目的 评价围术期目标导向液体治疗用于老年高危患者的优越性。方法 50例行择期全髋关节置换术的老年患者,随机分成传统液体治疗组(C组)和目标导向治疗组(GDT组),每组25例。C组以MAP和CVP为指导进行围术期液体管理,GDT组以每搏量(SV)和氧供指数(DO₂I)最大化进行围术期液体管理。观察和比较两组患者围术期液体出入量、MAP、HR、SV和CI等参数。结果 GDT组总输液量、晶体液和胶体液的输注总量均高于C组(P＜0.05);GDT组各时点MAP、HR、SV和CI高于C组(P＜0.05),与基础值比较,GDT组无变化,而C组在麻醉后和应用骨水泥后,MAP、HR、SV和CI一过性下降(P＜0.05)。结论 与传统围术期液体管理方案相比,以SV和DO₂I最大化为目标的GDT方案用于高危病人全髋置换手术,能使心脏前负荷处于更理想的充盈状态,血流动力学更稳定,并能有效预防骨水泥引起的循环抑制作用。

Objective To evaluate the priority of goal-directed fluid therapy(GDT) in high risk elderly patients. Methods Fifty elderly patients undergoing total hip replacement were randomly divided into traditional fluid therapy group(group C) and goal-directed fluid therapy group(group GDT). Group C received perioperative fluid management based on MAP and CVP, while Group GDT received goal-directed fluid therapy based on SV and DO₂I optimization. MAP, HR, SV, and CI were recorded at different time points; the intraoperative blood loss, fluid volume, and urine volume were also recorded. Results The total fluid volume, colloid volume and crystal volume of group GDT were much more than group C(P＜0.05); the intraoperative MAP, HR, SV, and CI in group GDT were much higher than group C(P＜0.05); compared withbaseline of MAP, HR, SV, and CI, there were no obvious change in group GDT, while there were significant decline in group C, especially after anesthesia and implantation of bone cements(P＜0.05). Conclusion Compared with traditional fluid management strategy, SV and DO₂I optimization based goal-directed fluid therapy has a significant priority in high risk elderly patients undergoing total hip replacement.It can maintain better preload and provide more stable hemodynamic status, and prevent cardiac side effect induced by implantation of bone cements

目的 探讨不同年份CLSI文件中头孢吡肟折点变化对肠杆菌科细菌药敏结果的影响,辅助临床合理调整用药。方法 应用2013年(S23)与2014年(S24)CLSI文件中的头孢吡肟折点回顾性分析我院2014年肠杆菌科细菌的药敏变化情况。结果 与S23折点相比,肠杆菌科细菌中大肠埃希菌、肺炎克雷伯菌对头孢吡肟的耐药率分别上升了2.6%、2.8%,耐药率差异有统计学意义(P<0.05);产ESBLs大肠埃希菌、产ESBLs肺炎克雷伯菌以及非产ESBLs肺炎克雷伯菌对头孢吡肟的耐药率分别上升了3.8%、2.4%、2.0%,耐药率差异有统计学意义(P<0.05); 对于其它肠杆菌科细菌如非产ESBLs大肠埃希菌、阴沟肠杆菌等对头孢吡肟的耐药率变化无差异(P>0.05)。与S23相比,在S24中头孢吡肟MIC值分布在4 μg/mL、8 μg/mL、16 μg/mL时对细菌的药敏变化最为显著。结论 依照S24折点,肠杆菌科细菌对头孢吡肟的耐药率有不同程度的升高;尤其对产ESBLs菌株耐药率影响更大;临床应结合实验室报告合理调整用药。

Objective To investigate the change of the break point of the CLSI in different years on the drug sensitivity of Enterobacteriaceae bacteria. This is valuable for rational use of antibiotics. Methods To retrospective analyze 2014 Enterobacteriaceae bacteria susceptibility variation by CLSI file cefepime breakpoint of 2013(S23) and 2014(S24). Results Compared with breakpoint of S23, E. coli and Klebsiella pneumonia, cefepime resistant rate rose by 2.6% and 2.8% respectively, and the resistance difference was statistically significant (P<0.05); ESBLs-producing E. coli, ESBLs-producing Klebsiella pneumoniae and ESBLs non-producing Klebsiella pneumoniae toword cefepime resistant rate rose by 3.8%, 2.4% and 2.0% respectively, and the resistance difference was statistically significant (P<0.05); For other Enterobacteriaceae bacteria, such as ESBLs non-producing E. coli and Enterobacter cloacae with cefepime in drug resistance rate had no significant difference (P>0.05). Compared with S23, variety in drug susceptibility of bacteria was most significant in S24, during cefepime MIC of 4 μg/mL, 8 μg/mL, 16 μg/mL. Conclusion According to the S24 breakpoint, the drug resistance rates of the bacteria in the intestines of the bacteria is increasing, especially in ESBLs strain; antibiotics use should be following laboratory results.

