昏迷恢复量表与ICU病房DOC患者预后关系

目的 探讨行为量表与ICU病房意识障碍(Disorders of consiousness,DOC)患者预后的关系。方法 选择2018年1～12月在我院ICU治疗的意识障碍患者为研究对象,根据随访GOS评分分为预后良好组39例与预后不良组29例。比较两组一般资料及临床资料、CRS-R评分以及EEG结果。多因素分析影响患者预后的相关因素。分析GRS-R评分与GOS评分的相关性。结果 (1)随访3个月,其中39例恢复良好,占57.35%,29例恢复不良,占42.65%。(2)预后良好组患者CRS-R评分显著高于预后不良组的患者,EEGⅠ～Ⅱ的比例显著高于预后不良组的患者,差异有统计学意义(P0.05)。(3)多因素分析结果显示,CRS-R评分、EEG是ICU病房DOC患者预后的相关影响因素(OR=8.712、5.709,P0.05)。(4)CRS-R评分与GOS评分呈显著正相关关系(r=0.903)。结论 ICU病房DOC患者的预后与入院时CRS-R评分以及EEG检查结果有密切的关系,临床上患者入院时通过CRS-R评分以及EEG检查可对患者病情以及预后进行初步判断。     

ICU 常规与优化治疗对心脏骤停后综合征患者心肺、脑复苏情况的影响分析

目的：分析ICU 常规与优化治疗对心脏骤停后综合征患者心肺、脑复苏情况的影响。方法：选取90 例心脏骤停后综合征患者作为本次的研究对象,患者就诊时间段为2018 年7 月到2019 年11 月,按照数字表达法将其分为两组,其中接受ICU 常规治疗的45 例患者设为对照组,将另外45 例接受ICU 优化治疗的患者纳入观察组。将两组心脏骤停后综合征患者的神经功能评分、全心舒张末期容积指数、心脏指数、意识恢复时间以及并发症发生率进行对比。结果：经过治疗后,观察组患者的神经功能以及临床指标改善情况明显优于对照组;观察组的并发症发生率为4.4%;对照组的并发症发生率为17.8%,两组心脏骤停后综合征患者的神经功能评分、临床指标以及并发症发生率结果差异存在统计学意义（P<0.05）。结论：与ICU 常规治疗相比,ICU 优化治疗对心脏骤停后综合征患者的临床疗效更为显著,能够促进患者脑复苏情况的改善,提高神经功能恢复效率,改善心功能指标,减少并发症的产生,提升综合征患者的生存质量,具有积极的推广价值。     

Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia

BackgroundVentilator associated pneumonia (VAP) is an important source of morbidity and mortality in patients receiving mechanical ventilation. VAP is associated with prolongation of mechanical ventilation, ICU and hospital stay and increases in costs.MethodsQuality improvement project. Mechanically ventilated patients received oral care every 8 h with chlorhexidine 2%. A formal process was developed to evaluate compliance with the following ventilator bundle initiatives: head of the bed elevation to 30–45°, daily sedation vacation and assess the readiness to extubate, providing peptic ulcer disease prophylaxis and providing deep vein thrombosis prophylaxis (unless contraindicated).ResultsThe rate of VAP before starting the project, in the first 6 months of year 1431H, was 16.2 cases/1000 ventilator days. Six month after inception of the quality improvement project, the VAP rates decreased to 5.6 cases/1000 ventilator days at the end of 1431H, and at the end of 1432H, it was 5.5 cases/1000 ventilator days. This leads to significant reduction in mortality (adjusted according to APACHE II) from 23.4% to 19.1% (p value 0.024) and the length of stay in ICU from 9.7 to 6.5 days (p value 0.00002).ConclusionThe combination of regular oral hygiene with chlorhexidine 2% and rigorous implementation of ventilator care bundle was associated with significant reduction in VAP rate in mechanically ventilated patients. This has led to reduction in length of stay in ICU from 9.7 to 6.5 days and reduction in mortality from 23.4% to 19.1%.     

Serial estimations of blood lactate predict postoperative outcome in cancer patients undergoing head and neck surgeries

To determine predictability of serial estimations of blood lactate levels for postoperative outcome of head and neck cancer patients and determine validity of single versus serial estimations for accurate prediction of outcome.The study included 322 cancer patients assigned for major head and neck surgeries and admitted to ICU. Data collection included age, sex, and associated comorbidities, and clinical status was determined using APACHE II score. Arterial lactate was measured at time of admission (T0), and 8-hourly (T8, T16, T24), and percentage of change of blood lactate level was calculated versus T0 level. Patients were categorized as survivor and non-survivors, and among each group, patients were categorized according to estimated level of blood lactate into four categories.The mean of APACHE score at ICU admission was 16.6 ± 3.1, and mean duration of ICU and hospital stay was 3.2 ± 1.2 and 19.3 ± 5.5 days, respectively. Fifty-two patients died for postoperative mortality rate 16.1%. Non-survivors were significantly older and had significantly higher APACHE score and significantly longer ICU and hospital stay. At admission blood lactate level was significantly higher in non-survivors compared to survivors. All patients showed progressive increase of blood lactate level, but non-survivors showed significantly higher frequency of elevated blood lactate strata compared to survivors with significantly higher difference between both groups at T8, T16, and T24. There was positive significant correlation between high at admission blood lactate level and APACHE score. Regression analysis defined % of change of blood lactate at T16, high APACHE score, high at admission blood lactate and old age as specific predictors for postoperative mortality in descending order of specificity. Serial estimations of blood lactate are conclusive test for follow-up of patients undergoing major surgical procedures requiring ICU admission. Combined high APACHE score and percentage of change of blood lactate could discriminate survivors from non-survivors especially 16-h after ICU admission.     

