胃镜检查现已成为胃癌诊断的金标准.然而胃镜检查时剧烈的胃蠕动会引起 5％～32％的黏膜下隆起或息肉漏诊[1],同时还有贲门黏膜撕裂出血的危险[2].因此,降低普通胃镜检查时患者的不适感,抑制胃蠕动,提高对检查的耐受性和体验感,以及改进普通胃镜检查的质量是目前临床急需解决的一个重要问题[3].L-薄荷醇可抑制胃肠道平滑肌的蠕动[4].在内镜检查期间,直接将L-薄荷醇喷洒到胃肠黏膜上可显著改善胃肠痉挛[5],并提高腺瘤检出率(ADR)[6].一项Meta分析也证实薄荷醇在胃肠道使用的可行性和安全性[7].本研究探讨薄荷糖在普通胃镜检查前准备中的应用价值.

Objective To compare the detection of microorganisms in flexible endoscopes with the new endoscope detection sampler and traditional sampling, so as to strengthen the management and monitoring of disinfection of flexible endoscopes and prevent hospital infection. Methods The traditional endoscopic test sampling culture（control group） and endoscopic test sampler sampling culture（experimental group） were used to sample and test the reprocessed flexible endoscopes in the endoscopic center. The detection rate of microorganisms and the species and quantity of bacteria detected by the two sampling methods were compared. Results The positive rate of microorganisms detected by flexible endoscopy in the experimental group（6.54%） was higher than that in the control group（1.83%）, and the difference was statistically significant（χ~2=10.568, P=0.001）. The species and quantity of microorganisms detected in the experimental group were more than those in the control group, and the difference was statistically significant（P＜0.05）. Conclusions Compared with the traditional sampling method, the new endoscope detection sampler can improve the microbial elution rate, bacterial detection rate, and the species and quantity of bacteria detected in the flexible endoscope.

目的 评价一元低腐蚀性过氧乙酸消毒液对通过建立铜绿假单胞菌生物膜模型的内镜钳子管道的消毒和生物膜去除效果,并观察验证过氧乙酸消毒液消毒的有效性和时效性.方法 生物膜去除效果检测选取奥林帕斯内镜售后服务机构集中回收的临床已使用的内镜钳子管10条搭建生物膜模型后采用过氧乙酸浸泡后抽样.临床观察消毒液有效性和时效性,选取2019年1-12月300条胃镜和300条肠镜作为研究对象,采用过氧乙酸消毒液消毒,统计内镜消毒效果;比较每条内镜连续5d经步骤a、b来采集样本以检测管道表面附着情况.比较连续使用14 d,浸泡212条内镜后消毒效果.结果 内镜钳子管道经过刷洗+过氧乙酸杀灭5 min和15 min,细菌培养无菌生长,生物膜有效去除.胃镜消毒后菌落数平均为(9.362±2.621)CFU低于消毒前菌落数(P<0.001),胃镜消毒合格率为100.00％(300/300).肠镜消毒后菌落数为0 CFU低于消毒前(P<0.001);肠镜消毒合格率为100.00％.连续使用过程中采集天数对菌落数目无明显影响,且采集天数、采集步骤的交互作用对菌落数目无明显影响.连续使用14 d后浓度仍>1000 mg/L,为有效浓度,消毒后内镜抽样合格率为100.00％.结论 过氧乙酸消毒液在软式内镜消毒中具有较好效果,能有效去除生物膜,具有较高安全性.

Objective:To explore the effect and nursing experience of vein-artery extracorporeal membrane oxygenation (V-A-ECMO) combined with continuous renal replacement therapy(CRRT) in the treatment of fulminant myocarditis.Methods:From January 2014 to October 2019, 15 cases of fulminant myocarditis were treated by V-A-ECMO combined with CRRT in the department of critical care medicine of Zhejiang People′s Hospital. During the operation of V-A-ECMO combined with CRRT, heart rate, blood pressure, coagulation function, troponin, creatinine and other indicators were closely monitored, strict liquid management and extracorporeal circulation pipeline management were implemented, and various complications such as arrhythmia, hypotension, bleeding and acral circulation disorder were timely observed and treated.Results:After 48 hours of treatment with V-A-ECMO and CRRT, the troponin value, lactic acid and creatinine of the patients were (21.53 ± 3.19) μg/L, (2.24 ± 0.37) mmol/L, and (58.13 ± 2.41) μmol/L, which were significantly lower than the start of the machine (79.65 ± 6.08) μg/L, (7.65 ± 1.28) mmol/L, (185.24 ± 5.63) μmol/L, the difference were statistically significant ( t values were -32.784, -15.726, -80.386, P<0.01), except for one dead patient, the left ventricular ejection fraction was significantly increased, reaching 45%-55% within 72 hours, and the left ventricular systolic and diastolic function was normal. Among the 13 patients who successfully withdrew the machine, 11 were cured, 3 were discharged automatically and 1 died. The success rate of withdrawing the machine was 86.67% and the cure rate was 73.33%. Conclusions:V-A-ECMO combined with CRRT can effectively improve cardiac renal function, maintain the stability of internal environment and improve the survival rate of patients. High-quality nursing can effectively improve the healing of patients, clinical need to continue to summarize the relevant nursing experience, improve the level of nursing, prevent various complications, improve the success rate of treatment, promote the recovery of patients.

