Invasive ventilation in the emergency department: Part 2: Implications for patient safety

The use of mechanical ventilation in the Emergency Department requires adequate resources in order to maintain patient safety and avoid potential risks. Moreover, developments in technology require increased knowledge of mechanical ventilation techniques to address the complexity of decision-making involved. Organisational issues and system factors have the potential to negatively impact on the ability of the emergency service to provide optimum care to patients receiving mechanical ventilation. These issues include staffing and skill-mix, demand on emergency services, role-delineation, scope of practice, and current mechanisms for monitoring of quality and safety. Furthermore, in response to advances in ventilator technology, current education programs for both nursing and medical staff require review to ensure that they provide comprehensive information about the types of ventilation techniques now available and the relative risks and benefits associated with their application.This article is the second in a two-part series and explores the educational and organisational factors that impact upon safety and quality of care delivered to patients receiving mechanical ventilation in the emergency department. Recommendations for future policy development, curriculum review and reporting mechanisms to support further research in the application of mechanical ventilation in the emergency department are made.     

Der operierte mechanische Ileus

Zusammenfassung Von 1972 bis 1983 wurden 351 Patienten wegen eines mechanischen Dünndarm- (n = 256) bzw. Dickdarmileus (n = 95) operiert. Die chirurgische Komplikationsrate betrug beim Dünndarmverschluß 28,1 bzw. beim Dickdarmileus 24,3%, wobei am häufigsten Anastomosendehiscen-zen nach Resektionen (17,7% bzw. 53,8%), Enterotomien (5,8%/27,2%), Platzbäuche (3,5%/4,2%) und ein Re-Ileus (5,5%/3,2%) vorlagen. Die internistischen Komplikationen (postop. Pneumonien, Lungenembolien, kardiale Dekompensationen etc.) betrugen 17,9% bzw. 22,1 %. Die perioperative Letalität lag beim Dünndarmileus bei 20,6% und beim Dickdarmileus bei 33,4%. Als Schlußfolgerungen dieser retrospektiven Analyse ergaben sich die frühzeitige, perioperative, intensiv-medizinische Behandlung, die generelle Thrombose-, Pneumonie- und StreBulcusprophylaxe, die exakte, präoperative Röntgendiagnostik, die strenge Indikationsstellung für Enterotomien und Resektionen, das dreizeitige Vorgehen beim linksseitigen Dickdarmileus, die Inkontinuitätsresektion nach Hartmann bei entzündlichen Prozessen im Sigmabereich und die innere Dünndarmschienung bei Peritonitis bzw. ausgedehnten Adhäsionen. Dadurch konnte seit Anfang 1984 die Komplikationsbzw. Letalitätsrate beim Dünndarmileus (n = 64) auf 9,4% bzw. 4,7% und beim Dickdarmileus (n = 20) auf 10% bzw. 5% gesenkt werden.

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Experiences with operations of mechanical ileus

Summary Between 1972 and 1983 a total of 351 patients was operated suffering from mechanical occlusion of the small intestine (n = 256) and of the colon (n = 95). The surgical complication rate amounted to 28.1% in cases of small intestine ileus and to 24.3% in cases of colon ileus; the most frequent complications were anastomotic dehiscences following resections (small intestine 17.7%/colon 33.8%), enterotomies (5.8%/27.2%), abdominal wall ruptures (3.5%/4.2%) and re-ileus (5.5%/3.2%). The medical complication rate (postop. pneumonia, pulmonary embolism, cardial decompensation etc.) amounted to 17.7% resp. 22.1%. All these complications carried a mortality of 20.6% in small intestine ileus and of 30.4% in colon ileus. The consequences of this retrospective analysis resulted in: early intensive care treatment, general perioperative thrombosis-, pneumonia- and stress ulcer prophylaxis, exact preoperative radiological diagnosis, strict indications for enterotomies and resections, sole transversostomy in stage of ileus for the left-sided colon obstruction caused by carcinoma, discontinuity resection by Hartmann in cases of inflammatory or perforated large bowel stenoses and tube decompression of the small bowel in cases of peritonitis or wide-spread adhesions. Since 1984 we could prospectively decrease the complication resp. mortality rate of the small intestine ileus (n = 64) to 9.4% resp. 4.7% and of the colon ileus (n = 20) to 10% resp. 5%.

     

院前紧急气管插管与机械通气24例临床分析

目的总结紧急气管插管与机械通气在院前急救中应用的经验,以期提高院前急救水平。方法回顾性分析24例院前气管插管与机械通气抢救心搏呼吸骤停病人的临床资料。结果24例病人气管内插管均获成功,成功率100%。完成气管内插管的时间是15s～60s,平均时间(25±15)s。心搏、自主呼吸恢复4例(16.7%),心搏恢复8例(33.3%);心搏及自主呼吸均未恢复12例(50.0%)。结论气管插管与机械通气是急诊抢救危重病人的基础,对保证进一步心肺复苏、挽留手术机会以及提高危重患者抢救成功率有重要意义。要加强对抢救人员进行紧急气管插管和机械通气的培训。     

