肺保护性通气在老年患者腹腔镜子宫内膜癌根治术中的应用

目的探讨肺保护性通气在老年患者腹腔镜子宫内膜癌根治术中的应用效果。方法选择2019年6月至2020年6月择期行腹腔镜子宫内膜癌根治术的老年女性患者60例,年龄65～80岁,BMI 20～28 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:肺保护性通气组(P组)和常规机械通气组(R组),每组30例。P组设置V_T 7 ml/kg、呼气末正压通气(PEEP) 7 cmH_2O、每30分钟规律手法肺复张一次;R组仅设置V_T 9 ml/kg,未采用PEEP和肺复张。记录气腹前即刻、气腹后2 h、手术结束即刻的气道峰压(Ppeak)、气道平台压(Pplat)、肺动态顺应性(Cdyn)及血清IL-6、IL-8、TNF-α浓度。记录气腹前即刻和出复苏室即刻的氧合指数(PaO_2/FiO_2)。结果与气腹前即刻比较,气腹后2 h、手术结束即刻两组Pplat、Ppeak及血清IL-6、IL-8、TNF-α浓度均明显升高(P0.05),Cdyn明显降低(P0.05);出复苏室即刻两组PaO_2/FiO_2明显降低(P0.05)。与R组比较,P组气腹后2 h、手术结束即刻Pplat、Ppeak及血清IL-6、IL-8、TNF-α浓度明显降低(P0.05),Cdyn明显升高(P0.05);出复苏室即刻PaO_2/FiO_2明显升高(P0.05)。结论肺保护性通气可以减轻老年患者腹腔镜子宫内膜癌根治术围术期呼吸功能损伤和炎症反应,可安全用于老年患者腹腔镜子宫内膜癌根治术。     

肺超声评分评价肺保护性通气策略对老年开腹手术患者肺损伤的影响

目的通过肺超声评分探讨肺保护性通气策略减轻老年开腹手术患者肺损伤的作用。方法选择2019年8月至2020年6月择期开腹手术患者50例,男33例,女17例,年龄65～80岁,BMI 18～25 kg/m~2,ASAⅠ—Ⅲ级。采用随机数字表法将患者分为两组:对照组(C组)和肺保护性通气组(P组),每组25例。所有患者常规麻醉诱导,采用容量控制的通气模式。C组设置V_T 8 ml/kg,不使用呼气末正压(PEEP);P组设置V_T 6 ml/kg, PEEP 6 cmH_2O,每间隔30 min给予手法肺复张。采用床旁超声评估患者双侧共12个区域的肺部超声,各区域分数累积为肺超声评分(LUS)。记录入室时(T_0)、麻醉诱导气管插管后5 min(T_1)、手术开始后2 h(T_2)、手术结束时(T_3)、气管导管拔除后15 min(T_4)、2 h(T_5)、术后1 d(T_6)的LUS评分、HR、MAP、SpO_2、PaO_2和PaCO_2。记录T_1—T_3时的氧合指数(PaO_2/FiO_2)、气道峰压(Ppeak)、吸气末平台压(Pplat)和驱动压力(ΔP)。记录术后7 d内肺部并发症(PPCs)的发生情况。结果与T_0时比较,T_1—T_5时C组和P组LUS评分明显升高(P0.05)。与T_1时比较,T_2—T_3时C组PaO_2/FiO_2明显降低(P0.05),P组ΔP明显降低(P0.05)。与C组比较,P组T_2—T_5时LUS评分明显降低(P0.05),T_2—T_3时PaO_2/FiO_2明显升高(P0.05)、ΔP明显降低(P0.05)。C组术后7 d内PPCs发生率为20%,P组未发生PPCs(P0.05)。结论床旁肺超声监测下,老年开腹手术患者在全麻期间和术后早期LUS评分升高,肺通气丢失。肺保护性通气策略可降低患者围术期的肺超声评分,减少肺通气损失,降低术后7 d的肺部并发症发生率。     

