早期器官功能障碍的监测在重症急性胰腺炎治疗方案选择中的意义

目的 探讨影响重症急性胰腺炎合并早期器官功能障碍治疗效果的因素和治疗方案的选择.方法 收集2007年7月至2008年12月连续收治的167例重症急性胰腺炎患者的临床资料,分析出现早期器官功能障碍患者的临床特点、病情演变趋势和治疗结果.分析正规非手术治疗、手术治疗及时机对治疗效果的影响.结果 167例患者中,68例(40.72%)出现了不同程度的早期器官功能障碍,其中单一器官功能障碍39例(57.4%),2个及2个以上器官功能障碍29例(42.6%).最常累及器官包括:心血管系统32例(47.1%)、肺脏24例(35.3%)和肾脏20例(29.4%).高龄(P<0.05)、APACHE Ⅱ评分高(P<0.05)是重症急性胰腺炎合并早期器官功能障碍预后不良的指标,早期手术干预有助于降低病死率.结论 重症急性胰腺炎合并早期器官功能障碍患者的病死率与患者的年龄、器官功能障碍严重程度相关.治疗方案应采用正规非手术治疗包括合理液体复苏、去除病因治疗,同时结合手术治疗.急性反应期的手术治疗应根据病情演变趋势、器官功能障碍程度加以判断,手术应在坏死感染发生之前进行.SOFA评分可作为手术指征判断的参考指标.     

腹腔镜置管行腹腔灌洗治疗重症急性胰腺炎

目的 提高急性重症胰腺炎早期治疗效果。方法 回顾分析总结1996年10月~1998年7月间急性重症胰腺炎早期行腹腔镜置管闭式腹腔灌洗治疗10例经验。结果 临床疗效满意,治愈8例,2例死于重症胰腺炎的并发症。结论 腹腔镜置管行闭式腹腔灌洗是急性重症胰腺炎早期治疗的一种良好方法,有利于提高重症胰腺炎的治愈率。     

腹腔镜置和行腹腔灌洗治疗重症急性胰腺炎

目的 提高急性重症胰腺炎早期治疗效果。方法 回顾分析总结１９９６年１０月－１９９８年７月间急性重症胰腺炎早期行腹腔镜置管闭式腹腔灌洗治疗１０例经验。结果 临床疗效满意，治愈８例，２例死于重症胰腺炎的并发症。结论腹腔镜置管行闭式腹腔灌洗是急性重症胰腺炎早期治疗的一种良好方法，有利于提高重症胰腺炎的治愈率。     

早期临床干预策略在阻断胰腺炎重症化进程中的作用

目的 评价在急性胰腺炎早期应用临床干预策略预防轻症胰腺炎转化为重症胰腺炎或阻断重症胰腺炎进一步恶化的临床疗效.方法 将我院2001年1月至2008年12月期间收治的急性胰腺炎患者按胰腺炎诊疗方案不同分为两个治疗阶段,第一阶段(2001年1月至2004年12月)胰腺炎患者采用常规治疗措施,第二阶段(2005年1月至2008年12月)胰腺炎患者采用常规治疗措施加个体化的早期临床干预措施的综合治疗,比较两阶段胰腺炎重症化及重症胰腺炎的预后情况.结果 第二阶段胰腺炎重症化率(4.48%)较第一阶段(21.18%)明显降低(P＜0.05),SAP平均治愈时间明显缩短(P＜0.05),局部、全身并发症发生率及死亡率也均明显降低(P＜0.05).行早期临床干预措施的患者中35例出现了一些不良反应及并发症,但均无严重后果.结论 早期临床干预应用于胰腺炎的治疗是阻断胰腺炎重症化进程的有效治疗策略.     

