下肢深静脉腔内瓣膜成形术治疗瓣膜功能不全20例报告

目的:研究下肢深静脉腔内瓣膜成形术的临床应用价值.方法:选择经过静脉造影或彩色多普勒检查确诊为原发性下肢静脉瓣膜功能不全的20条患肢行静脉瓣膜腔内成形术.结果:20条患肢随访5～7年,疗效优良.18例经彩色多普勒检查,均无返流.2例患肢色素加深,经彩色多普勒检查轻度返流,局部浅静脉曲张复发2例.结论:下肢深静脉腔内瓣膜成形术疗效确切,但有一定的并发症.     

Practical considerations for the dosing and adjustment of continuous renal replacement therapy in the intensive care unit

Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.     

Venous thromboembolism in critical illness in a community intensive care unit

BACKGROUND: Venous thromboembolism (VTE) can be a life-threatening complication of critical illness. Venous thromboembolism rates observed depend on the population studied, the screening modality used, and thromboprophylaxis prescribed. Few studies report on the rates of clinically diagnosed VTE in critically ill patients. The purpose of this study was to characterize the incidence of clinically diagnosed VTE, prophylactic strategies used, and diagnostic studies ordered in a critically ill population at a tertiary community intensive care unit (ICU), both during and after their ICU stay. METHODS: We did a retrospective chart review of 600 consecutive critically ill patients admitted to a tertiary community ICU. RESULTS: Fifty (8.3%) patients developed VTE over the course of their ICU and hospital stay (18 [3.0%] patients during their ICU stay and 32 [5.7% of 561 ICU survivors] patients after ICU discharge). By ICU admission diagnosis, most events occurred in neurosurgical patients, although this group comprised only 24.8% of the population. Across all subgroups, most VTE events occurred after ICU discharge. Intensive care unit patients received thromboprophylaxis 87.6% (95% confidence interval, 81.5-93.7) of the time spent in ICU. However, thromboprophylaxis was administered significantly less often after transfer to the ward compared with within the ICU (from 87.6% to 59.8%, P < .001). CONCLUSION: The rates of clinically diagnosed VTE rates in critically ill patients are substantial. Venous thromboembolism occurs before, during, and after ICU discharge. Continued vigilance and thromboprophylaxis are warranted across the continuum of critical illness.     

股静脉与颈内静脉留置双腔导管在血液透析中的应用

目的 比较股静脉与颈内静脉插管建立临时性血液透析通路的优缺点。方法 采用回顾性对照研究,106例尿毒症患者先后共留置股静脉导管72根,颈内静脉导管59根。观察两种插管途径的导管留置时间、导管相关并发症、血流量及 Kt/V值等。结果 颈内静脉插管的导管留量时间为 38±15天,明显长于股静脉插管21±11天(P<0.01);血流量分别为260±35ml/分、215±61ml/分(P<0.05);颈内静脉插管的血流量不足、感染及导管堵塞发生率低于股静脉插管;而且前者Kt/V值高于后者(1.1±0.4,0.8±0.5,P<0.05)。结论 相对而言,颈内静脉插管是一种更理想的临时性血液通路。     

多普勒超声诊断股静脉血液反流的探测点研究

目的 探讨多普勒超声检查下肢深静脉瓣膜功能不全(DVI)时股静脉内测点选择对诊断的影响。方法 对患有下肢浅静脉曲张的67例患者共134条股静脉分别在3个不同的测点进行Valsava屏气下脉冲多普勒(PW)频谱分析，并结合彩色多普勒血流显像(CDFI)将检查的结果与数字减影血管造影(DSA)和(或)手术结果进行比较。结果 股浅静脉上端测点的检查结果较另两个测点更加贴近DSA和(或)手术的结论。结论 脉冲多普勒频谱分析是检查DVI有效的方法，而合理地选择取样点(股浅静脉上端)是保障正确诊断的关键。     

