麻醉ICU收治新型冠状病毒感染患者的思考及建议

近期随着新型冠状病毒(以下简称新冠病毒)感染重症及危重症患者的救治进入关键阶段, 归属于麻醉科的外科ICU、麻醉ICU(AICU)、甚至术后恢复室逐渐收治新冠病毒感染肺炎为主的重症及危重症患者(以下简称新冠病毒感染重症患者), 充分体现了麻醉科医生的责任担当。为在新冠病毒感染重症患者生命救治的关键时刻发挥更大作用, 笔者有以下思考及建议。     

显微外科医护人员在抗击新冠肺炎疫情中的角色转换与作用浅析

新型冠状病毒肺炎(简称新冠肺炎,COVID-19)疫情在全球爆发,确诊病例超过200万例,多个国家出现医疗资源挤兑,医护人员严重短缺.在武汉抗击新冠肺炎疫情的阻击战中,全国众多显微外科医护人员投入到新冠肺炎患者救治工作中.本文通过回顾作者抗击新冠肺炎疫情的亲身经历,分析显微外科医护人员支援前线、救治新冠肺炎患者时所面临的挑战,探讨如何转换角色,同时发挥自身专业优势,为抗击疫情作贡献.以期为今后在应对重大急性传染病疫情时如何更好的发挥显微外科医护人员力量提供参考.     

新型冠状病毒肺炎疫情期间普通外科门诊筛查的临床价值

目的探讨新型冠状病毒肺炎(以下简称新冠肺炎)疫情期间普通外科门诊筛查的临床价值。方法采用回顾性描述性研究方法。收集2020年2月1—26日华中科技大学同济医学院附属协和医院收治的57例外科门诊或急诊就诊患者的临床资料;男30例,女27例;年龄为(53±16)岁,年龄范围为17~87岁。57例患者均行普通外科门诊筛查评分,总分≥3分为高危,<3分为低危。观察指标:(1)患者临床资料。(2)患者新冠肺炎筛查评分情况。正态分布的计量资料以±s表示,组间比较采用t检验。偏态分布的计量资料以M(IQR)表示,组间比较采用秩和检验。计数资料以绝对数表示,组间比较采用χ2检验。结果(1)患者临床资料:57例患者中,26例新冠肺炎确诊或疑似患者男、女分别为12、14例,年龄为(57±16)岁;31例非新冠肺炎患者男、女分别为18、13例,年龄为(50±16)岁,两者上述指标比较,差异均无统计学意义(χ2=0.805,t=-1.646,P>0.05)。(2)患者新冠肺炎筛查评分情况:57例患者中,26例新冠肺炎确诊或疑似患者新冠肺炎筛查评分为3.0分(4.0分),31例非新冠肺炎患者新冠肺炎筛查评分为1.0分(1.0分),两者比较,差异有统计学意义(Z=-3.695,P<0.05)。26例新冠肺炎确诊或疑似患者新冠肺炎筛查为高危、低危例数分别为17、9例,31例非新冠肺炎患者新冠肺炎筛查为高危、低危例数分别为3、28例,两者比较,差异有统计学意义(χ2=19.266,P<0.05)。结论新冠肺炎疫情期间普通外科门诊筛查可有效筛查新冠肺炎高危患者。     

新型冠状病毒肺炎危重症患者床旁纤维支气管镜治疗的流程管理

目的 探讨新型冠状病毒肺炎疫情下危重症患者行床旁纤维支气管镜检查和治疗的流程改进及效果。方法 对18例机械通气新型冠状病毒肺炎患者行床旁纤维支气管镜治疗,从人员培训、操作前准备、操作流程、用物消毒处理、环境处理、标本送检方面进行改进。结果 18例次的纤维支气管镜治疗操作过程顺利,送检标本合格,无医护人员感染。结论 加强新型冠状病毒肺炎危重症患者床旁纤维支气管镜治疗流程管理,对安全、高效、有序完成新冠肺炎危重症患者救治工作具有重要作用。     

新型冠状病毒肺炎隔离病房的紧急筹建与管理

目的总结新型冠状病毒肺炎(下称新冠肺炎)隔离病房改建及管理经验,为应对突发公共卫生事件提供参考。方法将感染科5个病区紧急改建为符合收治新冠肺炎的隔离病区,收治新冠肺炎患者338例,严格按国家诊治隔离标准进行培训及管理。结果经治疗327例患者好转出院,11例死亡。结论紧急改建新冠肺炎隔离病区有效缓解了疫情初期患者入院难的问题,严格规范化培训与管理使新建隔离病区发挥了较好的作用。     

