Risk factors and prognosis of critically ill cancer patients with postoperative acute respiratory insufficiency

BACKGROUND:This study aimed to investigate the risk factors and outcome of critically ill cancer patients with postoperative acute respiratory insufficiency.METHODS:The data of 190 critically ill cancer patients with postoperative acute respiratory insufficiency were retrospectively reviewed.The data of 321 patients with no acute respiratory insufficiency as controls were also collected.Clinical variables of the first 24 hours after admission to intensive care unit were collected,including age,sex,comorbid disease,type of surgery,admission type,presence of shock,presence of acute kidney injury,presence of acute lung injury/acute respiratory distress syndrome,acute physiologic and chronic health evaluation(APACHE Ⅱ) score,sepsis-related organ failure assessment(SOFA),and PaO_2/FiO_2 ratio.Duration of mechanical ventilation,length of intensive care unit stay,intensive care unit death,length of hospitalization,hospital death and one-year survival were calculated.RESULTS:The incidence of acute respiratory insufficiency was 37.2%(190/321).Multivariate logistic analysis showed a history of chronic obstructive pulmonary diseases(P=0.001),surgeryrelated infection(P=0.004),hypo-volemic shock(P<0.001),and emergency surgery(P=0.018),were independent risk factors of postoperative acute respiratory insufficiency.Compared with the patients without acute respiratory insufficiency,the patients with acute respiratory insufficiency had a prolonged length of intensive care unit stay(P<0.001),a prolonged length of hospitalization(P=0.006),increased intensive care unit mortality(P=0.001),and hospital mortality(P<0.001).Septic shock was shown to be the only independent prognostic factor of intensive care unit death for the patients with acute respiratory insufficiency(P=0.029,RR:8.522,95%CI:1.243-58.437,B=2.143,SE=0.982,Wald=4.758).Compared with the patients without acute respiratory insufficiency,those with acute respiratory insufficiency had a shortened one-year survival rate(78.7%vs.97.1%,P<0.001).CONCLUSION:A history of chronic obstructive pulmonary diseases,surgery-related infection,hypovolemic shock and emergency surgery were risk factors of critically ill cancer patients with postoperative acute respiratory insufficiency.Septic shock was the only independent prognostic factor of intensive care unit death in patients with acute respiratory insufficiency.Compared with patients without acute respiratory insufficiency,those with acute respiratory insufficiency had adverse shortterm outcome and a decreased one-year survival rate.

Septic Superficial Femoral Vein Thrombophlebitis Causing Pulmonary Emboli and Respiratory Failure: Case Report and Review of the Literature

Septic pulmonary emboli rarely cause respiratory failure that requires mechanical ventilation. The most common causes of septic pulmonary emboli are related to intravenous drug abuse, indwelling intravenous catheters, endocarditis and septic pelvic thrombophlebitis. In addition, soft tissue injury-related thrombophlebitis rarely causes septic pulmonary emboli. We describe a unique case of a 43-year-old man who developed septic thrombophlebitis of the femoral vein following soft tissue injury from trauma to the shin with ensuing septic pulmonary emboli which necessitated endotracheal intubation and mechanical ventilation. The patient required mechanical ventilation for eleven days, developed empyema and grew out methicillin-resistant Staphylococcus aureus on blood cultures. A transesophageal echocardiogram was normal, and there was no indication of bacterial endocarditis. In addition to eleven days of mechanical ventilation, the patient was treated with intravenous heparin, cefepime and clindamycin. These medications were then discontinued and the patient was treated with weight-adjusted vancomycin. Following the return of cultures, the patient was treated for six weeks with ceftaroline 600 mg IV twice a day. In addition, the patient received bilateral thoracentesis followed by chest tube drainage until resolution of the pleural effusions. The patient made a complete recovery. We describe this case and the implications for differential diagnosis and treatment of these two uncommon conditions.

