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静脉用盐酸去甲万古霉素致红人综合征一例

Resuming of oral anticoagulation after intracerebral hemorrhage

Resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) is still a dilemma to clinical decision. To date, no high-quality randomized controlled trials demonstrate the timing and mode of safely resuming OAC. In recent years, some moderate-quality researches have suggested that OAC resuming after ICH can decrease the incidence of thromboembolic events and long-term mortality, without significantly increasing the risk of ICH; it is safer to resuming OAC in patients with non-lobar ICH than in patients with lobar-ICH; new OACs are superior to vitamin K antagonists; patients with high thromboembolic risk should resume OAC 2 weeks or even earlier after ICH, otherwise, a time-window for optimal resumption is between 4-8 weeks; meanwhile, individual patient characteristics should be considered and blood pressure should be strictly controlled.

Diagnosis and Treatment of Deep Venous Thrombosis of Lower Limb

目的 总结我科2002年3月至2005年10月收治的下肢深静脉血栓形成(deep vein thrombosis,DVT)患者的诊治经验.方法 本组下肢DVT患者275例,患肢294条.男134例,女141例,年龄14～92岁,平均(50.76±16.43)岁.单侧下肢DVT 256例(左侧159例,右侧97例),19例为双下肢DVT(其中有8例是仅一侧肢体有临床表现); 属混合型194条,中央型74条,周围型26条.行彩色多普勒或静脉造影检查了解血栓部位及范围; 对怀疑有肺动脉栓塞(pulmonary embolism, PE)者行肺部增强CT扫描.治疗包括抗凝、溶栓、祛聚、梯度压力静脉弹力袜以及对症处理.对反复发生PE、存在抗凝治疗禁忌证、需要手术取栓、下肢静脉存在悬浮游离血栓者安置下腔静脉滤器.对发生股青肿患者行手术取栓.疗效评价: 住院期间观察症状变化,监测膝关节上、下15 cm处周径; 对随访患者行CEAP(clinical-etiology-anatomic-pathophysiologic)临床表现分级、功能障碍评分(venous disability score, VDS).结果 本组DVT常见的危险因素包括活动受限史、2周以内有手术史、恶性肿瘤及外伤史.本组患肢主要临床表现包括: 肿胀、疼痛、皮温增高、皮肤暗红、浅静脉迂曲等.并发症: PE 9例,股青肿2例,下腔静脉阻塞综合征3例.275例中2例行手术取栓,25例安置下腔静脉滤器.本组患者症状经治疗后1～5 d开始缓解,出院时膝关节上、下周径较入院时明显缩小(P＜0.05).随访时间6个月～3年,195例(70.9%)的201条(68.4%)患肢获得随访,患肢CEAP分级: C0级78条,C1级53条,C2级16条,C3级20条,C4级15条,C5级11条,C6级8条; VDS评分: 0分77例,1分66例,2分33例,3分19例.结论 下肢DVT的诊断中应注意对危险因素以及无症状的DVT的搜寻; 早期治疗以非手术治疗为主,通过抗凝、溶栓等综合治疗可以达到满意效果; 在早期如发生股青肿应及时手术治疗; 有选择地安置下腔静脉滤器可防止PE的发生; 后期应根据病情特点确定治疗方案和疗程.

Treatment of Acute Limb Arterial Embolism and Influencing Factors of Its Prognosis

Objective　To present and summarize the data concerning the treatment and prognosis of acute limb arterial embolism in West China Hospital. Methods　Forty three patients with 52 limbs of acute arterial embolism were treated in West China Hospital from January 2003 to March 2006. There were 15 males and 28 females, aging from 26 years to 77 years 〔(58.88±13.90) years〕. The diagnosis was based on clinical manifestations and results of color Doppler sonography or DSA. The follow-up ranged from 1 month to 39 months. The following factors, which might influence the prognosis, were analysed through multiple linear regression of SPSS 10.0: age, sex, uper limb or lower limb, location of embolus, ischemic time, clinical categories of acute limb ischemia, history of smoking, atherosclerosis and other combined diseases, pervious history of acute limb arterial embolism, operative or nonoperative treatment, and postoperative complications. Results　 Clinical categories of acute limb ischemia include: Ⅰ (n=0),Ⅱa (n=16), Ⅱb (n=29), Ⅲ (n=7). The ischemic time varied from 3 h to 2 weeks. The sources of embolus: heart (n=39), vessle (n=7), iatrogenic origin (n=1), unidentidied origin (n=5). The therapies included embolectomy (n=38), catheter-directed thrombolysis (n=2) and medical treatment (n=12). The following postoperative complications occured: compartment syndrome (n=12), respiratory failure (n=3), alkalolsis (n=3), acute renal failure (n=2), wound infection (n=2) and pulmonary infection (n=1). Two patients died of cerebral infarction in hospital and one patient died of heart failure 3 months after discharge. Thirty-eight patients with 45 diseased limbs were followed up. The results were excellent in 13 limbs, good in 15 ones, fair in 8 ones and poor in 9 ones. The statistically significant influencing factors of prognosis include ischemic time, clinical categories of acute limb ischemia and history of smoking (P＜0.05). Conclusion　 The operation of embolectomy is the main treatment of acute limb arterial embolism. In selected patients, catheter-directed thrombolysis and medical treatment could be used to alleviate the limb ischemia. The treatment against the etiological factors should not be ignored. The prognosis of this disease could be influenced by ischemic time, clinical categories of acute limb ischemia and history of smoking.

