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2024泰山科技论坛—“胸心海纳 精医天下”胸部疾病精准综合治疗纪要

Clinical Study on the Optimal Time to Establish Enteral Nutrition in Hypertensive Intracerebral Hemorrhage Patients

目的　研究高血压脑出血患者开始建立肠内营养的时间，以揭示其建立肠内营养的最佳时机。 方法　选取2010年7月－2011年9月收治的高血压脑出血患者69例，随机将其分为A、B、C组，A组23例在血流动力学稳定后24 h内采取鼻胃管方式开始建立肠内营养；B组23例在24～48 h内开始肠内营养支持；C组23例在48～72 h开始肠内营养支持，并分别于营养支持前1 d及营养支持后的14 d检测三组患者三头肌皮皱厚度、上臂肌围、血清白蛋白、血红蛋白水平等相关营养指标的波动情况；监测第3、14天各组患者腹泻、便秘、应激性溃疡、肺部感染等临床并发症的发生情况。 结果　相关营养指标监测结果研究发现：建立肠内营养支持14 d后，三组患者其三头肌皮皱厚度及上臂肌围在营养支持前后差异无统计学意义（P＞0.05）；A、B组患者其血清白蛋白及血红蛋白水平在营养支持后较前有增高表现，差异有统计学意义（P＜0.05），且B组患者其血清白蛋白及血红蛋白水平增高程度较A组更为显著；C组患者其血清白蛋白水平在营养支持后有增高表现，且差异有统计学意义（P＜0.05），但血红蛋白水平较前比较差异无统计学意义（P＞0.05）。相关临床并发症发生率的研究结果如下：给予肠内营养支持3 d后，A、C组患者分别与其余两组比较发现，其腹泻、胃潴留、应激性溃疡、肺部感染发生率较其余两组比较差异无统计学意义（P＞0.05）；B组患者与其余两组比较，其应激性溃疡发生率较其余两组减低，且差异有统计学意义（P＜0.05）；腹泻、胃潴留、肺部感染较其余两组比较无显著差异；但随着观察时间的不断延长，在肠内营养支持后的14 d，A组患者较其余两组比较，其腹泻、胃潴留、应激性溃疡发生率仍无显著差异，但其肺部感染的发生率较B组增高，而较C组减低，且差异有统计学意义（P＜0.05）；B组患者较其余两组比较，其腹泻、应激性溃疡、肺部感染的发生率较其余两组均减低，且差异有统计学意义（P＜0.05），并且其肺部感染发生率减低程度较A组明显，其胃潴留发生率与其余两组比较时差异无统计学意义（P＞0.05）；C组患者与其余两组比较，其应激性溃疡、肺部感染个例发生率较其余两组增高，但差异无统计学意义（P＞0.05）。 结论　高血压脑出血患者于血流动力学稳定后的24～48 h内给予建立肠内营养支持，可利于患者相关营养指标的恢复，减少相关临床并发症的发生，可能会在一定程度益于患者的预后。

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.

急诊外科手术治疗危重心瓣膜病192例

目的 总结危重心瓣膜病患者行急诊手术的临床经验，以提高其疗效和治愈率。 方法 自1996年10月至2007年11月对192例危重心瓣膜病患者施行了急诊手术。所有患者均为心瓣膜病合并严重心力衰竭，心功能分级（NYHA）为Ⅲ~Ⅳ级。经内科治疗2~7 d无效时采取急诊手术治疗；行二尖瓣置换术76例次，主动脉瓣置换术64例次，双瓣膜置换术43例次，三尖瓣置换术4例次，三尖瓣成形术45例次，左心房血栓清除和左心房减容 术各5例次，冠状动脉旁路移植术5例次，其他心血管手术9例次。 结果 术中和术后早期分别死亡3例和8例，总手术死亡率为5.7%（11/192），主要死亡原因为术中不能脱离体外循环机、术后发生低心排血量综合征和突发心室颤动等。随访168例，随访时间1个月~11年，失访13例。随访期间死亡8例，主要死于左心衰竭、瓣周漏或心内膜炎复发、尿毒症、夹层动脉瘤等。长期生存160例，心功能恢复至Ⅰ级132例，Ⅱ级15例，Ⅲ级13例；生活质量较术前有所提高。 结论 危重心瓣膜病患者经内科治疗无效时急诊手术具有良好的疗效，是较好的治疗选择。

