并用人工肾与膜式人工肺治疗呼吸性酸中毒合并代谢性碱中毒的实验研究

寻求迅速改善呼吸性酸中毒合并代谢性碱中毒患者机体的自稳态，使pH值很快得以纠正的治疗方法。应用中空纤维人工肾，选择低HCO_3~-透析液，利用透析液与血液间HCO_3~-浓度梯度的不同，将血液中过多的HCO_3~-透析出去；同时将透析器与微孔聚丙烯膜式人工肺合并应用，排出过多的CO_2增加动脉血的氧分压（PO_2）。结果：经转流30，60，90和120分钟与转流前比较，HCO_3~-、二氧化碳分压（PCO_2）、PO_2均有明显差异（P＜0．05或＜0．01）。提示：并用人工肾与膜式人工肺是治疗呼吸性酸中毒合并代谢性碱中毒的一个新的治疗方法。     

维持性血液透析患者代谢性酸中毒对钙磷代谢的影响

分析比较维持性血液透析(MHD)患者的代谢性酸中毒对钙磷代谢的影响.方法:选择MHD患者120例,测定透析前碳酸氢根(HCO3-)、血尿素氮(BUN)、肌酐(CR)、钙(Ca)、磷(P)、碱性磷酸酶(ALP)、甲状旁腺激素(iPTH)及透析后BUN和CR,计算钙磷乘积(Ca×P)、Kt/V.根据HCO3-分为3组:A组(HCO3-＜ 20 mmol/L)、B组(HCO3-为20～24 mmol/L)和C组(HCO3-≥24 mmol/L),比较3组酸中毒对钙磷紊乱的影响.结果:B、C组的P、ALP及iPTH均低于A组(P＜0.05),C组的P、Ca×P低于A、B组(P＜0.05).HCO3-浓度与P、iPTH、ALP及Ca×P呈负相关(P＜0.05).结论:对于MHD患者,HCO3-＜ 20 mmol/L较HCO3-≥20 mmol/L者易合并高磷血症、低钙血症,可刺激iPTH的合成,最终导致肾性骨病及转移性钙化.     

慢性肾功能衰竭患者复合酸碱失衡的判断

健康机体由于细胞内、外缓冲体系,肺(呼出C0_2)及肾(回吸收HCO_3和排泌H~+)的调节使人体血液pH值维持在7.35～7.45,HCO_3~-22～27mmol/L,PC0_2 4.7～6.0kPa(34～45mmHg)的狭小范围内,以保持人体正常的生命活动。如肾功能衰竭、酸性物质产生过多或碱性物质丢失,使血pH<7.35,HCO_3~-<22mmol/L,谓之代谢性酸中毒(代酸)。慢性肾功能衰竭患者病程中因心力衰竭、肺水肿、感染及静脉应用利尿剂,使其在代酸的基础上并呼吸性酸中毒、呼吸性碱中毒及代谢性碱中毒,谓复合酸碱失衡,加重病情和治疗难度,增加病死率,临床并不少见(尤其是晚期未进行血液净化治疗和肾移植的患者),但未引起足够重视。 1 阴离子间隙的意义 阴离子间隙(Anion Gap,AG)是指血浆中可测定的阳离子(Na~+)与可测定阴离子(HCO_3~-、Cl~-)的相差数,     

基于碱缺失情况的创伤性失血性休克早期复苏策略

目的依据碱缺失(BE)情况探讨创伤性失血性休克早期液体复苏策略。方法选取创伤性失血性休克患者60例,其中急诊术后无代谢性酸中毒6例,48 h内未纠正代谢性酸中毒13例,48 h内纠正代谢性酸中毒41例。将纠正代谢性酸中毒41例依据BE≤-6 mmol/L、BE-6 mmol/L分为重度代谢性酸中毒组29例(A组)、轻度代谢性酸中毒组12例(B组),回顾性分析2组创伤严重程度(ISS)评分、就诊时间、血小板计数、代谢性酸中毒实际纠正时间、输血占比、液体输入速率。结果 A组与B组在补液速率、BE方面比较有显著差异(P 0. 05)。结论对于创伤性失血性休克患者,在损伤出血控制情况下,依据BE值快速选择补液速率可尽早纠正代谢性酸中毒,提高抢救成功率。     

