血乳酸水平及清除率和升高时间与重症监护病房危重患者预后的关系

Objective To study and quantify the relationship between dynamic lactic acid monitoring indexes and prognosis of critically ill patients in intensive care unit (ICU). Methods One hundred and one critically ill patients with elavated blood lactic acid level were included in this study and divided into death group (n= 50) and survival group (n = 51). Differences in their lactic acid indexes (including: lactic acid level, duration of lacticemia, lactic clearance), acute physiology and chronic health evaluation Ⅰ (APACHE Ⅰ ) score, and other clinical indicators which reflected organ/system status were compared, and prognostic significant lacticemia indexes were formulated by multi-variable logistic analysis. Subsequently, patients were grouped by significant lactic indexes separately and compared with incidence of shock/multiple organ dysfunction syndrome (MODS), APACHE Ⅰ score and mortality. Results Differences in lactic acid level, peak lactic acid level, 12-hour and 24-hour lactic acid clearance between death group and survival group showed statistically significant difference (P<0. 05 or P<0. 01). Peak lactic acid level, 12-hour lactic clearance, APACHE Ⅰ score and blood pH had significant correlation with prognosis, odds ratios (OR) were 1. 466, 0. 922, 1. 208, 0. 032, respectively. Patients with peak lactic acid value≥10 mmol/L or 12-hour lactic clearance≤10% had significantly higher mortality: 77. 8% and 70. 6%, respectively (P<0. 05 and P< 0.01). Although patients with lacticemia > 24 hours had higher mortality, there was no statistically significant difference. Conclusion Peak lactic acid level, 12-hour lactic clearance, APACHE Ⅰ score and blood pH are good indicators to evaluate patients' prognosis. Peak lactic acid value≥10 mmol/L or 12-hour lactic clearance≤10% is an alert of extremely bad prognosis. Prognosis value of duration of lacticemia is limited.     

莫西沙星治疗慢性支气管炎急性加重的临床疗效及体外抗菌活性的研究

 目的评价莫西沙星口服胶囊治疗慢性支气管炎急性加重(AECB)的临床疗效及体外抗菌活性。方法采用随机、开放、平行对照试验设计。选择AECB病例100例,其中可评价病例86例,莫西沙星治疗组(试验组)42例,给莫西沙星400 mg qd,疗程5～10 d;左氧氟沙星治疗组(对照组)44例,给左氧氟沙星200 mg,hid,疗程7～14 d。结果莫西沙星治疗组与左氧氟沙星治疗组临床有效率分别为92.86%(39/42)和88.64%(39/44);痊愈率分别为78.57%(33/42)和68.18%(30/44)。两组有效率、痊愈率经统计学处理,无显著差异(P>0.05);细菌清除率分别为96.88%(31/32)和82.14%(23/28),细菌阴转率分别为96.88%(31/32)和82.14%(23/28),两组细菌清除率、阴转率无显著差异(P>0.05)。结论莫西沙星治疗AECB临床疗效可靠。     

