目的 通过监测外周血淋巴细胞计数来评估脓毒症患者的免疫状态及其对预后的临床价值.方法 研究对象为2019年01月至2020年06月我院重症医学科(ICU)收治的病程超过7天的脓毒症患者.根据其确诊后第1天及第7天外周血淋巴细胞计数水平,将淋巴细胞计数持续减少(≤1.0×109/L)的患者作为观察组,其余作为对照组.同时记录患者的急性生理和慢性健康评分Ⅱ(APACHEⅡ)、第1天及第7天序贯器官衰竭评分(SOFA)、是否继发感染及28天的转归.结果 研究期间共纳入65例脓毒症患者,其中对照组30例,观察组35例.两组患者在年龄、性别、APACHEⅡ评分、第1天SOFA评分方面均无明显统计学差异(P>0.05).与对照组相比,观察组的第7天SOFA评分升高、继发感染的比例增加、28天的死亡率更高(P<0.05).结论 进入迁延期的脓毒症患者容易发生免疫功能的持续抑制,表现为淋巴细胞水平持续低下,这部分患者器官功能障碍更重、易于继发感染、预后更差.

目的探讨静脉补充丙氨酰-谷酰胺对全胃肠营养支持的脓毒症患者血浆谷胱甘肽浓度及预后的影响。方法选取诊断明确的脓毒症患者40例,分为观察组和对照组,观察组给予静脉使用0.5 g/(kg·d)丙氨酰-谷酰胺,对照组仅给予8.5%复方氨基酸液,分别在用药前,第3、7、10天留取血液标本监测血浆谷胱甘肽、前白蛋白、C反应蛋白浓度,并比较两组预后的差异。结果强化谷氨酰胺治疗后观察组血浆谷胱甘肽的浓度明显升高,在第7、10天明显高于对照组,差异有统计学意义(P<0.05);血浆前白蛋白浓度逐渐升高,C反应蛋白浓度逐步下降,但与对照组比较差异无统计学意义(P>0.05)。观察组多器官功能障碍综合征(MODS)的发生率低于对照组(P<0.05),但总体预后与对照组比较差异无统计学意义(P>0.05)。结论对全胃肠内营养的脓毒症患者强化补充谷氨酰胺可以提高其血浆谷胱甘肽浓度,降低C反应蛋白浓度,降低MODS的发生率,但并未改善白蛋白的合成能力,未能改善预后。

Objective: To observe the clinical curative effect of fish oil fat emulsion in the early application of ARDS.Methods: 58 ARDS patients were randomly divided into two groups-experimental group and control group,each of which had 29 patients.Those in control group were given conventional treatment while those in the experimental group received intravenous infusion of fish oil fat emulsion on the basis of normal treatment.Then the average time of using ventilator and the average hospitalization days in ICU were compared and the serum procalcitonin(PCT) and D-blood lactate were tested.Results: The time of using ventilator in the experimental group reached(7.2±3.8)days,obviously shorter than(10.2±4.2)days of the control group(P<0.05).The average hospitalization time in the experimental group was(10.8±4.1)days,shorter than(13.58±4.4) days of the control group(P<0.05).After treatment,the experimental group's PCT was(6.73±1.20)μg/L,lower than that(9.2±1.49)μg/L before treatment(P<0.05).At the same time,the D-lactic acid level was(5.33±0.93)U/ml after treatment,lower than that(7.18±0.94)U/ml before treatment(P<0.05).Conclusion:The application of fish oil fat emulsion on ARDS's early stage has obvious auxiliary therapeutic effect.

Objective: To explore the effect of early enteral nutrition support on nutritional status and clinical therapeutic effect in mechanical ventilation patients.Methods: 118 mechanical ventilation patients were randomly divided into two groups:early enteral nutrition group(n=59) and late enteral nutrition group(n=59).The levels of serum albumin,prealbumin,transferrin and nitrogen balance were assessed for 7 days since the onset of mechanical ventilation.Mechanical ventilation time,ICU length of stay and hospital length of stay and the incidence of ventilated-associated pneumonia(VAP) were compared between the groups.Results: The serum prealbumin level and nitrogen balance were much higher in early enteral nutrition group than that in late enteral nutrition group on the 7th day(P0.05).Compared with the late enteral nutrition group,mechanical ventilation time,ICU length of stay and hospital length of stay was shorter and incidence of VAP was lower in early enteral nutrition group(P0.05).Conclusion: Early feeding can improve nutrition status and the outcome of mechanical ventilation patients.