Image guidance to improve reliability and data integrity of transcranial Doppler sonography

Background

Principles and accuracy of image-guided transcranial Doppler (IG TCD) sonography have been published recently. However, it remains open whether combination of image guidance and TCD offers an additional clinical advantage. This study scores the accuracy of conventional TCD examinations and investigates the potential improvement of TCD data integrity and reliability regarding the additional use of IG.

Methods

Conventional TCD was performed by a group of experienced investigators, who were blinded to images of a navigation system tracking the Doppler probe, whereas an independent observer documented the TCD findings, acquired by the investigators, due to saving spatial data of the TCD sample volume using IG for subsequent analysis. In a second set of experiments, image guidance was available to investigators without any previous TCD experience.

Results

The analysis of 3D data of vessels (n = 173) labeled by experienced investigators in conventional TCD, revealed a rate of 37% misinterpreted Doppler signals regarding the target vessel. Correctness of labeling was comparable between the different vascular segments. The rate of correct labeling was higher for right- (69%) than for left-sided vessels (57%). In comparison, by using IG, TCD investigators without any previous TCD experience achieved a significantly lower rate of 10% (n = 39) mislabeled vessels.

Conclusions

Our data suggest, that misinterpretation of the vascular source of the Doppler signal is a common source of errors in conventional TCD. Visualization of the vascular anatomy by image guidance offers improved accuracy and reliability of TCD results and may positively influence the learning curve for inexperienced investigators.     

重症加强护理病房急性呼吸窘迫综合征患者28日死亡率影响因素分析

目的 研究重症加强护理病房(ICU)中急性呼吸窘迫综合征(ARDS)患者的28日死亡率及其影响因素.方法 纳入2012年5月至2014年5月间在我院ICU治疗超过24 h、年龄>12岁的ARDS患者237例,统计其临床资料,采用单因素及多因素Logistic回归分析评价患者28日死亡危险因素.结果 根据柏林定义,轻度、中度、重度患者分别为47例、112例和78例,病死率分别为17.1%、49.1%和65.4%;ARDS原发病以肺外疾病为主,占60.3%;致死率最高的原发病为肺炎,42例中死亡31例,占73.8%;患者死亡的直接因素主要为脓毒性休克,占34.5%.轻度及中度ARDS患者28日死亡危险因素包括确诊前住院时间>48 h (OR=4.712,4.773;P<0.05)、急性生理学和慢性健康评价(APACHE)Ⅱ评分(OR=1.171,1.389;P<0.05);重度患者28日死亡危险因素包括序贯性器官功能衰竭(SOFA)评分(OR=1.447;P<0.05)和免疫抑制状态(OR=7.917;P<0.05).结论 ICU病房ARDS患者主要原发病为肺外疾病,致死率最高的原发病为肺炎,死亡直接因素主要为脓毒性休克,不同程度ARDS患者28日死亡危险因素有差异,临床需注意区分.     

白细胞介素-33在不同严重程度脓毒症中的变化

目的  分析血浆白细胞介素-33（IL-33）在不同严重程度脓毒症中的变化。方法  选取2012年1月- 2015年4月该院重症加强治疗病房（ICU）收治的120例脓毒症患者为研究对象。根据器官功能、感染严重程度将患者分为一般脓毒症组（36例）、严重脓毒症组（36例）和感染性休克组（48例）,并选取同期在该院行健康检查的120例志愿者作为对照组。比较患者ICU各时间的APACHE Ⅱ评分、降钙素原（PCT）、白细胞介素-33（IL-33）、白细胞介素-6（IL-6）、白细胞介素-1β（IL-1β）、肿瘤坏死因子-α（TNF-α）和可溶性人基质裂解素2（sST2）的变化;比较患者ICU住院时间和机械通气时间;比较不同预后脓毒症患者ICU各时间的IL-33水平变化。结果  脓毒症患者的APACHE Ⅱ评分、PCT和IL-33水平高于对照组,且脓毒症患者的APACHE Ⅱ评分、PCT和IL-33水平随患者病情加重而升高,差异有统计学意义（P <0.05）。脓毒症患者的ICU住院和机械通气时间随患者病情加重而延长,且感染性休克组的死亡率显著高于其余两组,差异有统计学意义（P <0.05）。脓毒症患者的APACHE Ⅱ评分,PCT、IL-33、IL-6、IL-1β、TNF-α、sST2水平与对照组比较,差异有统计学意义（P <0.05）。脓毒症患者的APACHE Ⅱ评分,PCT、IL-33、IL-6水平随ICU住院时间延长而降低,差异有统计学意义（P <0.05）。脓毒症患者的IL-1β、TNF-α、sST2水平随ICU住院时间延长,变化不明显（P >0.05）。入ICU 30 d后有9例患者死亡为死亡组,111例患者存活为存活组。死亡组患者的IL-33水平随ICU住院时间延长而上升,但差异无统计学意义（P >0.05）。存活组患者的IL-33水平随ICU住院时间延长而下降,死亡组患者入ICU 3 h内IL-33水平较存活组低,入ICU 24 h和5 d时IL-33水平高于存活组,差异有统计学意义（P < 0.05）。结论  脓毒症患者入ICU时血浆IL-33水平升高,而后随ICU住院时间延长而降低,且随患者病情加重而升高,因此血浆IL-33水平能提示患者的预后。