双肺移植术后呼吸道并发症的防治一例

目的探讨双肺移植术后呼吸道并发症的防治。方法为1例终末期肺淋巴管平滑肌瘤病合并双肺感染的患者施行体外循环下序贯式双侧单肺移植手术。结果术后患者发生肺部细菌和真菌混合感染,纤维支气管镜检查发现右侧支气管吻合口愈合不良,术后第14d发生急性排斥反应,第29d因气管内大出血而死亡。结论肺移植术后的呼吸道并发症较为严重,应通过控制肺部感染、预防急性排斥反应及提高手术技巧等综合防治。     

23例次肺移植术后受者的临床分析

目的 评估23例次肺移植术后受者的临床预后情况.方法 总结2003年1月至2007年8月施行的23例次(21例患者)肺移植的临床资料.分析存活率及并发症.结果 肺移植围手术期死亡率为13%;术后3个月、1年、2年和3年的累积存活率分别为82.6%、82.6%、69.7%和58.1%.受者术后2个月时的通气和换气功能较术前明显改善(P<0.05).有10例受者术后6个月内出现轻度急性排斥反应,经激素冲击治疗后均缓解.4例受者分别于术后8个月、9个月、14个月和24个月时出现慢性排斥反应;术后6、12和24个月时未发牛慢性排斥反应的受者分别为95%、78.2%和71.1%.术后肺部感染发生率为33.3%;气管吻合口软化和狭窄发生率为14.3%.结论 肺移植术后受者的中期存活率较高;肺部感染和支气管吻合口软化及狭窄是肺移植术后主要并发症.     

心肝联合移植一例报告

目的 总结原位心肝联合移植1例的诊治体会.方法 2011年11月24日施行了1例原位心肝联合移植,患者原发病为先天性三尖瓣下移畸形、三尖瓣置换术后5年,合并淤血性肝硬化,术前心功能Ⅳ级,肝功能Child Pugh评分为B级.手术采用分次体外循环辅助的方式,先建立腔静脉主动脉转流完成心脏移植,然后建立股静脉-升主动脉转流完成肝移植,最后停机中和.术中主动脉阻断时间为54min,无肝期为38 min,3次体外循环转流时间共计199m in,手术耗时共计517 min.给予巴利昔单抗联合甲泼尼龙免疫诱导治疗,并采用他克莫司+吗替麦考酚酯+泼尼松的方案抗排斥反应,术后加强护肝治疗、抗感染治疗和营养支持治疗.结果 术后第78天受者因多器官功能衰竭而死亡.受者接受呼吸机辅助治疗的时间为78 d,因术后出现低氧血症而接受体外膜肺氧合辅助治疗的时间为63 d.结论 心肝联合移植术是治疗心肝功能衰竭的有效手段,手术前后的管理具有较高要求.     

体外循环下单肺移植一例的体会与教训

目的 总结体外循环下单肺移植的经验和教训。方法 在体外循环下给１例终末期双肺纤维化患者施行左侧单肺移植术,供肺采用Ｅｕｒｏ－Ｃｏｌｌｉｎｓ液灌洗,管道吻合时间为５５ｍｉｎ。术后联合应用环孢素Ａ、激素及硫唑嘌呤进行免疫抑制治疗。结果 移植肺术后即刻发挥功能,术后第１、２ｄ因出血致心脏压塞,２次剖胸止血,第３、７ｄ发生急性排斥反应,第９ｄ死于急性排斥反应。结论 肺移植术后应注重出血及急性排斥反应的监测     

肺移植急性排斥反应的诊治(附三例报告)

目的观察和探讨肺移植急性排斥反应的临床表现、诊断方法、经支气管活检排斥反应的病理分类和治疗。方法2002年9月至2003年6月，分别为3例肺气肿、肺功能重度减损的患者进行了单肺移植。其中后2例为同一供者的左、右肺，第2例受者HLA无1个位点匹配。结果第1例左肺移植术后第9d发生1次急性排斥(A2b级)，经大剂量甲泼尼龙冲击治疗后症状消退；第2例右肺移植第7d持续发生急性排斥(A4c级)，经甲泼尼龙冲击并用OKT3治疗无效，术后第15d死亡；第3例左肺移植第9d、第15d发生2次急性排斥(A3a级)，经甲泼尼龙冲击并用OKT3治疗8d后缓解。结论选择组织相容性好的供、受者进行肺移植，是成功的保证。肺组织活检成为诊断急性排斥的金标准，对肺移植急性排斥反应的及时诊治是减少术后死亡率的关键。     

