肝移植术后持续性胸腔积液的危险因素分析

目的对肝移植术后需穿刺置管引流治疗的胸腔积液并发症进行原因分析,了解其危险因素,从而有效预防及治疗肝移植术后胸腔积液。 方法回顾性分析2015年1月至2016年12月中山市人民医院52例肝移植患者临床资料,单因素分析持续性胸腔积液胸腔置管引流组和未引流组之间的差异,再建立Logistic多元回归模型分析肝移植术后胸腔置管引流的持续性胸腔积液相关危险因素。 结果术后48例（92.3%）发生胸腔积液,13例（25.0%）持续性胸腔积液患者需要胸腔置管引流。单因素分析显示术后肺部感染（P=0.005）、胸腔感染（P=0.012）、沙门杆菌感染（P=0.012）、表皮葡萄球菌感染（P=0.013）、白假丝酵母菌感染（P<0.001）、术后胆管并发症（P=0.025）、腹腔置管引流（P=0.003）是术后发生持续性胸腔积液的相关因素。Logistic回归分析显示,肝移植术后肺部感染及腹腔穿刺置管术是患者胸腔穿刺置管引流持续性胸腔积液的危险因素,其中肺部感染患者行胸腔置管引流持续性胸腔积液的风险是无肺部感染患者的7.354倍（P=0.027）,术后腹腔置管引流术患者行胸腔置管引流的风险为术后无腹腔置管引流术患者的31.601倍（P=0.012）。 结论肝移植术后应密切观察患者病情,积极预防肺部感染,减少腹腔穿刺置管引流,以有效控制持续性胸腔积液的发生。     

恶性胸腔积液穿刺引流与置管引流的合理应用

目的探讨恶性胸腔积液穿刺引流与置管引流的合理应用。方法对20例恶性胸腔积液患者先给予穿刺引流2～3次，然后给予置管引流。结果全组患者均减轻了痛苦，提高了生活质量，延长了生存时间。结论当恶性胸腔积液产生较快时，尽早给予置管引流，一般抽液2～3次后置管较为合理。     

超声定位引导心包穿刺置管引流治疗心包积液的效果分析

目的观察超声定位引导心包穿刺置管引流治疗心包积液临床效果及安全性。方法对32例心包积液患者实施超声定位引导心包穿刺置管引流术,观察穿刺成功率及术后改善效果及并发症等指标。结果 32例患者均一次穿刺置管成功,穿刺过程未发生头晕、气短、心律失常等不适。术后引流通畅,2例出现穿刺孔渗液伴局部疼痛,考虑心包积液压力升高所致,经进一步抽液后痊愈,未发生引流管阻塞、脱出,继发感染,心肌、冠状动脉组织损伤等。导管留置引流时间为(6.82±2.16)d。患者临床症状均消失或明显缓解。结论采用超声定位引导心包穿刺置管引流术治疗心包积液,创伤小、操作简便,术后并发症少、症状缓解明显、安全性高,患者经济负担轻。     

胸腔置管引流并腔内给药治疗恶性胸腔积液患者的护理进展

概述胸腔内置管的适用范围、导管的选择、穿刺的方法及常用药物,总结了恶性胸腔积液患者胸腔置管引流和腔内给药的围术期护理方法,为临床实践提供参考。     

心包积液超声引导经皮心包穿刺置管引流术围术期护理体会

目的总结心包积液超声引导经皮心包穿刺置管引流术期间的护理体会。方法对18例心包积液患者在接受超声引导经皮穿刺心包置管引流术期间,实施术前准备,术中医护间配合,加强术后病情监测、体位、导管引流、心理及康复指导等围术期系统护理措施。结果 18例患者一次穿刺置管成功率为100.00%,术后管道引流过程通畅。引流管留置时间5～18 d,平均12.26 d。心包填塞等症状完全消失或显著改善,无感染、计划外管道脱出等并发症出现。结论对心包积液患者实施心包积液超声引导经皮心包穿刺置管引流术的,围术期做好系统护理措施,是提高手术效果,促进患者康复的重要保障。     

超声引导下穿刺置管治疗心包积液

目的探讨超声引导下经皮穿刺置管引流在心包积液疾病中的应用价值。方法对2004年5月—2009年5月在我院诊治的28例心包积液患者进行回顾性分析。结果28例心包积液穿刺置管引流术均获得成功。术中超声均能较清晰显示穿刺针穿入心包的位置、导丝进入心包腔的行进方向及深度、导管在心包腔的位置等。并发症主要有疼痛、渗血、引流管阻塞及脱出等。结论在心包积液的诊治中,超声引导下心包穿刺置管引流术具有实时、准确,置管快捷、方便、安全、并发症少等优点,且可在床边进行,是目前心包积液最安全而理想的诊断和治疗方法。     

中心静脉导管在胸腔积液引流中的应用及护理

对37例胸腔积液的患者采用中心静脉导管穿刺引流并注入化疗药物。结果一次穿刺成功100%,5例置管过程中发生堵管,冲洗后畅通,置管6～24(17.5±5.5)d。提出中心静脉导管减轻了患者反复穿刺引流胸水的痛苦,须加强置管后的皮肤和导管护理。     

双腔中心静脉导管穿刺置管术治疗多发伤患者创伤后局限性积液

目的 探讨在多发伤患者中使用双腔中心静脉导管置管术治疗不同部位局限性积液的治疗结果.方法 19例多发伤患者创伤后形成局限性积液,其中胸部积液15例,腹部积液3例,背部皮下积液1例.所有患者在B超证实积液后,行中心静脉导管穿刺置管.结果 所有患者均一次穿刺置管成功.术后均未发生穿刺相关并发症,所有胸腔积液患者均治愈.腹腔积液患者2例积液消失,1例好转.1例背部皮下血肿完全治愈.结论 作为一种微创方式,中心静脉导管穿刺置管可以有效引流创伤后不同部位的局限性积液,为临床治疗各种局限性积液提供了另一种新的治疗性选择.     

超声引导穿刺置管负压引流治疗肾周脓肿(附11例报告)

目的：探讨超声引导穿刺置管负压引流治疗肾周脓肿的疗效。方法：回顾性分析B超引导下用胸腔穿刺针置管负压引流治疗11例肾周脓肿患者的临床资料。结果：11例肾周脓肿全部治愈，无复发。结论：利用超声引导采用穿刺负压引流治疗肾周脓肿是很可取的有效方法，其疗效确切，简易可行，微创，费用低廉。     

超声引导经皮置管引流在重症急性胰腺炎治疗中的应用价值

目的探讨超声引导经皮置管引流在重症急性胰腺炎治疗中的应用价值。方法自2002年1月至2004年6月对9例重症急性胰腺炎采用了包括超声引导经皮置管引流在内的多种非手术治疗手段,其中对6例腹腔渗液较多者,实施超声引导下经皮穿刺置管引流和腹腔灌洗;对4例合并胰腺周围积液并感染者,实施超声引导下经皮穿刺置管引流。结果9例病人全部治愈,包括1例暴发性急性胰腺炎,无一例需手术治疗,腹腔引流管留置时间为5～7d,胰周引流管留置时间为7～60d(平均为30d),住院时间32～152d,平均68d。结论超声引导经皮置管引流对于重症急性胰腺炎腹腔积液较多者以及胰腺周围积液合并感染者能够进行简便、安全、有效的治疗,它的成功应用为非手术治疗重症急性胰腺炎提供了有益的经验。     

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.     

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.     

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.     

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.