目的 对比纤维支气管镜肺灌洗治疗和常规治疗重症肺部感染患者的临床疗效。方法 将2015年5月—2017年4月间在我院接受治疗的92例重症肺部感染患者作为研究对象,按照随机数字表分为实验组(n=46)和对照组(n=46),其中对照组采用常规对症治疗,实验组加以实施纤维支气管镜肺灌洗治,治疗后,纤支镜气道灌洗检测两组患者的血气分析指标变化,采用ELISA测定血清炎症因子含量,及放射免疫法测定血清应激激素含量。结果 经比较,实验组患者治疗后的PaO₂、SaO₂、PaCO₂高于对照组患者(P<0.05);实验组患者的血清炎症因子hs-CRP、IL-6、IL-8水平低于对照组患者(P<0.05);此外,实验组患者的Ang-II、NE、Cor含量低于对照组患者(P<0.05)。结论 纤支镜气道灌洗可有助于改善重症肺部感染患者的肺通气功能,降低全身炎症应激程度,促进疾病康复。

Objective To compare the clinical efficacy of bronchoalveolar lavage and conventional treatment in patients with severe pulmonary infection. Methods 92 patients with severe pulmonary infection treated in our hospital from May 2015 to April 2017 were selected as research objects. They were randomly divided into experimental group (n=46) and control group (n=46). The control group was treated with conventional symptomatic treatment, The experimental group implemented bronchoscopy lung lavage treatment. After treatment, blood gas bronchoscopic airway lavage in two groups were detected with analysis indexes. Serum inflammatory factors were determined by ELISA, and the serum levels of stress hormones were determined by radioimmunoassay. Results After the treatment, the PaO₂, SaO₂ and PaCO₂ in the experimental group were higher than those in the controlgroup(P<0.05). The levels of serum inflammatory factors hs-CRP, IL-6、IL-8 in the experimental group were lower than those in the control group (P<0.05); in addition, the levels of Ang-II, NE and Cor in the experimental group were lower than those in the control group(P<0.05). Conclusion Bronchoscopy airway lavage may help to improve the pulmonary ventilation function of patients with severe pulmonary infection, reduce the degree of systemic inflammatory stress, and promote disease recovery.

目的 探讨及比较CURB-65、PSI、SMART-COP及APACHEⅡ 4种临床评分对重症社区获得性肺炎(SCAP)患者的早期诊断价值。方法 采用前瞻性研究方法,收集2011年10月—2014年2月广州市第一人民医院呼吸内科收治的67例SCAP及同期33例普通CAP患者的临床资料,记录入组后24小时内CURB-65、PSI、SMART-COP及APACHEⅡ评分的最差值,比较4种临床评分系统对SCAP的早期诊断价值。结果 SCAP组CURB-65、PSI、SMART-COP及APACHEⅡ评分均高于普通CAP组患者[CURB-65(分):3.06±1.10 比0.85±0.79,P<0.001;PSI(分):144.93±36.48比73.94±27.17,P<0.001; SMART-COP(分):6.54±1.41比 1.67±1.02,P<0.001; APACHEⅡ(分):20.79±5.69比7.94±3.87,P<0.001]。CURB-65≥3分、PSI≥130分、SMART-COP≥3分及APACHEⅡ≥15分诊断SCAP的受试者工作特征曲线(ROC)下面积(AUC)分别为0.940[95% CI:0.89~0.98, P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001],敏感度分别为65.6%、71.6%、100%、88.1%,特异度分别为100%、100%、78.7%、93.9%。结论 CURB-65及PSI评分特异度好,但敏感度低,易漏诊,SMART-COP和APACHE Ⅱ评分诊断效能更佳。

