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AIM In order to provide the TCM therapeutic basis for MODS in clinical critical patients, the role of shockdecoction in anti-bacterial translocation from the gut was tested in rats.METHODS Based on the pathophysiology of MODS following bacterial translocation from the gut causedby severe injuries such as burn, shock, hemorrhagic shock model that induced obvious bacterial translocationwas established and used to determine whether shock decoction, that is composed of modified WenpiDecoction, reduces bacterial translocation. Bacterial culture for mesenteric lymph nodes, liver and spleen ofrats in shock, treatment and control groups was used to calculate the incidence of bacterial translocation.RESULTS The incidence of intestinal bacteria translocating to mesenteric lymph nodes, liver and spleenwas lower in the shocked rats infused via gastrogavage with shock decoction (3/ 15) than that in thenoninfused shocked rats (11 / 13), (P = 0.0009, < 0.01 ). The incidence of intestinal bacteria translocationof rats in shock and control groups were distinctly different (P = 0.0017, <0.01). The amounts and speciesof intestinal flora between infused and noninfused shocked rats were not different statistically (P=0.101,P>0.05). Histological examination showed that intestinal mucosa edema was severer in the shocked ratsthan in the shocked rats with gastrogavage.CONCLUSION Shock beverage could inhibit the shock-induced enterogenous bacterial translocation in ratsprobably by its protective role in intestinal mucosa structure; and has no effect on the growth of intestinalbacteria.
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在指南与实践中加深对危重病人侵袭性真菌感染的认识
随着骨髓移植、实体器官移植、肿瘤化疗、大剂量广谱抗菌药物的长期应用,以及糖皮质激素、免疫抑制剂的广泛应用等因素,侵袭性真菌感染(IFI)的患病率和病死率显著上升.
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经颅多普勒超声在危重患儿脑功能监测中的应用
脑功能监测是危重患儿监测的重要内容之一,其目的除了解患儿脑功能状态及受损程度外,对于判断疾病治疗效果和预后也有重要作用.常用监测方法包括Glasgow评分、颅内压、脑电图、脑血流和影像学监测等.经颅多普勒超声(TCD)可以穿透颅骨较薄的区域,直接获取颅底Willis环大动脉的血流动力学参数,反映脑血管的功能状态.
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脑电双频指数在重症患儿镇静监测中的应用
脑电双频指数(BIS)是1997年被美国FDA批准的作为麻醉和镇静深度监测的一项指标.作为脑电信号的分析方法,BIS具有客观、连续的特点,已广泛用于评判麻醉深度和意识状态,也在指导ICU镇静用药、控制镇静深度、避免镇静不足或过量方面起着重要作用.
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儿科危重病治疗中应注意的医源性致病因素
儿科危重病发病急、病情重,为挽救患儿的生命,临床常需要集中诊断和治疗,某些诊治手段本身是有创性的,可导致严重甚至致命性的医源性合并症。这些合并症,或者使原发病治疗更加困难;或者在原发病基础上又添加另一种脏器功能障碍和(或)衰竭。某些医源性合并症是为挽救患儿生命而难以避免的,有些则是因医师的知识水平和经验不足所致。 Stambouly等[1]对PICU中的1 035例患儿进行了调查分析,结果83例患儿发生了115项合并症,平均每百个住院日发生2.7项,重度合并症48项(占42%)、中度45项(39%)、轻度22项(19%)。其中60项(52%)与使用呼吸机相关、14项与使用药物有关、 13项与操作有关、24项为感染性、22项与侵入性器械有关(其中18项与血管导管有关)。 4l例(36%)系人为错误所致,其中21例较为严重。有合并症的患儿死亡13例(15.7%),其中2例合并症为直接原因。由于近年家长自我保护意识加强及个别媒体的误导,无论何种原因均常引起医疗纠纷。作为医师既要救死扶伤确保患儿健康,又要保护医院和医师自己,因此,重视医源性致病因素,从而预防医源性合并症发生具有十分重要的意义。
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关注转化医学加强危重病的临床与基础研究
随着基础学科分工的越来越精细和研究的不断深入,客观上扩大了基础研究与临床实践相互沟通的距离,在二者之间形成了所谓的"死亡之谷".因此,应用多学科交叉推动医学发展的转化医学应运而生,并已成为国际医学界倡导的新型交叉学科.转化医学作为医学发展的前沿领域,对医学的发展将起到重要的引领和支持作用,其研究的结果将直接提示医疗质量.
