手术后早期低钾的临床观察及护理

观察１２３例手术后病人早期血钾浓度，其中低血钾６３例，占５１．２２％。对手术后早期发生低血钾的可能因素进行探讨并提出如何防治，同时还阐述了手术后早期补钾的观察和护理。１２３例病人分别在术后２４ｈ内补钾２．０￣９．０ｇ，无１例出现异常反应，且血钾浓度均能维持在正常范围内。     

外科病人围手术期钾离子水平的变化

目的 了解手术后病人血钾下降的原因及其影响因素。方法 前瞻性观察了39例外科手术病人的围手术期电解质水平的变化。结果 术后早期（术后24h）未补钾的病人，血钾有明显下降趋势。36例病人术后血钾下降，占92.31%，而术后24h尿钾无明显减少（平均24h尿钾108.92mmol/L）。根据术后血钾情况补钾3－6g,39例病人术后第1天血钾均处于正常范围内。结论 术后早期并不存在大量钾离子自细胞内向细胞外的转移，术前胃肠道准备时摄入量减少，同时细胞外钾仍在通过尿液、胃肠液等向体外丢失是导致术后低血钾的重要原因之一。术后早期根据血钾情况及时补钾则是防止术后低血钾的主要方法。     

直肠癌病人手术前低钾血症的防治

目的观察直肠癌病人人院至手术前血钾浓度的变化,为预防直肠癌病人术前低钾血症提供临床依据。方法收集2015年1月至2015年12月期间进行直肠癌手术治疗并符合本研究条件的病人资料。其中男性20例,女性16例;年龄在27~77岁,平均年龄51.0岁;病程在1~30个月,平均病程7个月;术前住院天数为4~8 d,平均为5 d。分三个时间点监测36例直肠癌病人自入院至手术之前的血钾浓度变化,即入院第1天、服用泻药前、手术当天早晨,并根据术前是否补钾进行分组,即观察组(补钾)、对照组(未补钾),观察各时间点之间及两组之间血钾浓度,使用SPSS(18.0版)统计软件进行统计分析。结果对照组病人血钾浓度平均值入院第1天为(4.17±0.68)mmol/L;服用泻药前为(3.80±0.50)mmol/L,较入院第1天有所下降,差异有统计学意义(P0.01);手术当天早晨为(3.38±0.43)mmol/L,与前两次差异均有统计学意义(P0.01)。观察组各时间点血钾浓度差异无统计学意义(P0.05);观察组与对照组在入院时血钾浓度差异无统计学意义(P0.05),在服用泻药前及手术当天早晨差异均有统计学意义(P0.05和P0.01)。结论直肠癌病人手术之前即可能处于低钾血症状态,其原因可能与入院后饮食结构改变及服用泻药清洁肠道相关,人院后至术前进行常规补钾可预防直肠癌病人术前低钾血症的发生。     

43例原位肝移植病人手术中血电解质浓度的变化

目的：动态观察原位肝移植手术期间病人血电解质浓度的变化。方法：患者在气管插管全身麻醉下行肝移植手术，分别于麻醉诱导前及手术开始后各期定时抽取桡动脉血标本做血浆钠、钾、氯、钙水平测定。结果：血钾在无肝期及肝脏再灌注５￣１５分钟后明显降低，而在再灌注后１￣５分钟内明显升高（最高７．２ｍｍｏｌ·Ｌ＾－１）。所有病人血钙浓度从手术开始后即呈下降趋势，以无肝期尤为显著。术中血钠浓度轻度升高，但极少超出正常值     

骨科围手术期监测D-二聚体和同型半胱氨酸的临床意义

[目的]探讨骨科围手术期D-二聚体及同型半胱氨酸的变化对监测深静脉血栓形成的临床意义.[方法]选择55例骨科大手术患者,分别于术前24h,术后24、48、72 h静脉血检测其D-二聚体及同型半胱氨酸的水平,将并发深静脉血栓组与未发生组比较及分别与正常对照组比较,分析它们对监测深静脉血栓形成的早期诊断价值.[结果]手术前24h患者D-二聚体和同型半胱氨酸的浓度,并发深静脉血栓组与未发生组比较结果无显著性差异(P＞0.05),且分别与正常对照组比较差异无显著性(P＞0.05);手术后24、48、72 h,同时间两组比较,并发深静脉血栓组D-二聚体和同型半胱氨酸的浓度明显高于未并发深静脉血栓组,有显著性差异(P＜0.05);并发深静脉血栓组手术后24、48、72hD-二聚体和同型半胱氨酸的浓度与正常组比较,有显著性差异(P＜0.05);未并发深静脉血栓组手术后24hD-二聚体与正常组比较,有显著性差异(P＜0.05),而手术后48、72 h与正常组比较,无显著性差异(P＞0.05);未并发深静脉血栓组手术后24、48、72 h同型半胱氨酸浓度与正常组比较,无显著性差异(P＞0.05);且D-二聚体和同型半胱氨酸血浆浓度升高与手术后深静脉血栓的发生呈显著正相关(P＜0.05);[结论]动态联合监测D-二聚体及同型半胱氨酸的水平对早期诊断骨科大手术后并发深静脉血栓具有重要意义.     

