Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

BACKGROUND: Emergency physicians have been successful in implementing procedural sedation and analgesia(PSA) to treat emergency department(ED) patients who need to undergo painful procedures.However, 25% of the EDs in the Netherlands are not staffed by emergency physicians.The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians.METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands.Data were gathered using a standardized questionnaire.RESULTS: The response rate was 34.3%(148/432).Of the respondents, 84/148(56.8%) provided adult PSA and 30/148(20.3%) provided paediatric PSA.Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure.The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients.CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Patient controlled intravenous analgesia with tramadol for labor pain relief

Objective To evaluate the safety and analgesic efficacy of patient controlled intravenous analgesia (PCIA) with tramadol, and to compare its benefits and risks with combined spinal-epidural analgesia (CSEA) + patient controlled epidural analgesia (PCEA).Methods Eighty American Society of Anesthesiologist (ASA) Ⅰ - Ⅱ at term parturients in active labor were randomly divided into 3 groups: the control group (n =30) received no analgesia; group A (n =30) received spinal administration with ropivacaine 2. 5 mg and fentanyl 5μg, then with PCEA; group B (n = 20) received 1 mg/kg tramadol loading dose i. v.. PCIA with 0. 75% tramadol and it included: PCA dose 2 ml, lockout time 10 minutes, background infusion 2 ml/h, total dose no more than 400 mg. The intensity of pain was evaluated using Visual Analogue Scale (VAS).Results Both group A and B showed good pain relief. VAS pain scores were significantly decreased in group A and B compared with those in the control group (P<0. 01). In comparison with group B, the VAS pain scores decreased in group A (P<0. 05). The onset times of analgesia in group A were shorter than those in group B (P<0. 05). Apgar scores in group B were lower than those in group A (P<0. 05). The periods of second stage of labor in group A were longer than those in the control group and group B (P<0. 05). The cesarean delivery rate was significantly higher in the control group (16. 7%) than in group A (3. 3%) and group B (5. 0%), but it did not differ between group A and B. There were no significant differences in vital signs, fetal heart rate, degree of motor block, and uterine contractions among the 3 groups.Conclusions PCIA with tramadol is now a useful alternative when patients are not candidates for CSEA for labor, or do not want to have a neuraxial block anesthesia. However, sometimes it may not provide satisfactory analgesic effect.

The presenting and prescribing patterns of migraine in an Australian emergency department: A descriptive exploratory study

BACKGROUND: Migraine is a common neurological condition that frequently presents to the emergency department(ED). Many medications are available to treat migraine. This study aims to characterize the demographics of patients who present to a large metropolitan ED with migraine, and to identify the medications used in treating this condition.METHODS: This study is a retrospective database interrogation of clinical records, used to collect quantitative data on patient demographics and medication prescriptions in the ED.RESULTS: A total of 2 228 patients were identified as being treated for migraine over a 10-year period. The proportion of the ED population presenting with migraine steadily increased in this time. Females(71%) more commonly presented to the ED with migraine than males. The migraine population was signifi cantly younger(M=37.05, SD=13.23) than the whole ED population(M=46.17 SD=20.50)(P<0.001). A variety of medications were used in the treatment of migraine in the ED. Simple analgesics such as paracetamol and ibuprofen, anti-emetics and intravenous(IV) fluids with phenothiazine additives were commonly used. Over 20% of patients were prescribed oral or parenteral opiates(42 of 194 initial medication prescriptions, and 64 of 292 as required medication prescriptions). Triptans were very rarely used.CONCLUSION: Migraine is an increasingly common presentation to the ED. People presenting to the ED with migraine are more likely to be younger and female than the general ED population. Peak presentations for migraines occurred in January and February. The medications that are prescribed in the ED for migraine is varied and are not always in line with current evidence for the treatment of migraine. The excessive reliance on opiates and lack of the use of triptans denotes a signifi cant variation from published guidelines.