小潮气量联合低PEEP对老年腹腔镜胆囊切除术患者术中氧合功能及肺功能的影响

目的探讨小潮气量联合低呼气末正压通气(PEEP)对老年腹腔镜胆囊切除术患者术中氧合功能及肺功能的影响。方法择期行腹腔镜胆囊切除术的老年患者共计100例,年龄65～74岁,ASA分级Ⅰ～Ⅱ级,体重指数(BMI)30kg/m~2。采用随机软件将纳入患者随机分为小潮气量联合低PEEP组(T组)和常规容量控制通气组(C组),每组各50例。记录两组患者手术开始即刻(T_0)、气腹后15分钟(T_1)、撤除气腹后15分钟(T_2)、拔除气管导管前(T_3)气道峰压(Ppeak)、平均气道压(Pmean)并计算动态肺顺应性(Cdyn)。于T_0、T_1、T_3时点进行血气分析记录动脉氧分压(PaO_2)、动脉CO_2分压(PaCO_2)并计算氧合指数(OI)。结果 T组患者T_1、T_2时点Ppeak、Pmean显著低于C组患者,但Cdyn显著高于C组患者,差异有统计学意义(P0.05)。两组患者T_0、T_1、T_3时点PaO_2、PaCO_2和OI差异均无统计学意义(P0.05)。结论小潮气量联合低PEEP有助于维持老年腹腔镜胆囊切除术患者术中肺功能及氧合功能。     

不同通气模式在腹腔镜妇科手术肥胖患者中的应用效果评价

目的探讨压力控制通气(Pressure-controlled ventilation,PCV)与容量控制通气(Volume-controlled ventilation,VCV)对腹腔镜妇科手术肥胖患者呼吸功能及血气分析相关指标的影响。方法选取本院2014年1月至2017年6月择期于腹腔镜下行妇科手术的肥胖患者共计80例。ASA分级Ⅰ~Ⅱ级,体重指数(Body Mass Index,BMI)30kg/m2。患者采用计算机随机软件分为PCV与VCV每组各40例。于气管插管后10分钟(T_0)、气腹后10分钟(T_1)、气腹后30分钟(T_2)、撤除气腹后10分钟(T_3)记录患者气道平台压(Pplat)、气道峰压(Ppeak)、平均气道压(Pmean)、动态肺顺应性(Cdyn)。于上述各时点抽取动脉血行血气分析并记录PaO_2、PaCO_2、PH值。观察术后24小时内气胸、皮下气肿、肺水肿发生情况。结果在T_1、T_2时点,PCV组患者Pplat、Ppeak、Pmean显著低于VCV组患者,PCV组患者Cdyn显著高于VCV组,差异有统计学意义(P0.05);PCV组患者PaO_2显著高于VCV组患者,PCV组患者PaCO_2显著低于VCV组,差异有统计学意义(P0.05)。两组患者PH值在各时点差异均无统计学意义(P0.05)。所有患者均未发生气胸、皮下气肿、肺水肿等并发症。结论对行妇科腹腔镜手术的肥胖患者而言,PCV能够在气腹期间维持较低的气道压力及较高的肺顺应性,同时还能维持较高的PaO_2及较低的PaCO_2,与VCV相比具有良好的安全性和有效性。     