目的 探讨护理目标管理策略预防体外膜肺氧合并发症的应用效果.方法 选择2015年1月—2017年12月收治的46例接受体外膜肺氧合治疗的患者为研究对象,所有患者均实施护理目标管理策略:包含维持体外膜肺氧合管道通畅、运行通畅、出凝血情况、监测呼吸功能、监测血流动力学、感染防控、预防压疮和自身防护等内容,每项内容都有明确的护理目标并且进行量化,制定成表格并严格按照条目进行实施护理并观察体外膜肺氧合治疗期间并发症的发生情况.结果 体外膜肺氧合运行时间最短80～296﹙163.2±21.5﹚h.最终存活24例﹙52％﹚,死亡22例﹙48％﹚.体外膜肺氧合治疗期间无1例出现管路滑脱,2例氧合器出现少量血栓但不影响使用,2例导管相关血流感染,3例消化道出血,经对症治疗后好转,1例并发颅内出血后放弃治疗;仅1例骶尾部轻度压疮,无1例医护人员出现医源性感染.结论 应用护理目标管理策略能够明显减少体外膜肺氧合治疗期间的并发症,提高治疗效果.

目的 观察枸橼酸钠在脓毒症伴高危出血因素患者行连续性肾脏替代治疗中的抗凝效果.方法 选择100例伴有高危出血因素且需要接受连续性肾脏替代治疗的脓毒症患者为研究对象,根据患者意愿分为无肝素组48例和枸橼酸钠组52例.比较两组间滤器凝血情况、管路平均使用寿命、总管路数量、血液净化总费用、连续性肾脏替代治疗期间输血量及连续性肾脏替代治疗前后血肌酐、Na+、K+和pH值差异.结果 枸橼酸钠组滤器凝血情况明显优于无肝素组(Z=22.671),每副管路平均使用寿命长于无肝素组(t=-8.395),总管路数量(t=10.641)和血液净化总费用(t=60.019)明显低于无肝素组,差异均有统计学意义(均P<0.05).连续性肾脏替代治疗期间枸橼酸钠组输注血浆量明显少于无肝素组(t=22.944,P<0.05),而两组间输注红细胞和血小板差异无统计学意义(t值分别为1.541和1.771,均P>0.05).连续性肾脏替代治疗前后两组间血肌酐、Na+、K+和pH值差异无统计学意义(均P>0.05),治疗后两组血肌酐、Na+和K+均明显降低,pH值明显改善,与治疗前相比均明显下降,差异均有统计学意义(均P<0.05).结论 脓毒症伴高危出血因素患者行连续性肾脏替代治疗中使用枸橼酸钠抗凝效果显著,明显减少输血量和血液净化费用.

目的:探讨护理目标管理策略预防静-静脉体外膜肺氧合(VV-ECMO)并发症的效果.方法:对32例重症肺炎行VV-ECMO治疗患者实施护理目标管理策略,分析VV-ECMO治疗期间的并发症情况.结果:本组患者ECMO运行时间86～296(169.5±22.8)h;其中5例出现急性肾损伤联合CRRT;ECMO治疗期间无1例出现管路滑脱,2例氧合器出现少量血栓但不影响使用,2例出现导管相关血流感染,3例并发消化道出血,经对症治疗后好转,1例并发颅内出血后放弃治疗,1例骶尾部出现轻度压疮,无医源性感染.最终存活14例(43.8％),死亡18例(56.2％).结论:护理目标管理策略能够减少重症肺炎行VV-ECMO治疗患者的并发症,提高治疗效果.

