肾移植术后早期急性排斥反应与肾小管坏死的临床特点及护理

对９６８例行肾移植手术后发生急性肾小管坏死的２５８例及排斥反应２９６例进行分析。结果发现肾移植术后早期两者的临床特点有明显差异。提示做好早期临床观察，为医疗提供正确依据尤为重要。同时要做好少尿期的护理，注意血压及保持水电解质平衡，对预防种种上并发症发生及保证移植肾功能的恢复有重要意义。     

48例心脏死亡婴幼儿供肾儿童肾移植的护理

[目的]总结婴幼儿供肾儿童肾移植的手术治疗和临床护理特点。[方法]回顾性分析48例婴幼儿供肾儿童肾移植的手术治疗方案,总结术后护理措施和随访情况。[结果]12例双肾整块移植患儿术后肾功能延迟恢复(DGF)发生率为16.7%,36例单肾移植患儿术后DGF发生率为48.6%;1年人/肾存活率为100%/88.6%。[结论]婴幼儿供肾能有效缓解儿童移植肾脏短缺,手术难度较大,其围术期护理有特殊性,护士应根据儿童特点做好围术期尤其是术后早期护理及观察,及时发现并发症,提高移植肾存活率。     

肾移植术后肾功能延迟恢复行血液净化治疗的观察和护理

肾功能延迟恢复(DGF)是肾移植术后常见并发症,其定义为术后1周内需要透析治疗移植肾功能延迟恢复[1].DGF是肾移植术后急性肾衰竭的一种形式,以移植肾少尿、无尿为特征.在移植肾功能恢复之前进行血液净化治疗是非常重要的.在血液净化过程中维持血流动力学的稳定性、减少并发症的发生对移植肾功能的恢复以及减缓以后可能发生的慢性移植物肾病的进展都有重要作用[2].本文报告对28例尸肾肾移植术后肾功能延迟恢复患者行血液净化治疗的观察和护理.     

肾移植术后肾功能延迟恢复行血液净化治疗的观察和护理

肾功能延迟恢复（DGF）是肾移植术后常见并发症,其定义为术后1周内需要透析治疗移植肾功能延迟恢复^[1]。DGF是肾移植术后急性肾衰竭的一种形式,以移植。肾少尿、无尿为特征。在移植肾功能恢复之前进行血液净化治疗是非常重要的。     

肾移植围手术期补液监控

背景：多尿期肾移植患者围手术期的水及糖电解质的平衡与及时的营养支持治疗对移植肾脏的功能恢复至关重要。 目的：探讨。肾移植围手术期的水电解质平衡维护及营养支持的方法和时机。 设计、时间及地点：回顾性临床分析，于2003-06／2007-06在解放军第四军医大学西京医院泌尿外科完成。 对象：接受同种异体。肾移植的慢性肾功能衰竭患者96例，男59例，女37例，年龄17～67岁，平均35．7岁。 方法：以移植肾动、静脉血流开放时间为分界点，总结患者围手术期的生理特点。术前维持患者生命体征平稳，手术开始时即开始匀速输血，移植动、静脉血管开放前积极补充清蛋白，开始排尿且尿量大于每小时100mL，即开始循环补循环补液配方，简化的肾移植术后多尿期输液。 主要观察指标：术后1d检测患者血肌酐、尿素氮、电解质、血糖和尿液。 结果：术后最初12～16h。患者尿量在260～1200mldh，平均520mL／h。术后测血常规显示，8例出现轻度低钠血症，占8.3％。3例出现高钾，于肾功能恢复后正常，1例发生低钾，补钾治疗及肾功能恢复后正常。血氯无异常变化。21例血糖高于正常，占21．9％，激素冲击结束后恢复正常。其他患者电解质、血糖均正常，无低钙、镁者。尿比重均在1．010～1．015之间。 结论：移植。肾动、静脉血流开放前的输液应以胶体如浓缩红细胞、血浆及清蛋白为主，多尿期应规律及时的补充水及电解质，适当的营养支持有助于吻合口愈合，尿量稳定后应预防代谢性酸中毒。     

脑死亡供体肾移植受者的围术期护理

目的探讨脑死亡供体肾移植受者围术期的护理方法。方法回顾性分析并总结18例脑死亡供体肾移植受者的临床资料。结果 18例脑死亡供体肾移植受者均成功度过围术期,有2例(11.1%)受者术后发生感染,体温升高、白细胞及中性比例增高,经抗感染治疗后恢复正常;有4例(22.2%)受者发生移植肾肾功能恢复延迟,经对症治疗后肾功能恢复正常。结论脑死亡供体肾移植受者的术后并发症发生率相对较高,应严格监控脑死亡供体肾移植受者的液体出入量和免疫抑制剂用量,密切观察其有无药物不良反应和移植肾排斥的症状、体征等,从而促进受者移植肾肾功能的尽早恢复,避免或减少严重并发症的发生。     

