Analysis of admissions and outcomes in verified and nonverified burn centers.

The American Burn Association instituted a burn center verification process to ensure optimal care for patients with burn injury. Limited data exist regarding differences in admissions and outcomes between verified (VC) and nonverified burn centers (NVC). The study purpose was to compare demographics, treatment, and outcomes of VC and NVC. The five VC were compared with the 12 NVC using data from California's discharge database for the year 2003. A total of 2867 patients were admitted to a burn center, 1645 to NVC (132/center), and 1222 (244/center) to VC. NVC admitted 1496 (91%) of their patients from local area and 118 (7%) from other acute care hospitals; in contrast, 948 (78%) of VC patients were local and 253 (21%) were transfers from other acute care hospitals. VCs admitted twice as many burns > or =80% total body surface area as NVC. VCs admitted more patients with face burns (18% VC vs 14% NVC, P < .001), had more patients on mechanical ventilation (12.4% VC vs 9.9% NVC P < .04), and performed fewer operations (61% VC vs 66% NVC, P < .006). Mortality rate was 3% in NVC and 4% in VC. During the study period verified centers in California admitted more patients per center and treated more severely injured patients than nonverified centers. Despite these differences, VC had mortality rates comparable to their nonverified counterparts. These findings support the need for additional studies evaluating the impact of verification on burn care.     

Methamphetamine-related burns in the cornbelt.

Methamphetamine (MA) is a highly addictive drug that is easily manufactured from everyday household products and chemicals found at local farm stores. The proliferation of small MA labs has led to a dramatic increase in patients sustaining thermal injury while making and/or using MA. We hypothesized that these patients have larger injuries with longer hospital stays, and larger, nonreimbursed hospital bills compared with burn patients not manufacturing or using MA. In a retrospective case-control study, all burn patients >or=16 years of age admitted to our burn center from January 2002 to December 2005 were stratified into two groups based on urine MA status. Of the 660 burn patients >or=16 years of age admitted during this 4 year period, urine drug screens were obtained at admission on 410 patients (62%); 10% of urine drug screens were MA (+). MA (+) patients have larger burns compared with MA (-) patients (9.3 vs 8.6% body surface area burns), have higher rates of inhalation injuries (20.4 vs 9.3%, P = .015), and more nonthermal trauma (13.0 vs 3.1%, P = .001). When compared with MA (-) patients, MA (+) patients require longer hospital stays (median 9.5 vs 7.0 days, P = .036), accrue greater hospital bills per day (dollars 4292 vs dollars 2797, P = .01), and lack medical insurance (66.7 vs 17.7%, P < .0001). The epidemic of MA use and its manufacture mandates that burn centers monitor patients for MA use and develop and institute protocols to ensure proper care of this increasingly costly population.     

Influence of injury characteristics and payer status on burn treatment location in Washington state.

The provision of optimal burn care is a resource-intensive endeavor. The American Burn Association has developed criteria to help guide the decision to refer a patient to a burn center for definitive injury care. The purpose of this study was to compare the patient and injury characteristics of patients admitted to the single verified burn center in Washington State with those treated at other facilities in the state. We performed a retrospective review of all patients admitted to a hospital with a burn injury in Washington State from 1987 to 2005 using the state's discharge database (Comprehensive Hospital Abstract Reporting System). Patient and injury factors of patients admitted to the state's single verified burn center or at other hospitals were compared. Multivariate poisson regression was used to calculate the relative risk of injury and patient factors that were significantly associated with admission to the verified burn center. From 1987 to 2005, a total of 16,531 patients were admitted to a Washington State hospital after burn injury. Of these patients, 8624 (52.2%) were treated definitively at the University of Washington Burn Center. Patients treated at this verified center had larger overall burn size (7.4% vs 4.5% TBSA, P < .001), higher percent full-thickness burn (4.3% vs 1.2%, P < .001), and higher rates of inhalation injury (2.3% vs 1.5%, P = .005). Uninsured status (relative risk = 1.46, 95% confidence interval = 1.4-1.5) was also significantly associated with treatment at the verified burn center. Injury severity and payer status were both found to be independent predictors of treatment at the single verified burn center in Washington.     

