Clinical Characteristics of 28 Patients with Diabetes and COVID-19 in Wuhan,China

Objective: Previous studies on coronavirus disease 2019 (COVID-19) were based on information from the general population. We aimed to further clarify the clinical characteristics of diabetes with COVID-19.Methods: Twenty-eight patients with diabetes and COVID-19 were enrolled from January 29, 2020, to February 10, 2020, with a final follow-up on February 22, 2020. Epidemiologic, demographic, clinical, laboratory, treatment, and outcome data were analyzed.Results: The average age of the 28 patients was 68.6 ± 9.0 years. Most (75%) patients were male. Only 39.3% of the patients had a clear exposure of COVID-19. Fever (92.9%), dry cough (82.1%), and fatigue (64.3%) were the most common symptoms, followed by dyspnea (57.1%), anorexia (57.1%), diarrhea (42.9%), expectoration (25.0%), and nausea (21.4%). Fourteen patients were admitted to the intensive care unit (ICU). The hemoglobin A1c level was similar between ICU and non-ICU patients. ICU patients had a higher respiratory rate, higher levels of random blood glucose, aspartate transaminase, bilirubin, creatine, N-terminal prohormone of brain natriuretic peptide, troponin I, D-dimers, procalcitonin, C-reactive protein, ferritin, interleukin (IL)-2R, IL-6, and IL-8 than non-ICU patients. Eleven of 14 ICU patients received noninvasive ventilation and 7 patients received invasive mechanical ventilation. Twelve patients died in the ICU group and no patients died in the non-ICU group.Conclusion: ICU cases showed higher rates of organ failure and mortality than non-ICU cases. The poor outcomes of patients with diabetes and COVID-19 indicated that more supervision is required in these patients.Abbreviations: COVID-19 = coronavirus disease 2019; ICU = intensive care unit; MERS-CoV = middle East respiratory syndrome-related coronavirus; 2019- nCoV = 2019 novel coronavirus; NT-proBNP = N-terminal prohormone of brain natriuretic peptide; SARS-CoV = severe acute respiratory syndrome-related coronavirus     

AECOPD并重度呼吸衰竭患者有创机械通气的治疗时机探讨及其预后的影响因素分析

摘要 目的：探讨慢性阻塞性肺疾病急性加重（AECOPD）合并重度呼吸衰竭患者有创机械通气的治疗时机,并分析其预后的影响因素。方法：选取2020年3月~2021年12月期间于首都医科大学附属北京世纪坛医院治疗的161例AECOPD合并重度呼吸衰竭患者,按照气管插管时间分为早期组（n=89）和延期组（n=72）,对比两组治疗后临床指标、血气分析指标及28 d内病死率（预后）。根据预后的不同将患者分为死亡组（n=29）和存活组（n=132）,收集患者的一般资料和实验室资料,采用Logistic回归分析预后的影响因素。结果：早期组的总机械通气时间、有创通气时间、重症监护室（ICU）住院时间均短于延期组（P<0.05）。两组治疗后动脉血二氧化碳分压（PaCO₂）较治疗前下降,氧合指数（OI）、动脉血氧分压（PaO₂）较治疗前升高,且早期组变化程度大于延期组（P<0.05）。延期组28 d内病死率为15/72（20.83%）。早期组28 d内病死率为14/89（15.73%）,两组患者的28 d病死率对比无差异（P>0.05）。单因素分析结果显示,AECOPD合并重度呼吸衰竭患者的预后影响因素与并发呼吸机相关肺炎、并发多脏器功能不全综合征、年龄、PaCO₂、血红蛋白（Hb）、血尿素氮（BUN）、白细胞计数（WBC）、pH值、中性粒细胞计数/淋巴细胞计数比值（NLR）、血小板计数/淋巴细胞计数（PLR）、C反应蛋白（CRP）、D-二聚体（D-D）、B型尿钠肽有关（P<0.05）。AECOPD合并重度呼吸衰竭患者预后不良的危险因素主要有并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高（P<0.05）。结论：AECOPD合并重度呼吸衰竭患者早期使用有创机械通气,可有效改善血气分析,缩短有创通气时间、总机械通气时间、ICU住院时间。并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高均是导致AECOPD合并重度呼吸衰竭患者预后不良的危险因素。     

Long-Term Outcome of Critically Ill Adult Patients with Acute Epiglottitis

BackgroundAcute epiglottitis is a potentially life threatening disease, with a growing incidence in the adult population. Its long-term outcome after Intensive Care Unit (ICU) hospitalization has rarely been studied.

