儿童手术应激后外周血淋巴细胞凋亡及线粒体膜电位变化的研究

目的探讨手术应激后儿童外周血淋巴细胞的凋亡及线粒体膜电位变化。方法选择择期手术患儿16例,分别于术前24h、术后24h、术后72h采集外周静脉血,用梯度离心法分离出淋巴细胞,置于RPMI-1640培养基中,培养15h。加入藻红蛋白标记的抗CD4+、CD8+作标记,分等量二份分别加入20μg/ml的7-AAD、40nmol/L的DioC6(3)。然后通过流式细胞仪检测细胞凋亡和线粒体膜电位。结果术后24hCD4+、CD8+淋巴细胞凋亡率明显增加(术前分别为1.97±0.45、2.47±0.27,术后为3.50±0.42、4.26±0.53,P<0.05)。术后72h又恢复至术前水平(1.67±0.22、2.70±0.38,P>0.05)。同时伴随荧光指数明显增加(术前分别为503.31±59.43、381.67±61.15,术后700.41±59.12、645.86±69.58,P<0.05),术后72h恢复至术前水平(521.62±68.05,431.07±79.26,P>0.05)。结论手术创伤使外周血淋巴细胞凋亡增加,同时线粒体膜电位下降,导致机体免疫功能发生改变。     

新生儿和婴幼儿手术应激后外周血单核细胞Toll样受体水平变化及临床意义

目的 探讨新生儿、婴幼儿手术应激后外周血单核细胞Toll样受体(TLR)2、4表达变化规律及临床意义.方法 选择择期手术患儿32例,包括新生儿组9例,婴幼儿组23例,分别于术前、术后、术后1天、3天、7天采集外周血2ml肝素抗凝.采用流式细胞术检测单核细胞表面TLR2、4的水平;分离外周血单核细胞,用LPS刺激后,EUSA法测定上清液中TNF-α和IL-6的水平.结果 新生儿组和婴幼儿组术后TLR2和TLR4表达均明显降低,与术前比较差异有统计学意义(P<0.05),术后1天均恢复正常(P>0.05).LPS刺激的TNF-α水平术后明显抑制,术后1天逐渐上升;IL-6水平无明显变化.结论 手术创伤早期可致TLR2和TLR4表达下调,导致机体对病原微生物的敏感性下降.     

手术应激对婴幼儿Th1/Th2细胞平衡的影响

目的 大手术后机体防御功能的改变在术后并发症和感染的发展中起着重要的作用,了解手术应激时Th1／ Th2平衡的变化,为进一步的免疫凋控提供依据 方法 15例行大手术的婴幼儿分别于术前、术后2 h、24 h和96 h果集外 周血标本,应用流式细胞仪测定IL-4和IFN-γ,酶标法(ELISA)测定IL-10和IL-6。结果 与手术前相比,经过PHA刺 激,细胞内的细胞因子IFN-γ在手术后明显下降,手术后第1天为(29.71±2.73)IU／ml,手术后第2天为(46.85±5.98)IU／ml, 与手术前(61.98±4.34)IU／ml相比,差异有显著性(P<0.05);Th2细胞因子IL-4水平在手术后亦下降;血清IL-10水平手术 后明显增加。结论 婴幼儿大手术后Th1细胞因子IFN-γ的产生明显下降,Th1／Th2平衡向Th2偏移     

白细胞介素-6和中性粒细胞凋亡在婴幼儿手术应激中的作用

目的探讨婴幼儿重大手术后血浆中白细胞介素-6(IL-6)水平对外周血中性粒细胞(PMN)凋亡的影响以及两者在手术应激时对机体的影响.方法①选取35例择期手术患儿(1～3岁,平均2.8岁),参照手术应激评分标准[1]分为大手术组和小手术组,检测患儿术前与术后血浆中IL-6水平及外周血中性粒细胞计数;②采用percoll非连续梯度密度沉降法获人外周血PMN,置于不同浓度的人重组白细胞介素-6(rhIL-6)的RPMI1640培养基中培养24h,用流式细胞术(FCM)进行DNA凋亡分析.结果①发现术后血浆中IL-6水平大手术组(121.0±27.3)pg/m1明显高于小手术组(33.5±15.9)pg/ml,且外周血中PMN大幅上升;②在体外实验中,随着IL-6浓度的升高,PMN的凋亡率逐渐下降.结论IL-6通过延迟PMN的凋亡,参与机体手术应激后的"升白”过程,从而影响机体创伤后由PMN介导的高炎症反应所致的组织损伤.     