酮症酸中毒动脉血和脑脊液酸碱关系的研究

脑脊液(CSF)酸碱内环境稳定对于保持清醒、控制通气、维持正常心血管功能、调整脑血流均有重要作用.动物实验发现在急性代谢性酸中毒时,虽然血液HCO_3~-明显下降.而CSF HCO_3~-能相对维持在正常范围.目前认为主要是通过两个方面的机制完成的:①CSFPCO_2决定CSF HCO_3,呈正相关;②血-脑屏障对H~+、HCO_3~-的下通透性及其主动转运.糖尿病酮症酸中毒在临床上是典型的有机酸浓度增加引起的原发性代谢性酸中毒,完全不同于动物实验.本研究的目的旨在通过酮症酸中毒患者动脉血和CSF酸碱变量的分析探讨酮体在CSF酸碱紊乱中的作用及CSF的代偿机制.     

腹膜透析与血液透析对尿毒症皮肤瘙痒疗效的比较

目的:探讨尿毒症患者皮肤瘙痒的发病原因。方法:将40例患者分为血透组(22例)及腹透组(18例)。血透组每周3次血液透析,每次4h。腹透组行连续性非卧床腹膜透析治疗,每天4次,每次2L。8周后检测尿素氮(BUN)、血肌酐(SCr)、磷(P3-)、甲状旁腺素(PTH)、β2微球蛋白(β2-MG)。结果:腹透组皮肤瘙痒症状明显好转,腹透组P3-较血透组明显下降(P<0.05),血透组BUN、SCr较腹透组下降明显(P<0.05),腹透组β2-MG和PTH较血透组下降明显(P<0.05)。结论:尿毒症患者的皮肤瘙痒原因是多因素的,主要的致敏因子存在于大中分子物质中,P3-与皮肤水分的保持也有一定关系。     

护理干预对20～50岁血脂异常伴全血低钙患者的影响

目的探讨护理干预对20-50岁血脂异常伴全血低钙患者的影响。方法将325例20—50岁的血脂异常伴全血低钙患者随机分为干预组（162例）和对照组（163例）。两组患者均行常规保健建议,干预组在此基础上实施护理干预。在护理干预6个月后,比较两组的血清血脂、全血钙的含量。结果干预前两组患者TC、TG、LDL—c、全血钙值比较差异均无统计学意义（P〉0．05）;干预后干预组Tc（5．05＋-0．93）mmol／L,TG（1．73±1．01）mmol／L,LDL—C（3．08±0．87）mmol／L,均低于对照组（5．55±0．97）,（2．11±1．35）,（3．68±0．69）mmol／L,干预组全血钙值（1．53±0．11）mmol／L高于对照组（1．46±0．13）mmol／L,差异均具有统计学意义（t=4．75,2．87,6．34,5．14;P〈0．05）;干预后干预组生化指标控制率TC46．05％,TG47．30％,LDL-C63．04％,全血钙54．94％均高于对照组6．32％,8．96％,21．64％,19．63％,差异均具有统计学意义（x2=34．46,25．07,47．64,43．34;P〈0．05）。结论护理干预能有效地降低血脂、改善钙的代谢,具有实用性、持续性和可补性。     

纠正酸中毒对维持血透患者营养状况的影响

目的探讨口服碳酸氢钠纠正酸中毒对维持血透患者营养状况的影响。方法入选30例透析前HCO-3≤21 mmol/L的维持血液透析患者,随机分为观察组和对照组,观察组给予碳酸氢钠口服。3个月后比较两组间以及观察组干预前后营养指标。结果 1组间比较:观察组实际碳酸氢根(AB)、血尿素氮(BUN)、血磷较对照组升高(P0.05);2观察组自身前后比较:干预后AB(P0.05)、肱三头肌皮褶厚度、网织红细胞比例、总胆固醇较干预前升高,高密度脂蛋白(HDL-C)较干预前降低(P0.05)。结论口服碳酸氢钠治疗可以有效纠正维持性血液透析患者酸中毒并部分改善营养状况及贫血,但同时可能导致这部分人群血脂异常、血磷升高。     