Herpes simplex activation prolongs recovery from severe burn injury and increases bacterial infection risk

Recovery from severe burn injury is complicated by infections that are result of immune suppression created by massive inflammatory states. One indication of immune suppression may be activation of viruses like herpes simplex virus (HSV), which may negatively impact recovery. A 5-year retrospective review was performed of adult patients with ≥30% TBSA burn injury. TBSA burn injury, length of hospital stay, ventilator days, mortality, and cultures were reviewed. Twenty-one patients had cutaneous HSV activation (HSV+) and 50 did not (HSV-). Age (44.2 vs 39.8 years) and TBSA burn injury (45.9 vs 45.5%) did not differ between the groups. Length of hospital stay (60.9 vs 39.8 days, P < .05) and ventilator days (34.9 vs 22.2 days, P < .05) were greater in HSV+ patients. HSV activation increased hospital stay (odds ratio [OR] 1.6, confidence interval [CI] 1.08-2.39, P < .05) and mechanical ventilation (OR 1.02, CI 1.00-1.05, P < .05). HSV activation increased the risk of developing positive Acinetobacter baumannii pulmonary cultures (OR 6.4, CI 1.8-22.3, P < .05) and methicillin-resistant Staphylococcus aureus wound cultures (OR 3.3, CI 1.2-9.6, P < .05). HSV activation also increased the risk of developing any positive A. baumannii cultures (OR 9.1, CI 1.9-44, P < .05). HSV activation during severe burn injury is associated with increased length of mechanical ventilation and hospital stay. In addition, these patients have an increased risk of infections from opportunistic bacteria.     

自主呼吸试验在撤机中的应用

目的 对应用自主呼吸试验(SBT)撤机方式与逐渐降低机械通气支持水平撤机方式成功拔管的患者进行比较,以寻找最佳撤机方式.方法 选择57例机械通气患者,病情稳定后通过撤机试验前评估,然后准备撤机.采用前后对照的方法将患者分为两组,2004年6月-2005年12月的21例患者作为对照组,采用逐渐降低机械通气支持水平的撤机方式拔管;2006年1月-2007年3月的36例患者作用为试验组,采用SBT的撤机方式拔管.分别观察两组患者的机械通气时间、住重症监护病房(ICU)时间、呼吸机相关性肺炎(VAP)发生率、48 h内再插管率、ICU病死率.结果 试验组与对照组的机械通气时间分别为(59.45±37.1)h和(111.4±59.8)h(P=0.001),住ICU时间分别为(8.0±5.5)d和(15.3±14.3)d(P=0.034),VAP发生率分别为16.7%和38.0%(P=0.070),48 h内再插管率分别为19.4%和5.0%(P=0.253),ICU病死率分别为25.0%和24.0%(P=0.920).结论 SBT的撤机方式比逐渐降低机械通气支持水平的撤机方式具有机械通气时间和住ICU时间短的优点,而两组VAP发生率、48 h内再插管率、ICU病死率基本相同.     

Assault and substance abuse characterize burn injuries in homeless patients.

The homeless are at an increased risk for traumatic injury, but little is known about the injury etiology and outcome of homeless persons who sustain burn injuries. In this study, we analyze patient and injury characteristics of homeless persons admitted to a regional burn center. This is a retrospective cohort study of patients admitted to our burn center between 1994 and 2005. A total of 3700 adult patients were admitted during the study period and, of these, 72 (1.9%) were homeless. The cohort of homeless patients was compared with domiciled adult patients admitted during the same time period, analyzing baseline patient and injury characteristics and injury outcomes. Overall, homeless patients had more extensive burn injuries than domiciled patients (17.8% vs 11.2%TBSA, P < .001) and overall longer lengths of hospital stay (22 vs 12 days, P < .001). The homeless population also had significantly higher rates of alcohol (80.6% vs 12.8%, P < .001) and drug abuse (59.4% vs 12.8%, P < .001), history of mental illness (45.2% vs 11.0%, P < .001), and injury by assault (13.9% vs 2.0%, P < .001). Homeless patients tended to have more severe injuries; higher rates of substance abuse and mental illness; increased incidence of assault by burning; and longer lengths of hospital stay. Hospitalization of a homeless patient following injury may provide a unique opportunity to address co-occurring substance abuse and mental illness and approach injury prevention to improve patients' outcomes and reduce injury recidivism.     

