强离子隙等指标在重症肺炎中的应用价值分析

目的探讨强离子隙(SIG)、乳酸和阴离子隙(AG)等指标在重症肺炎中的应用价值。方法在测定血气、血pH、电解质结果基础上,应用Stewart-Figge方法学的方程式计算SIG。结果 223例重症肺炎患者与71例非重症肺炎患者进行比较,钠、钾、SIG、AG、清蛋白(ALB)、pH、磷酸盐及乳酸水平差异均有统计学意义(P<0.05),重症肺炎患者中217例存活患者与6例死亡患者比较,SIG、AG及ALB水平差异有统计学意义(P<0.05)。结论 SIG、乳酸和AG等指标对重症肺炎的诊断、治疗、病情监测具有指导意义;SIG值在重症肺炎患者预后评估中有较大的应用价值。     

强离子隙等指标在 ICU 中的应用探讨

目的：探讨继 pH、阴离子隙（AG）后的第三代方程式产生的强离子隙（SIG）在危重症患者中的临床应用价值。方法在测定血气、血生化结果基础上,应用 Stewart-Figge 方法学的方程式计算 SIG。结果（1）危重症患者各组 K＋、Na＋、HCO3-、AG、pH、PO43-、ALB、SIG 及 Cr 水平与对照组比较差异有统计学意义（P ＜0．05）。（2）死亡组与非死亡组 SIG 均值的比值为3．04,差别最大,两组间 AG 和 Cr 的比值次之。结论SIG 作为一个新的指标在与其他生化、血气指标如 HCO3-、AG、pH、PO43-、Cr 及乳酸联合应用时,能更好地反映危重病患者的酸碱紊乱情况,对预测疾病发展趋势有较强的指示作用。     

Delta（△）隙在混合型酸碱失衡诊断中的应用

设计一种简捷的直线型算图,通过查算Delta(△)隙以判断混合型酸碱失衡,探讨△隙在某些危重患者酸碱失衡诊查中的应用价值。     

强离子隙和肝肾功能在百草枯中毒中的应用比较

目的 比较急性百草枯中毒患者的强离子隙(strong ion gap,SIG)水平和肝肾功能指标与其预后的相关性.方法 回顾性研究2006年到2013年共148例口服百草枯中毒的患者,根据预后被分为生存组和死亡组,比较中毒早期强离子隙、谷丙转氨酶(glutamic pyruvictransaminase,ALT)、谷草转氨酶(glutamic oxalacetic transaminase,AST)、肌酐(creatinine,Cr)、尿素氮(blood urea nitrogen,BUN)指标的水平以及其他一般资料结果,并通过分析优势比(oddsratio,OR)以及建立ROC曲线比较强离子隙水平和肝肾功能指标对百草枯中毒患者的预后有效性.结果 异常的谷丙转氨酶(x2=10.257,P=0.001)、谷草转氨酶(x2=9.109,P=0.003)、肌酐(x2=10.257,P=0.021)、尿素氮(x2 =10.257,P＜0.001)较正常的指标对患者预后有更高的死亡风险,SIG较ALT、AST、Cr、BUN对致死率有明显的ORs (P ＜0.05).在ROC曲线中,SIG、ALT、AST、Cr、BUN对死亡预后的曲线下面积分别为0.822、0.708、0.724、0.603、0.625.结论 随着百草枯中毒患者早期的SIG、ALT、AST、Cr、BUN水平的升高,百草枯中毒患者的死亡风险增加,且SIG对患者的死亡预后较肝肾功能指标更有效.     

强离子隙对脓毒血症患者预后的预测价值

目的:分析强离子隙对脓毒血症患者预后的预测价值。方法:回顾性分析中山市火炬开发区医院感染科2016年3月～2019年12月收治的80例脓毒血症患者临床资料,依据预后分为存活组50例、死亡组30例,对两组强离子隙、凝血指标、降钙素原、血乳酸、C-反应蛋白进行测定和比较,利用Spearman相关性分析法检验强离子隙与脓毒血症患者预后的相关性,绘制受试者工作特征曲线(ROC)评价强离子隙对脓毒血症患者预后的预测价值。结果:两组脓毒血症患者强离子隙、凝血指标、降钙素原、血乳酸、C-反应蛋白相比较,差异有统计学意义(P0.05);Spearman相关性分析结果提示:强离子隙与脓毒血症患者预后呈负相关性(r=-0.51,P0.05);ROC曲线分析提示:强离子隙预测脓毒血症患者预后的曲线下面积为0.74,截断值为6.57,敏感度75.10%、特异度70.45%。结论:强离子隙与脓毒血症患者预后密切相关且具有较高的预测价值,可以被用于预后预测工作中。     