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危重病急救要注重关联领域的应用研究
从关联度讲,危重病急救是急救医学学科领域相关专业的基础与核心.因此,也是急救医学及其临床应用研究的方向与重点.由于危重病急救涉及面广,关键点多,反映医疗机构,尤其是综合性医院的综合实力和技术水平,因而备受关注.
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危重症患者的人工气道管理
临床上急危重症病人常合并呼吸功能衰竭.建立人工气道及必要时机械通气在其救治过程中起着举足轻重的作用[1].当人工气道建立后,黏膜纤毛清除功能受损、小气道塌陷、肺不张、咳嗽反射受抑制,分泌物储留在支气管中,肺泡表面活性物质减少,可导致痰栓及诱发肺部感染等并发症[2].因此人工气道的管理成为危重症患者救治过程中的一个重要部分.现将危重患者人工气道管理方法综述如下.
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危重病人上报及访视制度临床应用效果研究
护理质量管理中环节控制的重要内容就是危重病人护理管理,危重病人能否救护成功,不仅能综合地反映一个医院的科学管理水平和医疗技术水平,而且可以体现出护理质量的优劣[1].
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危重病性神经肌病危险因素的研究
近年来,随着重症监护病房的发展,危重病患者的治疗和预后得到了很大改善.而随着对危重疾病的深入研究,危急重症后出现的周围神经、肌肉及神经肌肉接头损害逐渐被重症监护病房医生所认识.这些损害包括以感觉、运动神经元轴突变性为主的危重病性多发性神经病(critical illness polyneuropathy, CIP)和以肌肉萎缩、坏死为主的危重病性肌病(ctitical illness myopathy, CIM),由于两者均表现为肌无力与肌肉萎缩,在临床上难于分辨,而被统称为危重病性神经肌病(critical illness neuromyopathy, CINM).
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危重病人的床旁检验乳酸测定
重症患者大多出现呼吸或循环系统障碍而进入ICU病房,传统的生命体征监测是体温,脉搏,呼吸,血压,心输出量等几项指标.随着医疗技术的飞速发展,现在的ICU病房已经按人体各系统配备了多种监护设备以完成对呼吸,循环,血液系统和肝,肾等脏器的监测.
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进一步提高急危重症抢救的存活率
内科急危重症是内科范围内的一个特殊领域。急危重症患者往往处于生与死的边缘,这生与死的跨越很大程度上取决于医师的即刻判断和及时正确的处理。对急危重症患者抢救的存活率是反映一个医师、一个医疗单位、一个医院的医疗水平重要的指标之一。这一指标更是衡量一个国家医疗卫生事业发展水平的重要依据。 如何大限度地提高抢救存活率,是世界各国临床医学家们所共同关注的热点。随着临床医学的迅速发展,急诊抢救的诊疗措施及相关设备的日益专业化,自60年代后期,西方国家已开始建立独立的急诊医学专科和相应的学术机构。通过总结经验、专题研讨以及组织多中心研究制定相应的指南,在提高临床诊疗水平促进学科发展上起着十分重要的作用。我国急诊医学作为一个专业的新兴学科,始建于80年代后期,十几年来已有了较快的发展,但各个城市、各医院之间的发展很不平衡,与国际水平相比尚有较大的差距。在专科的建制、专业人员的培训、相应的抢救设施的配备以及院前急救和社区的支持配合上还远远不够完善,特别是缺乏有代表性的以循证医学为基础的临床研究,以及以此为基础制定的具有我国特色的诊疗指南。
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连续性血液净化治疗儿童危重症合并急性肾功能衰竭
连续性血液净化(CBP)已广泛用于成人多种危重症的抢救治疗,然而由于儿童体重低、血容量少以及置管困难等因素的影响,目前该技术在国内儿科界尚未广泛开展.我院从2004年7月以来应用CBP技术治疗儿童危重症合并急性肾功能衰竭(ARF)11例,取得很好疗效,现报告如下.
