重症患者急救插管预氧合的临床研究

目的:观察预氧合在ICU重症患者急救插管中的效果并探讨预氧合的最佳方式。方法:选择ICU内低氧血症成年危重患者28例,按入ICU顺序随机分为3组:A组(对照组,n=10),B组(气囊-面罩预氧合组,n=9)和C组(麻醉机-面罩预氧合组,n=9)。A组入室后即行快速气管插管,B组气囊-面罩预氧合5 min后行气管插管,氧流量为15 L/min。C组麻醉机-面罩预氧合5 min后行气管插管,氧流量为4 L/min。观察指标:持续脉搏血氧饱和度(SpO2),动脉血气分析及相关并发症。结果:三组在预氧合之前,各项基本指标比较无统计学差异。在预氧合后,B、C组的SpO2明显高于A组(P0.05);在插管后即刻,B、C组的SpO2也显著高于A组(P0.05),同时C组SpO2高于B组(P0.05)。血气分析中,预氧合后,C组的PaO2和SaO2均高于A、B组(P0.05);在插管后即刻,C组PaO2和SaO2高于A组,同时C组SaO2高于B组(P0.05)。并发症的比较上,C组的腹胀发生率明显低于B组(P0.05)。结论:ICU内急救插管前的预氧合能显著提高患者的血氧水平,效果明显好于直接气管插管;在预氧合的方式中,麻醉机-面罩的预氧合效果要优于常规使用的气囊-面罩,且并发症也较少。     

急救中光棒法与直接喉镜法气管插管引发心血管反应的比较

目的:比较光棒法与直接喉镜法气管插管对心血管系统的影响,探讨光棒在临床急救领域的适用性。方法:选取我院急诊科室进行抢救的80名患者,随机分为两组,分别采用光棒法和直接喉镜法进行气管插管。记录插管所需时间、一次插管成功次数,以及插管前、插管时、插管后1分钟、插管后3分钟患者的收缩压、舒张压、平均动脉压、心率和血氧饱和度的变化情况。数据分析使用使用检验、t检验秩和检验、重复测量方差分析。结果:两组间性别、年龄、身高、体重、ASA、Mallampati评分差异无统计学意义,具备可比性。光棒组平均插管时间少于喉镜组(光棒:31.23 9.94秒,喉镜:48.15 8.67秒),一次插管成功率(97.5%)也高于喉镜组(80.0%)。经重复测量方差分析结果显示,光棒组各时点的收缩压(F=38.312,P=0.000)、舒张压(F=219.692,P=0.000)、平均动脉压(F=54.739,P=0.000)、心率(F=195.161,P=0.000)的整体趋势要低于与喉镜组。血氧饱和度(F=0.020,P=0.889)在两组间差异无统计学意义。结论:在气管插管过程中,光棒法比直接喉镜法引发的心血管系统变化更小,而且插管所需时间更短、一次成功率更高,是一种值得在急诊科室推广的气管插管技术。     

Prevalence and Factors Associated with Herpes Simplex Virus Type 2 Infection in Patients Attending a Baltimore City Emergency Department

Objectives

Herpes simplex virus type 2 (HSV-2) is a common sexually transmitted disease, but there is limited data on its epidemiology among urban populations. The urban Emergency Department (ED) is a potential venue for surveillance as it predominantly serves an inner city minority population. We evaluate the seroprevalence and factors associated with HSV-2 infection among patients attending the Johns Hopkins Hospital Adult Emergency Department (JHH ED).

Methods

An identity unlinked-serosurvey was conducted between 6/2007 and 9/2007 in the JHH ED; sera were tested by the Focus HerpeSelect ELISA. Prevalence risk ratios (PRR) were used to determine factors associated with HSV-2 infection.

Results

Of 3,408 serum samples, 1,853 (54.4%) were seropositive for HSV-2. Females (adjPRR  = 1.47, 95% CI 1.38–1.56), non-Hispanic blacks (adjPRR  = 2.03, 95% CI 1.82–2.27), single (adjPRR  = 1.15, 95% CI 1.07–1.25), divorced (adjPRR  = 1.28, 95% CI 1.15–1.41), and unemployed patients (adjPRR  = 1.13, 95% CI 1.05–1.21) had significantly higher rates of HSV-2 infection. Though certain zip codes had significantly higher seroprevalence of HSV-2, this effect was completely attenuated when controlling for age and gender.

Conclusions

Seroprevalence of HSV-2 in the JHH ED was higher than U.S. national estimates; however, factors associated with HSV-2 infection were similar. The high seroprevalence of HSV-2 in this urban ED highlights the need for targeted testing and treatment. Cross-sectional serosurveys in the urban ED may help to examine the epidemiology of HSV-2.     

