重症胰腺炎合并急性肾功能衰竭相关因素分析

目的分析重症急性胰腺炎(SAP)合并急性肾功能衰竭(ARF)的临床特点及防治措施。方法回顾分析我院2000年1月至2006年12月收治SAP合并ARF的46例病人的临床资料,并用直线回归方法,对影响SAP合并ARF病死率的相关因素进行分析。结果病人的年龄、全身炎症反应综合征(SIRS)持续时间、病情严重程度(APACHEⅡ评分),急性呼吸窘迫综合征(ARDS)、多器官功能障碍综合征(MODS)、腹腔间室综合征(ACS)、感染及局部并发症等因素对预后有显著的影响。46例中死亡28例(60.9%),同时合并ARDS和MODS是病死率增加的重要原因。结论早期液体复苏、控制病情发展、积极有效的引流及早期重要脏器功能的支持是预防SAP并发ARF,改善预后的重要手段。     

重症急性胰腺炎合并急性肾功能衰竭的临床特点及治疗体会

目的 分析重症急性胰腺炎(SAP)合并急性肾功能衰竭(ARF)的临床特点,并总结治疗体会.方法 ①回顾分析南京军区南京总医院近9年63例SAP合并ARF临床资料,用多元直线回归方法分析影响ARF发生率的相关因素;②63例病人均行肠内营养支持(62.4±20.6d)和连续性肾脏替代治疗(CRRT)(15.6±8.7 d),51例行机械通气(21.7±12.4 d),54例早期腹腔穿刺,34例置鼻胆管或经皮经肝胆囊穿刺引流,18例行腹膜后脓肿穿刺引流,50例手术治疗.结果 SAP合并ARF的死亡率为31.7%,发生率为10.6%,SIRS持续时间、病情严重程度、ARDS、MODS、腹腔间室综合征等是SAP合并ARF的重要影响因素.结论 SIRS持续时间、病情严重程度、ARDS、MODS、腹腔间室综合征等是SAP合并ARF的重要影响因素;早期液体复苏、CRRT、有效维护脏器功能和局部引流是治疗成功的重要环节.     

重症急性胰腺炎并发ARDS的诊断和处理

重症急性胰腺炎（SAP）所致的全身炎症反应综合征（SIRS）能够引起远隔脏器功能发生障碍，其中急性呼吸窘迫综合征（ARDS）为最常见的严重并发症之一，也是早期引起病人死亡和导致多器官功能障碍综合征（MODS），甚至多器官功能衰竭（MOF）的重要原因，其病死率超过40％。因此如何防治SAP病人并发ARDS，对提高SAP疗效具有重要意义。     

重症急性胰腺炎急性肾功能衰竭临床危险因素及其预防

目的研究重症急性胰腺炎(severe acute pancreatitis，SAP)病人急性肾功能衰竭(acute renal failure，ARF)发生的易患因素，估价ARF与SAP病人预后的相关性，探讨预防ARF发生的措施。方法回顾性分析我院1990年以来收治的SAP病人246例，对病人年龄、性别、病因、Ranson评分、APACHEⅡ评分、低氧血症、腹腔室隔综合征、感染、血淀粉酶水平、尿淀粉酶水平、急诊手术、禁食天数、是否应用生长抑素等因素，进行多因素Logistic回归分析。结果246例SAP病人31例发生ARF，ARF的发病率为12．6％。ARF组APACHEⅡ评分明显高于无ARF组，两组比较有显著性差异。腹腔室隔综合征、低氧血症和急诊手术在两组之间比较有显著性差异。结论在SAP发病过程中，APACHEⅡ评分增高、低氧血症和腹腔室隔综合征可能是导致ARF发生的危险因素。维持病人全身状态稳定、防止肾脏低灌注损害、预防低氧血症的发生以及手术引流腹腔减压可能有预防ARF发生的作用。     

提高对重症急性胰腺炎多脏器功能障碍的认识及防治水平

重症急性胰腺炎（SAP）是一种特殊类型的外科急腹症。因其病情凶险，进展迅速，临床表现出明显的个体差异，病情转归复杂多变，而倍受外科临床和学术界关注。近20年来，随着对SAP发病机制研究的深入和临床救治技术水平的提高，其疗效亦有了明显改善，但总体病死率仍在10％以上。SAP病人死亡主要有两个高峰：其一是SAP发病的早期，即全身炎症反应综合征期（SIRS期），致死的主要原因是速发性多器官功能障碍（MODS），如急性呼吸窘迫综合征（ARDS）、急性肾功能衰竭（ARF）等，占SAP死亡病例的半数以上；其二是全身感染期和残余感染期，     

连续性血液净化在重症急性胰腺炎合并肾损害中的应用

急性出血坏死性胰腺炎又称作重症急性胰腺炎（severeacutepancreatitis,SAP）,约占15％～20％,常合并急性呼吸窘迫综合征、急性肾损伤（acutekidneyinjury,AKI）、感染性休克或多脏器功能障碍综合征（multipleorgandysfunctionsyndrom,MODS）等。SAP病死率约209／6～30％,如合并脓毒血症或MODS,则高达509／6～80％。     