心胸外科危重患者院内转运流程探讨

【摘要】　目的　总结并完善心胸外科危重患者院内转运流程。　方法　2007年1月-2009年12月将16名危重患者按院内转运流程安全转至外科重症监护病房（ICU）。　结果　实现危重患者安全转运，为患者病情的特别监护和后续治疗赢得时间和时机。　结论　危重患者院内转运流程在实际工作中发挥了重要作用，制订和实施严谨、有序、高效的流程方案是提高危重患者院内转运成功率的关键。

Early identification and contribution factor analysis of severe coronavirus disease 2019 in Xinyang city of Henan province

ObjectiveTo investigate the clinical characteristics and contribution factors in severe coronavirus disease 2019 (COVID-19).MethodsThe clinical symptoms, laboratory findings, radiologic data, treatment strategies, and outcomes of 110 COVID-19 patients were retrospectively analyzed in these hospitals from Jan 20, 2020 to Feb 28, 2020. All patients were confirmed by fluorescence reverse transcription polymerase chain reaction. They were classified into a non-severe group and a severe group based on their symptoms, laboratory and radiologic findings. All patients were given antivirus, oxygen therapy, and support treatments. The severe patients received high-flow oxygen therapy, non-invasive mechanical ventilation, invasive mechanical ventilation or extracorporeal membrane oxygenation. The outcomes of patients were followed up until March 15, 2020. Contribution factors of severe patients were summarized from these clinical data.ResultsThe median age was 50 years old, including 66 males (60.0%) and 44 females (40.0%). Among them, 45 cases (40.9%) had underlying diseases, and 108 cases (98.2%) had different degrees of fever. The common clinical manifestations were cough (80.0%, 88/110), expectoration (33.6%, 37/110), fatigue (50.0%, 55/110), and chest tightness (41.8%, 46/110). Based on classification criteria, 78 (70.9%) non-severe patients and 32 (29.1%) severe patients were identified. Significant difference of the following parameters was found between two groups (P<0.05): age was 47 (45, 50) years vs. 55 (50, 59) years (Z=–2.493); proportion of patients with underlying diseases was 27 (34.6%) vs. 18 (56.3%) (χ2=4.393); lymphocyte count was 1.2 (0.9, 1.5)×109/L vs. 0.6 (0.4, 0.7)×109/L (Z=–7.26); C reactive protein (CRP) was 16.2 (6.5, 24.0) mg/L vs. 45.3 (21.8, 69.4) mg/L (Z=–4.894); prothrombin time (PT) was 15 (12, 19) seconds vs. 18 (17, 19) seconds (Z=–2.532); D-dimer was 0.67 (0.51, 0.82) mg/L vs. 0.98 (0.80, 1.57) mg/L (Z=–5.06); erythrocyte sedimentation rate (ESR) was 38.0 (20.8, 59.3) mm/1 h vs. 75.5 (39.8, 96.8) mm/1 h (Z=–3.851); lactate dehydrogenase (LDH) was 218.0 (175.0, 252.3) U/L vs. 325.0 (276.5, 413.5) U/L (Z=–5.539); neutrophil count was 3.1 (2.1, 4.5)×109/L vs. 5.5 (3.7, 9.1)×109/L (Z=–4.077). Multivariable logistic analysis showed that there was positive correlation in elevated LDH, CRP, PT, and neutrophil count with the severity of the disease. Currently, 107 patients were discharged and 3 patients died. Total mortality was 2.7%.ConclusionsOld age, underlying diseases, low lymphocyte count, elevated CPR, high D-dimer and ESR are relevant to the severity of COVID-19. LDH, CPR, PT and neutrophil count are independent risk factors for the prognosis of COVID-19.

