非计划性拔管中行为形成因子与人为差错的定性分析

目的通过非计划性拔管中行为形成因子与人为差错的定性分析,找出人为差错类型的影响因素,降低非计划性拔管发生率。方法采用Delphi法确定16个行为形成因子,并将行为形成因子与人为差错类型关联程度利用矩阵形式表示。结果主要影响技能型疏忽与遗忘的行为形成因子是精力、工作态度、知识、工作数量及工作时间;主要影响规则型疏忽与错误的行为形成因子是工作态度、风险意识、管道风险标识、操作方法、固定约束设备;主要影响知识型错误的行为形成因子是工作的复杂性、工作的新颖性、知识、经验水平及有效监控。结论对行为形成因子与人为差错进行定性分析,可为管道护理的行为矫正提供理论指导,从而降低非计划性拔管人因失误的可能性。     

ICU患者外周动脉导管非计划性拔管风险预测模型的构建及验证

目的 构建并验证ICU患者外周动脉导管非计划性拔管的风险预测模型。方法 选择300例(建模组)ICU留置外周动脉导管患者作为研究对象,回顾性收集患者相关资料,采用单因素分析、logistic回归分析筛选非计划性拔管的危险因素,构建风险预测模型。选择117例ICU留置外周动脉导管患者对风险预测模型进行验证。结果 建模组23.00%患者发生非计划性拔管。年龄≥65岁,并存高血压、静脉血栓栓塞症,置入部位为桡动脉及置入导管为静脉留置针是ICU患者外周动脉导管非计划性拔管的高危因素（均P<0.05）。预测模型的ROC曲线下面积为0.888。模型验证结果显示,ROC曲线下面积为0.903,灵敏度为86.2%,特异度为85.2%,约登指数为0.714。结论 构建的ICU患者外周动脉导管非计划性拔管的风险预测模型预测效果良好,可为医护人员及时采取预防性护理措施提供依据。     

管道滑脱危险评估表在预防神经外科患者非计划性拔管的应用

目的探讨管道滑脱危险评估表在预防神经外科患者非计划性拔管的应用。方法选取2014年入住神经外科289例置管的患者作为实验组,另选取2013年入住神经外科296例置管的患者作为对照组。对照组按管道护理常规护理管道,实验组在常规的方法上运用管道滑脱危险评估表对置管患者进行评分,根据管道滑脱危险程度采取相应的防范措施,对非计划性拔管的患者进行登记。结果实验组实际发生非计划性拔管3(1.03%)例,与对照组非计划性拔管12(4.3%)例相比,差异有统计学意义(P0.01)。结论运用管道滑脱危险评估表能有效预防神经外科患者非计划性拔管。     

肝胆外科术后脱管风险评估在非计划性拔管预防中的应用

【摘要】 目的 探讨对于肝胆外科术后的患者,导管护理风险评估在非计划性拔管风险控制中的应用效果。方法〓根据标准选择2013年1月~2014年12月就诊于我院肝胆外科并行过手术的85名患者,分为试验组43例和对照组42例,两组患者术后均留置导管。对照组患者(n=42)采用采用常规导管护理,试验组患者(n=43)在对照组的基础上进行留置导管护理风险评估后采用预见性护理干预措施,比较两组患者导管非计划性拔管情况。结果〓试验组患者总的非计划性拔管率低于对照组,其中试验组的胃管、腹腔单腔管、腹腔双套管、中心静脉置管和导尿管的非计划性拔管率均显著低于对照组。试验组的患者在出院时对管道护理相关知识掌握的人数相对比对照组多(P<0.05)。结论〓建立完善管道护理风险评估标准可预防、及时发现和处理意外事故,减少非计划性拔管的发生率。     

管路固定指导图谱和实操手册在非计划性拔管专项管理中的应用

目的探讨管路固定指导图谱联合实操手册用于护士非计划性拔管专项管理的效果。方法成立预防非计划性拔管专项管理小组,编制"临床常见管路固定指导图谱",制作"导管固定实操手册",并对全院低年资护士实施预防非计划性拔管的培训和管理,比较实施专项管理前后护士管路固定合格率及患者非计划性拔管率。结果实施专项管理后,患者非计划性拔管率显著降低,护士管道固定合格率显著提高(P0.05,P0.01)。结论管路固定指导图谱联合导管固定实操手册应用于临床护士非计划性拔管的预防管理,能有效提高护士管道固定合格率,降低患者非计划性拔管率,提高临床护理质量。     

