床旁肺部超声在急性呼吸窘迫综合征患者中的应用价值研究

【】目的：探讨床旁肺部超声评价ARDS患者的肺水肿以及指导肺部治疗在急性呼吸窘迫综合征(ARDS)患者救治中的应用价值。方法: 收集上海市第七人民医院重症医学科收治的60例ARDS患者的临床资料进行分析,随机分为两组,肺部超声组和对照组,每组各30例患者。收集患者性别、年龄、病因,记录患者入科时及第7天的相关数据, APACHE II评分、SOFA评分WBC、CRP、PCT、血管外肺水指数、氧合指数、中心静脉压、机械通气治疗时间,肺部超声组收集肺部超声评分,两组患者的7天好转率、ICU住院时间、28天死亡率。研究：肺部超声在评估患者病情危重程度、治疗过程、预测预后的价值,以及肺部超声评分与血管外肺水指数等的相关性。结果: ①两组在治疗前的APACHEⅡ评分、SOFA评分、氧合指数、血管外肺水指数、WBC、CRP、PCT无明显统计学差异(P>0.05),治疗7日后两组患者治疗后均有改善,肺部超声组改善更明显,且机械通气时间更短(P<0.05)。②两组患者治疗前中心静脉压(CVP)无明显差异,治疗7日后两组患者的CVP无明显差异(P>0.05)③肺部超声组患者7日好转率较对照组高,入住ICU时间较对照组缩短,28天死亡率肺部超声组比对照组低(P<0.05)。④所有患者治疗前后患者的血管外肺水指数与APACHE Ⅱ评分、血管外肺水指数、中心静脉压均呈正相关,与氧合指数呈负相关。⑤肺部超声组肺部超声评分与APACHE Ⅱ评分、SOFA评分、血管外肺水指数均呈正相关,肺部超声评分与中心静脉压呈正相关,肺部超声评分与与氧合指数呈负相关。结论：肺部超声在急性呼吸窘迫综合征患者中能有效评估患者的严重程度,指导ARDS患者的个体化治疗,预测患者预后,可作为重症监护室ARDS患者的常规诊疗方法。     

无创正压通气治疗术后低氧血症的临床分析

目的:探讨无创正压通气(NPPV)在术后发生低氧血症治疗中的作用.方法:采用回顾性分析的方法,按不同病因将26例术后低氧血症病人分为2组,一组为心源性肺水肿15例,另一组为急性呼吸窘迫综合征(ARDS)11例.均采用鼻(面)罩行NPPV治疗,模式为双水平气道正压通气(BiPAP),设置参数吸气压(IPAP)及呼气压(EPAP).观察并比较两组病人治疗后呼吸(RR)、心率(HR)、氧合指数(OI=PaO2/FiO2)及NPPV治疗时间.结果:两组病人比较在通气治疗后2小时RR、HR、OI等变化均有显著性差异(P＜0.05).每组病例在NPPV治疗前后RR、HR、OI的差异有显著性(P＜0.05).心源性肺水肿组使用NPPV时间明显短于ARDS组,差异有显著性(P＜0.05).结论:NPPV治疗能改善术后低氧血症.与ARDS相比,心源性肺水肿所致低氧血症更容易纠正.     

脑缺血后脑组织和血浆中内皮素的变化

建立兔大脑中动脉阻断(MCAO)脑缺血模型。将48只兔随机分为四组:C(正常对照和假手术对照组)和脑缺血 I_2、I_4、I_(24)组,每组12只,测脑 H_2O、Na~+、K~+、Ca~(2+)、内皮素(ET)和血浆 ET。结果示脑缺血侧脑皮质和血浆中 ET 含量显著高于对照组(P<0.001),且随时相递增(P<0.01),ET与脑 H_2O 含量之间呈显著正相关(P<0.05),提示 ET 可能参与脑缺血、脑水肿的发生发展。     

Vascular permeability in experimental spinal cord injury

Following spinal cord injury in rats there was a time-dependent change of vascular permeability as reflected by extravasation of ¹²⁵I-labelled serum albumin. The change of vascular permeability correlated with tissue calcium and water accumulation suggesting that cord exposure to plasma calcium as a consequence of vascular injury may contribute to the progressive post-traumatic cord necrosis.     

