关于肠黏膜屏障功能衰竭临床分期标准的初步探讨

目的 初步建立肠粘膜屏障功能衰竭(Intestinal barrier failure,IBF)的临床分期标准。方法　选取消化系统恶性肿瘤、肝硬化、炎性肠病等患者共50例作为病例组，选取25例健康志愿者作为对照组，均口服双糖探针后检测样本尿液中乳果糖/甘露醇（lactulose/mannitol，L/M）含量以评价肠道通透性，同时采集其新鲜粪便行菌群分析，记录其临床指标及实验室指标，分析病例组与对照组的临床表现、肠道通透性、肠菌群及免疫指标间的关系。结果　同对照组(0.02938±0.00725)相比，病例组尿L/M比值(0.06694±0.02343)显著增高，差异有统计学意义（t＝9.874，P<0.01）。不同程度菌群失调患者肠道通透性无显著差异（F＝2.285，P＝0.113）。随着患者腹胀及腹泻程度的增高，肠道通透性增高及中重度菌群失调的比率也增加。病例组C反应蛋白（47.8±33.5mg/L VS 3.2±2.6mg/L）、血浆内毒素（5.806±4.219EU/ml VS 0.018±0.056EU/ml）及血清IL-6(22.19±8.45pg/ml VS 6.24±0.13pg/ml)水平较之对照组均有显著升高（P均<0.01）。结论 　根据患者的临床症状、肠粘膜通透性、肠菌群状态及免疫指标间的关系，可初步建立IBF的临床分期标准。     

血浆乳酸测定及其在儿科急腹症中的应用

目的探讨急腹症患儿血浆和腹腔液乳酸测定对小儿急腹症鉴别诊断的意义.方法用乳酸快速测定仪检测61例急腹症患儿,其中腹膜炎组33例,包括绞窄性肠梗阻3例、肠穿孔腹膜炎7例、阑尾炎穿孔脓肿23例;非腹膜炎组28例,包括单纯性肠梗阻8例、肠系膜淋巴结炎7例,单纯性或早期化脓性阑尾炎13例.结果腹膜炎组血浆乳酸值[(5.37±2.40)mmol/L]明显高于非腹膜炎组[(3.71±1.00) mmol/L,P<0.001];腹膜炎组腹腔液乳酸值[(11.93±4.17)mmol/L]明显高于非腹膜炎组[(4.25±0.97) mmol/L,P<0.001];腹膜炎组腹腔液-血浆乳酸的差值均≥2.75 mmol/L,非腹膜炎组<1.65 mmol/L;腹膜炎组的腹腔液乳酸值水平明显高于血浆乳酸值(P<0.001).结论血浆和腹腔液乳酸的快速测定对小儿急腹症的鉴别诊断有重要意义.     

创伤修复期间参附注射液对肠黏膜的保护作用

背景创伤修复期间胃肠道存在再灌注损伤和灌注不全,引起肠黏膜损伤.目的观察人用等效剂量参附注射液对创伤修复期间家兔肠pH、肠黏膜一氧化氮、丙二醛、Ca2+含量、血清双胺氧化酶的影响.设计以实验动物为观察对象的随机对照实验.单位武汉大学人民医院麻醉科.材料实验于2003-08/10在武汉大学人民医院麻醉学研究室完成,选择健康家兔24只随机分为3组参附注射液治疗组、单纯创伤修复组和对照组,每组8只.干预措施通过股动脉放血[2 mL/(kg·min)],平均动脉压降至40mmHg并持续60 min,回输自体血及等量平衡盐液制备兔创伤修复模型;参附注射液组于回输自体血同时先静注参附注射液2.1 mL/kg,随后持续注入参附注射液5 mL/(kg·h).主要观察指标分别于实验前,创伤修复1 h,及再灌注1,3 h检测乙状结肠黏膜内pH、肠黏膜一氧化氮、丙二醛及钙含量、血清双胺氧化酶活性.结果24只家兔均进入结果分析.①参附注射液治疗组再灌注1,3 h肠黏膜pH为7.171±0.102,7.194±0.106,高于单纯创伤修复组(6.920±0.155,6.971±0.165,P＜0.05,P＜0.01)及对照组(7.329±0.038,7.322±0.101,P＜0.05).②参附注射液治疗组再灌注1,3 h血清双胺氧化酶为(35.090±1.184),(32.440±2.884)μkat/L,显著高于单纯创伤修复组[(50.994±2.684),(52.377±1.217)μkat/L,P＜0.01]及对照组[(15.970±1.734),(16.620±0.767)μkat/L,P＜0.05].③再灌注3 h肠黏膜一氧化氮、丙二醛含量参附注射液治疗组均显著低于单纯创伤修复组[(61.8±5.3,72.2±5.8)μmol/g,(68.2±4.9,96.9±8.5)μmol/L,P＜0.05].再灌注3 h肠黏膜Ca2+含量参附注射液治疗组为(2.43±0.27)μnol/L,低于单纯创伤修复组[(2.93±0.34)μmol/L,P＜0.05],高于对照组[(2.26±0.31)μnol/L,(P＜0.05)].结论给予家兔人用等效剂量的参附注射液,增加了肠黏膜灌注及氧合作用,抑制了肠黏膜一氧化氮活性和清除氧自由基及减轻钙超载,对创伤修复期间肠黏膜具有良好的保护作用.     