Sub-dissociative dose ketamine administration for managing pain in the emergency department

BACKGROUND： We describe our experience of utilizing sub-dissociative dose ketamine （SDK） in managing a variety of acute and chronic painful conditions in the emergency department （ED）. METHODS： A descriptive study was conducted in our ED over a period of seven years （2010-2016） by retrospectively reviewing charts of patients aged 18 and older presenting to the ED with painful complaints and receiving SDK analgesia. Primary data analyses included type of SDK administration （intravenous push [IVP], short-infusion [SI] or continuous infusion [CI]）, dosing, rates of analgesic utilization before and after SDK administration, and adverse effects. RESULTS： Three hundred sixty-two patients were enrolled in the study. Mean ketamine doses given by IVP, St and CI were 26.3 rag, 23.4 rag, and 11.3 rag. The mean duration of CI was 135.87 minutes. The percentage of patients not requiring post-SDK analgesia increased by 16%, 18%, and 37% in IVP, SI and CI groups. Adverse effects were recorded for 13% of patients. CONCLUSION： SDK administered by IVP, SI, and CI in the ED for a variety of painful conditions is a feasible analgesic modality in the ED that is associated with a decrease in overall requirements of post-ketamine analgesia and opioid sparing.

情景模拟结合CBL对提升产科住院医师医患沟通能力的效果分析

目的探讨在产科住院医师规范化培训(简称住培)中进行情景模拟结合以案例为基础的教学对医患沟通技能培训的效果。方法选取50名在产科规范化培训的住院医师为研究对象。培训前进行学员调查和医患沟通能力SEGUE测评。基于产科住培大纲选择5个典型病例情景,由教师录制5个典型病例病情医患沟通的示范视频,并梳理相关背景知识,在产科住院医师中依次开展培训课程,即视频示范、小组讨论、病例背景知识梳理讲解、分角色演练、演练后反馈和评价以及临床实践。培训后再次进行学员调查和医患沟通能力SEGUE测评。使用配对样本的非参数检验方法评价培训效果。结果情景模拟结合以案例为基础的教学的医患沟通技能培训后,学员医患沟通能力SEGUE测评总分提高[13.00(11.00~16.00)vs.22.00(20.00~24.00)],差异具有统计学意义(Z=-6.159,P<0.001);医患沟通能力SEGUE测评总体合格率提高[36.0%(18/50)vs.98.0%(49/50)],差异具有统计学意义(χ^(2)=43.464,P<0.001)。结论情景模拟结合以案例为基础的教学的医患沟通技能培训可有效提高学员医患沟通能力,调动学员的学习主动性,激发学员内在学习动力,建议在产科住培中纳入此类课程。

NICU早产儿母乳喂养链式管理效果评价

目的观察链式管理对NICU早产儿母乳喂养及喂养并发症的影响。方法将180例NICU早产儿按入院时间分为对照组和试验组各90例。对照组实施常规NICU母乳喂养策略,试验组在对照组基础上进行链式管理,构建并实施产房、产科和NICU间横向管理和各科室内部纵向管理。结果最终对照组82例、试验组81例早产儿完成研究。干预后,试验组纯母乳喂养率显著高于对照组,试验组早产儿喂养不耐受、坏死性小肠结肠炎、宫外发育迟缓和新生儿高胆红素血症发生率显著低于对照组(均P<0.05),试验组恢复至出生体质量日龄显著短于对照组,出院体质量显著大于对照组(均P<0.05)。结论链式管理有利于提高NICU早产儿的纯母乳喂养率,降低喂养并发症发生率,促进新生儿生长发育。

Blood Transfusion Practices at the Gynecology-Obstetrics Department of the Sylvanus Olympio University Hospital in Lomé: A Study of 254 Cases

Objective:?To describe blood transfusion practices in obstetric at the Sylvanus Olympio University Hospital in Lomé. Patients and method: Prospective, cross-sectional and descriptive study, conducted from 1 June 2017 to 31 May 2018 at the gynecology-obstetrics department. The study focused on transfused pregnant, parturient and delivered women. Study parameters were sociodemographic, clinical, therapeutic and prognostic. Results: 252 patients, aged 16 to 49 with an average age of 30.4 years, referred in 74% of cases. Hemorrhage was observed in 238 cases (94.4%) and anemia in 14 cases (5.6%). Blood transfusion was urgently used in 89.7% of cases and hemorrhagic abortion was the main indication. Blood group O+ (34.5%) was the most used and blood products were obtained after two hours in 81% of cases. Conclusion: Blood transfusion is often performed urgently and for bleeding. But the Gynecology-Obstetrics department does not have any blood in reserve, whereas the Sylvanus Olympio University Hospital collection and distribution station covers less than 10% of the needs.

