Pneumothorax and pneumomediastinum during pediatric mechanical ventilation.

The incidence of pulmonary barotrauma during mechanical ventilation in children beyond the neonatal age group was studied in two groups of patients. In the first group, 179 cases of pediatric mechanical ventilation for over 12 hours were retrospectively analyzed for the occurrence of pneumothorax and pneumomediastrinum. Eleven percent (6 of 57) of young infants (0--6 months) without hyaline membrane disease and 3% (4 of 122) of older infants and children (over 6 months) developed these complications. Pulmonary barotrauma in young infants occurred only after cardiothoracic surgery and involved the same site as the intraoperative repair in all cases. Pulmonary barotrauma in older infants and children occurred in patients with severe respiratory disease requiring high peak airway pressures, PEEP, and respiratory rates. In the second group, the incidence of pulmonary barotrauma during ventilation with PEEP greater than or equal to 15 cm H2O was analyzed in 14 patients including 4 patients from the previous group. Overall, 64% (9 of 14) of this group developed pulmonary barotrauma and 43% (6 of 14) developed pneumothorax. Of 9 patients receiving PEEP greater than or equal to 15 cm H2O for longer than 24 hours, 6 developed pulmonary barotrauma after the first 24 hours. The incidence of pneumothorax and pneumomediastinum in ventilated infants without hyaline membrane disease and children is comparable to adult series.     

机械通气治疗新生儿并发呼吸机相关肺的相关因素及预防措施探讨

目的 探讨机械通气治疗新生儿并发呼吸机相关性肺炎(VAP)的相关因素及预防措施。方法 回顾性分析2018年1月至2020年12月于我院行机械通气治疗的200例新生儿临床资料,根据VAP发生情况分为VAP组与非VAP组,统计两组资料,分析机械通气患儿并发VAP的相关危险因素,并制定相关预防措施。结果 200例行机械通气治疗的新生儿中,有70例发生VAP,占比为35.00%(70/200);VAP组胎龄＜37周、出生体重＜2.5kg、营养不良、通气时间≥5d、吸痰次数≥6次、合并败血症占比均高于非VAP组,差异有统计学意义(P＜0.05);Logistic回归分析：胎龄＜37周、出生体重＜2.5kg、营养不良、通气时间≥5d、吸痰次数≥6次、合并败血症是机械通气患儿并发VAP的独立危险因素(P＜0.05且OR≥1)。结论 胎龄＜37周、出生体重＜2.5kg、营养不良、通气时间≥5d、吸痰次数≥6次、合并败血症是机械通气患儿并发VAP的独立危险因素,临床需予以高度重视。     

食管癌术后使用无创面罩式咳痰机的效果研究

目的 探讨无创面罩式咳痰机(mechanical insufflation-exsufflation,MI-E)对食管癌手术后的排痰效果及改善其呼吸功能的作用.方法 选择120例食管癌手术后患者,按随机原则分为实验组与对照组,各60例,监测2组患者咳痰效果,对2组患者术后发生低氧血症及肺不张的情况、术后住院时间与医疗费用、患者满意度进行对比分析,并将2组患者并发低氧血症及肺不张后治疗前与治疗后30 min的动脉血气指标结果进行对比.结果 实验组发生低氧血症及肺不张的例数、术后住院时间少于对照组,实验组患者满意度与对照组比较有显著性差异(P＜0.01).发生低氧血症及肺不张后,实验组治疗后30 min的PaO2及PaCO2的改善程度均明显优于对照组(P＜0.01).结论 无创面罩式咳痰机可预防并改善食管癌手术患者的通气障碍,是一种安全有效的辅助预防与治疗方法.     

术后机械通气患者吸痰操作疼痛现状及影响因素研究

目的 描述ICU患者术后24h内机械通气吸痰操作疼痛现状、疼痛变化趋势及影响因素。 方法 便利选取ICU术后机械通气患者101例,使用中文版行为疼痛评估量表、Richmond躁动镇静评分量表评估机械通气患者术后24h内第1次吸痰操作的操作前5min ,操作中,操作后5min、10min、15min、20min6个时间点的疼痛强度和镇静状态。结果 吸痰 操作明显增加了患者的疼痛强度,吸痰时疼痛评分中位数为 8 分,最高为 12 分;有疼痛感受者 100 例（ 99.0% ）;有明显疼痛感受者 94 例（ 93.1% ）;在操作后 5 min ,疼痛强度恢复到操作前5min水平。单因素分析和多因素分析结果显示,患者的镇静水平越低、引流管数量越多、有既往手术史,其疼痛评分越低。结论 吸痰操作会明显增加ICU机械通气患者术后24h内的疼痛强度。Richmond 躁动-镇静评分、引流管数量、既往手术史会影响患者的疼痛强度。     

Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial

ABSTRACT: INTRODUCTION: Weaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol. METHOD: Patients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed. RESULTS: Seventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay. CONCLUSION: Inclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.     