高容量血液滤过治疗心脏手术后急性肾功能衰竭

目的探讨高容量血液滤过(HVHF)对心脏手术后急性肾功能衰竭的治疗效果。方法对11例心脏手术后并发急性肾功能衰竭的患者行HVHF治疗,观察治疗前、治疗结束时的心率、平均动脉压、肾功能、动脉血气和电解质的变化;记录治疗前、治疗后24h4、8h、72h和96h去甲肾上腺素、肾上腺素的用量情况。结果经HVHF治疗后心率明显减慢(P<0.01),平均动脉压显著上升(P<0.01),血肌酐、尿素氮、尿酸水平均显著下降(P<0.01),动脉血氧分压明显升高(P<0.01),血钾明显降低(P<0.01);治疗后的24h、48h、72h和96h去甲肾上腺素、肾上腺素的剂量逐渐减少,血压逐渐上升(P<0.05)。结论HVHF是治疗心脏手术后急性肾功能衰竭的有效方法。     

腹部手术后钾代谢的临床研究及早期补钾对胃肠功能的影响

目的　观察腹部手术后早期补钾对胃肠功能恢复的影响。方法　测定 6 7例腹部手术前后血钾、钠、氯的变化和尿、胃肠减压液及引流液中电解质丢失量 ,并观察手术后不同时间补钾者的胃肠功能恢复情况。结果手术日和术后钾丢失平均 72 .6mmol/d ,最多达 2 76 .3mmol/d ,尿钾浓度无明显改变 ,尿钾丢失主要为尿量增加所致。术后平均补钾 49.6mmol/d ,但血钾较术前明显降低 (P <0 .0 5 ) ,5例血钾低于 3 .5mmol/L ,无 1例出现高血钾。术后早期补钾者胃肠功能恢复快。结论　只要肾功能正常 ,术后第 1d可开始见尿即补钾 ,除应常规补钾外 ,应根据尿量随时调整钾的补充量     

术前健康状态和血清钾浓度的变化

病人术前如果血清钾不正常则能改变心脏节律并引起心律紊乱,轻度低钾不需处置,血钾严重紊乱术前则必需纠正,术后也应继续治疗。但是病人的健康状态,服药情况对术前血钾变化的影响尚不十分清楚。为此作者选择150例泌尿手术男性病人平均69岁(45～88岁),术前1～4天测定血钾和血清肌酐浓度。术前1～2     

手术前后血钾的观察

作者对66例手术分为四组进行手术前后血钾的观察。临床资料及结果见附表。讨论临床上手术中和手术后可致血钾下降的因素有: 1.血液稀释:本组术中每例平均输液1600ml(每小时529ml),椎管内麻醉用液体维持血压,其中半数液体用5—10％葡萄糖。葡萄糖同化速度为0.3～0.5g/kg/h,每合成     

直肠癌患者手术前血钾浓度变化的分析

目的 观察直肠癌患者入院至手术前血钾浓度的变化,为预防直肠癌患者术中及术后血钾紊乱提供临床证据.方法 分3个时间点监测40例直肠癌患者自入院至手术之前的血钾浓度变化,即入院第一天、服用泻药前、手术当天早晨,并根据患者年龄(低龄组、中龄组、高龄组)、性别(男性组、女性组)、饮食状况(饮食正常组、饮食稍下降组、饮食严重下降组)、病程(长病程组、中病程组、短病程组)进行分组,观察各时间点之间及各组之间血钾浓度,使用SPSS1 3.0统计软件进行统计分析.结果 所有患者血钾浓度平均值入院第一天为(4.09 ±0.62) mmol/L,服用泻药前为(3.83±0.46) mmoL/L,较入院第一天有所下降,差异有统计学意义(P＜0.01),手术当天早晨为(3.36±0.40) mmol/L,与前两次均有统计学差异(P＜0.o1);不同性别之间各时间点血钾浓度差异无统学意义(P＞0.05);不同年龄组除低龄组与高龄组在手术当天早晨血钾浓度差异有统计学意义(P＜0.05)外,其他年龄组在不同时间点之间血钾浓度差异无统计学意义(P＞0.05);不同饮食状况组、不同病程组在各时间点之间差异均有统计学意义(P＜0.01).结论 直肠癌患者手术之前即可能处于低钾血症状态,其原因可能与患者病程长、饮食量下降、年老体弱、入院后饮食结构改变及服用泻药清洁肠道相关.     