甘氨酰脯氨酰二肽氨基肽酶动力学测定方法探讨及初步临床应用

目的建立甘氨酰脯氨酰二肽氨基肽酶(GPDA)自动化分析方法.方法用甘氨酰脯氨酰对硝基苯胺对甲苯磺酸盐为底物,在Tris-HCl-双甘肽缓冲系统下,在405 nm处测定产物吸光度的变化,得出GPDA活性.结果最适pH值为8.6,基质浓度为2.0 mmol/L.批内、批间平均变异系数分别为3.01%、5.04%.米氏常数(Km)为1.89 mmol/L.标本存于4 ℃冰箱10 d内稳定性良好.参考值为(102.8±26.0) U/L.肝癌组该酶范围为(139.9±71.8) U/L,与正常组比较差异有显著性(P<0.05).胃癌组和慢性胃炎组该酶范围分别为(58.83±18.18) U/L和(61.5±15.8) U/L,与正常组比较差异均有显著性(P<0.001、P<0.005).结论该法简便、快捷、精确,可用于自动化分析,并可作为评价肝癌、胃癌及慢性胃炎的血清学指标.     

脐动脉血乳酸水平早期诊断新生儿缺氧缺血性脑损伤的意义

目的通过测定新生儿脐动脉血中的乳酸水平早期诊断新生儿缺氧缺血性脑损伤(HIE)。方法49例产前无胎儿窘迫征象,出生后1分钟min Apgar评分≥9分的新生儿为对照组;27例诊断为新生儿缺氧缺血性脑病的新生儿为病例组。所有新生儿出生后立即收集脐动脉血,检测乳酸及血气分析。结果病例组脐动脉血乳酸水平为5.12±1.09mmol/L、pH=7.20±0.08。对照组脐动脉血乳酸水平为2.35±0.31mmol/L、pH=7.29±0.07。病例组均明显高于对照组(t=5.10-16.69,P<0.01);且脐动脉血pH与乳酸水平呈显著负相关(r=-0.706,P<0.01)。结论测定脐动脉血乳酸水平是一种准确、可靠的早期诊断新生儿缺氧缺血性脑损伤及其严重程度的指标。     

急性缺血性卒中患者血浆和脑脊液中谷氨酸测定及其临床应用价值

目的探索稳定性和进展性急性缺血性卒中患者体液中谷氨酸(Glu)升高的时限。方法应用高效液相色谱分析检测128例首次发病的急性脑梗死(ACI)患者发病1～7日的血浆Glu、脑脊液(CSF)Glu浓度的变化，并与同期检测的神经功能缺失程度(CSS积分)、脑梗死容积(CTV)进行相关分析。结果128例ACI患者的平均血浆Glu、CSF-Glu浓度分别为(136.29±32.53)mmol/L和(6.48±3.29)mmol/L，均显著高于对照组〔(129.20±28.15)mmol/L和(3.09±1.48)mmol/L，P<0.05和P<0.001〕；进展性ACI组平均CSF-Glu浓度为(6.47±1.32)mmol/L，极显著高于稳定性ACI组〔(5.32±1.07)mmol/L，P<0.001〕；稳定性组1～7日各时间点的血浆Glu浓度无显著变化，而进展性ACI组于发病4日内的血浆Glu浓度进行性升高；CTV≥10 cm     

内给氧改善缺血再灌注后脑组织能量代谢的实验研究

目的:探讨内给氧改善大鼠脑组织缺血再灌注后能量代谢障碍,起到脑保护作用的机制。方法:30只Wistar大鼠随机分成3组:假手术组、缺血组、治疗组,制备大鼠脑缺血再灌注损伤模型,予内给氧治疗后,分别测定各组大鼠脑组织中的三磷酸腺苷(ATP)、二磷酸腺苷(ADP)、单磷酸腺苷(AMP),乳酸含量及Na+-K+-ATPase活性,计算能量负荷值。结果:内给氧治疗组的ATP含量(2.3309±0.0866)mg/L、能量负荷值为0.0960±0.0052,Na+-K+-ATPase活性为(0.903±0.117)μkat/g,均高于缺血组犤(0.8199±0.0591)mg/L,0.1663±0.0044,(0.465±0.064)μkat/g犦差异存显著性意义(P<0.05),乳酸含量(16.0342±1.0136)mmol/g低于缺血组(24.2513±4.3571)mmol/g,差异有显著性意义(P<0.05)。结论:内给氧可明显改善大鼠脑缺血再灌注后能量代谢,具有脑保护作用。     

