多发伤后多系统脏器衰竭早期指征的研究附68例临床分析

目的：探求多发伤后多系统脏器衰竭的早期指征。方法：选择了68例因交通事故所致的胸腹联合伤病人于入院后损伤发生6h内至急诊手术后6天对中性粒细胞计数,补体C3、C4、CH50,乳酸脱氨酶,总胆红素,谷草转氨酶,肌酐,C反应蛋白诸项指标进行连续观察,并按最终是否出现多系统脏器衰竭（MSOF）分为两组,对相应的项目进行比较分析。结果：MSOF组外周血补体C3、C4和CH50明显低于非MSOF组。结论：科体系统的激活情况是早期预测MSOF的较好指标,对临床上及早干预MSOF的出现或进展可能有重要意义。     

Pulmonary issues in acute and critical care: pulmonary embolism and ventilator-induced lung injury

Many patients admitted to acute care hospitals are at risk for VTE. Nurses play a pivotal role in prevention of VTE events by assessing risk and implementing prophylactic interventions, promptly recognizing and reacting to signs and symptoms of DVT and PE, and collaborating with other team members to ensure rapid treatment ensues. When patients require mechanical ventilation, nurses need to remain alert for complications indicative of VILI, effectively communicate assessment findings to other team members and confidently implement nursing and ordered medical interventions to promote the best possible patient outcomes.     

孕产妇危重症并发多器官功能衰竭临床分析

目的 探讨产科多器官功能衰竭临床诊断与处理。方法 回顾性总结12例多器官功能衰竭病例的临床资料，分析发病原因。结果 12例多器官功能衰竭诱因为重度妊高征、胎盘早剥、产后出血、子宫破裂、产褥感染。6例死亡，病死率50％。结论 治疗和预防原发病，积极去除病因，是降低多器官功能衰竭病死率的关键。     

Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury

Objective: To determine how immediate enteral nutrition (EN) affects gut permeability and the development of multiple organ failure (MOF) in multiply injured patients. Design: Prospective, randomised clinical trial. Setting: 20-bed surgical intensive care unit (ICU), university hospital. Patients: 28 consecutive multiply injured patients, admitted in shock and stabilised in 6 h. Interventions: Patients were randomly assigned to EN started not later than 6 h after admission to the ICU (group A), and to EN started later than 24 h after admission (group B). Measurements and main results: The lactulose/mannitol (L/M) test was performed in patients on days 2 and 4 after trauma, and in 5 healthy volunteers. MOF scores were calculated daily. The mean MOF score from day 4 onwards was 1.84 in group A versus 2.81 in group B (p < 0.002), and was correlated with the time of initiation of EN after injury and the L/M ratio on day 2. The median L/M ratio on day 2 was 0.029 for group A and 0.045 for group B, while on day 4 it was 0.020 and 0.060, respectively. On day 2 after trauma, the L/M ratio was significantly higher in group B (p < 0.05) than in normal volunteers (median 0.014) and was positively correlated with the time of starting EN. Conclusions: In contrast with normal volunteers, the patients started on EN later than 24 h after admission to the ICU demonstrated increased intestinal permeability on the second day after sustaining multiple injury. Also, they had a more severe form of MOF than the group placed on EN immediately upon admission. However, early EN had no influence on the length of ICU stay or the time of mechanical ventilation. Received: 16 March 1998 Final revision received: 15 September 1998 Accepted: 18 September 1998     

心内直视手术后多脏器功能衰竭的危险因素与防治措施

目的　探讨心脏直视手术后多脏器功能衰竭 (MSOF)的危险因素和防治措施。方法　回顾分析 33例心脏直视手术后MSOF的临床资料 ,并就基础心脏病变、术前心肺功能状况、体外循环时间等与MSOF的发生率和病死率进行统计分析。结果　本组MSOF发生率为 0 73% (33/ 4 5 5 0 ) ,总计发生衰竭脏器 91个 ,平均 2 76个 ;总的病死率为 5 4 5 % (18/ 33) ,2个衰竭脏器的病死率为 36 8% (7/ 19) ,3个衰竭脏器的病死率为 6 2 5 % (5 / 8) ,4个衰竭脏器的病死率为 10 0 % (6 / 6 )。结论　基础心脏病变重、术前心肺功能差、体外循环时间过长是MSOF发生的高危因素 ,病死率与衰竭脏器数有关 ,数目越多病死率越高 ,重在预防。     