食管癌患者术后撤机困难一例

目的　总结1例食管癌术后机械通气患者的撤机经验和体会。 方法　对2011年8月8日收入ICU的1例食管癌术后机械通气患者予以抗感染、营养支持、有创无创序贯通气、肺康复等支持治疗的资料进行回顾性分析。 结果　经治疗，该患者成功撤离机械通气，病情逐渐稳定，从经面罩吸氧逐渐过渡到鼻导管吸氧，转出ICU。 结论　对食管癌手术后撤机困难的患者，不仅要防治术后肺部并发症，还应关注手术方式对肺功能的影响，有创无创序贯通气撤机策略和早期肺康复治疗对提高撤机成功率和促进肺功能的恢复具有重要意义。

The Bundle Treatment in Patients with Severe Burn

【摘要】　目的　总结2例特重烧伤患者在ICU的救治经验和体会，旨在进一步提高特重烧伤患者的救治水平。　方法　回顾分析2009年6月2例重症烧伤患者的诊治经过程和临床资料。　结果　1例患者病情好转，转出ICU继续治疗，1例患者伤后37 d因消化道出血死亡。　结论　特重烧伤患者的治疗需要整体计划和多科协作。【Abstract】　Objective　To summarize the experiences of the management of two patients with severe burn, so as to improve the treatment of severe burn patients.　Method　Treating processes and clinical data of two patients with severe burn in June 2009 were analyzed retrospectively.　Result　After prompt treatments, one patient died of severe bleeding in the digestive tract 37 days after the burn and the other patient recovered and left ICU for further treatment.　Conclusion　Bundle treatment and multi-subject cooperation are important for treating patients with severe burn.

经皮气管切开术在神经重症医学科中的临床应用

目的探讨经皮气管切开术在神经重症医学科（ICU）危重症患者中的应用效果。 方法对2011年6月－2012年6月192例行经皮气管切开术患者术中及术后并发症的临床资料进行回顾性分析。 结果192例手术平均时间（6.4±2.1）min，平均出血量＜2 mL，无大出血、气管食管瘘、气道狭窄等严重并发症发生。 结论经皮气管切开术操作简单，创伤小，并发症发生率低，值得在神经ICU危重症患者中推广应用。

系统性红斑狼疮合并肠穿孔的临床分析

目的探讨系统性红斑狼疮（SLE）引发肠穿孔的临床特点。 方法对2011年1月－2013年1月外科重症监护室收治的3例SLE引发肠穿孔病例，结合相关文献分析该类疾病的临床表现和治疗方法。 结果患者经积极治疗，病情逐渐稳定，均康复出院。 结论SLE合并肠穿孔临床上较少见，迷惑性强，容易误诊误治，未及时发现穿孔可引起严重后果。

被动抬腿试验预测容量反应性的最新研究进展

在重症患者的循环支持中，容量状态的判断非常重要。静态指标及动态指标易受多种因素的影响，容量负荷试验安全性较差，在临床实施时均有一定局限性。被动抬腿试验预测容量反应性具有简单、快速、安全、受干扰小等特点，在不增加患者全身容量的基础上，可以迅速判断患者容量反应性。近年来将被动抬腿试验与其他血流动力学监测手段相结合，逐渐成为研究容量反应性的热点。

Clinical Significance of Combined Use of Incentive Spirometry and Aerosol Inhalation in Patients after Abdominal Surgery in General Anesthesia

Objective To evaluate the therapeutic effects of different airway management strategies early used for patients after abdominal surgery in general anesthesia. Methods According to gender, age,and operation location,200 patients after abdominal surgery in general anesthesia were randomly assigned to four groups, ie. a conventional treatment group ( Group A) , an incentive spirometry ( IS) therapy group ( Group B) , an aerosol inhalation group ( Group C) , a combination of inhalation and IS therapy group ( Group D) . Inhalation drugs included Budesonide, Terbutaline, and Ambroxol. The index of pulmonary function test ( FVC, FEV1 , PEF) and arterial blood gases analysis ( ABG) were measured, and the effect of secretions clearance and the improvement of respiratory symptoms were evaluated at 0.5 h,24 h, 48 h after extubation.Intratracheal intubation of the patients after leaving ICUwas followed up. Results FVC, FEV1 , PEF, ABG,sputumvolume, the effect of secretions clearance, clinical efficacy, and intratracheal intubation rate in group B, C and D were improved more significantly than those in group A. And the therapeutic effect was best in group D ( P lt;0. 05) . The secretions clearance was improved more better in group C and D, especially in those high-risk patients with advanced age, smoking history, and pulmonary cormobidities ( P lt; 0. 05) .Conclusions The combined use of IS training and inhalation therapy can improve airway secretions clearance and pulmonary function particularly for those patients after abdominal surgery in general anesthesia, especially for those high-risk patients.