生脉注射液联合乌司他丁治疗感染性休克的临床研究

目的探讨生脉注射液联合乌司他丁治疗感染性休克的临床疗效。方法对2013年3月—2016年3月在屯昌县人民医院接受治疗的感染性休克患者80例,随机分为对照组(40例)和治疗组(40例)。对照组患者静脉滴注注射用乌司他丁,20万U加入生理盐水200 m L,2次/d。治疗组在对照组的基础上静脉滴注生脉注射液,60 m L加入生理盐水250 m L,1次/d。两组患者均连续治疗7 d。比较两组患者治疗前后临床效果、血清细胞因子水平和免疫功能变化。结果治疗后,对照组和治疗组总有效率分别为80.00%和95.00%,两组总有效率比较差异有统计学意义(P0.05)。治疗后,两组患者血清白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、血小板(PCT)、内皮素-1(ET-1)及NO水平都显著降低,IL-10则升高,同组治疗前后比较差异具有统计学意义(P0.05);且治疗组上述指标水平优于对照组,两组比较差异具有统计学意义(P0.05)。治疗后,两组患者CD~(3+)和CD~(4+)水平及CD~(4+)/CD~(8+)都显著升高,同组治疗前后比较差异具有统计学意义(P0.05);且治疗组患者免疫功能显著优于对照组,两组比较差异具有统计学意义(P0.05)。结论生脉注射液联合乌司他丁治疗感染性休克疗效显著,可增强机体免疫功能及减轻炎症反应,具有一定的临床推广应用价值。     

药师参与1例重症肺部感染患者用药方案的调整

本文报告临床药师参与的1例入住呼吸内科重症监护病房治疗的感染性休克合并急性肾功能不全的慢性阻塞性肺疾病急性加重患者的抗感染治疗及药学监护过程,探讨严重肾功能不全情况下抗菌药物的选择及其用法用量的调整以及嗜麦芽窄食单胞菌的合理治疗方案,体现了临床药师能在促进合理用药、降低药物不良反应,保证临床安全、有效地用药方面发挥积极作用。     

去甲肾上腺素、肾上腺素及去甲肾上腺素—多巴酚丁胺对感染性休克病人全身及胃粘膜氧代谢的影响

目的:比较多巴胺、去甲肾上腺素、肾上腺素及去甲肾上腺素-多巴酚丁胺对感染性休克患者全身及胃 粘膜氧代谢的影响.方法:首先用多巴胺,然后随机应用肾上腺素、去甲肾上腺素,或去甲肾上腺素-多巴酚丁胺,调整剂量维持平均动脉压>9.31 kPa.药物注射后 120 min,记录血流动力学、氧代谢及胃粘膜pH参数.结果:与其它三组比较,肾上腺素使心率明显增加(P<0.05),心排指数明显高于去甲肾上腺素组或去甲肾上腺素-多巴酚丁胺组(P<0.05),氧摄取率明显低于其它三组(P<0.05).与多巴胺、肾上腺素比较,去甲肾上腺素-多巴酚丁胺合用时动脉血乳酸值明显降低(P<0.05).与肾上腺素比较,去甲肾上腺素-多巴酚丁胺合用时胃粘膜pH值明显增加(7.25±0.09 vs 7.14±0.07,P<0.05).结论:多巴胺、去甲肾上腺素、肾上腺素及去甲肾上腺素-多巴酚丁胺均能升高血压.但是肾上腺素和多巴胺使氧代谢恶化,而去甲肾上腺素与小剂量多巴酚丁胺合用可改善胃粘膜灌注和组织氧利用.     

去甲肾上腺素和多巴酚丁胺联用与多巴胺单用对感染性休克绵羊内脏灌流的比较

目的:观察多巴酚丁胺加去甲肾上腺素和单用多巴胺对感染性休克绵羊内脏灌注的影响.方法:利用内毒素(LPS)复制感染性休克模型,当收缩压下降至5.3kPa时记录血流动力学及肠粘膜pH(pH_i)的基础值.20只绵羊随机分为两组,分别静脉注入多巴酚丁胺加去甲肾上腺素及多巴胺,调整药物剂量,使平均动脉压升高到12kPa,观察用药前(基础值)及用药后1,2,3,4h的血流动力学和内脏灌注指标pH_i.结果:两组动物在用药后血压、心排指数及氧输送较用药前明显升高。多巴胺组动脉乳酸浓度及pH_i无明显改变,但动脉pH值在用药后1h从7.40±0.05降至7.26±0.06(P<0.05).应用多巴酚丁胺加去甲肾上腺素后3h和4h,动脉乳酸浓度从(4±2)mmol/L降至(2±1)mmol/L和(2±1)mmol/L(P<0.05),用药后3h,pH_i从7.19±0.04明显升高到7.36±0.07(P<0.05).结论:多巴酚丁胺加去甲肾上腺素和单用多巴胺均能改善感染性休克绵羊全身血流动力学状态,但在改善内脏灌注上,多巴酚丁胺与去甲肾上腺素联用明显优于多巴胺单用.     

Paediatric orthopaedic infections

Bone and joint infections in children are uncommon, but potentially devastating. The use of effective antibiotic chemotherapy has minimized associated mortality, but prompt recognition and treatment is necessary to preserve normal growth and function of the affected bone or joint. Diagnostic challenges include inability of patients to report symptoms, non-specificity of clinical signs and low sensitivity of diagnostic tests while treatment challenges include choosing appropriate empiric antibiotics, accounting for patient and epidemiological risk factors, and ensuring adequate compliance with long antibiotic courses in children. Successful management requires regular review of clinical progress and assessment for development of complications requiring surgical intervention. This article will cover the commonest infections seen clinically. Septic arthritis and osteomyelitis are discussed separately though concurrent infection can occur, particularly in children under 2 years of age, and recognition of this can alter the duration of treatment required.     