股静脉置管在老年脑卒中患者中的临床应用研究

目的：对比分析股静脉置管在老年脑卒中患者行静脉治疗的优越性。方法：将60例老年脑卒中患者分为两组,实验组使用股静脉置管,对照组使用留置针,观察并记录两组的穿刺次数、并发症发生率;自行设计问卷调查患者或家属对使用该穿刺方法的主观评价。结果：实验组的穿刺次数、并发症发生率明显少于对照组（P〈0.01）;行股静脉置管后患者或家属在减轻痛苦及费用方面给予了较高的评价（P〈0.01）。结论：股静脉置管为老年脑卒中患者静脉治疗的顺利进行提供了保障,保护了患者的外周静脉;为护理提供了方便,确保了护理质量及护理安全,值得在老年脑卒中患者中推广使用。     

应用双腔股静脉置管进行外周血干细胞采集的效果分析

目的对比分析双腔股静脉置管与一次性内瘘针在外周血干细胞采集中的应用效果。方法 34例外周血干细胞采集健康供者采用随机数字表法分为两组各17例。分别采用双腔股静脉置管（试验组）与16 G内瘘针（对照组）采集外周血干细胞。观察两组穿刺成功率、采集顺利程度、术中舒适度及采集物中的有核细胞数、CD34＋细胞计数。结果两组供者采集物中的有核细胞数、CD34＋细胞计数均达标,差异无统计学意义（P〉0.05）;试验组穿刺成功率、采集顺利程度、术中舒适度均高于对照组,差异有统计学意义（P〈0.05）。结论双腔股静脉置管在外周血干细胞采集中穿刺成功率高,采集顺利,并能增加供者舒适度,且不影响采集效率和效果。     

血栓靶向超声造影剂对犬股静脉急性栓塞后血栓增强效果研究

目的探讨血栓靶向造影剂对犬股静脉急性血栓增强的效果。方法异物引入法制备10只健康杂种犬双侧股静脉急性血栓模型;血栓靶向超声造影剂经前肢浅静脉按0.06 ml/kg团注进行超声造影,采集造影后第0,2,4,6,8,10,12,14 min血栓声像图并存入磁光盘,采用目测观察和声学密度定量分析评价血栓增强效果。结果目测观察,注射靶向造影剂后血栓回声明显增强,与管腔无回声背景分界清晰,图像质量得到明显改善;造影后声学密度定量分析,血栓声学密度值随时间逐渐升高,于第8 min达峰值后,迅速下降;声学密度值[峰值密度(PI)=(333.21±38.56)dB,曲线下面积(AUC)=(884.40±94.62)dB]与造影前[PI=(168.18±28.18)dB,AUC(439.65±98.54)dB]比较差异有统计学意义(P<0.01)。结论血栓靶向超声造影剂可使犬急性血栓回声明显增强。     

皮下隧道股静脉穿刺置管用于重型颅脑损伤患者长期保持静脉通道的探讨

目的 :总结重型颅脑损伤患者长期静脉输液药物治疗、静脉高营养预防导管相关性感染的经验。方法 :随机将 137例重型颅脑损伤所致昏迷患者分为两组 ,实验组 (6 9例 )用经皮下隧道股静脉穿刺置管法建立静脉通道 ;对照组 (6 8例 )用传统股静脉穿刺置管法。两组均经此通道常规输液及补充静脉高营养素。穿刺点每周换药 2次 ,细菌培养 1次 ,发热患者行血培养 ,拔管时取导管尖端培养。观察导管阻塞、脱落、导管相关性感染等并发症以及留管时间等。结果 :实验组留管时间长于对照组 ,导管脱落及相关性感染、穿刺点感染等并发症的发生少于对照组 ,差异有显著性 (P <0 0 5或 0 0 1)。导管阻塞的发生率两组无差异 (P >0 0 5 )。结论 :经皮下隧道股静脉穿刺置管能有效降低导管相关性感染的发生率 ,延长留管时间 ,适合需长时间保留静脉通道的患者     

双侧股静脉交替置管在乳腺癌化疗中的应用效果评价

目的 探讨双侧股静脉交替置管术在乳腺癌化疗中的临床应用价值.方法 对28例乳腺癌化疗患者行双侧股静脉交替置管术80例次,分别于置管后1、3、7、>10 d对穿刺口皮肤取样进行细菌培养,拔管前自导管处采血5 ml及拔管后取导管头端5 cm行细菌培养,同时观察患者穿刺口局部皮肤及全身情况,并对阳性结果进行分析.结果 穿刺口采样细菌培养阳性率术后第3天比第1天明显增高,而术后第7天比第3天明显下降,两者比较P<0.01.导管血、导管头端培养无细菌生长.局部皮肤轻度红肿9例次(11.25%)、轻度疼痛1例次(1.25%)、无穿刺口渗液、发热及静脉炎、血栓发生.结论 双侧股静脉交替置管术应用于多周期化疗的乳腺癌患者是安全、可行的,解决了外周血管置管困难的难题.     