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.     

Diabetes and burns: retrospective cohort study

Burn injuries are often associated with multisystemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alterations in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcome. The effects of diabetes on morbidity and mortality of the burn-injured patient have not been examined in great detail. The purpose of this retrospective study was to compare clinical outcomes between diabetic and nondiabetic burn patients. We reviewed the charts of 181 diabetic (DM) and 190 nondiabetic (nDM) patients admitted with burns between January 1996 and May 2000, matched by sex and date of admission. Burn cause and size, time to presentation, clinical course, and outcomes were evaluated. Because age was a factor, the analysis was done by three age groups: younger than 18 years, 18 to 65 years, and older than 65 years. Of patients 18 to 65 years, 51% (98/191) were diabetic, whereas 84% (81/96) of those older than 65 and only 4% (3/85) of patients younger than 18 were diabetic. Because of the disproportion in numbers of diabetics compared with nondiabetics in the younger than 18 and older than 65 years-old groups, these patients will not be discussed. Diabetics were more likely to incur scald injury from tub or shower water rather than hot fluid spills (33% DM vs 15% nDM; P < or = 0.01), and have a delayed presentation (45 vs 23%; P = 0.00001). There was no difference in total burn size in all groups. Diabetics in the 18 to 65 years group had a higher rate of full-thickness burns (51 vs 31%; P = 0.025), skin grafts (50 vs 28%; P = 0.01) and burn-related procedures (57 vs 32%; P = 0.001), infections (65 vs 51%; P = 0.05), and longer lengths of stay (23 vs 12 days; P = 0.0001). Although there was no statistically significant difference in incidence of specific infections, the rates of cellulitis, wound infection, urinary tract infection, line infection, and osteomyelitis, were consistently higher in the diabetic population. Partial graft slough was 6% in diabetics 18 to 65 years with a 3% regraft rate, whereas nondiabetics had a 1% regraft rate. Comparing diabetics with controlled vs uncontrolled glucose levels, diabetics with uncontrolled glucose had higher rates of infection (72 vs 55%; P < or = 0.025), all burn-related procedures (68 vs 45%; P < or = 0.025), and longer ICU stays (24 vs 10 days; P = 0.048). Mortality rate was 2% for diabetics and for nondiabetics. In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increased cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professionals, recognizing the elderly population as a "high-risk" group. We believe that targeted prevention measures and treatment strategies, emphasizing earlier and more aggressive intervention for this population, may have a favorable effect on morbidity and mortality.     

Decreased pulmonary barotrauma with the use of volumetric diffusive respiration in pediatric patients with burns: the 1992 Moyer Award.

Pulmonary barotrauma is a frequent, life-threatening complication in the pediatric patient who is treated with mechanical ventilation. The volumetric diffusive respiration (VDR) ventilator, which employs a high-frequency progressive accumulation of subtidal volume breaths in a pressure-limited format with a percussive waveform, is capable of providing adequate gas exchange at lower airway pressures; this theoretically decreases the incidence of pulmonary barotrauma compared with conventional mechanical ventilation (CV). The incidence of pulmonary barotrauma since 1988 was evaluated in pediatric patients with burns who were younger than 2 years of age. Twenty-four patients who were treated with only CV were compared with 15 patients who were treated with only VDR. Pulmonary barotrauma was defined as the development of pneumothorax, pneumomediastinum, pneumopericardium, or pneumoperitoneum. There were no significant differences between CV-treated and VDR-treated groups (mean +/- SEM) in the patient characteristics of age (15.9 +/- 1.3 months vs 16.6 +/- 1.8 months), weight (11.2 +/- 0.5 kg vs 12.5 +/- 0.7 kg), percent total body surface burn (46.2% +/- 4.9% vs 55.6% +/- 6.2%), percent full-thickness burn (38.1% +/- 5.3% vs 50.0% +/- 6.6%), inhalation injury (40% vs 60%), or total number of days that mechanical ventilation was required (18.2 +/- 4.2 days vs 22.4 +/- 5.9 days); although these parameters show a slightly more severe degree of injury in the VDR-treated group. There was a reduction in the incidence of pulmonary barotrauma when VDR was used.(ABSTRACT TRUNCATED AT 250 WORDS)     

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens

OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.     