Blood eosinophils and mortality in patients with acute respiratory distress syndrome: A propensity score matching analysis

BACKGROUND: The effect of blood eosinophils(EOSs) on mortality in acute respiratory distress syndrome(ARDS) patients and whether corticosteroids affect this effect are unclear.METHODS: The Medical Information Mart for Intensive Care III database(version 1.4) was used to extract data. Patients with ARDS were selected for inclusion. Cox regression models using the backward stepwise method and propensity score matching(PSM) were used to assess the relationship between blood EOS counts and 28-day mortality. RESULTS: A total of 2,567 patients with ARDS were included, and the 28-day mortality rate was 24.19%. The crude 28-day mortality was significantly lower in patients with EOS counts ≥2%(18.60% [85/457] vs. 25.40% [536/2,110], P=0.002) than in those with EOS counts <2%. In the Cox regression model, the EOS counts ≥2% showed a significant association with the decreased 28-day mortality(hazard ratio [HR] 0.731;95% confidence interval [95% CI] 0.581–0.921, P=0.008). In the corticosteroid non-use subgroup, EOS counts ≥2% was significantly related to decreased 28-day mortality(HR 0.697, 95% CI 0.535–0.909, P=0.008), but the result was not significant in the corticosteroid non-use subgroup model(P=0.860). A total of 457 well-matched pairs were obtained by a 1:1 matching algorithm after PSM. The 28-day mortality remained significantly lower in the EOS counts ≥2% group(18.60% [85/457] vs. 26.70% [122/457], P=0.003).CONCLUSIONS Higher EOS counts are related to lower 28-day mortality in ARDS patients, and this relationship can be counteracted by using corticosteroids.

Alcoholism and critical illness: A review

Alcohol is the most commonly used and abused drug in the world, and alcohol use disorders pose a tremendousburden to healthcare systems around the world. The lifetime prevalence of alcohol abuse in the United States is estimated to be around 18%, and the economic consequences of these disorders are staggering. Studies on hospitalized patients demonstrate that about one in four patients admitted to critical care units will have alcohol-related issues, and unhealthy alcohol consumption is responsible for numerous clinical problems encountered in intensive care unit(ICU) settings. Patients with alcohol use disorders are not only predisposed to developing withdrawal syndromes and other conditions that often require intensive care, they also experience a considerably higher rate of complications, longer ICU and hospital length of stay, greater resource utilization, and significantly increased mortality compared to similar critically ill patients who do not abuse alcohol. Specific disorders seen in the critical care setting that are impacted by alcohol abuse include delirium, pneumonia, acute respiratory distress syndrome, sepsis, gastrointestinal hemorrhage, trauma, and burn injuries. Despite the substantial burden of alcoholinduced disease in these settings, critical care providers often fail to identify individuals with alcohol use disorders, which can have significant implications for this vulnerable population and delay important clinical interventions.

Stress cardiomyopathy in critical care:A case series of 109 patients

BACKGROUND Critically ill patients are at risk of developing stress cardiomyopathy(SC)but can be under-recognized.AIM To describe a case series of patients with SC admitted to critical care units.METHODS We conducted a retrospective observational study at a tertiary care teaching hospital.All adult(≥18 years old)patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.RESULTS Of 24279 admissions to the critical care units[19139 to medical-surgical intensive care units(MSICUs)and 5140 in coronary care units(CCUs)],109 patients with SC were identified.Sixty(55%)were admitted to the coronary care units(CCUs)and forty-nine(45%)to the medical-surgical units(MSICUs).The overall incidence of SC was 0.44%,incidence in CCU and MSICU was 1.16%and 0.25%respectively.Sixty-two(57%)had confirmed SC and underwent cardiac catheterization whereas 47(43%)had clinical SC,and did not undergo cardiac catheterization.Forty-three(72%)patients in the CCUs were diagnosed with primary SC,whereas all(100%)patients in MSICUs developed secondary SC.Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine(59%)MSICU patients.There were no statistically significant differences in intensive care unit(ICU)mortality,in-hospital mortality,use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.CONCLUSION Stress cardiomyopathy can be under-recognized in the critical care setting.Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability,arrhythmias or respiratory failure in ICU.

