围术期与 ICU 内急性肾损伤管理指南

1急性肾损伤（AKI）的诊断和分级R1.1推荐使用 KDIGO 标准（stage 1）定义 AKI，包含至少以下标准中的一条：（1）48 h 内 Scr 增加≥26.5μmol／L；（2）7 d 内 Scr 较基线水平增加≥1.5倍；（3）尿量＜0.5 mL／（kg·h）持续6 h。

香港重症监护概况

重症监护(critical care or intensive care)是一个新兴的医疗专科.其主要任务就是处理及护理患有严重生理机能失调或衰竭的危重患者,如:急性呼吸衰竭,感染性休克.重症监护的起源及发展可以追溯到1949～1952年,北欧发生了脊髓灰质炎的暴发流行[1],许多患者发生了急性呼吸衰竭.为了集中资源及有效、方便地护理患者,专家把他们都集中在同一个病房处理.因而出现了重症监护室(intensive care unit,ICU),带动了正压呼吸机及临床监测技术的急速发展.

著名麻醉学家谢荣教授

谢荣教授1921年出生于昆明，1946年毕业于同济大学医学院。1947年在美国Michigan大学学习外科学时，立志专攻麻醉学。1950年回国后，在我国自己创建的北京大学医学院从事麻醉工作。历任北医大临床医学研究所副所长、第一医院学术委员会主任、外科主任、麻醉科和麻醉学研究室主任；1987～1993年为国务院学位委员会学科评议组成员；第七、八届全国政协委员；中华医学会麻醉学会第二、三、四届委员会主任委员；第一、二、三、四届《中华麻醉学杂志》编委会总编，《中华外科杂志》、《北京医科大学学报》、《J．Disaster Medicine》(美国)和《Current Anesthesia and Intensive Care》(英国)的编委；1990年被推选为“英国皇家麻醉学院名誉院士(EFRCA)”。

"2016年脓毒症和感染性休克处理国际指南"解读

美国危重症医学会( Society of Critical Care Medicine , SCCM )和美国胸科医师学会( American College of Chest Physicians , ACCP) 在1991年将脓毒症( sepsis )定义为感染引起的全身炎症反应综合征( systemic inflammatory response syndrome , SIRS) ,即"脓毒症1";2001年SCCM、ACCP、欧洲危重症医学会( European Society of Intensive Care Medicine , ESICM )等对"脓毒症1"进行了修订,即"脓毒症2",其核心仍是感染及其引起SIRS;2014年1月起, SCCM和ESICM的专家探讨并修订了脓毒症的定义与诊断标准(脓毒症3),并于2016年2月正式颁布,其定义和诊断标准较前有重大改变,引起了重症医学界广泛而激烈讨论,至今对其质疑仍未停止.现结合文献,对指南相关条款进行解读.

美国儿科重症监护病房分级指南

儿科重症监护病房(pediatric intensive care umt,PICU)在我国方兴未艾,目前存在的PICU,无论数量,还是质量都远不能满足患儿日益增长的医疗需求.今后若干年,在我国必然会增加许多PICU,但PICU如何构建,其基础设施、设备和人员应如何配置,在我国均无现成的方案可循,亦缺少一个相关的指南性文件.在这方面,先进国家的经验值得我们借鉴.美国危重医学会、美国儿科学会危重症分会于1993年制定并颁布了PICU监护分级指南[1],2004年,又再度对该指南进行了全面更新[2].该指南对PICU的组织管理、基础设施及病房结构、人员配备要求、药品器械、院前管理和继续教育均作了详尽的规定.并对不同级别的PICU作出相应的要求,应该说无论是十年前还是今天的指南,对我国PICU的构建发展都具有重要的借鉴作用.

达肝素与普通肝素对危重症患者静脉血栓栓塞的预防作用比较

静脉血栓栓塞是危重症思看的重妥开发症,危重症患有是静脉血栓栓塞的高危人群.目前尚不肯定在危重症患者中应用低分子肝素比普通肝素具有优势.加拿大危重症试验组和新西兰危重症学会临床试验组进行的危重症患者血栓栓塞预防试验(The PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group,C00k D,Meade M,et al.Dalteparin versus unfraetionated heparin in critically ill patients.N Engl J Med,2011,364:1305-1314.),对达肝素(Dalteparin)和普通肝素的作用进行了比较.

关注重症监护病房获得性肌无力

重症监护病房获得性肌无力(ICU-AW)是危重病常见的后遗症[1],可导致重症监护病房(ICU)患者住院时间延长与病死率增加.危重病导致的肌无力是缓慢的,早期常被临床医师忽略[2-3].导致ICU-AW重要的危险因素有多器官功能衰竭、肌肉制动、高血糖、皮质激素和神经肌肉阻断剂[4].