新型冠状病毒肺炎患者围手术期处理及防护的认识与思考

新近在中国武汉集中暴发的新型冠状病毒(SARS-CoV-2)所致肺炎(新冠肺炎,WHO定名:COVID-19)疫情严重威胁人民健康,目前已累及25个国家和地区。截至2020年2月13日,中国累计确诊病例63 946例,疑似病例10 109例,病死率2.06%。目前认为SARS-CoV-2传播途径主要是飞沫传播和密切接触,尚不能排除气溶胶和粪-口传播的可能。最新研究表明,新冠肺炎具有非常高的传播效率(R0为3.77)。按照国家卫生健康委员会的要求,疫情暴发期间外科手术的开展限于急诊手术和限期手术。对于疑似或确诊感染新冠肺炎患者外科手术时如何进行围手术期的防护,目前国内外尚无相关指南和共识,缺乏可借鉴的成熟经验。据不完全统计武汉大学中南医院与武汉大学人民医院在疫情期间共收治50例围手术期新冠肺炎患者,其中2例为术后确诊新冠肺炎,围手术期导致16名医务等相关人员感染;48例为术前新冠肺炎疑似或确诊患者,围手术期采取针对性的防护措施后未出现医务相关人员的感染。笔者根据中南大学湘雅医院在新冠肺炎流行期间制定的隔离措施和防护经验,结合上述武汉市两所医院的病例资料,探讨在新冠肺炎流行期间医务人员如何进行围手术期规范操作,制定有效的防护措施。     

抗击新型冠状病毒肺炎疫情联合病区的护理管理

目的 总结驻地医院和驰援医疗队建立联合病区的护理管理经验。 方法 由驻地医院和驰援医疗队建立联合病区，并通过全体人员的动员和准备、组建联合管理团队、分工与协作、培训与管理、强化支持系统等保障联合病区护理管理高效运行。 结果 联合病区共收治新型冠状病毒肺炎危重症患者90例，治愈出院73例，未发生医护人员医院感染。 结论 积极探索驻地医院与驰援医疗队联合工作模式，可保障护理质量，保证患者救治效果，同时保障医护人员安全。     

新型冠状病毒肺炎疫情下实施普通外科手术的思考和建议

由2019新型冠状病毒(2019-nCoV)引起的肺炎(简称新冠肺炎)目前正在我国肆虐。已经证实,新冠肺炎可以在人际间传播。根据最新的临床报道,由医院相关性传播导致的新冠肺炎并不少见,给外科医护人员和住院患者造成严重威胁。在此疫情之下,普通外科医生应掌握新冠肺炎的临床表现和流行病学特点,尤其是了解新冠肺炎可能引起的消化道和腹部症状,避免误诊漏诊。针对急诊手术和限期手术,应在积极排查和防控新冠肺炎的基础上,合理有序开展。为新冠肺炎患者实施紧急手术时,必须严格遵照当地卫生行政主管部门或所在医疗机构的相关防护规定,密切协调手术各方,所有人员均应做好二级或三级防护,手术必须在负压手术间进行。对于不具备上述医疗条件的单位,宜尽快将需要紧急手术的新冠肺炎患者转诊至有条件的医疗单位。     

新型冠状病毒肺炎危重症救治定点医院驰援护士院感防控培训与管理

目的探讨在疫情紧急的情况下,针对新型冠状病毒肺炎危重症救治定点医院驰援护士进行医院感染防控培训和管理的方法。方法综合运用现场授课、网络培训、培养感控专员法、宣传法、视频监控法、日常巡查法和主题会议法对外省医疗队的护理人员进行新冠定点医院感染防控培训与管理。结果以来自江苏省的100名护理人员为例,在驰援51d后全部安全撤离,无医护人员感染新型冠状病毒。结论新型冠状病毒肺炎救治定点医院感染防控方案在驰援护士医院感染防控培训和管理工作中取得了较好效果,符合疫情特殊时期医院感染防控要求,保障了医护人员的职业防护安全。     

基于新型冠状病毒肺炎疫情形势下泌尿系结石危重患者的急诊处理策略

2019年12月以来我国武汉市爆发的新冠肺炎疫情目前已逐步发展成为蔓延至全球的爆发性流行性疾病。出于疫情防控需要,我国部分医院的择期外科手术暂停进行。而由泌尿系结石导致的危重患者,往往合并发热、感染性休克等症状,可能需要与新冠肺炎的相关临床表现进行鉴别;另外,在妊娠期肾绞痛合并发热患者中新冠肺炎相关筛查手段中有一部分运用受限,这些都给临床筛查和处理带来了挑战。陆军军医大学第二附属医院泌尿外科在2020年1月18日至2月19日救治了7例泌尿系结石危重患者,我们采用轻重分层模式、严格实施感染防控措施并遵照泌尿外科指南,使所有危重患者均手术顺利平稳出院。本文结合7例诊疗经验,探讨在疫情形势下开展此类临床救治工作的策略。     

