肠瘘患者腹腔感染的病原学调查与危险因素分析

目的 研究分析肠瘘病发腹腔感染的危险因素及主要病原菌分布、常用抗菌药物的耐药性,以降低感染率.方法 对2002年1-11月在医院就诊的肠瘘并发腹腔感染患者119例,留取患者的腹腔引流脓液等标本做培养,应用ABBott(MS-2 System)系统做细菌鉴定及抗菌药物药敏试验,分析腹腔感染的细菌及其引起腹腔感染的危险因素和对抗菌药物耐药特点.结果 肠瘘并发腹腔感染的病原菌主要为大肠埃希菌、屎肠球菌、铜绿假单胞菌、金黄色葡萄球菌、粪肠球菌、表皮葡萄球菌、肺炎克雷伯菌,分别占23.02％、7.19％、7.19％、7.19％、6.48％、6.84％、6.84％,其中革兰阴性菌占58.63％,革兰阳性菌占41.37％;革兰阴性菌超广谱β-内酰胺酶检出阳性率为46.01％,大肠埃希菌的耐药性高于肺炎克雷伯菌与阴沟肠杆菌,对阿米卡星、头孢哌酮、亚胺培南耐药性较低,并且亚胺培南(碳青霉烯类)显示了较强的抗菌作用;铜绿假单胞菌对阿米卡星、头孢哌酮、亚胺培南的耐药率＜30.00％;鲍氏不动菌对头孢噻肟、头孢哌酮的耐药率＜30.0％;嗜麦芽寡养单胞菌对环丙沙星耐药率为18.18％、头孢哌酮为36.36％;革兰阳性菌对替考拉宁与万古霉素耐药率均为0,金黄色葡萄球菌耐药率整体高于表皮葡萄球菌,金黄色葡萄球菌均为耐甲氧西林金黄色葡萄球菌;屎肠球菌整体耐药性高于粪肠球菌;对青霉素敏感的链球菌属对氨苄西林的耐药率较低,无耐万古霉素的菌株.结论 肠瘘并发腹腔感染主要病原菌为革兰阴性菌,且ESBLs检出阳性率达46.0％;检出病原菌均呈现多药耐药性,因此对肠瘘并发腹腔感染的患者在更改引流方式等手术治疗外,需合理应用抗菌药物.     

原发性胆汁性胆管炎病人能量代谢特点研究

目的:探讨原发性胆汁性胆管炎(PBC)病人能量代谢特点.方法:选取2016年5月至2019年4月首都医科大学附属北京佑安医院肝病科收治的33例PBC病人为研究对象,同时以11例健康体检者为对照.采用间接能量代谢测定仪进行两组能量代谢相关指标测定,包括实测静息能量消耗(REE)、预测REE(pREE)、呼吸商(RQ)、碳...     

不同评分系统对老年导管相关性血流感染预后评估的比较研究

目的比较急性生理和慢性健康状况评分(APACHE-Ⅱ评分)、序贯性脏器衰竭评价评分(SOFA评分)和简化急性生理评分(SAPS-Ⅱ评分)3种评分系统对老年导管相关性血流感染患者1周、4周预后的评估价值。方法收集2009年1月-2015年12月260例老年导管相关性血流感染患者临床资料,整理感染前24h(Day-1)、感染后24h(Day1)的APACHE-Ⅱ、SOFA、SAPS-Ⅱ评分,比较不同时间节点(1周、4周)各个评分系统死亡组与生存组的评分差异,绘制ROC曲线,通过比较ROC曲线下面积(AUC)比较不同评分系统对预后的评估价值。结果患者平均年龄(88.6+5.8)岁,感染前后APACHE-Ⅱ评分、SOFA评分、SAPS-Ⅱ评分在发生导管相关性血流感染1周、4周的死亡组与生存组之间均存在差异性(P<0.001),ROC曲线的AUC分别为(0.849、0.878、0.786、0.887、0.843、0.867)、(0.805、0.829、0.789、0.850、0.794、0.817)。结论对于老年导管相关性血流感染4周内预后评估,感染前24小时评分优于感染24小时评分,SOFA评分优于APACHE-Ⅱ评分及SAPS-Ⅱ评分。     