目的 统计分析2011—2014年我院分离的肠杆菌科细菌数据,探讨耐碳青霉烯肠杆菌科细菌(CRE)的流行特征。方法 收集肠杆菌科细菌,根据药敏结果筛选出CRE菌株,并对相关临床资料进行统计分析。结果 共分离得到CRE菌株187株,标本来源依次为尿液(32.6%)、痰液(28.9%)和血液(10.7%)。从科室分布来看,39.0%的菌株来自重症监护室病区,23.0%的菌株来自泌尿外科病区,在其它病区呈散发分布。菌株的种属分布方面,肺炎克雷伯菌的比例为39.6%, 大肠埃希菌的比例为20.9%;从病人年龄构成来看,50岁以上高龄患者的分离比例达74.4%。CRE的分离数目随年份的递增而不断升高。结论 耐碳青霉烯肠杆菌科细菌的流行率呈现逐年递增的趋势,临床应合理使用相关抗生素,预防和控制CRE在医院环境中的流行。

Objective To investigate the epidemiological features of carbapenem resistant Enterobacteriaceae in a collection of clinical Enterobacteriaceae strains isolated during 2011-2014 from our hospital. Methods The Enterobacteriaceae strains were collected and CRE strains were screened by their resistance to carbapenems. Clinical information was analyzed to characterize the epidemiological traits of CRE strains. Results The total number of CRE isolates was 187. These CRE strains were isolated from various clinical specimens, including urine(32.6%), sputum (28.9%), blood (10.7%), and so on. These strains were frequently isolated from intensive care units (ICU) (39.0%) and department of Urology (23.0%). The most frequently isolated species were Klebsiella pneumoniae (39.6%), Escherichia coli (20.9%). The isolation rate is much higher in elderly patients more than 50 years old (74.4%). The percentage of CRE isolates were kept on increasing by years. Conclusion The prevalence carbapenem resistant Enterobacteriaceae in our hospital is increasing every year and it is important to prevent and control the transmission and outbreaks of CRE in the hospital by proper use of related antibiotics in clinical treatment.

目的 了解中山市7家医院金黄色葡萄球菌感染的临床分布,并对耐药基因进行检测,为临床经验治疗金黄色葡萄球菌感染提供用药及分子生物学依据。方法 收集2015年1月—2015年6月中山市7家医院分离到的金黄色葡萄球菌,使用ATB半自动细菌鉴定及药敏分析仪(法国梅里埃)对分离到的菌株进行鉴定及药敏试验,使用PCR技术对耐甲氧西林金黄色葡萄球菌(MRSA)的耐药基因进行检测。结果 7家医院共分离到89株金黄色葡萄球菌,其中MRSA检出33株,检出率为37.1%。金黄色葡萄球菌主要来源于呼吸内科(32株,36.0%)、骨科(20株,22.5%),主要分离自痰(41株,46.1%),伤口分泌物(16株,18%),对万古霉素、替考拉宁、奎奴普丁/达福普丁、复方新诺明、左氧氟沙星、诺氟沙星具有较高敏感性,MRSA对常用抗菌药物耐药率高于甲氧西林敏感金黄色葡萄球菌。共有32株MRSA检出bla_mecA基因,检出率为97%。结论 MRSA耐药情况较为严峻,临床科室应根据微生物培养报告合理使用抗菌药物。bla_mecA基因在MRSA检出较高,是MRSA主要的耐药机制。

Objective To analyze clinical distribution of Staphylococcus aureus infections from 7 hospitals in Zhongshan city, as well as to provide basis of empirical treatment and molecular biology for Staphylococcus aureus infections. Methods Staphylococcus aureus were collected from January 2015 to June 2015 in Zhongshan city, and then the strains were identified and tested antibiotic susceptibility by using ATB semiautomatic analyzer(Merieux). Resistance gene of methicillin-resistant Staphylococcus aureus(MRSA) was detected by polymerase chain reaction. Results 89 strains of Staphylococcus aureus were isolated from 7 hospitals and with prevalence of 33 strains of MRSA. Of all strains, 32(36.0%) were isolated from respiratory medicine and 20(22.5%) from orthopedics. 41(46.1%) strains of Staphylococcus aureus were isolated from sputum and 16(18.0%) from wound secretion. 89 strains of Staphylococcus aureus had highly susceptibility to vancomycin, teicoplanin, quinupristin/dalfopristin, cotrimoxazole, levofloxacin, norfloxacin. Resistance rates to commonly used antimicrobial drugs of MRSA were significantly higher than methicillin-sensitive. A total of 32 MRSA were detected carrying bla_mecA gene with the detection rate of 97%. Conclusion Clinical departments should be based on microbial culture report for rational use of antibiotics because of MRSA with more serious drug resistance. The gene of bla_mecA is the main mechanism of resistance for MRSA.

