1 病历资料 患者,男性,46 岁,赞比亚务工 1 年余,于 2015 年12 月 28 日回国. 2016 年 1 月 2 日无明显诱因发热,发热前伴畏寒、寒战,体温骤升后降至正常,高热与正常反复交替,间隔 1d,体温最高达 39.9℃,无其他伴随症状,至 1 月 4 日来我科门诊,因有非洲务工史门诊给予相关检查,患者未等结果回报直接回家. 当晚患者出现醉酒步态,意识逐渐丧失,小便失禁. 又急来我科就诊,追问血涂片检查结果:恶性疟原虫,见到环状体. 故门诊以"恶性疟疾 脑型? "收住. 患者平素体健.

Objective:To evaluate the consistency and correlation between invasive blood pressure(IBP)and non-invasive blood pressure(NIBP)in critically illed patients.Methods:Five hundred critically illed patients in department of critical care medicine in General Hospital of NingXia Medical University from March 2010 to March 2012 were randomly enrolled.Right radial artery IBP monitoring and bilateral brachial artery NIBP monitoring were conducted synchronistically.According to IBP level,patients were divided into three groups:group A,systolic blood pressure(SBP)< 90 mmHg,n=116;group B,SBP 90-140 mmHg,n=172;group C,SBP≥140 mmHg,n=212.Methods of correlation coefficient and Bland-Altman analysis were employed to assess the correlation and consistency of NIBP and IBP.Results:(1)Consistency analysis showed that the average difference levels for invasive SBP and noninvasive SBP in group A were accordingly-2.9 mmHg(left brachial artery)and-5.6 mmHg(right brachial artery),in group B(4.5 mmHg and 1.9 mmHg),in group C(20 mmHg and 17.3 mmHg),respectively.Incidences beyond the consistency zone of upper and lower limit in group A were 0.0%,3.4%(left brachial artery)and 0.0%,4.3%(right brachial artery),in group B(1.7%,3.5% and 1.7%,2.3%),in group C(2.0%,0.0% and 2.0%,0.0%),respectively.(2)Consistency analysis showed that average difference levels for invasive diastolic blood pressure(DBP)and non-invasive DBP in group A were accordingly-3.5 mmHg(left brachial artery)and-5.8 mmHg(right brachial artery),in group B(-3.2 mmHg and-3.5 mmHg),in group C(0.3 mmHg and 1.2 mmHg),respectively.Incidences beyond the consistency zone of upper and lower limit in group B were 6.0%,1.7%(left brachial artery)and 3.4%,2.6%(right brachial artery),in group B(1.2%,2.9% and 1.7%,3.5%),in group C(2.4%,4.2% and 3.3%,2.8%),respectively.③ Correlation coefficients between invasive and non-invasive SBP of three groups were accordingly 0.105-0.108(group A),0.417-0.444(group B)and 0.144-0.166(group C).As to DBP,they were 0.409-0.427(group A),0.598-0.617(group B)and 0.546-0.596(group C).Conclusions:During hypotension and hypertension in critically illed patients,consistency between IBP and NIBP is obviously decreased.NIBP monitoring tends to overestimate or underestimate patient's real blood pressure.

<正>近几年,重症监护室(ICU)危重患者由非发酵菌所致的院内获得性肺炎(HAP)的发生率日益增多,治疗非常困难,分析其危险因素并选择敏感抗生素有助于提高危重患者的救

OBJECTIVE:To observe related factors in the stress hyperglycemia (SHG) of critical illness and to investigate possible pathogenesis of insulin-resistance (IR).METHODS:Blood glucose (BG), insulin (INS), C-peptide (C-P), cortisol (Cor), somatostatin (SS), glucagon (Gluc), tumor necrosis factor-alpha (TNF-alpha),soluble tumor necrosis factor receptor I (sTNFRI) and sTNFRII were determined respectively by radioimmunoassay (RIA) or enzyme linked immunoadsorbent assay (ELISA) in 47 SHG patients with critical illness and 15 healthy volunteers serving as normal controls. Their insulin sensitivity index (ISI) was calculated.RESULTS:(1)Eleven of 47 patients died, while 36 cases survived. Mean acute pathology and chronic health evaluation II (APACHEII) was (13.89+/-6.29) scores within 24 hours after admission to intensive care unit (ICU), mean days of stay in ICU was (5.5+/-6.3) days,and mean duration of mechanical ventilation (MV) was (51.49+/-66.01) hours. (2)The concentrations of INS, ISI, C-P, Cor, Gluc, TNF-alpha, sTNFRI and sTNFRII in 47 SHG patients with critical illness were significantly higher than those in normal controls, except for SS, the differences among groups were significant (P<0.05 or P<0.01). (3)The results of analysis of severity of SHG showed that the more severe SHG was, the higher C-P and INS were, and the less prominent ISI was. (4)Analysis of scores of APACHEII in 47 cases of SHG showed that BG was not increased, but duration of MV, Cor, Gluc, SS, TNF-alpha, sTNFRI and sTNFRII were significantly increased with higher scores of APACHEII. (5)The effect of SHG was significant on MV (F=10.438,P<0.01), but not significant for outcome and days of stay in ICU. (6)The main correlative factors of BG were respectively concentrations of INS (r=0.674, P<0.01), C-P(r=0.552,P<0.01), ISI (r=-0.787, P<0.01), APACHE II(r=0.267,P<0.05) and sTNFRI(r=0.465, P<0.01).CONCLUSION:These results show that main reason of SHG in critical illness is IR. There is no strong significant correlation between acute stress hormones and the level of SHG. sTNFRI has an influence on SHG. However, the over release of TNF-alpha and sTNFRII could be the results of seriousness of the critical illness. There is closely correlation between BG and MV, but not with the age, outcome and days of stay in ICU. The strategy of control and therapy of SHG should be alleviation of stress and improve the utilization of BG in the tissue, and increase sensitivity of INS in the tissue.