Levels of Troponin I and Cardiac Enzymes After Reinfusion of Shed Blood in Coronary Operations

Background. Reinfusion of shed blood after coronary artery bypass grafting might increase the levels of cardiac enzymes with consequent difficulties in the diagnosis of perioperative myocardial infarction.

Methods. Thirty consecutive patients undergoing coronary artery bypass grafting who bled at least 400 mL within the first 4 hours after operation underwent reinfusion of shed blood. Thirty consecutive patients who were not autotransfused served as control. All patients underwent enzyme determination (total creatine kinase, MB fraction, lactate dehydrogenase, and troponin I) in the shed blood and in circulating blood preoperatively, at arrival in the intensive care unit, and 6, 24, and 48 hours after operation.

Results. The shed blood contained significantly higher concentration of cardiac enzymes than the circulating blood at all time intervals (p = 0.0001). The levels of creatine kinase, its MB fraction, and lactate dehydrogenase in circulating blood were significantly elevated in patients receiving autotransfusion up to 24 hours after autotransfusion. The blood levels of troponin I were not significantly different between the two group of patients at all time points. The percent fraction of MB did not increase after autotransfusion.

Conclusions. The measurement of cardiac troponin I is a useful marker for the diagnosis of perioperative myocardial infarction in patients undergoing transfusion of shed blood after coronary operation.     

Perioperative Changes in the Microcirculation in Feet After Foot and Ankle Surgery

The senior author (N.P.G.) observed that if the foot became dependent in the first 48 hours after foot surgery, the patient had swelling and pain. This effect seemed less after about 48 hours. The authors set out to see if there was a scientific basis for this. Laser Doppler was used to assess blood flow in 14 patients. Flow was recorded in the big toe, at heart level, and on dependency, preoperatively and postoperatively. Postural vasoconstriction was calculated, and time for blood flow to normalize was recorded. Mean postural vasoconstriction preoperatively was 51.31%; postoperative mean at 24 hours was 23.05%, at 48 hours 36.62%, and at 72 hours 44.24%. There was a difference between the preoperative levels and the 24-, 48-, and 72-hour postoperative levels (P < .05). Results showed that it takes longer than 72 hours rather than 48 hours for microcirculation to return to normal. The results emphasized the importance of postoperative foot elevation for at least 48 hours because of this phenomenon.     

Skeletal muscle glutathione after surgical trauma.

OBJECTIVE: The authors investigate the effect of surgical trauma on skeletal muscle concentrations of glutathione in patients undergoing selective abdominal surgery. SUMMARY BACKGROUND DATA: The posttraumatic state is accompanied by characteristic changes in the pattern of free amino acids and a decline of protein synthesis in human skeletal muscle. Glutathione has multiple metabolic functions that are involved in cellular homeostasis. It is unknown how surgical trauma affects the glutathione metabolism of skeletal muscle in surgical patients. METHODS: Eight patients undergoing elective abdominal surgery were investigated. Percutaneous muscle biopsies and blood samples were taken before operation and at 6, 24, and 48 hours after operation. The concentrations of glutathione were determined in muscle tissue, plasma, and whole blood, as well as the concentrations of the related amino acids in muscle and plasma. RESULTS: In skeletal muscle, the levels of both reduced and total glutathione decreased by 40% (p<0.01) at 24 hours and remained low at 48 hours after operation compared with the preoperative values. The glutathione concentration in plasma was 20% lower after operation compared with the concentration before operation (p<0.05). There were no changes at the whole blood levels of glutathione. Tissue glutamate and glutamine decreased significantly after operation (p<0.001), whereas intracellular cysteine and glycine remained unchanged. CONCLUSIONS: Skeletal muscle glutathione deficiency occurs after surgical trauma. This may lead to an increase in the susceptibility to intracellular oxidative injury.     

Pulmonary hypertension and polymorphonuclear leukocyte elastase after esophageal cancer operations

To evaluate the role of polymorphonuclear leukocyte (PMN) elastase in pulmonary impairment occurring after operation for esophageal cancer, 10 patients were randomized preoperatively into two equal groups. One group received a placebo infusion and the other, an infusion of the PMN elastase inhibitor ulinastatin. In the placebo group, the mean plasma PMN elastase level increased from 154 +/- 23 micrograms/L preoperatively to 449 +/- 56 micrograms/L at 6 hours postoperatively (p less than 0.01), whereas the mean plasma fibronectin concentration decreased from 490 +/- 70 micrograms/mL preoperatively to 265 +/- 81 micrograms/L on postoperative day 2 (p less than 0.01). The mean pulmonary vascular resistance increased markedly from 151 +/- 24 dynes.s.cm-5.m-2 preoperatively to 284 +/- 76 dynes.s.cm-5.m-2 at 6 hours postoperatively (p less than 0.01). In the group given ulinastatin, 150,000 units every 12 hours from the start of the operation, the mean PMN elastase value at 6 hours postoperatively was lower (275 +/- 66 micrograms/L; p less than 0.01) and the fibronectin level on postoperative days 1 and 2, higher (p less than 0.05). A lower pulmonary vascular resistance was noted into day 2 (p less than 0.05). Our results suggest that PMN elastase may participate in the development of postoperative pulmonary impairment.     

