颅脑创伤后脑盐耗综合征的诊断和治疗

脑盐耗综合征(CSWS)是低血钠综合征的一种.临床表现为低血钠、高尿钠、低血容量,部分患者同时伴有多尿.在颅脑创伤后并发的低钠血症中,其较易与抗利尿激素分泌不当综合征(SIADH)及低钠性失水等相混淆[1],影响临床治疗及预后,本文报告2例颅脑创伤后CSWS的诊治经验.     

颅脑损伤并发脑性盐耗综合征诊疗分析

目的探讨颅脑损伤患者并发脑性盐耗综合征的诊断及治疗方法。方法回顾性分析22例颅脑损伤后并发脑性盐耗综合征患者的临床表现、实验室检查及治疗过程。结果21例患者尿钠逐渐下降,尿量正常,5~16 d血钠恢复正常,平均恢复时间9.8 d。1例特重型脑外伤死于多器官功能衰竭。结论颅脑损伤并发的脑性盐耗综合征的发病机制与治疗措施不同于抗利尿激素分泌异常综合征,早期诊断、早期治疗能降低颅脑损伤患者的病残率和病死率。     

重型颅脑损伤中枢性低钠血症45例

分析重型颅脑损伤中枢性低钠血症的临床特点,为预防、诊断及治疗提供参考。选取住院的重型颅脑损伤中枢性低钠血症患者45例,根据临床特点及检查结果进行分组,脑性盐耗综合征(CSWS)为CSWS组(36例),抗利尿激素分泌不当综合征(SIADH)为SIADH组(9例),分别给予对症治疗,比较两组临床效果。治疗前血钠浓度为122.57±10.53mmol/L,治疗后血钠浓度为137.13±14.33mmol/L,治疗后血钠浓度高于治疗前,差异有统计学意义(P<0.05)。SIADH组ANP检查结果低于CSWS组,差异有统计学意义(P<0.05)。SIADH组ADH、CVP检查结果均高于CSWS组,差异有统计学意义(P<0.05)。经明确分型对症治疗后存活42例,存活率为93.33%,死亡3例。对颅脑损伤后低钠血症进行明确的分型,并且采取有针对性的治疗可有效降低病死率。     

颅脑外伤后脑性盐耗综合征的观察与护理

目的探讨颅脑伤后脑性盐耗综合征(CSWS)的观察和护理。方法对13例颅脑外伤后发生CSWS患者的临床数据进行回顾性的分析,观察患者意识变化,监测尿量、尿比重、血清钠、血浆渗透压、血抗利尿激素(ADH)浓度及中心静脉压(CVP),并探讨相应的护理对策。结果13例患者中,伤后第4～7天血钠平均107mmol/L,尿钠平均为62mmol/L,血渗透压平均205mOsmol/kg,抗利尿激素浓度不高,尿渗透压平均409mOsmol/kg,尿比重平均1·025,其中5例治疗上予以限水,出现低血钠伴有中心静脉压下降,意识障碍加深;补足水、盐后,伤后第14～21天,血钠平均回升至137mmol/L,基本恢复正常。2w恢复8例,4w内恢复3例,1例患者伤后7d死亡。结论在脑性盐耗综合征病人的护理环节上要重视预见性护理,严密观察病人意识状态及生命体征、监测血生化指标、准确记录出入量,掌握好补钠、补液的均衡速度,维持血容量及钠的平衡,掌握脑性盐耗综合征、抗利尿激素分泌不当综合征、中枢尿崩症三类不同的病症的鉴别护理。     

重型颅脑损伤后脑性盐耗综合征的诊治

目的：探讨重型颅脑损伤后脑性盐耗综合征的病因、诊断及治疗方法。方法：回顾分析18例重型颅脑损伤后发生脑性盐耗综合征患者的临床资料。结果：18例患者的血内经治疗后恢复正常。结论：低血钠、高尿钠、低血容量是脑性盐耗综合征的诊断标准，其治疗方法为水化与补钠。     