The changing epidemiology of mechanical ventilation: a population-based study

The number of critical care beds in the United States has been increasing considerably, but it is unclear how these additional beds have been used. Mechanical ventilation for acute respiratory failure almost always demands ICU care and is likely to be a reliable indicator of critical care resource requirements on a population level. The objective of this study was to measure changes in the yearly incidence of mechanical ventilation in a statewide population. The North Carolina Hospital Discharge Database contains data on all discharges from nonfederal, nonpsychiatric hospitals in North Carolina. Authors extracted data on adult patients with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for mechanical ventilation from 1996 to 2002. The incidence of mechanical ventilation for adults grew from 284/100,000 population in 1996 to 314/100,000 in 2002, an increase of 11% (P < .05). While patients aged >64 had the highest age-specific incidence of mechanical ventilation each year, the greatest increase in incidence occurred in younger age groups (19% increase for age 18-64 vs 4% increase for age >64). The mean Charlson score increased from 1.76 +/- 1.73 to 1.89 +/- 1.86 (P < .001). Renal disease became more prevalent among patients requiring mechanical ventilation (17% of patients in 1996 vs 24% in 2002). Hospital charges adjusted for the medical consumer price index increased by 12%. The proportion of patients discharged to home declined from 45.4% to 34.4%, and discharges to nursing homes grew from 7.3% to 10.7%. The incidence of mechanical ventilation is increasing, and the increase is associated with a higher burden of comorbidities and fewer discharges to home.     

急性呼吸窘迫综合征患者早期应用气道压力释放通气的疗效

目的探讨早期应用气道压力释放通气（APRV）对急性呼吸窘迫综合征（ARDS）患者的临床疗效。 方法将2017年9月至2019年6月收住在兰州大学第一医院ICU的71例ARDS患者分为APRV组（36例）和小潮气量（LTV）组（35例）。APRV组患者起初给予容量辅助控制通气模式,测量气道平台压后转为APRV模式;LTV组患者接受LTV通气,目标潮气量设置为6~8 mL/kg,依据ARDSnet协议调节呼气末正压（PEEP）水平、潮气量和呼吸频率。记录两组患者的一般资料,比较其机械通气第1天和第7天呼吸机参数、呼吸力学指标、血气功能指标、循环功能指标及预后情况;绘制Kaplan-Meier生存曲线,比较两组患者28 d生存情况。 结果机械通气第7天,APRV组和LTV组患者吸入氧浓度（FiO₂）[（47 ± 5）% vs.（66 ± 5）%,t = 3.746,P < 0.001]、呼吸频率[（24 ± 4）次/min vs.（18 ± 4）次/min,t = 3.453,P < 0.001]、PEEP[（5.6 ± 2.3）cmH₂O vs.（10.8 ± 4.4）cmH₂O,t = 3.011,P < 0.001]、气道峰压[23.9（18.5,29.6）cmH₂O vs. 25.1（11.3,31.8）cmH₂O,H = 2.736,P = 0.014]、气道平台压[22.2（18.7,24.3）cmH₂O vs. 19.6（17.2,22.4）cmH₂O,H = 2.154,P = 0.023]、平均气道压[23.8（22.1,24.3）cmH₂O vs. 15.4（13.9,19.4）cmH₂O,H = 2.814,P = 0.018]、肺顺应性[52.7（37.4,62.3）mL/cmH₂O vs. 41.8（31.5,57.6）mL/cmH₂O,H = 2.008,P = 0.034]、动脉血氧分压（PaO₂）[（89 ± 7）mmHg vs.（72 ± 7）mmHg,t = 2.324,P < 0.001]、PaO₂/FiO₂ [（201 ± 15）mmHg vs.（140 ± 12）mmHg,t = 2.743,P < 0.001]、动脉血氧饱和度（SaO₂）[（95.4 ± 2.1）% vs.（92.3 ± 1.8）%,t = 2.658,P < 0.001]、心率[（99 ± 9）次/min vs.（108 ± 9）次/min,t = 2.733,P = 0.014]及平均动脉压[（84 ± 11）mmHg vs.（74 ± 13）mmHg,t = 3.012,P = 0.011]比较,差异均有统计学意义。APRV组ARDS患者机械通气时间[（9.6 ± 2.2）d vs.（11.9 ± 2.9）d,t = 3.687,P < 0.001]、住ICU时间[（11.3 ± 3.1）d vs.（13.2 ± 2.7）d,t = 2.722,P = 0.008]、住院时间[（13.9 ± 2.5）d vs.（16.2 ± 2.4）d,t = 3.924,P = 0.004]均较LTV组显著缩短,拔管成功率[80.6%（29/36）vs. 54.3%（19/35）,χ² = 5.592,P = 0.018]显著升高,肺复张[5.6%（2/36）vs. 48.6%（17/35）,χ² = 16.753,P < 0.001]、俯卧位通气[11.1%（4/36）vs. 34.3%（12/35）,χ² = 5.460,P = 0.019]、气胸发生率[8.3%（3/36）vs. 28.6%（10/35）,χ² = 4.860,P = 0.028]及28 d住院病死率[13.9%（5/36）vs. 34.3%（12/35）,χ² = 4.054,P = 0.044]均显著降低。Kaplan-Meier生存曲线结果显示,APRV组ARDS患者生存情况显著优于LTV组（χ² = 4.118,P = 0.015）。 结论与LTV组比较,早期应用APRV可显著改善ARDS患者的氧合功能和呼吸系统顺应性,提高拔管成功率,降低气胸发生率,并减少机械通气时间和住院时间。     