Treatment of Acute and Critical Choledochal Cyst Report of 41 Cases)

【摘要】目的探讨急危重胆总管囊肿的治疗。方法对我院1984~2001年收治的41例急危重胆总管囊肿患者的临床资料进行回顾性分析。结果41例患者均行囊肿切除、胆道重建术，其中3例患者分两期完成，全部病例均获治愈，随访9例近、远期效果均较好。结论囊肿切除、胆道重建术已成为根治胆总管囊肿的首选术式，但必须做好高危因素的处理，以提高手术安全性及疗效，只要度过围手术期，其预后较好。

危重患者持续静静脉血液滤过时血糖监测的影响因素研究

目的 观察危重患者持续静静脉血液滤过( CVVH) 过程中血糖监测的影响因素。方法 选择CVVH治疗的危重患者30 例, 根据其入选时的循环状态将患者分为休克组和非休克组, 同时监测两组患者动脉血糖、末梢血糖及CVVH 导管动脉端血糖, 比较同一时点各部位血糖监测值。结果 所有患者动脉血糖值与末梢血糖值比较有显著差异( P lt; 0. 05) , 动脉血糖值与CVVH 导管动脉端血糖值差异无统计学意义( P gt; 0. 05) , 且二者存在明显相关性( r = 0. 989, P lt; 0. 001) , 末梢血糖值与CVVH导管动脉端血糖值差异有统计学意义( P lt;0. 05) ; 休克组末梢血糖值较动脉血糖值低, 差异有统计学意义( P lt; 0. 05) , 非休克组末梢血糖值与动脉血糖值差异无统计学意义( P gt;0. 05) 。结论 危重患者末梢血糖监测值偏低, 该差异在休克患者中更加明显; CVVH时可通过导管动脉端采血监测血糖。

Nursing Intervention for Patients with Severe Influenza A

【摘要】 目的 探讨甲型H1N1流感重症与危重症的护理干预。 方法 回顾分析2009年10月-2010年2月收治的20例甲型H1N1流感重症与危重症患者的治疗方案及其护理干预措施。 结果 16例治愈出院， 4例死亡。其中7例需要呼吸机辅助通气。 结论 甲型H1N1流感重症与危重症需要综合治疗，同时，有效的护理干预也是提高甲型H1N1流感危重症患者治愈率和降低死亡率的关键。【Abstract】 Objective To evaluate the nursing intervention for patients with severe influenza A (H1N1). Methods The clinical data of 20 patients with severe influenza A (H1N1) from October 2009 to February 2010 were retrospectively analyzed. Results In 20 patients, 16 were cured and four died. A total of seven patients needed ventilation assisted with ventilators. ConclusionsThe patients with severe influenza A (H1N1) needs combined modality therapy. At the same time, active and effective nursing intervention is the key point of increasing the recovery rate and decreasing the mortality rate.

Bundle Therapy in Five Severe Patients with Influenza A (H1N1)

【摘要】　目的　探讨甲型H1N1流感危重症患者的抢救疗效。　方法　2009年10月－2010年1月，对我院ICU收治5例甲型H1N1流感危重症患者采用集束化治疗方案进行救治，并就患者的器官功能变化进行评价。　结果　5例患者平均住院天数为（11.8±5.59）d，4 例存活，1例死亡。存活患者在治疗过程中急性生理和既往健康 （APACHE）Ⅱ、多器官功能障碍综合征评分（MODS）、全身性感染相关的器官衰竭评分 （SOFA）总体呈逐渐下降趋势。死亡者APACHEⅡ、SOFA评分均呈逐渐升高趋势。　结论　对甲型H1N1流感危重症患者采取集束化救治疗效良好。【Abstract】　Objective　To explore the effect of bundle therapy on severe patients with influenza A (H1N1).　Methods　Bundle therapy were used in 5 severe patients with influenza A from October 2009 to January 2010. The patients’ organ dysfunction were observed for.　Results　The average in-hospital duration was (11.80±5.59) days. Four patients survived and one died with the survival ratio of 80%. Acute physiology and chronic health evaluation (APACHE) II score, Multiple organ dysfunction syndrome (MODS) score and sepsis-related organ failure assessment (SOFA) score gradually decreased in 4 survived patients, while gradually increased in the died patient.　Conclusion　Bundle therapy is effective on patients with severe influenza A.