婴幼儿先天性胸腹裂孔疝的手术治疗

目的探讨婴幼儿先天性胸腹裂孔疝的治疗方法，提高生存率。方法回顾我院1986～2003年收治16h-2岁先天性胸腹裂孔疝53例的手术治疗，其中5例经胸手术，48例经腹手术。结果治愈47例，死亡6例。随访30例2月-10年。X线透视肺膨胀良好，术后早期体重增加，呼吸道感染明显减少。结论提高诊断、急救技术，完善新生儿围手术期措施，可提高婴幼儿先天性胸腹裂孔疝的生存率。     

155例婴幼儿室间隔缺损的手术治疗

目的 探讨婴幼儿期室间隔缺损的手术治疗经验。方法 对155例婴幼儿室间隔缺损手术患者进行回顾性总结。应用膜式肺氧合器、胶体预充，常规建立体外转流，多采用低温体外循环，心肌保护经升主动脉根部灌注，4℃含钾晶体液或4℃4：1氧合血，同时心脏表面置冰屑或冰盐水。大于5mm的VSD采用dacron涤纶补片修补，注意缝针深度。合并肺高压者延长呼吸机辅助时间。结果 术后出现各种并发症15例次，无手术死亡，平均住院日11.6天。结论 5mm以上的膜周部VSD和干下型VSD难以自然闭合，婴幼儿期手术可显著降低器质性肺动脉高压和心功能损害，改善预后，但应加强心肺并发症的防治。     

危重症早产儿血清皮质醇水平的变化

目的 以血清皮质醇水平作为监测指标,观察其变化与临床的相关性,评价危重症早产儿皮质醇水平与短期预后之间的关系.方法 出生72 h内转入湖南省儿童医院新生儿科的早产儿90例(胎龄＜37周),排除遗传代谢性疾病,母孕期及患儿出生时均未用过糖皮质激素.全部患儿分别在入院时(日龄72 h内)、日龄7 d、日龄14 d静脉采血,留取血标本,分离血清,放射免疫法检测血清皮质醇水平.3个时间点皮质醇水平进行比较.结果 血清皮质醇水平在下四分位组(P25之下)时,发病率及病死率无明显增高.血清皮质醇水平在上四分位组(P75之上)时,机械通气、危重患儿比例、病死率、糖代谢紊乱、消化道出血、Ⅲ~Ⅳ级脑室周围-脑室内出血及脑白质软化、慢性肺疾病发病率呈上升趋势.其中在入院时及日龄14 d时,血清皮质醇水平在上四分位组的患儿,机械通气的比例显著增高,差异有统计学意义(P<0.05);日龄7 d时及日龄14 d时,危重症患儿比例显著增高,差异有统计学意义(P<0.05). 结论 在早产儿中,应激发生时机体已具有调节皮质醇分泌的能力.血清皮质醇水平增高与疾病的严重程度、并发症及预后密切相关.     

婴幼儿先天性心脏病手术治疗47例

目的总结婴幼儿先天性心脏病的手术治疗经验。方法回顾性分析2004年12月～2006年12月经手术治疗的婴幼儿先天性心脏病47例。平均年龄15.3±2.6个月(4～28个月),平均体重8.2±1.3kg(5.0～10.0kg)。结果全组治愈46例,死亡1例,为法洛氏四联症(TOF)术后,死亡原因为呼吸窘迫综合征及肺部严重感染。停机拔管后并发肺炎3例,肺不张2例,术后出现低心排血量综合征1例,肺动脉高压危象1例,暂时性Ⅲ度房室传导阻滞1例,重度低氧血症1例,急性肾功能不全1例,治疗后均痊愈出院。结论婴幼儿期先天性心脏病手术治疗可以取得满意的疗效,符合婴幼儿生理特点的围术期处理是成功的关键。     