Methodology and Principal Findings

Thirty-four adult patients admitted for acute epiglottitis were included in this retrospective multicentric study. The mean age was 44±12 years (sex ratio: 5.8). Sixteen patients (47%) had a history of smoking while 8 (24%) had no previous medical history. The average time of disease progression before ICU was 2.6±3.6 days. The main reasons for hospitalization were continuous monitoring (17 cases, 50%) and acute respiratory distress (10 cases, 29%). Microbiological documentation could be made in 9 cases (26%), with Streptococcus spp. present in 7 cases (21%). Organ failure at ICU admission occurred in 8 cases (24%). Thirteen patients (38%) required respiratory assistance during ICU stay; 9 (26%) required surgery. Two patients (6%) died following hypoxemic cardiac arrest. Five patients (15%) had sequelae at 1 year. Patients requiring respiratory assistance had a longer duration of symptoms and more frequent anti inflammatory use before ICU admission and sequelae at 1 year (p<0.05 versus non-ventilated patients). After logistic regression analysis, only exposure to anti-inflammatory drugs before admission was independently associated with airway intervention (OR, 4.96; 95% CI, 1.06-23.16).

Conclusions and Significance

The profile of the cases consisted of young smoking men with little comorbidity. Streptococcus spp. infection represented the main etiology. Outcome was favorable if early respiratory tract protection could be performed in good conditions. Morbidity and sequelae were greater in patients requiring airway intervention.     

High Prevalence of Respiratory Muscle Weakness in Hospitalized Acute Heart Failure Elderly Patients

IntroductionRespiratory Muscle Weakness (RMW) has been defined when the maximum inspiratory pressure (MIP) is lower than 70% of the predictive value. The prevalence of RMW in chronic heart failure patients is 30 to 50%. So far there are no studies on the prevalence of RMW in acute heart failure (AHF) patients.ObjectivesEvaluate the prevalence of RMW in patients admitted because of AHF and the condition of respiratory muscle strength on discharge from the hospital.MethodsSixty-three patients had their MIP measured on two occasions: at the beginning of the hospital stay, after they had reached respiratory, hemodynamic and clinical stability and before discharge from the hospital. The apparatus and technique to measure MIP were adapted because of age-related limitations of the patients. Data on cardiac ejection fraction, ECG, brain natriuretic peptide (BNP) levels and on the use of noninvasive ventilation (NIV) were collected.ResultsThe mean age of the 63 patients under study was 75 years. On admission the mean ejection fraction was 33% (95% CI: 31–35) and the BNP hormone median value was 726.5 pg/ml (range: 217 to 2283 pg/ml); 65% of the patients used NIV. The median value of MIP measured after clinical stabilization was -52.7 cmH2O (range: -20 to -120 cmH₂O); 76% of the patients had MIP values below 70% of the predictive value. On discharge, after a median hospital stay of 11 days, the median MIP was -53.5 cmH₂O (range:-20 to -150 cmH₂O); 71% of the patients maintained their MIP values below 70% of the predictive value. The differences found were not statistically significant.ConclusionElderly patients admitted with AHF may present a high prevalence of RMW on admission; this condition may be maintained at similar levels on discharge in a large percentage of these patients, even after clinical stabilization of the heart condition.     

Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients

IntroductionPatients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality.MethodsA retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis.ResultsOf the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO₂/FiO₂ ratio, and a low lymphocyte count at the time of ICU admission.ConclusionsThe outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.     

Individual Organ Failure and Concomitant Risk of Mortality Differs According to the Type of Admission to ICU – A Retrospective Study of SOFA Score of 23,795 Patients

Introduction

Organ dysfunction or failure after the first days of ICU treatment and subsequent mortality with respect to the type of intensive care unit (ICU) admission is poorly elucidated. Therefore we analyzed the association of ICU mortality and admission for medical (M), scheduled surgery (ScS) or unscheduled surgery (US) patients mirrored by the occurrence of organ dysfunction/failure (OD/OF) after the first 72h of ICU stay.

Methods

For this retrospective cohort study (23,795 patients; DIVI registry; German Interdisciplinary Association for Intensive Care Medicine (DIVI)) organ dysfunction or failure were derived from the Sequential Organ Failure Assessment (SOFA) score (excluding the Glasgow Coma Scale). SOFA scores were collected on admission to ICU and 72h later. For patients with a length of stay of at least five days, a multivariate analysis was performed for individual OD/OF on day three.

