危重患者两种血糖控制方法效果比较

目的探讨危重患者血糖控制的适宜方法,以提高血糖控制治疗效果、降低相关并发症。方法将126例ICU危重患者随机分为胰岛素强化治疗组（强化组）和常规治疗组（常规组）各63例,常规组将目标空腹血糖控制在11．9mmol／L以下,强化组12～24h使血糖控制在4．4～6．1mmol／L;均严格动态监测血糖变化。结果入ICU第2、3、5天强化组空腹血糖显著低于常规组（均P〈0．01）;低血糖、病死、医院感染发生率,机械通气时间,ICU入住时间低于或短于常规组,但差异无统计学意义（均P〉0．05）。结论胰岛素强化治疗对危重患者有益,但较常规治疗并不能显著改善危重患者状况和预后。在护理过程中坚持严格动态观察血糖变化,避免低血糖的发生,可保证危重患者各项治疗顺利进行。     

ICU两种血糖控制方案的比较研究

目的比较基于动脉血糖控制方案与强化胰岛素治疗在ICU患者中的应用效果。方法将545例危重症术后患者分为对照组280例和实验组265例。对照组采用强化胰岛素治疗控制血糖;实验组采用动脉血糖为指导的血糖控制新方案。结果实验组术后入ICU 48h内血糖监测次数、胰岛素用量、血糖值、血糖4 mmol/L发生率与对照组比较,差异有统计学意义(P0.05,P0.01);两组术后并发症发生率比较,差异无统计学意义(P0.05)。结论以动脉血糖为指导的血糖控制新方案较强化胰岛素治疗方案,能减少血糖监测次数和低血糖发生次数,降低胰岛素用量,在未增加并发症发生率的同时,能够将血糖控制在比较安全的范围,使患者最大获益,同时也减轻护理工作量。     

重症患者应激性高血糖血糖控制水平的研究

<正>严重患者常伴有应激性高血糖,应激性高血糖可增加危重患者的并发症和死亡率。目前还没有统一的血糖控制标准和规范,国外有研究报道胰岛素强化治疗控制血糖于4.4-6.1mmol/l效果更加[1、2]。本研究主要通过对危重患者控制不同的血糖水平,观察血糖与并发症发生率及预后的关系。     

控制血糖水平对外科危重患者预后的影响

创伤、手术、感染、烧伤等极度应激状况下的危重患者常出现应激性高血糖;非糖尿病危重患者类似糖尿病的症状;糖尿病危重患者则高血糖程度明显加重。创伤后出现不同水平的高血糖,随着血糖的增高,其死亡危险性也呈阶梯样成倍增长[1,2]。手术后高血糖明显增加糖尿病患者围手术期肺炎、手术切口等感染风险;手术后血糖较正常水平（〈110mg/dl或6.1mmol/L）每增高2.2mmol/L（40mg/dl）,手术后感染危险性则增高30%。     

两种血糖控制护理对腹部手术后肠外营养患者预后的影响

目的观察两种血糖的控制护理对腹部手术后肠外营养患者预后的影响。方法选择2009年5月至2010年3月行腹部手术后应用肠外营养支持治疗1周以上的危重患者120例,随机分为胰岛素强化控制组(强化组,58例)和胰岛素常规控制组(常规组,62例)。强化组给予强化胰岛素治疗,控制血糖在4.4～6.1mmol/L;常规组在血糖10mmol/L时,启动胰岛素治疗,使血糖控制在7.8～10.0mmol/L。结果强化组低血糖发生率显著高于常规组(P0.05),而两组术后并发症(均为切口愈合不良)发生率和住院时间比较,差异无统计学意义(均P0.05)。结论腹部手术后肠外营养的患者,常规胰岛素治疗较强化胰岛素治疗能减少患者的低血糖发生率,并且不会增加术后切口愈合不良发生率。     

ICU的血糖控制

ICU患者即使无糖尿病史,在应激情况下也常伴有高血糖和胰岛素抵抗（IR）,而显著的高血糖将使危重患者发生许多并发症。严格控制血糖可以明显减少患者的病死率、住院时间,减少机械通气和肾脏替代治疗的需求,     

危重病人的强化胰岛素治疗

合理控制危重病人的血糖是临床医生常规工作之一，但是如何有效控制血糖至今仍有争论。长期以来普遍认为将危重病人的血糖控制在稍高于正常水平（10．0～11．1mmol／L），对于机体是有利的。然而，多年来高血糖对免疫功能的抑制，导致感染机会增加，或使感染难以控制的证据在不断增加。特别是近年来，国内外多项研究均表明强化胰岛素治疗能改善危重病人的预后，使得如何控制危重病人的血糖开始备受重视。本文就危重病人强化胰岛素治疗的有效性、安全性、可行性，以及可能的机制等进行讨论。     

