Search

Treatment of critically ill patients with gas gangrene resulted in the 2008 W enchuan earthquake

Objective To investigate the efficacy of interdisciplinary therapy in critically ill patients with gas gangrene in the 2008 W enchuan earthquake．Methods Four critically wounded patients with gas gangrene caused by Wenchuan earthquake were treated by interdisciplinary cooperation．Results Two patients received debridement and decompression were not amputated．Two amputated patients did not received futher amputation．Conclusions Interdisciplinary therapy of critically ill patients with gasgangrene in earthquake could limited the area of tissue necrosis，minimized the necessity of amputation and further amputation．

动脉瘤重症患者合并中毒性表皮坏死松解症死亡一例

Relationship Between Using Proton Pump Inhibitors and the Hospital-acquired Pneumonia in Critical Patients

【摘要】 目的 〖JP2〗研究质子泵抑制剂（PPI）是否为危重患者发生医院获得性肺炎的危险因素。 方法 收集2002年6月-2009年6月收治的198例重症患者资料，分为使用PPI组（96例）和未使用PPI组（102例）。采用logistic回归分析PPI使用情况和医院获得性肺炎的关系。 结果 使用PPI组肺炎的发生率较高（26.9%），尤其是PPI使用时间超过7 d者（37.5%）。在不同的多变量logistic回归模型中，分别用APACHE Ⅱ评分和入住重症监护室原因校正后，使用PPI以及使用天数均是医院获得性肺炎发生的危险因素（P=0.031，OR＝2.230，95%CI：1.957~2.947；P=0.002，OR＝1.824，95%CI：1.457~2.242）。 结论 长时间应用PPI可能是增加ICU患者发生医院获得性肺炎的一种风险因素。【Abstract】 Objective To identify whether proton pump inhibitors (PPI) is a risk factor of hospital-acquired pneumonia (HAP) in critical patients. Methods The clinical data of the critical patients admitted to ICU from June 2002 to June 2009 were retrospectively analyzed. A total of 198 patients were divided into two groups: 96 in PPI group and 102 in non-PPI group. The relationship between PPI and HAP was analyzed by logistic regression. Results The patients in PPI group had a higher risk of HAP (26.9%), especially who were treated with PPI more than 7 days (37.5%). Adjusted by APACHE Ⅱ score and reason for admission to ICU, PPI therapy and the using duration of PPI were both the risk factors of HAP in different multiple logistic models (P=0.031, OR=2.230, 95%CI: 1.957-2.947; P=0.002, OR=1.824, 95%CI: 1.457-2.242). Conclusion Long-term use of PPI is a risk factor of HAP.

Evaluation of Resting Energy Expenditure in Critically Surgical Patients Undergoing Mechanical Ventilation

ObjectiveTo compare the indirect calorimetry (IC) measured resting energy expenditure (MREE) with adjusted Harris-Benedict formula calculating resting energy expenditure (CREE) in the mechanically ventilated surgical critically ill patients and to evaluate the relationship between the resting energy expenditure (REE) with the severity of illness. MethodsTwenty-one patients undergonging mechanical ventilation for critical illness in the intensive care unit of general surgery between August 2008 and February 2010 were included in this study. Data during the study period of nutrition support were collected for computation of the severity of critical illness by acute physiology and chronic health evaluation Ⅱ scores (APACHE Ⅱ scores) and organ dysfunction scores (Marshall scores). MREE was measured by using IC of the MedGraphics CCM/D System within the first 7 d after nutrition therapy. CREE was calculated by using the HarrisBenedict formula adjusted with correction factors for illness at the same time. According to APACHE Ⅱ scores on admission, the enrolled patients were divided into two groups: APACHEⅡ score ≥20 scores group (n=8) and APACHE Ⅱ score lt;20 scores group (n=13), and the differences between MREE and CREE of patients in two groups were determined. ResultsThe reduction of variation tendency in CREE other than MREE in the enrolled patients within the first week of nutritional support was statistical significance (Plt;0.001). The CREE of patients 〔(1 984.49±461.83) kcal/d〕 was significantly higher than the MREE 〔(1 563.88±496.93) kcal/d〕 during the first week of nutritional support (Plt;0.001). The MREE on the 0, 1, 2, and 4 d after nutrition therapy were statistically significant lower than CREE at the same time interval in these patients (Plt;0.01), and the differences at the other time points were not significant (Pgt;0.05). There was a trend towards a reduction in APACHE Ⅱ and Marshall scores within the first week of nutrition therapy that reached statistical significance (Plt;0.001). During the first week of nutrition therapy, APACHEⅡ and Marshall scores of patients in ≥20 scores group were significantly higher than those in lt;20 scores group, respectively (Plt;0.05 or Plt;0.01), and the reductions of APACHE Ⅱ scores and Marshall scores were significant in patients of two groups (Plt;0.001). A significant positive correlation was found between CREE with APACHE Ⅱ scores (r=0.656, Plt;0.001) and Marshall scores (r=0.608，Plt;0.001) in patients within the first week after nutrition support. Although no statistically significant correlation was observed between MREE and APACHEⅡ scores (r=-0.045， P=0.563), a significant positive correlation was observed between MREE and Marshall scores (r=0.263, P=0.001) within the first week after nutrition therapy. There was no correlation between MREE and CREE (r=0.064, P=0.408) in patients at the same time interval. The reduction of MREE of patients in ≥20 scores group other than in lt;20 scores group was statistically significant within the first week after nutrition therapy (P=0.034). In addition, the MREE of patients in ≥20 scores group were not significantly different from those in lt;20 scores group (Pgt;0.05), and the mean CREE was not different in two groups patients within the first week of nutritional therapy 〔(1 999.55±372.73) kcal/d vs. (1 918.39±375.27) kcal/d, P=0.887〕. CREE was significantly higher than MREE of patients in ≥20 scores group within the first week except the 3 d and 5 d after nutrition therapy (Plt;0.05), while in lt;20 scores group CREE was significantly higher than MREE in patients only within the first 3 d after nutrition therapy (Plt;0.05 or Plt;0.01). MREE and CREE of patients in ≥20 scores group were not different from those in lt;20 scores group, respectively (Pgt;0.05).

