静脉麻醉下行无痛结肠镜检查病人的护理

[目的]探索无痛结肠镜检查中的配合与护理。[方法]在226例病人进行无痛结肠镜检查中,护理人员加强心理护理、肠道准备、术中观察、密切配合医生插镜。[结果]在226例病人检查中,镜检成功率99.56%,无一例穿孔、出血、麻醉意外等并发症发生。[结论]无痛苦肠镜检查是安全可靠的,它能增加病人的依从性,在有严格监护条件下值得临床推广应用。     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

Objective To demonstrate the electroanatomic substrates of right-sided free wall (RFW)accessory pathways (APs) which were refractory to conventional catheter ablation utilizing three-dimensional (3D) mapping. Methods Seventeen patients with RFW APs that failed initial conventional catheter ablation(s)by a mean of 1～3(1.8±0.6) attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during right ventricular pacing in 14 patients and orthodromic reciprocating tachycardia in 3patients. Radiofrequency energy was delivered via irrigation catheter to the earliest atrial activation site. Results The earliest atrial activation site, which represented the atrial insertion of the APs, was separated from the tricuspid annulus by an average of 9 ～ 20 ( 13.6 ± 3.4 ) mm, and the local activation time was 18 ～ 80(31.5±16.3) ms earlier than that of the corresponding annular point. The target electrogram demonstrated AP potential in fourteen patients and ventriculoatrial fusion in the rest three. Accessory pathway was blocked in one case during moving the catheter and RF ablation delivery on the areas. One patient exhibited an AP with wide branching on the atrial side during mapping. RF ablation with an irrigated catheter successfully interrupted AP conduction in remaining 16 patients without complications. After a mean follow-up of 3 ～ 41 (18.6±12.7) months, there were no recurrences of ventricular preexcitation or episodes of tachycardia. Conclusion RFW APs refractory to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distance from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.     

碎裂QRS波在致心律失常性右心室心肌病诊断中的价值

Objective To evaluate diagnostic value of fragmented QRS complex (fQRS)in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods Forty-three patients [33 men, aged (40. 4 ± 13.9)years]meet the ISFC/ESC diagnostic criteria for ARVC were enrolled in this study. A standard twelve-lead electrocardiogram was obtained during the resting status. Characteristics of fQRS were detailedly studied by three doctors independently. A comparison of the prevalence among fQRS, epsilon wave and T wave inversion( TWI )in the right precordial leads exceeding V3 was done. Results Most fQRS could be found in the inferior leads (44. 3% ) and the right precordial leads (24. 2% ). Within the QRS complex, the prevalence of fQRS in the R wave was significantly higher than it in the S wave(58. 4% vs 32. 9% ,Z =4. 30,P ＜0. 01 ).fQRS could be found in a total of 31 of 43 cases( mean 4. 6 ± 1.7 ( range 2 to 9) per patient). The prevalence of fQRS was significantly higher than that of epsilon wave ( 73.8% vs 30. 2%, Z = 3.67, P ＜ 0. 01 ) and TWI (73.8% vs41.9% ,Z =2. 61 ,P＜0. 01 ). Conclusion fQRS was a common electrocardiographic abnormality,and most was found in the inferior and right precardial leads in patients with ARVC. It may be used as an important noninvasive preliminary screening electrocardiographic criteria.     

磁导航遥控射频导管消融治疗房室结折返性心动过速的初步体会

Objective To evaluate the safety and feasibility of remote radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia (AVNRT) using the magnetic navigation system (MNS). Methods A total of 37 patients[female 29, mean age (44 ± 15 )years]with documented AVNRT were enrolled in this study from March 2007 to June 2009. A 4 mm tip magnetic mapping and ablation catheter ( Helios Ⅱ ,Stereotaxis, USA),which was remotely controlled by the MNS (Niobe Ⅱ , Stereotaxis, USA), was used for both mapping and ablation. Conventional slow pathway modification with focal ablation at the fight posterior septum was first performed in all patients. If it was failed, linear lesions at the base of Koch' s triangle was then done. Results After ablation, AVNRT was non-inducible in all 37 patients without any complication except one case experienced transient first degree AV block. Focal ablation was performed in 34 patients, and linear ablation strategy was used in the remaining three cases to achieve the end point. Among all the 37 patients, slow pathway ablation was achieved in 14, whereas slow pathway modification was reached in the remaining 23 cases.The mean procedural time, the RF deliveries, the duration of RF application were ( 120 ± 32) min, (2. 9 ± 1.6)times, ( 130 ± 33 )s,respectively. The total fluoroscopy time and the physician X-ray exposure time were(5.3 ±2. 7)min and(2.9 ± 1.1 ) min,respectively. There was no significant change of the AH interval,the HV interval,and the atrioventricular nodal conduction refractory period after ablation. Compared with the first 18 patients, the mean procedural time, the total fluoroscopy time and the X-ray fluoroscopy time during magnetic navigation were significantly decreased in the later 19 patients (P ＜0. 001 ). It indicated that the learning curve of remote catheter ablation using the MNS is short. Conclusion Remote catheter ablation using the MNS to cure AVNRT is safe and effective with short learning curve and decreasing X-ray exposure time for interventional physicians.     