纳布啡用于硬脊膜穿破硬膜外阻滞分娩镇痛的有效性及安全性

目的探讨纳布啡用于硬脊膜穿破硬膜外阻滞分娩镇痛的有效性及安全性。方法选择经阴试产的足月单胎初产妇319例,按使用药物不同分为舒芬太尼硬脊膜穿破硬膜外阻滞组(A组)160例,纳布啡硬脊膜穿破硬膜外阻滞组(B组)159例。两组均采用硬脊膜穿破硬膜外阻滞分娩镇痛法,置入硬膜外导管后,注入1.5%利多卡因3 mL试验量,然后A组注入0.5 mg/L舒芬太尼复合1 mg/L罗哌卡因混合液,B组注入0.3 g/L纳布啡复合1 mg/L罗哌卡因混合液,均6~15 mL为首次量,30 min后两组均连接电子镇痛泵,分别使用舒芬太尼和纳布啡进行自控硬膜外镇痛。收集两组患者的如下指标:镇痛起效时间、首次自控按压镇痛(PCA)时间、PCA有效按压次数、罗哌卡因用量;镇痛前(T0)、镇痛后30 min(T1)、宫口开全(T2)与用力分娩(T3)时疼痛视觉模拟(VAS)评分及Ramsay镇静评分;产妇发热、恶心呕吐、皮肤瘙痒、术后头痛发生等不良反应情况以及胎儿胎心减速发生率、新生儿1 min Apgar评分≤7分发生率、脐动脉血气分析,新生儿神经与适应能力评分。结果与A组比较,B组恶心呕吐、皮肤瘙痒、胎心减速及新生儿1 min Apgar评分≤7分的发生率显著降低(χ^(2)=4.159~5.628,P<0.05),PCA有效按压次数、罗哌卡因用量显著增加(χ^(2)=8.594、6.363,P<0.05),T2及T3产妇VAS评分明显升高(F=45.314、26.717,P<0.05),其他观察指标两组间比较差异无统计学意义(P>0.05)。结论纳布啡用于硬脊膜穿破硬膜外阻滞分娩镇痛与舒芬太尼相比第一产程镇痛效果类似,第二产程效果较差,但可降低产妇镇痛相关不良反应发生率,对新生儿具有较高的安全性。

CBL联合纠错教学应用于妇产科规范化培训中的价值

目的分析以案例为基础的教学法(Case Based Learning,CBL)联合纠错教学应用于妇产科规范化培训中的价值。方法选取2022年1月—2023年12月在潍坊医学院附属医院妇产科轮转的40名规范化培训医师为研究对象,采用随机数表法将其分为两组,每组20名。对照组实施传统规范化培训,观察组实施CBL联合纠错教学规范化培训,对比两组医师专业理论知识考试成绩、临床技能操作考核成绩及满意度。结果观察组专业理论知识考试成绩高于对照组,差异有统计学意义(P<0.05);观察组病例问询、查体、病例分析、治疗计划分数及总分均高于对照组,差异有统计学意义(P均<0.05);观察组教学模式、学习兴趣、自学能力、表达沟通能力、团队协作能力评分均高于对照组,差异有统计学意义(P均<0.05)。结论在妇产科规范化培训中,采用CBL联合纠错教学方法具有显著的价值,能够提高住培医师的专业理论知识水平,增强他们在实践中的能力,并促进他们的自主学习和团队合作能力。

妇产科住培教学方法改革探索

为进行妇产科住培教学改革,提升妇产科住培医生的综合素质和实践能力,文章通过文献总结并分析当前妇产科住培现状,按照国家《关于加强医学教育工作提高医学教育质量的若干意见》,结合笔者在教学大赛中的具体做法,提出以病例为导向,采用沉浸式情景模拟教学、以问题为基础的教学法(problem-based learning,PBL)等多种教学法在妇产科住培理论教学中的应用;建议采用分层培养模式进行妇产科人才实践能力的培养,以满足不同层次人才的成长需要。为提高医学人才培养质量,加强妇产科人才队伍的建设,在理论教学及临床实践能力培养中挖掘、提炼妇产科课程中所蕴含的思政元素,推进妇产科教学模式改革,高质量地完成妇产科住培教育工作,以期更好地完成培训目标,满足新时代人才培养需要。

