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新生儿危重病例评分在新生儿转运中的临床分析
随着新生儿急救(neonatal intensive care unit,NICU)技术水平的日趋成熟,我院至2003年9月开展危重新生儿转运工作以来,极大地提高危重新生儿的抢救成功率.降低围生新生儿死亡率.并且与市内多家基层医院产科建立转运网络关系,一年多来已转运危重新生儿116例,现总结分析如下.
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小儿呼吸急救医学的实践与发展
自20世纪80年代初起,国内主要的儿童医院相继建立了具有正规呼吸支持的重症监护病房(pediatric intensive care unit,PICU),此后的儿童呼吸衰竭治疗逐渐放弃了单用呼吸兴奋剂刺激呼吸的方法,进入了机械通气支持时代.在PICU的起始阶段,多数综合医院将儿科呼吸危重症收入成人ICU接受呼吸支持;在专科儿童医院,常将呼吸危重症收入综合性(多学科)ICU(multi-disciplines intensive care unit,MICU).
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防止新生儿监护室交叉感染的措施
随着医学的发展,新生儿重症监护室(neonatal intensive care unit NICU)已成为危重新生儿密集,病情复杂、危象丛生的场所.如何预防重症监护室内新生儿的交叉感染将直接关系到危重症患儿的抢救成功率.
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应用危机管理理论防控新生儿重症监护室护理纠纷的探讨
新生儿重症监护室(Neonatal Intensive Care Unit,NICU)具有无家属陪护、工作强度大、高风险等特点,护理工作稍有不慎极易造成护理纠纷。一旦发生护理纠纷会给患儿、家属及护理人员都带来不同程度的伤害,对医院将会产生负面影响,因此加强护理纠纷的防范至关重要。护理管理者加强危机意识,积极采取相应危机管理对策,消除有可能促使护理纠纷发生的不利因素,从而提高护理质量,减少护理纠纷。现浅析新生儿重症监护室护理纠纷发生的原因,并基于危机管理理论提出防范对策。
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成人EB病毒感染相关性噬血综合征一例报告
1 病例资料患者,女,26岁,主诉"发热、皮疹、关节痛3个月"于2007年8月8日入我院急诊重症监护室(emergency intensive care unit,EICU).患者2007年5月5日始咽部疼痛,在家中自服阿莫西林,5月8日双下肢出现皮疹,不高于皮肤,红色有痒感,伴双手关节痛,皮疹逐渐扩散至全身,5月12日出现发热,体温(Temperature,T)38℃,就诊于天津市某医院,查血常规白细胞计数(white blood cell,WBC)11.3×109/L,中性粒细胞百分比(Neutrocyte,NE%)86.6%,予以地塞米松及抗炎药物(具体不详)治疗一周.患者体温仍高达40℃,并伴有寒战.
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重症监护中的连续性肾脏替代治疗
连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)是近年来发展迅速的一种治疗技术,初用于急性肾衰竭的肾脏替代治疗,与间断血液透析治疗相比,CRRT具有显著的代表性:①对血流动力学影响小,故重症患者伴血流动力学不稳定不能接受血液透析治疗者,可成功的接受CRRT;②膜的生物相容性好,膜的孔径大,对中分子物质清除有效;③膜具有吸附作用:④可同时使用高流量置换液和透析液,以对流和弥散两种方式清除溶质.为此CRRT除可替代肾脏功能,清除过多的水、尿毒症毒素,纠正水、电解质及酸碱平衡外,还可清除中分子物质,清除细胞因子和炎症介质.使用范围已扩展到败血症、挤压综合征、肝功能衰竭、成人呼吸窘迫综合征等.