肾移植术后超延迟肾功能恢复15例治疗体会

背景：肾脏移植患者急性排斥反应已不再成为术后的主要并发症,延迟肾功能恢复和慢性移植肾肾病仍然是移植患者术后需要面对的问题。目的：总结分析15例术后发生超延迟肾功能恢复的肾移植患者资料,探讨临床经验及治疗对策。方法：对肾移植后发生超延迟肾功能恢复患者15例进行回顾性分析。15例患者移植后均采用常规剂量的半量（环孢素A3.0～4.0mg/kg,他克莫司0.5～1mg/kg）,并定期监测血药浓度,随时调整免疫用药剂量,采用血液透析/连续性肾脏替代治疗。分析超延迟肾功能恢复诱因,患者观察患者肾功能恢复情况。结果与结论：术中低血压、供肾热缺血时间过长、早期急性排斥反应、环孢素中毒、外科并发症、动脉粥样硬化致移植肾血液灌流不足可能为患者超延迟肾功能恢复的诱因。患者术后由少尿期开始进入多尿期时间最长者为108d,平均32～108d。肾功能正常8例（血清肌酐78～135μmol/L）,肾功能轻度异常5例（血清肌酐135～300μmol/L）,血清肌酐〉300μmol/L者2例。随访时间最长1例11年,至今移植肾功能正常。结果提示,肾移植后尽早行移植肾穿刺活检及移植肾彩超,根据结果采取综合治疗并制订个体化治疗方案可以使大多数的患者移植肾功能恢复正常。     

肾移植术后超延迟肾功能恢复15例治疗体会

背景:肾脏移植患者急性排斥反应已不再成为术后的主要并发症,延迟肾功能恢复和慢性移植肾肾病仍然是移植患者术后需要面对的问题.目的:总结分析15例术后发生超延迟肾功能恢复的肾移植患者资料,探讨临床经验及治疗对策.方法:对肾移植后发生超延迟肾功能恢复患者15例进行回顾性分析.15例患者移植后均采用常规剂量的半量(环孢素A 3.0～4.0 mg/kg,他克莫司0.5～1 mg/kg),并定期监测血药浓度,随时调整免疫用药剂量,采用血液透析/连续性肾脏替代治疗.分析超延迟肾功能恢复诱因,患者观察患者肾功能恢复情况.结果与结论:术中低血压、供肾热缺血时间过长、早期急性排斥反应、环孢素中毒、外科并发症、动脉粥样硬化致移植肾血液灌流不足可能为患者超延迟肾功能恢复的诱因.患者术后由少尿期开始进入多尿期时间最长者为108 d,平均32～108 d.肾功能正常8例(血清肌酐78～135 μmol/L),肾功能轻度异常5例(血清肌酐135～300 μmol/L),血清肌酐> 300 μmol/L者2例.随访时间最长1例11年,至今移植肾功能正常.结果提示,肾移植后尽早行移植肾穿刺活检及移植肾彩超,根据结果采取综合治疗并制订个体化治疗方案可以使大多数的患者移植肾功能恢复正常.     

中老年肾移植患者12例术后并发症观察及护理

对12例中老年肾病患者行肾移植术,并给予术后并发症观察及护理.结果发生排斥反应3例,肺部感染2例,尿漏2例,肾功能延迟恢复1例,术后糖尿病1例,应激性溃疡1例.1例死亡,1例移植肾失去功能;其余患者均康复出院.认为做好肾移植术后并发症的观察及护理,是中老年肾移植术患者手术成功的重要保障.     

中老年肾移植患者12例术后并发症观察及护理

对12例中老年肾病患者行肾移植术,并给予术后并发症观察及护理。结果发生排斥反应3例,肺部感染2例,尿漏2例,肾功能延迟恢复1例,术后糖尿病1例,应激性溃疡1例。1例死亡,1例移植肾失去功能;其余患者均康复出院。认为做好肾移植术后并发症的观察及护理,是中老年肾移植术患者手术成功的重要保障。     

Electrophysiological interventions for treatment of congestive heart failure in pediatrics and congenital heart disease

Heart failure therapy, while well tested in the adult population, therapeutic interventions are less well defined in the pediatric population. Several treatment strategies are available for the adult patient with heart failure, thought few of these therapies have been proven in children. Morbidity and mortality in the pediatric population with a failing heart is significant, and rhythm management as well as strategies to improve hemodynamics are important in the care of these children. This review will address issues of rhythm management and resynchronization therapy in pediatric and congenital heart disease patients with heart failure.     