强离子隙和动脉血钙离子等指标在急性胰腺炎中的应用比较

目的:比较急性胰腺炎(AP)患者的强离子隙(SIG)、动脉血钙离子(ABC)、血糖(BG)等指标与其预后的相关性。方法:回顾性研究2014-01-2014-12我院救治的130例AP患者,根据预后将其分为生存组和死亡组,比较2组患者AP早期SIG、ABC、BG等指标水平及其他一般资料结果,并通过分析病死率OR值和建立受试者工作特征(ROC)曲线,比较SIG、ABC、BG等指标对AP患者预后的有效性。结果:SIG值9的患者死亡风险明显高于SIG值≤9的患者,ABC≤0.9 mmol/L的患者死亡风险高于ABC0.9 mmol/L的患者,BG≤13mmol/L的患者死亡风险低于BG13 mmol/L的患者(P0.05),SIG病死率OR值明显高于ABC和BG(P0.05)。在ROC曲线中,SIG、ABC、BG预测AP患者死亡的曲线下面积分别为0.812、0.699、0.606。结论:早期SIG、BG水平升高以及ABC水平降低将增加AP患者的死亡风险,且早期的SIG水平对AP患者的死亡风险预测较BG和ABC更加准确,值得临床上进一步应用和研究。     

阴离子间隙在诊断混合型酸碱平衡紊乱中的作用

目的：应用阴离子间隙（AG）值判断混合型酸碱平衡紊乱。方法：抽取动脉血2ml均以肝素抗凝即时送检。以公式AG=[Na＋]-[HCO3]-[CL-]计算AG值,参考范围8～16mmol／I。。酸碱血气分析结果按预计代偿公式计算,并结合AG值及临床诊断、病史、用药等情况,做出酸碱平衡紊乱类型的诊断。在此基础上以AG〉16mmol／L为筛选标准,筛选出63例;63例又分为2组：单纯型酸碱平衡紊乱7例和混合型酸碱平衡紊乱56例。全部数据以x±s表示,组间比较采用方差分析。结果：混合型酸碱平衡紊乱AG值升高的例数明显多于单纯型酸碱平衡紊乱AG值升高的例数（P〈0．05）。结论：因此,AG值升高,可帮助诊断混合型酸碱平衡紊乱,特别是对伴有代谢性酸中毒的混合型酸碱平衡紊乱的诊断具有重要意义。     

Influence of hypoalbuminemia or hyperalbuminemia on the serum anion gap

BACKGROUND: Conflicting data exist as to what extent hypoalbuminemia reduces the anion gap; estimates range from 1.5 to 2.5 mM per g/dL decrease in serum albumin. METHODS: We measured serum albumin, total protein, and electrolyte concentrations in 5328 consecutive patients aged 1 month to 102 years. Most patients (3750; 70%) had a normal albumin, but 1158 had hypoalbuminemia (< or =3.4 g/dL); 420 had hyperalbuminemia (> or =4.7 g/dL). Relationships between serum albumin or total protein and the anion gap were analyzed by linear regression. RESULTS: 309 (27%) hypoalbuminemic patients had a decreased anion gap, and 257 hyperalbuminemic patients (61%) had an increased anion gap. Among the entire group of 5328 patients, there were highly significant correlations between either serum albumin or total protein and the anion gap (P < 0.001). The slope of the regression for albumin versus anion gap was 2.3 mM per g/dL. Using this slope, anion gap could be adjusted for abnormal serum albumin levels: anion gap(adjusted) =anion gap + 2.3 (4-albumin). The initial assessment of an anion gap as being increased, normal, or decreased changed in 44% of the patients with hypo- or hyperalbuminemia once anion gap had been adjusted with this formula. CONCLUSIONS: Before considering whether a disorder associated with an increased or decreased anion gap is present, the anion gap should be first adjusted for abnormal serum albumin concentrations. Our data suggest that physicians use 2.3 times the change in serum albumin, whereas those of Figge et al suggest 2.5; either approach gives similar results.     

