困难撤机

本文讨论国际上困难撤机的时间界定及困难撤机的原因,讨论了困难撤机的常见问题,困难撤机患者脱机模式的管理方法.在近代机械通气撤离新理念方面的发展趋势,尽管机械通气应用水平有很大发展,但在诸多环节上仍存在很多问题,撤机仍需经验,需多学科合作.     

ICU长期机械通气患者撤机困难的因素分析

为探讨ICU长期机械通气患者撤机困难的原因,回顾性分析大连医科大学附属第一医院重症医学科的62例长期机械通气患者的临床资料,回顾撤机过程,分析其撤机成功或失败的原因。结果显示,62例长期机械通气患者,34例成功撤机;10例死亡;18例因各种原因出现撤机困难,其中运动神经元病1例,脑外术后2例,间质性肺病4例,慢性阻塞性...     

呼吸机依赖患者撤机失败原因及对策

机械通气是近年来抢救呼吸衰竭患者的重要生命支持手段,但使用呼吸机的时间超过2周可导致撤机困难。本文详细分析了诸如心理障碍、营养不良、心肺功能不全以及撤机方法不当等各种可导致困难撤机的原因,并针对各个原因提出相应的治疗及护理对策,从而降低临床上困难撤机的发生率。     

呼吸机依赖患者撤机失败原因及对策

机械通气是近年来抢救呼吸衰竭患者的重要生命支持手段,但使用呼吸机的时间超过2周可导致撤机困难.本文详细分析了诸如心理障碍、营养不良、心肺功能不全以及撤机方法不当等各种可导致困难撤机的原因,并针对各个原因提出相应的治疗及护理对策,从而降低临床上困难撤机的发生率.     

呼吸机的撤离

呼吸机的脱机和撤离过程是一个重要的临床问题。呼吸机撤离是呼吸机由全部同期支持转为自主呼吸过程。在脱机过程中不必要的延迟会增加机械通气的复杂性,如肺炎或气道损伤,同时增加治疗的费用。撤机分为脱机和撤离人工气道,撤机参数对撤机后果预测的准确率不高,本文论述了对自主呼吸试验失败原因及实施自主呼吸方法以及完整呼吸机撤离过程。     

呼吸机的撤离

呼吸机的脱机和撤离过程是一个重要的临床问题.呼吸机撤离是呼吸机由全部同期支持转为自主呼吸过程.在脱机过程中不必要的延迟会增加机械通气的复杂性,如肺炎或气道损伤,同时增加治疗的费用.撤机分为脱机和撤离人工气道,撤机参数对撤机后果预测的准确率不高,本文论述了对自主呼吸试验失败原因及实施自主呼吸方法以及完整呼吸机撤离过程.     

长期机械通气患者的气道管理方法初探

探讨ICU长期机械通气患者人工气道的管理方法及其对预后的影响。回顾性分析我院中心ICU2006年1月至今4例连续机械通气时间大于3个月患者的临床资料,总结人工气道管理经验。通过加强气道管理,可以明显减少抗菌药物的应用,有效改善预后。4例患者中1例成功撤机封管出院,2例至今仍生存,1例死亡。提示具体有效的呼吸道管理措施是减少呼吸机相关性肺炎、延长患者生命及提高治愈率的保证。     

长期机械通气患者的气道管理方法初探

探讨ICU长期机械通气患者人工气道的管理方法及其对预后的影响。回顾性分析我院中心ICU2006年1月至今4例连续机械通气时间大于3个月患者的临床资料,总结人工气道管理经验。通过加强气道管理,可以明显减少抗菌药物的应用,有效改善预后。4例患者中1例成功撤机封管出院,2例至今仍生存,1例死亡。提示具体有效的呼吸道管理措施是减少呼吸机相关性肺炎、延长患者生命及提高治愈率的保证。     

体外循环术后患者延迟撤机的危险因素分析

为了探讨ICU内体外循环术后患者延迟撤机的危险因素,收集了2005年5月～2007年10月我院体外循环术后患者共305例,根据患者机械通气时间分为延迟撤机组（机械通气时间≥24h）和早期撤机组（机械通气时间〈24h）,对患者术前基础血糖、白蛋白、肌酐及射血分数（EF）,术中是否应用球囊反搏术、转机时间（CPB）、主动脉阻断时间（ACC）及输血量,术后生命体征、肾功能、24h引流量、APACHEⅡ评分及机械通气时间等围手术期临床指标进行回顾性分析。结果显示,患者年龄、术前白蛋白和EF,CPB、ACC、是否行球囊反搏术,术后APACHEⅡ评分、血糖、肌酐、血小板、APTT、氧合指数、是否再次行开胸探查术等围手术期参数差异有显著性（P〈0．05）;Logistic多元回归分析显示低EF（EF〈40％,OR=6．07）、CPB（〉234min,OR=4．69）及ACC时间（〉172min,OR=4．32）延长、术后高APACHEⅡ评分（〉16,OR=5．36）是体外循环术后延迟撤机患者预后的主要影响因素。提示体外循环术后患者EF低、CPB（〉234min,OR=4．69）及ACC时间延长、术后APACHEⅡ评分高是延迟撤机的主要危险因素。     

直立位机械通气可行性的探讨

机械通气是治疗急性肺损伤／急性呼吸窘迫综合征（ALI／ARDS）的重要措施之一,本文从理论上探讨直立位机械通气的可行性,推测其可能的机制,与肺保护通气策略的关系,尚需要解决的问题,以期证明优于传统机械通气方式。     

Assessing the remedy: the case for contracts in clinical trials

Current orthodoxy in research ethics assumes that subjects of clinical trials reserve rights to withdraw at any time and without giving any reason. This view sees the right to withdraw as a simple extension of the right to refuse to participate all together. In this paper, however, I suggest that subjects should assume some responsibilities for the internal validity of the trial at consent and that these responsibilities should be captured by contract. This would allow the researcher to impose a penalty on the subject if he were to withdraw without good reason and on a whim. This proposal still leaves open the possibility of withdrawing without penalty when it is in the subject's best interests to do so. Giving researchers recourse to legal remedy may now be necessary to protect the science, as existing methods used to increase retention are inadequate for one reason or another.     

