减低,但两组间差异无统计学意义(P0.05)。[结论]应用基于气管护理量化评估模式的呼吸道护理,为术后何时进行气道吸痰提供有力的依据,可以减少先天性心脏病患儿术后呼吸系统相关并发症,提高治疗效果。     

5kg以下婴幼儿体外循环术后ICU护理体会

目的:总结低体重先天性心脏病患儿术后ICU的护理措施与经验。方法:对40例低体重先天性心脏病患儿术后在ICU对其呼吸系统、循环系统、电解质及其并发症的监护及护理管理进行分析。结果:本组病例中39例康复出院,1例死亡,其中发生低心排2例,出血1例,严重心律失常2例,肺不张4例。结论:加强对低体重儿体外循环术后ICU的监护和护理管理,能及时发现和减少并发症,提高手术成功率,使患儿早日康复。     

呼吸道集束化护理在先天性心脏病患儿围术期中的应用研究

目的:探讨集束化护理措施在婴幼儿先天性心脏病围术期呼吸道护理中的应用与效果。方法:将201例先天性心脏病手术患儿纳入研究,将2010年1～12月收治的77例患儿作为对照组,采用常规护理方法;将2011年1～12月收治的124例患儿作为试验组,采用集束化护理措施,包括术前呼吸道管理、呼吸机使用管理、加强气管插管的护理、吸痰护理、肺部体疗、术后康复护理等。结果:试验组患儿术后血氧饱和度高于对照组,术后肺部感染率试验组(4.84%)低于对照组(12.99%),住院天数试验组比对照组短。结论:婴幼儿先天性心脏病围术期患儿实施科学、完善的集束化护理,能提高护理质量、降低术后呼吸道并发症。     

量化评估模式在小儿先天性心脏病术后气道管理中的应用

目的探讨创新设计的量化评估模式在小儿先天性心脏病术后气道管理中的应用效果。方法选取2015年1月-2016年6月在我院手术治疗并住院的小儿先天性心脏病共62例,随机分为对照组33例和观察组29例,观察组应用量化评估模式进行呼吸道护理,对照组给予常规的呼吸道护理,比较两组患儿术后监护时间、上机时间、呼吸系统相关并发症(主要包括肺不张、呼吸机相关性肺炎、气胸等)发生情况。结果与对照组相比,观察组的呼吸机使用时间明显缩短、并发症明显减少,差异有统计学意义(P0.051);在监护室监护时间明显缩短,差异无统计学意义(P=0.065)。结论应用量化评估模式进行呼吸道护理,为先心病术后提供了量化的气道护理评估依据,可以减少先天性心脏病患儿术后呼吸系统相关并发症,提高治疗效果,改善预后,值得在临床推广应用。     

重症先天性心脏病患儿术后呼吸机脱机的护理

[目的]探讨小于8 kg的重症先天性心脏病患儿术后呼吸机脱机护理要点及效果.[方法]145例小于8 kg的重症先天性心脏病患儿术后,严格掌握呼吸机脱机指证,给予恰当的脱机方法和呼吸道管理措施.[结果] 8例患儿行2次插管,其余均1次脱机成功,因术后低心排血量综合征死亡9例,无一例因脱机而导致死亡.[结论] 加强脱机前后的护理可提高重症先天性心脏病患儿术后呼吸机脱机的安全性和成功率.     

复杂先天性心脏病伴肺动脉高压患儿围手术期的呼吸道护理

目的 总结复杂危重先天性心脏病伴肺动脉高压患儿行体外循环术围手术期呼吸道管理的护理经验.方法 回顾分析2012年7月至2013年2月1 10例复杂危重先天性心脏病伴肺动脉高压行体外循环手术患儿的临床资料,总结围手术期呼吸道管理的护理经验.室间隔缺损、房间隔缺损93例,完全性房室通道6例,主动脉缩窄3例,完全性肺静脉异位引流4例,右室双出口3例,永存左上腔静脉1例,均伴肺动脉高压,肺动脉收缩压≥55 mm Hg;年龄1～12个月,平均(5.6±6.2)个月;体质量3.6～12.5 kg.术后均使用呼吸机辅助呼吸,呼吸机使用时间(36.5±10.6)h.术后均使用一氧化氮气体吸入.术前详细评估,术后重点观察预防呼吸机相关性肺炎的发生,控制肺动脉压力.结果 110例患儿监护室停留时间为(3.2±24)d,均未发生呼吸机相关性肺炎及肺动脉高压危象.平均住院时间19.4 d,均顺利出院.结论 复杂先天性心脏病伴肺动脉高压的患儿做好围手术期呼吸道的管理能有效改善患儿的呼吸功能,减少ICU停留时间.危重患儿特别是伴有肺动脉高压患儿围手术期降低肺动脉压力,术后积极预防呼吸机相关性肺炎是患儿快速恢复呼吸功能的关键.     

低体重先天性心脏病并肺动脉高压患儿的术后呼吸道护理

[目的]总结低体重先天性心脏病并肺动脉高压患儿的术后呼吸道护理。[方法]对200例低体重先天性心脏病并肺动脉高压患儿进行体外循环下心内直视手术治疗,同时加强术后呼吸道护理。[结果]200例患儿无死亡,均痊愈出院;术后仅1例发生肺动脉高压危象,经抢救好转,5例发生肺不张,经肺部理疗后好转,2例发生气胸,经胸腔闭式引流后痊愈,其余患儿无明显肺动脉高压表现及并发症。[结论]加强低体重先天性心脏病并肺动脉高压患儿的术后呼吸道护理是手术成功的保证。     

先天性心脏病术后呼吸机相关性肺炎的现状调查及护理对策

目的 探讨先天性心脏病外科手术后持续机械通气并发呼吸机相关性肺炎的现状及临床护理方法.方法 收集我院治疗的先天性心脏病且术后机械通气≥3 d的患儿224例,分析术后持续机械通气并发呼吸机相关性肺炎的临床特征,并提出有针对性的护理干预措施.结果 224例患儿中有34例占15.2％在先天性心脏病术后并发呼吸机相关性肺炎,并发呼吸机相关性肺炎的患儿死亡5例占14.7％.共分离出致病菌84株,其中,革兰阴性菌占70.2％、革兰阳性菌占16.7％、真菌占13.1％.结论 分析先天性心脏病术后各项指标,对预防术后呼吸机相关性肺炎具有重要意义;而加强患儿呼吸道的护理管理、加强呼吸肌功能锻炼、胃肠减压护理、加强营养支持、控制感染并把握脱机时机对先天性心脏病术后并发呼吸机相关性肺炎患儿的康复具有重要的意义.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.     

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.     

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.