Results

M patients had the lowest prevalence of cardiovascular failure (M 31%; ScS 35%; US 38%), and the highest prevalence of respiratory (M 24%; ScS 13%; US 17%) and renal failure (M 10%; ScS 6%; US 7%). Risk of death was highest for M- and ScS-patients in those with respiratory failure (OR; M 2.4; ScS 2.4; US 1.4) and for surgical patients with renal failure (OR; M 1.7; ScS 2.7; US 2.4).

Conclusion

The dynamic evolution of OD/OF within 72h after ICU admission and mortality differed between patients depending on their types of admission. This has to be considered to exclude a systematic bias during multi-center trials.     

早期渐进性康复训练对机械通气重症患者神经肌肉功能恢复的影响

目的:探讨早期渐进性康复训练对行机械通气重症患者神经肌肉功能的影响。方法:选择我院自2015年4月~2016年4月收治的80例机械通气重症患者。通过随机数字表法将患者分为观察组及对照组各40例,患者进入ICU后,给予所有患者常规的机械通气治疗方案及干预。在此基础上给予观察组患者早期渐进性康复训练,分别于气管插管拔管时、转出ICU时以及出院时采用功能独立性评分表(FIM)对两组患者功能独立性水平进行评价,统计比较两组患者机械通气时间、ICU治疗时间、住院总时间及并发症的发生情况。结果:气管插管拔管时观察组自理能力、括约肌控制、转移功能及总分水平均高于对照组,差异均有统计学意义(均P0.05)。转出ICU时和出院时观察组自理能力、括约肌控制、转移、行进、交流、社会认知及总分水平均高于对照组,差异均有统计学意义(均P0.05)。观察组机械通气时间、ICU治疗时间及住院总时间及并发症发生率低于对照组,差异有统计学意义(P0.05)。结论:早期渐进性康复训练可有效者提高ICU患者自理能力,加速患者意识的恢复,使患者更早的脱机,减少住院时间,降低并发症情况的发生。     

HFNC与NIV治疗合并Ⅱ型呼衰的COPD患者的临床疗效对比

摘要 目的：探讨高流量湿化治疗仪（HFNC）治疗合并Ⅱ型呼吸衰竭的慢性阻塞性肺疾病患者的临床效果及安全性。方法：选择2020 年 4 月至 2022 年 3 月就诊于我院的合并Ⅱ型呼吸衰竭的慢性阻塞性肺疾病的患者共151名。随机分为接受 HFNC治疗组和NIV治疗组（HFNC组77名，NIV组74名）。分别评估患者治疗前和治疗后1小时、24小时以及治疗结束前心率（heart rate，HR）、呼吸频率（respiratory rate，RR）、氧合指数（Oxygenation index，PaO₂/FiO₂）、CO₂分压（arterial partial pressure of CO₂，PaCO₂）的变化、治疗不耐受和失败、有气管插管需求的情况、住院时间以及住院死亡率。结果：治疗后，两组各有6名患者死亡，死亡率分别为HFNC组7.8%，NIV组8.2%，组间比较差异无统计学意义（P=0.94）。两组患者治疗前后HR、RR、平均动脉压、白细胞计数、中性粒细胞百分比、C-反应蛋白、降钙素原及PaO₂/FiO₂、PaCO₂、动脉血酸碱度均无明显统计学差异。与NIV组相比，HFNC组气道护理干预次数明显减少（4±1 vs 8±2，P<0.05），皮肤破损发生率明显降低（5.2% vs 20.3%，P<0.05），住院天数明显缩短（6±2 vs 8±2，P<0.05）。结论：HFNC治疗合并Ⅱ型呼吸衰竭的COPD 患者效果并不亚于NIV，且HFNC的安全性更高，可作为该类患者的首选通气支持治疗方式。     

Effect of Testosterone on Insulin Sensitivity in Men with Idiopathic Hypogonadotropic Hypogonadism

