经皮肾镜/输尿管镜取石术中、术后感染性休克15例报告

目的 总结经皮肾镜/输尿管镜取石术中、术后感染性休克的救治经验.方法 回顾分析2004年1月～2009年4月432例微创经皮肾镜取石术及645例输尿管镜碎石取石术中、术后发生感染性休克15例(男4例,女11例)的临床资料,其中11例发生在经皮肾镜取石术,4例发生于输尿管镜碎石术,术中1例,术后14例.感染性休克诊断明确...     

经皮肾镜致尿源性脓毒血症的危险因素及最佳干预时机的初步探讨

目的探讨经皮肾镜碎石取石术（PCNL）所致尿脓毒血症的危险因素,及脓毒血症最佳干预时机。 方法回顾性分析2016年1月至2020年2月在郁南县人民医院及南方医科大学第三附属医院进行PCNL治疗的497例患者临床资料,利用Fisher精确检验和二元Logistic回归分析尿脓毒血症相关危险因素,构建预测模型,通过ROC曲线验证该模型的预测效能。 结果在这497例行PCNL术的患者中19例发生尿源性脓毒血症（3.82%）;Fisher精确检验和二元logistic回归分析显示女性、术前尿培养阳性、结石直径>2.5 cm,手术时间>90 min、术者经验（<100例）、合并糖尿病为PCNL术后脓毒血症的独立危险因素。ROC曲线分析显示这些危险因素可以很好的预测尿脓毒血症的发生（AUC=0.926）。在这19例患者中,8例出现感染性休克（42.1%）,3例死亡（15.8%）。其中12例早期应用亚胺培南抗感染只有1例进展为感染性休克阶段,余7例则均进展为感染性休克,其中3例死亡。 结论女性、术前尿培养阳性、结石直径>2.5 cm、手术时间>90 min、术者经验<100例、合并糖尿病为PCNL术后尿脓毒血症的危险因素,且这些危险因素对PCNL所致尿脓毒血症具有良好预测效率。早期应用广谱抗生素是降低尿脓毒血症风险的有效方案。     

经皮肾微造瘘联合二期经皮肾镜碎石术治疗上尿路结石并感染性休克12例报告

目的：探讨经皮肾微造瘘联合二期经皮肾镜碎石术治疗上尿路结石并感染性休克的临床疗效。方法：对12例上尿路石并感染性休克患者在积极抗感染及抗休克治疗的同时行经皮肾微造瘘术,并于术后1～4周行二期经皮肾镜碎石术。结果：12例患者。肾造瘘术均顺利完成,感染及休克症状得到控制。二期手术均顺利完成,结石基本完全清除。结论：对于上尿路结石并感染性休克患者,早期行经皮肾脏微造瘘能有效控制感染及休克症状,联合二期经皮肾镜碎石术能完整清除结石,临床效果满意。     

经皮肾镜取石术所致尿源性脓毒血症的预测因子临床分析

目的寻找可以预测患者在经皮肾镜碎石术后从全身炎症反应综合征(SIRS)进展为尿源性脓毒血症的危险因素。方法回顾性分析2014年3月至2016年2月间156例经皮肾镜取石术(PCNL)后并发感染并发症的患者的临床资料。将可能导致尿源性脓毒血症的围手术期危险因素与只发生SIRS的患者进行比较。结果156例患者中的135例仅发展为SIRS,其余21例患者均发展为尿源性脓毒血症。尿源性脓毒血症组术前尿亚硝酸盐阳性率明显高于对照组(P<0.001),结石直径大(P=0.015),手术时间长(P<0.001)。多因素logistic回归分析显示术前尿亚硝酸盐(OR=10.570,P=0.025),结石大小(OR=11.512,P=0.009)和术后血白细胞减少(OR=0.009,P<0.001)。在尿激酶休克前3 h内白细胞计数阈值为2.98×10^9/L。白细胞计数预测尿源性脓毒血症的敏感性和特异性分别为90.5%和92.6%。结论术前尿亚硝酸盐、结石大小和术后白细胞计数与PCNL术后的尿路感染性休克相关。可将PCNL后3 h内白细胞减少低于2.98×10^9/L,可作为尿路感染性休克的预测指标。对于有高危因素的患者发生尿路感染性休克,应在PCNL后3 h内测量白细胞计数。     

