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Journal of emergency and critical care medicine (Hong Kong, China)最新文献

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Idiopathic intrahepatic arterioportal shunt rupture 特发性肝内动脉门静脉分流破裂
Pub Date : 2019-11-09 DOI: 10.21037/jeccm.2019.08.12
S. Limchareon, Weravit Ruangsirinusorn
A 70-year-old Thai female end-stage renal disease (ESRD) patient, with a 4 years history of peritoneal dialysis, was brought to the emergency department because of syncope after her regular peritoneal dialysis, and a mixture of fluid and blood was obtained from the peritoneal fluid. Blood loss was suspected from her physical examinations and labs. Her past medical history showed hypertension, dyslipidemia, ischemic stroke, causing right hemiparesis 10 years ago and aspirin (ASA) has been prescribed.
一名70岁的泰国女性终末期肾病(ESRD)患者,有4年腹膜透析史,在定期腹膜透析后因晕厥被送往急诊科,并从腹膜液中获得液体和血液的混合物。根据她的身体检查和实验室检查,怀疑她失血过多。她过去的病史显示,10年前患有高血压、血脂异常、缺血性中风,导致右偏瘫,并开具了阿司匹林(ASA)处方。
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引用次数: 0
A biomarker-based stratification tool for pediatric acute respiratory distress syndrome: a new approach to an old problem 一种基于生物标志物的儿科急性呼吸窘迫综合征分层工具:一种解决老问题的新方法
Pub Date : 2019-11-01 DOI: 10.21037/JECCM.2019.01.01
J. Balcells, O. Roca
Assessing the prognosis of a disease is an essential component of a high-quality healthcare process. In the clinical scenario, prognostic information is relevant to prioritizing patients, to selecting treatment modalities or level of care, and to informing patients and relatives about what is expected to happen. From the ethical standpoint, expected prognosis is a key element in the process of ascertaining the suitability of the treatment options being considered.
评估疾病的预后是高质量医疗保健过程的重要组成部分。在临床情况下,预后信息与优先考虑患者,选择治疗方式或护理水平以及告知患者和亲属预期发生的情况有关。从伦理的角度来看,预期预后是确定所考虑的治疗方案是否合适的关键因素。
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引用次数: 0
Diagnosis of invasive pulmonary aspergillosis in the intensive care unit: what we should concern and how to do better 重症监护室侵袭性肺曲霉病的诊断:我们应该关注什么以及如何做得更好
Pub Date : 2019-10-29 DOI: 10.21037/jeccm.2019.10.02
Hui Shen, Wentao Bao, Yuetian Yu
Invasive pulmonary aspergillosis (IPA) is no longer a rare disease in the intensive care unit (ICU) on account of the increased number of immunocompromised hosts admitted, the application of invasive treatment procedures and the widespread use of broad-spectrum antibiotics. Different from those with agranulocytosis, symptoms and signs of IPA in ICU patients are subtle or non-specific which are unable to be distinguished from those with bacterial pneumonia or even with noninfectious diseases. Thus, accurately diagnosing of IPA is quite challenging. In this review, we will navigate through the IPA diagnostic tests currently available and how they apply to ICU population. Special attention is paid to the non-culture- based tests as well as have a look into what the future holds.
侵袭性肺曲霉病(IPA)在重症监护病房(ICU)不再是一种罕见的疾病,这是由于越来越多的免疫功能低下的宿主入院,侵入性治疗程序的应用和广谱抗生素的广泛使用。与粒细胞缺乏症不同,ICU患者IPA的症状和体征是微妙的或非特异性的,无法与细菌性肺炎甚至非传染性疾病区分开来。因此,准确诊断IPA是非常有挑战性的。在这篇综述中,我们将浏览目前可用的IPA诊断测试以及它们如何应用于ICU人群。特别关注的是非文化基础的测试,以及对未来的展望。
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引用次数: 2
Consideration for thrombolysis for significant pulmonary embolism in haemodynamically stable patients—is it time for a rethink? 对血流动力学稳定的显著肺栓塞患者进行溶栓治疗的考虑——是时候重新考虑了吗?