Nonthermal surgical complications in burn patients

Patients with severe burn injuries are generally admitted to specialized units and managed by physicians who specialize in burn care. Complications requiring operative intervention and not directly related to the burn wound occur frequently but are easily overlooked. To determine the nature and frequency of these complications, we conducted a retrospective study of all burn cases in our burn unit over a 5-year period. Twenty-three of the 309 patients (7%) had 45 complications not related directly to the burn wound and required surgical intervention or consultation. The population with surgical complications was generally older (52 vs 42 years), more severely burned (36% vs 25% total body surface area), and had a higher mortality (44% vs 13%). Sixteen of the 23 patients with complications had a single surgical problem, while seven patients sustained multiple complications. In six of the 10 deaths, the surgical complication was believed to be either directly related or significantly contributory to the cause of death. Because the number of burn patients requiring surgical intervention is high, burn patients must be thoroughly examined for possible complications.     

早期膈肌萎缩对急性呼吸窘迫综合征机械通气患者撤机结局的影响研究

目的探讨急性呼吸窘迫综合征（ARDS）机械通气患者早期膈肌萎缩的发生情况及对撤机结局的影响。 方法选取2019年1月至2021年6月入住宁波市医疗中心李惠利医院东部院区重症医学科的53例ARDS并接受机械通气治疗患者,采用床旁超声连续监测机械通气后即刻、72 h的吸气末膈肌厚度（DTei）和呼气末膈肌厚度（DTee）,定义机械通气后72 h的DTee ≤ 2 mm为早期膈肌萎缩,并将患者分为早期膈肌萎缩组（A组,27例）和非萎缩组（B组,26例）。比较两组患者的一般资料、急性病生理学和长期健康评价（APACHE）Ⅱ评分、机械通气后即刻及72 h的DTei和DTee、撤机结局、机械通气时长以及DTei、DTee与ARDS患者撤机结局的相关性,采用受试者工作特征（ROC）曲线确定预测拔管成功的最佳截断值。 结果A组患者机械通气72 h肺泡动脉氧分压差[P（A-a）O₂][（210 ± 118）mmHg vs.（155 ± 63）mmHg,t = 4.344,P = 0.042]和机械通气时间[188.0（112.0,281.0）h vs. 92.5（71.8,167.8）h,t = 2.642,P = 0.008]均大于B组,而撤机成功情况（8/27 vs. 24/26,χ² = 21.751,P < 0.001）、机械通气后72 h DTei[（0.224 ± 0.067）cm vs.（0.312 ± 0.094）cm,t = 3.933,P < 0.001]及72 h DTee[（0.159 ± 0.027）cm vs.（0.268 ± 0.082）cm,t = 6.570,P < 0.001]均明显低于B组。Spearman相关分析结果显示,机械通气后72 h DTei（r = 0.337,P = 0.014）及72 h DTee（r = 0.503,P < 0.001）均与机械通气撤机成功呈正相关。ROC曲线分析结果显示,ARDS患者机械通气后72 h DTei[曲线下面积（AUC）= 0.699,95%置信区间（CI）（0.557,0.817）,P = 0.009]和72 h DTee[AUC = 0.797,95%CI（0.664,0.895）,P < 0.001]均对机械通气撤机成功具有预测价值,二者最佳截断值分别为0.240 cm和0.200 cm,且后者预测撤机成功的特异度高于前者（90.5% vs. 71.4%）。 结论ARDS机械通气患者早期膈肌萎缩的出现与不良撤机结局密切相关,机械通气后72 h DTei和72 h DTee均可用来预测撤机结局,相较于72 h DTei,72 h DTee是指导预测撤机结局的较好指标。     