根据校正体重测算消瘦患者全麻机械通气潮气量

目的:探讨低体重患者气管插管全身麻醉机械通气时根据校正体重设置潮气量的可行性。方法:择期行四肢手术的低体重患者60例,均为平卧位手术,ASA Ⅰ~Ⅱ级,随机分成3组,每组20例;分别按8 mL/kg实际体重(ABW组)、校正体重(CBW组)和理想体重(IBW组)设置初始潮气量,呼吸频率为12次/min;观察记录气道峰压(Ppeak)、气道平台压(Pplat)和气道阻力(Raw);于机械通气后30 min抽动脉血测血气分析,记录动脉血二氧化碳分压(PaCO_2),并对PaCO_245 mmHg或35 mmHg的患者重新调整潮气量;记录各组需要调整潮气量的例数、动脉血氧分压(PaO_2)并计算氧合指数,同时记录该时刻的动脉平均压和心率。结果:与CBW组相比,ABW组PaCO_2[(49.5±3.9)mmHg vs(40.0±2.5)mmHg]明显升高(P0.01),IBW组PaCO_2[(31.5±3.9)mmHg vs(40.0±2.5)mmHg]明显降低(P0.01);3组患者的PaO_2和OI比较差异无统计学意义(P0.05);与CBW组(0例)相比,IBW组(14例)和ABW组(16例)调整呼吸参数的患者例数明显增加(P0.01);与CBW组相比,IBW组Ppeak[(16.0±1.7)cm H_2O vs(14.7±1.7)cm H_2O]、Pplat[(12.4±1.6)cm H_2O vs(11.4±1.3)cm H_2O]、Raw[(16.9±2.9)cm H_2O·L~(-1)·S~(-1) vs(12.6±2.4)cm H_2O·L~(-1)·S~(-1)]明显升高(P0.01)。结论:对于肺功能正常的低体重患者,当呼吸频率设为12次/min时,按8 mL/kg校正体重设置初始潮气量较为合适。     

压力控制通气模式在合并轻度阻塞性通气功能障碍老年患者腹腔镜胆囊手术中的通气效果

目的评价压力控制通气(PCV)模式用于合并轻度阻塞性通气功能障碍的老年患者行腹腔镜胆囊切除术中的通气效果。方法选择择期拟行腹腔镜胆囊切除术患者40例,男23例,女17例,年龄65~75岁,ASAⅡ或Ⅲ级,合并轻度阻塞性通气功能障碍,BMI 18.5~23.9kg/m~2,采用随机数字表法,均分为两组:容量控制通气(VCV)组(V组)和PCV组(P组)。新鲜气流量均为2L/min,FiO_260%,VT_8~12ml/kg(P组调整吸气压),I∶E 1∶2,RR 12~16次/分。调整通气参数维持PET_CO2 35~45mm Hg。直至手术结束后气管导管拔除期间两组均分别维持以上通气模式及呼吸参数。于气管插管后5min(气腹前)(T_1)、气腹开始后30min(T_2)、气腹结束后10min(T_3)时记录气道峰压(Ppeak)、气道平台压(Pplat)、吸气阻力(Raw)和动态肺顺应性(Cdyn),采集桡动脉和混合静脉血行血气分析,计算氧合指数(PaO_2/FiO_2)、呼吸指数(RI)、死腔通气率(VD/VT_)和肺内分流率(Qs/Qt)。记录拔管时间、复苏室停留时间和拔管后2h内高碳酸血症、低氧血症等不良反应的发生情况。结果与V组比较,T_1~T_3时P组Ppeak、Pplat和Raw明显降低,Cdyn、PaO_2/FiO_2明显升高,RI、VD/VT_、Qs/Qt和拔管后低氧血症发生率明显降低(P0.05)。两组拔管时间、复苏室停留时间及高碳酸血症发生率差异无统计学意义。结论 PCV模式可安全用于合并轻度阻塞性通气功能障碍的老年腹腔镜胆囊切除术患者,其通气效果好,低氧血症发生率降低。     

老年人单肺通气时呼气末二氧化碳监测的可信度

目的 观察老年人单肺通气(OLV)麻醉时P_(ET)CO_2C_2和PaCO_2的相关性,以评定P_(ET)CO_2监测在老年人单肺通气麻醉的可信度.方法 37例老年肺部肿瘤患者,胸腔镜下行胸部肿瘤切除、活检或肿瘤根治术,采用静脉复合全麻,术中行OLV.记录麻醉前及OLV 30、60、90、120、180和240min时BP、HR、SpO_2、P_(ET)CO_2和动脉血气,计算氧合指数(PaO_2/FiO_2)、动脉-呼气末二氧化碳分压差(P_(a-ET)CO_2),及对应时间点P_(ET)CO_2和PaCO_2的相关性.结果 除OLV 180 min时点外,术中各时点PaCO_2与P_(ET)CO_2有较好的相关性.术中5例发生低氧血症.结论 老年人OLV麻醉中P_(ET)CO_2不能完全反映PaCO_2的变化,长时间OLV者需同时行血气分析,以保证老年人的安全.     