监护室中脓毒症患儿血乳酸监测的临床意义

目的:评估脓毒症患儿早期血乳酸水平与病情严重程度及预后的关系。方法:对监护室收治的56例脓毒症患儿进行回顾性的分析,将患儿分为死亡组和存活组。根据小儿死亡危险评分(PRISM评分)评定56例患儿严重程度,同时观察两组患儿入监护室时、治疗24h血乳酸的变化,血乳酸与PRISM评分、患儿预后的关系。结果:56例患儿分存活组37例(66.1%)、死亡组19例(33.9%);入监护室时死亡组血乳酸及PRISM评分明显高于存活组,差异有显著性(P<0.05);两组血乳酸值与PRISM评分显著正相关(r=0.314,P<0.05)。治疗24h时存活组血乳酸水平、PRISM评分下降,分别为(2.3±0.6)mmol/L、13.4±3.2,死亡组血乳酸水平、PRISM评分升高,分别为(7.3±4.4)mmol/L、29.6±4.5,两组血乳酸水平、PRISM评分差异有显著性(P<0.05)。结论:早期动态监测乳酸是判断脓毒症患儿的危重程度及预后的良好方法之一,且简便易行。     

二甲双胍对老年2型糖尿病患者的疗效及安全性

目的:观察二甲双胍对老年2型糖尿病患者的疗效与安全性。方法:42例老年2型糖尿病患者服用磺脲类降糖药物效果不佳时加服二甲双胍治疗,在随访24周的过程中,监测空腹血糖、糖化血红蛋白、胰岛素、血乳酸及血脂,并观察药物的副作用。结果:治疗后4周空腹血糖(7.6±1.9)mmol/Lvs(9.8±2.2)mmol/L,P<0.01、糖化血红蛋白(11.3±2.6)%vs(13.6±2.5)%,P<0.01显著下降;服药12周后LDL(2.3±0.8)mmol/Lvs(2.8±0.9)mmol/L,P<0.01、TG(3.0±1.1)mmol/Lvs(3.6±1.2)mmol/L,P<0.01显著下降;服药24周HDL升高(0.89±0.08)mmol/Lvs(0.85±0.08)mmol/L,P<0.01,但血胰岛素(16.7±3.6)mmol/Lvs(18.2±4.1)mmol/L,P>0.05、血乳酸(1.6±0.5)mmol/Lvs(1.4±0.5)mmol/L,P>0.05无显著变化。23.8%患者服用二甲双胍后出现恶心与腹泻,但症状轻微且短暂。结论:二甲双胍是治疗老年2型糖尿病患者安全、有效的药物。     

失血性休克时胃粘膜内pH监测的实验研究

根据胃内PCOz和同时测得的动脉血HCO3^-浓度，通过Henderson-Hasselbalch公式可间接测定胃粘膜内pH(pHi)。为进一步探讨pHi与胃肠粘膜组织氧合的关系，以失血性休克大鼠为模型，测定动脉血、混合静脉血及门静脉乳酸(Laep)、动脉血、混合静脉血血气分析。结果发现：失血性休克时，pHi与门静脉乳酸(Laep)显降低；pHi的降低不仅与胃肠粘膜的氧合障碍有关，同时还与全身组织氧合不足有关。研究结果表明：pHi的变化是反映肠道及全身组织氧合情况的重要指标。     

血液净化救治毒鼠强中毒患者的临床研究

目的探索血液净化对毒鼠强中毒的治疗价值。方法应用血液净化方法治疗10例毒鼠强中毒患者,进行疗效总结;并与既往常规治疗（未血液净化）的7例患者疗效进行比较。结果血液净化治疗后患者血液毒鼠强浓度、心肌酶、APACHEⅡ评分、脑电图评分较治疗前均有明显降低（P均<0.01);血液净化组与常规非血液净化治疗组患者比较,相同时期(入院第5日)内血液毒鼠强浓度下降值〔分别为(82.3±21.7）μg／L和(27.9±14.2)μg／L〕有显著差异(P<0.01),意识转清醒及抽搐停止时间〔血液净化组分别为(5.7±2.6)小时和(0.9±0.7)日,非血液净化组分别为(16.2±10.1）小时和(4.5±3.7)日〕均显著提前(P均<0.01)。结论血液净化治疗毒鼠强中毒比常规方法更有效。     