早期护理干预在机械通气患者中的应用及效果观察

目的:探讨早期护理干预在机械通气患者中的应用及临床效果。方法:将2006年1月～2007年12月收治的342例机械通气患者作为对照组,给予常规护理;将2008年1月～2009年12月收治的342例机械通气患者作为护理组,在常规护理基础上给予护理干预。比较两组送检标本细菌检出阳性率、呼吸机相关肺炎(VAP)发生率、机械通气时间及ICU住院时间。结果:护理组送检标本细菌培养阳性率为37%,对照组阳性率为45%;护理组VAP发生率低于对照组(P<0.05),机械通气时间及ICU住院时间少于对照组(P<0.05)。结论:早期护理干预可以降低机械通气患者VAP发生率,缩短机械通气时间及ICU住院时间,促进患者康复。     

High-frequency oscillatory ventilators in burn patients: experience of Riley Hospital for Children

The objective of the study is to review a single institution's experience with high-frequency oscillatory ventilation (HFOV) and compare patient characteristics, outcomes, and complications with other reported studies of HFOV use in burn patients with acute respiratory distress syndrome and respiratory failure. This study is a retrospective chart review of the burn patients treated with HFOV in Pediatric Burn Unit at Riley Hospital for Children from October 1996 to April 2007. Patient data were collected, including demographics, percentage of TBSA burn, percentage of full-thickness burn, mechanisms of burn, settings on conventional mechanical ventilation and HFOV, and blood gas data before initiation of HFOV and at 1, 3, 6, 12, 24, 72 (3 days), 120 (5 days), 168 (7 days), 240 (10 days), and 336 hours (14 days). Length of stay, mortality, and complications were also included. HFOV was used 24 times in 21 patients between October 1996 and April 2007 with a mean age of 10 ± 11 years. At initiation of HFOV, the PaO2/FiO2 and oxygenation index values were 109 ± 26 and 36 ± 12, respectively. At stop, the PaO2/FiO2 improved to 166 ± 24 with an average increase from before HFOV of 57 ± 39 (P < .002). At 5 days of HFOV, oxygenation index improved to 14.1 ± 1.7 (P < .02) but did not significantly improve at discontinuation of HFOV at 28.8 ± 6.2 (P = .11). The mortality rate during admission to the burn unit was 29%. Barotrauma occurred in 38% of patients during HFOV. Severe hypercapnea was present briefly in 49% of patients, and this was refractory to standard treatment in 19%. In our experience, HFOV in severe burn patients has significant, early, and sustained improvement in oxygenation. Earlier institution of HFOV seems to significantly lower rates of barotraumas.     

Efficacy and safety of procedural sedation and analgesia for burn wound care

The study aim was to quantify efficacy and patient safety of registered nurse-administered procedural sedation and analgesia in a regional burn center. The investigators conducted a review of procedural sedation forms for all pediatric and adult patients admitted to this burn center from January 1, 2005, through December 31, 2005, for demographic and clinical data including patient age, gender, body weight, TBSA, dates of burn injury and wound care procedures, length of procedure, pre- and postprocedural pain assessment, procedural sedation/analgesia medications and doses, adverse drug events, and related interventions. During the 12-month study period, a total of 328 burn patients received 1293 procedural sedation procedures; child subjects (≤ 18 years) received 356 procedures and adult subjects (19-87 years) received 937 procedures. The mean (SD) length of the procedure was 60.1 (22.49) minutes with a range of 10 to 170 minutes. The mean subject age was 34.2 years (range: 6 weeks to 87 years), 67% were male, and the mean TBSA was 17% (0.5-68%). Ninety-four percent received fentanyl for analgesia and 85% received midazolam for anxiolysis and amnesia. The mean preprocedural pain score was 3.2 and the mean postprocedural pain score was 2 (t = 14.795; df = 1243; P < .001). Ten adverse events, all respiratory related, were documented in eight patients, two of whom experienced a second adverse event for an overall adverse event rate of 0.77%. No patient required intubation. Procedural sedation administered by a registered nurse competent in administration and monitoring in a burn center provided safe and effective pain management during wound care.     