Fluid management in acute kidney injury

Acute kidney injury (AKI) and fluids are closely linked through oliguria, which is a marker of the former and a trigger for administration of the latter. Recent progress in this field has challenged the physiological and clinical rational of using oliguria as a trigger for the administration of fluid and brought attention to the delicate balance between benefits and harms of different aspects of fluid management in critically ill patients, in particular those with AKI. This narrative review addresses various aspects of fluid management in AKI outlining physiological aspects, the effects of crystalloids and colloids on kidney function and the effect of various resuscitation and de-resuscitation strategies on the course and outcome of AKI.     

先天性心脏病患儿手术后行腹膜透析的护理

目的了解先天性心脏病（先心病）惠儿手术后行腹膜透析（腹透）的监测指标及护理措施。方法2004年2月～2005年2月在我院行先心病纠治术患儿565例,其中8例患儿术后采用人工间歇性腹透治疗,通过对尿量的观察、血电解质的监测、容量负荷的计算以及肝肾功能的检测,及时把握腹透时机并积极处理并发症。结果8例患儿中1例因严重低心排出量而死亡。1例在完成腹透治疗后放弃治疗自动出院,余6例均在腹透支持下安全渡过急性肾功能衰竭少尿期后逐步恢复肾功能。顺利撤机,痊愈出院。结论复杂先心术后行腹透治疗能及时有效地纠正水电解质和酸碱平衡失调,帮助患儿渡过术后急性肾功能不全期,提高患儿的生存率。密切观察生命体征的变化,把握腹透的关键时机以及腹透期间的精心护理对患儿疾病的转归极为重要。     

AANA Journal course: update for nurse anesthetists--intraoperative fluid management for the pediatric surgical patient

Intraoperative fluid management for the pediatric surgical patient is a critical element of the anesthetic care plan. In contrast with adult patients, the fluid management is systematized by the use of established protocols that calculate fluid on a per kilogram basis. Children are relatively volume sensitive, and mismanagement of fluid and electrolytes can contribute to morbidity and mortality in infants and young children undergoing even the simplest procedures. Failure to correct volume deficiencies can lead to multisystem failure and death. Inappropriate overhydration can result in pulmonary edema and respiratory problems that can prove fatal. Regardless of the fluid management plan, perioperative fluid management must be flexible and take into account the physiologic development and age of the pediatric patient. The goals of intraoperative fluid management are to restore intravascular volume, maintain cardiac output, and, ultimately, ensure provision of oxygen to the tissues.     

小儿先心病心脏直视手术后心肺功能的监护

目的 :总结先天性心脏病患儿体外循环心脏直视手术后围手术期心肺功能监护的经验。方法 :对 2 45例先心病患儿行心脏直视手术 ,重点监护血液动力学和呼吸功能。结果 :2 45例中 2 37例痊愈出院 ,死亡 8例。结论 :先天性心脏病患儿心脏直视手术后可出现心肺功能障碍。因此 ,加强监护 ,严密观察病情变化 ,及时发现和处理异常情况 ,是保证患儿顺利渡过围手术期的关键     

Fluid balance in critically ill children with acute lung injury*

OBJECTIVES:: In the Fluid and Catheter Treatment Trial (NCT00281268), adults with acute lung injury randomized to a conservative vs. liberal fluid management protocol had increased days alive and free of mechanical ventilator support (ventilator-free days). Recruiting sufficient children with acute lung injury into a pediatric trial is challenging. A Bayesian statistical approach relies on the adult trial for the a priori effect estimate, requiring fewer patients. Preparing for a Bayesian pediatric trial mirroring the Fluid and Catheter Treatment Trial, we aimed to: 1) identify an inverse association between fluid balance and ventilator-free days; and 2) determine if fluid balance over time is more similar to adults in the Fluid and Catheter Treatment Trial liberal or conservative arms. DESIGN:: Multicentered retrospective cohort study. SETTING:: Five pediatric intensive care units. PATIENTS:: Mechanically ventilated children (age ≥1 month to <18 yrs) with acute lung injury admitted in 2007-2010. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Fluid intake, output, and net fluid balance were collected on days 1-7 in 168 children with acute lung injury (median age 3 yrs, median PaO2/FIO2 138) and weight-adjusted (mL/kg). Using multivariable linear regression to adjust for age, gender, race, admission day illness severity, PaO2/FIO2, and vasopressor use, increasing cumulative fluid balance (mL/kg) on day 3 was associated with fewer ventilator-free days (p = .02). Adjusted for weight, daily fluid balance on days 1-3 and cumulative fluid balance on days 1-7 were higher in these children compared to adults in the Fluid and Catheter Treatment Trial conservative arm (p < .001, each day) and was similar to adults in the liberal arm. CONCLUSIONS:: Increasing fluid balance on day 3 in children with acute lung injury at these centers is independently associated with fewer ventilator-free days. Our findings and the similarity of fluid balance patterns in our cohort to adults in the Fluid and Catheter Treatment Trial liberal arm demonstrate the need to determine whether a conservative fluid management strategy improves clinical outcomes in children with acute lung injury and support a Bayesian trial mirroring the Fluid and Catheter Treatment Trial.     