Objective To investigate the effect of fluid management strategy in sptic shock patients by intrathoracic blood volume index(ITBVI)、extravascular lung water(EVLW).Methods 36 septic shock patients in Intensive Care Unit(ICU)were enrolled in the study,18 patients who were monitored with PiCCO,and patients who used ITBVI、EVLW as indicator of fluid management were enrolled into PiCCO group;the other patients who received traditional fluid management strategy were enrolled into control group.Results After 72h APACHEⅡscore,vasopressor score,clearance rate of lactic and PaO2/FiO2 in PiCCO group improved more than those in control group.There were no differences in 28-Day mortality,in hospital mortality,hospitalization time in ICU and time of mechanical ventilation between two groups;Compared with the control group the recovery success rate of the frist time of shock was higher in PiCCO group,duration of vasopreeor was shorter in PiCCO group.Conclusion Capacity index monitoring by PiCCO directed fluid management strategy can elevate reversal rate,improve tissue perfusion early and reduce damage of organ.EVLW in fluid management strategy maybe reduce edema of lung and improve oxygenate,but no advantage in improving outcome.

中心静脉导管(Central venous catheter,CVC)在ICU已广泛应用于血流动力学监测、输液、胃肠外营养支持以及血液净化等治疗,但在应用过程中出现的导管相关性感染也越来越多.本文对我院综合ICU近3 a以来确诊的36例中心静脉导管相关性感染病例进行分析,探讨其菌群分布情况及相关影响因素.寻找预防及治疗中心静脉导管相关性感染的依据.

<正> 在急诊抢救急危重症患者时,传统的给氧方法(又称为第一条给氧途径)有3:(1)经鼻导管或面罩吸高浓度氧气;(2)经面罩或人工气道机械通气;(3)高压氧。这些措施在临床应用已久,且疗效确切,各有优劣。近年来,国内临床开展了一种新的输氧技术,即静脉输注高氧液(oxygen-enriched liquidinfusion,简称静脉输氧)的给氧方法。本研究旨在验证静脉输注高氧液在急诊急救时的有效性和安全性。

Objective To investigate the curative effect of oxygen-enriched liquid by infusion of on patients with severe brain trau- ma.Methods One hundred and eight patients with severe brain trauma were randomly divided into two groups:the experimental group trea- ted by oxygen-enriched liquid plus rontine treatment(n=54) and the control group treated only by routine treatment (n=54).The same measures such as srugical operation,hemostasis and transfusion were used in two groups.5% GS 10～20 ml/kg was applied in the control group and oxygen-enriched liquid 10～20 ml/kg injected in the experimental group.The physical signs of life,intracranial pressure or cere- brospinal fluid pressure,blood-gas markers and the severity of cerebral edema were also observed,and consciousness rate(GCS) recorded 7 days after admission and GOS recorded three months later and comparison performed.Results PaO_2 and SaO_2 improved significantly quicker after treating by oxygen-enriched liquid in experimental group than those in control group (P0.01).The physical signs of life were much smooth in experimental group than those in control group.In 7 days after operation,the ICP was lower in experimental group than that in com- trol group(P0.01).On seventh day the incidence rate of severe cerebral edema reduced significantly(P0.01).The duration from co- ma to GCS affer first week and GOS after 3 month in experiment group were higher than those in control group respectively(P0.05～ 0.01).Conclusion Oxygen-enriched liquid by infusion may he an effective measure in patients with severe brain trauma.

目的:探讨静脉输氧对全麻术后患者低氧血症的预防作用.方法:将高浓度氧气溶解在常规输液用液体内制备成为高氧液,通过静脉输液的方式进行输氧.把 96例全麻术后需呼吸机支持并入住 ICU监护的患者随机分为两组:对照组(48例),有创-无创序贯脱机拔管后只予普通输液治疗;预防组(48例),有创-无创序贯脱机拔管后予静脉输氧.监测两组患者脱机拔管前和拔管后输液 15、 30、 45、 60 min的血气指标变化.结果:对照组在常规输液后不同时间,动脉氧分压(PaO2)和氧饱和度(SaO2)均较输注前降低(P< 0.05);而预防组静脉输氧后, PaO2和 SaO2逐步增加,至 60 min时与输注前相比差异亦有显著性(P< 0.05).预防组静脉输氧后, PaO2始终高于对照组(P< 0.05), SaO2在输液后 45、 60 min亦高于对照组(P< 0.05).结论:静脉输氧对全麻术后患者低氧血症有较好的预防作用.