第六届全国危重病医学学术会议纪要

[据杜斌等报道]由中国病理生理学会危重病医学专业委员会和<中华医学杂志>编辑委员会主办,云南省生理学会危重病医学专业委员会承办的第六届全国危重病医学学术会议于2004年9月22日至26日在云南省昆明市召开.与会代表来自全国各地(包括台湾省和中国香港特别行政区)及美国、荷兰、法国、比利时、瑞典、澳大利亚、新加坡等国家逾500人,包括从事危重病医学工作的医护人员和病理生理学研究的科研人员.中国病理生理学会危重病医学专业委员会还邀请了美国危重病医学会(Society0f Critical Care Medicine)主席Margaret Parker教授及欧洲危重病医学会(European Society of Intensive Care Medicine)主席Graham Ramsay教授分别率团参加.同时,亚太危重病医学联合会主席Patrick Tan教授也出席了会议.严重感染是当今住院患者三大急性杀手之一,死亡率居高不下.2001年Barcelona宣言旨在唤起全球医学界对于严重感染的重视,以期改进治疗,降低死亡率.2004年由美国危重病医学会和欧洲危重病医学会等11个国际学术团体共同制定发表了全身性感染治疗指南(surviving sepsis campaign guideline).本届会议根据Barcelona宣言的精神,重点介绍了全身性感染治疗指南,并从循证医学和临床实践的不同角度展开了讨论.

重症真菌感染的现状和治疗对策

1 重症真菌感染的现状[1,2]1.1 重症真菌感染流行病学资料 20世纪90年代以来,医院内(尤其在ICU内)真菌感染发生率明显上升,其上升速度远远超过其它病原体.美国疾病控制中心报告[1]:真菌感染是院内感染的第6位病原体,念珠菌是ICU中第4位常见感染病因;一些大的教学医院内念珠菌感染的发生率上升了500%,大剂量化疗患者5%～20%并发真菌感染.我国虽无完整资料统计,但城市三级甲等医院的真菌感染报道并非少见,抗真菌已成为ICU内危重病的重要治疗内容.近年来北京市儿童医院PICU白血病、胶原病和其他免疫功能低下患儿的继发性真菌感染呈增加趋势,原发性重症真菌感染(主要为肺炎或ARDS)也时有发现.这种增加趋势与广泛应用广谱抗生素导致耐药株增加;化疗药物在肿瘤、自身免疫疾病和器官移植等病人中应用;各种血管内导管留置有关;旅游与饲养宠物导致人与动、植物接触机会增加也可能是原发性重症真菌感染的原因之一.

电阻抗无创心输出量监测在危重病监护中的应用

心输出量(CO)监测是危重病监护体系中非常重要的内容.目前临床常用SWAN-GANZ导管或多普勒心脏超声进行监测,都能比较准确地提供血流动力学方面的信息.但SWAN-GANZ导管是一项有创监测技术,会给患者带来多种并发症,甚至导致致命的导管败血症;而多普勒心脏超声也难以做到连续实时进行监测.电阻抗无创心输出量监测是一项无创、连续、简便的新型监测技术,不仅避免了有创技术所带来的一系列并发症,而且使监测变得简便、安全.我院ICU应用此项技术对患者进行监测,并与心脏多普勒超声测得数据进行对比,发现两者具有良好的相关性,现报告如下.

新生儿休克86例临床分析

休克是由多种病因引起的以微循环障碍为特征的危重临床综合征,为新生儿常见急症,是继呼吸衰竭之后第2个常见死亡原因,自我科建立新生儿重症监护病房(neonatal intensive care units,NICU)以来,2002年1月～2005年10月,共收治新生儿休克患儿86例,现报告如下:

第6届儿科危重症国际会议纪要——护理与社会心理学分会场

2011年3月13～17日第6届儿科危重症国际会议在澳大利亚悉尼会展中心隆重召开,本次会议由小儿危重医学会国际联盟(World Federation of Pediatric Intensive and Critical Care Society,WFPICCS)、澳大利亚危重症护理大学(Australian college of critical care nurses,ACCCN)和澳大利亚新西兰重症监护联盟(Austral-ian and New Zealand intensive care society,ANZICS)联合主办.来自世界各地儿科危重症专家及医护人员、社会工作者和心理学者等1450人参加了会议,其中护理专家和代表400多人参加了学术交流.开幕式上WFPICCS主席Andrew C Argent教授、大会执行主席悉尼儿童医院的David Schell教授分别致辞,护理专家就危重症医学是艺术还是科学进行了激烈的辩论发言.会议期间护理专家们等针对护理和社会心理领域的新理念、新技术、新进展进行了专题报告及小组讨论,期间穿插了小型护理研究口头报告会及展板科研结果 讨论展示,通过专家讲座、代表论文汇报和同行们发言提问等形式进行交流,来自78个国家的护理和社会心理学工作者们积极沟通和交流,分享工作经验,共享研究成果.大会闭幕式上,向出席本次会议的优秀文摘交流者颁发了获奖证书.