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脓毒症并发急性呼吸窘迫综合征在急诊ICU的急救和护理
急性呼吸窘迫综合征(acute respiratory distresssyndrome , ARDS)为临床常见的危重症之一。脓毒症合并ARDS的患者预后差,病死率极高,我国多中心研究报告显示,各ICU脓毒症并发ARDS病死率高达50%~90%[1-2]。急诊重症监护室(emergency intensive care unit,EICU)是急诊危重病抢救的核心单位,收治患者多具有起病急、进展快、病种繁多、病情多样化等特点。目前,脓毒症合并ARDS临床治疗预后普遍较差。如何在医生早期诊断、早期干预的同时,通过综合护理改善脓毒症合并ARDS患者的临床预后,是护理工作的重要目标。我院EICU自2003年1月至2011年9月共收治107例脓毒症并发ARDS患者,经医护人员积极治疗及精心护理后,痊愈出院26例,治愈率为24.30%。81例患者因多器官功能衰竭,抢救无效死亡或自动出院,病死率为75.70%。现回顾总结临床护理经验,报道如下。
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品管圈在儿科重症监护病房新进护士护理质量与安全管理的应用分析
品管圈为品质质量持续改进小组,由日本石川馨博士在1962年所创,是指同一工作现场的人员自愿组成团队,针对目前工作中存在问题,运用品质管理方法及相关管理手段,全员参加持续质量改进的方式不断进行维护和改善自己工作现场的活动,从而实现管理目标[1]。近年来,由于昆明医科大学附属儿童医院的扩建,ICU短期内新进护士增加20名,加之儿科重症监护病房(pediatric intensive care unit,PICU)自身存在高风险、高难度、高技术的工作要求,而新进护士专业知识及技能不足,出错的概率高,护理安全得不到有效保障,问题突出,且采取一些干预措施后收效甚微[2]。因此本研究应用品管圈活动来解决对PICU新进护士护理质量安全管理中的难题和热点,现报告如下。
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超声心动图检查在新生儿重症监护中的应用
新生儿重症监护病房(neonatal intensive care unit,NICU)收治的多为危、急、重症患儿,先天性心脏病(congenital heart disease,CHD)患儿比例较高,且病情变化快,不宜转出病区,因此,超声心动图检查技术作为一种有效的床旁检查方式日益受到临床重视[1]。本研究旨在通过总结分析床旁心脏超声的检查结果及部分相关因素,探讨其在NICU病情监测中的应用价值。
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重视心脏多普勒超声在重症医学领域中的应用
早在综合ICU,心脏多普勒超声检查大多由心脏专科医生来进行,主要目的是帮助诊断心血管疾病.对血流动力学的无创评估仅仅是应用二维联合多普勒技术来测量每搏输出量和每分心输出量.直至20世纪80年代中期,ICU医生首先推荐在感染性休克和急性呼吸窘迫综合征(ARDS)患者应用心脏超声,替代右心漂浮导管进行血流动力学评估,并率先由ICU医生进行心脏超声检查,尤其是可以24 h随时进行和重复检查与评估,并指导治疗.
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重症右心功能管理专家共识
To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE(Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle . (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion(TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. ( 25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.
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重症监护病房中急性肾衰竭的早期诊断与防治
急性肾衰竭(ARF)是严重威胁危重病患者生命的常见疾病.流行病学调查显示,ICU中ARF的患病率高达31%,甚至有报道达到78%.心脏术后的肾功能障碍是影响患者生存的独立因素,其OR值是无肾功能障碍的7.9倍.对需要肾脏替代治疗的危重患者的研究亦显示,在疾病严重程度类似的情况下,伴有ARF患者的死亡风险高4倍(62.8%比15.8%).ARF成为影响和决定ICU危重患者预后的关键性因素.加强ICU中ARF的早期诊断、积极防治、逆转ARF的发生发展,对改善危重患者的预后,实属当务之急.
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"胎儿腹裂合并其他畸形:临床的重要性"点评
1原文Objective To report the prevalence of the association between gastroschisis and other anomalies,their prenatai characteristics and the postnatal follow-up.Methods Prenatal and postnatal data from all patients with gastroschis prenatally diagnosed between January 1998 and December 2006 were reviewed concerning the presence of associated anomalies.RtsultsGastroschisis was prenatally diagnosed in 108 fetuses.Associated anomalies were identified in 14 cases (prevalence of 13.O%),with prenatal diagnosis being made in 5(35.7%)patients.Postnatal examination revealed the association of other anomalies in nine other newborns not observed during prenatal examinations.Maternal age,parity,gestational age at diagnosis and birth,delivery mode and birth weight were similar in cases with‘isolated gastroschisis'and associated anomalies(p>0.05).Survival rates in the‘isolated gastroschisis group'and‘associated anomaly group'were 91.5 and 78.6%(P>0.05),respectively.The median time before oral feeding tended to be longer(but not statistical significantly)in the‘associated anomaly group'(32,range:5-720 days)compared to the ‘isolated gastroschisis group'(22,range:5-180 days;p=0.06),but with a significantly longer permanence in neonatal intensive care unit(p=0.04).Conclusion This study highlights the importance of identifyirig other anomalies when evaluating fetuses with gastroschisis to permit counselling concerning the postnatal outcomes.