目的:比较新型肠内营养剂(瑞代)与普通肠内营养剂对脑外伤病人血糖水平的影响.方法:60例伤后6h首诊的、格拉斯哥昏迷评分(GCS)≤8分,且未进行手术的脑外伤病人,随机分为研究组和对照组,每组30例.两组病人均于伤后48 h内给予全肠外营养支持(TPN),伤后1周均给予肠内营养(EN).对照组采用瑞素,研究组为瑞代,均经鼻胃管滴入.结果:瑞代对脑外伤病人血糖水平的影响显著小于对照组(P＜0.05).结论:脑外伤病人肠内营养时,瑞代对血糖水平的影响较小.

目的 探讨危重病患者医院内深部真菌感染的易感因素与防治对策.方法 回顾性分析重症监护病房(ICU)内60例深部真菌感染的危重病患者的临床资料.结果 深部真菌感染除了与患者的年龄和原发病有关外,还与长期住院、广谱抗生素和糖皮质激素的使用、大型手术以及各种侵入性操作和全肠外营养的广泛开展等有密切关系.结论 合理使用抗生素和糖皮质激素,减少不必要的侵入性操作,加强全身营养支持,改善肠道微生态平衡,密切检测,及早治疗,可以改善深部真菌感染的危重病患者的预后.

目的:探讨静脉输注高氧液对心跳呼吸骤停患者心肺复苏(cardiopulmonary resuscitation,CPR)过程中的作用,评价其对心肺复苏成功率的影响.方法:选择心跳呼吸骤停患者30例,随机分为治疗组和对照组,每组15例.每组其它抢救措施均相同,对照组输入复方乳酸钠溶液10～20 mL/kg,治疗组输入等量的高氧液.观察记录复苏过程中患者血气指标的动态变化、心跳和呼吸恢复正常率及心肺复苏成功率.结果:治疗组心跳恢复和呼吸恢复正常率较对照组增高(P＜0.05),血气恢复正常时间较对照组提早(P＜0.05),心肺复苏成功率较对照组提高(P＜0.05).结论:静脉输注高氧液是心跳呼吸骤停患者心肺复苏时有效的治疗方法之一.

目的:探讨静脉输注高氧液对感染性休克的治疗价值.方法:选择感染性休克患者66例,随机分为治疗组和对照组,每组33例.每组在抢救中除了采用抗感染、输液等相同措施外,对照组输入复方乳酸钠溶液10～20mL/kg;治疗组输入等量的高氧液.观察记录治疗前后患者的血气指标、多脏器功能障碍综合征(MODS)的发生率及死亡率.结果:治疗组血气恢复正常所需时间较对照组少(P＜0.01),治疗组MODS的发生率和死亡率均较对照组明显降低(P＜0.01).结论:静脉输注高氧液是治疗感染性休克的有效方法之一.

OBJECTIVE To investigate the change of respiratory and circulatory function of patients with COPD during sequential invasive noninvasive mechanial ventilation. METHOD 13 COPD patients with respiratory failure were ventilated by endotracheal intubation. When the case was in accord with the condition of extubation, they were extubated and received mask ventilation. The parameters of blood gas and hemodynamics were measured during endotracheal ventilation and mask ventilation (3 hrs after extubation)respectively. RESULT The changes of respiratory and circulatory parameters were of no signifcant difference between invasive mechanial ventilation and noinvasive mechanical vetilation (P0.05). CONCLUSION The respiratory and circulatory function of COPD patients remained stable during sequential invasive-noninvasive mechanical ventilation.

对13例酒醉后引起脑外伤合并内脏损伤的麻醉处理进行分析总结.结果提示:麻醉前置胃管,给予抗酸药,以减少误吸,麻醉诱导和维持采用浅全麻,正确处理好降低颅内压与扩容之间的矛盾,维持呼吸循环平稳,可使病人顺利渡过手术期.