校正体重设置肥胖患者全身麻醉机械通气潮气量的可行性

目的 评价校正体重设置肥胖患者全身麻醉机械通气潮气量的可行性.方法 肥胖患者60例,拟全麻下择期手术,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其分成3组(n=20):实际体重潮气量组(A组)、理想体重潮气量组(I组)和校正体重潮气量组(C组).麻醉诱导后气管插管,根据相应体重水平,按8 ml/kg设置机械通气初始潮气量,呼吸频率15次/min.于机械通气开始后10min记录气道峰压(Ppeak)、气道平台压(Pp1at)和气道阻力(Raw),机械通气30 min时采集动脉血行血气分析,并记录PaO2、PaCO2及患者需调整潮气量的发生情况.结果 与A组比较,I组和C组PaCO2升高,Ppeak、Pplat、Raw降低(P＜0.01);与I组比较,C组PaCO2降低,Ppeak、Pplat、Raw升高(P＜0.01或0.05);患者需调整潮气量的发生率,C组为0,而A组(95％)和I组(80％)明显升高(P＜0.01).结论 肺功能正常的肥胖患者全身麻醉机械通气时,根据校正体重8 ml/kg设置潮气量是可行的.     

小潮气量联合低水平呼气末正压通气策略在妇科腹腔镜手术麻醉中的应用

目的观察小潮气量联合低水平呼气末正压通气策略应用于妇科腹腔镜手术的效果。方法随机将40例妇科腹腔镜手术患者均分为常规机械通气组(Ⅰ组)和小潮气量联合低水平PEEP通气组(Ⅱ组)。Ⅰ组新鲜气体流量2 L/min,VT 8 m L/kg,吸呼比1∶2。Ⅱ组新鲜气体流量2 L/min,VT 6 m L/kg,吸呼比为1∶2,PEEP 5 cm H2O。调整通气频率,维持PETCO235~45 mm Hg。于插管后5 min(T1)、气腹30 min(T2)和气腹结束后5 min(T3)时记录气道峰压(Ppeak)、气道平台压(Pplat)、动态肺顺应性(Cdyn)和气道阻力(Raw),并计算肺泡-动脉血氧分压差(A-a DO2)、氧合指数(Pa O2/Fi O2)、呼吸指数(RI)和死腔率(VD/VT)。记录拔管时间、术后48h内呼吸并发症发生情况和住院时间。结果与Ⅰ组比较,Ⅱ组T2时Ppeak和Pplat、T1、2时Raw降低,T2时Cdyn升高,T1~3时Pa O2/Fi O2升高(P0.05),RI、VD/VT和A-a DO2降低(P0.05)。2组各时点动脉血p H值、拔管时间、住院时间无显著差异(P0.05。Ⅱ组术后48 h内呼吸并发症发生率降低(P0.05)。结论小潮气量(6 m L/kg)联合低水平PEEP(5 cm H2O)通气是妇科腹腔镜手术麻醉较适宜的呼吸管理模式。     

