Hypotension during transsphenoidal pituitary surgery associated with increase in plasma levels of brain injury markers

Background

Patients undergoing pituitary surgery may experience short- and long-term postoperative morbidity. Intraoperative factors such as hypotension might be a contributing factor. Our aim was to investigate the association between intraoperative hypotension and postoperative plasma levels of tau, neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) as markers of perioperative brain injury.

Methods

Between June 2016 and October 2017, 35 patients from the Gothenburg Pituitary Tumor Study were included. For tau, NfL, and GFAP, concentrations were measured in plasma samples collected before and immediately following surgery, and on postoperative days 1 and 5. The difference between the highest postoperative value and the value before surgery was used for analysis (∆tau_peak, ∆NfL_peak, ∆GFAP_peak). Intraoperative hypotension was defined as the area under the curve of an absolute threshold below 70 mmHg (AUC70) and a relative threshold below 20% (AUC20%) of the baseline mean arterial blood pressure.

Results

Plasma tau and GFAP were highest immediately following surgery and on day 1, while NfL was highest on day 5. There was a positive correlation between AUC20% and both ∆tau_peak (r² = .20, p < .001) and ∆NfL_peak (r² = .26, p < .001). No association was found between AUC20% and GFAP or between AUC70 and ∆tau_peak, ∆NfL_peak or ∆GFAP_peak.

Conclusion

Intraoperative relative, but not absolute, hypotension was associated with increased postoperative plasma tau and NfL concentrations. Patients undergoing pituitary surgery may be vulnerable to relative hypotension, but this needs to be validated in future prospective studies.     

神经外科患者脑脊液病原菌分布及耐药性变迁

目的了解北京天坛医院神经外科患者脑脊液分离病原菌及其耐药趋势变化情况。方法对1997年8月—2013年8月该院神经外科患者脑脊液标本分离的病原菌情况及其药敏结果进行分析。结果共分离病原菌2 732株,其中革兰阳性(G+)菌1 946株(71.23%),革兰阴性(G-)菌786株(28.77%)。居前3位的病原菌分别为葡萄球菌属(1 751株,64.09%)、不动杆菌属(254株,9.30%)和肠球菌属(172株,6.30%)。G+菌仍占主体,其中耐甲氧西林金黄色葡萄球菌(MRSA)和耐甲氧西林凝固酶阴性葡萄球菌(MRCNS)检出率分别为74.34%和80.73%;但近年G-菌逐渐增多。所有葡萄球菌属对万古霉素、利奈唑胺保持较高敏感性(90%);G-菌总体敏感率下降,尤其不动杆菌属对亚胺培南及美罗培南的敏感率分别为51%、44%。结论神外患者颅内感染仍以G+菌多见,MRSA和MRCNS检出率高;但近年,G-菌,尤其是泛耐药的不动杆菌属所占比例呈上升趋势。     

流程优化对神经外科手术室工作效率的影响

目的研究流程优化对神经外科手术室工作效率的影响。方法通过对手术室现有资源的合理运用,关键时间点的确立,成立手术供应保障团队,人力资源优化重组,建立手术医生喜好卡等流程优化的实施,评价其对手术室效率的影响。结果优化流程后(2012年1—6月)第1台手术切皮时间准时率由45.3%提高到86.5%;连台手术衔接时间缩短了8~11 min,护士人均手术量由100.05台增加到114.29台;每日人均配合手术时间由615.5 min减少到585.5 min;医生满意度由88.3%提高到98.5%,患者满意度由85.5%提高到97.6%。结论流程优化过程中合理利用有效资源,重视时间管理,成立手术保障团队,优化重组人力资源,建立手术医生喜好卡等,可提高神经外科手术室工作效率。     

神经外科ICU终末消毒效果监测

目的 了解终末消毒前后物体表面微生物的变化情况,为医院感染防控提供依据.方法 对神经外科ICU终末消毒前、后进行环境卫生学采样,样本进行细菌培养与鉴定,比较终末消毒前、后物体表面细菌数量及种类的变化.结果 神经外科ICU终末消毒前,27.45%的物表菌落数达到物表消毒效果标准（≤5 CFU/cm2）,终末消毒后88.24%的物表菌落数达标.消毒前后物表微生物均以凝固酶阴性葡萄球菌（89.22%/34.41%）、革兰阳性杆菌（37.25%/39.22%）、微球菌（29.41%/12.75%）、霉菌（10.78%/18.63%）为主;消毒前检出最多的医院感染病原菌是鲍曼不动杆菌,符合神经外科医院感染特点;消毒前检出的临床常见条件致病菌在消毒后绝大多数被杀灭,同时也检出少量其他的条件致病菌,主要分布于潮湿、平时容易忽视、难清洁消毒及接触频繁的物表.结论 终末消毒效果较为明显,应定期对病房进行终末消毒,保证病房环境的清洁卫生.     