危重患者双向转诊效果分析

目的：探讨危重患者在社区医院与综合性三级医疗机构之间双向转诊的效果及优势。方法：调查2005年1月1日-2010年6月30日广州军区广州总医院与广州市越秀区正骨医院之间的双向转诊情况。结果：调查期间两院共完成危重患者双向转诊683人次,其中由三级医院广州军区广州总医院向基层医院正骨医院转诊361人次,IcU平均住院天数为11．3d,救治成功322例,救治成功率为89．2％,死亡39例中心血管疾病5例,脑血管疾病11例,呼吸疾病15例,脓毒症6例,麻醉意外2例,转运途中无一例病情加重或死亡。康复期转返正骨医院患者322例,康复治疗平均住院天数为14．6d,临床治愈率达100％。结论：通过在社区医院与综合性三级医疗机构之间实施危重患者的双向转诊,可使危重症救治成功率提高,同时紧密合作和优势互补更有利于医疗资源的共享与利用。     

High-dose glucose-insulin-potassium after cardiac surgery: a retrospective analysis of clinical safety issues

BACKGROUND: Metabolic treatment with insulin or glucose-insulin-potassium (GIK) has received attention in association with myocardial infarction, cardiac surgery and critical care. As a result of insulin resistance during neuroendocrine stress, doses of insulin up to 1 IU kg-1 b.w.*h are required to achieve maximal metabolic effects after cardiac surgery. The clinical experience with regard to safety issues of such a high-dose GIK regime in critically ill patients after cardiac surgery is reported. METHODS: Retrospective, observational study involving all patients treated with high-dose GIK after cardiac surgery during one year in a cardiovascular center at a University Hospital. RESULTS: Eighty-nine patients out of 854 adult patients undergoing cardiac surgery were treated with high-dose GIK. Mean age was 69 +/- 1 years, Higgins score 5.3 +/- 0.3. Preoperatively 31.4% had left ventricular function EF< or =0.35 and 32.5% had sustained a myocardial infarct during surgery. Mortality was 5.6% and the average ICU stay was 3.7 +/- 0.5 days. The main indication for GIK was intraoperative heart failure (69.7%). The average glucose infusion rate during the first 6 h was 4.22 +/- 0.15 and 4.91 +/- 0.14 mg kg-1 b.w.*min, respectively, in diabetic and non-diabetic patients (P = 0.023). Blood glucose and s-potassium control was acceptable. CONCLUSIONS: The high-dose GIK regime allowed substantial amounts of glucose to be infused both in diabetic and critically ill patients with maintenance of acceptable blood glucose control. Provided careful monitoring, this regime can be safely used in clinical practice and deserves further evaluation for treatment of critically ill patients following cardiac surgery.     

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??Pay attention to multidisciplinary team (MDT) for diagnosis and treatment of the malignant tumor in general surgery YE Ying-jiang, WANG Shan. Department of Gastroenterology Surgery, Peking University People’s Hospital, Beijing 100044, China. Corresponding author: WANG Shan, E-mail: shwang60@sina.com Abstract The continual and rapid expanding range of potential efficacious treatment options introduces therapeutic dilemmas about optimum management plans and how those should be presented to patients. Coordination, communication, and decision-making between healthcare team members and patients are aspects of cancer cares and can be improved by multidisciplinary team (MDT) working, which is named as MDT modality. MDT modality is different from traditional modality, which is patient-oriented and supported by multidisciplinary experts group and improves the communication and comprehension each other among disciplinarys. In China, there has been an increasing focus on MDT modality in the medical field in recent years. However, it is just in the primary stage. Promoting and applying MDT modality contributes to sharing of medical resources, decreasing the misdiagnosis and mistreatment, and improving the prognosis and the survival rate.     

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??Essentials of nutritional support therapy in critically ill patients LI Zi-jian, CHEN Wei.Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
Corresponding author??CHEN Wei??E-mail??txchenwei@sina.com
Abstract With the continuous update of clinical nutrition concept??the nutrition support therapy in the adult critically ill patients has always been the hotspot. Over the past 30 years?? exponential advances have been made in the understanding of the molecular and biological effects of nutrients in maintaining homeostasis in the critically ill population. Traditionally?? nutrition support in the critically ill population was regarded as adjunctive care designed to provide exogenous fuels to preserve lean body mass and support the patient throughoutthe stress response. Recently?? the strategy has evolved to represent nutrition therapy?? in which the feeding is thought to help attenuate the metabolic response to stress?? prevent oxidative cellular injury?? and favorably modulate immune responses. Improvement in the clinical course of critical illness may be achieved by early EN?? appropriate macro- and micronutrient delivery?? and meticulous glycemic control. In February 2016?? Society of Critical Care Medicine ??SCCM?? and American Society for Parenteral and Enteral Nutrition??ASPEN??jointly updated the guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. The particular report is an update and expansion of guideline published by ASPEN and SCCM in 2009. The intended use of the guideline is for all healthcare providers involved in nutrition therapy of the critically ill—primarily?? physicians?? nurses?? dietitians?? and pharmacists?? with a view to provide guidance and advice for the medical team aiming to reduce disease severity?? diminish complications?? decrease length of stay in the ICU?? and favorably impact patient outcomes.     