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Sepsis and septic shock have continued to produce significant morbidity and mortality, in recent times, in acutely injured patients as well as patients in the intensive care units despite advances in antibiotic therapy and in the cardi ovascular and pulmonary support for these patients. This emphasizes the need to gain a better understanding of the fundamental mechanisms of the pathogenesis of sepsis syndrome in the critically ill or injured patients. The present knowled ge of the mechanisms of septic pathogenesis clearly indicates involvement of mod ulations in the functions of the cells of body's immune defense system, namely, monocytes/macrophages, polymorphonuclear leukocytes, and lymphocytes. Most of su ch knowledge has been derived from laboratory experiments in animal models of se ptic injury, or from studies of immune-system cells, in vitro. Clinical stud ies have also supported the role of immune perturbations. Yet, to date, very few the rapeutic approaches are available to effectively counter the sepsis-related immu ne disturbances. Functional modulations in the immune system cells, in the injured/septic hos ts, can exert not only adaptive/beneficial effects but also profoundly adverse effects on the non-immune-system cells such as endothelial, epithelial, neurona l, endocrine, neuro-endocrine, smooth muscle, skeletal muscle, and cardiac muscl e cells. The primary functional modulation in the immune-system cells after inju ry or with critical illness is activation of such cells via molecules from pat hogens, for example, lipopolysaccharide from gram negative organisms, lipoteic hoic acid/peptidoglycan from gram positive organisms, or zymosan from fungi. Suc h pathogenic molecules activate monocytes and tissue macrophages to result in th e expression and release of cytokine mediators (TNFα, IL-1, IL-6, IL-8, and IL- 10), as well as certain lipid mediators (PGE2, LTB4, PAF). While these media tors could play a host-defense role in support of the host via containment/destr uctio n of the pathogens, they could also exert detrimental effects in the host and co ntribute to host morbidity and mortality. Some of these mediators (TNFα, IL-1, IL-6, IL-8, LTB4, PAF) have been shown to be “pro-inflammatory”,and to potenti al ly exert a harmful effect on non-immune cell systems such as endothelial cells, epithelial cells, and muscle cells. Among the pro-inflammatory mediators, TNFα a nd IL-1 could play major harmful roles, and thus contribute to the injured host morbidity and mortality. Mediators, IL-10 and PGE2 have been shown to be “an ti-inflammatory” and to potentially contribute to a dreadful state of immuno-s uppression in the injured hosts, which can also lead to morbidity and mortality. Whi ch is worse, a harmful pro-inflammatory phase or harmful immuno-suppression ? Or Which occurs first, a harmful pro-inflammatory condition or a harmful immuno-su ppression? These are questions which can not be definitively answered for the g eneral population of critically ill/injured patients. It is reasonable to assum e that the answers to these question would vary from one patient subset to anot her patient subset. Thus, whether to treat the patient with a putative anti-pro- inflammatory agent or with a putative anti-anti-inflammatory agent remai ns unresolved for the general sepsis patient population. Paradoxically, TNFα, IL-1, and other pro-inflammatory mediators under certa in circumstances may serve as natural “blockers” of immuno-suppression or “pr omoters” of immune stimulation. This may be true in the case of some of the se ptic patients. Understandably, these patients should not be treated with anti-pro-inf lammatory agents. On the other hand, the anti-inflammatory mediators such as PGE 2, IL-10, and certain other naturally occurring antagonists of TNFα and IL-10 a ctions (TNFα, and IL-1 receptor antagonists) could not only be producing a cert ai n level of immune-suppression but also serving as important feed back controller of the pro-inflammatory mediators. Thus some of the naturally occurring anti-I nflammatory agents could indeed serve as adaptive/beneficial “anti-pro-inflamma tory”, therapeutic agents in certain subset of sepsis patients. Although there is little doubt that effective therapeutic control of the sep sis syndrome could be achieved via appropriate modulation of the cells of the I mmune system, at the present time we do not have an immune therapeutic regimen w hich can singly be efficacious for the general population of patients with the s eptic complication. This implies that before an effective treatment of sepsis p atients, the patients must be identified, by some diagnostic procedure, as to wh ether they need an anti-pro-inflammatory therapy or an anti-anti-inflammatory th erapy. Thus, although immuno-therapy of sepsis remains promising, its efficacy a waits further investigative work particularly through clinical studies in sepsis patients.