Effects of early treatment with immunoglobulin on critical illness polyneuropathy following multiple organ failure and gram-negative sepsis

Objective: The evaluation of incidences and relating factors of severe persisting critical illness polyneuropathy (CIP) in survivors of multiple organ failure (MOF). Design: Prospective study with an entry period of 24 months. Electrophysiological studies for the diagnosis of CIP were performed 1 or 2 days before the patients were discharged from the intensive care unit (ICU). Factors which might have been related to the development of CIP were identified by a retrospective chart analysis. Setting: The interdisciplinary ICU of a university hospital. Patients: Thirty-three patients who survived MOF. Sixteen of these critically ill patients developed severe sepsis due to nosocomial infections with gram-negative bacteria. Results: In seven survivors of MOF and sepsis typical electrophysiological features of CIP, like spontaneous fibrillations and low compound muscle action potentials, were detectable at the time of discharge from the ICU. Seventeen patients with MOF following multiple trauma who developed no sepsis, and nine survivors of MOF with sepsis showed no signs of persisting CIP at the end of their ICU stay. Chart analysis revealed that eight survivors of MOF with sepsis and without the development of CIP had been treated with intravenous immunoglobulin (IVIG) with a dosage of 0.3 g/kg per day for 3 days immediately (within 24 h) after the diagnosis of sepsis. Four out of seven patients with MOF and sepsis who developed CIP were transferred to our ICU after the onset of sepsis and had not received IVIG treatment. The IVIG treatment in three patients was delayed for more than 24 h after the diagnosis of sepsis and was then omitted. Obviously not related to the development of CIP were aminoglycoside antibiotics, steroids, nutritional disturbances and episodes of hypotension or hypoxia. Neuromuscular blocking agents were not used during intensive care treatment. Conclusions: A high incidence of severe CIP persisting until the day of discharge from the ICU was related to gram-negative sepsis but not to MOF alone. Retrospective chart analysis suggested that early application of IVIG may prevent or mitigate this severe complication. However, these results have to be confirmed in a prospective, placebo-controlled study. Received: 22 April 1997 Accepted: 17 September 1997     

火器伤烟雾吸入致吸入性肺损伤细胞因子的变化及与多器官功能损害的关系

目的 观察火器伤烟雾吸入致重度吸入性肺损伤后支气管肺泡灌洗液（BALF）中致炎、抗炎细胞因子含量变化，及其在多器官功能损害中的作用。方法复制火器伤致大鼠重度吸入性肺损伤模型。观察大鼠伤后2、4、6、8、12和24h肺湿重／干重比，BALF中白蛋白、乳酸脱氢酶（LDH）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、IL-4的含量，外周血丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、血尿素氮（BUN）、血肌酐（SCr）、肌酸激酶同工酶（CK-MB）含量，并与正常对照组比较。结果大鼠肺湿重／干重比、BALF中白蛋白及LDH含量随时间的延长而增加；TNF-α在损伤后即增加，2h达高峰；IL-6损伤后4h明显增加，且伤后4～24h保持较高浓度；IL-4于伤后6～8h下降。外周血ALT、AST、BUN、SCr、CK-MB伤后持续增加。结论细胞因子可能是介导多器官功能损害的直接介质。多器官功能损害可能由TNF-α触发，随后引起细胞因子的级联反应，致炎因子IL-6的持续高表达和抑炎因子IL-4后期失控加剧了MOF的发展。     

Possible role of short-term parenteral nutrition with fat emulsions for development of haemophagocytosis with multiple organ failure in a patient with traumatic brain injury

We describe a case of life-threatening haemophagocytosis after a short term nutrition with fat emulsion in a 21-year-old woman who sustained an isolated traumatic brain injury. Hypertriglyceridemia and creaming plasma were observed after a three-day period of parenteral fat nutrition (Intralipid 20%). She also developed rash, high fever (40–41°C), hypertension, raised intracranial pressure, hepatic and renal failure, haemolysis, marked thrombocyto- and leucopenia, coagulation disorder and pulmonary failure. These symptoms, together with a typical bone marrow smear, indicated haemophagocytosis with hyperactivation of the mono-cyte-macrophage system. We suggest that the hyperactivation was an effect of fat retention or agglutination of the fat particles; the initial triggering mechnism may emanate from the brain damage by hypercytokinaemia. The steroid treatment given most likely contributed to the successful outcome, as indicated by the stepwise improvement related in time to the steroid infusions.     