Heparin versus citrate for anticoagulation in critically ill patients treated with continuous renal replacement therapy

Background: Continuous renal replacement therapy (CRRT) is commonly used in the care of critically ill patients ( Gabutti et al., 2002 ). Critical illness increases the likelihood to both coagulation and bleeding, making anticoagulation for CRRT problematic. Aims: This mini‐review aims to examine the evidence that compares the use of systemic heparin and regional citrate as forms of anticoagulation for CRRT in critically ill patients. The primary outcome of interest was haemofilter circuit survival, and the secondary outcome was reduced risk of bleeding. Search strategy: A systematic literature search was undertaken to identify all studies comparing these drugs. The Cochrane Library , Medline and Embase databases were searched. Eighty‐nine articles were found. Included studies were randomized controlled trials (RCTs), which used a target population of critically ill adults. Studies were excluded if they had not been written in English and if they were not available through King’s College London. After applying the inclusion and exclusion criteria, three RCTs comparing the use of systemic heparin and regional citrate were included in the review. Results: Two studies showed significant differences in circuit survival time, with citrate prolonging survival time. All studies showed an increased risk of bleeding in the heparin group, resulting in a higher rate of transfusion while heparin was being used. Conclusions: The studies examined lacked reference to the power of the studies and strength in the presentation of the results. Because of the lack of reliability in the studies, it would be suggested that further research is needed on this topic in order to produce rigorous high‐quality reviews with limited bias. The use of citrate, as with all treatments in clinical practice, should be used with caution and assessed on an individual patient basis. Reviewing this evidence helps to gain an insight into different treatment options available, identifying some of the risks and benefits.     

Necessity of the Periodical Ultrasound Assessment of the Peripheral Venous System in Intensive Care Unit Patients

The utility of periodic sonographic assessment and monitoring for early diagnosis of deep vein thrombosis (DVT) in patients hospitalized in intensive care units (ICUs) was investigated. Of 314 patients hospitalized in an ICU over a 24-mo period, 248 were examined. The first examination of the patients was carried out within the first 48 h of ICU admission, and weekly examination followed until discharge. Peripheral veins were examined according to the general principles of the ultrasound study using the compression test in B-mode imaging (image to gray scale). The criterion for the absence or presence of a clot within the lumen was the presence or absence of full compressibility of the venous lumen, respectively. Intermittent compression was applied to multiple cross sections along the entire extent of the limbs. Three patients (1.2%) were diagnosed with sub-clinical DVT. The diagnoses were made on the third (sapheno-femoral junction), fourth (right internal jugular) and fifth (left gastrocnemius) weeks of hospitalization, respectively, although patients received full anticoagulation prophylaxis. DVT in a general-population ICU patient on anticoagulation prophylaxis did not seem to occur very frequently, and hence, regular ultrasound monitoring is not recommended. However, it may have value after the third week or in a selected population of ICU patients with very severe and/or multiple predisposing factors or who are not undergoing anticoagulant treatment because of contraindications.     

Bioavailability of fondaparinux to critically ill patients

Introduction

Venous thromboembolism is a common problem in the intensive care unit (ICU). To decrease its incidence, prophylactic pharmacologic interventions are part of the ICU routine. However, common ICU conditions may impair the bioavailability of subcutaneously administered agents. The present study evaluates the bioavailability of prophylactic subcutaneous fondaparinux to critically ill patients.

Purpose

The purpose of the study was to evaluate vasopressor effect on the bioavailability of subcutaneously administered fondaparinux.

Materials and Methods

A 2-center, prospective, observational study was performed. Forty patients were enrolled and divided into 2 groups depending on their vasopressor requirements. All subjects were critically ill patients admitted to a medical ICU for an anticipated stay of more than 72 hours.

Interventions

All patients received subcutaneous fondaparinux 2.5 mg/d, and serum anti-Xa factor was serially assessed during the first 100 hours of medical ICU stay.