Objective To discuss the anticoagulation effects and safety of sodium citrate in continuous renal replacement therapy (CRRT).Methods A total of 140 cases who underwent CRRT in the intensive care unit (ICU) of Zhejiang Provincial People′s Hospital from January 2014 to December 2016 were selected as research objects and divided into the heparin sodium group (n=56),the low molecular weight heparin calcium group (n=48) and the sodium citrate group (n=36) according to the anticoagulation methods. The differences of anticoagulation effects,the average service life of the pipelines,the overall pipeline quantity,the total cost of blood purification,the blood transfusion amount during CRRT,total bilirubin (Tbil),serum creatinine (Cer), Na+,K+,prothrombin time (PT),activated partial prothrombin time (APTT),platelet count (PLT) before and after CRRT and the complications related to CRRT among the three groups were compared.Results The anticoagulation effect of the sodium citrate group was obviously better than that of the other two groups (χ2=18.809,P<0.05). The average service life of the pipelines of the sodium citrate group was (29.3±5.4) h, which was obviously higher than that of the heparin sodium group (16.5±3.5) h and the low molecular weight heparin calcium group (24.8±4.1) h,and the intergroup difference was statistically significant (F=6.596, P<0.05). The transfusion amount of red blood cells,plasma and platelets of the sodium citrate group was (12.3±2.8) U,(1875.5±198.6) ml and (23.5±8.6) U,which was obviously lower than that of the heparin sodium group [(16.5±5.6) U,(2463.4±265.4) ml and (58.3±18.5) U] and the low molecular weight heparin calcium group [(13.4±3.2) U,(1954.4±214.5) ml and (32.6±11.5) U],and the intergroup differences were all statistically significant (F=4.563,3.896,7.456;P<0.05). The Tbil,Cer,Na+ and K+ of all groups decreased after CRRT,and the differences were all statistically significant (P<0.05). There were statistical significance in PT,APTT and PLT among the three groups (F=4.562,4.153,5.468;P<0.05). The PLT of the sodium citrate group increased significantly after CRRT,with statistical difference (P<0.05). The incidence rate of hemorrhages in skin,digestive tract,puncture point and trachea of the sodium citrate group was respectively 2.8％,5.6％,2.8％ and 5.6％,which was obviously lower than that of the heparin sodium group (23.2％,12.5％, 16.1％,12.5％) and the low molecular weight heparin calcium group (6.3％,10.4％,8.3％,8.3％),and the differences were all statistically significant (χ2=6.678,7.553,6.849,7.534;P<0.05). The incidence rate of heparin induced thrombocytopenia (HIT) of the heparin sodium group was 8.9％ (5/56).Conclusions The anticoagulation effect of sodium citrate in CRRT is remarkable with less complications. It can significantly reduce the amount of blood transfusion and the cost of blood purification and is worth of promotion in clinical application.

目的 探究人工气道行机械通气患者同时采取持续气囊压力监测与持续声门下吸引的措施对VAP的预防效果.方法 随机选取我院2014年11月至2015年11月收治的建立人工气道行机械通气的病人120例,将此120例患者随机分成两组,实验组60例采用一次性压力传感器持续监测气囊压力结合持续声门下吸引;对照组60例则采用气囊压力测定表间隙测定气囊压力和间隙声门下吸引.比较两组患者声门下分泌物的量、及隐血情况以及VAP发生率.结果 建立人工气道后患者的声门下分泌物引流液量实验组高于对照组(P<0.05);实验组患者隐血试验阳性率低于对照组患者,具有统计学意义(P<0.05);实验组的机械通气时间、ICU住院时间、VAP发生率均低于对照组,差异具有统计学意义(P<0.05);两组病死率相比,数据差异无统计学意义(P>0.05);对已发生VAP患者进行痰培养后,发现其病原菌多为鲍曼不动杆菌、铜绿假单孢菌和MRSA.结论 采用一次性压力传感器持续监测气囊压力结合持续声门下吸引可以降低机械通气患者VAP的发生率,减少机械通气时间以及ICU住院时间,值得临床推广.

目的：研究微信结合微信公众平台在ICU家属宣教中的应用效果。方法将98例ICU患者家属分为对照组与观察组，每组各49例；对照组常规予探视时口头与书面常规健康教育；观察组在对照组基础上结合微信健康教育，5天后发放满意度调查表，进行洗手依从性的统计，规范洗手考核。结果观察组主动洗手依从性、洗手规范性、满意度明显高于对照组（ P＜0．05）。结论微信健康教育有助于提高宣传效果，增进医患间有效沟通，提高满意度。

目的:探讨加强型气管切开导管在重症肥胖患者中的应用方法。方法:将11例肥胖的脱管患者改用加强型气管切开导管,观察其使用效果。结果:本组11例肥胖患者使用加强型气管切开导管后未发生一例脱管。结论:重症肥胖型患者更适宜用加强型气管切开导管。

胸腔积液、腹水是临床常见的症状,需置管进行引流.传统方法是单腔中心静脉导管穿刺成功后通过灭菌橡胶管或输血器、输液器连接引流袋.我科2005年改用一次性2ml注射器为连接器,取得满意效果,现报告如下.