上尿路腔内碎石术后并发感染性休克的处理和预防

目的：探讨上尿路腔内碎石术后并发感染性休克的原因和防治措施。方法i回顾性分析2005年1月～2008年3月上尿路腔内碎石术后6例感染性休克患者的临床资料：男4例,女2例,年龄38～61岁,平均47岁。其中经皮肾镜（PCNL）治疗者4例,经尿道输尿管镜治疗者2例,均表现为术后3～16h内出现高热（体温〉39．0℃）,血压降至80／50mmHg（1mmHg-0．133kPa）以下,心率〉110次／min。根据临床表现均诊断为感染性休克。6例均给予抗休克和抗感染等治疗。结果：5例患者在10～52h后逐渐停用升压药物,1周内体温和血常规恢复正常,最后治愈出院。1例因出现多脏器功能障碍综合征（MODS）而于术后第6天抢救无效死亡。结论：感染性休克是上尿路腔内碎石术后严重并发症之一,早期发现及合理处理是治疗成功的关键,加强预防措施可减少术后重症感染。     

Predictors of septic shock in obstructive acute pyelonephritis

Purpose

Acute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi.

Methods

We retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was performed for empirical treatment in cases of failure of initial treatment and for severe cases. We assessed the risk factors for septic shock by multivariate logistic regression analysis.

Results

Overall, 45 patients (65.2 %) underwent emergency drainage and 23 (33.3 %) patients showed septic shock. Poor performance status and the presence of diabetes mellitus (DM) in the septic shock group were more common than in the non-septic shock group (p = 0.012 and p = 0.011, respectively). The platelet count and serum albumin level in the septic shock group were significantly lower than in the non-septic shock group (p = 0.002 and p = 0.003, respectively). Positive rates of midstream urine culture and blood culture in the septic shock group were significantly higher than in the non-septic shock group (p = 0.022 and p = 0.001, respectively). Multivariate analysis showed that decreases in the platelet count (OR 5.43, p = 0.014) and serum albumin level (OR 5.88, p = 0.023) were independent risk factors for septic shock.

Conclusion

Patients with obstructive APN associated with upper urinary tract calculi who have decreases in platelet count and serum albumin level should be treated with caution against the development of septic shock.     

经皮肾微造瘘联合输尿管镜碎石术治疗输尿管结石并感染性休克75例报告

目的：探讨经皮肾微造瘘联合输尿管镜碎石术治疗输尿管结石并感染性休克的疗效及意义。方法：对75例输尿管结石并感染性休克患者在积极抗感染及抗休克治疗的同时行经皮肾微造瘘,并于术后1～4周行输尿管镜碎石术。结果：75例患者肾造瘘均jr~,,tl完成,感染及休克症状得到控制。输尿管镜手术均顺利完成,结石基本完全清除。结论：对于输尿管结石并感染性休克患者,早期行经皮肾微造瘘能有效控制感染及休克症状,联合输尿管镜碎石术能完整清除结石,临床效果满意,并能有效防I}术后感染并发痒的发牛。     