ObjectiveTo assess the presence of insulin resistance (IR) among a homogeneous cohort of male patients with idiopathic hypogonadotropic hypogonadism (IHH) and to investigate the effects of testosterone therapy on IR in this specific group.MethodsTwenty-four male patients with untreated IHH and 20 age-, sex-, and weight-matched eugonadal healthy control subjects were recruited for the study. Plasma glucose, plasma insulin, total and free testosterone, follicle-stimulating hormone, luteinizing hormone, estradiol, and sex hormone-binding globulin levels were measured in fasting blood samples, and biochemical and hormonal analyses were performed for all study participants. IR was calculated by the homeostasis model assessment of insulin resistance (HOMA-IR) formula and the quantitative insulin sensitivity check index (QUICKI). Body mass index was calculated by weighing and measuring the heights of all study participants at the beginning of the investigation. Body fat mass and body lean mass were calculated as percentages of body weight by bioelectrical impedance analysis of body composition. Sustanon 250 (a combination of 4 testosterones) was administered intramuscularly once every 3 weeks for 6 months to male patients with IHH after a basal anthropometric, biochemical, and hormonal evaluation. The response to therapy was monitored by regular clinical examinations and serum testosterone measurements. After 6 months of testosterone treatment, the entire anthropometric, biochemical, and hormonal evaluation was repeated 14 days after the last injection of testosterone.ResultsBefore treatment, male patients with IHH had higher fasting plasma glucose concentrations, higher fasting plasma insulin levels, a higher HOMA-IR score, and a lower QUICKI when compared with the control group. After testosterone treatment in the patient group, the HOMA-IR score decreased dramatically to the level in the control group. The high body fat mass of the male patients with IHH was reduced significantly after testosterone treatment, concomitant with significant increases in body mass index and body lean mass.ConclusionInsulin sensitivity improves and body fat mass decreases with long-term testosterone replacement therapy. (Endocr Pract. 2007;13:629-635)     

Optimal Free Thyroxine Levels for Thyroid Hormone Replacement in Hypothyroidism

ObjectiveTo determine whether a difference exists in the free thyroxine level required to achieve a normal thyrotropin (thyroid-stimulating hormone or TSH) level between patients with primary hypothyroidism and euthyroid control subjects and compare the free thyroxine levels in patients with primary and secondary hypothyroidism receiving thyroid hormone replacement.MethodsWe retrospectively assessed TSH and free thyroxine values in 58 patients with primary hypothyroidism and 78 euthyroid control subjects for whom screening thyroid function tests had been performed. From the medical records, we also obtained free thyroxine values for 23 patients with central hypothyroidism receiving stable levothyroxine replacement therapy.ResultsThe mean free thyroxine level was significantly higher in patients with primary hypothyroidism than in euthyroid control subjects (1.36 ± 0.201 ng/dL versus 1.10 ± 0.155 ng/dL, respectively, P < .0001), whereas the corresponding mean TSH concentrations did not differ significantly (1.60 ± 1.183 mlU/L versus 1.73 ± 0.792 mlU/L, P = .46). The mean free thyroxine value was also significantly higher in the patients with central hypothyroidism in comparison with that in the euthyroid control subjects (1.31 ± 0.278 ng/dL versus 1.10 ± 0.155 ng/dL, respectively, P < .0001), and no significant difference was noted between the patients with primary and central hypothyroidism (1.36 ng/dL versus 1.31 ng/dL, P = .60).ConclusionPatients with hypothyroidism require a higher level of serum free thyroxine to achieve a normal TSH value in comparison with euthyroid control subjects. This finding suggests that patients with central hypothy-roidism should be treated to achieve free thyroxine levels in the upper part of the reference range. (Endocr Pract. 2008;14:550-555)     

机械通气对ICU肺动脉高压伴呼吸衰竭患者血浆脑钠肽水平的影响

目的探讨机械通气对ICU肺动脉高压伴呼吸衰竭患者血浆脑钠肽水平的影响。方法随机抽取86例ICU肺动脉高压伴呼吸衰竭患者分为两组,观察组43例患者应用面罩呼吸机予以辅助呼吸治疗,对照组43例患者行气管插管呼吸机辅助治疗,并对两组患者治疗前后脑钠肽、肺动脉压水平以及并发症发生率进行比较分析。结果治疗后,观察组脑钠肽、肺动脉压力均高于对照组(均P0.01);观察组并发症发生率为6.98%,低于对照组的23.26%(P0.05)。结论 ICU肺动脉高压伴呼吸衰竭患者行气管插管机械通气治疗的临床效果肯定。     

