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【医学ppt课件】一例重症甲流病人的救治经过及体会

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Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. n一例重症甲流病人的 救治经过及体会 德州市人民医院ICU 庞国忠 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 患者男,18岁,因发热伴咳嗽5天,咯血、 乏力、纳差伴精神萎靡1天,于2009年12月12 日2时30分急诊入院。患者五天前受凉后出现 发热,体温达39 ℃以上,输注阿奇霉素和穿 琥宁治疗效果不佳。 查体:T37.7℃,P110次/分,R33次/分, BP100/45mmHg。神志清,喘憋貌,口唇紫绀。 听诊双肺呼吸音粗,可及明显水泡音。心音低 钝,无心脏杂音。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 辅助检查: n血常规:WBC 6100 x10 9/L N 81%. HB 137g/L Plt 139x10 9/L 血生化:TP 59g/L ALB 38g/L ALT 81 U/L AST 189 U/L BUN 11.8mmol/L CREA 154umol/L 血钾 4.4mmol/L 血钠 131.2mmol/L 血氯 89.4mmol/L GLU14.5mmol/L Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 辅助检查 心肌酶 LDH 917 U/L CK 3652 U/L CK-MB 97U/L 血气分析 PH 7.384 PaCO2 40.8mmHg PaO2 29mmHg BE -1mmol/L Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 入院初步诊断: 甲型H1N1流感 ? 重症肺炎 急性呼吸窘迫综合征 Ⅰ型呼吸衰竭 病毒性心肌炎 电解质紊乱 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 诊治经过:入院后立即给予达菲150mg口服,紧急经口气 管插管连接机械通气,设定模式IPPV,f20次/分、 VT500ml、FiO2 100%、PEEP 8cmH2O。SpO2由41%逐渐升至 70%左右,由气管插管内吸出大量粉红色分泌物。考虑肺 泡渗出不断增多,给予甲强龙500mg静脉注射,白蛋白 20g静脉滴注后,速尿40mg静脉推注。3小时后PEEP增加 至12cmH2O,气道分泌物量减少, SpO2 渐升至90%左右。 8时30分,将呼吸机模式改为SIMV+PSV, f15 次/分、 VT500ml、 FiO2 85%、PEEP 12cmH2O、 PS 16cmH2O。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 n 入院当天取咽试子,甲型H1N1流感病毒核酸 检测阳性,确定为甲型H1N1流感。给予奥司他 韦150mg bid和更昔洛韦抗病毒治疗;甲强龙 80mg q8h,乌司他丁80万U和血必净抗炎抗应激 治疗;果糖二磷酸钠营养心肌;万古霉素和亚 胺培南预防感染;静脉及肠道营养保证热量供 应;甲型H1N1流感抗体血浆及其它对症治疗。 为便于气道管理,于13日11时给予气管切开。 13时患者SpO2降至80%,逐渐增加PEEP达 18cmH2O, SpO2 维持在90%以上。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 n14日20时发现患者右颈肩部皮下气肿伴 血氧再度下降,查胸片显示右胸腔积气 。右肺压缩8%,给予胸腔闭式引流。将 PEEP降至14cmH2O。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病例介绍 n 15日呼吸机模式改为CPAP,PEEP14cmH2O、 PS16cmH2O。 17日患者再度出现体温升高38.5 度,WBC 18.4 x10 9/L, N89.9%。痰涂片发 现真菌,考虑合并二重感染,给予伏立康唑抗 真菌治疗。18日起只给予PEEP、 FiO2 50%, SpO2 可达到93%以上,逐渐缓慢减少PEEP,于 2009年12月31日机械通气20天后脱机。继续巩 固治疗于2010年1月15日出院。期间还发生心 衰,给予西地兰和米力农治疗;肝功能损伤给 予谷胱甘肽保肝治疗和营养支持疗法。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 治疗成功的体会 n1.早期识别甲流重症病人,早期经验性给予抗 病毒治疗对于阻断病毒复制,减轻对肺组织的 损害是至关重要的。 n2.早期使用抗体血浆对于中和和清除甲流病毒 可能是有益的。 n3早期应用大剂量抗炎药物乌司他丁和血比净 可以对抗和清除在ARDS已经存在的炎性介质和 细胞因子,阻断重症甲流的病理过程。 n4在极危重的病人,肺毛细血管渗漏是十分严 重的,糖皮质激素对减少肺水肿可能有效。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 治疗成功的体会 n5.重症甲流病人是否存在病毒对于自身免疫系 统的抑制和破坏,预防和控制细菌和真菌的感 染也关系到治疗的成败。 n6.重症甲流病人主要引起肺间质的病变,表现 为低氧血症、进行性呼吸衰竭,因此氧疗和机 械通气是治疗的重要措施之一。在治疗过程中 ,应该密切关注治疗效果和并发症,随时调整 ,及时处理。 n7.加强监护,综合治疗也是成功救治必不可少 的。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 谢谢 谢谢
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