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妊娠合并急性胰腺炎的研究进展
妊娠合并急性胰腺炎( acute pancreatitis in pregnancy, APIP)是妊娠期少见的外科急腹症之一。 APIP的发病具有地区性和种族差异性,西方国家发病率1/1000~1/12000,东亚发病率为2/1000~42/1000[1],该病可发生在妊娠的任何一个时期,以妊娠晚期居多,早孕、中孕和晚孕期发病率分别为19%、26%和53%,而产后仅为2%[2]。过去20年,孕产妇和围产儿的死亡率分别为37%和11%~37%,随着早期诊断、产科重症监护病房( intensive care unit, ICU)及新生儿重症监护病房( neonatal intensive care unit, NICU)的发展,使得母儿死亡率分别降至<1%和0~18%[1]。现就妊娠合并急性胰腺炎的诊治进展综述如下。
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板层状鱼鳞病1例
患儿 女性,10 min.因“气促、口吐泡沫10 min”于2012-01-27入本院新生儿重症监护病房(neonatal intensive care unit,NICU).病史采集:生后出现气促、口吐泡沫.G2P2,孕龄为34+1孕周时,胎膜早破36 h后因“疤痕子宫”剖宫产娩出,出生体重为3.39 kg,Apgar评分1 min-5 min为7分-8分,羊水呈乳白色,脐带及胎盘未见异常.家族史无特殊.入院查体:反应欠佳,哭声小,呼吸促,全身被覆羊皮纸样无弹性薄膜,部分皮肤皲裂,露出浅红色皮下组织,眼睑外翻(图1),前囟平软,心、肺、腹查体(-),四肢肌张力偏低,原始反射未引出.
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重症胎粪吸入综合征的临床治疗分析
l intensive care unit, NICU)2002年1月至2006年6月收治的95例重症MAS患儿临床资料分析、报道如下.
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肺表面活性物质联合鼻塞式持续气管正压通气治疗新生儿呼吸窘迫综合征
早产儿易发呼吸窘迫综合征(respiratory distress syndrome of newborn,RDS),常因肺表面活性物质(pulmonary surfactant,PS)缺乏伴结构、功能不成熟所致.RDS临床表现为新生儿早期出现呻吟、呼吸困难、发绀、三凹征及呼吸增快等.若不及时治疗,可因进行性低氧血症及呼吸衰竭而死亡.PS替代疗法是治疗RDS安全、有效的方法[1].本院2005年3月至2009年5月在新生儿加强监护病房(neonatal intensive care unit,NICU)采用猪肺磷脂注射液(固尔苏,curosurf)为PS联合鼻塞式持续气管正压通气(nasal continuous positive airway pressure,NCPAP)治疗RDS取得良好疗效,可明显减少有创机械通气(mechanical ventilation,MV)的使用,现将研究结果报道如下.
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新生儿行为神经测定与听力筛查结果分析
听力障碍是新生儿常见的出生缺陷.正常足月新生儿中,重至极重度听力障碍发病率约为0.1%,若将轻、中度听力障碍包括在内,则听力障碍发生率可达1.3%,新生儿重症监护室(neonatal intensive care unit, NICU)中高危儿听力障碍发病率则高达2.0%.1999年中华人民共和国卫生部、残联等10部委联合下达通知,首次把新生儿听力筛查纳入妇幼保健常规项目[1,2].
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新生儿重症监护病房呼吸机治疗导致呼吸相关性肺炎的护理干预
随着新生儿学科的日益发展,机械通气(mechanical ventilation,MV)技术成为救治危重新生儿常用的抢救和治疗技术,这在很大程度上提高了危重新生儿的抢救成功率与成活率.由于MV在临床的广泛使用,呼吸机相关肺炎(ventilator associated pneumonia,VAP)的发生率也随之升高.如何降低VAP的发生率和死亡率是目前临床关注焦点.本研究对2008年1月1日至2011年12月31日本院新生儿重症监护病房(neonatal intensive care unit,NICU)收治的554例经口气管插管行MV治疗中70例并发VAP患儿实施护理干预,取得较好疗效.现将研究结果,报道如下.
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双水平无创正压通气在新生儿呼吸衰竭的应用
双水平无创正压通气(duo positive airway pressure,DuoPAP)技术是一种新型无创辅助通气模式,已应用于部分成人慢性呼吸系统疾病的治疗,并取得良好疗效果.目前国内常采用经鼻塞持续气道正压通气(nasal continuous positive airway pressure,NCPAP)治疗新生儿呼吸衰竭,而DuoPAP应用较少.本研究自2011年2月至2012年6月在本院新生儿重症监护病房(neonate intensive care unit,NICU)采用DouPAP治疗多种新生儿疾病引起的呼吸衰竭,取得满意疗效.现将研究结果,报道如下.