影响心脏骤停患者心肺复苏成功率的因素分析

目的:分析我院心脏骤停患者心肺复苏的成功率,并探讨其影响因素。方法:选取198名行心肺复苏的心脏骤停患者为研究对象,实施心肺复苏,并记录患者一般情况、复苏开始时间和地点、复苏过程和复苏结局等多项指标,统计分析复苏效果。结果:1198名患者,72例取得最终复苏成功,心肺复苏成功率为36.4%;2不同年龄(=15.380,P0.001)、基础性疾病(x~2=11.465,P=0.043)、复苏开始时间(x~2=57.968,P0.001)、地点(x~2=61.384,P0.001)患者心肺复苏成功率差异有统计学意义,年龄16~60岁、非心血管疾病、心脏骤停5分钟内、院内开始心肺复苏者成功率较高;3复苏成功者和失败者复苏持续时间(t=-5.961,P0.001)和气道建立时间(t=-4.045,P=0.004)的差异具有统计学意义,成功者复苏持续时间要短于失败者,而气道建立时间要早于失败者。结论:快速建立人工气道,不盲目延长心肺复苏时间,提高心脏骤停患者心肺复苏的成功率。     

Factors Associated with Blood Culture Contamination in the Emergency Department: Critical Illness,End-Stage Renal Disease,and Old Age

Background

Blood culture contamination in emergency departments (ED) that experience a high volume of patients has negative impacts on optimal patient care. It is therefore important to identify risk factors associated with blood culture contamination in EDs.

Methodology/Principal Findings

A prospectively observational study in a university-affiliated hospital were conducted between August 2011 and December 2012. Positive monomicrobial and negative blood cultures drawn from adult patients in the ED were analyzed to evaluate the possible risk factors for contamination. A total of 1,148 positive monomicrobial cases, 391 contamination cases, and 13,689 cases of negative blood culture were identified. Compared to patients with negative blood cultures, patients in triage levels 1 and 2 (Incidence Rate Ratio, IRR = 2.24), patients with end-stage renal disease (ESRD) (IRR = 2.05), and older patients (IRR: 1.02 per year) were more likely to be associated with ED blood culture contamination.

Conclusions/Significance

Critical patients (triage levels 1 and 2), ESRD patients, and older patients were more commonly associated with blood culture contamination in the ED. Further studies to evaluate whether the characteristics of skin commensals contribute to blood culture contamination is warranted, especially in hospitals populated with high-risk patients.     

Azurocytes in Wild Field Voles: Factors Associated with Their Occurrence

The occurrence of azurocytes (AZ), a type of leukocyte unique to voles and previously described for three Microtus species, is now reported in Microtus agrestis. The goal of this study was to shed new light on the possible function and significance of these cells and on how they play a role in the natural history of rodent species. Individuals from three vole populations were sampled monthly for 2 years. A hemogram was produced for each individual, and AZ counts estimated. The counts of AZ were much higher in pregnant females, and these levels were higher the higher the past vole density. Males had low prevalences and counts, both for breeding and nonbreeding individuals, but they showed a seasonality that varied with age, body condition, and current and past vole density. Also, the occurrence of AZ in males was more likely after they had had low levels of indicators of condition, suggesting that azurocytes may result from a response to infection. Hence, overall our results suggest that, in females, these cells may be important for reproduction and may have a role in inducing abortion when conditions are not favorable, while in males they might be a response to infection.     

可视喉镜气管插管对心跳骤停抢救患者血流动力学及心肺复苏质量的影响

摘要 目的：探讨可视喉镜气管插管对心跳骤停抢救患者血流动力学及心肺复苏质量的影响。方法：选取联勤保障部队第九四〇医院于2020年4月~2022年5月期间收治的98例心跳骤停抢救患者为研究对象,根据插管方式将患者分为B组（可视喉镜气管插管,n=50）、A组（传统直接喉镜气管插管,n=48）。对比两组插管次数、声门暴露时间、插管时间、气道与牙齿损伤、心肺复苏质量及血流动力学指标变化情况,观察两组不良反应发生情况。结果：B组的插管次数少于A组,声门暴露时间、插管时间短于A组,气道与牙齿损伤比例少于A组（P<0.05）。B组的插管成功率、心肺复苏（CPR）成功率、存活率均高于A组（P<0.05）。B组插管后15 min的收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）及心率（HR）均低于A组同期（P<0.05）。B组的不良反应发生率低于A组（P<0.05）。结论：相比于传统直接喉镜气管插管用于心跳骤停抢救患者,可视喉镜气管插管可维持血流动力学稳定,提高插管成功率和心肺复苏质量,安全性较好。     