4种方法预防危重患者失禁相关性皮炎效果比较

目的探讨危重患者失禁相关性皮炎的预防方法。方法将180例患者随机分为A组43例、B组45例、C组44例、D组48例。A组实施常规护理,B、C、D三组于常规护理后分别应用3M皮肤保护膜、银尔舒及赛肤润,每日3次。结果四组失禁相关性皮炎发生率、发生时间比较,差异有统计学意义(均P0.01);B、C、D三组经济成本比较,差异有统计学意义(P0.01),其中D组成本最低。结论使用3M皮肤保护膜、银尔舒、赛肤润均能有效降低危重患者失禁相关性皮炎的发生,赛肤润预防成本最低,建议临床使用赛肤润预防失禁相关性皮炎。     

危重病人的高血糖症及处理

危重病人无论其既往是否有糖尿病,都经常会出现急性高血糖症和胰岛素抵抗,并成为其他并发症和死亡的高风险因子,而外科普通病人应激性血糖水平不变,可很快纠正,因此不会对机体造成很大影响。近年来,国外在危重病人的血糖控制水平、控制方案及血糖控制的评估等研究中已取得很大进展,并表明强化胰岛素治疗控制血糖至理想水平可明显降低其并发症率及死亡率。     

危重病人应激性高血糖的研究进展

ICU危重病人常伴应激性高血糖，这种急性一时性的高血糖可产生有害的病理生理效应。胰岛素反向调节激素的分泌增加，细胞因子的大量释放和胰岛素抵抗是产生应激性高血糖的主要原因。近年来研究显示胰岛素强化治疗将血糖控制在4．0～6．1mmol／L范围内能有效地减少高血糖所致的并发症，促进疾病的恢复，改善疾病的预后。现就此方面的研究进展作一简介。     

鼻饲方式对ICU危重症患者免疫功能及病情的影响

目的进一步研究不同鼻饲方式对ICU危重症患者免疫功能及病情的影响,为选择恰当的鼻饲方式提供依据。方法将180例ICU危重症患者根据随机数字表分为三组各60例。持续24h组用输液泵持续泵注;持续16h组泵入16h,休息8h;间断24h组用输液泵分8个时间单元泵入,每个时间单元为3h,即持续泵入2h,间隔1h。结果三组淋巴细胞计数及APACHEⅡ评分比较,差异无统计学意义(均P0.05);住院第1天与第9天APACHEⅡ评分比较,差异有统计学意义(P0.01)。结论 3种鼻饲方式维持ICU危重症患者免疫功能及改善病情方面未体现显著差别。结合前期研究,间断泵注24h可减少胃潴留,更适于ICU危重症患者的营养支持。     

Blood glucose control in critically ill perioperative patients

Hyperglycemia is common in critically ill patients with approximately 90% of patients treated in an intensive care unit (ICU) developing blood glucose concentrations greater than 110 mg x dl(-1). Recently the international multicentre NICE-SUGAR study reported increased mortality with adopting intensive glucose control for critically ill patients and recent meta-analyses do not support this approach. Whilst the initial trials in Leuven produced enthusiasm and recommendations for intensive blood glucose control, the results of the NICE-SUGAR study have resulted in the more moderate recommendation to target a blood glucose concentration between 144 and 180 mg x dl(-1). As critical care practitioners paid greater attention to glycemic control it became clear that currently used point-of-care measuring systems are not accurate enough to target tight glucose control. Unresolved issues include whether increased blood glucose variability is inherently harmful and whether even moderate hypoglycemia can be tolerated in the quest for tighter blood glucose control. Until another level I evidence will be available, clinicians would be well advised to hasten slowly and abide by the age-old adage to "first, do no harm".     

Closed-loop control of blood glucose levels in critically ill patients

A closed-loop control system was constructed for automatic intravenous infusion of insulin to control blood sugar levels (BSL) in critically ill patients. We describe the development of the system. A total of nine subjects were recruited to clinically test the control system. In the patients who underwent closed-loop control of BSL, the controller managed to control only one patient's glycaemia without any manual intervention. The average BSL attained during closed-loop control approached the target range of 6-10 mmol/l, and had less deviation than when BSL had been maintained manually. We conclude that closed-loop BSL control using a sliding scale algorithm is feasible. The main deficiency in the current system is unreliability of the subcutaneous glucose sensor when used in this setting. This deficiency mandates high vigilance during use of the system as it is being developed.     