大脑中央区脑囊虫病灶的立体定向手术治疗

目的 ;探讨CT或MRI导向的立体定向手术切除中央区脑囊虫病灶的应用价值,总结手术治疗的经验。方法采用Leksell-G型立体定向仪,在CT或MRI导向下对25例中央区脑囊虫病灶,通过环钻开颅和显微外科技术摘除病灶。结果 25例脑囊虫病灶均能精确定位后完全切除,全组无新的神经功能损伤出现。结论 CT或MRI导向下的立体定向手术治疗中央区脑囊虫病灶安全有效。     

经皮内镜下胃造瘘术在神经外科术后的临床应用探讨

目的：探讨经皮内镜下胃造瘘术方法及其在神经外科术后的临床应用。方法：对14例无法经口进食但胃肠功能正常的神经外科术后患者行PEG术。结果：14例PEG术均置管成功，均未发生严重并发症。患者一般状态明显改善，5例已拔管，其余带管3个月．8个月年。结论：PEG能有效改善神经外科术后患者营养状态，是安全、有效、经济的经胃肠道营养方法。     

重症颅脑损伤患者发生肺部感染的危险因素及其预防

目的 探讨重症颅脑损伤患者发生肺部感染的相关危险因素,为临床预防和控制感染提供依据。方法 选取海口市第三人民医院收治的408例重症颅脑损伤患者,根据是否发生肺部感染将其分为肺部感染组（149例）和无肺部感染组（259例）,对肺部感染患者进行痰培养检查。应用多因素Logistic回归分析重症颅脑损伤患者发生肺部感染的危险因素。结果 408例重症颅脑损伤患者中肺部感染的发生率为36.52%（149/408）。149例肺部感染患者共分离出病原菌163株,以革兰阴性菌（67.48%）和革兰阳性菌（25.15%）为主。多因素Logistic回归分析发现,手术持续时间、机械通气时间、气管切开、引流管留置、GCS评分及APACHEⅡ评分是重症颅脑损伤患者发生肺部感染的独立危险因素,其OR（95%CI）值分别为5.837（3.125～13.168）、3.172（1.748～5.975）、5.106（2.683～11.829）、4.913（2.284～10.716）、3.625（1.972～7.218）、2.618（1.327～4.721）。结论 重症颅脑损伤患者肺部感染的发生率较高,应加强对其危险因素的早期预防和护理,降低感染的发生。     

Other Surgical Interventions

Abstract:   Optimal management of patients with chronic neuropathic pain requires a multidisciplinary approach that may include surgery. Yet despite the fact that lumbosacral spinal surgery, for example, is performed in thousands of patients every year, there is very little controlled clinical data to support its use or that of other surgical techniques in the treatment of chronic nonmalignant pain, especially neuropathic pain. Nevertheless, there is evidence of some success for ablative techniques such as dorsal root entry zone lesioning for phantom limb pain and girdle-zone neuropathic pain, and sympathectomy for the treatment of complex regional pain syndrome, and a variety of operations for tic douloureux. However, before considering a surgical procedure, a nonsurgical approach should have been tried and the suitability of the patient must be carefully assessed. To fully establish the role of surgery in the treatment of chronic neuropathic pain, further well-designed, prospective, controlled trials are essential.     

早期纤支镜吸痰及支气管肺泡灌洗救治重症脑科患者的临床意义

目的探讨早期纤维支气管镜吸痰及支气管肺泡灌洗对纠正重症脑科患者缺氧及防治肺部感染的临床意义。方法分析比较重症脑科患者早期纤维支气管镜吸痰及支气管肺泡灌洗25例和常规吸痰机吸痰25例动脉血氧纠正情况、肺部感染发生率、肺部感染控制时间,两组其他治疗相同。结果早期纤维支气管镜吸痰及支气管肺泡灌洗能明显迅速改善缺氧,纤维支气管镜吸痰组肺部感染发生率及肺部感染治愈时间显著低于非纤维支气管镜吸痰组(P<0.01)。结论对重症脑科患者可先考虑早期纤维支气管镜吸痰及支气管肺泡灌洗取代常规吸痰以通畅呼吸道,尤其是合并明显缺氧、呼吸道异物和肺部感染者。