Immunoglobulin G Subclasses and Lymphocyte Subpopulations and Function in Osteomyelitis and Septic Arthritis

ABSTRACT. We investigated serum IgA, IgG, IgM and IgG subclass concentrations, complement activity, lymphocyte subpopulations, Iymphocyte responses to mitogens and natural killer cell cytotoxicity in 15 children who had had osteomyelitis and septic arthritis and in a group of control subjects. IgG subclass concentrations below the fifth percentile for age occurred in 4 patients. We found isolated deficiencies of IgGI and IgC3 and combined deficiencies of IgG2/IgG3/IgC4 and IgG2/IgG4. Concentrations of IgA and of IgG tended to be below the mean for age. The percentage of Leu-11 + cells was reduced in patients. Other immunological parameters studied were normal. These findings suggest that although most patients who have had osteomyelitis and septic arthritis do not have low immunoglobulin concentrations, impaired antibody production may be a predisposing factor in at least a few such children.     

瘦素在严重感染及脓毒性休克中作用的研究进展

瘦素(leptin,LP)是一种主要由脂肪细胞分泌的细胞因子,受肥胖基因调节,通过中枢和外周调节摄食和体质量的平衡.同时,LP参与免疫应答、抗炎和创伤修复等病理生理过程.新近发现LP可通过抑制中性粒细胞和单核细胞活化和坏死,对危重病患者脏器功能可能有保护作用.严重感染时,LP的改变对判断脓毒症及脓毒性休克预后有一定的参考价值.本文综述在严重感染及脓毒性休克时LP的表达及与主要细胞因子的关系.     

Angiotensin II: A New Vasopressor for the Treatment of Distributive Shock

PurposeAngiotensin II (ATII) is a potent endogenous vasoconstrictor that has recently garnered regulatory approval for the treatment of distributive shock, including septic shock. Traditional vasoactive substances used in the management of distributive shock include norepinephrine, epinephrine, phenylephrine, and vasopressin. However, their use can be associated with deleterious adverse drug effects, such as splanchnic vasoconstriction and associated hypoperfusion. The purpose of this review is to describe ATII, including its pharmacologic mechanisms, pharmacokinetic profile, evidence of efficacy and tolerability, and potential role in contemporary critical care practice.MethodsPeer-reviewed clinical trials and relevant treatment guidelines published from 1966 to September 14, 2019, were identified from Medline/PubMed using the following search terms: angiotensin II OR angiotensin 2 AND shock OR septic shock OR vasodilatory shock. Pertinent review articles were reviewed for additional studies for inclusion and discussion. The final decision on the inclusion of studies in the current review was based on the expert opinion of the authors.FindingsOn the basis of the available evidence, ATII is effective at elevating blood pressure in patients with distributive shock and appears to reduce the dose of concurrent vasopressors to maintain adequate blood pressure. ATII has been investigated for other causes of shock; however, robust evidence of off-label indications is lacking and is much needed. Clinical and cost benefits compared with traditional vasopressors have yet to be established.ImplicationsATII represents a welcome addition to the armamentarium of critical care clinicians. Enthusiasm for the use of ATII should be balanced with the current gaps in our understanding of ATII in patients with shock. Until further evidence provides more clinically meaningful benefits, as well as cost-effectiveness compared with currently available vasopressors, critical care clinicians should reserve ATII for salvage therapy in patients with septic shock.     

Pharmacology,clinical efficacy and safety of terlipressin in esophageal varices bleeding,septic shock and hepatorenal syndrome

Terlipressin, a vasopressin agonist, is a commonly used drug with different indications, particularly in patients with end-stage liver disease. As a V₁ receptor agonist, it increases systemic vascular resistance, particularly in the splanchnic area, resulting in a decrease of portal pressure. Besides the approved use for variceal bleeding, terlipressin also has beneficial effects in the treatment of hepatorenal syndrome and norepinephrine-resistant septic shock. In patients with cirrhosis and variceal bleeding, the use of terlipressin reduces the portal vein pressure and decreases the pressure in esophageal varices. This can save lives when skilled endoscopists are not immediately available. Hepatorenal syndrome is associated with vasodilation in the mesenteric circulation with arterial underfilling and consecutive renal vasoconstriction. Restoration of an effective arterial blood volume can be achieved by the combination of terlipressin and volume expansion. In some cases, a success rate of up to 75% is reported. The early use of terlipressin in catecholamine-resistant shock can improve organ perfusion.     

Spontaneous Intrahepatic Gas Gangrene and Fatal Septic Shock

Gas gangrene of the liver is a rare clinical syndrome associated with a high rate of mortality. It is mostly associated with malignancy and immunosuppression.

We report on a male patient who presented at the department of emergency medicine with high fever but no localised complaints. CT scan revealed a cavitary lesion filled with air in the liver. Clostridium perfringens was proved to be present in the hepatic lesion and the blood, and clostridium perfringens sepsis with gas gangrene of the liver was diagnosed. Despite early diagnosis and treatment the patient died. The importance of “an aggressive treatment policy” in this kind of life-threatening disease is emphasised.