Relation of Neurological Findings after Cardiac Arrest to Outcome

Routine neurological examination of patients one hour after cardiac arrest seems to be of value in determining the prognosis for life and likelihood of intellectual impairment.In 48 patients 53 episodes of cardiac arrest were followed by serial neurological examinations. Patients were divided into two groups according to neurological findings one hour after cardiac arrest. Patients in group 1 were unresponsive or at most responded in a reflex fashion to painful stimuli at one hour; these patients died or survived with intellectual damage. Patients in group 2 responded purposefully at one hour and survived without neurological damage. These patients commonly showed transient confusional states and a variety of other non-focal abnormalities, and focal signs were seen occasionally.     

成年大鼠气管插管方法的改良

目的寻找一种较好的成年大鼠气管插管方法;方法对比明视经口气管内插管法与逆行导管引导插管法的成功率及并发症;结果明视经口气管内插管法的成功率为100%,逆行导管引导插管法的成功率为87%。插管后并发症明显低于逆行导管引导插管法。结论明视经口气管内插管法优于逆行导管引导插管法,值得推广应用。     

Emergency Department Non-Urgent Visits and Hospital Readmissions Are Associated with Different Socio-Economic Variables in Italy

Objective

The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits.

Methods

The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use.

Results

Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32–6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65–84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37–52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38–15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3–7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30–0.90).

Conclusions

In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization.     

Evolution of the Acid-Base Status in Cardiac Arrest

In a study of the evolution of acid-base status in 26 patients who had cardiopulmonary arrest in the operating room, it appeared that:The determination of acid-base status within the first hour post-cardiac arrest is useful in differentiating final survivors from non-survivors.Respiratory or combined acidosis carries a poor prognosis not evidenced for metabolic acidosis.Late respiratory complications are more frequent in patients with initial combined acidosis.Treatment should be instituted on the basis of frequent determinations of acidbase status, since accurate diagnosis of degree and type of acidosis cannot be done on clinical grounds only.Recovery of consciousness is influenced by the type and severity of acidosis, less so by duration of arrest; and that high pCO₂ is associated frequently with unconsciousness after recovery of circulatory function.     

气囊面罩联合气管插管通气救治对急诊心肺复苏患者动脉血气指标及预后的影响

摘要 目的：观察气囊面罩联合气管插管通气救治对急诊心肺复苏患者动脉血气指标及预后的影响。方法：选取中国人民解放军联勤保障部队第九四〇医院2020年4月-2022年10月期间收治的急诊心肺复苏患者86例作为研究对象。根据通气方式的不同将患者分为A组（n=41,常规气管插管通气救治）和B组（n=45,气囊面罩联合气管插管通气救治）。对比两组临床指征、急性生理与慢性健康评分（APACHEⅡ）、血气指标[二氧化碳分压（PCO2）、实际碳酸氢根（AB）、氧分压（PO₂）、二氧化碳总量（TCO₂）]、复苏成功率、格拉斯哥昏迷评分（GCS）、6个月存活率。结果：与A组相比,B组的自主呼吸恢复时间、心跳恢复时间、气道开放时间、意识恢复时间更短（P<0.05）。治疗后B组AB、TCO₂、PCO₂低于A组,PO₂高于A组（P<0.05）。治疗后B组APACHEⅡ评分低于A组,GCS高于A组（P<0.05）。B组的复苏成功率、6个月存活率高于A组（P<0.05）。结论：急诊心肺复苏患者使用气囊面罩联合气管插管通气救治,患者的临床指征、动脉血气指标均得到显著改善,且预后良好。     

Physician Presence in an Ambulance Car Is Associated with Increased Survival in Out-of-Hospital Cardiac Arrest: A Prospective Cohort Analysis