Pub Date : 2019-10-12 DOI: 10.21037/jeccm.2019.09.07
Debkumar Chowdhury
Pulmonary embolism (PE) is a common diagnosis made in the emergency department with 60–70 cases per 100,000. The clinician needs to have up to-date knowledge and potential treatment strategies for management of this common condition. Thrombolysis for PE is one of the options that can be considered in the Emergency Department. The British Thoracic Society (BTS) has formed a set of recommendations for consideration of thrombolysis. We will discuss two clinical cases of differing severity and discuss the rationale behind the treatment strategies. Firstly, we present a lady in her late 40s with acute shortness of breath with pleuritic chest pain. She was brought in by ambulance and the resuscitation suite was pre-alerted that she was due to arrive. She had been recently treated for a lower limb deep venous thrombosis (DVT) and had presented to a local hospital 2/7 previously with some associated pleuritic chest pain. She was noted to be profoundly compromised from a cardiovascular perspective. She was treated with a systemic thrombolytic agent and she was subsequently discharged soon afterwards. The second case we present is that of a 50-year-old previously fit and well gentleman who presented with acute shortness of breath on minimal exertion for the previous 3 days. There was no background history of airway diseases with no smoking. He was noted to be marked hypoxic requiring 5 litres of oxygen to maintain an oxygen saturation of 95%. His blood pressure was noted to be stable throughout his time in the department. There was imaging and electrocardiographic evidence of right ventricular strain. It was also noted to be a marked rise in cardiac enzymes indicating cardiac involvement, based on the findings he subsequently underwent treatment with a systemic thrombolytic agent and made subsequently satisfactory recovery. The presence of raised troponin in the presence of an acute PE classifies as a massive PE. Systemic thrombolysis is the first line treatment for massive PE and should be started on clinical grounds alone if cardiac arrest in imminent with alteplase being the drug of choice. The decision to perform systemic thrombolysis in the haemodynamically stable patient is multifactorial and should be assessed in a case by case manner as highlighted by this article.
肺栓塞(PE)是急诊科的常见诊断,每10万人中有60-70例。临床医生需要掌握最新的知识和潜在的治疗策略来管理这种常见疾病。溶栓治疗PE是急诊科可考虑的选择之一。英国胸科学会(BTS)已经形成了一套建议考虑溶栓。我们将讨论两个不同严重程度的临床病例,并讨论治疗策略背后的基本原理。首先,我们报告一位40多岁的女士急性呼吸急促并伴有胸膜性胸痛。她被救护车送进医院,急救人员提前通知她即将到达。她最近因下肢深静脉血栓(DVT)接受了治疗,并于7月2日到当地医院就诊,此前曾出现胸膜炎性胸痛。从心血管的角度来看,她被认为是严重受损的。她接受了全身溶栓剂治疗,随后不久出院。我们提出的第二个案例是一个50岁以前健康和良好的绅士谁提出了急性呼吸短促最小的努力,在过去的3天。无呼吸道疾病病史,不吸烟。他明显缺氧,需要5升氧气才能维持95%的氧饱和度。他的血压在系里一直很稳定。有影像学和心电图证据显示右室劳损。还注意到心脏酶的显著升高表明心脏受损伤,根据检查结果,他随后接受了全身溶栓剂治疗,随后恢复良好。急性PE时肌钙蛋白升高可归类为块状PE。全身性溶栓是治疗大面积PE的一线治疗方法,如果心脏骤停迫在眉睫,应根据临床理由单独开始,选择阿替普酶作为药物。在血流动力学稳定的患者中进行全身溶栓的决定是多因素的,应该根据具体情况进行评估,这篇文章强调了这一点。
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引用次数: 0
Defining the high-risk patient 高危患者的定义
Pub Date : 2019-10-09 DOI: 10.21037/jeccm.2019.08.10
Gemma Phillips, A. Cameron, T. Szakmany
As the volume of surgery continues to grow worldwide, the identification of high-risk patients is an important goal to guide clinical decision making in the perioperative period. Risk stratification evolved over the last decade from simple risk stratification tools, still used widely in the clinical arena to more sophisticated risk prediction models based on machine learning and latent class analysis, which can be incorporated into a well-developed electronic patient record or critical care clinical information system. As the debate about which patients will benefit most from critical care admission and interventions is still ongoing, the identification of the high-risk patient is a continuing challenge. In this review we will summarise the latest developments in the use of these risk stratification tools and risk prediction models, which can be utilised to identify the high-risk surgical candidate.
随着全球手术量的持续增长,识别高危患者是指导围手术期临床决策的重要目标。在过去的十年里,风险分层从仍然在临床领域广泛使用的简单风险分层工具发展到基于机器学习和潜在类别分析的更复杂的风险预测模型,这些模型可以被纳入完善的电子病历或重症监护临床信息系统中。由于关于哪些患者将从重症监护入院和干预中受益最大的争论仍在进行中,识别高危患者是一个持续的挑战。在这篇综述中,我们将总结使用这些风险分层工具和风险预测模型的最新进展,这些工具和模型可用于识别高风险的候选手术。
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引用次数: 0
Setting intraoperative fraction of inspired oxygen 设定术中吸氧分数
Pub Date : 2019-10-09 DOI: 10.21037/jeccm.2019.08.04
R. M. Artigas, M. Soro, C. Ferrando
Each year, millions of patients undergo surgery under general anaesthesia. Oxygen, the most ubiquitous drug used in the operative setting, is often titrated to the anaesthesiologist preference. The choice of a high inspired fraction of inspired oxygen (FiO2) is commonplace. Safety criteria along with a debatable effect on a decrease in surgical site infection (SSI) are the potential reasons to justify a high FiO2 usage. Based on the latter, several organizations such as the World Health Organization (WHO) or Centers for Disease Control (CDC) have issued recommendations to keep high FiO2 during surgery and the immediate postoperative period. In this article, we will review the evidence behind these beneficial effects and several potential side effects of a high FiO2 intraoperative strategy.