婴幼儿先天性脊柱侧后凸畸形的手术治疗

目的总结婴幼儿先天性脊柱侧后凸畸形的手术治疗经验。方法回顾性分析1999年10月~2006年12月经手术治疗的20例先天性脊柱侧后凸畸形病例资料。其中男8例,女12例。年龄11个月~3岁8个月。根据Winter及MCmaster分型,前方和单侧形成不全(后外侧1/4椎体)9例,前方形成不全(后方半椎体)7例,凸侧半椎体凹侧骨桥4例。脊柱侧凸Cobb角30°~50°,后凸Cobb角36°~56°。手术方法:4例行单纯脊柱后路短段融合术;6例经脊柱后路凸侧椎弓根行半椎体半骺切除 融合术;2例行侧前路椎体骺板及半锥体切除术;8例行脊柱后路短段融合 钢丝襻及钩棒系统矫形固定术。结果全部病例术后脊柱侧凸及后凸畸形部分矫正或原位融合,无并发症。经1~7年随访,5例脊柱侧后凸减轻;8例脊柱侧后凸无明显变化;2例脊柱畸形加重半椎体复出;3例假关节形成;2例钩棒脱出,无钢丝断裂。结论婴幼儿脊柱柔韧,可塑性强,在畸形尚未加重之前可通过脊柱后路手术矫正并控制脊柱畸形的进展,用钢丝襻固定可及时矫正畸形,稳定脊柱。近期疗效满意,远期疗效有待继续随访。     

Endorphin and cortisol responses to surgical stress in newborns and infants

The beta-endorphin (BE) response to surgical stress in newborns and infants and its relation to pituitary-adrenal dynamics during stress is still unknown. Nine newborns 5 h to 5 days of age, and 5 infants 5 to 10 months old undergoing surgery were studied. All patients were anesthetized with N₂O–O₂ and halothane. Blood samples for BE and cortisol determinations were taken preoperatively and 30 min, 12 h, and 24 h after operation for radioimmunoassay. Both BE and cortisol levels in newborns were not significantly different from those in infants preoperatively (196±85.2 pg/ml vs. 138±47.8 pg/ml for BE and 23.7±17.5 g/dl vs. 10.1±5.6 g/dl for cortisol, P >0.05). At 30 min after operation, no significant increase in BE (220±106 pg/ml) and cortisol (36.1±21.2 g/dl) was found in newborns, while significant increases (BE 493±281 pg/ml, cortisol 43.9±24.2 g/dl) were found in infants compared to preoperative levels (both P <0.05). A significant difference between groups was seen in BE but not cortisol levels 30 min after operation. Both BE and cortisol declined to preoperative values within 24 h after surgery. Our study showed significant BE and cortisol responses to surgical stress in infants, but not in newborns. Factors such as age-related differential responses to the same anesthetic technique, duration of operation, and developmental differences in stress response are considered responsible for the differences.Supported by the Research Grant of Chang Gung Memorial Hospital, CMRP No. 176.     

休克新生儿血浆儿茶酚胺,皮质醇变化及其临床意义

为观察新生儿休克时血浆儿茶酚胺（CA）中去肾上腺素（NE）、肾上腺素（E）和皮质醇（CT）的动态变化，采用高效液相色谱-电化学法检测36例休克新生儿血浆NE、E的浓度，用放射免疫法测定血浆CT。结果，NE、E及CT的浓度明显高于对照组，分别为：NE16．0±3．0，2．9±1．1；E3.7±3.4，0.8±1．2，CT801±4，105±4（单位均为nmol／L，P均＜0．01）。感染性休克组NE高于非感染组（23．9±2．9nmol／L，10．7±2．7nmol／L，P＜0．05）。血浆NE、E浓度随病情加重而增高，提示抢救休克时血管活性药物应以扩血管为主．血浆NE、E值与毛细血管再充盈时间里显著正相关（P＜0·01），与血pH值是非常显著的负相关（P＜0.01），与血压无相关性，提示毛细血管再充盈时间及pH值是判所休克程度的较好指标。血浆CT增高可能系分泌增加和结合减少之故，提示休克时应及早应用糖皮质激素。     

Cortisol response to surgical stress in neonates

To determine the metabolic response of newborns to surgical stress, 36 neonates between 2 h and 3 weeks of age and 11 infants of 1–3 months were included in a 7-year study. Plasma cortisol levels were determined by radioimmunoassay with blood samples taken before, during, and after surgery until they were within normal limits; the response to chemical stress (ACTH) was also studied and compared. The preliminary conclusions on cortisol response were: (1) absence of the circadian cycle in all neonates in the study; (2) a statistical relationship was observed between age and cortisol response; and (3) in newborns less than 9–10 days of age, the response to surgical stress was statistically different from that of newborns older than 10 days, whose response was similar to that of infants. These results suggest that there are two different stages during the neonatal period that correspond to different degrees of neuroendocrinological maturation. Offprint requests to: J. Boix-Ochoa     

Lavender bath oil reduces stress and crying and enhances sleep in very young infants

Very young infants were given a bath with or without lavender-scented bath oil. The mothers in the lavender bath oil group were more relaxed, smiled and touched their infants more during the bath. Their infants looked at them a greater percentage of the bath time and cried less and spent more time in deep sleep after bath. The cortisol levels of this group of mothers and infants significantly decreased, confirming the behavioral data showing increased relaxation of the mothers and their infants. These findings support a body of research showing the relaxing and sleep-inducing properties of lavender aroma.     