分期微通道经皮肾治疗合并尿脓毒症输尿管上段结石的临床分析

目的探讨采用分期微通道经皮肾手术治疗合并尿脓毒症输尿管上段结石的疗效。方法自2011年8月至2016年1月收治的24例合并尿脓毒症输尿管上段结石患者采用分期手术治疗,对其术后出现感染性休克,出血,结石残留等并发症进行分析。结果本组24例均完成Ⅰ期肾造瘘、Ⅱ期钬激光碎石。Ⅰ期肾造瘘术后15例不同程度发热,其中2例出现感染性休克,治疗后病情转平稳;Ⅱ期钬激光碎石一次碎石及清石,结石清除率为100%。术中无较严重出血,术后有2例出现发热,无感染性休克、输尿管撕脱、穿孔等并发症。结论采用分期微通道经皮肾手术治疗合并尿脓毒症输尿管上段结石,能有效解除梗阻,控制感染,且创伤小、安全可靠,可减少并发症的发生,具有较高临床价值。     

经输尿管镜碎石术后尿源性脓毒性休克的预后影响因素分析

目的:探讨影响经输尿管镜碎石术后尿源性脓毒性休克的预后因素。方法:选取本院2013年1月至2018年8月收治的1877例经输尿管镜碎石术治疗的患者为研究对象,其中22例发生尿源性脓毒性休克。在性别一致、年龄相差1岁以内的基础上,按照1∶4个体匹配,选取88例对照患者,就所有患者术前的一般资料、血常规、尿常规、止凝血、血...     

泌尿系结石腔镜碎石术后重症感染的诊治

目的探讨经皮肾镜、输尿管镜碎石术后重症感染的发生原因并总结治疗经验。方法回顾性分析2004年9月～2012年3月11例泌尿系结石腔镜碎石术后重症感染的临床资料。年龄45～68岁,平均52岁。经皮肾镜3例,经输尿管镜8例。术后2～10h出现高热、烦燥不安,血压降至70—80／45～50mmHg,心率110～130次／min,诊断感染性休克,均予以抗感染及抗休克治疗,保持肾造瘘管及导尿管在位通畅。结果生命体征逐渐平稳,尿量恢复正常,均在术后12。48h开始逐渐停用升压药物,5d体温及血常规恢复正常。结论泌尿系结石腔镜碎石术后重症感染的发生多见于术前合并泌尿系梗阻、感染,术中灌注压过高,术后引流不畅及手术时间过长的患者,针对上述原因采取积极有效的措施可降低重症感染的发生几率,而治疗的关键在于对感染性休克的早期诊断和及时处理。     

软输尿管镜激光碎石致败血症休克原因分析

目的分析软性输尿管肾镜激光碎石导致术后脓毒败血症性休克及多器官功能衰竭（MOF）的原因及预防。方法总结我院2013年6—7月份采用软性输尿管肾镜激光碎石术治疗。肾脏结石21例,分析严重手术并发症的发生原因。结果17例患者成功治愈且一周内出院,4例患者术后5h内发生脓毒败血症性休克,其中有2例进展为多器官功能衰竭（MOF）,1例抢救无效死亡。回顾性分析所有病例,发现所有4例发生脓毒血症性休克的患者术前尿培养均为阳性,3例结石较大（〉2cm）,1例多发结石,碎石时间均超过1h。结论术前尿培养阳性,结石大或多发结石导致碎石时间长（〉1h）是软性输尿管。肾镜激光碎石术后发生脓毒血症性休克的丰要原因。     

经皮肾镜术后感染性休克一例报告并文献复习

目的探讨经皮肾镜术后感染性休克的防治。方法报告1例62岁女性双肾结石并左肾积水，尿培养发现细菌，术前给予3d抗感染治疗后，行左侧经皮肾镜钬激光碎石术后出现感染性休克，结合文献对经皮肾镜术后出现感染性休克的防治进行复习。结果术中行大通道经皮。肾镜钬激光碎石，手术时间105min。术后12h开始出现血压下降，体温升高，血白细胞升高。经抗感染补液扩容等治疗后治愈出院。结论术前给予充分抗感染治疗，术中灌洗保持低压，术后密切监测生命体征和神志变化并加强抗感染治疗，可有效防治经皮。肾镜术后感染性休克的发生。     

Postoperative sepsis and septic shock after hip fracture surgery

IntroductionThere is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population.MethodsThe ACS-NSQIP (2015–2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality.ResultsOf 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%).ConclusionsThe incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.     