妊娠合并急性胰腺炎的诊断与治疗（附5例报告）

目的　提高对妊娠合并急性胰腺炎的认识和警惕性 ,降低孕产妇的病死率。方法　对本院 1992年 3月～ 2 0 0 2年 3月收治的妊娠合并急性胰腺炎的 5例进行回顾性分析。结果　本组病例大多发病于妊娠晚期 ,且多为重症急性胰腺炎 ;误诊 2例 ,误诊孕产妇病死率显著增高 ;中止妊娠不能降低孕产妇病死率。结论　妊娠合并急性胰腺炎的早期诊断与治疗是改善病人预后的基础 ,其治疗应遵循“个体化”原则 ,并协同妇产科医生妥善进行胎儿的处置     

104例胆源性急性胰腺炎手术治疗时机探讨

目的 探讨胆源性急性胰腺炎的诊断和手术时机。方法 2004年6月至2006年12月间收治胆源性急性胰腺炎104例，根据有无胆道梗阻及轻重程度分为4类：轻症非梗阻型、轻症梗阻型、重症非梗阻型、重症梗阻型，对其临床治疗结果 进行回顾性分析和总结。结果轻症非梗阻型35例．轻症梗阻型22例、重症非梗阻型20例、重症梗阻型27例。轻症非梗阻型或轻症梗阻型胰腺炎早期手术与延期手术在并发症的发生率、平均住院日、死亡率上差异无统计学意义（P〉0．05）；对重症非梗阻型和重症梗阻型胰腺炎而言，早期手术并发症的发生率高、平均住院日长，与延期手术比较，差异有统计学意义（P〈0．05），但重症梗阻型胰腺炎早期手术死亡率明显低于延期手术（P〈0．05）。结论 手术时机对胆源性急性胰腺炎患者的预后有重大影响，早期宜行保守治疗，根据患者个体情况选择适当时机进行手术治疗是减少并发症、提高治愈率的关键。     

重症急性胰腺炎入院24 h内死亡因素剖析

目的探讨重症急性胰腺炎死亡因素.方法应用SPSS10.0软件对52例重症急性胰腺炎病人入院24h内临床资料进行Logistic回归分析,筛选重症急性胰腺炎死亡的危险因素,并建立Logistic回归方程式.结果在调查的27个因素中血pH值、APACHEⅡ评分、早期休克、合并多脏器功能衰竭与死亡关;单因素Logistic回归分析发现休克、胸腔积液、血pH值、APACHEⅡ评分以及并发症的发生与死亡有关,而多因素分析发现只有血pH值与重症急性胰腺炎的死亡有关.结论该回归方程在病程早期对预测重症急性胰腺炎的预后及临床治疗有一定帮助;重症急性胰腺炎早期治疗中应强调维护全身脏器功能,积极纠正水电解质和酸碱平衡的紊乱,对降低死亡率具有重要的作用.     

重症急性胰腺炎并发结肠瘘的探讨

目的　了解重症急性胰腺炎并发结肠瘘的易发因素 ,提出诊治措施 ,提高重症急性胰腺炎的治愈率。方法　回顾性分析我院在 1991年 1月～ 1998年 12月收治的重症急性胰腺炎所致结肠瘘 8例 ,了解其发生的部位、时间 ,分析治疗方法对预后的影响。结果　本组治愈 7例 ,有 1例因患者拒绝行结肠造瘘术而致严重全身感染、成人呼吸窘迫综合症死亡。结论　重症急性胰腺炎易发生结肠瘘与其解剖因素和治疗方法有关。及时发现结肠瘘的存在 ,积极施行结肠造瘘和脓腔引流可以取得满意的治疗效果。     

重症急性胰腺炎早期非手术治疗的再认识

目的: 探讨重症急性胰腺炎的早期治疗方法. 方法: 对80例急性重症胰腺炎资料分别采用早期手术治疗和早期非手术治疗的两种方法进行回顾分析,并对病死率及主要并发症进行总结. 结果: 1992年1月~1994年12月的29例患者经早期手术治疗,病死率和并发症发生率分别为55.2%和93.1%,1995年1月~2000年12月的51例经早期非手术治疗,病死率和并发症发生率分别为23.5%和51.0%.两组比较差异有显著性(P<0.01). 结论: 对急性重症胰腺炎患者采用早期非手术治疗能降低病死率和并发症发生率.     

肾移植术后急性及重症胰腺炎的治疗

目的:探讨肾移植术后急性及重症胰腺炎的治疗方法。方法:采用保守治疗方法治疗肾移植术后急性及重症胰腺炎6例,其中4例为急性胰腺炎,2例为重症胰腺炎。结果:4例急性胰腺炎患者全部治愈,2例重症胰腺炎患者均死亡。结论:对肾移植术后重症胰腺炎的治疗应因人而异,保守治疗对重症胰腺炎也有较好的效果;对急性胰腺炎以保守治疗为主。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.