胆囊切除术后急性胰腺炎患者314例的发病特点分析

目的:研究胆囊切除术后患者发生急性胰腺炎的发病特点。方法:回顾性分析2009年10月至2013年10月四川大学华西医院诊断为急性胰腺炎且既往行胆囊切除术患者的病因、病情严重程度、临床特征与转归。结果:研究共纳入314例患者,以高脂血症性胰腺炎占比最高,共110例(35%),胆源性胰腺炎和混合性胰腺炎分别为107例(32%)、96例(31%),酒精性仅7例(2%)。轻症215例,中度31例,重度68例。高脂血症性胰腺炎患者重症率(36%)、胰腺及胰周坏死率(28%)、持续性器官功能衰竭率(36%)、呼吸衰竭率(41%)、ICU转入率(26%)均显著高于胆源性组和混合组,差异具有统计学意义(P0.05)。结论:胆囊切除后的急性胰腺炎以胆源性胰腺炎和高脂血症性胰腺炎居多,其中高脂血症性胰腺炎的病情更严重。     

腹式呼吸训练法对COPD伴Ⅱ型呼吸衰竭患者肺通气状态、血气指标及运动耐力的影响

摘要 目的：探讨腹式呼吸训练法对慢性阻塞性肺疾病（COPD）伴Ⅱ型呼吸衰竭患者肺通气状态、血气指标及运动耐力的影响。方法：选择我院2020年07月2022年12月期间收治的100例COPD伴Ⅱ型呼吸衰竭患者,根据随机数字表法将患者分为对照组[常规治疗基础上接受双水平气道正压（BIPAP）辅助通气,n=50]和研究组（对照组的基础上接受腹式呼吸训练法干预,n=50）。对比两组临床相关指标、肺通气状态、血气指标及运动耐力指标。结果：研究组的喘憋消失时间、体温恢复正常时间、住院时间、肺部啰音消失时间短于对照组（P<0.05）。两组干预1周后第1秒呼气的最大容积（FEV₁）、最大自主分钟通气量（MVV）、用力肺活量（FVC）均升高,且研究组高于对照组（P<0.05）。两组干预1周后氧分压（PaO2₂）、血氧饱和度（SpO₂）均升高,且研究组高于对照组;二氧化碳分压（PaCO₂）下降,且研究组低于对照组（P<0.05）。两组干预1周后6 min步行距离（6MWT）升高,且研究组高于对照组（P<0.05）。结论：腹式呼吸训练法有助于改善COPD伴Ⅱ型呼吸衰竭患者的临床症状,调节肺通气状态、血气指标,提高运动耐力。     

针刺疗法联合穴位贴敷对急性呼吸衰竭机械通气患者血气分析指标、膈肌功能及炎症免疫指标的影响

摘要 目的：观察穴位贴敷、针刺疗法联合治疗对急性呼吸衰竭机械通气患者血气分析指标、膈肌功能及炎症免疫指标的影响。方法：选择2021年11月～2022年12月期间在安徽中医药大学附属六安医院接受治疗的92例急性呼吸衰竭机械通气患者,按照随机数字表法将患者分为对照组（常规治疗,46例）和研究组（对照组的基础上增加针刺疗法联合穴位贴敷治疗,46例）。对比两组血气分析指标、膈肌功能、炎症免疫指标及胃肠功能,同时记录两组并发症发生率。结果：研究组撤机前氧合指数（OI）、pH、动脉血氧分压（PaO2）高于对照组,动脉血二氧化碳分压（PaCO₂）低于对照组（P<0.05）。研究组撤机前右侧膈肌呼气末厚度（Tdi-ee）、吸气末厚度（Tdi-ei）、膈肌增厚分数（TFdi）低于对照组（P<0.05）。研究组撤机前超敏C反应蛋白（hs-CRP）、降钙素原（PCT）、白细胞计数（WBC）低于对照组,CD4⁺高于对照组（P<0.05）。研究组撤机前胃肠功能评分低于对照组（P<0.05）。两组并发症发生率组间对比无统计学差异（P>0.05）。结论：针刺疗法联合穴位贴敷在改善急性呼吸衰竭机械通气患者的血气分析指标、膈肌功能、炎症免疫指标中的应用价值较好。     

Relationship of Prostate -Specific Antigen to Age and Testosterone in Men With Type 2 Diabetes Mellitus