SARS是一种新的急性呼吸道传染性疾病,以传染性强、传播途径多、缺乏特异性的治疗为特征.如何治疗、护理好每一位SARS患者,提高治愈率,降低死亡率,是医务工作者关注的问题.本文对2003年4月7日-2003年5月14日间收入我院感染疾病科的5例SARS患者进行心理干预治疗的观察,现浅谈体会.

目的探讨脑肿瘤切除术后病人在ICU过渡治疗的管理方法,以减少术后并发症的发生.方法 对2001年8月-2002年7月间收入ICU的27例脑肿瘤切除术后病人进行机械通气和镇静药物应用等方面的观察.结果 27例病人中,1例放弃治疗,1例行气管切开,其余均顺利脱机、拔管.结论 对于脑肿瘤切除术后病人合理应用机械通气及镇静药物过渡,并严密监护和综合救治,可以提高术后恢复的安全性.

ObjectiveTo explore the value of thrombocytopenia and its time course in evaluating prognosis in critically ill patients.MethodsThe critically ill patients were divided into thrombocytopenic group(defined by a platelet count100×10 9/L)and non-thrombocytopenic group,and survivor group and non-survivor group according to the results of following up.Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score,duration of ICU stay,duration of mechanical ventilation and platelet count after hospitalization,3,5,7 days were recorded.Results①Thrombocytopenic patients had higher APACHE Ⅱ scores at admission,longer mechanical ventilation time and higher hospital mortality than non-thrombocytopenic patients (all P0.01),but there was no difference in ICU stay days between the two groups.②Logistic regression analysis with hospital mortality was as dependent variable,the occurrence of thrombocytopenia was still significantly related with hospital mortality of critically ill patients (OR=25.773,P=0.000).③The platelet count was lower in nonsurvivors than in the survivors throughout the ICU course( all P0.05).The platelet count in survivors decreased significantly on the third day after admission,and continued to rise(all P0.01).In the nonsurvivors,the platelet count decreased continuously after admission,and kept stably by the end of the first week(P0.05 or P0.01).ConclusionThrombocytopenia,as an independent risk factor,can predict outcome for ICU patients,especially dynamic changes in platelet count has more predictive value.

目的分析呼吸机对急性心肌梗死合并呼吸衰竭的治疗效果,提高临床医师对机械通气的认识和合理应用.方法回顾性地分析12例急性心肌梗死合并呼吸衰竭患者对呼吸机的治疗效果.结果 12例患者中2例死亡,1例放弃治疗,其它患者呼吸衰竭纠正后转心内科巩固治疗.结论提示临床上正确掌握机械通气的适应症,合理使用呼吸机条件,结合临床综合治疗,就能够取得良好的疗效.

目的提高临床医生对甲减合并呼吸衰竭的认识,减少误诊、提高救治率.方法对3例甲减合并呼衰的病例进行回顾性分析,找出误诊和治疗失败的原因,总结治疗经验.结果 3例患者中2例治愈,1例死亡.结论甲减合并呼吸衰竭时机械通气是最有效的治疗手段,早期甲状腺激素替代治疗可有效地改善预后,是治疗成功的关键,加强监护和综合支持治疗可提高抢救成功率.

