A randomized controlled trial of sedation in the critically ill

A randomized controlled trial comparing: a) a combination of oral chloral hydrate and promethazine to b) a continuous intravenous midazolam infusion, for maintenance sedation in critically ill children, was carried out. The level of sedation was assessed four hourly using a specifically devized sedation scale. Forty-four children entered the study of whom two were subsequently excluded. The number of satisfactory assessments (desired and actual levels of sedation equal) was significantly greater in the chloral hydrate and promethazine group (Chi-squared P <0.01; confidence intervals of the difference 0.06 to 0.20). The number of assessments at level 5 on the sedation scale (patient restless/distressed) was significantly greater in the midazolam group (Chi-squared P <0.05). The total number of satisfactory assessments in the two groups were only 61 and 48% respectively, suggesting that sedation can be considerably improved. Chloral hydrate and promethazine are more effective than midazolam as maintenance sedation in critically ill children. It is possible to prospectively study the efficacy of sedative drugs in critically ill children.     

危重患者肠内营养安全实施流程的构建

目的探索危重患者肠内营养安全实施流程,确保肠内营养实施的安全性和有效性。方法在分析现有临床工作及查阅相关文献的基础上,初步拟订危重患者肠内营养安全实施流程;应用Delphi专家咨询法,对10名专家进行2轮问卷咨询。结果经2轮专家咨询,构建了包括10个项目、36个子项目的流程,专家的积极系数分别为100%和88.9%,权威系数为0.81,子项目的协调系数为0.305。结论应用Delphi法所构建的危重患者肠内营养安全实施流程的条目专家意见集中,研究结果可信度高,对肠内营养的实施提供了客观依据。     

Haemodynamic effects of famotidine and cimetidine in critically ill patients

To compare the cardiovascular effects of the histamine H2 receptor antagonists, famotidine and cimetidine, in critically ill patients, seven ICU patients were given 20 mg of famotidine or 200 mg of cimetidine intravenously in a randomized fashion. Each patient was studied on 2 separate days. In a random fashion, they received famotidine on one of the days and cimetidine on the other. Mean systemic arterial pressure (MAP) was maximally decreased 2 min after intravenous cimetidine from 103 +/- 10 (13.7 +/- 1.3 kPa) (mean +/- s.d.) to 83 +/- 15 mmHg (11.1 +/- 2.0 kPa) (P less than 0.05). MAP returned to control values 8 min after administration of the drug. Systemic vascular resistance (SVR) was significantly decreased during the 8-min observation period (P less than 0.01). In contrast, famotidine produced little haemodynamic effect over the 8-min period. Therefore, we suggest that famotidine may be a better H2 antagonist than cimetidine in critically ill patients requiring vasoconstrictor drug support, since it avoids the significant decrease in systemic blood pressure and peripheral vasodilation seen after cimetidine.     

Beneficial effects of intensive insulin therapy in critically ill patients.

Critically ill patients in intensive care units (ICU) for morethan a few days have a mortality of approximately 20% world-wide.These critically ill patients, in the absence of a previousdiagnosis of diabetes, commonly exhibit stress hyperglycemiaand insulin resistance [1]. Many of these critically ill patientsdie of multiorgan dysfunction (MOD) and sepsis. Since stresshyperglycemia has been shown to associate with impaired polymorphonuclearneutrophil function and bactericidal activity [2], the questionarose whether lowering of blood glucose in critically ill patientswould decrease morbidity and mortality. To address this question the Leuven group of Van den Bergheand associates performed a prospective, randomized control studyin 1548 patients admitted to their surgical ICU who were receivingmechanical ventilation [3]. The patients were randomly assignedto receive intensive     

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目的 研究肠内营养（EN）和肠外营养（PN）支持对外科危重病人的治疗效果。方法 将80例不能进食的研究对象随机分成EN组和PN组,比较营养指标、免疫功能指标、病人耐受性指标的变化。结果在治疗10d后,两组病人均由负氮平衡转为正氮平衡,营养指标及免疫功能指标明显增高,且EN组免疫功能指标增高更显著;病人耐受性指标中,EN组无显著变化而PN组血糖明显增高。结果 EN和PN对外科危重病人均有营养支持和提高机体免疫功能的作用。耐受性强,且EN支持在提高机体免疫功能优于PN支持,病人耐受性较好。     

危重症患者肠内营养液间歇泵入效果观察

目的观察危重症患者接受肠内营养治疗的最佳输注方式,减轻反流、误吸风险。方法将60例ICUEN患者随机分为对照组和观察组各30例。对照组采用持续泵入输注（16h）,观察组采用间歇泵入输注,即榆注90min暂停150min,4＆／d。结果两组胃残留液、胃液pH值,营养液反流入口、胃管内营养液反流发生率比较,差异有统计学意义（P〈0．05,P〈0．01）。结论肠内营养间歇泵入输注方法可减少患者胃残留液量和降低胃液pH值,有效减少反流、误吸发生率,是ICU患者较理想的鼻饲方法。     

外科重症患者早期肠内营养误吸状况及影响因素研究

目的 探讨重症患者早期肠内营养误吸发生现况及影响因素,为临床护理干预提供参考.方法 采用便利抽样法,选取实施早期肠内营养的外科重症患者,动态监测并记录患者从实施肠内营养开始7 d内误吸情况,采用Logistic回归分析误吸发生的影响因素.结果 共纳入126例患者,发生误吸30例(23.81％).误吸组第7天目标热量达标...     