比较不同剂量地塞米松对小鼠脓毒症致急性肾损伤的保护作用

目的 比较不同剂量地塞米松(DEX)对脓毒症导致的急性肾损伤(AKI)的影响.方法 健康雄性昆明小鼠130只,按随机数字表法均分为假手术组、脓毒症模型组和DEX生理剂量组(0.12 mg/kg)、应激剂量组(1.2 mg/kg)、大剂量组(12 mg/kg).采用盲肠结扎穿孔术(CLP)制备脓毒症模型,分别在术后24 h、48 h观察肾组织病理学变化,免疫组化法检测肾组织糖皮质激素受体-α(GR-α)蛋白表达水平,实时荧光定量聚合酶链反应(PCR)检测肾组织GR-α、核转录因子-κB(NF-κB)的mRNA表达水平,酶联免疫吸附试验(ELISA)测定血浆肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)的含量.结果 与假手术组比较,脓毒症模型组小鼠肾小管病理损害严重;肾组织GR-α蛋白和mRNA表达明显降低,NF-κB mRNA表达及血浆TNF-α、IL-1β水平均明显升高.与脓毒症模型组比较,各剂量DEX组肾小管病理损害不同程度减轻;肾组织GR-α蛋白和mRNA表达均明显升高,NF-κB mRNA表达和血浆TNF-α、IL-1β水平均明显降低,其中以DEX生理剂量组作用尤佳[AKI评分(分)24 h:1.480±0.334比3.040±0.517,48 h:1.840±0.167比3.400±0.400;GR-α蛋白(A值)24 h:0.102±0.009比0.088±0.005,48 h:0.103±0.008比0.085±0.006;GR-o mRNA 24 h:0.0400(0.0300,0.0400)比0.0100 (0.0093,0.0100),48 h:0.0350 (0.0300,0.0475)比0.0100 (0.0010,0.0138); NF-κBmRNA 24 h:0.009±0.001比0.012±0.000,48 h:0.011±0.000比0.013±0.001;TNF-α (ng/L)24 h:105.84±3.84比135.52±4.49,48 h:111.35±3.67比141.22±4.46;IL-1β(ng/L)24 h:45.71±2.93比64.12±3.62,48 h:57.04±3.04比74.87±3.67; P＜0.05或P＜0.01].结论 生理剂量DEX可以通过上调肾组织中GR-α表达,减轻脓毒症引起的肾组织损伤,其作用明显优于大剂量DEX.     

山东省革兰阳性球菌耐药性监测

为了解山东省革兰阳性球菌感染分布及细菌耐药情况，对2001年12月-2002年12月间，山东省10城市，共12家医院收集的细菌感染标本，进行耐药性测定。     

急性肺血栓栓塞症的鉴别诊断

急性肺血栓栓塞症(PTE)的临床表现缺乏特异性,漏诊及误诊率较高.临床中应注意与以下疾病鉴别. 1 急性心肌梗死 PTE栓塞面积较大时,患者可出现重度呼吸困难,剧烈胸痛甚至血压下降,心电图表现酷似心肌梗死,血清酶学也可升高.急性心肌梗死主要发生于中年以上有基础冠心病患者中,其胸痛的性质剧烈、持久,可伴有休克症状,但一般不伴有呼吸困难,其心电图呈特征性演变过程,超声心动图往往示左室扩大、左室节段性运动不良、左室射血分数(LVEF)降低,肌钙蛋白T(TnT)或肌钙蛋白I(TnI)明显升高.PTE发病年龄范围较广,患者有PTE的高危因素,常伴有明显的呼吸困难,以劳力性呼吸困难显著,心电图改变呈一过性,常表现为SⅠQⅢTⅢ或右束支传导阻滞,心前导联T波低平或倒置,一般1～2周明显好转或消失,超声心动图示右室扩大、右室壁运动减弱、心室间隔左移、肺动脉高压、三尖瓣反流等征象,LVEF一般正常;也可伴有TnT(或TnI)升高,但不如急性心肌梗死明显,必要时可行强化CT、MRA或选择性动脉造影进行鉴别诊断.     

手术后肺栓塞28例

肺栓塞因其症状无特异性而常被漏诊,故临床诊断率低,但尸检证实者多[1,2].近几年,随着对肺栓塞诊治水平的提高,手术后肺栓塞的诊断率及治愈率明显增加.现将我院近5年内所收治的术后肺栓塞病例总结如下.     

急性肺动脉栓塞症的溶栓治疗

目的：比较尿激酶2h方案(UK2h)、12h方案(UK12h)及重组组织型纤溶酶原激活剂(rt—PA)溶栓治疗急性肺栓塞的安全性及有效性。方法：选择34例APE患者，分为三组：①UK2h组：尿激酶20000IU／kg，2h内静脉滴入；②UKl2h组：尿激酶首剂4400IU／kg，继而每h 2200IU／kg，静脉滴注12h；③rt—PA组：rt-PA 50mg静脉滴注。结果：uK2h、UK12h、rt—PA组治愈率分别为72．2％、71．4％、77．8％，有效率分别为83.3％、85．7％、88.9％，死亡率分别为5，6％、14．3％、11．1％，三组间差异无统计学意义。主要不良反应为出血，出血率UK12h组高于rt—PA、UK2h组。结论：UK2h、UK12h方案及rt—PA溶栓效果均好，但UK2h、rt—PA方案更安全。     