Objective To evaluate and compare the early diagnosis value of CURB-65,PSI,SMART-COP and APACHEⅡin patients with severe community-acquired pneumonia. Methods This was a prospective study conducted in department of respiratory in Guangzhou First People's Hospital. We included 67 SCAP patients and 33 CAP patients between October of 2011and February of 2014. The lowest scores within 24 hours of CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score,respectively,for each patients were recorded. Prediction of SCAP as made in four scoring systems was compared. Results CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score were higher in SCAP as compared with that of CAP(CURB-65:3.0±1.1 vs 0.9±0.8,P<0.001;PSI:144.6±36.4 vs 73.9±27.1,P<0.001; SMART-COP:6.5±1.4 vs 1.6±1.0,P<0.001; APACHEⅡ:20.6±5.6 vs 7.9±3.8,P<0.001). ROC curve for CURB-65 score≥ 3 scores,PSI score≥ 130 scores,SMART-COP score≥3 scores and APACHE Ⅱ score ≥ 15 scores in the early diagnosis SCAP were 0.940[95%CI:0.89~0.98,P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001]. Sensitivity of four kinds of scoring system was 65.6%,71.6%,100%,88.1%, with specificity of 100%,100%,78.7%,93.9% respectively. Conclusion The specificity of diagnosis was better in the CURB-65 and PSI score,but the sensitivity was low and easy to miss diagnosis. SMART-COP and APACHEⅡscore systems had a better diagnostic value on SCAP.

目的 探讨标准化沟通模式在重症孕产妇院前转运前评估与交接环节中的应用效果。方法 设计转运前标准化沟通信息登记表,用以标准化转运前评估与交接环节,护士按照登记表中的项目逐条交接,对方未交代的项目护士进行主动评估,并将结果登记并汇报接诊医生。结果 运用标准化沟通模式后,有效缩短了转诊的通话时间和抵院后的处理时间,护士评估信息的错漏率由13.84%降低至4.23%,交接不清导致的不良事件发生率由7.41%降至1.21%,并在改善母婴结局等方面均取得较好效果。结论 SBAR 沟通模式在重症孕产妇孕前转运的评估和交接环节中保证了重要信息的准确传递,为重症孕产妇的救治争取宝贵时间,值得临床上推广应用。

Objective To explore the application effects of SBAR (situation, background, assessment and recommendation) communication mode in the transfer of critically ill obstetric women. Methods A transfer from based on SBAR communication mode was designed and used to assess the psychological status and illness condition of critically ill obstetric women. Results After the application of SBAR communication transfer model, the communication time and hospital action time were both shortened and the occurrence of transfer problems decreased,while the pregnancy outcomes were improved (P＜0.05). Conclusion Applying SBAR communication mode in the transfer of critically ill obstetric women is helpful to reduce the transfer time and the occurrence of transfer problems,and improve the quality of patient handover.

目的 探讨红细胞分布宽度(RDW)与老年重症社区获得性肺炎(CAP)患者病情严重程度及预后的相关性。方法 将103例老年重症CAP患者按照近期预后分为存活组(n=83例)及死亡组(n=20例),按照RDW的水平分为RDW≥14.5%组(n=83例)和RDW＜14.5%组(n=20例);记录患者的一般临床资料及相关实验室检查指标,比较各组之间的差异,并利用Logistic回归模型分析老年重症CAP患者近期死亡的危险因素。结果 死亡组中的患者入院APACHEⅡ评分、CRP、PCT、RDW水平均高于存活组,差异有统计学意义(P＜0.05)。RDW 异常率随着PSI 级别的增高而增高,RDW 异常率分别为PSIⅠ-Ⅱ级7.32%(3/41、 PSI Ⅲ级16.67%(6/36)、PSI Ⅳ级39.13%(9/23)、PSIⅤ级 66.67%(2/3),差异有统计学意义(P＜0.05)。Spearsman相关性分析显示:RDW与APACHEⅡ评分、CRP、PCT、PSI评分呈正相关(r_s分别为=0.353,0.363,0.432,0.362,P均＜0.05)。多因素Logistic回归分析显示: RDW(OR=2.024,P＜0.05)是老年重症CAP患者近期死亡的独立危险因素。结论 RDW水平随着老年重症CAP患者病情严重程度的增加而增加,RDW增高亦是患者近期死亡的高危因素。

