Objective To evaluate the effects and the clinical significances of liquid resuscitation on blood gas analysis， acid-base balance， electrolytes， acute physiology and chronic health evaluationsⅡ（APACHEⅡ） score of patients with septic shock， and then to analyze the relations between serum chlorine （Cl－） level and APACHEⅡscore and the volume of liquid resuscitation. Methods According to the target of resuscitation （centre venous pressure 8-12mm Hg and mean arterial pressure≥65mm Hg）， 21 patients with septic shock received enough fluid for resuscitation during 24h . The results of blood gas analysis， acid-base balance， electrolytes， and APACHE Ⅱ score were compared between pre-resuscitation and 24h post-resuscitation by self-controlled prospective study. The relationships of the level of serum Cl－ and APACHEⅡ score with the volume of liquid used in resuscitation were analyzed . Results The mean resus-citation duration was （18.09±4.57） h， and the volume of liquid during 24 h resuscitation was 5 320-11 028mL with mean volume of （7 775±1 735） mL in 21 patients with septic shock. Serum sodium （Na＋， mmol/L） and Cl－（mmol/L）levels of post-resuscitation were significant higher than those of pre-resuscitation （Na＋：138.71±5.67 versus 135.62±7.23， P=0.024；Cl－：109.10±4.90 versus 101.67±8.59， P=0.000）. Compared with the levels of pre-resuscitation， the blood pH value， hematocrit （Hct，%）， anion gap （AG， mmol/L）， lactic acid （mmol/L）， and APACHE Ⅱscore significantly decreased （pH：7.31±0.05 versus 7.37±0.06， P=0.000；Hct：28.48±2.56 versus 32.76±9.19， P=0.049；AG：8.33±3.45 versus 14.17±8.83， P=0.004；lactic acid：1.66±0.89 versus 2.96±1.23， P=0.001；APACHEⅡ：10.90±3.73 versus 17.24±4.06， P=0.000） after 24h resuscitation. The correlation analysis showed that the level of serum Cl- was positively correlated with the volume of liquid used in resuscitation （r=0.717，P＜0.01）. However， there was no correlation between APACHEⅡscore and the volume of liquid used in resuscitation （P＞0.05）. Conclusions The target of liquid resuscitation in patients with septic shock should be cautiously determined， including control of the volume of crystal liquid for resuscitation， in order to avoid acid-base imbalance or hyperchloraemia. At the same time， the change in internal environment should be monitored. An optimistic fluid resuscitation to decrease APACHE Ⅱ score in patients with septic shock is unrelated to the volume of liquid resuscitation.
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。
ObjectiveTo explore the value of inferior vena cava inspiratory collapsibility (ΔIVC) in guiding septic shock resuscitation with early goal-directed therapy (EGDT).MethodsA single center, randomized controlled trial was conducted at an 812-bed hospital in Mianyang, Sichuan. Adult patients with early septic shock in the intensive care unit were assessed and treated at defined intervals over 6 h using an ΔIVC-guided resuscitation protocol or an EGDT protocol. Feasibility outcomes were fluid balance and norepinephrine administration. The primary clinical outcomes were in-hospital mortality rate, 90-day survival rate. Secondary outcomes included incidence of acute kidney injury and consumption of health resources.ResultsSixty-eight patients with septic shock were enrolled in this study. Baseline characteristics were similar between the two groups. The ΔIVC-guided septic shock resuscitation group was lower than the EGDT group in the ICU 24 h fluid replacement (L): 3.8 (4.0, 5.3) vs. 4.7 (4.0, 6.6), 72 h liquid positive balance (L): 0.2 (–0.65, 1.2) vs. 2.5 (0.0, 4.1), intensive care unit length of stay (d): 7.5 (5.0, 14.0) vs. 15.0 (7.0, 21.5), mechanical ventilation cumulative time (d): 3.0 (0.0, 7.0) vs. 7.5 (2.2, 12.0), ICU costs (ten thousand yuan): 3.4 (2.1, 5.9) vs. 8.6 (4.2, 16.5), bedside blood purification treatment costs (ten thousand yuan): 2.3 (1.1, 3.3) vs. 6.8 (2.1, 10.0) (P<0.05). No difference was observed in the incidence of acute kidney injury (P > 0.05), in-hospital mortality and 90-day survival between the two groups (log-rank χ2=0.35, P>0.05).ConclusionsAmong patients with septic shock, a ΔIVC-guided septic shock resuscitation, compared with EGDT, did not reduce in-hospital mortality. It might prevent the risk of over resuscitation, shorten the duration of mechanical ventilation, and lead to a better utilization of intensive care unit resources.
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.
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.
目的通过漂浮导管（Swan-Ganz导管）监测外周血管阻力指数（SVRI）作为优化的心功能不全状态下感染性休克早期目标导向治疗（EGDT）的临床意义。 方法2012年1月至2014年1月第四军医大学附属西京医院心血管外科ICU收治体外循环心脏术后感染性休克患者8例，其中男7例、女1例，年龄（50.9±11.1）岁。以中心静脉压（CVP）为复苏目标行经验性容量复苏治疗，循环未见改善，则实施漂浮（Swan-Ganz）导管监测血流动力学指标，以外周血管阻力指数（SVRI）为优化目标复苏，观察Swan-Ganz导管复苏前及复苏6 h、24 h后的血流动力学及氧代谢指标，分析复苏达标所需时间。 结果8例患者平均住ICU时间（16.87±3.35）d，发生肺部并发症8例，急性肾功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好转存活，死亡2例。8例感染性休克患者经Swan-Ganz导管目标导向治疗6 h和24 h后平均动脉压（MAP）分别为（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心静脉压（CVP）分别为（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指数（CI）分别为（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指数（SVRI）分别为（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各项指标均较治疗前升高；治疗6 h和24 h后动脉血乳酸分别为（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，较治疗前[（14.98±0.45）mmol/L]下降。 结论采用Swan-Ganz导管监测SVRI作为优化目标导向治疗心功能不全状态下感染性休克可以提高6 h复苏成功率，改善患者预后。