高职助产实习护生妇产科实习真实体验的质性研究

目的 了解高职助产实习护生在妇产科临床实习的真实体验,为临床实习管理及助产教育采取针对性的策略提供参考依据。方法 运用质性研究中的现象学研究方法,选取12名已完成产房、产科、妇科、妇产科门诊实习轮转的助产实习护生进行一对一深入访谈。结果 经过资料分析共提炼出3个主题:学习核心技能体验(能力提升不足、获得成就感、角色适应不良),职业角色体验(正负性体验并存),人际关系体验(师生关系、护患关系)。结论 医院管理者及助产教育者应健全校院合作机制,协同育人。可以从课程思政、教学模式、临床实习管理、临床实习带教与评价等多方面进行改革,改善助产实习护生的临床实习体验,提高岗位胜任力,保障母婴健康。

超声医学科住院医师规范化培训:妇产超声培训中国指南(2024版)

为进一步提升妇产超声亚专业规范化培训质量,中国医师协会超声医师分会组织国内相关专家,参考《住院医师规范化培训基地标准(2022年版)》及《住院医师规范化培训内容与标准(2022年版)》,结合自身经验,经过充分讨论形成本指南,旨在指导实施妇产超声教学工作。

艾司氯胺酮在产科临床应用的进展研究

艾司氯胺酮作为氯胺酮的异构体,与消旋体氯胺酮相比,其应用剂量更小,具有较强的镇痛和镇静作用。艾司氯胺酮在心血管和精神方面不良反应小,代谢快、体内清除率高,对呼吸循环影响轻微,在产科麻醉方面有显著的效果。

分娩镇痛产妇不同饮食后超声观察胃排空的临床研究

目的观察分娩镇痛产妇进食不同食物后使用超声评估胃排空的情况。方法选择2020年10月至2021年6月足月、单胎、头位自愿接受硬膜外分娩镇痛初产妇80例,美国麻醉医师协会(ASA)Ⅱ级,进入产程前禁食6~8 h,禁饮2~4 h。随机数字表法将产妇分为2组,每组40例,碳水化合物饮料(CHO)组和对照组。胃窦部超声由一位经过培训的麻醉医师执行,分娩镇痛后即刻(T0)超声测量产妇基础标准矢状切面胃窦横截面积(CSA)。随后CHO组在20 min内饮用碳水化合物饮料400 ml,分别在饮用CHO后30 min(T1)、60 min(T2)、90 min(T3)、120 min(T4)、150 min(T5)、180 min(T6)测量CSA,直到CSA测量值≤T0定义为排空,再根据需求饮用碳水化合物饮料直到分娩结束。对照组20 min内食用营养科统一配制容积为400 ml的面条汤,分别在30 min(T1)、60 min(T2)、90 min(T3)、120 min(T4)、150 min(T5)、180 min(T6)、240 min(T7)、300 min(T8)和360 min(T9)测量CSA,任何时间点测量CSA≤T0,同时看不到胃内有固体颗粒定义为排空,胃容量根据CSA计算得出。记录2组产程时长、分娩方式、缩宫素使用率、恶心呕吐的发生率、新生儿1 min、5 min Apgar评分。结果8名产妇中转剖宫产和2名产妇超声图像成像质量差被剔除。CHO组50%胃排空率为120 min,对照组50%胃排空率为360 min,差异有统计学意义(P<0.05)。T1~T6任一时间点对照组胃容量显著高于CHO组,差异有统计学意义(P<0.05)。2组产妇在产程时长、分娩方式、缩宫素使用率、恶心呕吐发生率、新生儿Apgar评分差异无统计学意义(P>0.05)。结论与食用面条汤相比,碳水化合物饮料不增加分娩镇痛产妇胃容量,具有胃排空快,胃内残留低,不影响产程时长和母婴分娩结局等优势,安全可行。

一院多区双重视角下护理不良事件风险的管理及成效

目的:探讨基于ORTCC模型的产科护理质量安全不良事件管理及成效。方法:采取前瞻性类试验研究,选取江西省某三级甲等专科医院产科区域2023年1月—6月收治11638例住院病人为对照组;2024年1月—6月收治14124例住院病人为干预组。对照组采用常规方法实施护理质量安全不良事件管理,干预组给予围绕目标、规则、训练、检查与考核和文化5个要素的ORTCC模式实施不良事件管理。比较两组护理人员决策能力以及护理质量安全不良事件发生率和发错药物隐患事件发生率。结果:干预组病人发生不良事件及发药错误隐患事件少于对照组;护士临床决策能力得分高于对照组,差异均有统计学意义(P<0.05)。结论:基于ORTCC模型形成集预防、处置、反馈、分析、改进的长效型闭环的护理质量安全不良事件管理方案,可有效降低产科区域不良事件发生率,提升护理人员决策能力,全方位保障母婴生命安全,为探索护理新质生产力作出贡献。