Surgical critical care: from old boundaries to new frontiers.

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.     

普通外科重症病人围手术期处理新进展

重症病人病情复杂，器官功能损伤严重，ICU内的加速康复策略制定应强调个体化差异。应从术前病人器官功能评估和优化、术后转入ICU必要性及ICU中加速康复策略制定三方面入手。对于普通外科重症病人的围手术期处理应将加速康复理念贯穿整个治疗过程。     

Notfälle auf chirurgischen Stationen

Many deaths in hospital and unplanned intensive care unit admissions of surgical patients are predictable and potentially preventable by ensuring the timely recognition of critical illnesses and facilitating management by appropriately skilled and experienced personnel. Critical illness is often preceded by slow but progressive physiological deterioration independent of the causative disease. Many international studies have demonstrated that simple measurements of physiological parameters enable early recognition of critically ill patients on general wards. Based on these predetermined criteria standardized early warning scores were developed to identify patients with potential or established critical illness in time. These track and trigger warning systems ensure timely attendance of patients by more experienced or skilled staff, the so-called critical outreach (COT), rapid response (RRT) or medical emergency team (MET) outside the critical care unit. Because medical emergency teams are activated early they have the potential to prevent the catastrophic event of death following unrecognized patient deterioration. Compared to the well-established cardiac arrest teams, emergency medical teams are activated before the worst event of patient death. In-hospital morbidity and mortality of surgical ward patients can be reduced by establishing rapid response systems.     

Surgery in the air--evacuating Finnish tsunami victims from Thailand.

In connection with the Asian tsunami disaster on December 26, 2004, a specially equipped Finnair B-757 airplane capable of evacuating badly injured patients was remodeled into an ambulance airplane. The vehicle could take up to 22 severely injured or ill patients and intensive care and limited surgical procedures could be provided to the patients. The plane was manned with a civilian medical team of 37 physicians and nurses. The plane left for Thailand to evacuate the most severely injured Finnish citizens within 10 hours of the evacuation decision. A total of 14 patients including 4 critically ill (two on ventilator) were transferred to Helsinki within 32 hours of takeoff. The medical team included a general, an orthopedic and a plastic surgeon. Soft tissue wounds, some of them severely infected, were the most common injuries, followed by extremity fractures and head injuries. The surgical procedures that were performed mid-air included wound surgery, to remove necrotic tissue, and external fixation and fasciotomy for a lower extremity fracture. The facilities under these circumstances would allow performing life-saving procedures to maintain airway and breathing, and surgical procedures of the soft tissues, extremity and pelvic fractures. Cavitary surgery would require additional equipment and resources.     

危重症病人营养支持治疗要点

在临床营养理念不断更新的同时,危重症病人的营养支持治疗始终是大家关注的焦点。尤其是近30年来,人们对营养素在维持危重症病人内稳态的分子与生物学效应方面的认识取得了巨大进步。传统观点认为,营养支持对于危重症病人起辅助作用,通过提供外源性能量物质以维持自身的瘦体组织,帮助病人渡过整个应激反应期。而最近的观点更倾向于“营养治疗”,通过早期肠内营养、恰当的宏量及微量营养素的供给、细致的血糖调控等手段达到减轻病人的应激代谢、防止细胞的氧化损伤、调节整体的免疫反应等目的。2016年2月,美国重症医学会（SCCM）和美国肠外肠内营养学会（ASPEN）联合发布了新的重症病人营养支持治疗实施与评价指南,将2009年版的12个章节增至18个章节,面向临床医生、护士、营养师和药师,针对18岁以上的重症病人,提供了最佳营养疗法的新建议,以期能够协助医疗团队进行个体化的营养治疗,减少并发症、缩短住院时间、降低疾病严重程度、改善病人结局。     

Critically ill medical patients, their demographics and outcome

There are few reports describing the demographic details and outcome of noncoronary medical patients on adult general intensive care units. It is not known how medical patients differ from other critically ill patients and how this may influence their outcome. Consequently, we recorded the demographic details of 374 critically ill medical patients and followed their survival for up to 3 years. Patients referred from medical specialties are younger, more severely ill and suffer a higher severity-of-illness-adjusted intensive care unit mortality than other patients. The short-term survival of medical patients is poor with a median survival of 40 days. Twenty per cent of medical patients die after discharge from intensive care but before 40 days. However, the long-term survival of medical patients is better than other patients and almost as good as the general population. Further research is required to identify those patients who are likely to survive beyond 40 days.