目的 探讨小脑延髓池注射纳洛酮对心肺复苏大鼠脑神经保护的作用机制。方法 将30只雄性SD大鼠随机分为假手术组、常规复苏组和纳洛酮复苏组。采用窒息法建立大鼠心脏骤停模型,复苏的同时给予药物治疗。恢复自主循环(ROSC)后24 h取脑组织,荧光定量PCR法检测脑组织c-Fos mRNA表达水平,免疫组化法检测脑组织c-Fos蛋白的表达。结果 与常规复苏组比较,纳洛酮可显著降低大鼠脑组织c-Fos mRNA及蛋白表达量(P<0.01)。结论 小脑延髓池注射纳洛酮可及时有效的作用于c-Fos基因,发挥脑神经保护作用。

Objective To investigate the neuroprotective mechanism of naloxone injected into cisterna magna on cerebral ischemia-reperfusion. Methods Thirty adult male SD rats were randomly divided into sham group, conventional cardiopulmonary resuscitation (CPR) group and naloxone CPR group. Asphyxiation was used to set up rat cardiac arrest model, and corresponding drugs were given when the resuscitation was carried out. The Brain tissues were taken at 24 h after restoration of spontaneous circulation(ROSC). Fluorescence quantitative polymerase chain reaction (PCR) and immunohistochemical was used to detect the expression of c-Fos proteins was used to detect the expression of c-Fos mRNA level. Results Compared with the conventional CPR group, Naloxone could significantly decrease the expression of c-Fos protein and c-Fos mRNA in rat brain. Conclusion Naloxone injected into cisterna magna can promptly and effectively act on c-Fos gene, playing a neuroprotective role.

目的 探讨糖尿病胃轻瘫大鼠不同血糖水平对Cajal间质细胞(ICC)的影响及其机制。方法 选择雌性Wista大鼠60只进行随机分组,实验组40只,对照组20只。实验组糖尿病Wista大鼠模型以单次腹腔注射链脲佐菌素法诱导。免疫组织化学荧光染色检测不同血糖浓度大鼠胃ICC数量及网络结构。结果 实验组大鼠血糖浓度高于对照组,ICC数量,低于对照组,且比较差异有统计学意义(P<0.05)。实验组大鼠中血糖浓度越高,ICC数量越低,说明血糖浓度升高可能与平滑肌及神经末梢之间缝隙连接的减少及其ICC网络的超微结构损伤及异常有关。结论 DM小鼠胃组织中血糖水平的升高,可能是DM胃中ICC数量减少的原因;外源性降低血糖能改善DM相关的胃肠道ICC病变。

Objective To observe the effects of glucose fluctuations on Cajal interstitial cells (ICC) of rats with diabetic gastroparesis(DGP) and its mechanistic. Methods 60 Wistar rats were selected and randomly divided into two groups. 20 rats in experimental group and 40 rats in control group. Used immunofluorescence staining to detect the amount of gastric ICC and network structure in DGP rats with different glucose levels. Results The blood glucose concentration in the experimental group was significantly higher than that in the control group, the amount of ICC in the experimental group was significantly lower than that in the control group(P<0.05). The amount of ICC decreased with the increase of glucose levels. In the experimental group, The gap junctions between smooth muscle and nerve endings, ultrastructural damage and abnormalities of the ICC network were probably related to glucose level. Conclusion The increase of glucose level was probably the cause of the decrease of the amount in ICC. Exogenousy decrease glucose levels probably can help to improve the lesion of ICC with DGP.

