热带地区小儿烧伤休克复苏特点的研究

目的研究热带地区应用乳酸钠林格氏液与血浆对婴幼儿烧伤休克进行个体化液体复苏的特点。方法1985年以来，我科收治6160例各种原因小儿烧烫伤，其中2583例入院时需要液体复苏，年龄〈36个月，烧伤面积10％～85％的重度烧伤合井烧伤休克的患儿接受了复苏治疗，根据患儿体重分类和烧伤面积计算24h液体需要量，我院地处海南，热带潮湿特点应用烧伤治疗机（额外丢失量）增加200～300ml水分，输液泵均匀控制输液速度并根据每小时尿量调整。结果2583例烧伤休克患儿在伤后24h内全部成功复苏，未出现心肺脑肾等重要脏器并发症的电解质紊乱，实际输液量与按体重计算量无差异（P〉0．5）。结论婴幼儿烧伤液体复苏应用乳酸钠林格氏液与血浆抗休克并按患儿不同体重段和烧伤面积估计输液总量是比较合理，有效和精确的。     

颅脑损伤合并出血性休克的液体复苏探讨

目的：探讨颅脑损伤合并失血性休克患者的液体复苏。方法：分析了157例颅脑损伤合并失血性休克患者不同的输液治疗方法和与之对应的治疗效果。结果：按国际GOS评定，立即输液组死亡率为34％；延迟输液组死亡率为22％；输全血组死亡率为16％；输高渗液组死亡率为29％；输等渗液组死亡率为42％。结论：颅脑损伤合并出血性休克应适当延迟和限制液体复苏，输液的液体以全血优于晶体液，高渗性电解质溶液优于等渗性电解质溶液。     

大面积烧伤创面深度与补液量的关系临床资料分析

目的探讨烧伤深度与早期补液量的关系。方法从我科4年收治的32例大面积烧伤中选取了21例入院时无特殊并发症病例早期液体复苏临床资料进行回顾性总结。本组病例平均烧伤面积81．3％，平均深度烧伤面积57．6％，开始液体复苏最短为伤后1．5h，最长为伤后6h。以平均心率100次／min，平均尿量80ml／h为输液调控基本指标。结果伤后第1天平均晶，胶体补液量每公斤体重每1％烧伤面积2．19ml，基础液体量（成人）平均4662ml／d。伤后第2天平均晶、胶体补液量每公斤体重每1％烧伤面积1．40ml；深度烧伤占比例越大，晶胶体补液量越多。21例患者有2例分别于伤后第1天和第3天发生DIC，1例伤后第3天发生高钠血症，其余全部平稳度过休克期。除1例伤后6d自动出院外，其他患者均痊愈出院，平均住院天数58d．结论大面积烧伤早期补液不仅与烧伤面积有关，而且与烧伤深度关系密切，浅度烧伤与深度烧伤对补液的需求存在较大差异。传统烧伤补液公式仅以烧伤面积为依据，实有缺陷，建议进行改进修定。     

烧伤早期液体复苏患者水和电解质平衡状况分析

目的:回顾分析烧伤早期(伤后1-5d)乳酸纳林格氏液和血浆复苏患者的水、电解质和酸碱平衡状况,了解其中存在的问题和防治对策。方法:烧伤患者786例,其中小儿114例。烧伤总面积12％-96％,平均36±28％。伤后早期按照“瑞金公式”计算,采用乳酸纳林格氏液和血浆复苏方法,并根据监测指标调整。分析指标:伤后1-5d的每天乳酸纳林格氏液、血浆和水的输入量;每小时尿量;血、尿中电解质含量;血气分析;尿pH值。结果:血流动力学稳定735例(93.5％),48h内血清电解质和酸碱平衡正常,26例(3.5％)48h后出现低钠血症。延迟复苏或发生过休克51例(6.5％),输液量超过计算量20％以上,尿量一度<0.5ml·kg-1·h-1,均呈现低钠血症,25例合并低氯血症,13例出现代谢性酸中毒或混合性酸碱平衡紊乱。其中小儿12例,6例发生惊厥、抽搐。输注高渗盐溶液后改善。结论:(1)乳酸纳林格氏液和血浆混合输注补充血容量、预防休克的方法,对绝大多数烧伤患者是适宜和有效的。(2)对延迟复苏或有休克的患者,须根据患者的治疗反应增加补液量。(3)大量“等渗”电解质液和胶体液复苏,有引起低钠血症的倾向,应予关注。对此类患者,在乳酸纳林格氏液和血浆复苏的基础上,适量输注高渗盐液对提高复苏效率、减少液体负荷、预防和治疗低钠血症均是有益的。     

重度烧伤不同的烧伤面积对休克期补液量的影响

目的再探讨重度烧伤不同的烧伤面积对休克期补液量的影响,对伤后第1个24 h的常规补液公式[晶体与胶体总量(mL)=1.5×体重×烧伤面积,补液系数为常数1.5]提出完善的建议。方法回顾2005年1月~2011年10月间本院收治的69例烧伤面积大于30%、年龄18~70岁、伤后到入院时间少于4 h并且平稳度过休克期的烧伤患者,记录其烧伤面积、体重及伤后第1个24 h的晶体、胶体量,计算出补液系数Y=(晶体+胶体)/体重/烧伤面积,使用SPSS 17.0统计软件对补液系数Y与烧伤面积X进行直线回归分析,求得回归方程,得到补液系数与烧伤面积的关系。结果自变量烧伤面积X与因变量补液系数Y呈直线性相关,回归方程:Y=0.0124X+1.1865,回归方程及相关系数有统计意义(P<0.001)。结论大面积烧伤患者早期补液系数不应局限于常数1.5,重度烧伤休克期补液量与烧伤面积不宜仅考虑为直线相关,而应考虑为曲线相关。传统的第1个24h烧伤补液公式可调整为:晶体与胶体补液量(mL)=(0.0124×烧伤面积+1.1865)×体重×烧伤面积。     

