经皮肾镜碎石术后致尿源性脓毒血症的危险因素研究

目的 总结经皮肾镜气压弹道碎石治疗肾结石术后尿源性脓毒血症的危险因素.方法 收集本院2013年5月至2016年4月间行经皮肾镜气压弹道碎石治疗肾结石的患者临床资料,共657例,术后出现尿源性脓毒血症15例.总结病例特点,对可能导致尿源性脓毒血症的相关因素进行分析.结果 在15例尿源性脓毒血症患者中,术前尿常规、中段尿培养、术前使用抗生素、手术时间、术中液体灌注量等因素与术后尿源性脓毒血症相关.术前使用抗生素、手术时间、液体灌注量为尿源性脓毒血症的危险因素.结论 术前充分抗感染治疗、缩短手术时间以及减少术中液体灌注是减少术后尿源性脓毒血症的主要措施.     

上尿路结石治疗与尿脓毒血症

上尿路结石治疗的主要微创手术方法是经皮肾镜碎石取石术和逆行途径的肾内手术。此两种手术围手术期都存在感染性并发症发生的风险，严重时会并发尿脓毒血症。结石引发的梗阻及并发的感染、碎石术导致结石内部的细菌及致热原的释放都是引发尿路感染或者全身炎症反应综合征，甚至尿脓毒血症的重要因素。深入认识上尿路结石治疗过程中尿脓毒血症发生的环节、危险因素及术中应该注意的事项对尿脓毒血症的预防和治疗具有重要的意义。现就上尿路结石治疗与尿脓毒血症的关系做简要概述。     

经皮肾镜碎石术并发脓毒血症的风险与防治

经皮肾镜碎石术（percutaneous nephrolithotomy．PCNL）围术期可出现多种相关并发症．脓毒血症是其中最严重之一．一旦发生感染性休克常致多器官功能衰竭，围术期死亡率高。本文以PCNL中并发严重脓毒血症及感染性休克致多器官功能衰竭为例，旨在分析该类手术并发脓毒血症的风险因素．探讨其防治措施。     

高龄结肠癌并发穿孔19例临床分析

目的探讨高龄结肠癌患者并发穿孔的临床特点、手术方式的选择以及围手术期的处理。方法回顾性分析2000年1月至2010年7月我科收治的19例高龄结肠癌患者并发穿孔的临床资料。结果 3例行肿瘤切除Ⅰ期吻合术,其中1例发生吻合口漏;12例患者行Hartman术,围手术期1例死于呼吸衰竭;4例行单纯双腔造瘘术,围手术期1例死于脓毒血症。围手术期的死亡率为10.53%。结论结肠癌并发穿孔后早期手术是治疗本病的关键,呼吸衰竭和脓毒血症是常见的死亡原因,手术方式应根据患者的具体情况选择个体化的手术治疗方案,Hartman术作为安全有效的手术方式,值得推荐。     

孤立肾结石患者电子输尿管软镜钬激光碎石术后出现尿脓毒血症的诊治分析

目的：探讨孤立肾结石患者接受电子输尿管软镜钬激光碎石术后出现尿脓毒血症的临床特点及治疗方法。方法：回顾性分析孤立肾结石患者行电子输尿管软镜钬激光碎石术后出现尿脓毒血症的5例患者的临床资料：2例为单侧肾切除术后,3例为功能性孤立肾。结石位于肾下盏3例,多。肾盏2例;结石大小20-31mm,平均25mm。术前3例患者尿培养阳性,其中2例为大肠埃希氏菌,1例为克雷伯杆菌。患者经由同一术者在全麻下行电子输尿管软镜钬激光碎石术。结果：5例患者术后出现不同程度尿脓毒血症。经及时进行有效液体复苏,选用敏感抗生素或亚胺培南,并选用小剂量短期地塞米松及血管活性药物等对症支持治疗,术后I周内均逐渐恢复,痊愈出院。结论：尿脓毒血症是上尿路结石腔内治疗后的严重并发症之一。充分的术前准备,熟练的手术操作,严密的术后监测,早期发现和及时有效的治疗,是防治孤立肾结石电子输尿管软镜钬激光碎石术后出现尿脓毒血症的有效措施。     

糖皮质激素对心脏手术患者预后影响的研究进展

正糖皮质激素(glucocorticoids,GCs)是参与调节机体应激反应的肾上腺皮质激素,具有抗炎、抗过敏、免疫抑制等作用,是围手术期最常使用的药物之一。在非心脏手术中,GCs常用于减轻术后恶心呕吐,抑制高气道反应,辅助镇痛治疗,过敏反应的治疗,脓毒血症和脓毒性休克的治疗以及防治脑水肿等~([1])。而在心脏外科手术中,GCs因具有强大的     

不同种类液体复苏对脓毒血症患者凝血功能的影响

背景 脓毒血症本身及其发病过程中产生的炎症因子均可导致患者全身凝血功能的改变,脓毒血症的治疗指南将液体复苏治疗列为一项重要的治疗措施.目的 液体复苏对脓毒血症患者凝血功能的影响.内容 描述了脓毒血症、晶体液、胶体及液体输注策略对脓毒血症患者凝血功能的影响.趋向 不同的液体种类及治疗方案均可对脓毒血症患者不同的凝血因子产生短暂的、程度不同的影响,但各种液体输注对脓毒血症患者的预后相似.     