多巴胺对恢复自主循环猪氧代谢的影响

目的 对心搏骤停心肺复苏(CPR)后自主循环恢复(ROSC)模型猪采用多巴胺升压,观察不同灌注条件对氧代谢的影响及神经功能恢复结果.方法 心室纤颤(VF)前将猪右股静脉连接连续心排血量监测仪,左颈内静脉置管并放置电极到右心室,分别行主动脉、颈动脉置管,采用电击致12头实验猪心搏骤停,VF 4 min后进行CPR,达到ROSC,按随机数字表法均分为高灌注组和正常灌注组.两组在4 h内均给予15 ml·kg-1·h-1生理盐水补液;高灌注组同时给予多巴胺持续静脉泵入升压,使平均动脉压(MAP)维持在复苏后基础血压的130%左右.于ROSC基础状态(0 h)及ROSC后0.5、1、2、4 h记录各组动物血流动力学参数并计算氧代谢各指标;24 h进行神经系统功能评价.结果 与正常灌注组比较,高灌注组ROSC 0.5、1、2、4 h氧输送量(DO2)、氧消耗量(VO2)明显升高[DO2(ml/min):556±43比375±25、660±56比381±53、674±53比362±44、685±44比400±38,VO2(ml/min):288±35比191±13、260±37比204±38、223±27比169±21、212±19比163±15,P＜0.05或P＜0.01];ROSC 1、2、4 h氧摄取率(ERO 2)明显下降[(39±4)%比(53±3)%、(33±2)%比(47±1)%、(31±3)%比(41±3)%,均P＜0.05];颈动脉血氧分压(PaO2)明显升高,但颈动脉血氧饱和度(SaO2)无差异;ROSC 0.5、1、2、4 h混合静脉血氧分压(PvO2,mm Hg,1 mm Hg=0.133 kPa)明显升高(38±4比33±1、42±2比36±2、40±2比36±2、43±2比38±1,P＜0.05或P＜0.01);ROSC 1、2、4 h混合静脉血氧饱和度(SvO2)和混合静脉血-颈动脉血乳酸含量差(PCLac)均升高[SvO2:0.60±0.04比0.45±0.03、0.66±0.02比0.52±0.01、0.68±0.03比0.58±0.03,PCLac(mmol/L):1.2±0.2比0.7±0.4、1.0±0.3比0.6±0.2、1.1±0.2比0.5±0.2,P＜0.05或P＜0.01];颈动脉氧含量(CAO2)升高,颈动-静脉氧含量差(CAvO2)、脑组织氧摄取率(C-ERO2)下降,颈动-静脉血乳酸含量差(VALac)升高.ROSC 24 h高灌注组6头猪均达到脑功能评分(CPC)1级;正常灌注组存活4头,其中3头达到CPC 2级,1头达到CPC 1级(P＜0.05).结论 在VF致心搏骤停模型猪ROSC后应用多巴胺升压,可以提高主动脉灌注压,改善全身和大脑灌注,对氧代谢、早期脑复苏有益.     

参附注射液对大鼠短暂性局灶性脑缺血损伤的保护作用

目的探讨参附注射液对脑缺血性损伤的保护作用及量效关系。方法40只雄性SD大鼠,随机分为4组,对照组（n=10）,即缺血再灌注组,在缺血前30分钟经腹腔注射生理盐水20ml/kg;各保护组（Cen5,Cen10,Cen20,各组n=10）在缺血前30分钟经腹腔注射参附注射液(剂量分别为5、10、20ml/kg)及生理盐水(剂量分别为15、10、0ml/kg)。采用右侧颈内动脉丝线栓塞致大脑中动脉阻闭120分钟,术后观察1、3、6、12、16和24小时神经行为学变化并评分,24小时时处死动物,取大脑行TTC染色以测量脑梗死容积。结果24小时神经功能评分,各保护组为Cen5〔(0.6±0.5)分,P<0.05〕,Cen10〔(0.8±0.9）分,P<0.05〕,Cen20〔(0.7±0.4)分,P<0.05〕,均明显低于对照组〔(1.8±1.0)分〕;24小时梗死容积各保护组为Cen5〔(58.7±21.4)mm     

肝移植术后脑病患者围手术期脑氧代谢的特点

目的 观察肝移植患者围手术期脑氧代谢指标变化的规律,分析术后并发脑病者的脑氧代谢特点及与术后脑病发生的关系.方法 观察并追踪肝移植患者30例,根据术后是否发生脑病分为两组,分别于术前、无肝25 min及新肝30 min、新肝3 h、新肝24 h抽取桡动脉和左颈静脉血进行血气分析,计算动脉血氧含量(CaO2)、颈静脉血氧含量(CjvO2)、动脉-颈静脉血氧含量差(Ca-jvO2)、脑氧摄取率(CERO2)、脑血流量/脑氧代谢率比值(CBF/CMRO2)等脑氧代谢指标,同时测定血糖、乳酸含量.结果 30例肝移植患者中有11例(占36.7%)术后出现了脑病症状.脑病组术中红细胞输入量、出血量和去甲肾上腺素用量均高于非脑病组.两组脑氧代谢指标整体变化趋势一致,CaO2、Ca-jvO2在无肝25 min、新肝30 min、新肝3 h时,CERO2在新肝30 min、新肝3 h时均较术前显著降低[CaO2(ml/L):脑病组132.4±23.5、125.9±17.6、133.4±11.1比148.5±28.8,非脑病组135.7±22.4、130.5±20.0、139.9±21.2比148.9±28.2;Ca-jvO2(ml/L):脑病组42.9±13.2、31.4±12.3、32.3±6.5比52.9±23.5,非脑病组33.0±14.1、26.6±9.1,30.6±10.3比50.2±23.2;CERO2:脑病组(24.9±9.7)%、(24.4±5.5)%比(35.4±11.5)%,非脑病组(20.6±7.3)%、(21.9±7.0)%比(33.4±13.1)%,均P<0.05],在新肝24 h时恢复至术前水平;颈静脉血氧饱和度(SjvO2)、CBF/CMRO2比值在新肝30 min、新肝3 h时均较术前显著增高(SjvO2:脑病组0.838±0.105、0.835±0.065比0.709±0.125,非脑病组0.854±0.074、0.824±0.074比0.713±0.138;CBF/CMRO2比值:脑病组37.8±16.6、31.9±6.8比20.9±6.7,非脑病组37.8±14.1、35.7±13.7比24.3±14.0,均P<0.05),在新肝24 h时恢复至术前水平.两组血糖、乳酸含量整体变化趋势一致,血糖在无肝期至新肝24 h均较术前显著升高;乳酸含量在无肝期至新肝3 h显著高于术前,至新肝24 h时恢复至术前水平.结论 肝移植围手术期脑氧代谢发生异常变化,但脑病组并无特异性.肝移植术后脑病的发生是多因素的,预防和治疗上要综合考虑.