目的 探讨重症急性胰腺炎诊治特点。方法 回顾性分析13例重症急性胰腺炎患者临床资料,包括一般资料、生化检测及影像资料、治疗措施与预后结果,纳入标准为急性胰腺炎合并器官衰竭＞48 h(改良Marshall评分≥2分)。结果 重症急性胰腺炎患者一般资料中普遍突出存在心率增快(121.07±28.09)次/分、APACHE II评分偏高(18.92±7.34),病因排序则是高脂血症(38.5%)＞胆石症(30.8%)＞酒精性(23.1%),SAP合并ARDS发生率可达46.2%,合并AKI则高达69.2%;WBC(12.60±5.57)×10⁹/L、CRP(138.16±67.06)mg/L及PCT(15.76±27.33)ng/L等炎症指标升高提示SAP普遍存在炎症反应,影像学中69.2%患者合并发生肺炎及腹腔积液则提示多处感染部位,其他脏器指标异常升高也提示SAP患者心肺肝肾均存在不同程度的受损;接受CRRT治疗及呼吸支持可分别达46.2%及76.9%,7天内死亡例数为1例(7.7%),28天内死亡例数为4例(30.8%),ICU及总住院时间为(10.77±7.38)及(19.61±13.40)天。结论 重症急性胰腺炎是全身及局部性的炎症反应累及全身各个脏器的急性复杂病变,以合并发生ARDS及AKI为临床特征,需要多器官功能保护与替代、外科干预等多学科综合协作治疗。

Objective To evaluate characteristics of diagnosis and treatment on severe acute pancreatitis. Methods To respective analysis clinical data of 13 patients with severe acute pancreatitis. The data included baseline characteristics, biochemical tests and imaging data, treatment and prognosis, inclusion criteria for acute pancreatitis with organ failure > 48 h (modified Marshall score > 2). Results Higher heart rate(121.07±28.09) times/min and APACHEII scores(18.92±7.34) were universally found in SAP, which primary disease contained hyperlipidemia (38.5%) > cholelith disease (30.8%) > alcohol (23.1%) with incidence of ARDS and AKI being 46.2% and 69.2%; Higher inflammatory biomarkers including WBC(12.60±5.57)×10⁹/L, CRP(138.16±67.06)mg/L and PCT(15.76±27.33)ng/L indicated widespread inflammation with many infection sites revealing by 69.2% pneumonia and peritoneal effusion on imaging; Other abnormally biochemical index prompted some injury of viscera including heart, lungs, kidney and liver; 1 case suffered death within 7 days and 4 cases also did within 28 days, ICU and total length of hospital stay was (10.77±7.38) and (19.61±13.40) days, CRRT treatment and respiratory support respectively reached 46.2% and 46.2%. Conclusion Severe acute pancreatitis is a acute complex pathological changes on various organs induced by acute systemic and local inflammation with feature of mergence with the ARDS and AKI, which need the multidisciplinary integrated collaborative treatment on organ function protection and sustain and surgical intervention.

目的 研究探讨重症监护病房(ICU)病原菌的分布及耐药情况,为临床合理使用抗菌药物提供科学依据。方法 回顾性分析2015年ICU住院患者送检细菌分离培养及药敏试验结果。结果 ICU共送检标本1 326份,分离出病原菌554株,其中革兰阴性病原菌462株(83.4%),革兰阳性病原菌48株(8.7%),真菌44株(7.9%)。革兰阴性杆菌前5位依次为鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷伯菌、粘质沙雷菌和大肠埃希菌,且多耐药菌株比例较高。革兰阳性病原菌以金黄色葡萄球菌为主,32株(66.7%),MRSA检出率78.3%(25/32)。结论 加强重症监护病房的细菌及药敏监测,根据病原菌药敏结果指导临床合理使用抗菌药物,控制耐药菌株的产生,预防及控制院内感染及感染暴发。

