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1、常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Severe acute pancreatitis S_c7 Academy for Infection Management 2006 (All Rights Reserved) .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料History33-year-old maleAlcohol binge: vodkaAwake and conve
2、rsantSevere abdominal pain, vomiting, dyspnoea.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Physical and laboratory examinationsTemperature 38.1CPulse 96 bpm, respirations 20/minBlood pressure 110/70 mmHgAbdomen tender, distended, quietAmylase 3500 IU/LLipase 1100 IU/LA
3、ST 250 IU/LLDH 350 IU/L WBC count 16 000/mm3 Arterial blood gases:pH 7.30, PaCO2 32, PaO2 58, BE -5.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Which evaluations would you perform to determine if the patient has severe pancreatitis?1.C-reactive protein2.Computed tomogr
4、aphy (CT) scan3.Severity scoresa.Ranson scoreb.Glasgow (Imrie) scorec.APACHE II or III scored.Balthazar score.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Initial tests and treatmentFluid resuscitation Chest radiographyCTCalculation of Ranson score (at 48 hours) .常见心律失常
5、心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料The patient has severe pancreatitisby CT criteriaCentral necrosis of the pancreas 30%Peripancreatic oedema and inflammation.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Ranson score: a pancreatitis-spe
6、cific severity of illness scoreAge 55 years WBC 16 000/mm3 Glucose 200 mg/dL LDH 350 IU/L AST 250 IU/L Haematocrit decrease 10% points BUN increase 5 mg/dL Serum calcium 8 mg/dL PaO2 60 mm Hg Base deficit 6 LPresent on admissionDuring the first 48 hours .常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险
7、法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料The patient has eight positive Ranson criteriaSGOT 250 IU/LLDH 350 IU/L WBC count 16 000/mm3PaO2 60 mm HgBase deficit 6 LCalcium concentration 0 percentage pointsThe predicted mortality rate for a Ranson score of 8 is 60%Eachempati et al. Arch Surg 2002Figure reproduced
8、 with permission from Arch Surg.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Would you start prophylactic antibiotics?1.No2.Yes, with a.Ceftriaxone?b.Gentamicin plus metronidazole?c.Imipenem/cilastatin or meropenem?d.Ciprofloxacin plus metronidazole?e.Other?3.Yes, plus
9、fluconazole.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Penetration of pancreatic tissue and pancreatic juice by antimicrobial agentsPoorAminoglycosidesVancomycinVariablePenicillinsCephalosporinsGoodCarbapenemsMetronidazoleQuinolones FluconazoleBassi et al. Antimicrob
10、Agents Chemother 1994;38:830836.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料What is this patients risk of developing infection?1.50%.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Incidence of peripancreatic infection after acute pancreatiti
11、sAll episodes 3%7%Any pancreatic necrosis 20%70%Pancreatic necrosis 30% 15%30%Pancreatic necrosis 50% 40%70%Beger et al. Gastroenterology 1986;91:433438Beger et al. Pancreatology 2003;3:93101Buchler et al. Ann Surg 2000;232:619625.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄
12、栽培培训材料Day 14Day 7Day 21Should prophylaxis be given? for the entire at-risk period?Pancreatic infections almost never occur before Day 7 The peak incidence is at Day 14Beger et al. Gastroenterology 1986;91:43343899% of data95% of data68% of data.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现
13、代农业示范工程设施红地球葡萄栽培培训材料How long would you administer antibiotic prophylaxis?1.Would not administer prophylaxis2.1 week3.2 weeks4.3 weeks5.Until ICU dischargeShould prophylaxis be administered for the entire risk period?.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophyla
14、ctic antibiotics for severe acute pancreatitisFirst double-blind, placebo-controlled trial114 patients enrolled, 76 with necrosisEntry criteriaC-reactive protein 150, orNecrosis on contrast-enhanced CT, and120 mg/dL, orMultiple organ dysfunction score 2 pointsMeropenem 1 g q8h vs placeboPrimary end-
15、pointPancreatic/peripancreatic infection within 42 daysDellinger et al. Ann Surg (in press).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophylactic antibiotics for severe acute pancreatitis: trial resultsOutcomeMeropenem %Placebo %p-valuePancreatic/peripancreatic infe
16、ction18120.41Surgical intervention26200.48Mortality20180.80Dellinger et al. Ann Surg (in press).常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料The downside of prolonged antibiotic prophylaxisAllergyExpenseResistanceSuperinfection.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社
17、会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Prophylactic antibiotics for severe acute pancreatitisRecovery of resistant bacteriap Week 1Sensitivity (%)8897Specificity (%)90100Pos. pred. value (%)83100Neg. pred. value (%)9398Accuracy (%)8998.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽
18、培培训材料Results of culture and susceptibility testingPatient underwent CT-guided fine-needle aspirationPeripancreatic fluid Proteus mirabilis (pan-sensitive)BloodNo growthUrineNo growthSputumNo growth.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Microbiology of infected pa
19、ncreatic necrosis (%)Fernandez-del Castillo 1998Buchler 2000Gram-positive5546Gram-negative2636Anaerobes 2 4Candida spp.17 6MixedNot reported10Fernandez-del Castillo et al. Ann Surg 1998;228:676684Buchler et al. Ann Surg 2000;232:619626.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施
20、红地球葡萄栽培培训材料TherapyFormal operative debridement and drainageOnly one operation requiredMeropenem x 14 daysChoice based on tissue penetration Dosage reduction for creatinine clearance 35 mL/min.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料OutcomeFever and leukocytosis res
21、olveOrgan dysfunction resolvesRenal function improvesCreatinine stabilises at 2.0 mg/dLPatient recovers.常见心律失常心电图诊断的误区诺如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料Key learning points1.Most patients (85%) with acute pancreatitis do not develop severe disease2.Determination of severity
22、 of illness provides prognostic information and can guide therapy3.Antimicrobial prophylaxis does not prevent secondary infection in severe acute pancreatitis, but does increase risk of resistant pathogens if infection does occur4.Antibiotics may be withheld until needed for therapy .常见心律失常心电图诊断的误区诺
23、如病毒感染的防控知识介绍责任那些事浅谈用人单位承担的社会保险法律责任和案例分析现代农业示范工程设施红地球葡萄栽培培训材料AIM core principlesSelect the most appropriate antibiotic depending on the patient, risk factors, suspected infection and resistanceRecognise that prior antimicrobial administration is a risk factor for the presence of resistant pathogensEnsure adequate containment of the infection source by removing contaminated devices and draining/debriding infectious tissue.