目的 研究分析甲强龙静脉注射对老年腹部全麻术患者血流动力学和呼吸动力学的影响。方法 选取2014年3月—2015年3月拟于我院行腹部全麻手术的老年患者76例,随机分为实验组和对照组,每组38例,均对其行全身麻醉。两组病人麻醉诱导用药咪达唑仑0.05 mg/kg,速眠安0.15 mg/kg,乙咪酯 0.2 mg/kg,气管插管后连接麻醉呼吸机。麻醉维持咪达唑仑和速眠安各0.05 mg/kg,给予实验组静脉注射甲强龙1 mL(40 mg),对照组静脉注射生理盐水1 mL。记录两组患者给药前(T₁)、给药后10 min(T₂)、20 min(T₃)、30 min(T₄)、40 min(T₅)的气道峰压(Ppeak)、气道平台压(Pplat)、肺的顺应性(Compl)、气道阻力(Raw)等呼吸动力学参数值。以及两组患者给药前20 min(T₀)和T₁～T₃患者的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)和心率(HR)等血流动力学参数值,并于以上各时间点采取两组患者静脉血测定其血浆中cAMP和cGMP含量。观察比较两组患者各时间点的数据变化以及拔管后10 min(T₆),15 min(T₇)和35 min(T₈)的RAMSAY镇静评分和RASS评分。结果 实验组在T₂～T₅时Compl明显增高,而同期Ppeak、Pplat、Raw则降低(P＜0.05)。与对照组相比较,实验组在T₀到T₄的SBP、DBP、MAP和HR无差异,且各时间点的数值低于同期对照组。两组患者在T₀和T₃cAMP和cGMP含量比较无差异,实验组cAMP和cGMP含量在T₁和T₂时低于对照组,两组患者在T₈时的Ramsay评分和RASS评分比较差异无统计意义,但实验组患者在T₆和T₇时的镇静评分高于对照组(P＜0.05),而同一时间点的RASS躁动——镇静量表评分则低于对照组(P＜0.05)。结论 甲强龙静脉注射能稳定老年腹部全麻术患者的血流动力学和呼吸动力学,抑制手术过程中的应激反应,改善苏醒质量和镇静效果,值得临床上推广使用。

目的 探讨清洁手术在围手术期间所出现的抗菌药物不合理现象的危险因素,提出应对措施。方法 选用我院普外科收治的四种清洁手术(骨折内固定取出手术、乳腺手术、甲状腺手术和疝气手术)患者460例,对所有患者在围手术期间抗菌药物的应用情况进行研究,并对其不合理使用危险因素进行多因素logistic回归分析。结果 患者在清洁手术中抗菌药物的应用率为100%,其中头孢菌素类药物的使用率最高,喹诺酮类药物次之,四种清洁手术的术后用药时间均>7天。对患者资料进行多因素logistic回归分析结果显示,围手术期抗菌药物的不合理使用危险因素主要包括无指征预防使用抗菌药物、给药时间不当、术后用药时间过长、药物选用不合理等七种危险因素(P<0.05)。结论 当前清洁手术的围手术期中,存在着抗菌药物不合理使用的情况,临床诊治过程中应强化科学应用意识和合理化使用观念,确保医药资源的充分利用。

目的 了解2014年广州地区儿童专科医院的病原菌分布及耐药情况与全国细菌耐药监测网(CARSS)公布数据的异同点,并提出相关用药建议,为儿童临床合理应用抗生素提供科学依据。方法 将2014年本中心儿童院区检测的儿童细菌耐药数据与同期国家卫生计生委合理用药专家委员颁布的CARSS数据进行比较。结果 儿童医院与CARSS数据比较,革兰阳性菌比例较高(49.8% vs 28.5%),革兰阴性菌比例较低(50.2% vs 71.5%);肺炎链球菌、化脓性链球菌及流感嗜血杆菌检出率较高;耐药率明显升高的是肺炎链球菌对青霉素耐药率(33.2% vs 4.3％),耐药率明显降低的是鲍曼不动杆菌对碳青霉烯类耐药率(10.3% vs 57.0％),大肠埃希菌对喹诺酮类耐药率(27.6% vs 54.3％)。结论 广州地区儿童病原菌分布及耐药情况与CARSS数据比较有一定差异,特别是儿童主要致病菌肺炎链球菌对青霉素耐药的形势严峻,经验性抗感染治疗时需考虑本地及儿童的病原菌特殊性。

目的 探讨S100B蛋白水平与进展性脑梗塞病情的相关性,分析不同 S100B 蛋白含量的患者预后情况。方法 选取2011年10月—2012年9月在我院接受治疗的急性进展性脑梗死患者80例为研究对象。比较不同脑损害程度,进展性脑梗塞患者S100B蛋白含量及NIHSS评分动态变化。结果 急性进展性脑梗死患者血清S100B蛋白含量在治疗后第1、3、7天均升高(P＜0.05),且第3天达最高,最高值随着脑梗死面积的增大而增加,第14天下降至最低,与对照组相比,差异有统计学意义(P<0.05)。急性进展性脑梗死患者NIHSS评分与治疗前相比,在治疗后第1、3、7天均升高(P＜0.05),且第3天达最高,最高值随着脑梗死面积的增大而增加,第14天下降至最低,与对照组相比,差异有统计学意义(P<0.05)。采用Pearson对患者血清S100B蛋白含量和NIHSS评分进行相关性分析,得出相关系数为0.583,P<0.05,即血清SI00B蛋白水平与NIHSS评分呈正相关。结论 急性进展性脑梗塞患者血清S100B蛋白水平与脑梗死损坏程度及神经功能正相关,可用来判定该类患者病情及预后情况。