起源于左侧希氏-浦肯野系统的特发性加速性室性自主心律

目的 介绍起源于左侧希氏-浦肯野系统的特发性加速性室性自主心律,揭示其临床特征并探讨可能的电生理机制.方法 回顾分析4例特发性加速性室性自主心律患者的心电图形态特征、临床表现、治疗方法及预后.结果 4例患者,男性2例,平均年龄48(40～54)岁,均无器质性心脏病.室性自主心律均呈右束支阻滞型,其QRS时限0.11～0.13 s,符合左侧希氏-浦肯野系统起源,其中3例电轴右偏,1例电轴左偏.自主心律RR间期不规则,平均频率为87(55～110)次/min,与窦性心律交替出现.所有患者临床均表现为发作性心悸.1例患者室性自主心律在短期服用普罗帕酮后消失,另1例短期服用维拉帕米后消失,余2例未予以特殊处理后自然消退.平均随访4.5(2～8)年,临床无心律失常发作,亦无其他心血管事件发生.结论 起源于左侧希氏-浦肯野系统的加速性室性自主心律是左侧希氏-浦肯野系统特发性室性心律失常的一种表现形式,多数为自限性,临床呈良性经过.     

骨髓间充质干细胞移植对心肌梗死后心室肌细胞钾离子通道Ito Kv4.2的影响

目的 研究心肌梗死后移植骨髓间充质干细胞(bone marrow mesenchymal stem cells,BMMSCs)对心室肌细胞钾离子通道Ito亚单位Kv4.2基因表达的影响方法 40只SD(Sprague-Dawley)大鼠随机分成4组(10只/组):假手术组、心肌梗死组、心肌梗死+干细胞组和心肌梗死+细胞培养基组.开胸结扎冠状动脉前降支建立心肌梗死模型,建模成功后,在梗死周围分别注入BMMSCs和细胞培养基,心肌梗死组仅建立心肌梗死模型,假手术组仅开胸子以前降支穿线但不结扎.2周后行心肌组织HE染色和荧光显微镜观察移植细胞,逆转录聚合酶链反应(RT-PCR)和Western blot分别检测钾离子通道Ito亚单位Kv4.2基因mRNA和蛋白水平.结果 (1)心肌组织免疫荧光检测发现,BMMSCs集中分布于梗死区和梗死心肌周围;(2)心肌梗死组和心肌梗死+细胞培养基组Kv4.2 mRNA量(0.39±0.02,0.41±0.04)和蛋白量(0.47±0.02,0.50±0.05)明显下降,与假手术组(0.76±0.05,0.74±0.06)相比差异有统计学意义(P＜0.01);心肌梗死+干细胞组Kv4.2 mRNA量和蛋白表达量(0.57±0.05,0.64±0.03)较心肌梗死组(0.39±0.02,0.47±0.02)明显升高(P＜0.01).结论 骨髓间充质干细胞移植后心肌梗死大鼠钾离子通道Ito亚单位Kv4.2基因表达上升,可能减少心律失常发生.     