The presence of a physician seems to be beneficial for pre-hospital cardiopulmonary resuscitation (CPR) of patients with out-of-hospital cardiac arrest. However, the effectiveness of a physician''s presence during CPR before hospital arrival has not been established. We conducted a prospective, non-randomized, observational study using national data from out-of-hospital cardiac arrests between 2005 and 2010 in Japan. We performed a propensity analysis and examined the association between a physician''s presence during an ambulance car ride and short- and long-term survival from out-of-hospital cardiac arrest. Specifically, a full non-parsimonious logistic regression model was fitted with the physician presence in the ambulance as the dependent variable; the independent variables included all study variables except for endpoint variables plus dummy variables for the 47 prefectures in Japan (i.e., 46 variables). In total, 619,928 out-of-hospital cardiac arrest cases that met the inclusion criteria were analyzed. Among propensity-matched patients, a positive association was observed between a physician''s presence during an ambulance car ride and return of spontaneous circulation (ROSC) before hospital arrival, 1-month survival, and 1-month survival with minimal neurological or physical impairment (ROSC: OR = 1.84, 95% CI 1.63–2.07, p = 0.00 in adjusted for propensity and all covariates); 1-month survival: OR = 1.29, 95% CI 1.04–1.61, p = 0.02 in adjusted for propensity and all covariates); cerebral performance category (1 or 2): OR = 1.54, 95% CI 1.03–2.29, p = 0.04 in adjusted for propensity and all covariates); and overall performance category (1 or 2): OR = 1.50, 95% CI 1.01–2.24, p = 0.05 in adjusted for propensity and all covariates). A prospective observational study using national data from out-of-hospital cardiac arrests shows that a physician''s presence during an ambulance car ride was independently associated with increased short- and long-term survival.     

GlideScope视频喉镜和Macintosh直接喉镜在颈椎损伤患者气管插管中的应用比较

目的:比较GlideScope视频喉镜(加拿大Saturn生物技术有限公司)和普通直接喉镜在颈椎损伤患者气管插管中的难易,及两种工具插管对血液动力学的影响。方法:拟在经口气管插管全身麻醉下行择期手术的患者40例,ASAI级,年龄18～60岁,随机分为G组和M组(n=20)。常规麻醉诱导后,手法制动头颈部,G组采用GlideScope视频喉镜,M组用Macintosh直接喉镜行气管插管。分析比较两组声门暴露情况(Cormark-Lehane分级)以及暴露时间,试插次数,失败例数,有无助手辅助,插管前后心率与收缩压乘积(RPP)变化。结果:与M组比较,G组声门暴露情况较好,但暴露时间显著延长(P<0.05)。M组需要助手辅助及插管失败的比例均高于G组。两组RPP的变化在各个时点无显著差别。结论:在为颈椎损伤患者气管插管中,GlideScope视频喉镜能够更好的显露声门,降低插管难度,提高插管的成功率。     

Electroencephalographic Prediction of Fatal Anoxic Brain Damage after Resuscitation from Cardiac Arrest

Ninety-three electroencephalograms (E.E.G.s) were recorded within a week of cardiac resuscitation from 41 patients in whom the subsequent outcome was known to be either recovery of cerebral function or death with associated pathological evidence of gross anoxic brain damage. A statistical analysis of observations on these E.E.G.s yielded a discriminant function for predicting death or survival. Predictions based on each of the 93 individual E.E.G.s would have been correct in 92 and at a confidence level better than 99%. The same discriminant function was found to be applicable to a further 19 patients who died but did not undergo neuropathological studies and to 33 others in whom the clinical picture was complicated by such factors as uraemia or head injury. Thus it seems that the presence or absence of fatal brain damage after cardiac arrest can be reliably predicted from E.E.G.s taken within a week of resuscitation. An estimate of the probability of survival is now routinely included in the clinical report on each E.E.G. taken after cardiac arrest.     

纳洛酮对心搏骤停患者心肺复苏后氧化应激反应及缺血缺氧性脑病的影响

目的:探讨纳洛酮对心搏骤停患者心肺复苏(CPR)后氧化应激反应及缺血缺氧性脑病的影响。方法:将我院收治的78例骤停时间≤10 min的心搏骤停患者随机分为治疗组和对照组,每组各39例。两组均按照美国心脏学会心肺复苏指南进行标准的心肺复苏,治疗组在此基础上静脉注射纳洛酮2 mg,复苏后用纳洛酮0.4 mg/(kg·d)微量注射泵24h持续泵入。比较两组的CPR成功率、血浆丙二醛(MDA)含量和谷胱甘肽过氧化物酶(GSH-PX)、超氧化物歧化酶(SOD)活性,监测其不同时点脑氧摄取量(CEO2)的变化。结果:与对照组比较,治疗组自主循环恢复成功率、复苏后24 h存活率均显著升高(P<0.05)。自主循环恢复后,治疗组SOD、GSH-PX活性较对照组明显增加(P<0.05);复苏后24 h,两组MDA含量均显著升高,SOD、GSH-PX活性明显减弱,而治疗组各氧化应激指标明显优于对照组(P<0.05)。两组患者在复苏早期CEO2迅速升高,但在复苏后24 h开始下降,48~72 h处于相对稳定的水平,治疗组各时间点CEO2均明显高于对照组(P<0.05)。结论:纳洛酮可减轻心搏骤停患者CPR后体内氧化应激损伤和缺血缺氧性脑病,改善患者的预后。