Objective To investigate the distribution characteristics and drug resistance of pathogenic bacteria in intensive care unit(ICU) and provide scientific evidence for clinically reasonable use of antibiotics. Methods Specimens from hospitalized intensive care unit patients in 2015 were obtained for routine bacterial isolation and culture. Results A total of 554 bacterial strains were isolated from 1326 specimens, in which Gram-negative bacilli accounted for 462 stains (83.4%),Gram-positive cocci accounted for 48 stains (8.7%),and fungi accounted for 44 stains (7.9%). Gram-negative bacilli of the top five were Acinetobacter baumannii,Pseudomonas aeruginosa,Klebsiella pneumoniae, Serratia marcescens and Escherichia coli,and the rate of multiple resistant bacteria was relatively high.Staphylococcus aureus were the main Gram-positive cocci, including MRSA accounted for 78.3%(25/32). Conclusion The monitoring of ICU clinical pathogens and their resistance should be strengthened. It is a great significance to use antibiotics rationally according to the results of susceptibility testing, in order to control the occurrence of resistant bacteria , prevent and control hospital infection and infection outbreak.

目的 探讨颅脑超声在高危新生儿颅内疾病的诊断应用。方法 2010年7月—2014年6月间在我院新生儿重症监护室(NICU)813例新生儿应用百胜Mylab Five型彩色多普勒超声诊断仪,探头频率5～7.5 MHz,进行常规颅脑超声检查。患儿取仰卧位,经前囱作矢状切面及冠状切面按顺序扫查,重点扫查几个标志性切面。头皮留置针遮盖前囟者先予拔除,以保证检查顺利进行。结果 超声异常者85.73%(697/813)。其中颅内出血45.62%(318/697)。早期脑室周围—脑室内出血(PIVH)88.05%(280/318),以I级和II级为多;大脑出血4.40%(14/318);丘脑出血2.22%(7/318);小脑出血1.89%(6/318);蛛网膜下腔出血1.89%(6/318);硬膜下出血1.57%(5/318)。缺氧缺血性脑损伤(HIHB) 36.01%(251/697)。足月儿缺氧缺血性脑病(HIE)67.33%(169/251),轻度HIE52.59%(132/251),中重度HIE14.74%(37/251)。早产儿缺氧缺血性脑病(PVL)33.67%(82/251),化脓性脑膜炎3.30%(23/697)。脑积水15.06%(105/697),以外围性脑积水多见。出院前复查: I度及II度PIVH大部分吸收,III级及IV级PIVH可见侧脑室扩大、脑实质液化性囊腔。大脑出血、丘脑出血、小脑出血均有不同程度吸收,严重者遗留液化性囊腔,蛛网膜下腔出血及硬膜下出血亦有不同程度地吸收。轻度HIE大部分恢复正常,中重度HIE 均有脑室扩大、脑萎缩、液化性囊腔。PVL后期见囊泡性改变。化脓性脑膜炎后期可见硬膜下积液及梗阻性脑积水。结论 颅脑超声便携,可床边,价廉,可重复,具有较实用临床应用价值。适用于新生儿颅内疾病的筛查及诊断。对脑中线部位脑室周围—脑室内出血,对脑积水的程度、预后具有特异性诊断价值。它可提示颅内病变类型、程度、部位及动态监测病情进展情况。对某些颅内病变如蛛网膜下腔出血,硬膜下腔出血,小脑出血则需要结合CT、MRI等其它影像技术,为临床诊断提供依据。