不同通气模式对老年患者腹腔镜结直肠手术呼吸参数的影响

目的观察小潮气量容量控制通气(VCV)联合呼气末正压通气(PEEP)和压力控制通气(PCV)联合PEEP对老年患者呼吸参数的影响。方法选择行腹腔镜直肠、乙状结肠手术患者51例,男25例,女26例,年龄65~80岁,BMI 18~30kg/m2,ASAⅠ或Ⅱ级,随机分为两组:VP组(VCV+PEEP)和PP组(PCV+PEEP),每组25例。气腹期间VP组以VT6 ml/kg+5cmH2O PEEP模式通气,PP组将VT设为6 ml/kg通气3 min后切换为PCV并加用5cmH2O PEEP进行通气。记录气管插管VCV通气5min(T1)、建立人工气腹5 min(T2)、建立人工气腹35min(T3)、建立人工气腹65min(T4)、手术结束(T5)、拔管前(T6)时VT、动态肺顺应性(Cdyn)、RR、气道峰压(Ppeak)、气道平台压(Pplat)和PETCO2。记录T1、T3、T4和离开PACU(T7)时PaO2、PaCO2,并计算肺泡-动脉血氧分压差(PA-aDO2)、氧合指数(OI)、呼吸指数(RI);记录术后5d内肺部并发症(PPCs)情况。结果与VP组比较,T2-T4时PP组VT明显升高、Cdyn明显增大(P0.05),T3-T5时PP组RR明显减慢(P0.05),T2-T5时PP组Ppeak和Pplat明显降低(P0.05),T4时PP组PETCO2和PA-aDO2明显降低、PaO2明显升高、RI明显减小、OI明显增大(P0.05)。术后随访两组患者PPCs差异无统计学意义。结论PCV联合PEEP通气模式明显降低Ppeak和Pplat、增高VT和增大Cdyn,同时明显改善气腹65min时肺氧合功能,所以老年患者腹腔镜结直肠手术术中应优先考虑使用。     

2015年乳腺癌辅助化疗进展

【摘要】〓乳腺癌是危害我国女性健康的头号杀手,尽管近年来辅助化疗的研究进展突飞猛进,但临床中仍有不少问题未能明确,如辅助化疗的合适人群、化疗的开始时间、蒽环及紫杉类的地位和用法、强化维持治疗的作用、疗效及预后的生物标志物等。本文结合乳腺癌辅助化疗在临床上的常见问题和2015年各大乳腺癌会议阐述乳腺癌辅助化疗的最新进展。     

Alterations in T-Cell Subset Frequency in Peripheral Blood in Obesity

Background: Obesity affects the regulation of immune and inflammatory responses. This study characterizes differences in peripheral blood lymphocyte phenotype in obese humans. Methods: Frequencies of lymphocyte subsets among peripheral blood mononuclear cells were compared between 10 obese (BMI ≥35) and 10 lean subjects, as determined by antibodies directed against cluster differentiation (CD) markers. Results: Obese patients demonstrated an increased frequency of CD3+CD4+ T-cells (mean difference 12%, P=0.004), a decreased frequency of CD3+CD8+ T-cells (mean difference 9.4%, P=0.016) and an increased frequency of CD3+CD8+CD95+ T-cells (mean difference 13.3%, P=0.032). No other differences among T-cell or monocyte subsets were noted. Conclusions: Obesity is associated with alterations in frequencies of peripheral CD4+ and CD8+ T-cells and aberrations in the expression of CD95 among CD8+ T-cells. These data suggest both CD4+ and CD8+ T-cell compartments, as well as the regulation of CD95 expression on CD8+ T-cells, as targets for further study into obesity's effects on the immune system.     

西宁地区烧伤病人动脉血气分析观察

对高海拔地区的27例烧伤病人动脉血气变化进行了分析和观察。结果证明:无论是存活病人还是死亡病人伤后均存在有低氧血症问题。并且在死亡病人和烧伤合并吸入性损伤病人其低氧血症的发生早于单纯烧伤病人。提示:吸入性损伤病人应立即行气管切开术以保障氧气供给,单纯烧伤病人可常规吸氧以维持正常血 PaO_2,ARDS 均发生在合并吸入性损伤的病人,高频喷射通气技术对纠正低氧血症有一定效果。     

Controversies in Fistula in Ano

Managing a complex fistula in ano can be a daunting task for most surgeons; largely due to the two major dreaded complications—recurrence & fecal incontinence. It is important to understand the anatomy of the anal sphincters & the aetiopathological process of the disease to provide better patient care. There are quite a few controversies associated with fistula in ano & its management, which compound the difficulty in treating fistula in ano. This article attempts to clear some of those major controversies.     