Utilization of extracorporeal membrane oxygenation during the COVID-19 pandemic

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2[SARSCoV-2,or coronavirus disease 2019(COVID-19)]was declared a pandemic by the World Health Organization on March 11,2020.Worldwide,more than 65 million people have been infected with this SARS-CoV-2 virus,and over 1.5 million people have died due to the viral illness.Although a tremendous amount of medical progress has been made since its inception,there continues to be ongoing research regarding the pathophysiology,treatments,and vaccines.While a vast majority of those infected develop only mild to moderate symptoms,about 5%of people have severe forms of infection resulting in respiratory failure,myocarditis,septic shock,or multi-organ failure.Despite maximal cardiopulmonary support and invasive mechanical ventilation,mortality remains high.Extracorporeal membrane oxygenation(ECMO)remains a valid treatment option when maximal conventional strategies fail.Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints.This article reviews the rationale behind its use,current status of utilization,and future considerations for ECMO in critically ill COVID-19 patients.

Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome

Coronavirus disease 2019(COVID-19)related acute respiratory distress syndrome(ARDS)is a severe complication of infection with severe acute respiratory syndrome coronavirus 2,and the primary cause of death in the current pandemic.Critically ill patients often undergo extracorporeal membrane oxygenation(ECMO)therapy as the last resort over an extended period.ECMO therapy requires sedation of the patient,which is usually achieved by intravenous administration of sedatives.The shortage of intravenous sedative drugs due to the ongoing pandemic,and attempts to improve treatment outcome for COVID-19 patients,drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy.Administration of volatile anesthetics requires an appropriate delivery.Commercially available ones are the anesthetic gas reflection systems AnaConDa®and MIRUSTM,and each should be combined with a gas scavenging system.In this review,we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS.We focus particularly on the technical details of administration of volatile anesthetics.Furthermore,we describe the advantages of inhaled sedation and volatile anesthetics,and we discuss the limitations as well as the requirements for safe application in the clinical setting.

Utility of convalescent plasma for addressing the COVID-19 infection: brief review and case reports

Novel coronavirus,SARS-CoV-2 is responsible for causing a pandemic that has affected individuals worldwide,over 192 million people and about 4.1 million people died so far.The spread is ongoing and the numbers are still increasing.Numerous therapeutic approaches have been explored and developed during this pandemic.Immunotherapy with virus-specific antibodies in convalescent plasma(CP)has shown potential benefits for various pathogenic diseases.In many instances,it is the only available and safe management option for the COVID-19 patients.Here we describe two confirmed cases of COVID-19 from two different geographical areas that were managed with standard treatment modalities initially.Both of the patients were presented with high-grade fever,dry cough,and sore throat.Lab reports showed increased values of D-dimer,serum ferritin,leukocyte count(LC),Lactate dehydrogenase(LDH),and C-reactive protein(CRP).Chest X-ray showed bilateral infiltration(multifocal and bilateral ground-glass opacities and consolidations with peripheral and basal predominance),consistent with the previous reports on COVID-19 infection.The patients received conservative treatment according to the hospital's protocol.The convalescent plasma(from recovered patients)infusion was the last treatment given to both patients.After the convalescent plasma transfusion,both patients showed a reduction of viral load,an increase of anti-SARS-CoV-2 IgG and IgM antibodies,reduction in lung infiltration,with no adverse events.However,further randomized controlled trials are needed to investigate the full scope of safety and efficacy(both short and long-term)of convalescent plasma therapy for COVID-19 and other related infections.

呼吸与危重症医学科住院医师胜任力评价体系的构建

目的 构建适合中国国情的呼吸与危重症医学科住院医师胜任力评价体系。方法 本研究于2022年8月至2023年7月进行,采用文献综述结合德尔菲法,包括2轮专家函询,筛选、优化呼吸与危重症医学科住院医师胜任力评价指标。结果 两轮函询的有效问卷回收率均为100%,专家权威系数分别为0.905和0.914,专家咨询的肯德尔和谐系数分别为0.193(χ^(2)=237.561,P<0.001)和0.157(χ^(2)=212.459,P<0.001)。研究构建了胜任力评价体系,包括一级指标8项,二级指标38项。结论 本研究初步构建了呼吸与危重症医学科住院医师胜任力评价体系,更加适用于我国呼吸与危重症医学科住院医师规范化培训的实践临床环境,为规范化培训和教学提供了简单可行的胜任力评价方式。