老年感染性休克病人的麻醉处理(附30例临床报告)

报道老年感染性休克病人的麻醉处理３０例，其中２４例选用持续硬膜外麻醉，５例选用气管内插管静脉复合麻醉，１例选用静脉氯胺酮麻醉，麻醉效果较为满意。术后痊愈２４例，死亡６例。讨论中重点强调了此类病人病情的危重性，并从麻醉前准备和用药，麻醉选择和麻醉维持，术中的监测和治疗，以及术后管理等几个方面介绍了对老年感染性休克病人围手术期处理的几点经验。     

感染性休克患者血浆弹性蛋白肽水平的变化及其意义

目的观察感染性休克患者血浆中弹性蛋白肽（EP）水平的变化,探讨其在感染性休克期间血流动力学改变中所起的作用。方法采集18例感染性休克患者的血样,同时采集同期住院的36例非感染性疾病患者和18名正常人的血样,采用ELISA技术测量血浆弹性蛋白肽的浓度。结果与非感染性疾病患者及正常人相比,感染性休克患者休克期间血浆EP水平明显增高,而非感染性休克患者与正常人之间差异无统计学意义,感染性休克患者在休克好转后血浆EP水平较休克期间明显降低（P〈0．05）。结论感染性休克患者在休克期间血浆EP水平明显增高,增高的EP可能参与了感染性休克血流动力学改变的病理生理过程。     

Risk factors for septic shock in acute obstructive pyelonephritis requiring emergency drainage of the upper urinary tract

Purpose

To assess the risk factors for septic shock in patients with acute obstructive pyelonephritis requiring emergency drainage of the upper urinary tract.

Methods

We retrospectively reviewed the records of 48 patients who underwent emergency drainage of the upper urinary tract for sepsis associated with acute obstructive pyelonephritis at our institute. Univariate and multivariate analyses were performed to identify the risk factors.

Results

Among 54 events of sepsis, we identified 20 events of septic shock requiring vasopressor therapy. Cases with shock were more likely than those without shock to have ureteral stone (70 vs 38 %, p = 0.024) and positive blood culture results (81 vs 28 %, p = 0.006). They received drainage significantly earlier than those without shock (1.0 vs 3.5 days, p < 0.001). Univariate analysis demonstrated that acute obstructive pyelonephritis by ureteral stone, rapid progression (the occurrence of symptoms to drainage ≤1 day), positive blood culture, leukocytopenia (<4,000/mm³), thrombocytopenia (<120,000/mm³), and prothrombin time international normalized ratio ≥1.20 were correlated with septic shock. Multivariate logistic regression analysis identified thrombocytopenia (p = 0.005) and positive blood culture (p = 0.040) as independent risk factors for septic shock.

Conclusions

Thrombocytopenia and positive blood culture were independent risk factors for septic shock in acute obstructive pyelonephritis requiring emergency drainage. Thrombocytopenia would be practically useful as a predictor of septic shock.     

Elevated methemoglobin in patients with sepsis

Background: It has been reported that large amounts of nitric oxide (NO) are released in patients with sepsis. NO is converted to methemoglobin and nitrate. This study was designed to determine whether blood methemoglobin levels were increased in patients with sepsis or septic shock.
Methods: Forty-five critically ill patients including 8 with sepsis but without shock, 6 with septic shock and 31 non-septic patients were enrolled in the study. For septic and septic shock patients, blood methemoglobin concentrations were measured during sepsis or septic shock and at the time of recovery or just before the onset of sepsis. For the remaining non-septic patients, methemoglobin concentrations were measured at ICU admission and discharge.
Results: Blood methemoglobin levels in the presence of sepsis or septic shock were significantly ( P <0.05) higher than those in non-septic patients and those at recovery or just before the onset of sepsis in both septic and septic shock patients.
Conclusions: Blood methemoglobin concentration may be useful as a marker of the onset of sepsis or septic shock.     