Acute swelling of striae distensae following TRAM operation

A case of acute swelling and enlargement of striae distensae shortly after immediate breast reconstruction with TRAM flap is described. Although this condition may be an alarming sign of compromised blood supply to the flap, the flap’s other features were normal. The edema subsided spontaneously within a week, and the flap demonstrated full survival. Possible mechanisms of this phenomenon are discussed. Received: 18 August 1997 / Accepted: 29 September 1997     

肢体间接淋巴管造影术的临床意义

作者用伊索显－３００对２０例患肢水肿及肢体静脉曲张患者作间接淋巴造影，与直接淋巴造影比较，该法局部损伤小，操作简便，节省时间，通过造影，明确了３例非静脉水肿患者的病因，并发现肢体淋巴系统与静脉系统关系非常密切。     

Altered nitric oxide synthase immunoreactivity in the brain of stroke-prone spontaneously hypertensive rats

To obtain information about the role of nitric oxide (NO) in the development of hypertensive cerebral lesions, we used immunohistochemical methods to study the distribution and level of nitric oxide synthase (NOS) in the brain of stroke-prone spontaneously hypertensive rats (SHRSPs). The early changes in the brain of SHRSPs were petechiae, edema and massive glial accumulation around fibrin deposits, which contained necrotized microvessels, whereas advanced cerebral lesions comprised massive bleeding, cavity formation and diffuse degeneration of the white matter. In the normotensive control rats, immunoreactivity for NOS was demonstrated in scattered neuronal cells, as has been reported previously, but there was no reactivity in glial cells. In the present study in SHRSPs, however, considerable NOS immunoreactivity was observed in most reactive astrocytes and in a proportion of the microglial cells and macrophages in the vicinity of the cortical lesions and in the subcortical white matter both ipsi- and contralateral to the cortical lesion. The nerve cells in the edematous region also showed weak immunoreactivity for NOS. The distribution of increased NOS in SHRSP brains corresponded well with the sites of extravasated plasma fluid as demonstrated by anti-fibrinogen antibody. Based on these findings, we postulate that edema and the simultaneously generated free radicals or some extravasated plasma components may induce expression of NOS in the reactive cells and nerve cells, and that the NO thus generated may be involved in the development of hypertensive cerebral lesions. Received: 19 June 1995 / Revised, accepted: 21 February 1996     

Cutaneous signs (Raynaud's phenomenon,sclerodactylia, and efladema of the hands) and hand-arm vibration exposure

Summary Dermatological tests and examinations of the hand(s) were carried out in vibration-exposed and un exposed males. The subjects were 179 chain-saw workers in private forestry companies and 205 local inhabitants who had never used vibrating tools. The prevalences of Raynaud's phenomenon (RP), sclerodactylia, and edema of the hands were estimated in both groups, and associations between these cutaneous signs and vibration exposure were evaluated. The prevalences of RP and edema in the exposed group were 9.5% and 1.7%, respectively, and in the unexposed group, 2.9% and 1.5%, respectively. Sclerodactylia was seen in 31.8% of the chain-saw workers but in only 6.4% of the unexposed individuals. In statistical analyses based on unconditional logistic regression models with adjustment for age, RP was associated with long-term ( 20 years) vibration exposure [odds ratio (OR) = 7.06; 95% confidence interval (CI) = 2.51–19.87]. Sclerodactylia was associated with both short- and long-term vibration exposure (OR = 6.54, Cl = 3.30-13.36; OR = 7.05; CI = 3.41-14.60, respectively). There were significant dose-response relationships between RP and duration of exposure and between sclerodactylia and duration of exposure. Results of function tests indicated a longer recovery time and a higher vibration threshold for the workers with RP. The presence of sclerodactylia, however, did not have any significant influence on function test results. It is possible to conclude that not only RP but also sclerodactylia could be induced by vibration exposure. However, most cases of sclerodactylia were not so serious as to involve disturbances of peripheral circulatory and nerve function.     

大脑完全缺血后形态学和代谢功能的改变Ⅱ

结扎蒙古沙土鼠颈总动脉,造成脑缺血模型,松解后,观察存活期14天、21天、28天的实验动物的大脑形态学和代谢功能的改变。结果显示大脑皮质、尾状核、海马和豆状核壳等部位对缺血损害最为敏感。存活4天～21天的动物对2-DG的摄取明显回升并缓慢恢复,血流恢复后28天的脑组织,其神经元结构出现不同阶段的恢复。     

Adjusting body weight for edema in severely burned patients

Weight loss is difficult to quantify in critically ill burn patients, as the presence of edema can mask changes in dry body weight. We sought to estimate dry body weight using measured weights adjusted for reported extremity edema. We evaluated patients with at least 20% total body surface area (TBSA) burns admitted to our intensive care unit over a 3½-year period. Body weights were collected for this analysis from admission to the time of a recorded dry weight after wound healing. Extremity edema was collected at the time of each weight measurement and was categorized into three groups: (1) no edema, (2) 1 + pitting edema, (3) 2 + or 3 + pitting edema. Logistic regression yielded the following formula for estimating dry weight (in kg): 0.66 x measured body weight + 25 – (3 for 1 + pitting edema or 4 for 2 + or 3 + pitting edema of either upper extremity) – (4 for any pitting edema to either lower extremity) (p < 0.01, R² = 0.81). These results may allow us to better estimate dry body weight changes in our edematous patients with severe burns. Nutrition goals can be adjusted earlier, when appropriate, based on these estimated dry body weight changes.