Abstract：

Objective To investigate the feature of cerebral oxygen metabolism during peri-operative stage of orthotopic liver transplantation(OLT),in order to identify the difference between the patients with or without complicating encephalopathy after OLT,and the relationship between the cerebral oxygen metabolism and encephalopathy after OLT.Methods Thirty patients undergoing OLT were studied.The patients were divided into two groups according to occurrence or not of encephalopathy after OLT:encephalopathy group and non-encephalopathy group. Blood samples were taken from radial artery and jugular vein simultaneously for blood gas analysis before operation,25 minutes after onset of anhepatic phase,30 minutes after graft reperfusion,3 hours after graft reperfusion,and 24 hours after graft reperfusion.Cerebral arterial oxygen content(CaO2),oxygen content of jugular vein blood(CjvO2),cerebral arterial-venous oxygen content difference(Ca-jvO2),cerebral oxygen extraction ratio(CERO2)and cerebral blood flow/cerebral metabolic rate of oxygen ratio(CBF/CMRO2)were calculated,and the levels of blood glucose and lactic acid were recorded.Results There were 11 patients(36.7%)complicated by encephalopathy after OLT.The quantity of red blood cell infusion,blood loss and the dosage of noradrenalin in encephalopathy group were significantly larger compared with non-encephalopathy group.The overall tendency of change in cerebral oxygen metabolism index was about the same for both groups,while CaO2 and Ca-jvO2 at 25 minutes after onset of anhepatic phase,30 minutes after graft reperfusion and 3 hours after graft reperfusion,and CERO2 at 30 minutes after graft reperfusion and 3 hours after graft reperfusion were significantly decreased compared with those before operation(CaO2(ml/L)in encephalopathy group:132.4±23.5,125.9±17.6,133.4±11.1 vs.148.5±28.8,in non-encephalopathy group:135.7±22.4,130.5±20.0,139.9±21.2 vs.148.9±28.2; Ca-jvO2(ml/L)in encephalopathy group: 42.9±13.2,31.4±12.3,32.3±6.5 vs.52.9±23.5,in non-encephalopathy group:33.0±14.1,26.6±9.1,30.6±10.3 vs.50.2±23.2; CERO2 in encephalopathy group:(24.9±9.7)%,(24.4±5.5)%vs.(35.4±11.5)%,in non-encephalopathy group:(20.6±7.3)%,(21.9±7.0)%vs.(33.4±13.1)%,all P<0.05],and they returned to the levels before operation at 24 hours after graft reperfusion.Jugular venous oxygen saturation(SjvO2)and CBF/CMRO2 ratio were significantly increased at 30 minutes after graft reperfusion and 3 hours after graft reperfusion compared with the levels before operation [SjvO2 in encephalopathy group:0.838±0.105,0.835±0.065 vs.0.709±0.125,in non-encephalopathy group:0.854±0.074,0.824±0.074 vs.0.713±0.138;CBF/CMRO2 ratio in encephalopathy groupl 37.8±16.6,31.9±6.8 vs.20.9±6.7,in non-encephalopathy group:37.8±14.1,35.7±13.7 vs.24.3±14.0,all P<0.05],and they returned to the levels before operation at 24 hours after graft reperfusion.The overall tendency of change in blood glucose and lactic acid was about the same in both groups,while the levels of blood glucose increased significantly from anhepatic phase to 24 hours after graft reperfusion compared with the levels before operation,and the levels of lactic acid increased significantly from anhepatic phase to 3 hours after graft reperfusion compared with the levels before operation and returned to the levels before operation at 24 hours after graft reperfusion.Conclusion There are significant changes in the features of cerebral oxygen metabolism during OLT,but there is no difference between encephalopathy group and non-encephalopathy group.The occurrence of encephalopathy can be attributed to many factors,so the prevention and treatment should be comprehensive considered.     

