Conclusion:
(11) Infect Control Hosp Epidemiol 2006; 27:662-669
An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.
(13) N Engl J Med 2006; 355:2725-32
An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period
Bad medicine: low-dose dopamine in the ICU
(36) Chest 2003;123:1266-1257
In addition to the lack of renal efficacy, the evidence demonstrated that low-dose dopamine administration worsens splanchnic oxygenation, impairs GI function, impairs the endocrine and immunologic systems, and blunts ventilatory drive. There is no justification for the use of low-dose dopamine administration in the critically ill.
(38) Ann Emerg Med. 2012 60:372-3
TAKE-HOME MESSAGE
Dopamine administration is associated with a higher incidence of arrhythmias and increased risk of death compared with norepinephrine in the treatment of septic shock.
(41) Anesthesiology 2014; 120:1098-108
9) 重症监护病房的管理模式
希望心脏手术有良好的预后是医生和患者的共同目标。 它不仅取决于外科手术效果,还与术中麻醉管理质量以及术后管理是否完善有关。 在此进修的医生也惊讶的发现国外麻醉医生更体现了向围术期医学职责转变的事实。 即使患者在麻醉门诊做过术前评估, 心胸麻醉主治医生术前必定和患者及其家属会有全方面的病情及手术麻醉方案的讨论,借此机会不仅构建良好的医患关系,还可用麻醉医生的自信解除患者的忧虑。 手术结束后, 麻醉医生团队要与重症监护团队(医生和护士) 紧密交流沟通所有重要的患者病情相关信息。有关流程必须遵守(Protocol for transfer of care)。 但这个环节往往被国内医生忽视, 认为这个过程对常规的心脏手术是“无关紧要的细节”。 国内主治医生常常不跟随每个患者去重症监护病房。 不幸的是我们有时可能低估了心脏手术患者术后瞬息万变的病情。 提高心脏手术预后效果,没有任何一个环节是“无关紧要的细节”。 术后的定期随访也应列为心脏麻醉医生围术期麻醉管理不可缺少的一部分。 只有通过随访才能掌握患者的预后情况,手术的效果以及麻醉的质量,从而考虑必要的改进措施。患者送入重症监护与麻醉医生无责的观念应该是时代的过去。快通道心胸麻醉的理念已经推广多年。但是心脏术后是否可以快通道恢复与很多因素有关。其中心胸麻醉规范化管理起至关重要的作用。
国内有些学者为了安全或方便,患者至少术后机械通气1-2天。 而美国受心胸外科协会数据库作为评判患者预后的其中一个影响指标(STS database)。 都是尽量个体化评估患者是否满足拔管标准,鼓励及早拔管和早期下床活动,以减少肺部并发症。我们医院和美国许多心脏中心相比术后重症恢复仍存在差距,排除简单的心脏手术实施快通道恢复以外,平均术后6-12 小时拔管。 24小时以内下床活动。
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