CO2气腹对脓毒血症炎症反应的研究进展

外科手术是治疗急性腹膜炎的基本方法 ,这类患者多伴有脓毒血症.近年来随着腹腔镜技术的发展,腹腔镜手术已越来越多地应用于脓毒血症患者的外科手术治疗;但其对术后炎症反应的影响和对细菌播散的影响一直是关注的焦点.现将近年来有关CO2气腹在这方面的研究进展作一综述.     

实时低剂量CT定位穿刺在复杂肾结石经皮肾镜术中的应用

目的探讨实时低剂量CT定位穿刺法建立经皮肾通道在复杂肾结石经皮肾镜术中的临床应用价值。方法广西中医药大学第一附属医院于2014年6月至2014年12月对30例复杂肾结石患者术前采用低剂量CT引导定位穿刺建立经皮肾通道后行经皮肾镜术,回顾性分析其临床资料。结果所有患者均成功建立经皮肾通道,其中单通道取石24例,双通道取石6例,Ⅰ期手术27例,Ⅱ期手术3例,清石率为90%,无一例出现大出血、胸腹腔脏器损伤、尿源性脓毒血症等并发症,无一例需术中或术后输血。结论实时低剂量CT定位穿刺法,可安全有效的建立理想的取石通道,提高复杂肾结石经皮肾镜碎石术的成功率,减少并发症,同时降低了患者接受的辐射剂量。     

输尿管软镜碎石术后尿脓毒血症的危险因素分析

目的探讨输尿管软镜联合钬激光治疗肾结石术后发生尿脓毒血的危险因素。 方法回顾性分析南方医科大学附属江门医院自2015年1月至2016年9月期间66例输尿管软镜术后患者的临床资料。对患者的一般资料进行收集整理,统计分析输尿管软镜术后尿脓毒血症的危险因素。 结果66例肾结石患者均顺利完成输尿管软镜联合钬激光碎石手术,术后9例（13.6%）患者发生尿脓毒血症。术后尿脓毒血症危险因素的单因素分析中,脓尿、结石大小、手术持续时间、感染性结石有统计学意义（P<0.05）。在对包括年龄、性别、糖尿病史、高血压病史、结石手术史、肾功能不全、肾盂积水、术前尿细菌培养、结石大小、脓尿、手术持续时间、感染性结石等作为自变量的多因素Logistic回归分析中,术后尿脓毒血症的危险因素有脓尿（P=0.019）,手术持续时间（P=0.021）,感染性结石（P=0.032）。 结论脓尿、手术持续时间、感染性结石是输尿管软镜碎石术后尿脓毒血症的危险因素。     

In situ extracorporeal shock wave lithotripsy for obstructing ureteral stones with acute renal colic.

In situ (no instrumentation) extracorporeal shock wave lithotripsy (ESWL*) was used to treat 49 patients with obstructing ureteral stones causing acute renal colic. Ureteral obstruction was diagnosed on the delayed films of an excretory urogram and was classified as severe (dilatation above and no contrast medium seen below the stone) in 17 patients and partial (dilatation above and contrast medium seen below the stone) in 32. Upper third ureteral stones were present in 41 patients (obstruction severe in 15 and partial in 26) and lower third ureteral stones were present in 8 (obstruction severe in 2 and partial in 6). ESWL was performed within 14 days of the onset of the acute renal colic because of persistent pain with an unmodified Dornier HM3 lithotriptor in 17 patients and a Medstone STS device in 32. With single stones the stone-free rate at 3 months, the repeat ESWL rate and the secondary procedure (stone basketing) rate were 92%, 6% and 8%, respectively, with severe obstruction, and 78%, 6% and 6%, respectively, with partial obstruction. No urinary drainage procedures for sepsis were required after ESWL. Obstructing ureteral stones, which presented mainly in the upper third of the ureter, were successfully treated with in situ ESWL without the need for either bypassing the stone with a ureteral stent or for pushing the stone back into the kidney before treatment with ESWL.     