Nasopharyngeal suctioning does not produce a salivary cortisol reaction in preterm infants

Aim: To investigate whether nasopharyngeal suctioning produces a physiological and behavioural stress reaction in preterm infants and if a possible reaction can be dampened by sweet solution. Methods: Eleven preterm infants were randomly assigned to receive either 30% oral glucose or nothing prior to morning nasopharyngeal suctioning; the procedure was reversed in the afternoon. The study included a total of 44 samples from preterm infants evaluated with salivary cortisol, pain score (Visual Analogue Scale), heart rate, oxygen saturation and recovery time through the Newborn Individualized Developmental Care and Assessment Program. For reference, 44 samples from eleven full-term infants were evaluated for salivary cortisol. Results: Regardless of whether or not preterm infants received glucose before nasopharyngeal suctioning, no statistically significant difference was found in salivary cortisol reactivity, pain score, heart rate, oxygen saturation or recovery time. Nor were any statistically significant differences between salivary cortisol baseline and response values found in full-term infants after nasopharyngeal suctioning. Conclusion: In the present setting, nasopharyngeal suctioning was not stressful enough to increase salivary cortisol or pain score. Oral glucose did not alter salivary cortisol levels.     

Lack of plasma leptin response to feeding in newborn infants

Objective:   Previous reports of the postprandial regulation of leptin are controversial, and there have been few studies on the effects of breast-feeding on postprandial regulation in newborn infants. We examined the response of plasma leptin to breast- and formula-feeding in newborn infants.
Methods:   We measured the plasma leptin levels using an enzyme-linked immunosorbent assay kit before and after feeding in 12 breast-fed and 11 formula-fed mature infants.
Results:   There was no significant difference in plasma leptin levels in breast-fed infants before and after feeding or in artificially fed infants before and after feeding.
Conclusion:   Our results suggest that feeding does not play a role in the acute response of circulating leptin levels in either breast- or formula-fed infants.     

Hormonal response to surgical stress in prepubertal children

The hormonal response to stress has not been previously studied in prepubertal children. We determined plasma cortisol, growth hormone (GH), prolactin, insulin, and glucose prior to anesthesia, 10 min after induction of anesthesia, 10 min after surgery began, and 60 min after anesthesia and surgery had ended, in 14 healthy children aged 5–9 years undergoing elective surgical procedures. Blood glucose rose significantly during surgery without a synchronous rise in insulin, which increased only in the immediate postoperative period. Prolactin values increased during anesthesia, remained high during surgery, and started to decline in the postoperative period. Cortisol also rose during anesthesia but remained at high levels throughout the study period. GH did not change during anesthesia; it increased during surgery and continued to rise during the postoperative period. In some children relatively high levels of cortisol or prolactin were detected preoperatively, possibly caused by psychological stress. The findings indicate that profound hormonal changes occur in prepubertal healthy children after even minor surgical procedures. This knowledge may lead to measures that could improve the outcome in sick or metabolically abnormal children undergoing surgical procedures. Offprint requests to: C. Dacou-Voutetakis     

The influence of Depot-β 1−24-Tetracosactide and of metyrapone on the excretion of free urinary cortisol in infants

In this paper we studied the urinary output of free cortisol using two experimental conditions: the first consists of basal values, a metyrapone test and a 3-days-load with tetracosactide. The second was carried out with a single dose of tetracosactid also after basal values.After metyrapone free urinary cortisol rose slighly less than the Porter-Silberchromogens the mean of raising factors being different with a p<0,02>0,01. The increase of free urinary cortisol may be used in this condition as a parameter for judging the capacity of C-11-hydroxylating enzyme system in basal state.After tetracosactide we found in both conditions an increase of urinary free cortisol showing a lens-effect regarding the values of the Porter-Silber-chromogens.It is concluded that free urinary cortisol can be used as a very sensitive parameter for judging increased adrenal activity, at least on premise of unaltered degradation rate of cortisol.We used in this study the ^1–24 with depot-effect from N. V. Organon, Oss, Netherlands.This study was supported by a grant (Sto 45/8) from the Deutsche Forschungsgemeinschaft, Bad Godesberg, West-Germany.