The anion gap (AG): studies in the nephrotic syndrome and diabetic ketoacidosis (DKA)

Although "unmeasured" anions contribute to metabolic acidosis in a variety of disease states, they are generally not measured directly but estimated from the calculation of "gaps." Among the most commonly used method, the anion gap (AG) is not only a function of "unmeasured" anions, but also it is a function of plasma non-carbonate buffers (albumin and phosphate), the plasma pH, and the method of measurement. To clarify the contribution of non-carbonate buffers to the AG, the Figge-Fencl-Waston model of human plasma was applied to laboratory values obtained from two novel populations, patients with nephrotic syndrome and patients with diabetic ketoacidosis (DKA). The model performed adequately, justifying the common clinical practice of correcting the AG for the net protein charge.     

The acid-base impact of free water removal from, and addition to, plasma

Water, compared with plasma at a pH of 7.4, is a weak acid. The addition of free water to a patient should have an acidifying effect (dilutional acidosis) and the removal of it, an alkalinizing effect (concentrational alkalosis). The specific effects of free water loss or gain in a relatively complex fluid such as plasma has, to the authors' knowledge, not been reported. This information would be useful in the interpretation of the effect of changes in free water in patients. Plasma samples from goats were either evaporated in a tonometer to 80% of baseline volume or hydrated by the addition of distilled water to 120% of baseline volume. The pH and partial pressure of carbon dioxide, sodium, potassium, ionized calcium, chloride, lactate, phosphorous, albumin, and total protein concentrations were measured. Actual base excess (ABE), standard bicarbonate, anion gap, strong ion difference, strong ion gap, unmeasured anions, and the effects of sodium, chloride, phosphate, and albumin changes on ABE were calculated. Most parameters changed 20% in proportion to the magnitude of dehydration or hydration. Bicarbonate concentration, however, increased only 11% in the evaporation trial and decreased only -2% in the dehydration trial. The evaporation trial was associated with a mild, but significant, metabolic alkalotic effect (ABE increased 3.2 mM/L), whereas the hydration trial was associated with a slight, insignificant metabolic acidotic effect (ABE decreased only 0.6 mM/L). The calculated free water ABE effect (change in sodium concentration) was offset by opposite changes in calculated chloride, lactate, phosphate, and albumin ABE effects.     

急性肾功能衰竭患者测定血清A1b、IgG和血脂水平诊断早期肾功能损伤的临床研究

目的探讨急性肾功能衰竭（ARF）患者测定血清A1b、IgG和血脂水平诊断早期肾功能损伤的临床意义。方法用免疫比浊法和生化法测定了86例ARF患者和42名正常对照组血清A1b、IgG和血脂（TC、TG、HDL—C、LDL—C、APOA和APOB）水平,并进行了对比性分析。结果ARF患者血清A1b和IgG水平分别为25．21±7．02mg／L和16．43±4．25g／L较正常对照组（42．36±4．58mg／L,24．71±5．01g／L）明显降低（P〈0．05,P〈0．01）。在血脂分析中,ARF患者血清TC、TG、LDL—C和APOB水平较正常对照组明显增高或非常明显增高（P〈0．05～0．01）,而血清HDL-C和APOA水平两组无明显差异（P均〉0．05）。结论ARF患者血清A1b和IgG水平明显降低以及血脂代谢紊乱是诊断早期肾功能损伤的有效指标。     

经皮肾穿刺造瘘术与开放手术治疗肾后性急性肾功能衰竭的疗效对比分析

目的 探讨经皮肾穿刺造瘘术(PCN)治疗肾后性急性肾功能衰竭(PARF)患者的效果及应用价值.方法 回顾性总结分析40例PARF患者在B超引导下行PCN的临床资料,并与20例行常规开放手术患者进行对比.结果 肾穿刺组PCN成功率为100%,引流后2～7 d,患者肾功能均恢复正常;治愈30例;长期留置肾造瘘管10例,其中2例为腹腔继发肿瘤患者,8例为宫颈癌晚期患者;无一例死亡、无造瘘后肾周血肿和胸膜损伤发生,未出现术后感染、多器官功能衰竭等并发症.开放手术组于引流后2～7 d 19例患者肾功能恢复正常,其中术后出现肺部感染3例,经抗感染、对症治疗后好转;多器官功能衰竭死亡1例.结论 PCN具有创伤小、出血少的优点,对挽救PARF患者肾脏功能有重要价值.     

Stewart analysis of apparently normal acid-base state in the critically ill

Purpose

This study aimed to describe Stewart parameters in critically ill patients with an apparently normal acid-base state and to determine the incidence of mixed metabolic acid-base disorders in these patients.