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.

脓毒症导致多器官功能障碍的发病机制

据国外流行病学调查［1］显示，全球每年约3150万例脓毒症患者和1940万例严重脓毒症患者，每年因脓毒症死亡的人数约530万。近年来，尽管脓毒症的治疗已经取得较大进步，但脓毒症患者的死亡率仍保持在25％～30％，脓毒症休克患者的死亡率高达50％［2－4］。所以，急需一种有效的治疗措施来缓解这种压力。前不久JAMA杂志上发布由美国危重病医学会（ Society of Critical Care Medicine ， SCCM）及欧洲危重病医学会（European Society Intensive Care Medicine， ESICM）发起制定的脓毒症新定义［5］，指出脓毒症是针对感染的宿主反应失调引起的致命性器官功能障碍；而脓毒症休克是脓毒症伴有持续性低血压，在充分液体复苏后仍需要升压药或血管活性药物维持平均动脉压≥65 mmHg且血清乳酸水平升高（＞2 mmol／L）。新定义在发布以来受到众多学术组织的反对，毕竟重新定义临床综合征本就不简单，新标准用于临床实践是否改善患者的预后还有待进一步观察。两个或两个以上重要器官同时或序贯发生功能障碍被称为多器官功能障碍综合征（multiple organ dysfunction syndrome， MODS）。目前评估MODS严重程度常用的标准有逻辑器官功能障碍评分（logistic organ dysfunction score， LODS）、序贯器官功能衰竭评分（sequential ［sepsis-related］ organ failure assessment， SOFA）、全身炎症反应综合征（systemic inflammatory response syndrome， SIRS）标准以及快速序贯器官功能衰竭评分（quickSOFA， qSOFA），各种评分旨在快速准确地预测疾病的死亡率，并指导临床治疗。然而，无论是新定义还是诊治新方法都离不开对疾病本身的了解，本文就MODS的病理生理机制展开论述。

Neonatal respiratory failure-An overview

Respiratory disorders in the neonates still remain the reason for postnatal hospitalization.Main reasons for respiratory failure in the term neonate include transient tachypnea(TTN) of the neonate;in preterms,respiratory distress syndrome(RDS) is a dominating cause.The incidence of TTN has increased during the past two decades due to an increased rate of C-sections in western countries,whereas the rate of RDS could be lowered,mainly due to improved perinatal care.Overall prognosis in respiratory failure could be improved due to advanced ventilation techniques,systematic use of surfactant and the establishment of systematic ECMO-support.1 IntroductionIn Western countries,postnatal respiratory failure is the main cause of treatment in intensive care units in preterm and term neonates.Due to the continuously high prevalence of neonatal respiratory distress,research on neonatal respiratory failure is one main stay in neonatology.During the past decades,there was a reduction of respiratory distress syndrome(RDS) regarding age-defined groups of very preterm neonates.On the other hand,there had been an increase in respiratory distress in term neonates due to an increased frequency of C-sections in Western countries and resulting transient tachypnea of the neonate(TTN)[1].

实施安全护理路径对EICU患者外出安全性的效果探讨

急诊重症监护病房（emergency intensive care u-nit，EICU）患者往往病因复杂，病情危重且变化较快，不宜搬动，但临床往往为了明确诊断和治疗效果，需要患者外出进行一些不能在床旁进行但必须要进行的检查。EICU患者外出途中可能存在心跳骤停、死亡、呼吸道梗阻、跌伤、管道脱落的风险及不良事件。如何保大限度的保证EICU患者外出的安全性、降低风险的发生一直备受关注。安全护理路径是医护人员基于EICU患者的实际病情，针对其外出可能会出现的安全事件而制定合理有效的护理计划和措施，本研究对我科住院的100例患者作为研究对象，根据是否实施安全护理路径来分组，观察实施安全护理路径后的患者外出风险发生的情况。

重型颅脑损伤的监护

神经外科的重症监护(neurosurgical intensive care,NIC)已经发展成为神经外科的一个专门领域.重型颅脑外伤作为具有较高病死率和致残率的常见急性颅脑疾患,从一开始就是NIC监护的重点.颅脑外伤临床与实验研究的进步也从多角度促进了NIC的发展.近二十年来,重型颅脑外伤病死率由50%下降至30%～40%,其重要原因就是NIC强化治疗方案的临床实施.