目的 调查重症监护病房(ICU)医院感染的常见细菌分布及耐药性变化,为合理使用抗生素和医院感染的预防控制提供相关科学依据。方法 回顾性分析医院2007—2011年ICU收治的381医院感染患者感染菌株分布特点及耐药性情况。结果 ICU医院感染常见菌株主要来源于痰液标本,占78.2%,其次是血液。381 株临床分离菌中共检出革兰阴性杆菌262 株、革兰氏阳性球菌70例和真菌49例,分别占68. 8%、24.9%和占17.4%。革兰阴性杆菌中鲍氏不动杆菌(24.7%)、肺炎克雷伯氏杆菌(10.8%)、铜绿假单胞菌(9.2%)排前三位。其中除碳青霉烯类药物及抑酶制剂,鲍氏不动杆菌对其余抗菌药物耐药率均＞40%。革兰氏阳性球菌以金黄色葡萄球菌为主。对青霉素、庆大霉素、红霉素的耐药率均＞50%。结论 呼吸道仍是ICU最常见的感染部位。病原菌以革兰阴性杆菌为主,且对常用抗菌药物的耐药率逐渐升高,临床应加强抗菌药物规范使用,避免耐药菌株的产生。

Objective To investigate the distribution and drug resistance of pathogens in intensive care unit(ICU)causing nosocomial infections so as to provide scientific basis for antibiotic adoption and the prevention and control of nosocomial infections. Methods The specimen sources and the clinical distribution of the 381 pathogens isolated from 2007 to 2011 were retrospectively analyzed. The drug resistance was observed in ICU that causing nosocomial infections. Results The sputum was the major specimens source in ICU, accounting for 78.2%. Of the 381 pathogens causing nosocomial infections in ICU, the 262 gram-negative bacilli (68.8%), 70 gram-positive cocci (24.9%),and 49 fungi (17.4) were isolated, Among gram-negative bacilli the top three were acinetobacter baumannii (24.7%), klebsiella pneumonia(10.8%),and pseudomonas aeruginosa (9.2%). The drug resisitance rate of baumannii to antibiotics were more than 40%,beside carbapenem and B-Lactamaseinhibitors. The main gram-positive cocci of causing nosocomial infections was saphylococcus aureus in ICU. The drug resisitance rate of S. aureus to penicillin, erythromycin and gentamicin were higher than 50.0%. Conclusion The main distribution area of nosocomial infections was the respiratory tract and the gram-negative bacilli were the common pathogens in ICU. It was benefit to avoid presenting of drug resistant strain, and antibiotics should be reasonably used in clinic.

目的 确定CD4⁺CD25⁺Treg调节性T细胞在重症肺炎克雷伯菌肺炎中的表达以及意义,探讨CD4⁺CD25⁺Treg在重症肺炎克雷伯菌肺炎的免疫抑制中的调控作用。方法 通过气管内滴注肺炎克雷伯菌菌液建立重症肺炎模型。采用流式细胞仪检测CD4⁺CD25⁺Treg细胞及酶联免疫吸附法(ELISA)等方法检测各种细胞因子。结果 重症肺炎克雷伯菌肺炎大鼠的脾脏和肺中CD4⁺CD25⁺Treg的数量增加。使用了CD25抗体(PC61)去除机体内源性的CD4⁺CD25⁺Treg,分别去除脾脏和肺的94%和90%的CD4⁺CD25⁺Treg。CD25抗体组在建模4 h,12 h及24 h后,肺部MPO及血清IL-1,IL-6,MIP-2较对照组高(P<0.05),肺和BLA比对照组高(P<0.05),CD25抗体组大鼠生存率比对照组低(P<0.05)。结论 内源的CD4⁺CD25⁺Treg对大鼠抑制重症肺炎克雷伯菌肺炎的过度免疫损害反应起到保护作用。

Objective To confirm the expression and meaning of the T regular cell in the severe Klebsiella pneumonia, and to evaluate the regular and control affect in the immunologic suppression of the severe Klebsiella pneumonia. Methods To build the severe pneumonia model by intratracheally inoculated with Klebsiella pneumoniae bacteria. To check sorts of inflammation factors by the methods of ELISA and flow cytometry. Results The quantity of the CD4⁺CD25⁺Treg in the splenic and lungs of the mice with severe Klebsiella pneumonia were increased. Anti-CD25Ab(PC61) was used to remove endogenousCD4⁺CD25⁺Treg. Anti-CD25 treatment remove 90% of CD4⁺CD25⁺Treg cells. The cytokine production(IL-1β,IL-6,MIP-2)in the anti-CD25-treated group were significantly increased. And it also increased significantly in the airway neutrophil infiltration, while the survival rate had been decreased. Conclusion Endogenous CD4⁺CD25⁺Treg can provide obvious protection effect to the restraining the over immunity damage of the severe Klebsiella pneumonia for the mice.