Materials and Methods

We conducted a prospective, observational multicenter study of 312 consecutive Dutch intensive care unit patients with normal pH (7.35 ≤ pH ≤ 7.45) on days 3 to 5. Apparent (SIDa) and effective strong ion difference (SIDe) and strong ion gap (SIG) were calculated from 3 consecutive arterial blood samples. Multivariate linear regression analysis was performed to analyze factors potentially associated with levels of SIDa and SIG.

Results

A total of 137 patients (44%) were identified with an apparently normal acid-base state (normal pH and − 2 < base excess < 2 and 35 < PaCO₂ < 45 mm Hg). In this group, SIDa values were 36.6 ± 3.6 mEq/L, resulting from hyperchloremia (109 ± 4.6 mEq/L, sodium-chloride difference 30.0 ± 3.6 mEq/L); SIDe values were 33.5 ± 2.3 mEq/L, resulting from hypoalbuminemia (24.0 ± 6.2 g/L); and SIG values were 3.1 ± 3.1 mEq/L. During admission, base excess increased secondary to a decrease in SIG levels and, subsequently, an increase in SIDa levels. Levels of SIDa were associated with positive cation load, chloride load, and admission SIDa (multivariate r² = 0.40, P < .001). Levels of SIG were associated with kidney function, sepsis, and SIG levels at intensive care unit admission (multivariate r² = 0.28, P < .001).

Conclusions

Intensive care unit patients with an apparently normal acid-base state have an underlying mixed metabolic acid-base disorder characterized by acidifying effects of a low SIDa (caused by hyperchloremia) and high SIG combined with the alkalinizing effect of hypoalbuminemia.     

A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure

Objective To compare the hemodynamic response of ICU patients with acute renal failure of a 24-h continuous arteriovenous hemofiltration (CAVH) and that of patients with a 4-h intermittent hemodialysis (HD).Design Cross-over randomized clinical trial. The two periods to be compared were a 24-h CAVH and the 24-h encompassing a 4-h HD. These two periods were separated by a 24-h wash-out period.Setting Ten bed medicosurgical ICU of a tertiary care center in Paris, France.Patients Inclusion criterion was the requirement of replacement therapy for acute renal failure in patients already submitted to mechanical ventilation.Interventions CAVH was performed with Ringers' lactate used for restitution and infused before the hemofilter. The ultrafiltrate output was maintained at around 15 ml/min. HD was performed with a bicarbonate-buffered dialysate.Mean outcome measures Mean arterial pressure (MAP), use of adrenergic drugs, and change in body weight during each period.Results Twenty-seven consecutive patients were included, 15 CAVH-HD and 12HD-CAVH. CAVH and HD allowed the same metabolic efficacy. No hemodynamic parameter (MAP, amount of adrenergic drugs, change in body weight) differed between the two methods.Conclusions CAVH is equivalent to HD in terms of MAP and the use of vasopressive drugs and fluids. Establishing the superiority of CAVH would require carefully controlled studies assessing either outcome or changes in tissue oxygenation.     

肝移植标准数学模型和CTP评分评估肝衰竭患者预后临床价值的比较研究

目的 比较肝移植标准数学模型(LTS)评分和Child-Turcotte-Pugh(CTP)评分对肝衰竭患者预后的临床评估价值.方法 回顾性分析2004年1月至2008年12月入住本院150例肝衰竭患者的病历资料,按患者入院后90 d的生存情况分为生存组(48例)和死亡组(102例).收集患者入院24 h内的LTS评分和CTP评分系统所需要的相关资料,分别计算LTS评分和CTP评分,比较生存组和死亡组的LTS评分和CTP评分.采用Spearman等级相关分析法分析LTS评分和CTP评分与肝衰竭预后的相关性;采用受试者工作特征曲线(ROC曲线)下面积(AUC)比较两个评分系统的预测能力.结果 生存组LTS评分[(38.88±4.27)分]和CTP评分[(11.25±0.97)分]均显著低于死亡组[LTS评分:(52.63±10.65)分,CTP评分:(12.18±1.22)分,均P＜0.01].LTS评分与肝衰竭预后的秩相关系数(r_s=0.651,P＜0.01)高于CTP评分(r_s=0.366,P＜0.01).LTS评分的AUC为0.897,敏感性(SN)为76.52%,特异性(SP)为91.18%,阳性预测值(PV+)为94.39%,阴性预测值(PV-)为66.67%,约登指数为0.677;CTP评分的AUC为0.716,SN为40.91%,SP为92.65%,PV+为91.53%,PV-为44.68%,约登指数为0.336.结论 LTS评分在评估肝衰竭患者预后的临床价值优于CTP评分.