重度肥胖合并急性呼吸窘迫综合征患者的护理

总结1例重度肥胖患者合并急性呼吸窘迫综合征的护理体会。该患者食用网购减肥药后合并急性呼吸窘迫综合征,存在困难气道、严重氧合障碍、感染加重与营养不良风险等问题,给予以下护理措施:①紧急开放困难气道,实施肺通气保护策略;②进行个性化体外膜肺氧合联合俯卧位通气;③落实感染控制策略,降低感染加重风险;④个性化营养供给,增强机体免疫功能;⑤阶梯式运动康复训练,改善呼吸功能;⑥加强健康宣教,建立健康生活习惯。经过积极的治疗与护理,患者入院第9天步行出院。

质量控制小组管理模式在护理质量管理中的应用价值

目的探讨质量控制小组管理模式在呼吸与危重症医学科临床护理质量管理工作中的应用价值。方法选取2021年1月至2022年6月实施质控小组管理模式工作后的呼吸危重症患者50例为观察组,2020年1月至2020年12月质控小组实施前的呼吸危重症患者50例为对照组,观察两组患者对护理工作满意度以及实施期间总护理不良事件发生情况,评估实施质控管理小组前后护理人员护理质量。结果观察组总护理不良事件发生率低于对照组,差异有统计意义(P<0.05);观察组患者护理总满意度高于对照组,差异有统计意义(P<0.05);实施质量控制小组管理模式前护理人员的基础护理质量评价、护理病历书写质量评价、健康教育宣教质量评价、应急专科能力质量评价、护理操作质量评价、消毒隔离质量评价均低于实施后,差异有统计意义(P<0.05)。结论质量控制小组管理的工作模式不仅能有效提高呼吸危重症患者对护理人员工作的满意度,减少临床工作中护理不良事件发生,还能提高护理人员护理工作质量。

慕课联合翻转课堂在呼吸与危重症医学科规范化培训中的应用

目的:探讨慕课结合翻转课堂在呼吸与危重症医学科住院医师规范化培训中的应用价值。方法:选取在安徽医科大学第二附属医院呼吸与危重症医学科参加住院医师规范化培训的84名内科学员,随机分为观察组和对照组。对照组给予常规教学方式,观察组在常规教学方式的基础上,录制慕课教学视频交住培学员自主学习,让住培学员利用自由时间学习慕课资源,随后通过翻转课堂进行实践、交流互动。比较两组出科理论考试成绩、临床技能成绩及住培学员对于教学的满意度。结果:观察组住培学员理论考试和临床技能成绩均优于对照组,且观察组学员对教学的满意度高于对照组(P<0.05)。结论:慕课联合翻转课堂在呼吸与危重症医学科住院医师规范化培训中有着积极意义。

呼吸与危重症学课程思政设计与实施策略

医学教育在高等教育领域里占有重要的地位,肩负着培养医学人才,维护和促进人民健康的重要使命。这一使命在公共卫生事件救治过程中得到很好的诠释,涌现出一批舍小家顾大家、不顾及个人利益、勇挑重担、无私奉献、生命至上的光辉事迹。如何将这些精神持续的传承值得思考。习近平总书记强调把思想政治工作贯穿教育教学全过程。用科学理论培养人,重视思政课的实践性。明确与挖掘每门课程都内在的思政元素,是推进课程思政的认识基础。呼吸与危重症学是临床医学中重要组成部分之一,呼吸道疾病也是我国的常见病与高发病之一,也是医学生踏入临床的必修课之一。为此,笔者根据课程特点探索呼吸与危重症学思政元素以及思政与专业知识融入方式,全面认识和把握课程中的思政元素,以促进学生全面发展。