产后重度腹腔感染合并低位肠瘘、不全肠梗阻营养支持一例报告

患者 ,女 ,31岁 ,已婚。于 2 0 0 0年 12月 8日在家中分娩后 3天出现发热 ,伴腹胀、腹痛 ,用抗生素治疗无效 ,经检查确诊为“腹膜炎盆腔脓肿” ,行后穹窿切开引流 ,排出脓液 2 0 0 0ｍＬ。用“先锋必 ,安塞隆”等抗感染治疗无明显好转 ,Ｂ超示子宫左上方可见一 4 .8ｃｍ包块。于 2 0 0 1年 2月 6日转入北京一家医院应用多种抗生素及中药治疗仍无好转 ,腹痛加重伴稀便。Ｂ超示子宫左上方异常回声及无回声包块。ＣＴ示下腹部囊实性占位 ,脓肿可能性大。于2 0 0 1年 2月 2 3日入我院。查体 :贫血貌 ,血红蛋白63ｇ/Ｌ ,腹部膨隆 ,下腹部可及一平…     

肠瘘感染控制与营养护理效果分析

目的总结肠瘘患者临床治疗的护理经验。方法对52例肠瘘患者充分引流,控制感染的基础上,实施肠外、肠内营养支持疗法,并予以有效的常规护理、心理护理和瘘口护理等措施。结果 52例肠瘘患者住院50~120 d,平均85 d。治愈37例,治愈率为71.2%,10例好转出院,死亡5例。结论在充分引流、控制感染的基础上,采用肠外、肠内营养支持治疗,同时加强患者心理护理、常规护理、引流管护理和瘘口护理等措施,可提高患者生活质量,取得满意的治疗效果。     

谷氨酰胺强化的肠外营养对肠瘘病人腔静脉导管感染的影响

目的:观察谷氨酰胺(Gln)强化的肠外营养(PN)对肠瘘病人腔静脉导管感染(CRI)的发生率及细菌谱的影响.方法:对2002年10月至2003年12月该院收治的使用腔静脉导管进行PN的肠瘘病人进行前瞻、随机研究.对照组接受常规全肠外营养(TPN),Gln组在常规TPN中加入力肽100ml.结果:117例肠瘘病人,共进行139次腔静脉置管.对照组71例病人共进行84次腔静脉置管,细菌定植的发生率为26.2%,导管相关性血行感染(CRBSI)的发生率为6.0%.Gln组46例病人共进行55次腔静脉置管,细菌定植的发生率为12.7%,CR-BSI为1.8%.Gln组和对照组病人革兰阴性细菌感染的发生率分别为3.6%与16.7%,二者有显著性差异(P=0.037).结论:Gln强化的PN可以减少肠瘘病人CRI的发生,尤其是来源于肠道的革兰阴性菌的感染.     

腹部手术并发肠瘘患者感染的回顾性分析

目的探讨腹部手术并发肠瘘患者感染的病原菌及危险因素,为降低感染率促进合理使用抗菌药提供参考。方法对2013年6月—2016年5月腹部手术后并发肠瘘的88例住院患者进行回顾性分析其病原菌分布、耐药及危险因素。统计数据采用χ2检验及多因素Logistic回归分析,P0.05为差异有统计学意义。结果感染病原菌检测发现感染菌株共86株,G-杆菌54株,占62.8%;G+球菌30株,占34.9%;真菌2株,占2.3%。经对引起感染的相关危险因素进行多因素Logistic回归分析,显示年龄、白蛋白水平、手术方式、手术时间、住院时间等为感染的危险因素,白蛋白水平和抗生素应用与住院天数有关,对比差异均有统计学意义(均P0.05)。结论肠瘘患者根据引流液细菌培养及药敏试验结果选择有效的抗生素,减少危险因素,促进患者尽快康复。     

