肾上腺髓质素对腹腔感染所致肺损伤大鼠肺组织中PPAR-γ的影响

目的探讨肾上腺髓质素(ADM)对腹腔感染所致急性肺损伤(ALI)大鼠肺组织中过氧化物酶体增殖物激活受体γ(PPAR-γ)蛋白表达的影响。方法采用盲肠结扎穿孔(CLP)制作大鼠腹腔感染模型,随机分为假手术组(Sham)、Sham ADM组,CLP组和CLP ADM治疗组。持续监测各组大鼠颈动脉压力。分别于手术后6h、18h测定支气管肺泡灌洗液(BALF)中白细胞计数及肿瘤坏死因子α(TNF-α)含量;肺组织HE染色及肺损伤组织学评分;测定肺组织湿/干重比值(W/D);用Westernblot法观察肺组织中PPAR-γ蛋白表达变化。结果各组之间平均动脉压在各时段差异无统计学意义(P>0.05)。CLP组6h、18h时的肺损伤组织学评分(P<0.05)以及BALF中白细胞数(P<0.05)、肿瘤坏死因子α(TNF-α)含量均明显高于Sham组和CLP ADM组(P<0.05)。CLP组在18h的W/D值较Sham组和CLP ADM有明显升高(P<0.05),而CLP ADM组18h的W/D值低于CLP组(P<0.05)。CLP组6h、18h大鼠肺组织中PPAR-γ蛋白表达较Sham组和CLP ADM均有显著下降(P<0.05)。结论肾上腺髓质素可以减轻腹腔感染大鼠的肺损伤程度,并且上调肺损伤大鼠肺组织中PPAR-r蛋白的表达。     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

动脉瘤病人围手术期凝血和纤溶状态及其与预后关系研究

目的 分析动脉瘤病人围手术期凝血与纤溶指标的变化特点及其与预后的关系。方法 回顾性分析2013年1-6月于中国医科大学附属第一医院重症医学科治疗的40例动脉瘤术后病人的临床资料,分析围手术期凝血及纤溶指标变化及其与预后的关系。结果 40例动脉瘤病人术后血小板及纤维蛋白原水平明显低于术前（P<0.05）,ISTH评分平均为（3.4±1.5）分,共7例病人诊断为弥漫性血管内凝血。动脉瘤破裂病人的ISTH评分明显高于未破裂者（P<0.05）。ISTH评分与APACHEⅡ、SOFA评分呈正相关关系（r=0.704、0.694,P<0.05）,ARDS、休克及死亡病人具有更高的ISTH评分。结论 动脉瘤病人围手术期凝血及纤溶系统激活,血小板及纤维蛋白原大量消耗,易发生出凝血功能障碍;ISTH评分高的病人更易发生器官功能损伤,且预后较差。     

脓毒症血管内皮细胞损伤与微循环功能障碍

脓毒症是由感染引起的机体过度炎症反应所致,其重要标志之一是微循环功能障碍,而内皮细胞活化和功能障碍在其中起到关键性的作用.1 内皮细胞活化和功能障碍1.1 内皮细胞功能:血管内皮细胞具有高度的生物活性,参与体内多种生理过程,包括调控血管平滑肌张力,完成细胞与营养物质的交换,维持血液流动性,调节局部促炎及抗炎介质的平衡,参与新生血管的生成及程序性细胞凋亡等[1].     

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??Perioperative coagulation disorder??Types and treatment strategies ZHANG Zhi-dan. Intensive Care Unit, the First Affiliated Hospital of China Medical University??Shenyang 110001??China
Abstract Coagulation disorder seriously affect prognosis of perioperative patients. Trauma-induced coagulopathy due to severe trauma or massive transfusion and consumptive coagulopathy due to severe sepsis are two major types of perioperative coagulation disorder. Different pathogenesis and treatment strategies need to be known which are important for management of perioperative patients.     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

危重症患者内分泌变化的临床意义

机体在大手术、重症感染等所致的严重应激状态下，不仅会发生肺脏、肾脏等脏器功能障碍，也会发生内分泌代谢紊乱，从而影响患者的临床过程和预后。本文通过动态监测45例不同病因的危重症患者血糖、血清甲状腺激素、皮质醇等改变，了解应激状态下内分泌激素的变化规律，探讨各项指标与疾病预后的相关性，为是否需要干预治疗提供依据。     