随着机械通气(MV)的普遍应用，呼吸机相关肺炎(VAP)作为危重患者主要的并发症和致死病因日渐受到关注。加之其细菌耐药性不断出现，为院内感染的控制带来了很大难度。现就我院重症监护病房(ICU)中139例次VAP的病原菌及其耐药性进行分析和研究如下。

危重状态下的麻醉插管与常规麻醉插管有很大不同.多数患者因生命体征的极不稳定,使麻醉插管过程复杂化,且危险性大,死亡率高.虽然诱导麻醉药物的作用快,作用时间短,但其引发的血流动力学改变对危重病人插管后期的循环状态可以造成难以克服或不可恢复的间接影响,为临床不可忽视的插管后期并发症.现就我院综合性ICU内44例危重病患者的诱导麻醉及其插管前和插管后4 h内的循环状态作了回顾性分析.

Objective To study the changes of arterial blood lactate(ABL) and serum enzymes activities and thier correlation.Method Lactate dehydrogenase(LDH),alkaline phosphatase(AKP) and creatine kinase(CK) in serum were determined in sixty-four critical patients in the intensive care unit(ICU) at admission immediately,following 24h,48h and 72h,respectively.The patients was divided into three groups:favorable,survival and death groups.Results Before treatment,ABL level was(3.9±2.5,2.9±1.3 and 3.8±2.3)mmol/L in favorable,survival and death groups respectively.Although ABL in favorable and survival groups were decreased gradually to normal level during 24～72h,the death group showed that the decline was very slowly it still persistent elevated in 72h.There was significanct difference between the death group and the favorable and survival groups(P＜0.05 or P＜0.01).AKP had significant difference between favorable and death groups(P＜0.05 or P＜0.01) in 24～72h.LDH and CK increased in three groups and there was significantly difference between the death group and the favorable and/or survival group(P＜0.05 or P＜0.01).The relationship of ABL to AKP in 48～72h,ABL to LDH in 24～48h was positive correlation,and ABL to CK in 24～72h was negative correlation.Conclusions We conclude that the significance of ABL for prognosis in critical illness dependent on the rapid of ABL' elimination.The ABL is slowly eliminated,or increased continually,and the LDH,AKP,CK the more are release,the more worse the patients' condition and prognosis.So it is that more multiple organ disorder syndrome(MODS) or multiple organ failure(MOF) occurred easily in the death group.The high ABL level with the high tissue release enzymes has better clinic value to judge the degree and prognosis of critical illness.

观察五联疗法治疗急性坏死性胰腺炎 (ANP)并发多器官功能衰竭(MOF)的疗效.全部病例(APACHE Ⅱ评分13～33分)术后入住ICU,采用:①早期机械通气支持治疗; ②全胃肠外营养支持治疗;③大黄鼻饲或/和灌肠;④持续大剂量腹腔灌洗;⑤早期应用强效、广谱抗生素.17例患者中,治愈或好转14例,死亡3例, 病死率17.6%.其中2个器官衰竭者6例,无死亡;3个器官衰竭者4例,死亡1例,病死率25.0%;4个以上器官衰竭者 7例,死亡2例,病死率28.6%.提示,在积极治疗原发病的基础上, 五联疗法能显著降低ANP合并MOF的病死率.

列举3例符合顽固性癫痫持续状态特点的病例(2 例死亡,1例治愈),结合文献资料分析和探讨其临床诱发因素及抢救治疗措施.结果,导致持续癫痫发作并进入顽固状态的诱发因素可以是原发病的进展,但对早期发作以及发作程度的认识不足或控制措施的不得当更为重要 .硫喷妥钠和急性期其多途径的加强治疗抢救有效.提示提高癫痫及其持续状态的早期诊断意识,尽早扼制其发作并避免顽固性状态的发生是抢救成功的关键,常规抗癫痫药物治疗无效时,持续静脉泵入硫喷妥钠和加强发作期的综合治疗与护理,可有效地提高救治率.

全身炎性反应综合征(Systemic lnflammatory Response Syndrome,SIRS)是继发于各种严重打击后全身高代谢状态,高动力循环状态及过度的炎症性反应.它在多脏器功能不全(Multiple Organ Dysfunction,MODS)的发生和发展中起重要的作用,对早期诊断MODS、逆转病情、减少MODS病死率有很大的意义.为了解综合ICU中SIRS的发生率、病死率及与MODS的关系,我们对我院综合ICU 1994年4月～1998年5月间收住的491例患者进行回顾分析.

院内下呼吸道感染是最常见的院内感染,ICU病人往往病情危重,均使用大剂量的广谱抗生素,其院内下呼吸道感染发生率和病死率有逐渐上升的趋势,已引起医学界的关注.本文对我院ICU病房1994年4月至1998年12月期间的142例危重病人下呼吸道分离的180株细菌进行分类及耐药性分析,旨在更准确指导临床抗生素的合理选择.