ObjectiveTo determine whether prostate-specific antigen (PSA) concentrations in type 2 diabetic men with hypogonadotrophic hypogonadism are lower than those in eugonadal men with type 2 diabetes and whether PSA concentrations are related to plasma testosterone concentrations.MethodsIn this cross-sectional study, we measured serum total testosterone, sex hormone–binding globulin, free testosterone, PSA, hematocrit, and hemoglobin A_1c in consecutive type 2 diabetic men who presented to 2 endocrinology referral centers between January 2006 and January 2007. We collected other clinical and demographic data including age, height, weight, and ethnicity.ResultsOf 400 eligible patients, 280 men met inclusion criteria. Plasma PSA concentrations were lower in type 2 diabetic men with low free testosterone concentrations than in those with normal free testosterone concentrations (25.65 ± 2.02 ng/dL vs 31.70 ± 2.31 ng/dL, P = .011). PSA concentrations were positively related to age (r = 0.34, P < .001), total testosterone (r = 0.29, P < .001), free testosterone (r = 0.17, P = .02), and sex hormone– binding globulin (r = 0.22, P < .001) and negatively related to body mass index (r = –0.28, P < .001). In stepwise backward regression analysis, PSA concentration was predicted by age (P < .001) and free testosterone (P < .001), but not by body mass index or sex hormone–binding globulin.ConclusionsPlasma PSA concentrations are lower in type 2 diabetic men with hypogonadism than in eugonadal men with type 2 diabetes, and plasma PSA is related to age, plasma total testosterone concentrations, and free testosterone concentrations in patients with type 2 diabetes. (Endocr Pract. 2008;14:1000-1005)     

ICU下呼吸道多重耐药菌医院感染的病原学临床特征及易感因素分析

摘要 目的：研究ICU下呼吸道多重耐药菌医院感染的病原学临床特征及易感因素。方法：选择2020年1月到2022年12月于我院ICU住院治疗的216例下呼吸道感染者,按照是否发生多重耐药菌感染分为研究组113例,对照组103例。分析两组患者感染相关因素的数量分布情况,通过Logistic回归分析多重耐药菌医院感染的危险因素。采用全自动细菌鉴定仪对菌种进行鉴定,采用K-B纸片法进行药敏试验,并分析多重耐药菌感染的病原学分布及对常用抗菌药物的耐药性。结果：（1）与对照组相比,研究组患者感染相关因素的分布率更高;（2）住院时间>3个月、使用糖皮质激素治疗、应用机械通气治疗、其他细菌感染、血红蛋白含量<100 g/L、抗菌药物使用时间>15 d、抗菌药物使用种类>4种、使用免疫抑制剂是ICU下呼吸道多重耐药菌感染的危险因素;（3）113例研究组共培养出细菌菌株93株,其中革兰氏阴性菌52株（55.91%）,革兰氏阳性菌25株（26.88%）,革兰氏阴性菌中较多的是铜绿假单胞菌（22株）、鲍曼不动杆菌（13株）、肺炎克雷伯菌（12株）;革兰氏阳性菌中最多的是肺炎链球菌（11株）和金黄色葡萄球菌（11株）;（4）耐药情况：铜绿假单胞菌对莫西沙星耐药率较低（15.83%）,肺炎克雷伯菌对亚胺培南耐药率较低（17.56%）,鲍曼不动杆菌对头孢哌酮/舒巴坦耐药率较低（16.37%）,金黄色葡萄球菌、肺炎链球菌对万古霉素无耐药性。结论：住院时间>3个月、使用糖皮质激素治疗、应用机械通气治疗、其他细菌感染、血红蛋白含量<100 g/L、抗菌药物使用时间>15 d、抗菌药物使用种类>4种、使用免疫抑制剂是多重耐药感染的独立危险因素。本院ICU下呼吸道感染以革兰氏阴性杆菌为主,应根据病原菌选择耐药性低的药物,并针对危险因素采取有效措施。     

Acute Kidney Injury in Severe Sepsis and Septic Shock in Patients with and without Diabetes Mellitus: A Multicenter Study