       目的   探讨支气管镜灌洗用于儿童重症肺部感染合并肺实变的治疗效果及对CT特征、肺功能的影响。方法   选取2022年5月—2024年5月铜仁市人民医院收治的100例重症肺部感染合并肺实变患儿开展前瞻性研究，应用随机数表法分为对照组和观察组，每组各50例。对照组患儿采取常规治疗，观察组则采取常规治疗加支气管镜灌洗治疗。对比其临床疗效，治疗前后炎症因子、CT特征及肺功能变化。结果   观察组治疗总有效率高于对照组（P＜0.05）；治疗后观察组患儿白细胞计数（10.36±2.52）×10⁹ /L、白细胞介素-6（20.57±5.05）ng/L、C反应蛋白（13.12±2.64）mg/L、降钙素原（101.62±12.16）pg/L均低于对照组白细胞计数（13.25±3.32）×10⁹ /L、白细胞介素-6（31.69±4.11）ng/L、C反应蛋白（16.16±4.44）mg/L、降钙素原（113.46±18.11）pg/L（P＜0.05）；治疗后两组患儿胸腔积液、支气管壁增厚、空气支气管征、肺部实变、磨玻璃影等相关CT影像特征占比下降，且观察组低于对照组（P＜0.05）；治疗后两组患儿呼气流量峰值水平均升高，观察组（90.67±18.45）L/s高于对照组（81.27±17.69）L/s，用力肺活量水平均更高，观察组（3.33±0.68）L高于对照组（2.68±0.25）L（P＜0.05）。结论   针对儿童重症肺部感染合并肺实变，在常规治疗基础上增加支气管镜灌洗可提升临床疗效，减轻机体炎症反应，改善胸部CT各种表现及肺功能。

        Objective  To explore the therapeutic effects of bronchoalveolar lavage in children with  severe pulmonary infection complicated by lung consolidation and its impact on CT features and pulmonary function．Methods A prospective study was conducted on 100 children with severe pulmonary infection complicated with pulmonary consolidation in a hospital from May 2022 to May 2024．They were randomly divided into observation group and control group using a random number table method，50 cases in each group．The control group of children received routine treatment，and the observation group received conventional treatment plus bronchoalvelar lavage．Clinical efficacy，inflammatory factors，CT features，and alterations in pulmonary function before and after therapy were compared．Results  The total effective rate of the observation group was higher than that of the control group（P＜0.05）．After treatment，the white blood cell count（10.36±2.52）×10⁹ /L，interleukin-6（20.57±5.05）ng/L，C-reactive protein（13.12±2.64）mg/L，and procalcitonin（101.62±12.16）pg/L in the observation group were all lower than those in the control group（13.25±3.32）×10⁹ /L，interleukin-6（31.69±4.11）ng/L，C-reactive protein（16.16±4.44）mg/L，and procalcitonin（113.46±18.11）pg/L（P＜0.05）．After treatment，the proportion of CT imaging features such as pleural effusion，bronchial wall thickening，air bronchogram sign，lung consolidation，ground glass opacities，decreased in both groups of children，and the observation group was lower than the control group（P＜0.05）．After treatment，the peak levels of expiratory flow in both groups of children increased，with the observation group（90.67±18.45）L/s higher than the control group（81.27±17.69）L/s．The forced vital capacity levels were also higher，with the observation group（3.33±0.68）L higher than the control group（2.68±0.25）L（P＜0.05）．Conclusions  Adding bronchoalvelar lavage to routine treatment for children with severe pulmonary infection complicated with pulmonary consolidation can improve their clinical efficacy，alleviate inflammatory reactions，and improve various chest CT manifestations and lung function．