N-乙酰半胱氨酸通过抑制活性氧-p38通路减轻缺氧复氧诱导的乳鼠心肌细胞凋亡

目的 探讨N-乙酰半胱氨酸(N-acetylcysteine,NAC)抑制缺氧复氧(hypoxia-reoxygenation,H/R)诱导的乳鼠心肌细胞凋亡的机制.方法 心肌细胞培养48 h后随机分为对照组、缺氧复氧组(H/R组)、缺氧复氧+NAC组(100 p.mol/L)(H/R+NAC组).H/R组心肌细胞先缺氧6 h,随后复氧72 h,H/R+NAC组在H/R组细胞培养液中加NAC(100 μmol/L).采用锥虫蓝检测心肌细胞活性.流式细胞仪与Annexin V测定细胞早期凋亡.TUNEL检测细胞晚期凋亡.活性氧绿色荧光显色试剂检测活性氧(reactive oxygen species,ROS)浓度.RT-PCR检测bcl2、bax基因mRNA水平.Western blot检测bel2、bax、p38与pp38基因蛋白水平.结果 H/R组有活性的细胞数量为74.9%,显著低于对照组(93.5%,P<0.01),H/R+NAC组有活性的细胞数为89.9%,显著高于H/R组(P<0.01).H/R组早期凋亡的心肌细胞数为25.2%,显著高于对照组(6.5%,P<0.01),H/R+NAC组早期凋亡的细胞数为11.1%,显著低于H/R组(P<0.01).H/R组晚期凋亡的心肌细胞数为33.5%,显著高于对照组(3.5%,P<0.01),H/R+NAC组晚期凋亡的细胞数为13.5%,显著低于H/R组(P<0.01).H/R组心肌细胞ROS产生显著高于对照组,H/R+NAC组心肌细胞ROS产生显著低于H/R组.H/R组pp38/p38条带密度比值(13.40)也显著高于对照组(3.89).H/R+NAC组pp38/p38条带密度比值(1.95)显著低于H/R组(13.4),P<0.01.H/R组bcl2 mRNA与蛋白水平显著低于对照组,bax mRNA与蛋白水平显著高于对照组.H/R+NAC组bcl2 mRNA与蛋白水平显著高于H/R组.H/R+NAC组bcl2/bax mRNA水平比值(1.79)显著高于H/R组(1.22),P<0.05,但仍低于对照组(1.85).H/R+NAC组bcl2/bax条带密度比值(0.71)显著高于H/R组(0.50),P<0.05,但仍低于对照组(2.53).结论 NAC通过抑制ROS-p38通路减轻缺氧复氧诱导的乳鼠心肌细胞凋亡,这一作用具有潜在的临床应用价值.     

铁皮石斛多糖对SHR-sp大鼠抗高血压中风作用的实验研究

目的：观察铁皮石斛多糖、铁皮石斛非多糖对易卒中型自发性高血压大鼠（SHR-sp）的降低血压、延长生存期作用,以明确铁皮石斛的有效部位。方法：实验设铁皮石斛多糖大、中、小剂量组,西药尼莫地平组,铁皮石斛水提取物组,铁皮石斛非多糖组,SHR-sp模型对照组,正常对照组,共8组。连续灌胃给药12周,停药继续观察9周,记录血压的变化及大鼠中风情况及生存期。结果：铁皮石斛多糖大、中、小剂量均有一定降压作用。铁皮石斛非多糖组降压作用幅度较铁皮石斛多糖各组弱,停药后无作用。铁皮石斛多糖大、中、小剂量均有一定延长生存天数和提高生存率作用;其作用较铁皮石斛非多糖组显著。结论：铁皮石斛多糖为铁皮石斛降低血压、预防中风作用的主要有效成份。     

新斯的明拮抗罗库溴铵神经肌肉阻滞程度T1为5%～10%的剂量-时效曲线关系

目的 探讨新斯的明拮抗罗库溴铵(ROC)神经肌肉阻滞(NMB)程度为T1 5%～10%的剂量-时效关系.方法 拟在全麻下行腹部手术患者45例,年龄20～59岁,ASA Ⅰ或Ⅱ级,以新斯的明拮抗剂量不同分为N30(新斯的明0.03 mg/kg)、N40(新斯的明0.04 mg/kg)和N50(新斯的明0.05 mg/kg)3组,每组15例.静脉注射异丙酚、芬太尼、ROC 0.6 mg/kg行麻醉诱导.以4个成串刺激反应方式(TOF)监测NMB深度,T1达最低时行气管插管.异丙酚靶控输注(效应室浓度3～4 μg/mL)及静脉注射芬太尼维持麻醉.T1恢复10%开始输注ROC,维持T1在5%～10%,术毕停止输注ROC,以不同组对应的不同剂量新斯的明拮抗ROC肌松效应,每间隔1 min记录1次T1、TOFr恢复值,连续记录10 min.应用SPSS统计软件,绘制3个剂量新斯的明拮抗ROC T1、TOFr恢复趋势图以及不同时间点剂量与ED50、ED80关系图.结果 随新斯的明剂量的增加,T1、TOFr时间-效应曲线左移.N50组10 min T1、TOFr恢复分别达95%、0.85左右.N40组和N30组T1 10 min内的恢复值均在80%(79.7%、70.7%)以下,TOFr在0.75(0.72、0.64)以下,3组间存在显著差异,P＜0.05.结论 拮抗ROC NMB T1 5%～10% 10 min内T1、TOFr恢复至0.8以上,新斯的明剂量应大于0.045 mg/kg.     

脑卒中的康复护理

脑卒中后遗症患者大多为老年人,随着人们生活水平的提高和饮食结构的改变,脑卒中呈现逐年增长的趋势.因此脑卒中后遗症的康复越来越受到人们的重视.现将2008年3月-2009年9月58例脑卒中后遗症患者康复护理报告如下.