急慢性肺栓塞的临床对比分析

目的提高对肺栓塞的认识,减少误诊。方法回顾性分析中国医科大学附属第一医院1995-01~2005-04收治的86例肺栓塞的临床资料。其中急性肺栓塞58例,慢性28例,并将其进行了对比分析。结果在年龄分布上慢性肺栓塞随年龄增长有增高的趋势。二者的基础疾病均以下肢深静脉血栓为主。劳力性呼吸困难、胸闷、心悸在慢性者更多见。肺动脉第Ⅱ心音亢进、颈静脉怒张、双下肢水肿等体征在慢性病人更加明显。动脉血氧分压降低及肺泡-动脉氧分压差的增大慢性者更加显著。60%的慢性病人有明显的右心扩大。所有慢性肺栓塞病人均有肺的多段灌注缺损。急性者84%经溶栓或抗凝治疗后症状改善,慢性者57%有效。慢性者5例(18%,5/28)在近期内死亡,高于急性者3例(5%,5/58)。结论慢性肺栓塞临床过程较急性肺栓塞更缺乏特异性,往往以慢性肺动脉高压和右心负荷过重的形式出现,更易误诊,且病死率高,对此临床医生更应给予足够的重视。     

急性胃肠损伤分级对疾病严重程度及预后评估价值研究（附296例报告）

目的 探讨急性胃肠损伤（AGI）分级与疾病严重程度及病人预后的关系。方法 回顾性分析2013年1-9月中国医科大学附属第一医院重症医学科（ICU）收治的296例重症病人资料,对不同AGI分级病人的发病原因、APACHE Ⅱ评分、SOFA评分、并发症发生及预后情况等进行统计分析。结果 296例病人中共289例（97.6%）发生AGI,其中以AGI Ⅰ、 Ⅱ级为主;原发AGI占67.8 %,继发AGI占32.2%;原发AGI分级高于继发AGI,差异有统计学意义（P<0.05）。不同AGI分级病人APACHE Ⅱ及SOFA评分差异有统计学意义（P=0.015、0.003）,AGI Ⅲ、Ⅳ级病人APACHEⅡ评分高于AGIⅠ、Ⅱ级,AGI Ⅳ级SOFA评分高于其他（P<0.05）。不同AGI分级病人28 d病死率及多器官功能障碍综合征发生率差异有统计学意义（P<0.05）;两两比较结果显示,除AGIⅠ、Ⅱ级间比较外,其余组间差异均有统计学意义（P<0.05）。发生严重AGI时间多在入ICU早期,AGI Ⅲ、Ⅳ级病人常见临床病因为严重腹腔感染。结论 重症病人AGI发生率较高,多数以轻度（Ⅰ、Ⅱ级）AGI为主,且轻度与重度（Ⅲ、Ⅳ级）AGI病人的病情严重程度及预后存在明显差异。     

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目的分析重症加强治疗病房呼吸机相关性肺炎(VAP)的病原菌分布特点及变迁。方法对中国医科大学附属第一医院重症加强治疗病房(ICU)2003年1月至2006年12月间VAP病人的痰培养病原菌及药敏结果进行回顾性分析。结果4年中ICU中VAP发生率为19.1%。铜绿假单胞菌为最常见菌,洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌4年中均排在前6位。金黄色葡萄球菌在2003-2005年间逐年增加,2006年有所下降;脑膜败血黄杆菌在2005、2006年分离率明显下降;近两年肺炎克雷伯杆菌的分离率增加。2004年铜绿假单胞菌对多种抗生素耐药率高(均在75%以上)。4年中对亚胺培南的耐药率均超过40%。鲍曼不动杆菌对亚胺培南和左氧氟沙星耐药率较低,嗜麦芽窄食单胞菌对复方磺胺甲恶唑、环丙沙星和左氧氟沙星耐药率较低。分离出的金黄色葡萄球菌中,耐甲氧西林金黄色葡萄球菌(MRSA)所占比例高。结论铜绿假单胞菌、洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌等非发酵菌仍为VAP主要致病菌。4年中VAP致病菌的分布特点和耐药性发生了改变。