心肺联合移植11例单中心经验

目的总结心肺联合移植经验。 方法回顾性分析2015年9月至2018年11月广州医科大学附属第一医院完成的11例心肺联合移植受者临床资料。男性7例,女性4例,平均年龄(32±11)岁。原发病为艾森曼格综合征3例,特发性肺动脉高压4例,复杂先天性心脏合并肺血管病变、肺动脉栓塞、双肺移植术后心肺功能衰竭及扩张型心肌病合并慢性阻塞性肺疾病各1例。供者选择参照肺移植及心脏移植标准。11例受者均采用胸骨正中切口,经主动脉和上、下腔静脉远端插管建立体外循环,切除受者心肺后,植入供肺和供心,依次吻合气管、主动脉、上腔静脉及下腔静脉。 结果11例受者中,4例术后30 d内死亡,其中2例死于胸腔及纵隔出血,2例死于脑血管并发症;术后30 d至1年死亡3例,死因为排斥反应引起的移植物功能障碍及感染、移植物功能障碍导致的多器官功能衰竭。术后1年有4例受者存活。 结论严格选择供、受者以及术中后纵隔彻底止血可显著降低心肺联合移植手术死亡率,提高受者术后生存率及生存时间。     

肺移植围手术期并发症防治单中心经验

目的探讨肺移植围手术期并发症的预防和处理。方法 2002年9月至2011年4月无锡市人民医院共完成临床肺移植105例：单肺移植73例,双肺移植32例。其中63例在体外循环支持下完成手术。术后带管进入ICU行机械通气、免疫抑制、预防感染和原发性移植物失功（PGD）等治疗。根据国际心肺移植学会的PGD分级分别给予受者液体负平衡、延长呼吸机治疗时间、前列腺素E1及体外膜肺氧合等治疗。结果 105例肺移植受者围手术期存活率为81.9%（86/105）,死亡原因包括肺部感染10例,PGD6例,肺梗死、急性排斥反应、支气管吻合口瘘各1例。围手术期主要并发症包括严重肺部感染12例、PGD3级10例、支气管吻合口狭窄10例、支气管吻合口瘘4例、急性排斥反应3例、出血3例、肺动脉栓塞3例、肺动脉狭窄1例和下肢深静脉血栓1例。86例存活受者心肺功能和生存质量均较好。结论防治感染、免疫抑制、液体负平衡、延长呼吸机治疗时间等围手术期管理可减少术后并发症和降低受者病死率。     

心、肺联合移植治疗艾森门格综合征四例

目的 总结心、肺联合移植的经验。方法 为4例艾森门格综合征患者施行同种异体心、肺联合移植，所有患者均合并严重的肺动脉高压，心功能Ⅳ级。受者主动脉、上腔静脉及下腔静脉远端插管，建立体外循环。供心置入心包内，于两侧膈神经前将左、右肺置入胸腔。于供肺隆突上1～2软骨环处切断气管，4-0 prolene线连续缝合气管膜部，4-0 ethibond线“8”字间断缝合软骨部，证实无漏气后，机械通气（〈2．94kPa，或〈30cmH2O）。再依次吻合主动脉、上腔静脉及下腔静脉，开放阻断钳，恢复心脏血液供应，心脏自动复跳。分别在右心房和右心室缝置双腔起搏导线。术中患者主动脉阻断时间平均为174．5min。结果 4例手术均顺利完成，无患者死亡。术后患者无严重出血和感染发生，气管插管拔出时间平均为17．75h。术后3例发生排斥反应，其中2例为轻度排斥反应，经甲泼尼龙治疗逆转；1例术后第20d发生严重血管性排斥反应，经甲泼尼龙、抗CD3单克隆抗体及抗胸腺细胞球蛋白治疗无效，于术后35d死亡。出院的3例患者目前存活3～24个月。结论 周密的术前准备是手术成功的保证；供心、肺的保存质量，以及术后排斥反应和感染是影响临床效果的重要因素。     

肺移植术后排斥反应的影像学检查方法现状及展望

肺移植是治疗终末期肺病的唯一有效手段,其术后发生的排斥反应是影响受者预后的主要因素.影像学检查可作为无创手段,辅助其他检查监测肺移植术后排斥反应.目前已报道的影像学方式较多,明确各种影像学检查的优势与不足,有助于排斥反应的早期诊断,使得肺移植受者可以得到及时治疗,进而提高其生活质量及预后.本文对肺移植术后排斥反应各种影...     

肝或肾移植术后受者再次行一期肝肾联合移植三例报告

目的 探讨肝或肾移植术后受者再次行一期肝肾联合移植的手术适应证、术后并发症及存活情况.方法 对2003年10月至2008年12月施行的3例肝或肾移植术后再次行一期肝肾联合移植的受者进行随访,并进行文献复习.对其围手术期死亡率、术后并发症及存活情况进行总结.结果 围手术期死亡率为33.3%(1/3).术后并发症:1例因腹腔出血术后第29天死于肺部感染、急性移植肾功能衰竭和多器官功能衰竭;3例患者均发生了肺部感染;无急性排斥反应发生.2例存活患者,从首次移植计算,已经分别存活56个月和228个月;从一期肝肾联合移植计算,已经分别存活40个月和48个月.结论 肝肾联合移植是治疗终末期肝肾疾病的有效方法.肝或肾移植术后受者再次行一期肝肾联合移植是可行的.     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

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.