Gastric tonometry and venous oximetry in cardiac surgery patients

OBJECTIVE: To determine the relationship between gastric intramucosal pH and several other indices of splanchnic perfusion in patients undergoing cardiopulmonary bypass. DESIGN: Prospective, single-arm study. SETTING: University Hospital. METHODS: Elective cardiac surgery patients (n = 8), free of hepatic disease, were studied. Before anesthetic induction, a triple-lumen, heparin-bonded fiberoptic catheter was inserted into the hepatic vein under fluoroscopic guidance. An identical catheter was inserted into the pulmonary artery. After endotracheal intubation, a nasogastric tube modified to permit measurement of gastric intramucosal pH was inserted into the stomach. Systemic oxygen delivery (DO2), and arterial, mixed venous, hepatic venous, and femoral venous blood gases and lactate concentrations were recorded at the following times: immediately before induction of anesthesia (time 1); during atrial cannulation (time 2); after 30 mins of hypothermic cardiopulmonary bypass (time 3); 15 mins after termination of cardiopulmonary bypass (time 4); and 1 hr after arrival in the ICU (time 5). Hepatic venous hemoglobin saturation (SO2) and mixed venous hemoglobin saturation (SvO2) were monitored continuously from times 1 to 5. Gastric intramucosal pH was recorded at times 2, 3, 4, and 5. The hepatic catheter was removed as soon as the last samples were collected in the ICU. RESULTS: The square of the weighted mean correlation coefficients (rw)2 for gastric intramucosal pH vs. hepatic venous lactate concentrations, gastric intramucosal pH vs. hepatic venous PO2, and gastric intramucosal pH vs. hepatic venous pH were (rw)2 = .50, (rw)2 = .58, and (rw)2 = .32, respectively. Systemic DO2, hepatic venous lactate concentrations, hepatic venous PO2, and hepatic venous pH were significant determinants in the multiple regression model for gastric intramucosal pH (r2 = .89). There were significant differences between SvO2 and hepatic venous SO2 at times 4 and 5. CONCLUSION: Gastric intramucosal pH may provide a minimally invasive way to monitor the adequacy of splanchnic DO2 in patients undergoing cardiopulmonary bypass. Additional data are necessary to determine whether low gastric intramucosal pH is truly a marker of supply-dependent oxygen uptake across the hepatosplanchnic vascular bed under these conditions.     

肺心病患者胰岛素抵抗的临床研究

目的观察肺心病急性期患者空腹血清胰岛素、空腹血糖、胰岛素敏感指数水平变化,探讨肺心病患者是否存在胰岛素抵抗。方法选择2006年11月至2008年12月在我院住院的31例肺心病急性期患者作为实验组,选择同期健康体检31例作为对照组。2组临床基线资料匹配。所有选定的参选者均测定空腹血糖(FBG)、FINS及胰岛素敏感指数(ISI)。FBG采用葡萄糖氧化法测定,FINS采用酶联免疫吸附法测定,ISI采用李光伟等提出的计算方法进行计算。结果实验组FINS水平明显高于对照组〔(16.63±8.74〕vs(6.08±2.53)μIU/ml,P<0.01〕,FBG水平显著高于对照组〔(6.48±2.33)vs(4.79±0.75)mmol/L,P<0.01〕,ISI显著低于对照组〔(-4.26±0.92)vs(-3.26±0.51),P<0.01〕。结论肺心病急性期患者存在胰岛素抵抗,胰岛素抵抗为其重要的危险因素,这为肺心病患者使用胰岛素增敏剂治疗提供了科学依据。     

高浓度氧对未成年大鼠肺部炎症反应的影响

目的 探讨高浓度氧对未成年大鼠肺部炎症反应的影响.方法 将40只出生21 d的SD大鼠按随机数字表法分为空气对照组及高氧暴露12、24、48、72 h组,每组8只,分别将大鼠置于空气和常压高氧箱(氧含量达92%～94%)中.于相应时间点采用放血法处死大鼠后取肺组织,并行支气管肺泡灌洗.采用硫代巴比妥酸法和比色法分别测定肺组织丙二醛(MDA)含量及髓过氧化物酶(MPO)活性;采用酶联免疫吸附法(ELISA)检测支气管肺泡灌洗液(BALF)中肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)和IL-10含量;观察肺组织病理改变,并进行肺损伤评分.结果 与空气对照组比较,高氧暴露12 h肺组织MDA含量(mmol/g)即显著升高(2.24±0.43比1.57±0.31),MPO活性(U/g)于高氧暴露24 h显著升高(1.24±0.25比0.69±0.22),并均随高氧暴露时间延长逐渐增加(P<0.05或P<0.01).BALF中TNF-α、IL-6和IL-10含量于高氧暴露24 h时较空气对照组显著增加[TNF-α(ng/L):135.2±44.0比94.5±22.3,IL-6(ng/L):73.1±14.2比55.7±17.3,IL-10(ng/L):67.9±21.7比48.2±7.6,P<0.05或P<0.01];但高氧暴露48 h时较24 h时显著降低(48 h时BALF中TNF-α、IL-6、IL-10分别为105.4±17.0,54.3±17.4,50.9±6.9,均P<0.05).高氧暴露12 h时肺损伤评分(分)即较空气对照组显著升高(4.5±1.4比1.3±0.5),并随高氧暴露时间延长进一步升高(P<0.05或P<0.01).结论 高浓度氧可引起未成年大鼠肺部炎症损伤;炎症细胞因子的出现高峰均在高氧暴露24 h.     

