目的 探讨孤立肾肾结石经皮肾镜取石（PCNL）术并发感染性休克的护理。 方法 回顾性分析2010年3月－2012年10月5例孤立肾肾结石患者行PCNL术后并发感染性休克的临床资料，对患者术后出现的休克及时补足血容量，使用有效的抗生素，早期足量应用激素、血管活性药物，同时加强心理疏导、健康教育等护理措施。 结果 5例患者体温均在3 d内降至正常；血管活性药物平均使用时间为1.8 d （2～4 d）；1例因血氧饱和度＜80%，血压＜85/50 mm Hg（1 mm Hg=0.133 kPa）转往重症监护病房行呼吸机辅助呼吸2 d后呼吸循环功能改善；另1例同时出现少尿无尿，及时行血液透析，第4天尿量逐渐恢复；5例患者均痊愈出院。 结论 感染性休克是PCNL术后最危险的并发症之一，对其采取积极预防、及早发现、及时有效的治疗和护理等措施，可有效促进患者康复。
目的 探讨早期碱剩余对感染性休克患者病情严重程度的预测价值。 方法 对2009年2月－2011年2月资料完整入院的感染性休克患者60例进行回顾性分析，按死亡及存活进行分组，对最初24 h的碱剩余值差异及血乳酸清除率情况进行对照研究。 结果 死亡组碱剩余值变化及乳酸清除率低于存活组（P＜0.05）。治疗后碱剩余≤−6 mmol/L较碱剩余＞−6 mmol/L的患者病死率明显增加，尤其是治疗后24 h 碱剩余仍≤−6 mmol/L病死率高达92.23%。 结论 早期碱剩余有助于感染性休克预后评估和指导临床治疗。
This article reports the management of thirty elderly patients of septic shock during anesthesia. Twenty-four of them received continious epidural anesthesia, five of them were under intravenous general anesthesia with endotracheal intubation, and onr patients recerived intravenous ketamine anesthesia. The effects of these patients on enesthesia wer satisfactory. Twenty-four patients recouverd after roperation. Six patients died. The authors atresses the high risk of anesthetic management in these patients. Experiences are introduced in per-anesthetic preparation and medication selection and maintenance of anesthesia, monitoring and treatment during anesthesia and postoperative care of septic shock of the elderly.
Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.
Objective To summarize and explore the clinical features, diagnosis and treatment of severe pulmonary tuberculosis (TB). Methods One death case of pulmonary TB in The First Affiliated Hospital of Soochow University was analyzed, related publications of case reports and articles relevant on the analysis and study of pulmonary tuberculosis deaths from Pubmed between January 2012 and March 2022 were also reviewed. Results A 25-year-old female patient was admitted for "intermittent cough with sputum for more than 1 year, aggravated with chest tightness and shortness of breath for 5 days". She had no underlying disease. Pulmonary TB was diagnosed by TB bacterium smear and next-generation sequencing of bronchoalveolar lavage fluid. The patient was in shock compensation period and developed acute respiratory distress syndrome immediately after admission. Through active anti-tuberculosis, invasive mechanical ventilation, intra-aortic balloon counterpulsation and continuous renal replacement therapy, the disease continued to deteriorate and she died on the third day after admission. A total of 269 pulmonary TB deaths were retrieved. An analysis of 244 patients' past medical history showed that human immunodeficiency virus co-infection was the most common among young people and chronic diseases were the most common among the elderly. All 269 patients died of septic shock, respiratory failure and multiple organ dysfunction syndrome (MODS), among which hyponatremia was also a significant complication. The shortest time from admission to death was 7 days, while the longest average time was only 35 days. Conclusions Pulmonary TB could develop into septic shock and MODS with poor prognosis and high mortality. Health education on TB should be strengthened.
目的 探讨特发性结肠穿孔的治疗方法及成因。方法 结合文献分析2001～2009年期间我院收治的特发性结肠穿孔患者的诊治经过。结果 共收治特发性结肠穿孔9例，占同期结肠穿孔患者的28.1%（9/32），其中5例穿孔（5/9）发生在乙状结肠。修剪破口后直接缝合者2例，行结肠双腔造瘘者7例。术后死亡3例。结论 特发性结肠穿孔好发于乙状结肠，与其解剖和生理上的特点有关。不明原因结肠穿孔的患者要想到本病的可能。及时、合理的手术治疗，仔细周到的术后管理是治疗成功的关键。
Objective To investigate the value of extravascular lung water index ( EVLWI) and intrathoracic blood volume index ( ITBVI) monitoring in fluid management of severe pneumonia patients with sepsis shock.Methods A prospective controlled study was conducted in106 patients who were diagnosed as severe pneumonia with sepsis shock in intensive care unit fromJanuary 2010 to February 2013. 54 patients who received pulse indicator continuous output ( PiCCO) monitoring were enrolled into the EVLWI + ITBVI group, and EVLWI and ITBVI were used as indicator of fluid management. 52 patients who received central venous pressure ( CVP) as indicator of traditional fluid managementwere enrolled into the control group. The time and the rate to achieve early goal-directed therapy ( EGDT) target were compared between two groups. Acute physiology and chronic health evaluation Ⅱ ( APACHE Ⅱ ) , sepsis related organ failure assessment ( SOFA) , noradrenaline dosage, serumlactic acid, serum creatinine were compared between 1 day and 3 days after treatment. The characteristics of fluid management were recorded and compared within 72 hours. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-day mortality were compared between two groups. Results The ratio of achieving EGDT target in 6 hours was significantly higher in the EVLWI + ITBVI group than that in the control group ( 75.9% vs. 55.7% , Plt;0.05) , whereas the time and the ratio to achieve EGDT target in 24 hours were not statistically different. APACHE Ⅱ, SOFA, norepinephrine dosage, serum lactate were significantly decreased 3 days after treatment in the EVLWI + ITBVI group, but did not change significantly in the control group. On3 days after treatment, serumcreatinine was increased in the control group, and did not change significantly in the EVLWI + ITBVI group. The fluid intake and fluid balance volume during 0-6 hours period were significantly higher in the EVLWI + ITBVI group than those in the control group ( Plt;0.05) , but showed no difference ( Pgt;0.05) in other periods. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-days mortality were significantly lower in the EVLWI + ITBVI group compared with the control group ( Plt;0.05) . Conclusion Compared with CVP, ITBVI and EVLWI can more accurately assess and guide fluid management in severe pneumonia patients with septic shock with less duration of mechanical ventilation, ICU stay and mortality.