Tight blood glucose control is renoprotective in critically ill patients

Two large, prospective, randomized, controlled trials have shown a beneficial effect of intensive insulin therapy (IIT) on the kidney function of critically ill patients. The data from these trials were combined for performance of a more detailed analysis of the renoprotective effect of IIT. After exclusion of 41 patients with preadmission ESRD, the study sample comprised 2707 critically ill patients who were randomly assigned to conventional or IIT. A modified risk-injury-failure-loss-ESRD (mRIFLE) system was used to classify acute kidney injury such that mRIFLE-Injury and -Failure (mR-IF) corresponded to peak serum creatinine levels >/=2x and >/=3x the admission levels, respectively. IIT significantly reduced the incidence of mR-I or -F from 7.6 to 4.5% (P = 0.0006), and this renoprotective effect was most pronounced in patients who achieved strict normoglycemia. In surgical patients, IIT also significantly reduced oliguria (from 5.6 to 2.6%; P = 0.004) and the need for renal replacement therapy (from 7.4 to 4.0%; P = 0.008). In medical patients, the incidence of mR-I or -F decreased to a lesser extent, perhaps because a greater severity of illness at admission may have rendered preventive therapies less effective. In conclusion, this secondary analysis of two large, randomized, controlled trials suggests that IIT, with a goal of achieving normoglycemia, protects the renal function of critically ill patients.     

Aeromonas infection in critically ill burn patients

Aeromonas infection in burn patients is extremely uncommon. Here we report on four cases of Aeromonas infection in burn patients admitted to the BICU at the Singapore General Hospital burn unit between June 2001 and May 2006. Two patients had positive blood cultures, and the other two had tissue samples with growth. There was no history of exposure to soil or fresh water in all patients. The average age of patients was 35 years (range 24-41) and the average % TBSA was 48% (range 35-80). Cultures were isolated between days 2 and 4 post burn. There was one mortality in the series. Increasing antibiotic resistance was noted among isolates of Aeromonas. Continued vigilance is essential to detect infection early, even in the absence of a suggestive history, with adequate debridement and appropriate antibiotic therapy.     

危重症清醒患者刷牙漱口吸引效果观察

目的探讨一种实用、便利、安全、舒适的口腔护理方法用于ICU危重症清醒患者。方法将103例ICU危重症清醒患者随机分为观察组52例和对照组51例。对照组采用常规口腔护理方法 ,观察组由患者自行或护士协助刷牙漱口,并用中心吸引器吸除漱口水。结果观察组恶心、口腔异味发生率显著低于对照组,患者舒适接受程度显著高于对照组(P0.05,P0.01)。观察组每天可节约口腔护理成本5.14元,操作耗时不超过8min。结论综合ICU危重症清醒患者口腔护理采用刷牙漱口吸引法优于传统的棉球擦拭法。     

Dexmedetomidine versus propofol for prolonged sedation in critically ill trauma and surgical patients

Backgroundand Purpose: Currently, dexmedetomidine versus propofol has primarily been studied in medical and cardiac surgery patients with outcomes indicating safe and effective sedation. The purpose of this study was to assess the efficacy of dexmedetomidine versus propofol for prolonged sedation in trauma and surgical patients.MethodsThis was a single-center prospective study conducted in the Trauma/Surgical Intensive Care Unit (ICU) at a Level I academic trauma center. It included patients 18 years of age or older requiring mechanical ventilation who were randomly assigned based on unit bed location to receive either dexmedetomidine or propofol. The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality; proportion of time in target sedation; incidence of delirium, hypotension, and bradycardia; and ICU and hospital length of stay (LOS).ResultsA total of 57 patients were included. Baseline characteristics were similar between groups. There was no significant difference in duration of mechanical ventilation (median [IQR]) between the dexmedetomidine (78.5[125] hours) and propofol (105[130] hours; p = 0.15) groups. There was no difference between groups in ICU mortality, ICU and hospital LOS, or incidence of delirium. Safety outcomes were also similar. Patients in the dexmedetomidine group spent a significantly greater percentage of time in target sedation (98[8] %) compared to propofol group (92[10] %; p = 0.02).ConclusionsOur results suggest that, similar to medical and cardiac surgery patients, dexmedetomidine and propofol are safe and effective sedation agents in critically ill trauma and surgical patients; however, dexmedetomidine achieves target sedation better than propofol for this specific population.