每年,数以百万计的病人在全身麻醉下接受手术。氧气是手术环境中最普遍使用的药物,通常根据麻醉医师的喜好进行滴定。选择高吸入氧(FiO2)的吸入分数是司空见惯的。安全标准以及对减少手术部位感染(SSI)的有争议的影响是证明高FiO2使用的潜在原因。基于后者,一些组织,如世界卫生组织(WHO)或疾病控制中心(CDC)已经发布了在手术期间和术后立即保持高FiO2的建议。在本文中,我们将回顾高FiO2术中策略的这些有益效果和几个潜在副作用背后的证据。
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引用次数: 1
Fluid management in the perioperative setting: mind the kidney 围手术期液体管理:注意肾脏
Pub Date : 2019-09-26 DOI: 10.21037/jeccm.2019.08.09
Emanuele Favaron, J. Montomoli, M. Hilty, C. Ince
Acute kidney injury (AKI) is one of the most frequent complications in critically ill patients and in the perioperative setting. The anatomical structure and the microvasculature of the kidney makes it highly vulnerable to hypoxia. Although fluid therapy is considered crucial in situations where improvement of cardiac output is needed, it can also contribute to AKI development when administered inappropriately. Hemodilution and anemia during cardio-pulmonary bypass have been demonstrated to be risk factors for AKI and they are likely to be a consequence of fluid administration. In order to assess the perfusion of the kidneys it is necessary to investigate the determinants of delivery of oxygen at the microcirculatory level. Indeed, fluids can decrease the capillary hematocrit and the functional capillary density, affecting the renal oxygenation and increasing the risk of AKI. Monitoring sublingual microcirculation can be a reliable tool to guide fluid administration, aiming to prevent or improve perioperative AKI.
急性肾损伤(AKI)是危重患者和围手术期最常见的并发症之一。肾脏的解剖结构和微血管结构使其极易缺氧。尽管液体治疗在需要提高心输出量的情况下被认为是至关重要的,但如果给药不当,它也会导致AKI的发展。心肺转流期间的血液稀释和贫血已被证明是AKI的危险因素,它们可能是液体给药的结果。为了评估肾脏的灌注,有必要研究微循环水平下氧气输送的决定因素。事实上,液体会降低毛细血管红细胞压积和功能性毛细血管密度,影响肾氧合并增加AKI的风险。监测舌下微循环是指导补液的可靠工具,旨在预防或改善围手术期AKI。
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引用次数: 2
Perioperative goal directed therapy—current view 围手术期目标导向治疗的现状
Pub Date : 2019-09-24 DOI: 10.21037/jeccm.2019.09.03
J. Zatloukal, J. Pouska, J. Beneš
High-risk surgery is frequently associated with increased number of complications and higher mortality. Cardiovascular reserves of patients undergoing such procedures are frequently low, limiting their ability to sustain adequate organ perfusion. This puts the organs into the risk of hypoperfusion with loss of function and even failure. Perioperative goal directed therapy is can improve postoperative outcome of intermediate-to-high-risk surgical patients. Based on current evidence it seems to be associated with decreased postoperative length of stay, number of complications and possibly even mortality. In following narrative review, we discuss the contribution of perioperative goal directed therapy as well as its limits and possible future perspectives.