改良鼻饲法应用于危重症患者的效果观察

目的观察改良鼻饲法应用于危重症患者的临床效果。 方法将2011年12月－2012年2月在重症监护病房住院且住院时间＞12 d的危重症患者58例，采用抽签法分为改良组和对照组，改良组32例，采用改良鼻饲法管喂肠内营养乳剂，3次/d，500 mL/次，用营养泵200～250 mL/h泵入；对照组26例，用营养泵持续泵入肠内营养乳剂1 500 mL，泵入时间＞20 h。两组营养乳剂均加热并应用恒温器保持其温度在38～40℃。观察两组并发症的发生情况。 结果改良组呕吐、高血糖等并发症发生率明显低于对照组，差异有统计学意义（P＜0.05）。 结论采用改良鼻饲法管喂肠内营养乳剂能有效降低危重症患者的并发症，是较为理想的喂养法。

A Cross-sectional Survey on Strategies for Choosing Venous Access Devices for Critically Ill Patients

ObjectiveTo investigate and analyze the strategies for choosing venous access devices for critically ill patients. MethodsThe medical staffs in ICU were required to fulfill a questionnaire on the knowledge and application of venous access devices in critically ill patients in May 2015.A descriptive statistical analysis was carried out on the answers generated from the questionnaire using SPSS 19.0 software. ResultsA total of 50 questionnaires were distributed randomly and 46 valid questionnaires were recovered.The effective response rate was 92.0%.The proportion of junior, intermediate and senior medical staffs was 80.4%, 13.0% and 6.6%, respectively.The proportion of doctors and nurses was 39.1% and 60.9%, respectively.The average seniority was (5.7±4.9)years.The proportion of ICU medical staffs who were acquainted with PIV, ACVC, PICC, TCVC, PORT and Midline was 100.0%, 100.0%, 100.0%, 69.6%, 43.5% and 13.0%, respectively.The proportion of ICU medicial staffs who would take the styles of drug, the time of treatment, the patients' condition and the costs into consideration when choosing venous access devices was 100.0%, 100.0%, 64.0% and 18.0%, respectively.91.3% and 39.1% of ICU medical staffs would choose PIV and ACVC respectively if the time of treatment was less than 1 week.56.5%, 69.6% and 26.1% of ICU medical staffs would choose PIV, ACVC and PICC respectively if the time of treatment was between 1 and 4 weeks.30.4%, 39.1%, 82.6% and 32.6% of ICU medical staffs would choose PIV, ACVC, PICC and PORT respectively if the time of treatment was more than 4 weeks.52.2% of ICU medical staffs were acquaint with the styles and the indication of antibiotic coating central venous catheter.The main reasons for infusion failure were poor vascular condition (91.3%), old age (52.2%), skin lesions (39.1%) and pipeline plugging (26.1%).The main reasons for choosing the peripheral vein were lower risk of infection (87.0%), short-term treatment (82.6%), common transfusion (78.3%) and antibiotic treatment (47.8%).The main reasons for choosing central venous infusion were irritant drugs (82.6%), peripheral vascular puncture difficulty (69.6%), long-term infusion (65.2%) and hemodynamic monitor (56.5%). ConclusionsIt is difficult to establish a vascular access for critically ill patients.The ICU medical staffs are experienced to PIV, ACVC and PICC but not to Midline, TCVC and PORT.A comprehensive evaluation is essential to choose a suitable and reliable venous access device for critically ill patients.