不同渗透压液体洗胃对兔胃黏膜的影响

目的探讨不同渗透压液体洗胃对兔胃黏膜和血浆渗透压的影响。方法将32只日本长耳大白兔随机分为正常对照组（ NC组）、清水组（ CW组）、0．45％氯化钠溶液组（ HS组）、0．9％氯化钠溶液组（NS组）,每组8只。根据重力洗胃法原理进行洗胃。洗胃参数：洗胃液温度37～38℃,进出压力10～15 kPa,进液量25 mL/kg,周期30 s,持续时间40～50 min。 CW组、HS组、NS组分别用清水、0．45％氯化钠溶液和0．9％氯化钠溶液进行洗胃;NC组仅置胃管不洗胃。在置胃管前及洗胃后,采动脉血;然后用气栓法处死兔,取出胃,在肉眼和光镜下评价胃黏膜损伤程度。结果洗胃前各组兔血浆电解质、渗透压比较差异无统计学意义。洗胃后CW组和HS组血钠浓度[（128．63±7．13） mmol/L 和（131．88±4．55） mmol/L]显著下降,与 NC 组（136．38±3．58）mmol/L和NS组（140．13±0．83）mmol/L比较,差异有统计学意义（P＜0．05）;CW组、HS组和NS组血钾浓度[（2．13±0．35）mmol/L、（2．19±0．36）mmol/L和（2．11±0．24） mmol/L]显著下降,低于NC组（2．73±0．41） mmol/L,差异有统计学意义（ P＜0．05）;CW组、HS组和NS组血钙浓度[（1．23±0．12）mmol/L、（1．34±0．13）mmol/L和（1．38±0．10）mmol/L]显著下降, CW 组显著低于 NS 组（ P ＜0．05）。 CW 组和 HS 组洗胃前后血浆渗透压显著下降[（295．59±11．75）mmol/L vs （269．32±13．94）mmol/L和（290．99±5．52）mmol/L vs （278．96±8．66）mmol/L）],也显著低于洗胃后NC组（290．74±6．11） mmol/L和NS组（292．56±2．59） mmol/L,差异有统计学意义（ P＜0．05）。 NS组、HS组和CW组胃黏膜损伤指数（28．88±14．63、42．63±21.03和48．25±17．27）较NC组（0．38±0．74）显著升高,CW组显著高于NS组（均P＜0．05）;NS组、HS组和CW组胃黏膜上皮损伤评分（2．88±2.03、3．50±2．14和5．50±2．20）较NC组（0.25±0．46）显著升高,CW组高于NS组（均P＜0.05）。结论用清水和0．45％氯化钠溶液洗胃可造成兔胃黏膜损伤,引起血钠、血钾、血钙和血浆渗透压下降;0．9％氯化钠溶液洗胃造成的胃黏膜损伤较轻,对血钠和血浆渗透压无显著影响,并可减缓血钙浓度的下降程度。不同渗透压液体洗胃导致兔不同程度的水电解质紊乱与胃黏膜损伤程度不同有关。     

乌司他丁对脓毒症大鼠肺损伤的保护作用

目的探讨乌司他丁(UTI)对脓毒症性急性肺损伤(ALI)的保护作用。方法采用盲肠结扎穿孔(CLP)制作SD大鼠脓毒症ALI模型,随机分ALI组、糖皮质激素(GC)治疗(GC)和UTI治疗(UTI)组。成模后3 h、6 h、12 h开腹抽血行动脉血气分析,提取支气管肺泡灌洗液(BALF)检测总蛋白(TP)、总磷脂(TPL)、饱和磷脂酰胆碱(DSPC)含量,测定肺组织湿/干重(W/D)比值和肺组织匀浆中髓过氧化物酶(MPO)、丙二醛(MDA)含量,血浆中肿瘤坏死因子(TNF-α)、白介素-6(IL-6)含量,观察与比较各组肺组织病理改变。结果UTI组PaCO_2、PaO_2、HCO_3~-、BE与GC组差异无统计学意义(P＞0．05),但高于ALI组(P＜0．05);两组W/D均明显低于ALI组(P＜0．01),BALF中TP显著低于ALI组(P＜0．01),TPL和DSPC/TPL高于ALI组(P＜0．05、P＜0．01),但两组间差异无统计学意义(P＞0．05);两组肺组织匀浆中MPO、MDA含量均明显低于ALI组(P＜0．01),UTI组MPO含量还明显高于GC组(P＜0．05);两组血浆TNF-α、IL-6水平均低于ALI组(P＜0．01),UTI组IL-6高于GC组(P＜0．05);两组病理变化均较ALI组轻(P＜0．01)。结论UTI能改善缺氧、过度通气和酸中毒,减轻肺水肿和肺组织病理损伤,具有抗氧化和抑制炎性细胞因子释放作用,其抗炎作用与GC相似。     

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.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

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.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.