出血中心重症监护室护理建设专家共识

【摘要】 本共识从护理管理层面对出血中心重症监护室硬件设施的配备需求、组织架构层级与人力配备原则、专科应急预案与规范化急救护理评估与处置流程、管理制度修订、人文关怀及质量控制措施与落实等方面进行了初步论述,并提出14条推荐意见,供各医疗单位参考,以推进出血中心重症监护室的标准化建设, 提高危急重症出血患者的救治成功率,促进患者康复。     

Preliminary report on the interaction of apolipoprotein E polymorphism with aortic atherosclerosis and acute nephropathy after CABG

Background

Renal dysfunction is a serious complication of cardiac surgery that is highly associated with short- and long-term adverse outcome. While the apolipoprotein E (APOE) ?4 allele has been linked to the occurrence of both postcardiac surgery acute renal injury (?4 favorable) and ascending aortic arteriosclerosis (?4 unfavorable), the role of ?4 in the relationship between these two conditions is unknown. We hypothesized that patients with and without the ?4 allele (E4/non-E4) would have different associations between atheroma burden and postoperative renal dysfunction.

Methods

Ascending, arch, and descending aorta atheromatous burden and APOE status were evaluated for 130 coronary bypass patients. Multivariable analyses were performed for aortic regions to assess the relationship of atheroma burden and APOE ?4 status with peak in-hospital postoperative serum creatinine. All p < 0.05 were considered significant.

Results

We found an interaction between E4 status (E4/non-E4; 24/106) and atheroma burden, with a much greater predicted peak in-hospital postoperative serum creatinine for increases in ascending aorta atheroma load for non-E4 patients versus E4 patients (beta coefficient −0.13; p = 0.002). We also confirmed the association between ascending aorta atheroma and peak creatinine (beta coefficient 0.11; p = 0.0008), after controlling for E4 status, preoperative creatinine, and the E4-atheroma interaction.

Conclusions

Equivalent ascending aortic atheroma burden is associated with a greater susceptibility to postoperative renal injury among patients undergoing cardiac operation who lack the APOE ?4 allele. Findings may be attributable to APOE-related differences in inflammation, susceptibility to atheroma detachment (eg, during operative aortic manipulation), or renal vulnerability to embolic injury.     

Preoperative Serum Potassium Levels and Perioperative Outcomes in Cardiac Surgery Patients

Context  Although potassium is critical for normal electrophysiology, the association between abnormal preoperative serum potassium level and perioperative adverse events such as arrhythmias has not been examined rigorously. Objective  To determine the prevalence of abnormal preoperative serum potassium levels and whether such abnormal levels are associated with adverse perioperative events. Design and Setting  Prospective, observational, case-control study of data collected from 24 diverse US medical centers in a 2-year period from September 1, 1991, to September 1, 1993. Patients  A total of 2402 patients (mean [SD] age, 65.1 [10.3] years; 24% female) undergoing elective coronary artery bypass grafting who were not enrolled in another protocol. The study population was identified using systematic sampling of every nth patient, in whichn was based on expected total number of procedures at that center during the study period. Main Outcome Measures  Intraoperative and postoperative arrhythmias, the need for cardiopulmonary resuscitation (CPR), cardiac death, and death due to any cause prior to discharge, by preoperative serum potassium level. Results  Perioperative arrhythmias occurred in 1290 (53.7%) of 2402 patients, with 238 patients (10.7%) having intraoperative arrhythmias, 329 (13.7%) having postoperative nonatrial arrhythmias, and 865 (36%) having postoperative atrial flutter or fibrillation. The incidence of adverse outcomes was 3.6% for death, 2.0% for cardiac death, and 3.5% for CPR. Serum potassium level less than 3.5 mmol/L was a predictor of serious perioperative arrhythmia (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.0), intraoperative arrhythmia (OR, 2.0; 95% CI, 1.0-3.6), and postoperative atrial fibrillation/flutter (OR, 1.7; 95% CI, 1.0-2.7), and these relationships were unchanged after adjusting for confounders. The significant univariate association between increased need for CPR and serum potassium level less than 3.3 mmol/L (OR, 3.3; 95% CI, 1.2-9.5) and greater than 5.2 mmol/L (OR, 3.0; 95% CI, 1.1-8.7) became nonsignificant after adjusting for confounders. Conclusions  Perioperative arrhythmia and the need for CPR increased as preoperative serum potassium level decreased below 3.5 mmol/L. Although interventional trials are required to determine whether preoperative intervention mitigates these adverse associations, preoperative repletion is low cost and low risk, and our data suggest that screening and repletion be considered in patients scheduled for cardiac surgery.