Outcome of mechanical ventilation for acute respiratory failure in patients with pulmonary fibrosis

OBJECTIVE: During the course of idiopathic pulmonary fibrosis patients may need invasive mechanical ventilation because of acute respiratory failure. We reviewed the charts of all patients with idiopathic pulmonary fibrosis admitted to our ICU for mechanical ventilation to describe their ICU course and prognosis. DESIGN AND SETTING: Retrospective, observational case series, from December 1996 to March 2001, in an 18-bed medical ICU in a tertiary university hospital. PATIENTS: Fourteen consecutive patients with idiopathic ( n=11) or secondary ( n=3) pulmonary fibrosis admitted to the medical ICU for mechanical ventilation. MEASUREMENTS AND RESULTS: Relevant factors of history and hospital course such as diagnostic and therapeutic interventions were retrieved as well as laboratory and radiological results. All patients were admitted for severe acute hypoxemic respiratory failure (PaO(2)/FIO(2) 111+/-64 mmHg), with a high clinical suspicion of lower respiratory tract infection. Despite ventilatory support and adjunctive therapies (antibiotics, steroids, or immunosuppressive drugs), all patients gradually worsened and eventually died in the ICU after a mean stay of 7.6+/-4.6 days. CONCLUSIONS: In this study mechanical ventilation for acute respiratory failure in pulmonary fibrosis patients was associated with a 100% mortality, despite aggressive therapeutic and diagnostic procedures.     

Daily cost of an intensive care unit day: the contribution of mechanical ventilation

OBJECTIVE: To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit. DESIGN: Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database. SETTING: A total of 253 geographically diverse U.S. hospitals. PATIENTS: The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics.Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001). CONCLUSIONS: Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

目的 探讨早期目标导向治疗(EGDT)对严重脓毒症/脓毒性休克患者的影响.方法 采用多中心、前瞻性、随机、对照研究方法,选择2005年1月至2008年1月浙江省8家三级甲等医院重症监护病房(ICU)住院的314例严重脓毒症/脓毒性休克患者,按随机数字表法分为常规组(151例)和EGDT组(163例).常规组以中心静脉压(CVP)、收缩压(SBP)和平均动脉压(MAP)、尿量变化指导液体复苏;EGDT组在此基础上增加中心静脉血氧饱和度(ScvO2)为观测指标进行复苏;对患者进行输液、输血和强等治疗,6 h内达标.比较两组患者28 d生存率、ICU住院病死率(主要终点)以及ICU住院时间、机械通气时间、抗生素使用时间、新发感染率和疾病严重程度评分(次要终点)的差异.结果 可供分析的有效病例中EGDT组为157例,常规组为146例.EGDT组28 d生存率较常规组增高约17.7%(75.2%比57.5%,P=0.001),EGDT组ICU住院病死率较常规组降低约15.7%(35.0%比50.7%,p=0.035).与常规组比较,EGDT能明显善患者的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分(分:14.4±8.5比18.0±7.1,P=0.043)、多器官功能障碍综合征(MODS)评分(分:5.8±3.1比8.9±3.7,P=0.014)和感染相关器官功能衰竭评分系统(SOFA)评分(分:5.6±2.9比10.4±3.7,P=0.001),减少抗生素使用时间(d:13.4±10.0比19.7±13.5,P=0.004),降低新发感染的发生率(37.6%比53.4%,p=0.014);EGDT对ICU住院时间、机械通气间均无明显影响.结论 EGDT能显著改善ICU中严重脓毒症/脓毒性休克患者28 d生存率和临床疾病严重程度评分,减少抗生素使用时间及降低新发感染的发生率.