呼吸机相关性肺炎相关因素分析及护理对策

[目的]探讨ICU病房中使用呼吸机机械通气病人呼吸机相关性肺炎(VAP)的相关因素及护理对策。[方法]回顾性分析2004年12月—2005年2月使用呼吸机45例病人资料。[结果]年龄、营养状况、与呼吸机进行机械通气的连接方式、上机时间、频繁吸痰、雾化吸入等与VAP的发生相关。[结论]加强ICU全方位管理,严格无菌技术和消毒隔离,病人尽量采用半卧位,减少不必要的吸痰和雾化吸入等危险因素,是降低VAP发生行之有效的措施。     

心脏机械瓣膜置换术后早期患者对华法林抗凝认知现状及其影响因素分析

目的：调查心脏机械瓣膜置换术后早期患者对华法林抗凝认知情况,并探讨其影响因素,为制定有针对性的华法林抗凝临床健康教育方案提供依据。方法：采用自行设计的华法林抗凝认知情况调查表,以及Zung焦虑自评量表、Zung抑郁自评量表和社会支持评定量表,以门诊复诊和电话随访的方式对115例心脏机械瓣膜置换术后服用华法林进行抗凝治疗的患者进行问卷调查。结果：患者抗凝认知得分为4～15（9.34±2.91）分,认知程度差者占40.0%,认知程度一般者占34.8%,认知程度好者占25.2%;认知程度主要影响因素为社会支持度、抑郁程度和现居住地。结论：患者抗凝认知程度尚待提高,护理人员应加强对患者进行华法林抗凝相关知识的宣教,特别是对于社会支持较差、有抑郁倾向或抑郁症状以及现居农村的患者。     

Complications associated with mechanical ventilation

A constellation of adverse effects and complications may be associated with mechanical ventilation, although in many instances the causal role of the ventilator itself has not been established. Complications occur with greater frequency than is generally appreciated, and tend to be under-reported in the medical literature. Among the potential adverse physiologic effects of positive-pressure ventilation are decreased cardiac output, unintended respiratory alkalosis, increased intracranial pressure, gastric distension, and impairment of hepatic and renal function. Failure of the ventilator to cycle, of safety alarms to function properly, and of inspired gas to be properly heated or humidified are examples of equipment-related complications. Perhaps most feared among medical complications occurring during mechanical ventilation are pneumothorax, bronchopleural fistula, and the development of nosocomial pneumonia; these entities may owe as much to the impairment of host defenses and normal tissue integrity as to the presence of the ventilator per se. Finally, a variety of avoidable "misadventures," due primarily to lapses of understanding and communication among the physicians, nurses, and respiratory care practitioners managing the ventilated patient, can adversely affect comfort, morbidity, and ultimate outcome.     

ICU中心静脉导管相关性感染危险因素的调查研究

目的通过对ICU中心静脉置管患者感染的观察与分析,找出导管相关感染的危险因素。方法选择2009年9月至2010年3月,在ICU行中心静脉置管的患者,观察并记录其年龄、性别、置管部位、导管放置时间、穿刺点周围皮肤情况、导管性质、管腔数量、有无静脉营养等内容。护士根据患者的实际情况结合动态护理记录单实施有针对性的导管护理并及早反馈相关信息。结果患者年龄(58.1±18.9)岁,置管天数(8.76±6.89)d。行中心静脉置管的患者105例,其中77例次锁骨下静脉置管,23例次颈内静脉置管,6例次颈内静脉置入漂浮导管。中心静脉导管感染4例,置管时间分别为3、14、18、21 d,感染率为3.8%,每1 000个导管日感染率3.95。结论 ICU患者病情危重,严格掌握中心静脉置管适应症;使用中心静脉导管动态护理记录单进行导管常规评价,对症护理,缩短留置时间;严格的无菌技术是控制导管感染的关键措施。     