β-半乳糖苷酶在体内外成骨细胞中的表达

目的 研究β—半乳糖苷酶(β—gal)在成骨细胞中的表达状况，为阐明MorquioB综合征的发病机制提供依据。方法 裸鼠各器官和骨组织标本行X-gal染色检测。抽取羊和人骨髓行骨髓基质细胞(BMSCs)培养，分为4组：I：Adv-hBMP-2转染组；Ⅱ：Adv—β—gal转染组；Ⅲ：未转染组；Ⅳ：地塞米松诱导组。分别行X-gal染色和RT-PCR检测β—gal的表达。结果 裸鼠骺板两侧、骨膜内面及松质骨的成骨细胞和破骨细胞可见多量β—gal的表达。未转染BMSCs组有少量β—gal的表达，其他3组细胞的β—gal表达增高。结论成骨细胞和破骨细胞可表达多量β—gal，该两种细胞的β—gal缺乏可能是MorquioB综合征骨骼异常的直接原因。     

Smoking-Attributable mortality in Spain in 2016

IntroductionSmoking-attributable mortality (SAM) is a valuable indicator that can be used to characterize the course and health burden of the smoking epidemic. The aim of this paper was to estimate SAM in Spain in 2016 in the population aged 35 and over, using the best available evidence.MethodsA smoking prevalence-dependent analysis based on the estimation of population-attributable fractions was performed. Smoking prevalence (never, former, and current smokers) was calculated from a combination of the Spanish Health Survey (2016) and the European Health Survey (2014); the relative risk of death among current and former smokers was taken from the follow-up of various cohorts; and mortality rates were obtained from National Center for Statistics data. SAM estimates are presented globally, and by sex, age groups, and major disease categories: cancer, cardiometabolic diseases and respiratory diseases.ResultsIn 2016, 56,124 deaths were attributed to tobacco consumption, 84% in men (47,000), and 50% in the population aged over 74 (27,795). Overall, 50% of SAM was due to cancer (28,281), 65% of which was lung cancer. One in 4 attributable deaths (13,849) occurred before the age of 65.ConclusionsOne in 7 deaths in Spain in 2016 were attributable to smoking. This estimation of SAM clearly highlights the great impact of smoking on mortality in Spain, mainly due to lung cancer and chronic obstructive pulmonary disease.     

MicroRNAs in hepatic pathophysiology in diabetes

MicroRNAs(miRNAs or miRs) are small approximately 22 nucleotide RNA species that are believed to regulate diverse metabolic and physiological processes.In the recent past,several reports have surfaced that demonstrate the role of miRNAs in various biological processes and numerous disease states.For a disease as complex as diabetes,the emergence of miRNAs as key regulators leading to the disease phenotype has added a novel dimension to the area of diabetes research.On the other hand,the liver,a metabolic hub,contributes in a major way towards maintaining normal glucose levels in the body as it can both stimulate and inhibit hepatic glucose output.This equilibrium is frequently disturbed in diabetes and hence,the liver assumes special significance considering the correlation between altered hepatic physiology and diabetes.While the understanding of the mechanisms behind this altered hepatic behavior is not yet completely understood,recent reports on the status and role of miRNAs in the diabetic liver have further added to the complexities of the knowledge of hepatic pathophysiology in diabetes.Here,we bring together the various miRNAs that play a role in the altered hepatic behavior during diabetes.     

Fluid-phase transcytosis in the primate epididymis in vitro and in vivo

Ligated tubules from the corpus epididymidis of men and monkeys were incubated in medium containing horseradish peroxidase (HRP) as a marker for fluid-phase endocytosis. HRP was localized by light and electron microscopy after 0, 15, 30 and 60 min of incubation. Movement between the cells was prevented by tight junctions, but bypass of this barrier was apparently achieved by an intracellular vesicular mechanism leading to a time-dependent appearance of HRP in the lumen. Uptake of HRP into basal cells and capture by the lysosomal apparatus of principal cells were also observed. HRP-filled vesicles also appeared in the basal, mid and apical cytoplasm of epithelial cells in the caput 1 h after injection of the tracer into the epididymal circulation of the monkey, suggesting that this pathway also operates in vivo.