高风险手术通常伴随着并发症的增加和更高的死亡率。接受此类手术的患者心血管储备通常较低,限制了他们维持足够器官灌注的能力。这会使器官面临灌注不足、功能丧失甚至衰竭的风险。围手术期目标导向治疗可以改善中高危手术患者的术后预后。根据目前的证据,它似乎与缩短术后住院时间、并发症数量甚至可能死亡率有关。在接下来的叙述性回顾中,我们讨论围手术期目标导向治疗的贡献,以及它的局限性和可能的未来前景。
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引用次数: 2
Monitoring the post surgery inflammatory host response 监测术后炎症宿主反应
Pub Date : 2019-09-18 DOI: 10.21037/jeccm.2019.08.06
F. Paruk, J. Chausse
The human response to surgery is meant to be protective and to promote healing. The cascade of events that ensue following tissue injury is highly complicated and involves an interplay of the metabolic, hemodynamic, hormonal and immunological systems. The release of biomolecules known as damage-associated molecular patterns (DAMPs) activates the pro-inflammatory innate and anti-inflammatory adaptive responses, which are designed to defend and contain the inflammatory process locally. The magnitude of tissue injury influences the scale of the inflammatory response. Further, patient factors as well as medical therapy influences this response. An imbalance between the pro-inflammatory and anti-inflammatory response or an exaggerated response may culminate with organ dysfunction, an increased susceptibility for infections or death. Cell mediated immunity (CMI) is often suppressed post surgery and patients are predisposed to the development of postoperative infections and complications. Mapping the immune response would be useful in terms of adjudging the patient’s response to surgery, alerting clinicians to the occurrence of complications thereby providing the opportunity to implement appropriate management timeously if necessary. There is a vast overlap in the surgical inflammatory response with that of the pathogen-associated molecular patterns (PAMPs) induced response that follows sepsis. This presents a challenge in the postoperative period in terms of distinguishing between infectious and non-infectious complications. Biomarkers have thus emerged as attractive contenders to map the immune response. Taking into account the complexity of the inflammatory response, it is unlikely that a single biomarker will ever be utilised to achieve this. In the era of personalised medicine, where our patient populations are quite heterogeneous, future directions point towards the use of multiple panels of novel biomarkers. Currently the procalcitonin (PCT) and C-reactive protein (CRP) are available for general use. This review explores the inflammatory response to surgery and the utility of CRP and PCT in the postoperative period. It highlights the importance of using biomarker kinetics coupled with the clinical response and the principle of individualised interpretation.
人类对手术的反应是为了保护和促进愈合。组织损伤后发生的一连串事件非常复杂,涉及代谢、血液动力学、激素和免疫系统的相互作用。被称为损伤相关分子模式(DAMP)的生物分子的释放激活了促炎先天和抗炎适应性反应,这些反应旨在局部防御和控制炎症过程。组织损伤的程度影响炎症反应的程度。此外,患者因素以及药物治疗会影响这种反应。促炎和抗炎反应之间的失衡或过度反应可能最终导致器官功能障碍、感染或死亡的易感性增加。细胞介导的免疫(CMI)通常在手术后受到抑制,患者容易发生术后感染和并发症。绘制免疫反应图有助于判断患者对手术的反应,提醒临床医生并发症的发生,从而在必要时及时实施适当的管理。手术炎症反应与败血症后病原体相关分子模式(PAMP)诱导的反应有很大的重叠。这对术后区分感染性和非感染性并发症提出了挑战。因此,生物标记物已成为绘制免疫反应图的有吸引力的竞争者。考虑到炎症反应的复杂性,不太可能使用单一的生物标志物来实现这一点。在个性化医学时代,我们的患者群体非常异质,未来的方向指向使用多种新型生物标志物。目前降钙素原(PCT)和C反应蛋白(CRP)可用于一般用途。这篇综述探讨了手术后的炎症反应以及CRP和PCT在术后的应用。它强调了使用生物标志物动力学与临床反应和个性化解释原则相结合的重要性。
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引用次数: 23
Peri-operative adverse respiratory events and post-operative non-invasive ventilation 围手术期呼吸不良事件及术后无创通气
Pub Date : 2019-09-17 DOI: 10.21037/jeccm.2019.08.11
S. Einav, M. Leone
Postoperative respiratory adverse respiratory events (AREs) are a common phenomenon. Multiple causes contribute to peri-operative impairment of respiration and the development of post-operative AREs. AREs have been associated with poor patient outcomes and impose an unplanned burden on the medical system. The treatment of perioperative AREs should be tailored to treat the injurious processes that predominate in the case at hand. Specific characteristics of non-invasive ventilation techniques may make them particularly relevant to specific types of post-operative AREs. Future research needs to focus on identification of patients at risk for perioperative AREs and on matching of ventilation techniques to specific causes of ARE.
术后呼吸系统不良反应(AREs)是一种常见现象。多种原因导致围手术期呼吸障碍和术后AREs的发展。ARE与不良的患者结局有关,并给医疗系统带来了计划外的负担。围手术期ARE的治疗应针对目前病例中占主导地位的损伤过程。无创通气技术的特定特征可能使其与特定类型的术后ARE特别相关。未来的研究需要重点识别围手术期ARE的风险患者,并将通气技术与ARE的具体原因相匹配。
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引用次数: 0
期刊
Journal of emergency and critical care medicine (Hong Kong, China)
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