肠瘘病人营养支持的疗效观察

0引言 肠外瘘是腹部外科术后严重的并发症.20世纪60年代,肠外瘘的病死率高达40%～60%.随着营养支持治疗中肠内营养(EN)和肠外营养(PN)的广泛开展,加之联合生长抑素和生长激素的应用,使得肠外瘘的治疗策略和方法大大改变,病死率降至10%～20%.我科自2002年10月至2004年5月共收治肠瘘病人16例均获得较好疗效,现报道如下:     

恶性肿瘤病人静息能量消耗研究的进展

处于不同生理或病理状态的机体 ,能量代谢特征不尽相同。在癌症病人中 ,由于肿瘤生长以及由此产生的机体代谢变化 ,使得肿瘤病人的能量代谢有其特殊性。本文对肿瘤病人的静息能量消耗研究进展进行了综述。一般认为 ,恶性肿瘤病人术前静息能量代谢较正常人有所升高 ,但有资料显示某些恶性肿瘤病人术前能量代谢并无变化。肿瘤部位、大小、分期、分型、治疗措施等的不同 ,对人体代谢有不同影响 ,且不同资料之间还存在着彼此矛盾之处     

连续性血液净化对外科危重症病人静息能量代谢的影响

目的:探讨连续性血液净化(CBP)对外科危重症病人并发全身炎症反应时静息能量代谢的影响及其临床意义。方法:收集外科ICU中并发全身炎症反应,需行CBP治疗的危重症病人29例,分别在CBP治疗前、治疗24和48 h时采用间接能量代谢仪测定病人静息能量消耗(REE)的实际值,并由机器根据录入的病人资料计算出REE预测值(Pred),在同一时间点抽血检测血液肾上腺素和皮质醇、促炎细胞因子(IL-6,IL-8)、抗炎细胞因子(IL-4,IL-10),记录血常规、血生化结果和营养支持情况,同时观察病人的生命体征。结果:危重症病人并发全身炎症时静息能量消耗值显著增高,行CBP治疗24、48 h后,能量代谢较治疗前明显下降(P0.05);治疗48h时病人血清肾上腺素和皮质醇水平较治疗前显著降低(P0.05),IL-6、IL-10和IL-4水平明显下降(P0.05)。结论:CBP治疗可有效地减少病人血清中应激激素和炎性递质,调控全身炎症反应病人的高代谢状态。     

Measured energy expenditure of tube-fed patients with severe neurodevelopmental disabilities

OBJECTIVE: To determine measured resting energy expenditure (REE) of nonambulatory tube-fed patients with severe neurological neurodevelopmental disabilities. METHODS: Twenty patients were prospectively studied. Only steady state indirect calorimetry measurements were taken. All measurements were conducted using a canopy system. Nutritional needs were met entirely by enteral feedings via a permanent ostomy. RESULTS: REE was widely distributed from 16 kcals/kg/day to 39 kcals/kg/day. The mean REE (888+/-176 kcals/day) of the patients was significantly (p<0.01) lower than predicted as estimated by the Harris-Benedict equations (1081+/-155 kcals/day) and World Health Organization equations (1194+/-167 kcals/day). Fat-free mass (FFM) was the best parameter for predicting REE. Two predictive equations were developed that are not significantly biased and more precise (< or =15% error) than conventional predictive formulas. CONCLUSION: Conventional formulas for estimating energy expenditure are inaccurate and generally overestimate measured energy expenditure of nonambulatory patients with severe developmental disabilities.     

Effect of neuromuscular blockade on energy expenditure in patients with severe head injury