肠内营养与肠内营养联合肠外营养在胰十二指肠切除术后患者中的应用比较

目的比较肠内营养(EN)、EN联合肠外营养(PN)在胰十二指肠切除术(PD)后患者中的应用。方法回顾性分析2005年1月~2014年1月我院87例PD后患者的临床资料,根据术后营养方式分为EN组(37例)及EN+PN组(50例),比较两组患者术后恢复情况、手术及术后营养相关并发症发生率、血生化相关性指标。结果两组患者术后恢复情况及手术相关并发症发生率比较,差异无统计学意义(P0.05),EN组与EN+PN组营养支持相关并发症率分别为30%、12%,差异有统计学意义(P0.05),EN+PN组血清总胆红素、丙氨酸转氨酶高于EN组(均P0.05),但两组均在正常值范围内。结论 PD患者术后应用EN联合PN安全性及实用性均与单独应用EN相似,但可明显减少营养相关并发症,是PD术后更好的营养方式。     

Subjective sleep assessment compared to polysomnography in mechanically ventilated critically ill ICU patients

Sleep deprivation is expected in the intensive care unit (ICU) and is associated with delirium and increased mortality. Polysomnography (PSG) is the gold standard for sleep assessment, but practical issues limit the method. Hence, many ICUs worldwide use subjective sleep assessment (SSA) for sleep monitoring, but the agreement between SSA and PSG is unknown. The hypothesis was that the level of agreement between SSA and PSG was low and that total sleep time (TST) assessed with SSA would be overestimated compared to PSG in this existing cohort database. In this sub-analysis, 30 consecutive study participants underwent 15-h PSG recordings during two consecutive nights. The attending nurse performed an hourly subjective observer rating of sleep quantity during both nights, and the agreement between SSA and PSG was determined along with mean TST. Primary outcome: The level of agreement between SSA and PSG determined by Bland–Altman analysis. Secondary outcome: (1) The overall mean TST estimated by SSA compared to PSG in all study participants enrolled in the main study during both study nights, (2) TST for all study participants evaluated hourly during both study nights, (3) TST assessed with SSA compared to PSG in study participants sedated with dexmedetomidine during the second night and for study participants treated with placebo or non-sedation the first and second nights. The level of agreement between SSA and PSG was low. Mean TST estimated by SSA during the time interval 4.00 p.m. to 7.00 a.m. was 481 min (428;534, 95% CI) vs. PSG at 437 min (386;488, 95% CI) (p = .05). When sedated with dexmedetomidine, TST estimated using SSA was 650 min (571;729, 95% CI) versus PSG which was 588 min (531;645, 95% CI) (p = 0.56). For participants treated with placebo or non-sedation TST estimated with SSA was 397 min (343;450, 95% CI) versus PSG at 362 min (302;422, 95% CI) versus (p = 0.17). In mechanically ventilated critically ill ICU patients, the level of agreement between SSA and PSG was low, and there was a significant overestimation of mean TST. SSA should only be used under awareness that it is imprecise and overestimates TST.     

急危重症患者院内安全转运路径的建立与实施

目的探讨急危重症患者院内安全转运临床路径实施的效果,以全面提高急危重患者院内转运的安全。方法将2009年1～12月从急诊科转送的609例危急重症患者设为对照组;2010年1～12月的759例危急重症患者设为观察组。对照组采用常规方法转运;观察组在建立安全转运路径后,按安全转运路径实施,流程包括转运前风险评估、转运前准备、转运前联络与协调;转运中监护与急救;转运后交接等措施。结果两组不良事件发生率、接收科室满意率比较,差异有统计学意义(P<0.05,P<0.01)。结论实施急危重患者院内安全转运路径能转变急诊科医护人员的观念,加强转运途中病情观察与监护,减少不良事件的发生,提收科室满意率,保证患者的生命安全。     

3M伤口保护膜在危重症患者管道护理中的应用

目的:探讨3M伤口保护膜(3M Cavilon)在危重症患者管道护理中的临床应用效果.方法:将90例危重症患者随机分为实验组45例和对照组4 5例.在采用常规管道护理的同时,对实验组应用3M伤口保护膜进行皮肤护理,比较两种方法的皮肤护理效果.结果:实验组应用3M伤口保护膜联合常规管道护理方法的疗效明显优于常规护理的对照组.结论:应用3M伤口保护膜可有效减少管道固定时对皮肤的理化刺激,比常规护理方法更有利于保持患者皮肤的完整性,不会增加患者的疼痛和不适,节省了护理时间.     