Endotoxin content in renal calculi

PURPOSE: Manipulation of infection calculi (struvite and calcium apatite) can cause the sepsis syndrome due to endotoxemia or bacteremia. We sought to determine whether concentrations of endotoxin sufficient to produce the sepsis syndrome could be embedded in renal infection stones. MATERIALS AND METHODS: Fragments of infection and noninfection renal calculi were processed and assayed for endotoxin concentration. Endotoxin concentrations, recorded as endotoxin units per gm. calculus, were converted to ng. (10 endotoxin units = 1 ng.). Urine culture results were available for some patients with infection stones. RESULTS: A total of 34 renal calculi (16 infection and 18 noninfection) were evaluated. The composition of 62.5% of the infection stones was struvite, whereas 50% of the noninfection stones were calcium oxalate monohydrate. Mean endotoxin concentration in infection calculi was 12,223 ng./gm. stone (range 0.6 to 50,000), compared to 340.3 ng./gm. stone (range 0 to 3,490) in noninfection calculi. The endotoxin content difference was significant (p = 0.001). Urine culture results available from 9 patients with infection stones did not correlate with endotoxin concentrations. CONCLUSIONS: Large endotoxin concentrations can be found in renal infection calculi. Noninfection stones can contain endotoxin but in much lower amounts. Massive endotoxin release could occur with infection stone manipulation, possibly producing increased serum endotoxin concentrations similar to those seen in gram-negative sepsis. Anti-endotoxin strategies may be beneficial in preventing and treating stone induced endotoxemia and the sepsis syndrome.     

经皮肾取石术在老年肾结石患者中的应用

目的探讨经皮肾取石术（percutaneous nephrolithotomy，PCNL）治疗老年肾结石的疗效及安全性。方法2005年1月-2011年12月对57例老年（年龄61—87岁，平均69岁）肾结石行PCNL。采用B超引导下建立经皮肾通道F16-F24，留置相应工作外鞘置入F8.0/9.8输尿管镜或F20.8经皮肾镜，钬激光或EMS碎石清系统碎石并清除结石。结果手术时间30～140min，平均65min。一期结石清除率78．9％（45／57）。1例术后体温〉38．5oC，经抗感染治疗后好转；2例术中、术后出血较多（分别出血1800、2500m1）给予输血治疗，其中1例因假性动脉瘤行肾动脉高选择性栓塞治疗好转。无一例损伤肝、脾等重要脏器及诱发呼吸和循环功能衰竭等其他严重并发症。12例结石残留者行二次PCNL4例及辅助ESWL5例，术后分别各有1例肾下盏少量结石残留，另7例无结石残留；5例结石残留随访6—24个月，除1例肾结石略有增大外其余4例无明显变化。46例结石清除者随访3—34个月，平均14．3月，除2例复发保守治疗外其余无复发。结论PCNL治疗老年肾结石安全，疗效满意。积极的术前准备、熟练的经皮肾镜技术及加强围手术期监测和管理是提高安全性的关键。     

软输尿管镜激光碎石致败血症休克原因分析

目的分析软性输尿管肾镜激光碎石导致术后脓毒败血症性休克及多器官功能衰竭（MOF）的原因及预防。方法总结我院2013年6—7月份采用软性输尿管肾镜激光碎石术治疗。肾脏结石21例,分析严重手术并发症的发生原因。结果17例患者成功治愈且一周内出院,4例患者术后5h内发生脓毒败血症性休克,其中有2例进展为多器官功能衰竭（MOF）,1例抢救无效死亡。回顾性分析所有病例,发现所有4例发生脓毒血症性休克的患者术前尿培养均为阳性,3例结石较大（〉2cm）,1例多发结石,碎石时间均超过1h。结论术前尿培养阳性,结石大或多发结石导致碎石时间长（〉1h）是软性输尿管。肾镜激光碎石术后发生脓毒血症性休克的丰要原因。     

Percutaneous nephrolithotomy and the solitary kidney

We reviewed 53 patients with stones in a solitary kidney who had undergone percutaneous nephrolithotomy. Previous surgery on that kidney had been performed in 35.8%, and 50.9% had other medical conditions including 26.4% who had impaired renal function. Staghorn or partial staghorn calculi were present in 52.9% and an additional 18.8% had multiple stones. Postoperative complications in 18.8% of the patients included sepsis, the need for transfusion and 1 death of bronchopneumonia. Percutaneous nephrolithotomy alone resulted in a 77.3% rate free of stone or fragments of 2 mm, or less. This rate increased to 86.8% with the addition of extracorporeal shock wave lithotripsy, ureteroscopy or open surgery (2 patients). Only 1 patient suffered long-term deterioration in renal function. Percutaneous nephrolithotomy is a safe procedure in the solitary kidney. It should be considered in those patients with complex stone burdens and impaired renal function when reduction in stone bulk and improved renal function may allow other treatment modalities to be used.     

The reversal of the hepatorenal syndrome in four pediatric patients following successful orthotopic liver transplantation.