单针血液透析在抢救多脏器功能衰竭中的应用

报告用单针血液透析抢救21例慢性肾功能衰竭并发急性左心衰竭和脑衰竭的昏迷患者。21例患者中男15例,女6例,年龄22～56岁。经降压,脱水和强心治疗无明显效果后,即行单针血液透析。血泵维持血流量开始为50ml/min,超滤500～1000ml液体,临床症状缓解后改为维持血流量100～200ml/min。常规给予肝素抗凝,每次透析4～6h。结果死亡7例,共原发病均为慢性肾小球肾炎性尿毒症;存活14例(有效率为66.6%),其原发病为慢性肾小球肾炎性尿毒症10例,恶性肾小动脉硬化性尿毒症4例。14例中透析1次便开始清醒、心衰和脑衰症状基本消失者6例;透析2～5次后清醒,同时心衰和脑衰症状完全消失者8例。4例恶性肾小动脉硬化者已脱离透析出院2年,情况良好。     

老年重症肺炎并发多器官功能衰竭患者临床危险因素分析

目的分析老年重症肺炎并发多器官功能衰竭患者的临床危险因素、治疗以及转归等。方法回顾73例老年重症肺炎并发多器官功能衰竭患者的临床资料,分析这些患者的相关化验指标、危险因素以及转归等。包括体重质量指数、白蛋白水平、血细胞比容、APACHEII评分、机械通气治疗、肺部感染评分等指标。结果临床肺部感染评分大于6分组患者的病死率高于小于6分组患者;未接受机械通气组患者病死率大于接受机械通气治疗组患者;A-PACHEII评分大于30分组患者的病死率大于小于30分组患者;存活组与死亡组患者的白蛋白水平、血细胞比容、体质量指数等无统计学差异。结论I临床肺部感染评分、APACHEII是预测老年重症肺炎并发多器官功能衰竭患者病死率非常重要的治疗,值得在,临床进一步推广。     

机械能：评估呼吸机相关肺损伤的新思路

机械能是指呼吸机为实现肺通气而传递给呼吸系统的能量，能量大小可以通过P-V环的曲线下面积得到，也可以将能量表示为包含呼吸机参数和肺部特性的函数。近年来，有研究者认为机械能或许是一个从总体上评估呼吸机相关肺损伤的良好指标，进而用于指导最佳的机械通气策略。     

Effects of frequency and inspiratory plateau pressure during recruitment manoeuvres on lung and distal organs in acute lung injury

Purpose  To evaluate the effects of frequency and inspiratory plateau pressure (Pplat) during recruitment manoeuvres (RMs) on lung and distal organs in acute lung injury (ALI). Methods  We studied paraquat-induced ALI rats. At 24 h, rats were anesthetized and RMs were applied using continuous positive airway pressure (CPAP, 40 cmH₂O/40 s) or three-different sigh strategies: (a) 180 sighs/h and Pplat = 40 cmH₂O (S180/40), (b) 10 sighs/h and Pplat = 40 cmH₂O (S10/40), and (c) 10 sighs/h and Pplat = 20 cmH₂O (S10/20). Results  S180/40 yielded alveolar hyperinflation and increased lung and kidney epithelial cell apoptosis as well as type III procollagen (PCIII) mRNA expression. S10/40 resulted in a reduction in epithelial cell apoptosis and PCIII expression. Static elastance and alveolar collapse were higher in S10/20 than S10/40. Conclusions  The reduction in sigh frequency led to a protective effect on lung and distal organs, while the combination with reduced Pplat worsened lung mechanics and histology. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. The work was supported by Centres of Excellence Program (PRONEX-FAPERJ), Brazilian Council for Scientific and Technological Development (CNPq), Carlos Chagas Filho, Rio de Janeiro State Research Supporting Foundation (FAPERJ), S?o Paulo State Research Supporting Foundation (FAPESP).     