以呼吸道为主的专项护理对呼吸科危重症患者血气指标及恢复状况的影响

目的 探究以呼吸道为主的专项护理对呼吸科危重症患者血气指标及恢复状况的影响。方法 选取我院2021年2月-2023年7月收治的142例呼吸科危重症患者进行研究。随机数字表法进行分组,2组各71例。对照组实施常规护理。观察组实施常规+以呼吸道为主的专项护理。比较两组患者恢复状况、血气指标、不良事件发生情况及睡眠质量改善情况。结果 观察组ICU入住时间(10.62±2.50)d、住院时间(15.48±2.45)d低于对照组(12.25±2.65)d、(17.33±2.62)d,差异有统计学意义(t=3.770,P=0.000,t=4.346,P=0.000)。干预前,观察组与对照组血气指标相比差异不显著(t=0.298,P=0.766、t=0.279,P=0.781),干预后的两组氧分压均增加,二氧化碳分压均降低,差异显著(t=38.843,P=0.000,t=22.742,P=0.000)、(t=34.442,P=0.000,t=22.081,P=0.000),且观察组氧分压高于对照组,二氧化碳分压低于对照组,差异显著(t=3.805,P=0.000,t=2.087,P=0.039)。观察组不良事件总发生率(2.82%)低于对照组(12.68%),差异显著(c2=4.829,P=0.028)。干预前,观察组与对照组睡眠质量评分相比差异不显著(t=0.745,P=0.458),干预后的两组评分均降低,差异显著(t=25.051,P=0.000,t=19.808,P=0.000),且观察组(7.21±1.25)分低于对照组(8.58±1.15)分,差异显著(t=6.796,P=0.000)。结论 以呼吸道为主的专项护理能够改善呼吸科危重症患者血气指标,降低不良事件的发生率,改善患者睡眠,促进患者恢复。

基于三维结构的案例教学法在护理实习生带教中的应用

目的:探讨基于三维结构的案例教学法在呼吸与危重症医学科护理实习生带教中的应用效果。方法:研究参与对象为60名呼吸与危重症医学科实习护生,均于2019年6月到2020年4月进入我科实习。随机分为两组,对照组30人,实施传统带教;试验组30人,在传统带教基础上实施基于三维结构的案例教学法带教。测评实施后两组学生的出科整体护理考核成绩及两组学生对教学效果的满意度。结果:试验组的考核成绩及教学满意度评价均优于对照组,差异具有统计学意义(P<0.05)。结论:基于三维结构的案例教学法对呼吸与危重症医学科护理实习生进行教学,可有效提高临床带教质量,提高护生整体护理能力,适应医学的发展需要。

呼吸与危重症医学科医疗设备可靠性管理模式构建及应用效果分析

目的:构建呼吸与危重症医学科医疗设备可靠性管理模式,探究其在呼吸与危重症医学科医疗设备管理中的应用效果。方法:以设备管理内容和管理方法的可靠性为评估指标,形成设备使用、清洁和应急管理规范化流程,构建呼吸与危重症医学科医疗设备可靠性管理模式,采用失效模式与影响分析(FMEA)、故障模式影响及危害性分析(FMECA)和威布尔分析方法进行可靠性分析。选取2022年1月至2023年1月首都医科大学附属北京安贞医院呼吸与危重症医学科在用的63台医疗设备,依据管理模式不同,分别采用常规管理模式(32台)和可靠性管理模式(31台),对比两种管理模式的设备管理指标评分、设备目标达成度和设备管理缺陷率以及设备使用管理的工程师、操作技师和医生对两种管理模式的设备管理认可度评分。结果:设备使用管理的工程师、操作技师和医生对采用可靠性管理模式的认可度平均评分分别为(90.66±5.25)分、(91.54±4.14)分和(92.17±5.17)分,均高于常规管理模式的认可度评分,差异有统计学意义(t=14.249、13.773、12.267,P<0.05);采用可靠性管理模式的设备资源配置、信息技术、技术支撑和管理绩效指标平均评分分别为(90.25±4.12)分、(92.45±3.26)分、(91.47±2.78)分和(90.25±3.11)分,均高于常规管理模式,差异有统计学意义(t=12.122、18.379、15.581、14.141,P<0.05);采用可靠性管理模式的设备使用规范度、清洗完成度和应急管理及时性平均评分分别为(92.36±3.25)分、(90.69±3.69)分和(91.87±3.01)分,均高于常规管理模式,差异有统计学意义(t=14.953、15.030、14.401,P<0.05)。采用可靠性管理模式的设备损坏、维修和返厂台数分别为1、1和2台,其缺陷率分别为3.22%、3.22%和6.45%,均低于常规管理模式,差异有统计学意义(x^(2)=8.581、9.908、8.782,P<0.05)。结论:基于可靠性的呼吸与危重症医学科医疗设备管理模式应用于呼吸与危重症医学科医疗设备管理,能提升设备管理与运行质量,降低设备故障率,改善设备服务水平。