缺血性脑卒中患者血清炎性细胞因子变化与神经功能缺损及其相关因素的关系

背景随着对急性脑梗死病理生理机制的深入探讨,发现炎症反应在中枢神经系统缺血性损伤中占有重要地位,其中肿瘤坏死因子α,白细胞介素1β和可溶性细胞间黏附分子1正成为研究的热点.目的研究缺血性脑卒中患者血清中炎性细胞因子水平与病程,病情严重程度的关系.设计以患者和健康人为研究对象,病例-对照研究.单位武汉大学医院的神经内科.对象2001-01/2003-12武汉大学人民医院神经内科住院和门诊缺血性脑卒中患者50例,其中男23例,女27例,平均年龄(60.26±8.77)岁.对照组40例为同期门诊体检的健康人,其中男18例,女22例,平均年龄(61.05±8.09)岁.干预采用双抗体夹心酶联免疫吸附法测定血清肿瘤坏死因子α,白细胞介素1β,可溶性细胞间黏附分子1水平.主要观察指标缺血性脑卒中患者病程不同时期、不同梗死体积、不同神经功能缺损程度血清中肿瘤坏死因子α,白细胞介素1β,可溶性细胞间黏附分子1水平.结果急性期、恢复期脑梗死患者血清肿瘤坏死因子α,白细胞介素1β和可溶性细胞间黏附分子1水平较对照组显著增高(P＜0.01),急性期又较恢复期高(P＜0.05),增高程度与神经功能缺损程度及梗死体积大小密切相关,且血清中肿瘤坏死因子α含量与白细胞介素1β和可溶性细胞间黏附分子1也相关. 结论肿瘤坏死因子α,白细胞介素1β和可溶性细胞间黏附分子1互相作用参与了急性脑梗死的炎症反应和再灌流损伤.对它们的监测可为早期临床治疗及康复干预提供试验指标,以便控制脑卒中的进展及复发.     

Health‐related quality of life and associated factors in patients with primary lymphedema

Aim: Primary lymphedema requires continuous conservative treatment during the patient's life, which may affect their health‐related quality of life (HRQOL). Physical and psychosocial characteristics related to lymphedema are associated with their HRQOL. This study aimed to assess HRQOL in those patients undergoing conservative treatment and to determine the factors associated with their HRQOL. Methods: This was a cross‐sectional, observational study that included 83 patients with primary lymphedema at an outpatient clinic for lymphedema. HRQOL was assessed with the Medical Outcomes Study 36‐Item Short Form Survey (SF‐36) and EuroQol 5‐Dimension (EQ‐5D). Lymphedema status/complications and psychosocial status were evaluated by medical records, physical assessment, and self‐administrative questionnaires. Results: The general health perception score in the SF‐36 was lower than the age‐ and sex‐stratified national norms (P = 0.001). In the EQ‐5D, the proportions of patients with some/moderate or severe problems were 42.2% for pain/discomfort, 21.7% for usual activities, and 20.5% for anxiety/depression. By multiple regression analyses, a lower physical component summary score in the SF‐36 was associated with a higher lymphedema stage (P = 0.021), cellulitis within 30 days (P = 0.003), exercise (P = 0.010), and more substance use coping (P = 0.012). A lower mental component summary score was associated with skin lesions over edematous limbs (P = 0.008), less humor coping (P = 0.005), and more self‐blame coping (P = 0.014). Conclusion: Patients with primary lymphedema have problems in health perception, discomfort, usual activities, and anxiety/depression. Preventing cellulitis and skin lesions and humor coping may be able to improve HRQOL.     

Positive tip cultures and related risk factors associated with intravascular catheterization in pediatric cardiac patients

The incidence and risk factors of positive catheter tip cultures were studied prospectively in 392 consecutive children undergoing cardiac surgery under cover of cephalothin prophylaxis. A total of 1649 catheter tips were cultured and 58 (3.5%) yielded positive cultures. Specifically, the incidence of positive catheter tip cultures for iv, central venous, arterial and pulmonary arterial (PA) catheters was 0.9%, 5.9%, 3.9% and 10.6%, respectively, whereas one of the six surgically placed venous and arterial catheters had a positive tip culture and none of the 279 transthoracic catheters. Staphylococcus epidermidis was isolated from 79% of the positive tip cultures. Ten percent of the children had one or more positive tip cultures but none developed catheter-related septicemia or endocarditis. Stepwise logistic regression analysis revealed that longer in situ time (p less than .001), younger age (p less than .001), and inotropic support (p = .003) were significant independent predictors of risk for children developing positive catheter tip cultures. The safe in situ period for arterial, central venous, and PA catheters is 3 days in infants under 1 yr and 4 and 6 days for arterial and central venous catheters, respectively, in older children, if 0.95 cumulative probability of remaining free of a positive tip culture is accepted. The data generally support the bacteriologic safety of invasive hemodynamic monitoring in infants and children undergoing cardiac surgery.     