动态通气参数对急性呼吸窘迫综合征犬肺损伤的作用机制

目的 探讨机械通气动态通气参数对ARDS犬肺内肺炎症介质的影响及其作用途径.方法 取36条健康杂种犬,采用气管内盐酸吸入法建立ARDS模型,随机(随机数字法)分为对照组,ARDS模型组及实验犬组,实验犬组随机分成A,B,c,D四组,每组6条.A组:小潮气量(6 mL/kg),低吸气流速[6mL/kg·s)],高通气频率(30次/min);B组:大潮气量(20mL/kg),高吸气流速[20mL/(kg·s)],高通气频率(30次/min);C组:大潮气量(20 mL/kg),高吸气流速[17 mL/(kg·s)],低通气频率(15次/min);D组:大潮气量(20 mL/kg),低吸气流速[10 mL/(kg·s)],低通气频率(15次/min).机械通气4 h后处死动物,留取肺组织标本行免疫组化、Western blotting检测TNF-α,IL-8,p38 MAPK蛋白的变化,RT-PCR测定TNF-α,IL-8 mRNA的表达,流式细胞仪检测NF-κB活性.结果 B组IL-8蛋白表达明显较A,D组高,c组IL-8蛋白表达较B组有下降趋势,但B,C组之间差异无统计学意义;B组TNF-α的灰度比值明显较其他组高(P<0.01),但与C组比较差异无统计学意义(P>0.05);B组p38 MAPK表达明显较A,D组高(P<0.01);A,D组之间的p38 NAPK表达差异无统计学意义(P>0.05).B组NF-κB p65(33.56±2.85)%表达较A(10.35±0.6)%,D(7.11±0.47)%两组差异有统计学意义,B组与C组(30.87±1.16)%之间差异无统计学意义.结论 在相同的大潮气量基础上,高吸气流速和高通气频率可以激活肺组织p38 MAPK及NF-κB通道,炎症介质的释放增加,导致呼吸机相关性肺损伤,小潮气量机械通气可减轻炎症反应.     

细胞膜泵活性在急性肾衰竭致多器官损伤中的机制

目的 观察急性肾衰竭(ARF)致多器官损伤家兔肾、心肌、胰腺细胞膜泵活性的变化,探讨ARF致多器官损伤的作用机制. 方法 将42只家兔按随机数字表法分为对照组、HgCl2组和甘油组,后两组再分为12、24、48 h 3个亚组,每组6只.以皮下注射1% HgCl2(1.3 ml/kg)或肌肉注射50%甘油(10 ml/kg)分别复制ARF模型.各组分别于不同时间点留取肾、心肌、胰腺组织并制备组织匀浆,采用定磷法检测上清液中的ATP酶活性. 结果 与对照组比较,两个ARF模型组肾组织匀浆Na+-K+-ATP酶、Ca2+-ATP酶、Ca2+-Mg2+-ATP酶活性均随ARF病情程度加重而逐渐降低,于48 h达最低水平[HgCl2组分别为(0.84±0.16)、(0.52±0.17)、(0.45±0.09) μmol·mg-1·h-1,甘油组分别为(0.85±0.22)、(0.49±0.21)、(0.54±0.17) μmol·mg-1·h-1];心肌和胰腺组织匀浆Na+-K+-ATP酶、Ca2+-ATP酶、Mg2+-ATP酶、Ca2+-Mg2+-ATP酶活性也逐渐降低,48 h时达最低[心肌HgCl2组分别为(0.56±0.11)、(0.51±0.19)、(0.55±0.19)、(0.37±0.19) μmol·mg-1·h-1,甘油组分别为(0.52±0.19)、(0.62±0.10)、(0.61±0.16)、(0.54±0.10) μmol·mg-1·h-1;胰腺HgCl2组分别为(0.81±0.12)、(0.71±0.15)、(0.73±0.18)、(0.62±0.16) μmol·mg-1·h-1,甘油组分别为(0.72±0.13)、(0.57±0.18)、(0.66±0.14)、(0.59±0.23) μmol·mg-1·h-1],与对照组比较差异均有统计学意义(P<0.05或P<0.01). 结论 ARF致心肌、胰腺损伤的机制与组织细胞膜泵活性降低有关.     