深低温停循环围手术期的高血糖监测及控制

目的 观察深低温停循环(DHCA)围手术期患者血糖的变化趋势,评价血糖升高的各种影响因素以及应用胰岛素控制高血糖的临床效果.方法 选择2000年1月至2010年1月长海医院胸心外科176例应用DHCA技术实施主动脉手术患者.在体外循环(CPB)前、DHCA前、DHCA后、术后进入重症监护病房(ICU)后检测血糖、动脉血气和乳酸.采用间断皮下注射或持续静脉微泵注射胰岛素的方式控制术后血糖在6～8 mmol/L,同时统计术后24 h内的胰岛素累积用量.结果 DHCA前血糖(mmol/L)较CPB前明显升高(9.62±1.79比5.04±1.40,P<0.05),DHCA后血糖(14.91±2.36)进一步升高(P<0.01),进入ICU后血糖(15.32±2.47)仍持续升高(P<0.01),且血糖升高水平与血乳酸升高水平呈明显正相关;134例患者(占76.1%)术后因间断皮下注射胰岛素控制血糖效果不佳而改用持续静脉微泵注射胰岛素,其中30例患者(占17.0%)有明显的胰岛素抵抗现象;高龄(≥50岁),合并原发性高血压、主动脉瓣中-重度病变、糖尿病或严重冠心病病史,急诊手术,CPB时间≥3 h及DHCA时间≥45 min等影响因素会明显加重DHCA围手术期高血糖,且术后24 h内胰岛素累积用量明显增加.入ICU后血糖(mmol/L)在年龄≥50岁和<50岁(18.66±2.52比12.90±2.27)、有无原发性高血压(18.98±2.55比12.31±2.34)、有无主动脉瓣中-重度病变(19.59±2.95比12.13±2.23)、有无糖尿病(20.62±1.76比11.75±1.11)、有无冠心病(19.77±2.98比12.01±2.02)、有无急诊手术(19.78±1.97比12.23±1.38)、CPB时间≥3 h和<3 h(19.86±1.89比11.70±1.15)、DHCA时间≥45 min和<45 min(19.92±1.88比11.64±1.12)等因素间差异均有统计学意义(均P<0.05);术后24 h内胰岛素累积用量(U)在年龄≥50岁和<50岁(169.5±56.6比110.2±38.5)、有无原发性高血压(171.6±64.0比104.8±34.3)、有无主动脉瓣中-重度病变(171.4±36.8比109.4±27.6)、有无糖尿病(202.5±46.7比100.4±31.5)、有无冠心病(178.5±38.6比104.6±26.4)、有无急诊手术(178.3±35.7比102.7±26.8)、CPB时间≥3 h和<3 h(168.6±37.2比107.3±27.5)、DHCA时间≥45 min和<45 min(172.5±36.1比105.4±28.7)等因素间差异均有统计学意义(均P<0.05).结论 DHCA 可引起围手术期明显的血糖和乳酸升高,甚至导致胰岛素抵抗,术后常需持续静脉应用大剂量胰岛素;DHCA 围手术期高血糖与诸多影响因素有关,在临床控制血糖的过程中应综合考虑.