先天性心脏病合并肺动脉高压患儿的围手术期护理

目的 :探讨先天性心脏病合并肺动脉高压患儿的围术期护理。方法 :对5 6例先天性心脏病合并肺动脉高压患儿加强围手术期护理 ,给予有效的镇静、止痛、肌松药、高浓度氧气吸入、适宜的过度通气等护理措施。结果 :本组除 2例术后早期死于呼吸衰竭和低心排外 ,其余 5 4例均痊愈出院 ,无护理并发症发生。结论 :先天性心脏病合并肺动脉高压患儿术后护理难度大、危险高 ,细致、规范的护理是提高手术成功率、减少并发症的重要保证     

小儿心力衰竭神经激素改变及其与心功能的关系

目的:了解小儿心衰时神经激素改变及其与心功能的关系,同时研究神经激素改变能否作为小儿心衰定量诊断指标。方法:23例心衰患儿测定血清肾素、血管紧张素Ⅱ、醛固酮、心钠素和24h尿中肾上腺素、去甲肾上腺素、多巴胺;23例心衰患儿的心脏指数、射血分数,与20名同年龄、同性别的正常小儿测定上述指标做对比;分析血清肾素、血管紧张素Ⅱ、醛固酮、心钠素、肾上腺素、去甲肾上腺素、多巴胺与心脏指数、射血分数之间的关系。结果:心衰患儿血清中肾素、血管紧张素Ⅱ、醛固酮、心钠素升高,24h尿中肾上腺素、去甲肾上腺素、多巴胺升高,心脏指数、射血分数下降;其血清肾素、血管紧张素Ⅱ、醛固酮、心钠素升高程度NYHA心功能Ⅳ级高于Ⅲ级,血清中肾素、血管紧张素Ⅱ、醛固酮、心钠素以及尿中肾上腺素、去甲肾上腺素、多巴胺与心脏指数、射血分数呈直线负相关,相关性最好的是心钠素与心脏指数、射血分数;其相关性为-0.74,P<0.01;血清心钠素与射血分数亦呈直线负相关,相关性为-0.71,P<0.001。结论:血清中肾素、血管紧张素I、醛固酮、心钠素与尿中肾上腺素、去甲肾上腺素、多巴胺在小儿心衰时增高;其增高程度与心脏指数、射血分数呈直线负相关,以心钠素与两者相关性最好;血清中心钠素可作为小儿心衰定量诊断指标之一。     

Prediction of the outcomes of renal replacement therapy for acute renal failure after cardiosurgical interventions

The aim of the study was to evaluate the influence of different predictors on the outcomes of acute renal failure (ARF) in cardiosurgical patients. A hundred and five cases of ARF in January 1995 to August 2004 were retrospectively analyzed. Sixty-one patients received continuous renal replacement therapy (CRRT) and 44 patients had intermittent RRT (IRRT). Eighteen preoperative, perioperative, and postoperative risk factors were assessed. The overall hospital mortality was found to be 42%: 48.4% in the CRRT group and 33.3% in the IRRT group. A statistical analysis revealed 8 significant predictors of fatal outcomes: (1) the severity according to the APACHE II scale (25 +/- 1 scores); (2) the number of organ dysfunctions (3.6 +/- 0.2); (3) large-dose inotropic support; (4) artificial ventilation; (5) oliguria; (6) severe concomitant hepatic failure; (7) moderate-to-severe concomitant posthypoxic encephalopathy. CRRT improved survival in AFR associated with severe cardiorespiratory failure, oliguria, and cerebral dysfunctions. The paper discusses criteria for choosing the modes of renal replacement therapy.     

13例儿童肾移植围手术期护理

目的探讨儿童尿毒症患者实施肾移植术的围手术期护理体会。方法回顾性分析2000年10月～2010年10月本院收治的13例儿童肾移植患者的临床资料,并总结术后护理要点。结果 13例患儿手术时间1.75～4h,中位时间2.37h;9例术后3～7d恢复肾功能,4例发生急性肾小管坏死,分别经5～11次连续肾脏替代疗法（continuous renal replacement therapy,CRRT）治疗后肾功能恢复正常,所有患儿均痊愈出院。随访1～10年,13例患儿1年人/肾存活率为92.3%/84.6%,其中9例患儿3年人/肾存活率为88.89%/77.78%,6例患儿5年人/肾存活率为66.67%/50.00%。结论儿童肾移植的围手术期护理有其特殊性,护理人员应根据患儿的特点展开术前后护理,做好出院的健康教育,保证患儿有良好的治疗依从性,其是儿童肾移植取得成功的关键。