力学刺激对3月龄骨质疏松大鼠成骨细胞增殖与合成功能的影响

探讨周期性双轴力学应变对成骨细胞增殖与分化合成功能的影响。将正常 3月龄雌性 SD大鼠和骨质疏松大鼠颅顶骨分离的成骨细胞分别在含 10 %胎牛血清的 F- 12培养液中培养 ,并接种在双轴力学应变装置中。当细胞生长至亚融合状态 (Subconfluence) ,给细胞施加力学刺激 ,频率为 1Hz,力学刺激分别为 4 0 0、10 0 0、4 0 0 0μ strain;作用时间分别为每天 30 m in,2、4、8h,共加载两天。以未受力学刺激的细胞为对照组 ,受力学刺激的细胞为实验组 ,并进行比较。采用流式细胞技术测定细胞增殖变化 ;采用同位素标记方法检测成骨细胞骨钙素、I型胶原 C端前肽 (PICP)和总蛋白的分泌量。结果表明 :1)在静态培养条件下 ,3ovx组与 3control组比较 ,其细胞功能活性无明显变化 ,但 3ovx组大鼠成骨细胞增殖活性明显增高 ,这与绝经后骨质疏松骨代谢的高转换率相一致。 2 )4 0 0、10 0 0 μstrain力学刺激可以促进 3control组成骨细胞 I型胶原、骨钙素和总蛋白的分泌量增加 ,促进成骨细胞的分化成熟 ;在 10 0 0μstrain力学刺激下 ,成骨细胞合成骨基质的能力增加最为明显。同时 ,在 4 0 0、10 0 0μstrain力学刺激的初期也可以促进成骨细胞的增殖 ,而促进成骨细胞的分化成熟的作用大于促进细胞增殖的作用。 3)在4 0 0 0 μ     

压迫及非压迫因素在实验性神经根性疼痛中的作用

目的：探讨压迫及非压迫因素在实验性椎间盘源性神经根性疼痛中的作用。方法：取大鼠白体脊椎关节突修剪后放置在L5神经根下．造成对L5神经根的直接压迫（压迫组）；取大鼠白体尾椎椎间盘组织无压迫下放置在L5神经根表面（非压迫组）：同时设立对照组。术后不同时间点测定各组大鼠后足底机械刺激疼痛阈值的变化。结果：压迫组与非压迫组大鼠后足底均产生了一个长时程机械刺激疼痛阈值的降低；与压迫组相比．非压迫组大鼠术后1天就开始出现了疼痛阈值降低（P〈0．05），明显早于压迫组大鼠，并且疼痛阈值降低更加显著：而压迫组大鼠术后1周时才出现明显的疼痛阈值降低（P〈0．05）。对照组大鼠疼痛阈值没有发生明显的改变。结论：尽管压迫和非压迫因素都参与椎间盘源性神经根性疼痛的发生．但二者作用的时间不同＋在椎间盘突出的早期阶段非压迫因素可能在疼痛中起着重要的作用：随后压迫因素可能逐渐成为致痛的主因。     

机械通气患者体位改变插入胃管效果与分析

目的提高有创机械通气患者插入胃管的成功率,减少因反复插管所致的并发症,减轻患者痛苦,提高护士的工作效率。方法把有创机械通气的60例患者,随机分为观察组30例和对照组30例,观察组采取改变常规的“去枕头后仰位”为“抬高床头70°~80°角,头正位”插入胃管,对照组采取常规的去枕头后仰卧位的体位方法插入胃管。结果对照组一次插管成功率为6.66%,观察组一次插管成功率为90%,经统计学分析,差异有显著意义(P<0.01)。结论有创机械通气患者改变常规的“去枕头后仰位”为“抬高床头70°~80°角,头正位”后一次插入胃管成功率明显提高。     

Impact response of periodontal tissues

A new impact response method using a fracture of a pencil-lead to produce an excitation pulse is proposed. Impact excitations (rectangular pulse, triangular pulse and half-sine pulse) are strictly given in physical and mathematical definitions and complete solutions to the impact excitations are provided for Noyes' model of the human tooth. When a relatively long triangular pulse is applied to Noyes' model, which can express the physical characteristic of periodontal tissues, a sinusoidal damped vibration of a single degree-of-freedom model is approximately obtained. The acceleration response is characterised by the physical parameters (T, δ and A_o) and mechanical elements (m₁, c₁ and k) of which a single degree-of-freedom model is composed. By means of this method, the values of the parameters and elements in the cases of healthy maxillary, healthy mandibular and pathological mandibular incisors are obtained. The single degree-of-freedom model can express the high-frequency spectra of Noyes' model. The pathological tooth is characterised by a longer damped time constant and a larger acceleration maximum. This impact response method can effectively be applied to clinical diagnosis in view of the physical parameters and mechanical elements which have been derived.     

机械振动的成骨效应研究进展

应力是骨形成的“指导性”因素。其机制是近十年来骨科学、生物医学工程及康复医学领域的研究热点。机械振动是力学刺激形式之一。诸多研究表明：振动具有显著的成骨效应,其在骨质疏松的治疗中将会有广阔的应用前景。但是,现有相关研究中,具有成骨效应的振动频率、强度等参数并不一致,尤其是振动的成骨机制不明,相关报道极少,本文对其作一论述,可为更系统、深入地研究及其在临床中的应用提供理论基础。     

吗啡对机械通气病人的应用

为获得病人在接受呼吸机期间充分的镇静、良好的耐管并与呼吸机合拍达到满意的治疗效果，对６０例不同年龄的患者在进行呼吸机支持治疗期间，采用平均０４５ｍｇ／（ｋｇｄ）的吗啡量持续微量泵静脉注入，间断辅助安定的方法．用药后连续２ｈ观察血压、心率、呼吸、意识等变化．结果：在用药期间病人血压、心率、呼吸平稳，保持清醒，安静耐管，解决了病人与呼吸机拮抗的矛盾．结果表明：该法在临床上有广泛使用价值