Abstract：

Objective To observe the trend of change in perioperative blood glucose level in patients undergoing deep hypothermic circulatory arrest(DHCA),in order to evaluate the influencing factors of inciting hyperglycemia and the clinical effects of insulin control.Methods In the Department of Cardiothoracic Surgery of Changhai Hospital,176 patients underwent aortic operation under DHCA from January 2000 to January 2010.Blood glucose,arterial blood gas and lactate levels were determined at four time points,including pre-cardiopulmonary bypass(CPB),pre-DHCA,post-DHCA,and at admission to intensive care unit(ICU).Hyperglycemia after surgery was controlled at the level of 6-8 mmol/L by intermittent subcutaneous injection or intravenous micropump injection of insulin.At the same time,the cumulative amount of insulin within 24 hours after surgery was recorded.Results The blood glucose (mmol/L)level at pre-DHCA time point was significantly higher than that of pre-CPB(9.62±1.79 vs.5.04±1.401,P<0.05),and the blood glucose level was further elevated at the time point of post-DHCA (14.91±2.36,P<0.01)and in-ICU(15.32±2.47)compared with that of pre-CPB(P<0.01).The level of blood glucose elevation was positively correlated with blood lactate level.One hundred and thirty-four patients(76.1%)insulin was given with intravenous micropump due to poor effect of intermittent subcutaneous injection of insulin in controlling blood glucose.Among whom 30 patients(17.0%)developed the phenomenon of insulin resistance.Perioperative hyperglycemia during DHCA was associated with old age (≥50 years old),primary hypertension,serious aortic valve disease,diabetes or coronary heart disease,emergency operation,CPB time≥3 hours and DHCA time≥45 minutes.The cumulative amount of insulin within 24 hours after surgery was increased significantly.The results of blood glucose(mmol/L)in-ICU were as follows:age≥50 years old or<50 years old(18.66±2.52 vs.12.90±2.27);hypertension with and without(18.98±2.55 vs.12.31±2.34);serious aortic valve disease with and without(19.59±2.95vs.12.13±2.23); diabetes with and without(20.62±1.76 vs.11.75±1.11); coronary heart disease with and without(19.77±2.98 vs.12.01±2.02); emergency operation with and without(19.78±1.97 vs.12.23±1.38);CPB time≥3 hours or<3 hours(19.86±1.89 vs.11.70±1.15);DHCA time≥45 minutes or<45 minutes(19.92±1.88 vs.11.64±1.12),and all of them should statistical difference(all P<0.05).The cumulative amount of insulin(U)within 24 hours after surgery was as follows:age≥50 years old or<50 years old(169.5±56.6 vs.110.2±38.5);hypertension with and without(171.6±64.0 vs.104.8±34.3);aortic valve disease with and without(171.4±36.8 vs.109.4±27.6);diabetes with and without(202.5±46.7 vs.100.4±31.5);coronary heart disease with and without(178.5±38.6 vs.104.6±26.4);emergency operation with and without(178.3±35.7 vs.102.7±26.8);CPB time≥3 hours or<3 hours(168.6±37.2 vs.107.3±27.5);DHCA time≥45 minutes or<45 minutes(172.5±36.1 vs.105.4±28.7),and all of them showed significant statistical difference(all P<0.05).and all of them showed significant statistical difference(all P<0.05).Conclusion DHCA may cause significant increase in perioperative blood glucose and lactate,and even may lead to insulin resistance.Patients often require continuous intravenous administration of large doses of insulin.Perioperative hyperglycemia during DHCA is related to many factors,which should be considered in control of blood glucose.     

不同类型面罩对慢性阻塞性肺疾病无创正压通气效果的影响

目的观察不同类型面罩对无创正压通气效果的影响。方法选择8例慢性阻塞性肺疾病(COPD)并呼吸衰竭患者,采用交叉自身对照试验,应用自行改良的双流向面罩及惯用面罩各通气1小时,两者间隔30分钟。在相同通气参数状态下,比较两种面罩通气效果。结果2组通气治疗后气促和呼吸费力改善,动脉血气pH升高、心率和呼吸频率显著降低（P<0.05或P<0.01）。改良面罩组动脉血二氧化碳分压(PaCO     

血清降钙素原水平检测对系统性红斑狼疮发热鉴别诊断的意义

目的探讨检测血清降钙素原(PCT)水平在系统性红斑狼疮(SLE)发热患者感染与否的判断中的临床意义。方法检测48例伴有发热的SLE住院患者以及同期门诊缓解期SLE患者20例的PCT值、C反应蛋白(CRP)值、红细胞沉降率(ESR)、白细胞计数、免疫球蛋白、补体、24h尿蛋白定量、自身抗体系列、病原学检查等,比较PCT、CRP对诊断非病毒感染的敏感性、特异性,评价其在SLE患者发热的鉴别诊断中的意义。结果 PCT值在非病毒性感染(包括细菌、真菌、结核等)组为(1.95±0.67)μg/L,明显高于病毒感染组〔(0.30±0.11)μg/L,P<0.05〕、非感染组〔(0.13±0.03)μg/L,P<0.05〕及对照组PCT(0.12±0.04)μg/L,P<0.05〕;CRP值在非病毒感染组为(45.7±15.2)mg/L,明显高于病毒感染组〔(10.9±3.2)mg/L,P<0.05〕、非感染组〔(16.7±5.6)mg/L,P<0.05〕及对照组〔(2.80±0.9)mg/L,P<0.05〕;而血清PCT值在病毒感染组、非感染组及对照组之间的差异无统计学意义(P>0.05)。以PCT≥0.5μg/L为诊断非病毒感染的阳性阈值,其诊断敏感性为73.3%,特异性为93.9%;以CRP≥8mg/L为诊断非病毒感染的阳性阈值,其敏感性为86.7%,特异性为45.5%,PCT特异性明显高于CRP(P<0.05)。结论检测血清PCT对SLE患者并发非病毒性感染具有重要鉴别诊断意义。