Results

Therapeutic anti–factor Xa levels among patients receiving vasopressors were observed. In hemodynamically normal patients, subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration.

Conclusions

Vasopressor therapy does not appear to affect fondaparinux bioavailability or to reduce anti–factor Xa levels. Subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration in hemodynamically stable patients. The clinical significance of reduced levels during the first 2 days of fondaparinux administration remains unknown.     

RIFLE classification in patients with acute kidney injury in need of renal replacement therapy

OBJECTIVES: To evaluate the association of RIFLE classification with the outcomes of critically ill patients with acute kidney injury (AKI) who require renal replacement therapy (RRT). DESIGN AND SETTING: Prospective cohort study in the medical-surgical ICUs at three tertiary hospitals. PATIENTS: 214 patients over 1 year (mean age 71.4+/-15.8 years). Continuous RRT was used in 179 (84%); patients were classified as risk (25%), injury (27%), or failure (48%). Overall mortality was 76%. MEASUREMENTS AND RESULTS: There were no significant differences according to RIFLE classification (risk 72%, injury 79%, failure 76%). Variables selected in multivariate analysis were: older age (OR 1.03, 95% CI 1.01-1.06), presence of comorbidity (3.15, 1.10-9.02), poor chronic health status (6.51, 1.95-21.71), number of associated organ dysfunctions (patients with one or two organ dysfunctions 5.93, 2.03-17.33; patients with three or more organ dysfunctions 26.76, 6.28-114.11), and start of RRT after the first day of ICU (2.46, 1.09-5.53). RIFLE classification was forced into the model and was not selected. However, a subgroup analysis of 150 patients who received mechanical ventilation and vasopressors found failure to be associated with increased mortality (3.58, 1.08-11.80). CONCLUSIONS: Older age, number of organ dysfunctions, presence of comorbidities, and reduced functional capacity were the main prognostic factors. Patients who required RRT after the first day of ICU had a worse outcome. The RIFLE classification did not discriminate the prognosis in patients with AKI in need for RRT.     

新股静脉体表定位法在急诊救治中的应用

目的 探讨股动脉搏动微弱或者不明显时,股静脉采血的体表定位技巧。 方法 选择2010年6月-2011年5月入急诊抢救室的319例周围循环衰竭需抽取股静脉血的危重患者,随机将其分为对照组和观察组。对照组163例患者按传统的股静脉穿刺方法,即在股三角区股动脉搏动明显处内侧0.5cm处进针穿刺,如触不到搏动则在印象区试抽;实验组156例患者按照新股静脉体表定位法穿刺,即在下腹部和外阴部形成的皮肤褶皱线与耻骨联合所在水平线2条线的中分水平线与腹股沟韧带内缘交点的内侧0.5cm处进针。 结果 对照组一次性穿刺成功率(62.58%)明显低于实验组(96.79%)。 结论 新股静脉体表定位法穿刺抽取血标本成功率高。     

颈静脉与股静脉留置针在NICU静脉输液中应用的效果比较

目的 比较颈静脉和股静脉留置针在NICU患儿中的应用效果.方法 将160例患儿按随机数字表法分为颈静脉穿刺组和股静脉穿刺组各80例.观察两组患儿留置套管针的时间、首针穿刺成功率和各种并发症发生的情况.结果 颈静脉穿刺组患儿留置套管针的时间为(7.26±2.16)d,股静脉穿刺组为(9.87±2.93)d,两组比较差异有统计学意义(t=-6.25,P＜0.05);首针穿刺成功率差异无统计学意义(P＞0.05).静脉炎、堵管、脱管、外渗、渗血、局部感染发生例数股静脉穿刺组均少于颈静脉穿刺组,差异有统计学意义(x2值分别为8.41,7.83,4.10,4.78,5.77,5.77;P ＜0.05).结论 NICU患儿选择股静脉留置套管针可以延长留置时间,降低并发症发生,减轻了患儿的痛苦,也降低了医疗费用,值得临床推广.     