Four pediatric patients are presented in whom profound renal failure (hepatorenal syndrome) developed in association with severe end-stage liver disease. All four patients had successful orthotopic liver transplantation. Special emphasis is given to the preoperative and postoperative renal function in the patients, and the criteria used to establish the diagnosis of the hepatorenal syndrome are discussed. In the initial work on liver transplantation and reversal of the hepatorenal syndrome, two of the three patients recovered renal function but died in the perioperative period. The four patients presented in this report have not only had reversal of the hepatorenal syndrome after successful orthotopic liver transplantation but have also survived long term. The four patients have been followed up for periods ranging from 18 months to 4.5 years. Three of the four patients have maintained near normal renal function, whereas the fourth patient (who had a left nephrectomy for obstruction and sepsis) has had a significant decline in renal function.     

经皮肾镜超声联合气压弹道碎石术治疗肾结石（附95例报告）

目的探讨经皮肾镜超声联合气压弹道碎石术治疗肾结石的疗效与安全性。方法2007年2月～2008年9月,对95例肾结石在B超引导下行经皮肾镜超声碎石术。采用EMS三代气压弹道联合超声碎石系统,单用超声或气压弹道碎石,若结石较硬则两者联合碎石。结果95例建立皮肾通道均成功。手术时间45～170min,平均85min。术中无严重并发症发生。残石17例,其中6例行二次碎石术。11例术后明显肾出血,其中9例经保守治疗成功,2例严重出血行病肾切除术。结论经皮肾镜超声联合气压弹道碎石术治疗肾结石具有高效、微创的优点。     

Staghorn calculus endotoxin expression in sepsis

Staghorn calculi are infrequent and generally are infected stones. Struvite or apatite calculi are embedded with gram-negative bacteria, which can produce endotoxin. Sepsis syndrome may occur after surgical therapy or endoscopic manipulation of infected or staghorn calculi. Sepsis, which can occur despite perioperative antibiotic use, may be due to bacteremia or endotoxemia. We present a child with an infected staghorn calculus who developed overwhelming sepsis and died after percutaneous stone manipulation. Endotoxin assay of stone fragments demonstrated an extremely high level of endotoxin despite low colony bacterial culture growth. This is the first reported case in which endotoxin was demonstrated in stone fragments from a child who died of severe sepsis syndrome after percutaneous staghorn stone manipulation.     

Pneumatic Lithotriptor - A Useful Tool for Challenging Renal Stone Surgery

Open surgical measures may be undertaken in the treatment of some complex calculi and manoeuvres such as extended pyelolithotomy or nephrolithotomy may be necessary. In an attempt to improve surgical results with less morbidity and maximum ease, we used the Swiss Lithoclast to disintegrate large stones presenting as hard cases.Five patients with renal pelvic stones associated with calyceal stones in two and two further cases with staghorn stones were treated surgically using the pneumatic lithotriptor probe with less dissection and without nephrotomy. Only one of the patients with staghorn stones had residual fragments which were then treated with ESWL.We believe that when open surgical treatment is considered in hard cases, especially in those with small renal pelvises, the best results may be achieved with minimum surgical intervention if it is combined with pneumatic lithotripsy.     

Thrombophilia in Cardiac Surgery—Patients with Symptomatic Factor V Leiden

Abstract   Background and aim of the study: Thrombophilia may cause severe complications in cardiac surgical patients. We analyzed our experience with symptomatic factor V Leiden patients. Methods: Over an eight-year period, 14 symptomatic patients previously diagnosed with activated protein C resistance, caused by factor V Leiden, underwent a cardiac surgical procedure. We retrospectively reviewed the clinical data, operative and postoperative courses, and the intermediate-term results of these patients. Results: Procedures performed were coronary artery bypass grafting (CABG, 10 patients), aortic valve replacement + CABG, pulmonary thromboendarterectomy, left ventricular thrombus removal, and aortic valve reconstruction (one patient each). Eleven patients survived; three patients died perioperatively, one from sepsis (25 days after surgery), one from recurrent stroke (28 days after surgery), and one from multiorgan failure following perioperative stroke (31 days after surgery). In one patient, all bypass grafts occluded intraoperatively. Three patients underwent cardiac surgery under continuous anticoagulation with phenprocoumon. In these three patients, no perioperative thromboembolic events occurred. At a mean follow-up of 32 months, three patients had suffered from cerebral stroke, two from graft occlusion, of which one was recurrent. Two more patients had died (one after cerebral stroke and one from cerebral metastases of a renal cell carcinoma). Conclusion: In 14 patients with symptomatic factor V Leiden who underwent cardiac surgery, we observed a considerable number of fatal and nonfatal thromboembolic events in the perioperative period and during a 32 months' follow-up. As conducted in three patients, continued anticoagulation with coumarin was safe and prevented perioperative thromboembolic events.