瘢痕子宫妊娠无症状型子宫破裂1例报告

子宫破裂是一种严重的产科并发症,指在分娩期或妊娠期间,子宫体部或子宫下段发生破裂,导致母儿灾难性后果。本研究回顾性分析1例瘢痕子宫妊娠无症状型子宫破裂患者的临床资料,探讨瘢痕子宫妊娠的处理策略。

妇产科门诊阴道分泌物检验结果的研究

目的评估妇产科门诊阴道分泌物检验结果。方法120例阴道分泌物检验者为研究对象,分析不同阴道清洁度下病原体(细菌、假丝酵母菌、滴虫)检出情况。结果120例阴道分泌物检验者中,清洁度Ⅰ度38例(31.67%)、清洁度Ⅱ度28例(23.33%)、清洁度Ⅲ度27例(22.50%)、清洁度Ⅳ度27例(22.50%)。120例阴道分泌物检验者中,20例(16.67%)检出细菌、13例(10.83%)检出假丝酵母菌、5例(4.17%)检出滴虫,且阴道清洁度越高,细菌、假丝酵母菌、滴虫的检出率越高。结论妇产科门诊阴道分泌物检验中,阴道病原体感染患者发病率高,需要加强防护措施,降低阴道感染的发生率。

基于雨课堂结合MOOC的线上教学模式在妇产科教学中的应用

目的探讨基于雨课堂结合慕课(MOOC)的线上教学模式在妇产科教学中的应用价值。方法选取贵州医科大学2019—2020学年第二学期2017级教改班级的48名同学作为试验组,采取基于雨课堂结合MOOC的线上教学模式;选取2018—2019学年第二学期2016级教改班级的50名同学作为对照组,采取传统线下教学模式。比较两组的教学效果。结果两组学生的期末理论成绩无显著差异(P>0.05)。试验组提升自学能力、拓展延伸知识的满意度评价占比高于对照组,而调动学习兴趣、培养临床思维、增强师生间交流互动的满意度评价占比低于对照组(P<0.05)。试验组中,54.17%(26/48)的学生认为学习主动性和自律性是影响线上教学效果的最主要原因,而20.83%(10/48)的学生则认为师生间交流互动是线上教学效果的关键影响因素;另外,分别有10.42%(5/48)、8.33%(4/48)、6.25%(3/48)的学生认为课堂学习氛围、课程设计及安排、在线学习条件亦会影响线上教学效果。结论基于雨课堂结合MOOC的线上教学模式可作为线下教学的补充手段。

“互联网+”背景下妇产科混合式教学模式的应用初探

随着国家对“互联网+”在教育领域应用的提出,为大力推进以“课程思政”为目标的教学改革,针对既往传统线下教学及疫情期间全程线上教学存在的问题,构建了基于“互联网+”背景下课程思政融入线上线下混合式教学模式在妇产科教学中的应用。通过将雨课堂及慕课平台作为载体,与线下课堂教学进行有机融合,以岗位胜任力为导向,同时在教学过程中适当融入课程思政教育,利用以问题为基础的学习(PBL)、以案例为基础的学习(CBL)、翻转课堂、同伴互助学习(PAL)、情景模拟等多种教学形式,既可以发挥教师在教学过程中的指导、监督作用,又能充分调动学生在学习过程中的积极性、创新性,实现知识传授、能力培养与价值引领的有效衔接及相互融合,以达到为社会培养德才兼备、全面发展的医学人才目的。

基于VR技术的宫颈LEEP锥切术虚拟仿真教学探索

宫颈LEEP手术适用于宫颈上皮内恶性病变的处理,是预防宫颈癌的重要手段。然而,由于隐私等诸多原因,单纯的理论教学使学生很难对该技术的操作有直观的体验,导致对相关疾病的认识不够全面,且本科医学教学又是为学生进一步深造奠基的重中之重。随着医学技术的发展,虚拟现实(virtual reality,VR)技术的重要性逐渐受到许多学者的关注。部分学者认为将VR技术中的一些好的理念应用到实际教学中,能够有效增加学生的理论知识感知能力和实际操作技能。文章通过VR技术实现宫颈LEEP锥切术的仿真教学训练,并进一步结合人工智能纠错模拟沉浸式的医疗环境,根据训练过程发现问题并解决问题,以改进和提升教学效果。