血乳酸水平及清除率和升高时间与重症监护病房危重患者预后的关系

Objective To study and quantify the relationship between dynamic lactic acid monitoring indexes and prognosis of critically ill patients in intensive care unit (ICU). Methods One hundred and one critically ill patients with elavated blood lactic acid level were included in this study and divided into death group (n= 50) and survival group (n = 51). Differences in their lactic acid indexes (including: lactic acid level, duration of lacticemia, lactic clearance), acute physiology and chronic health evaluation Ⅰ (APACHE Ⅰ ) score, and other clinical indicators which reflected organ/system status were compared, and prognostic significant lacticemia indexes were formulated by multi-variable logistic analysis. Subsequently, patients were grouped by significant lactic indexes separately and compared with incidence of shock/multiple organ dysfunction syndrome (MODS), APACHE Ⅰ score and mortality. Results Differences in lactic acid level, peak lactic acid level, 12-hour and 24-hour lactic acid clearance between death group and survival group showed statistically significant difference (P<0. 05 or P<0. 01). Peak lactic acid level, 12-hour lactic clearance, APACHE Ⅰ score and blood pH had significant correlation with prognosis, odds ratios (OR) were 1. 466, 0. 922, 1. 208, 0. 032, respectively. Patients with peak lactic acid value≥10 mmol/L or 12-hour lactic clearance≤10% had significantly higher mortality: 77. 8% and 70. 6%, respectively (P<0. 05 and P< 0.01). Although patients with lacticemia > 24 hours had higher mortality, there was no statistically significant difference. Conclusion Peak lactic acid level, 12-hour lactic clearance, APACHE Ⅰ score and blood pH are good indicators to evaluate patients' prognosis. Peak lactic acid value≥10 mmol/L or 12-hour lactic clearance≤10% is an alert of extremely bad prognosis. Prognosis value of duration of lacticemia is limited.     

下呼吸道MRSA、MRSE感染及治疗

近年来 ,耐甲氧西林金黄色葡萄球菌 (MRSA)及耐甲氧西林表皮葡萄球菌 (MRSE)感染成为临床感染 (尤其是院内感染 )的重要致病菌 [1～ 3]。由于地区差异 ,各地报道的 MRSA、MRSE分离率、对抗生素的敏感率不尽相同 ,有关呼吸道 MRSA、MRSE感染的资料则较少。 2 0 0 0年 5月至 2 0 0 2年 5月 ,我院收治 43例下呼吸道 MRSA、MRSE感染 ,现报告如下。1　资料与方法1 .1　临床资料　本组男 2 6例、女 1 7例 ,年龄 (6 8.5±1 0 .7)岁。其中 MRSA感染 1 9例 ,MRSE感染 2 4例。1 .2　研究方法　 1分离菌株按照美国国家临床实验室标准委…     

特发性间质性肺炎的诊断及治疗进展——弥漫性肺间质疾病诊断方法概述

许多急慢性肺部疾病可有不同程度的肺组织炎症及纤维化，可统称为肺间质疾病(ILD)、弥漫性间质性肺疾病(DILD)或弥漫性肺实质疾病(DPLD)，三者含义相同。其实弥漫性肺间质疾病的病理改变并非局限于肺间质，而是表现为弥漫性肺泡单位即肺实质受损和肺间质的结缔组织成分过度增生。以往对此类疾病的命名和分类存在较大的混乱，2002年美国呼吸病学会(ATS)和欧洲呼吸病学会(ERS)组织呼吸病临床学家、放射学家和病理学家对弥漫性肺间质疾病的分类进行了规范，分为原因已明DILD，如药物、结缔组织病等；