Withholding and Withdrawing Life-Sustaining Treatment: Ethically Equivalent?

Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment.     

Religion and United States Physicians’ Opinions and Self-Predicted Practices Concerning Artificial Nutrition and Hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians’ religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.     

A Working Memory Model of a Common Procedural Error

Systematic errors In performance are an important aspect of human behavior that have not received adequate explanation. One such systematic error is termed postcompletion error; a typical example is leaving one's card In the automatic teller after withdrawing cash. This type of error seems to occur when people have an extra step to perform in a procedure after the main goal has been satisfied. The fact that people frequently make this type of error, but do not make this error every time, may best be explained by considering the working memory load at the time the step is to be performed: The error is made when the load on working memory is high, but will not be made when the load is low. A model of performance In the task was constructed using Just and Carpenter's (1992) CAPS that predicted that high working memory load should be associated with postcompletion errors. Two experiments confirmed that such errors can be produced in a laboratory as well as a naturalistic setting, and that the conditions under which the CAPS model makes the error are consistent with the conditions under which the errors occur in the laboratory.     

关于白血病患儿放弃治疗的思考

对于那些不可治愈、无治疗价值的晚期白血病患儿,虽然借助现代医疗技术可以使他们的生命得以延长,但生命质量却得不到提高,选择放弃治疗可能更符合伦理学和患儿及家庭的最佳利益。对白血病患儿放弃治疗的原因进行了分析,并对这一社会问题进行了伦理、法律和医学等方面的思考。     

Art - A Feasible Illusion

This article discusses the approximation between art and psychoanalysis, considering both as manifestations of the unconscious. Art is viewed as a successful instinctual substitute which differs from the symptom in terms of effectiveness. A work of art is the symbolic universe of the artist, who, by withdrawing into the world of imagination, encounters the pathways of reality. Artistic manifestation is not interpretable, however it communicates with the observer who may also find satisfaction for his own unconscious desires therein.     

呼吸机管路集中消毒对新生儿呼吸机相关性肺炎的影响

探讨呼吸机管路集中消毒对新生儿呼吸机相关性肺炎（VAP）的影响。将200例应用呼吸机的患儿按照时间顺序分为观察组（80例）和对照组（120例）,对照组呼吸机管路由病区采用传统消毒方法消毒,自然晾干备用。观察组呼吸机管路由消毒供应中心集中回收,全自动清洗机清洗消毒、高温高压灭菌,比较两组患儿VAP的发生率。对照组VAP发生率为31．667％,观察组VAP发生率为16．250％,两组比较差异有统计学意义（P＜0．05）。呼吸机管路集中消毒,可有效降低新生儿VAP的发生率。     

过犹不及：情绪的效价-唤醒度冲突在动机倾向上的分离

本研究通过两个实验考察不同效价度和唤醒度的情绪刺激是否存在动机倾向上的分离模式。实验1要求被试对表情图片的动机倾向（趋近/回避）进行主观评分,发现被试对低唤醒表情或积极表情有更加趋近的倾向。实验2以运动的线索启动动机倾向（趋近/回避）,完成情绪词效价判断任务,从内隐的角度考察情绪刺激是否存在动机倾向上的分离模式,结果发现,被试对动机倾向一致的情绪刺激的反应时更快。趋近的消极情绪词比趋近的积极情绪词的N2波幅更大,远离的低唤醒情绪词比趋近的低唤醒情绪词的LPC波幅更大。结果说明积极或者低唤醒的情绪刺激引发趋近倾向,而消极或高唤醒的情绪刺激引发回避倾向。     

ICU呼吸机相关性肺炎临床相关因素分析

为了探讨呼吸机相关性肺炎（VAP）发生的危险因素,回顾性分析我院ICU机械通气的88例患者的临床资料,按诊断标准分为发生VAP组和未发生VAP组,对两组患者的相关因素及预后进行评价。结果显示,发生VAP组机械通气时间明显长于未发生VAP组（P〈0．05）;两组在年龄、APACHE评分、病死率差异显著（P〈0．05）。因此,机械通气时间是影响VAP发生的重要因素,患者年龄越大,APACHE评分越高,越容易发生VAP。VAP是病情危重的一个表现,发生VAP的患者,病死率高,防治VAP的措施是必要的。     

Exemplary cases in clinical ethics: commentary on the case of Mr. A

A commentary on a case of a man who is left a "high quad" (ventilator dependant as well as quadriplegic) after an accident discusses the following: The right of patients who sustain catastrophic injuries to choose to discontinue life-sustaining treatment, The role of capacity assessment in treatment decisions and in ethics consultations, The role of advance directives (ADs) for such patients if they lack capacity, Whether a do-not-resuscitate or do-not-attempt-resuscitation order should be seen as "a medical order" or an advance directive, Some hints about what might be intended when a patient refers to the criterion of having a "meaningful life."