深静脉置管患者并发症分析及护理

目的探讨深静脉置管患者并发症特点,并提出护理对策。方法给予50例需要长期输液的患者实施深静脉置管术,分析患者发生并发症情况,并提出护理对策。结果 50例深静脉置管患者一次性成功穿刺40例,再次穿刺成功7例,单侧失败改对侧穿刺3例。治疗过程发生感染2例,导管堵塞5例,导管松动脱落3例。结论深静脉置管后可发生穿刺部位感染、导管堵塞、导管松动脱落等,应合理选择穿刺静脉,加强导管留置期间的护理,严格执行无菌操作,保持导管通畅;加强患者及家属并发症的预防意识,尽可能减少或避免各种并发症的发生,从而减轻患者的痛苦。     

220例经大隐静脉置入PICC导管术在新生儿监护病房中的应用

[目的]探讨经大隐静脉置入中心静脉导管（PICC）导管在新生儿监护病房中（NICU）的应用效果。[方法]对住NICU的220例患儿经大隐静脉置入PICC导管,并对其临床资料进行总结、分析。[结果j220例患儿中成功置管于下腔静脉217例,3例因导管末端异位于腹壁下静脉拔管;一次穿刺成功196例,成功率89．1％;留置时间4d～98d（23．94d±13．73d）;置管期间导管堵塞13例次,发生静脉炎19例次,导管因渗液脱出l例,导管体外断裂1例;206例拔管后行导管末端培养,结果导管末端细菌培养阳性2例。[结论]经大隐静脉置入PICC导管技术一次穿刺成功率高、异位率低、并发症少。     

连续性肾脏替代治疗对非肾性危重患者的疗效及安全性研究

目的 探讨连续性肾脏替代治疗(CRRT)在MICU非肾性危重患者中应用的疗效及安全性.方法 选择内科重症监护室(MICU)实施CRRT患者29例,均采用Prisma机器以及配套的管路和滤器,血管通路均采用股静脉或颈内静脉留置双腔导管,根据患者情况选择连续静静脉血液滤过(CVVH)、连续静静脉血液透析滤过(CVVHDF),透析持续时间每日4～12 h,如病情需要则24 h持续进行,血流速100～180 ml/h,置换液30～50 L/次;每次脱水量根据病情设置0～4 kg.观察治疗前后临床症状、血流动力学、血生化、氧合指数(PaO2/FiO2)和pH值、前炎性细胞因子肿瘤坏死因子-α(TNF-α)的变化及APACHEⅡ评分,并监测治疗过程中的并发症.结果 26例患者在CRRT治疗后生命体征迅速稳定,血滤前:体温(37.6±0.88)℃、呼吸频率(110.3±19.54)次/min、氧合指数262.6±10.6、白细胞总数(11.33±2.27)×109/L、中性粒细胞比例(85.62±7.83)%、天冬氨酸氨基转移酶(AST)(74.58±19.34)U/L、APACHEⅡ评分24.37±9.23分,血滤后:体温(36.84±0.58)℃、呼吸频率(102.0±16.2)次/min、氧合指数373.2±11.2、白细胞总数(9.62±3.26)×109/L、中性粒细胞比例(71.58±10.54)%、AST(38.34±13.96)U/L、APACHEⅡ评分14.65±6.54分,血滤前后相比差异具有统计学意义(t值分别为2.04、1.76、38.62、2.31、5.76、8.18、1.59,P均＜0.05),治疗过程中患者严重的离子及酸碱紊乱纠正,无其他并发症的发生.结论 CRRT治疗能够降低患者炎性反应程度,改善器官功能水平,稳定内环境,且血流动力学稳定,未见严重并发症的发生,安全有效.CRRT对于非肾性危重症患者来说是一个基本的治疗工具和重要的支持疗法.     

彩色多普勒超声对颈内静脉置管后血栓形成的检查

目的探讨彩色多普勒超声对颈内静脉置管血栓形成的诊断价值。方法对行颈内静脉置管术的306例患者的置管静脉进行彩色多普勒超声检查,并总结其形成特点。结果306例患者中,共检出置管后血栓形成患者199例,阳性率65．03％。颈内静脉置管后1d内即可形成血栓,10d内是血栓易发生期。颈内静脉置管后置管静脉血栓特点是血栓沿置入管生长。结论颈内静脉置管血栓发生率高,隐蔽性强,临床使用应常规行置管颈内静脉超声监测。