多器官衰竭患者白细胞糖皮质激素受体和血浆皮质醇变化的观察

用放射配体结合法测定３６例多器官衰竭（ＭＯＦ）患者血白细胞糖皮质激素受体（ＧＣＲ）和血浆皮质醇（Ｆ）的变化，并行ＡＰＡＣＨＥⅡ评分。作者认为合理使用外源性糖皮质激素或提高ＧＣＲ水平有益ＭＯＦ的防治。     

不同急性肾损伤分期的MODS患者连续肾脏替代治疗预后分析

目的探讨RIFLE标准的急性肾损伤(AKI)分期与连续性肾脏替代治疗(CRRT)的多器官功能障碍综合征(MODS)患者预后的关系。方法回顾性分析第四军医大学西京医院肾脏病科2004年以来行连续性静脉-静脉血液滤过(CVVH)治疗的240例MODS患者,按RIFLE标准分为AKIⅠ期、Ⅱ期和Ⅲ期,对比分析不同AKI分期患者的医院死亡率和器官衰竭数,并将CVVH治疗前和治疗24h后的APACHEII评分、SOFA评分、平均动脉压(MAP)、氧合指数、血尿素氮(BUN)和血肌酐(Scr)等指标进行比较。结果①全部患者死亡率为38.75%,AKIⅢ期患者医院死亡率高于AKIⅠ期和Ⅱ期患者(P<0.05)。②随着AKI分期的加重,患者器官衰竭数增加(P=0.001)。发生脏器衰竭≥4个的患者医院死亡率明显高于脏器衰竭数≤3个的患者,(75.5%vs13.4%,P<0.05)。③CVVH治疗24h后,患者MAP、氧合指数、BUN和Scr均明显改善;APACHE II评分和SOFA评分在AKII期和II期患者显著降低,在AKI III期患者中则变化无显著性。结论CVVH是防治MODS合并重症ARF患者的有效手段,RILFE标准对AKI早期诊断和判断预后有指导意义。必须强调CVVH时机的选择,早期(AKIⅠ期和Ⅱ期)行CVVH可以明显改善MODS患者的预后。     

Leptospirosis with pulmonary haemorrhage and multiple organ failure: a case report and literature review

Pulmonary haemorrhage is an important complication of leptospirosis. We herein report an uncommon case of severe pulmonary haemorrhage and multiple organ failure caused by leptospirosis in a 49-year-old man who was previously healthy. He was a farm worker who was admitted to the hospital because of haemoptysis. He had worked in a paddy field 4 days prior to admission. Chest computed tomography revealed pulmonary haemorrhage, which rapidly deteriorated into haemorrhagic shock and multiple organ failure. Based on the patient’s possible history of contact with contaminated water and the DNA sequence of Leptospira detected in his bronchoalveolar lavage fluid, the patient was diagnosed with pulmonary haemorrhagic leptospirosis. Despite the administration of a fluid bolus, norepinephrine, broad-spectrum antibiotics, and haemostatics, and even with administration of a blood transfusion and extracorporeal life support, the pulmonary haemorrhage could not be controlled effectively. The patient eventually died of haemorrhagic shock. Leptospirosis can be a life-threatening disease despite aggressive treatment, even with extracorporeal life support. Next-generation sequencing can provide important diagnostic clues for patients with atypical leptospirotic symptoms.     

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。     

人工肝支持系统成功抢救妊娠急性脂肪肝合并多器官衰竭患者1例报道

目的 分析妊娠急性脂肪肝患者的病例特点、抢救措施及预后,提高对此病的认识及早期诊治水平.方法 回顾性分析1例妊娠急性脂肪肝合并多器官衰竭患者病情演变以及抢救治疗情况,并结合相关文献分析讨论.结果 患者以妊娠晚期出现重度黄疸伴消化道症状起病,常规保肝、退黄等治疗未能逆转病情,并迅速出现肺、肝、肾等多器官衰竭以及DIC等严重并发症,经积极终止妊娠、辅助呼吸及人工肝支持系统等综合抢救最终病情缓解,并经肝组织病理检查明确诊断.结论 妊娠急性脂肪肝病情凶险,极易并发多器官衰竭,早期诊断,多学科、全方位综合救治是提高本病成功抢救的关键.     

产科多器官功能衰竭17例临床分析

目的 探讨产科患者多器官功能衰竭(MOF)的临床诊断及处理.方法 对17例MOF病例的临床资料进行回顾性分析.结果 17例多器官功能衰竭的主要诱因是产后出血、重度妊娠期高血压疾病、羊水栓塞、胎盘早剥.器官功能障碍以凝血功能障碍及肾功能衰竭为最多见.8例死亡,病死率47.06%.结论 预防和治疗原发病,积极去除病因,早期诊断及治疗凝血功能障碍及肾功能衰竭,是降低MOF病死率的关键.