重症急性胰腺炎死亡的高危因素分析

目的探讨与重症急性胰腺炎（SAP）死亡相关的高危因素。方法回顾性分析2001年1月至2005年10月收治的141例SAP患者的临床资料。将患者分为死亡组和生存组,对可能影响SAP预后的15个因素采用Logistic回归分析。结果141例SAP患者中死亡34例（24．1％）。死亡组患者在年龄、体重指数、住院时间、APACHEⅡ评分和并发多器官功能障碍综合征（MODS）、腹腔室隔综合征（ACS）等方面与生存组相比差异有统计学意义（P〈0．05）。多因素分析显示,MODS（OR=67．358,P〈0．01）、APACHEII评分（OR=9．716,P〈0．01）和ACS（OR=5．775,P〈0．05）是早期影响SAP预后的独立危险因素;胰腺感染（OR=9．652,P〈0．01）、MODS（OR=5．212,P〈0．05）和腹腔出血（OR=4．707,P〈0．05）则是后期影响SAP预后的独立危险因素。结论SAP早期死亡的主要原因是MODS,特别是呼吸功能障碍和肾功能障碍,而后期死亡的主要原因是感染、MODS和腹腔出血。对高危因素进行早期预防和及时处理是降低SAP病死率的关键。     

急性重症胰腺炎Binder综合评分及其预后

目的 了解急性重症胰腺炎(SAP)器官功能或代谢合并症Binder评分与SAP预后的关系。方法 对我院收治的112例SAP回顾调查，根据Binder积分和SAP并发症如休克、ARDS、胰性脑病和全身感染发生率与SAP死亡的关系，估计SAP的预后。结果 SAPll2例，治愈92例(82．1％)，死亡20例，病死率为17．8％，发生各种并发症73例(65．2％)。ARDS、休克、胰性脑病和全身感染，其病死率分别为6．3％、7．1％、5．3％和3．5％。按SAP器官或代谢合并症综合评分大于7分(或等于)组和评分小于7分组，综合评分大于7分组病死率非常显著高于评分小于7分组(P＜0．01)。结论 休克、ARDS、胰性脑病和全身感染是SAP主要并发症和死亡原因。Binder积分高低与其有关，积分越高，SAP预后越差，Binder评分高低不仅可以判定SAP病情轻重，而且估计SAP的预后。     

急性肾衰竭伴多脏器功能障碍综合征临床特征分析

目的：了解急性肾衰竭（ARF）伴多脏器功能障碍综合征（MODS）发病情况及临床特征。方法：对2003年1月~2007年12月间住院的ARF患者进行回顾性分析。结果：伴MODS的ARF多见于老年,发病率占总ARF的62.3%,病死率45.5%;随着功能障碍脏器数量的增多,ARF病死率明显升高。引起伴MODS的ARF的原因中以感染性疾病、休克、严重创伤、外科大手术后（以胆道疾病、恶性肿瘤手术）多见。结论：MODS是影响疾病预后的重要因素,伴MODS的ARF多见于老年且发生比例高,病死率亦高,对于伴MODS的ARF患者应进行早期预防性及充分透析治疗,以改善ARF的预后。     

重症急性胰腺炎自然病程的临床研究

目的研究重症急性胰腺炎(SAP)的自然病程演进中的临床特征、脏器功能障碍特点以及死亡相关因素规律。方法回顾性分析1999年1月至2007年6月期间笔者所在医院收治的302例SAP患者的临床资料,按照入院时以及入院后1、3、5、7、14及28 d共7个时间点分别记录其APACHEⅡ评分、各脏器功能状态和死亡相关因素并予以分析。结果 SAP自然病程中APACHEⅡ评分呈双峰型分布,即在发病后3~7 d左右和发病后2周左右出现评分高峰;全身炎性反应综合征(SIRS)、低氧血症、代谢性酸中毒、高血糖和腹腔室间隔综合征(ACS)是导致早期脏器衰竭的主要原因;肠麻痹持续时间大于5 d的患者脏器衰竭发生率及感染率明显升高。脏器衰竭最多受累的器官为呼吸、外周循环、肾和胃肠道。当患者出现持续48 h以上的脏器衰竭,其病死率明显升高。入院后24 h死亡4例(9.5%),死亡原因为严重休克和心脏骤停;24~72 h死亡6例(14.3%),为持续性休克伴急性呼吸窘迫综合征(ARDS)或急性肾功能衰竭;3~10 d死亡14例(33.3%),主要为ARDS、急性肾功能衰竭伴多器官功能不全综合征(MODS);10 d以后死亡18例(42.8%),主要为腹内感染、出血、胰瘘、胆瘘等导致的MODS。结论 SAP自然病程分为全身炎症反应期、全身感染期和恢复期。肠麻痹持续时间是影响SAP自然病程的重要因素。早期脏器衰竭患者最先出现的并发症为SIRS、代谢性酸中毒、高血糖和ACS。SIRS所致的MODS是SAP早期的死亡因素;胰腺及胰周组织感染所致的MODS、腹腔内出血和胰瘘和胆瘘是SAP后期的死亡因素。胃肠道功早期恢复能减少MODS的发生。     

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 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.     

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.     

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.     

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.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.