严重烧伤休克期补液量影响因素的研究进展

烧伤休克是由于血浆外渗引起有效循环血量不足而在严重烧伤后早期呈现的影响病情发展与救治后果的全身性复杂病理生理过程与临床综合病症。成人烧伤面积超过20％、小儿超过10％就有可能发生休克．一般认为烧伤休克是血浆外渗引起有效循环血量不足的结果．而目前还缺乏防治毛细血管通透性增高的有效措施．液体复苏治疗仍然是平稳度过休克期最有效和必不可少的措施。国内外烧伤界学者在长期的临床实践和基础研究中发现，影响严重烧伤休克期补液量的因素多种多样．其中最为重要和相关的因素是烧伤面积与患者的体重．呈现出一定的规律性。根据这一点，早在20世纪50年代，首先由美国的Evans基于动物实验结果提出了第一个补液公式——Evans公式。其后经过各国烧伤界学者的不断改良和发展，逐渐形成适合于不同地域和特定条件的一系列烧伤抗休克补液公式。这些补液公式都继承了Evans公式的基本思想．以烧伤面积和体重作为核心因素来考虑补液量，在指导烧伤休克救治过程中发挥了巨大的作用。但随着对烧伤休克形成机制研究的不断深入、临床监测手段的不断发展以及对平稳度过休克期临床指标的不断完善，发现仅根据烧伤面积和体重来估计休克期补液量是不够的．影响严重烧伤休克期补液量的其他因素也不容忽视。本文仅就近年来国内外有关影响严重烧伤休克期补液量其他因素的研究进展综述如下。     

严重烧伤延迟复苏的快速补液治疗

目的大面积烧伤后,当体液丢失到一定程度便可导致低血容量性休克。延迟复苏会发生休克,需要加以大力复苏。本组病例观察在严重烧伤延迟复苏状况下,在临床上怎样通过补液迅速纠正休克。方法通过对41例烧伤面积大于50%TBSAⅡ度~Ⅲ度、因延迟复苏导致休克的患者,进行快速补液复苏。观察休克期补液量、尿量、脉搏、呼吸、TCO2等指标的变化。结果快速补液后2h内输人液体占第一个24h公式计算量的(40·1±5·6)%,第一个24h实际补入量占第一个24h公式计算量的(136·4±18·7)%;第二个24h实际补入量占第二个24h公式计算量的(120·6±5·8)%。快速补液后,尿量大幅增加,TCO2上升,未出现心肺功能不全情况,休克纠正率85%。结论烧伤休克延迟复苏需要加快补液速度、加大补液量,输液量不受输液公式的限制。快速补液可以迅速纠正休克。临床上通过尿量、脉搏、呼吸、血压变化及血中TCO2水平等临床指标来指导休克延迟复苏是可行的。     

延迟复苏治疗活动性失血性休克临床探讨

目的：探讨延迟复苏策略治疗重症活动性失血性休克在临床的应用实践。方法：延迟复苏组（A组）,限制输晶体液和胶体液量,扩容更多地依赖输血及血浆,控制目标血压以收缩压80~90 mm Hg（1 mm Hg=0.133 kPa）为允许性低血压;传统复苏组（B组）,不限制输晶体液和胶体液量,快速进行液体复苏。输液以晶体液和胶体液为主,输血及血浆为辅助,不有意控制血压上限。结果：A组抢救成活率显著高于B组。结论：在重症加强护理病房（ICU）临床上认识重症活动性失血性休克特殊性以及治疗的特殊性。应用延迟复苏方法,有望提高该类危重患者的治愈率。     

婴幼儿急腹症术中液体管理

婴幼儿并非成人的缩影,其体液代谢与成人不尽相同,手术室护土必须严格掌握婴幼儿术中的液体管理,尤其是急腹症婴幼儿术中液体输入种类的选择、输入量和速度的调节,对基层综合性医院的手术室护士来说尤为重要。本人就此方面体会如下,与同行共磋。1临床资料患儿共132例,男85例,女47例,年龄44天～3岁,体重4～且65kg,平均体重为8‘4kg。术中患儿输液情况见表三。晶体液：含糖等张乳酸林格氏液（DLR）液［l］,乳酸林格氏液LD、5％GS．09％NaCI液。肢体液：全血、血浆、血代。2或波方法2．1输液途径根据患儿的具体特点采用24～22G…     

大面积烧伤休克期的输液管理

烧伤引起全身微血管通透性增加,大量血浆液体港到体表外和组织间隙,导致有效循环血量减少,出现低血容量性休克。防治休克则是治疗严重烧伤的首要问题,而及时的液体复苏又是休克期平稳渡过的关键。现就我院治疗面积烧伤的输液管理介绍如下。1临床资料本组38例,男33例,女5例。年龄在10岁～44岁。烧伤面积均超过70％。致伤原因以火焰、热液为主,其次为火药、化学烧伤。入院时并发休克31例,吸入性损伤20例,合并伤5例。治愈30例,好转回当地治疗3例,死亡5例,均死于感染期。2输液管理根据197o年全国烧伤会议提出的补液公式：烧伤第一个…     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.