Characteristics of the Pathogens Causing Catheter-associated Urinary Tract Infection in Critically Ill Patients

ObjectiveTo investigate the species and resistance phenotypes of the pathogens causing catheter-associated urinary tract infection (CAUTI) in critically ill patients in West China Hospital of Sichuan University, and to provide the basis for the prevention and treatment of this kind of infection. MethodsThe clinical data and findings of the laboratory examination of the patients, who were admitted to intensive care units and suffered from CAUTI in our hospital during January 2012 to December 2014, were retrospectively analyzed. The pathogens isolates from the urine specimens of the patients with CAUTI and their resistance phenotypes were analyzed. ResultsThree hundred and seventy patients suffering from CAUTI were included in this study. Five hundred and seventeen strains of pathogens were isolated from the urine specimens of these patients, including 222 isolates (42.9%) of fungus, 181 isolates (35.0%) of gram negative bacteria, and 114 isolates (22.0%) of gram positive bacteria. In terms of species distribution, Candida albicans (105 isolates, 20.3%), C.glabrata (78 isolates, 15.1%) and C.glabrata (30 isolates, 5.8%) were the predominant fungus. Among the gram negative bacteria, Escherichia coli (81 isolates, 15.7%), Klebsiella pneumoniae (37 isolates, 7.2%), and Acinetobacter calcoaceticus-baumannii complex (23 isolates, 4.4%) were the main species. Enterococcus faecium (79 isolates, 15.3%) and E.faecalis (13 isolates, 2.5%) were the frequently isolated gram positive bacteria. Analysis of the resistance phenotype showed that the resistance rates to itraconazole, voriconazole and fluconazole of Candida spp. were above 10%. Thirty percent of the isolates of E.coli and K.pneumoniae, and 60% of the isolates of A.calcoaceticus-Baumannii complex were resistant to many of the regular antibiotics. Imipenem resistance rate of A.calcoaceticus-Baumannii complex was 60.8%. Sixty percent of the isolates of E.faecium and E.faecalis were resistant to many of the regular antibiotics. The vancomycin-resistant isolates accounted for 16.5% of E.faecium and 31.0% of E.faecalis. ConclusionCandida species are the major pathogens for CAUTI in critically ill patients in our hospital and show the resistance to azoles. We should focus on the drug resistance of gram negative bacteria and gram positive bacteria. The rational use of antibiotics and application of effective infection control measures are important to decrease the CAUTI.

胸腔水封引流瓶用于危重症患者腹腔引流的效果观察

目的观察胸腔水封引流瓶用于重症监护病房（ICU）患者腹腔引流管引流的效果。 方法选取2014年1月－2015年1月收治的100例危重症患者，按照入住ICU的先后顺序依次分为对照组和试验组，每组各50例。对照组患者腹腔引流装置使用一次性普通引流袋，试验组患者腹腔引流装置使用一次性胸腔水封引流瓶。比较两组患者腹腔引流管的堵管发生率，以及护士每天护理腹腔引流管所花费的直接护理时间。 结果试验组患者腹腔引流管发生堵管的例数（1例，占2%）明显少于对照组（7例，占14%），差异有统计学意义（P＜0.05）；试验组管护士每天花费的直接护理腹腔引流管的时间明显短于对照组，差异有统计学意义（P＜0.05）。 结论胸腔水封引流瓶用于危重症患者腹腔引流管的引流能明显降低腹腔引流管的堵管发生率，显著减少护士的工作量，并能精确记录腹腔引流液的量，值得临床推广应用。

刺激诱发出的脑电异常对重症患者脑功能的临床意义

刺激诱发出的节律性、周期性或者发作期放电(Stimulus-induced rhythmic，periodic，or ictal discharges，SIRPIDs)是Hirsch等在2004年首次命名的一种脑电现象，在意识障碍或者昏迷患者的长程脑电监测中所得。SIRPIDs机制可能与皮层下-皮层功能异常相关，尤其与丘脑皮层回路功能异常相关。但目前研究对于这一现象的病理生理学机制不甚明确。部分研究认为出现这一脑电现象提示患者预后较差，但从现有研究来看，该异常脑电活动能否引起神经损伤，或者这些异常是否仅仅为脑损伤严重的表现，以及是否需要药物干预治疗，临床中尚无法确定。文章目的是综述现有的文献了解SIRPIDs的概念、病理生理学机制、临床相关性，以及其对于神经重症患者脑功能的提示。

急性颅内动脉瘤破裂出血术后患者在重症医学科的血压管理

目的 探讨严格的血压管理对急性颅内动脉瘤破裂出血术后患者目标血压的控制效果。 方法 对 2015 年 1 月—9 月 28 例颅内动脉瘤破裂出血术后患者进行严格的血压调控和监护。 结果 28 例患者的血压经专科对症治疗及综合的血压管理，均得到较好控制。21 例单个动脉瘤术后患者平均动脉压控制在 90～110 mm Hg（1 mm Hg=0.133 kPa），收缩压控制在 135～160 mm Hg；7 例多个动脉瘤术后患者平均动脉压控制在 80～100 mm Hg，收缩压控制在 135～150 mm Hg。21 例患者血压在 24 h 内降至理想水平，7 例患者血压在 48 h 内降至理想水平，患者未出现颅内再出血。27 例患者呼吸机辅助呼吸 5～7 d 后顺利停机拔管，转入神经外科病房继续治疗；1 例患者于术后第 2 天自动出院。 结论 对急性颅内动脉瘤破裂出血术后患者采取有效的血压管理，可以减少患者术后并发症。