Severe sepsis and septic shock: a prospective population-based study in Icelandic intensive care units

Background: The aims of our study were to describe the nationwide epidemiology of sepsis requiring intensive care during an entire year and to evaluate compliance with treatment guidelines. Methods: This was a prospective, observational study of all adult patients admitted to Icelandic intensive care units (ICUs), who were screened for the ACCP/SCCM criteria for severe sepsis or septic shock on admission. Data were collected from 1 April 2008 to 31 March 2009. Results: One thousand five hundred and twenty‐four patients were admitted to the ICUs during the study year, 115 of them because of severe sepsis or septic shock. The incidence in Iceland was 0.48/1000 inhabitants ≥18 years per year [95% confidence intervals (CI) 0.42–0.55]. The mean APACHE II score was 20.7. Mortality was 24.6% (95% CI 17.5–33.3) at 28 days and 40.4% (95% CI 31.8–49.5) at 1 year. The main sources of infections were pulmonary (37%), abdominal (28%) and urinary tract (8%). Pathogens were gram‐positive (39%), gram‐negative (30%) and mixed (28%). No patient had sepsis caused by methicillin‐resistant Staphylococcus aureus or a monomicrobial fungal infection. Pulmonary infections were an independent predictor of death. Compliance to the resuscitation goals of the Surviving Sepsis Campaign ranged from 60% to 72% and the 6‐hour Sepsis Bundle was completed in 35% of patients. Conclusions: This nationwide study showed an incidence of 0.48/1000 inhabitants for severe sepsis and septic shock requiring intensive care therapy. The 28‐day mortality rate of 25 % was in the lower range of previous reports but the compliance to resuscitation goals and sepsis bundles was similar.     

微创经皮肾镜取石术后并发感染性休克的诊治体会

目的:探讨微创经皮肾镜取石术后并发感染性休克的发生原因及防治。方法:回顾性分析2007年5月～2011年4月11例患者行微创经皮肾镜取石术后并发感染性休克临床资料。出现休克后首要措施为补足血容量和控制感染,监测中心静脉压。血管活性药物在充分扩容的基础上使用,大剂量皮质激素和碱性药物的应用也极为重要。结果:11例患者均在6～36h后逐渐停用升压药物,3天后体温及血常规恢复正常。待血或中段尿细菌培养阴性后出院。结论:微创经皮肾镜取石术后发生感染性休克原因多为术前未能有效控制尿路感染、手术时间过长、术中肾盂压力过高、术后引流不畅等。术前充分准备和有效抗感染及术中提高碎石技巧和低压灌注、分期手术等是减少感染性休克发生的有效途径。成功救治的关键在于对感染性休克的早期诊断及处理。     

Cytokine serum level during severe sepsis in human IL-6 as a marker of severity.

Forty critically ill surgical patients with documented infections were studied during their stay in an intensive care unit. Among these patients, 19 developed septic shock and 16 died, 9 of them from septic shock. Interleukin 1 beta (IL-1 beta), tumor necrosis factor (TNF alpha), and interleukin 6 (IL-6) were measured each day and every 1 or 2 hours when septic shock occurred. Although IL-1 beta was never found, TNF alpha was most often observed in the serum at a level under 100 pg/mL except during septic shock. During these acute episodes TNF alpha level reached several hundred pg/mL, but only for a few hours. In contrast, IL-6 was always increased in the serum of acutely ill patients (peak to 500,000 pg/mL). There was a direct correlation between IL-6 peak serum level and TNF alpha peak serum level during septic shock and between IL-6 serum level and temperature or C-reactive protein serum level. Moreover, IL-6 correlated well with APACHE II score, and the mortality rate increased significantly in the group of patients who presented with IL-6 serum level above 1000 pg/mL. Thus, IL-6 appears to be a good marker of severity during bacterial infection.