脑性耗盐综合征临床特点与护理体会

目的探讨脑性耗盐综合征（CSWS）临床特点和护理要点。方法总结26例CSWS临床特点和护理要点。结果重型颅脑损伤18例、垂体瘤术后6例、颅咽管瘤术后2例合并CSWS,表现为低血钠、高尿钠和低血容量综合征。护理工作中应注重颅脑损伤和鞍区肿瘤术后患者的病情观察和发展;注重电解质监测和分析;注意与抗利尿激素不当分泌综合征鉴别;有效合理补液,纠正电解质紊乱,适当控制钠盐摄入量,维持血容量平衡;指导患者的营养给予,加强患者的心理护理。结论本组26例CSWS经有效治疗和积极护理,水电解质紊乱得到有效纠正,有利于患者预后。     

脑性盐耗综合征一例临床分析

脑性盐耗综合征(cerebral salt wasting syndrome,CSWS)由Peters等在1950年首先提出[1].该病症在颅脑创伤、颅脑肿瘤(尤其是颅咽管肿瘤)术后及蛛网膜下腔出血[2]较常见,极易与抗利尿激素分泌不当综合征(secreting inappropriate anti-duresis-hormone syndrome,SIADHS)相混淆.如颅脑损伤患者在常规补液或正常进食情况下出现顽固性低钠血症,同时又没有长期禁食、胃肠减压、严重呕吐、脱水过度、高热不退等情况,并且尿中钠的排出量超过正常,则要考虑发生了CSWS[3].CSWS的诊断标准[4]:①有中枢神经系统疾病存在;②血清钠＜130 mmol/L;③尿钠＞20 mmol/L或＞80mmol/24 h,尿渗透压＞血浆渗透压;④尿量＞1800 ml/d;⑤低血容量;⑥全身脱水表现(皮肤干燥、眼窝下陷、血压下降等).本文着重探讨一例颅脑损伤后作颅骨修补的患者并发脑性盐耗综合征的病因、诊断及治疗,从而进一步加深对CSWS的认识.     

重型颅脑损伤后脑性盐耗综合征的护理

总结16例重型颅脑损伤后脑性盐耗综合征的护理。认为颅脑损伤后密切观察患者的意识状态及生命体征，监测尿量、尿比重、尿钠、血电解质和中心静脉压，可以协助脑性盐耗综合征的早期诊断和治疗；合理补液、补钠是减少并发症、提高抢救成功率的关键。14例经治疗2周后血钠恢复正常，意识好转；2例死于多脏器功能衰竭。     

颅脑损伤并发中枢性低钠血症的诊断和治疗

目的:探讨颅脑损伤并发中枢性低钠血症的病因、发病机制、诊断及治疗方法.方法:对我院2000年1月～2008年6月收治的84例颅脑损伤并发中枢性低钠血症临床资料进行回顾性分析.结果:本组有抗利尿激素异常分泌综合征(SIADH)24例,脑性盐耗综合征(CSWS)60例,血钠均<130 mmol/L,最低107 mmol/L,血浆渗透压<270 mOsm/L,尿钠均>80 mmol/24h.中心静脉压<6 cmH2O 60例,>12 cmH2O 24例.除15例因重度颅脑损伤死于脑功能衰竭外,其余患者低钠血症均得以纠正,治愈时间为2～4周.结论:对颅脑损伤患者应密切监测血钠浓度,SIADH和CSWS发病机制与治疗措施不同,及时正确地诊治可改善预后,降低病死率.     

重型颅脑损伤后并发脑性盐耗综合征的护理

介绍18例重型脑损伤患并发脑性盐耗综合征的护理，提出在脑性盐耗综合征病人的护理环节上：重视预见性护理，严密观察意识改变及生命体征，准确记录出入量，掌握好补盐、补液的均衡速度，维持血容量及钠的平衡，掌握脑性盐耗综合征、抗利尿激素分泌不当综合征、中枢性尿崩症三类不同病症的鉴别护理。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.