IntroductionWhether diabetes mellitus increases the risk of acute kidney injury (AKI) during sepsis is controversial.ResultsFirst, we compared 451 patients with severe sepsis or septic shock and diabetes to 3,277 controls with severe sepsis or septic shock and without diabetes. Then, we compared 318 cases (with diabetes) to 746 matched controls (without diabetes). Diabetic patients did not have a higher frequency of AKI (hazard ratio [HR], 1.18; P = 0.05]) or RRT (HR, 1.09; P = 0.6). However, at discharge, diabetic patients with severe sepsis or septic shock who experienced acute kidney injury during the ICU stay and were discharged alive more often required RRT (9.5% vs. 4.8%; P = 0.02), had higher serum creatinine values (134 vs. 103 µmoL/L; P<0.001) and had less often recovered a creatinine level less than 1.25 fold the basal creatinine (41.1% vs. 60.5%; P<0.001).ConclusionsIn patients with severe sepsis or septic shock, diabetes is not associated with occurrence of AKI or need for RRT but is an independent risk factor for persistent renal dysfunction in patients who experience AKI during their ICU stay.     

Intensive treatment of respiratory failure--personal experiences

Controlled oxygen-therapy was used in 30 out of 49 patients (61%) with the acute respiratory failure or exacerbations of the chronic respiratory failure treated at ICU (Group Y), while artificial ventilation in the remaining 19 patients (39%; Group B). An improvement was achieved in 70% of patients of Group A and 42% in Group B. Overall improvement was achieved in 59% of the treated patients. There were 69% of treated patients with infections. Totally 41% of the treated patients died (30% of Group A and 58% of Group B). An analysis of the results has been carried out in various subgroups of the treated patients, i.e. the acute and exacerbated respiratory failure as well as partial and complete respiratory insufficiency. The result of high risk patients have also been analysed. This subgroup included sudden cardiac arrest, shock and non-compensated acidosis. Favourable effects of the intensive care of patients with infections have been discussed with particular reference to the life hazard in case of septic complications. Emphasis is on the unfavorable effects of therapy in patients with respiratory failure complicated with pulmonary embolism. Indications to the use of respirator and complications of the artificial ventilation have been discussed.     

经鼻盲探气管插管在抢救呼吸衰竭病人中的应用

目的比较经鼻盲探气管插管和气管切开在抢救呼吸衰竭病人的治疗效果。方法回顾性对比分析同期ICU住院病人采用经鼻盲探气管插管或气管切开建立人工气道后的病情转归,使用呼吸机后血气纠正时间,使用呼吸机时间,留置气管导管时间,平均住院时间及操作并发症。结果经鼻盲探气管插管组拔管率42.9%(9/21例),拔管成功率100%(9/9例);气管切开组拔管率60.7%(17/28例),拔管成功率76.5%(13/17例),两组间比较无显著性差异(P<0.05)。使用呼吸机后血气纠正时间无明显差别,但经鼻盲探气管插管组使用呼吸机时间,留置气管导管时间,平均住院时间均短于气管切开组(P<0.05)。气管切开组操作导致的并发症发生率46.4%(13/28例),而经鼻盲探气管插管组操作导致的并发症发生率23.8%(5/21例),明显少于前者(P<0.01)。结论经鼻盲探气管插管操作简便、实用,能减少并发症,缩短使用呼吸机时间,留置气管导管时间及住院时间,在抢救呼吸衰竭病人中较气管切开术有更好的临床应用价值。     

New-onset atrial fibrillation in sepsis is associated with increased morbidity and mortality

BackgroundThe development of new-onset atrial fibrillation in sepsis has been associated with adverse outcomes.MethodsA systematic literature search was conducted to retrieve articles that investigated the association of new-onset atrial fibrillation in patients diagnosed with sepsis. The primary outcome of interest was the pooled risk ratio (RR) of in-hospital mortality in patients with new-onset atrial fibrillation and sepsis.ResultsSix studies included 3100 patients with new-onset atrial fibrillation in sepsis and 36,900 patients without new-onset atrial fibrillation in sepsis. The pooled RR for in-hospital mortality was 1.45 (95 % CI 1.32–1.60, p < 0.00001, I^2 =24 %). New-onset atrial fibrillation was also associated with increased ICU mortality, ICU and in-hospital length of stay and stroke. New-onset atrial fibrillation occurred more in the elderly, those with a prior history of cardiovascular and respiratory disease, and those with increased severity of illness.ConclusionProspective randomised trials are needed to clarify the significance of new-onset atrial fibrillation in sepsis, optimal treatment strategies for these patients, and the benefit of systemic anticoagulation. Physicians should be aware that new-onset atrial fibrillation in sepsis is not merely an observed temporary arrhythmia but a marker of poor prognosis and should be managed accordingly.