基于关联规则的住院患者非计划性拔管危险因素分析

目的 挖掘住院患者非计划性拔管数据中有价值的关联规则,为制订院内非计划性拔管预防措施提供参考.方法 回顾性整理172例非计划性拔管事件的数据资料,采用Apriori算法进行数据挖掘并进行关联规则评定.结果 筛选出239条规则,结合专业知识选出具有临床指导意义的关联规则12条,其中男性、年龄60岁以上、意识清醒与自行拔除呈强关联,置管时长1～5 d、意识清醒、自行拔除与再次插管呈强关联,意识清醒的男性与3级导管拔除呈强关联等.结论 在护理工作中应防范患者自行拔除管道,加强对3级管道的保护、重视管道置入初期患者的管理、准确评估拔管时机及时撤除管道,以降低非计划性拔管发生率.     

气管插管患者非计划性拔管的预见性护理

目的探讨气管插管非计划性拔管的管理方法。方法将120例神经外科气管插管患者随机分为干预组和对照组,干预组选择有效的固定方法,建立管道标示及评估记录要求,正确书写护理诊断,规范护理操作等预见性的护理措施,对照组按常规进行护理。比较2组非计划性拔管的发生率。结果干预组和对照组非计划性拔管的发生比较,干预组比对照组明显减少,差异有统计学意义(P﹤0.05)。结论通过实施预见性护理措施,气管插管患者非计划性拔管的发生率明显降低,有力保障了导管护理安全。     

腰椎后路手术后椎管内血肿形成的影响因素分析

目的研究腰椎后路术后患者椎管内血肿(Intraspinal hematoma,IH)形成的危险因素,为其防治提供理论依据。方法纳入2013年1月～2018年1月行腰椎后路术治疗的30例患者,住院期间均发生IH,另按1:3比例随机选择未发生IH的90例患者,分别设为IH组与非IH组。分析两组患者病历资料,采用单因素、多因素分析确定腰椎后路术后IH形成的独立危险因素。结果两组患者的年龄、血清钙、翻修手术、明胶海绵止血、非计划性拔管、合并高血压、总蛋白、白蛋白、手术时间、出血量差异有统计学意义(P0.05); Logistic回归分析显示:血清钙2.03 mmol/L(OR=2.443)、明胶海绵止血(OR=2.043)、年龄65岁(OR=2.543)、非计划性拔管(OR=1.997)、翻修手术(OR=2.43)是术后IH形成的独立危险因素。结论血清钙2.03mmol/L、明胶海绵止血、非计划性拔管、年龄65岁、翻修手术,均可作为独立影响因素增加腰椎后路术后IH形成风险。     

ICU护士预防气管插管非计划性拔管护理知信行调查

目的了解ICU护士预防非计划性拔管护理知信行现状,分析其影响因素。方法采用自行设计的ICU护士预防气管插管非计划性拔管护理的知识、态度、行为问卷对80名护士进行调查分析。结果ICU护士预防非计划性拔管知识、态度、行为得分中位数分别为4.50分、7.50分、5.50分;ICU工作年限、职称和工作年限是认知水平的影响因素,ICU工作年限是态度和信念水平的影响因素,职称和科室是行为水平的影响因素(P0.05,P0.01)。结论ICU护士预防气管插管非计划性拔管护理的态度较为积极,但认知和行为状况不佳。应重点加强低年资、低职称的护士预防非计划性拔管的知识技能培训,以提高ICU护士知识水平和护理质量。     

前馈控制降低ICU气管插管患者非计划性拔管

目的探讨前馈控制降低ICU气管插管患者非计划性拔管的效果。方法对ICU气管插管患者,实施前馈控制干预方案,主要包含成立ICU气管插管患者非计划性拔管的前馈控制管理监督委员会、建立严格的气管插管非计划性拔管风险评估模式(基于SBAR沟通程序的导管交接班流程)、转变护理人员对气管插管非计划性拔管风险管理的理念、加强各能级护理人员相关护理知识及应急技能的培训。结果实施前馈控制后ICU气管插管非计划性拔管发生率由实施前的1.66%降到0.58%;护理人员非计划性拔管相关知识认知、评估技巧(工具)方面及护理对策方面的得分显著高于实施前(均P0.01)。结论前馈控制用于ICU气管插管非计划性拔管管理,能够有效降低气管插管非计划性拔管的发生率,提高ICU医疗护理质量,保障住院患者的医疗护理安全。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.