神经外科重症患者急性胃肠功能损伤管理模式的构建及实施

目的探讨神经外科重症患者急性胃肠功能损伤的有效管理模式。方法将421例神经外科ICU重症患者按时间段分为对照组203例、观察组218例,对照组采用常规治疗护理,观察组建立医护共同参与的急性胃肠功能损伤管理模式并用于患者管理。实施6个月后评价效果。结果观察组急性胃肠功能损伤程度、肠内营养等待时间、达到全量营养时间显著低于、短于对照组(均P0.01)。结论急性胃肠功能损伤管理模式的实施可减轻神经外科ICU重症患者急性胃肠功能损伤程度,使患者早期获得有效营养。     

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C‐collar) device in situ and are subsequently exposed to device‐related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C‐collar‐related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C‐collar were retrieved over a 9‐year period. Chi square and t‐tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine‐year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C‐collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024‐1.723, P = .033). Time in the C‐collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C‐collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.     

The role of flumazenil in the critically ill

Flumazenil is a specific benzodiazepine antagonist. It competitively inhibits the action of benzodiazepines at gamma aminobutyric acid (GABA) receptors in the central nervous system and thus reverses the sedative effects of benzodiazepines. Usually, it is given intravenously as a bolus dose or as an infusion. It has a short duration of action. Flumazenil is extensively metabolized to compounds that have minimal benzodiazepine antagonistic properties. Reversal of sedation can be useful in many conditions that are often encountered in the critically ill. The adverse effects of its use are usually predictable and, with sufficient clinical monitoring, are usually avoidable. These properties make it a useful and safe drug when used appropriately.     

Pharmacokinetics and analgesic effects of intravenous propacetamol vs rectal paracetamol in children after major craniofacial surgery

Background: The pharmacokinetics and analgesic effects of intravenous and rectal paracetamol were compared in nonventilated infants after craniofacial surgery in a double‐blind placebo controlled study. Methods: During surgery all infants (6 months–2 years) received a rectal loading dose of 40 mg·kg^?1 paracetamol 2 h before anticipated extubation. On admittance to the pediatric surgical ICU, the children were randomized to receive either a 15 min intravenous infusion of 40 mg·kg^?1 propacetamol, a prodrug of paracetamol, or 20 mg·kg^?1 paracetamol rectally every 6 h. A population pharmacokinetic analysis of the paracetamol plasma concentration time‐profiles was undertaken using nonlinear mixed effects models. The visual analogue scale (VAS) (score 0–10 cm) and COMFORT Behavior scale (score 6–30) were used to monitor analgesia in the 24‐h period following surgery. Results: Twelve infants received intravenous propacetamol and 14 paracetamol suppositories. Paracetamol pharmacokinetics were described according to a two‐compartmental model with linear disposition. Pharmacokinetic parameters were standardized to a 70 kg person using allometric ‘1/4 power’ models. Parameter estimates were: absorption half‐life from the rectum 4.6 h, propacetamol hydrolysis half‐life 0.028 h, clearance 12 l·h^?1·70 kg^?1, intercompartmental clearance 116 l·h^?1·70 kg^?1, central and peripheral volume of distribution 7.9 and 44 l·70 kg^?1, respectively. During the 24‐h study period 22 infants exhibited VAS scores <4 cm, which was considered a cutoff point. On single occasions four patients, two in each group, exhibited a VAS score ≥4 cm. Nine patients in the rectal treatment group and three patients in the intravenous treatment group received midazolam for COMFORT‐B scores exceeding 17 (P < 0.05). Conclusions: Intravenous propacetamol proved to be more effective than rectal paracetamol in infants after craniofacial surgery. Midazolam was more frequently administered to patients receiving paracetamol suppositories, indicating that these children experienced more distress, possibly caused by pain.     

清单制管理在危重患者院间长途转运中的应用

目的观察清单制管理在降低危重患者院间长途转运不良事件中的效果。方法将2014年1~12月符合院间长途转运标准的258例危重患者作为对照组,2015年1~12月261例作为观察组。对照组采取常规转运核查方法,观察组设计核查清单,转运护士根据清单逐项核查,比较两组转运中与仪器设备相关、与急救药品相关、与患者管路相关的不良事件发生率。结果观察组仪器设备功能障碍、氧气不足、电量不足、急救药品不足、导管堵塞等转运不良事件发生率显著低于对照组(P0.05,P0.01)。在药品过期方面,两组比较差异无统计学意义(P0.05)。结论清单制管理能有效降低危重患者长途转运中转运不良事件的发生率,为安全转运提供保障。