ICU机械通气患者呼吸机相关性肺炎危险因素与护理对策

目的探讨ICU机械通气患者呼吸机相关性肺炎(VAP)发生的危险因素及护理对策,为临床降低VAP发生率提供理论支持。方法选取2018年1月至2019年6月在我院ICU机械通气患者175例为研究对象,并发VAP 60例。采用多因素logistic回归分析法分析VAP发生危险因素。结果多因素logistic回归分析结果显示,年龄(OR=1.624)、APACHEⅡ评分(OR=1.915)、侵袭性操作(OR=1.942)、口腔清洁状况(OR=2.178)、机械通气时间(OR=2.652)、意识障碍(OR=2.154)为影响ICU机械通气VAP发生的独立危险因素(P<0.05)。结论ICU机械通气患者VAP发生的危险因素多且复杂,应采取针对性干预措施,尽量缩短机械通气、住院时间,加强防护,降低VAP发生风险,促进患者康复。     

机械通气合并下呼吸道感染和多器官功能障碍患者的预后因素分析

目的：探讨影响机械通气合并下呼吸道感染和多器官功能障碍综合征（MODS）患者的预后因素,为提高机械通气抢救危重病成功率寻找途径。方法：收集120例接受机械通气治疗患者的临床资料,分析下呼吸道感染及MODS发生率与病死率之间的关系,比较MODS存活组与非存活组患者的基本特征（年龄、急性生理和慢性健康状况评分（APACHEⅡ评分）、是否合并慢性器官功能不全和其它部位感染、机械通气时间等）。结果：120例中有105例（87．5％）并发医院下呼吸道感染,分离出486株细菌,其中G^-杆菌350株（72．0％）,尤以铜绿假单胞菌居多（212株,43．62％）;79例（65．8％）发生MODS,其中48例（60．8％）死亡;未合并感染者死亡2例,单一细菌感染者死亡15例,混合细菌感染者死亡56例（P＜0．005）,且MODS存活组与非存活组患者在年龄,APACHEⅡ评分及机械通气时间3个方面差异有显著性（P＜0．05或P＜0．001）。结论：虽然机械通气治疗是危重病患者抢救中不可缺少的手段,但合并下呼吸道感染和MODS是这类患者病死率高的主要原因,其中感染病原菌种类、数量、年龄、APACHEⅡ评分及机械通气治疗时间可能是不容忽视的因素。     

脑室外引流导管相关性感染危险因素分析

脑室外引流术作为神经外科最常见的暂时性治疗性手术,广泛应用于神经外科各种疾病的监护和治疗,如脑外伤、脑出血、脑肿瘤、动脉瘤等等引起的脑室出血、急性脑积水及颅内压管理.由于脑室外引流管往往需要摆放较长时间,而且引流管将颅内外相互联通,导致颅内感染常不可避免.尽管强效的抗生素不断出现及各种检查技术飞速发展,对颅内感染的诊断和治疗有了很大的进步,但颅内感染患者的病死率和致残率仍很高.     

Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections

OBJECTIVES: The efficacy of mechanical insufflation-exsufflation, in addition to standard chest physical treatments, was investigated as a first-line intervention for patients with neuromuscular diseases with respiratory tract infections and airway mucous encumbrance. DESIGN: The short-term outcomes of 11 consecutive neuromuscular disease patients with respiratory tract infections and tracheobronchial mucous encumbrance who were administered mechanical insufflation-exsufflation and conventional chest physical treatments in an intensive care unit were compared with the outcomes of 16 historical matched controls who had received chest physical treatments alone. Treatment failure was defined as the need for cricothyroid "minitracheostomy" or endotracheal intubation, despite treatment. The number of subjects administered bronchoscopy-assisted aspiration during the hospital stay was also compared. RESULTS: Treatment failure was significantly lower (P < 0.05) in the mechanical insufflation-exsufflation group than in the conventional chest physical treatments group (2/11 vs. 10/16 cases). The use of bronchoscopy-assisted aspiration was similar in the two groups (5/11 vs. 6/16 cases). Mechanical insufflation-exsufflation did not produce serious side effects and was well tolerated by all subjects. CONCLUSIONS: Provision of mechanical insufflation-exsufflation in combination with standard chest physical treatments may improve the management of airway mucous encumbrance in neuromyopathic patients; its use should be included in the noninvasive approach to treatment of respiratory tract infections with impaired mucous clearance.     

Intensivists’ response to hyperoxemia in mechanical ventilation patients: The status quo and related factors

BACKGROUND: Due to the still sparse literature in China, the investigation of hyperoxemia management is required. Thus, we aim to conduct a retrospective study to provide more information about hyperoxemia management in intensive care unit (ICU) patients.