基于紧密型医联体建设的区级医院重症医学科“一科两院”模式实践探索

以紧密型医联体建设为抓手,通过加强急危重症诊治水平和提升服务能力,把区级医院打造成区域医疗中心,解决群众的就近就医需求,是上海市完善分级诊疗制度的重要内容。2021年9月,上海市第十人民医院崇明分院在“区办市管”托管模式的基础上,选取一度面临关停的重症医学科作为“一科两院”学科共建模式试点科室,探索以医联体内部优质资源下沉共享、区级医院专科人才队伍培养为主的薄弱专科建设机制。经过2年的试点,崇明分院重症医学科在医疗服务能力、专科人才培养、合作平台建设、区域辐射效能等方面取得显著成效,并总结出了基于紧密型医联体建设的薄弱专科建设新路径。

药学干预对呼吸科门急诊抗菌药使用的影响

目的探讨基于合理用药监测系统(prescription automatic screening system,PASS)的处方点评与药学干预对呼吸与危重症科门急诊抗菌药物合理应用的影响。方法将2021年8月至2023年8月天津市胸科医院呼吸与危重症科门急诊使用抗菌药物的20270份处方作为研究对象。将2022年8月开始进行药学干预的处方作为干预组,干预之前的处方作为对照组。利用PASS系统对全部处方进行抽样,临床药师进行处方点评,对点评不合格处方进行合理性分析,将点评结果反馈医师并针对点评结果在全科范围内进行抗菌药物合理使用培训。结果干预组处方合格率显著高于对照组,差异有统计学意义(P<0.05),且随着药学干预时间的延长稳步增长。结论药学干预有助于提升呼吸与危重症科门急诊抗菌药物的合理应用。

多发性骨折并发急性呼吸窘迫综合征患者行俯卧位通气治疗的护理

总结1例多发性骨折并发急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者行俯卧位通气治疗的护理体会。针对患者多发性骨折并发ARDS、病情进展迅速、传统俯卧位风险高等问题,采取组建多发骨折俯卧位通气多学科团队、实施改良式俯卧位翻身流程、俯卧位联合运用气道廓清技术促进肺康复、舒适化镇痛镇静提高俯卧位的耐受性、积极鼓励家属参与患者精神症状管理等措施。经7 d的治疗和护理,患者从ICU转入普通病房,术后第26天康复出院。

渐进式肌肉放松训练在清醒俯卧位通气患者中的应用效果

目的探讨渐进式肌肉放松训练在急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者清醒俯卧位通气中的实施效果.方法采用类实验研究法,选取2023年5月-7月湖南省某三级甲等医院ARDS患者45例为试验组,清醒俯卧位通气前采用渐进式肌肉放松训练方案;2022年12月-2023年2月的ARDS患者45例为对照组,采用常规清醒俯卧位通气.比较两组患者清醒俯卧位通气治疗前3 d内的每日单次治疗最长时间、治疗总时长、耐受性和治疗效果.结果试验组在清醒俯卧位通气第3天的单次治疗最长时间[(3.68±0.71)h]高于对照组[(2.50±0.67)h],试验组前3 d治疗总时长[(36.72±0.56)h]高于对照组[(23.25±1.76)h](P<0.001);试验组在治疗第3天的耐受性指标(视觉模拟评分)[(2.83±1.74)分]小于对照组[(6.17±1.11)分](P<0.001);试验组在俯卧位治疗开始4 h后的血氧分压及氧合指数均优于对照组(P<0.001).结论渐进式肌肉放松训练能有效延长ARDS患者清醒俯卧位通气的治疗时间,提高耐受性,从而改善治疗效果.