BACKGROUND: The purpose of this study was to determine the effect of neuromuscular blockade on energy expenditure in severely head-injured patients; to determine the effects of body temperature, nutrition support, and morphine use on metabolic rate; and to compare measured energy expenditure with values from predictive equations. METHODS: Energy expenditure was measured using indirect calorimetry in 2 groups of ventilated patients-18 with severe head injury during and after administration of pancuronium bromide and morphine, and second, 14 severely traumatized patients without severe head injury (trauma group) who received morphine without neuromuscular blockade. RESULTS: The mean energy expenditure of head-injured patients increased significantly once pancuronium was discontinued, ie, from 24.2 +/- 3.1 to 28.7 +/- 4.6 kcal/kg (p = .002). This effect was independent of other relevant variables such as morphine dose, body temperature, and nutrition support. When compared with the Harris-Benedict and World Health Organization predictive equations, neuromuscular blockade resulted in a stress factor of only 0.96 and 0.95, respectively, which increased to 1.19 and 1.18, respectively, once blockade was discontinued. Head-injured patients not on neuromuscular blockade had a significantly greater energy expenditure when compared with the trauma group (p = .02). CONCLUSIONS: Neuromuscular blockade in severely head-injured patients decreases energy expenditure to basal levels, independent of morphine use, body temperature, and feeding. Levels of hypermetabolism in both the head-injured and trauma groups were relatively low, at 19% and 5% above predicted values, respectively. This study provides useful information for the management of nutrition support in severely traumatized patients.     

急性重症胰腺炎患者腹腔感染的临床诊断及治疗

目的探讨急性重症胰腺炎患者并发腹腔感染的临床诊断方法,统计常见病原菌及抗菌药物敏感性,为临床诊治急性重症胰腺炎提供参考。方法选取2009年4月-2013年10月急性重症胰腺炎并腹腔感染的患者79例,对其临床表现进行回顾性分析,并行病原菌培养和抗菌药物敏感性分析。结果 79例患者共检出病原菌84株,以革兰阴性菌最为首,检出65株占77.38%,以大肠埃希菌和肺炎克雷伯菌检出率最高,分别占39.29%和17.86%;革兰阳性菌检出16株占19.05%,其中葡萄球菌属占10.71%,真菌检出率最低,占3.57%;革兰阴性菌对亚胺培南、头孢哌酮/舒巴坦、哌拉西林/舒巴坦最为敏感,敏感率分别为100.00%、89.23%和80.00%,而对氨苄西林敏感性较低,仅18.46%;革兰阳性菌对万古霉素、利奈唑胺表现出了高度的敏感,敏感率达100.00%,对青霉素敏感率最低,仅为31.25%。结论急性重症胰腺炎并发感染者多有典型的临床表现,在确诊之后应及时给予抗菌药物经验性治疗,并及时进行病原菌培养和药敏试验,待结果报告后及时调整用药。     

左西孟旦用于严重脓毒血症和脓毒性休克并发心力衰竭患者的Meta分析

目的评价与标准强心剂(多巴酚丁胺类药物)对比,左西孟旦能否取得令临床满意的治疗效果。方法检索2005年1月-2015年12月CNKI、CBM、VIP、万方数据、BioMedCentral、Embase、Pubmed、Central中符合条件的文献;左西孟旦应用于严重脓毒血症和脓毒性休克并发心衰患者且有病死率描述的随机对照试验将被纳入;本研究首要结果是病死率,次要指标为心排血指数(CI)、血清乳酸浓度(LAC)、左心室射血分数(LVEF)、左心室每搏作功指数(LVSWI)、平均动脉压(MAP)。结果共411例患者的11项研究被纳入到本次分析;左西孟旦组病死率为36.8%(77/209),对照组病死率为47.5%(96/202),RR=0.77[0.62,0.95],P=0.02,同质性检验P=0.98,I2=0%;与对照组相比,CI、LVEF、LVSWI升高,LAC降低,MAP差异无统计学意义。结论在严重脓毒血症和脓毒性休克患者中,左西孟旦与标准强心剂治疗相比,可降低病死率。本结论需进行大型多中心随机对照试验验证。     

留置空肠造瘘管并发肠外瘘患者的护理

目的对留置空肠造瘘管并发肠外瘘患者的护理进行探索,进而有效提高患者的生活水平。方法针对患者肠外瘘的特点,对患者进行用药指导以及物理治疗,同时采用床上支架等综合护理干预措施对留置空肠造瘘管并发肠外瘘患者进行护理,运用统计学方法来比较干预前与干预后患者健康状况的变化。结果在患者社区采用有效的管理手段之后,能对患者的血糖浓度有效的控制,患者的健康状况也有明显的好转。结论综合护理干预措施为降低患者术后痛苦提高患者生活质量具有重要意义,值得在临床护理领域进一步的推广和发展。     

Total energy expenditure in underweight patients with severe chronic obstructive pulmonary disease living at home

AIM: The aim of the study was to assess total daily energy expenditure (TDE), as measured by doubly labelled water (DLW), and describe its components in home-living underweight patients with severe chronic obstructive pulmonary disease (COPD). METHODS: Basal metabolic rate (BMR) was measured prior to the study. Ten patients received DLW, followed by urine analysis by isotope ratio mass spectrometry from 10 standardised occasions during 15 days. Dietary intake was registered by each patient the first 7 days of the study. The patients were also interviewed about their physical activity pattern. RESULTS: Measured BMR was higher than predicted in five of the 10 patients using equations from WHO. Using disease-specific equations, estimated BMR was higher for male, but not for female COPD patients. The best estimation of BMR resulted from prediction including fat-free mass. TDE varied considerably between 5200 and 11,100 kJ. Physical activity level (PAL) ranged from 1.15 to 1.80. Energy intake varied between 4500 and 9100 kJ. In underweight patients with severe COPD, TDE is highly variable, ranging from 110 to 200 kJ/kg body weight. CONCLUSIONS: This is the first study assessing and describing total energy expenditure in underweight patients with severe COPD living at home. Energy requirement in the patient group cannot solely be calculated from prediction equations. BMR should be measured and physical activity level assessed.     

胰十二指肠术后胰瘘合并腹腔感染的诊疗分析

目的 探讨胰十二指肠切除术后胰瘘合并腹腔感染患者的诊断与治疗方法,以采取有效措施.方法 回顾性分析医院2008年1月-2011年12月137例行胰十二指肠切除术患者的临床资料,对于临床怀疑胰瘘合并腹腔感染的患者行血液及引流液培养、腹部CT等检查,一经确诊,即给予充分引流、抗菌药物等综合治疗措施.结果 19例胰瘘合并腹腔感染的患者中,发生胰瘘31例,胰瘘发生率为22.6％,其中19例合并腹腔内感染,感染率为13.9％;137例患者送检标本中检出阳性标本26例次,包括单一菌感染12例、混合感染7例；共培养出病原菌26株,其中粪肠球菌11株占42.3％,大肠埃希菌8株占30.8％,金黄色葡萄球菌3株占11.5％,18例患者经治疗后好转,死亡l例.结论 对于胰瘘合并腹腔感染的患者,影像学检查及病原学检查尤为重要,保持充分引流和应用抗菌药物是治疗的有效措施.     

Resting energy expenditure in cancer patients.

In this review, we provide evidence based on our studies, for zinc deficiency and cell mediated immune disorders, and the effects of protein and zinc status on clinical morbidities in patients with head and neck cancer. We investigated subjects with newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx. Patients with metastatic disease and with severe co-morbidity were excluded. Nutritional assessment included dietary history, body composition, and prognostic nutritional index (PNI) determination. Zinc status was determined by zinc assay in plasma, lymphocytes, and granulocytes. Pretreatment zinc status and nutritional status were correlated with clinical outcomes in 47 patients. Assessment of immune functions included production of TH1 and TH2 cytokines, T cell subpopulations and cutaneous delayed hypersensitivity reaction to common antigens.

At baseline approximately 50% of our subjects were zinc-deficient based on cellular zinc criteria and had decreased production of TH1 cytokines but not TH2 cytokines, decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood. The tumor size and overall stage of the disease correlated with baseline zinc status but not with PNI, alcohol intake, or smoking. Zinc deficiency was associated with increased unplanned hospitalizations. The disease-free interval was highest for the group which had both zinc sufficient and nutrition sufficient status.

Zinc deficiency and cell mediated immune dysfunctions were frequently present in patients with head and neck cancer when seen initially. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations. These observations have broad implications in the management of patients with head and neck cancer.