Effect of Single-Dose Preemptive Systemic Dexamethasone on Postoperative Dysphagia and Odynophagia Following Anterior Cervical Spine Surgery: A Double-Blinded,Prospective, Randomized Controlled Trial

BackgroundThe efficacy of preoperative dexamethasone in anterior cervical discectomy and fusion (ACDF) to reduce dysphagia and odynophagia remains controversial. This study evaluated the effect of a single dose of intravenous dexamethasone given as preemptive analgesia in the ACDF procedure.MethodsA total of 64 patients aged 18 years or over were randomized into two groups. The experimental group received dexamethasone 10 mg intravenously before surgery for 60 minutes, and the control group received normal saline. One surgeon operated on all patients. The Bazaz score and visual analog scale (VAS) for odynophagia were measured at 0 hour, 24 hours, 48 hours, 72 hours, and 2 weeks postoperatively. Prevertebral soft-tissue swelling (PSTS) and the modified Japanese orthopedic association (mJOA) score were measured preoperatively and 2 weeks postoperatively.ResultsThe Bazaz scores at 0, 24, 48, and 72 hours after operation were significantly lower in the dexamethasone group than in the placebo group (p < 0.001, p < 0.001, p < 0.001, and p = 0.004, respectively). The VAS scores of the dexamethasone group were significantly lower than those of the placebo group at 0, 24, 48, and 72 hours after surgery (all p < 0.001), but there was no significant reduction in the Bazaz score and VAS score at 2 weeks postoperatively. There was no difference in PSTS and mJOA preoperatively and 2 weeks postoperatively.ConclusionsA single dose of intravenous dexamethasone used preoperatively in single-level and multilevel ACDF can significantly improve symptoms of dysphagia and odynophagia early on postoperatively.     

跨越中线区皮瓣的血液动力学变化

目的　观察跨越鼠背部正中线皮瓣内的血液动力学变化。方法　在腰背部设计一跨越中线横形皮瓣 ,面积 7cm× 3cm ,跨中线长度 3cm ,皮瓣宽度为 3cm。在形成皮瓣术前及术后 6、2 4、4 8、72h及 7、14d时 ,中线区和远端采用非接触性激光多普勒血流仪对鼠背部皮瓣的蒂部测量血流值 ,并观察皮瓣筋膜面的色泽、血管数目和轴向的变化 ,皮瓣边缘出血情况。皮瓣成活情况。结果　皮瓣全部成活。跨越中线皮瓣在皮瓣掀起后的 3d内 ,皮瓣中线区和远端的血流较低 ,术后 7d ,血流变为稳定 ,14d左右皮瓣的血管完成其轴向性的变化。掀起皮瓣后 14d ,其轴型血管的方向顺应皮瓣的纵轴方向 ,中线区的血管管径扩大 ,较小的吻合血管变为粗大的轴型血管。皮瓣远端的变化同中线区的变化基本相同。结论　跨越中线的皮瓣最终变为顺流的轴型皮瓣 ,由非生理性的轴型皮瓣变为生理性的轴型皮瓣。     

腹腔镜直肠癌Miles手术对机体凝血纤溶系统的影响

目的:研究腹腔镜与传统开腹直肠癌Miles手术对机体凝血纤溶系统影响的差异.方法:将60例行直肠癌Miles手术的患者按其意愿分为开腹组(open resection,OR)和腹腔镜组(laparoscopic resection,LR),每组30例,分别于术前24h、术后0h、术后24h检测患者D-二聚体(D-dim...     

腹腔镜与传统小儿腹股沟疝高位结扎术对机体创伤的对比研究

目的:探讨腹腔镜小儿腹股沟斜疝高位结扎术对机体的创伤。方法:将60例腹股沟斜疝患儿随机分为腹腔镜组与传统手术组,对比两组患儿术前及术后8 h、24 h、48 h外周静脉血白细胞介素-6(interleukin-6,IL-6)、C-反应蛋白(C reac-tive protein,CRP)值。结果:两组患儿术后8 h血清IL-6、CRP均明显高于术前,且传统手术组高于腹腔镜组;术后24 h,腹腔镜组下降,而传统手术组仍高于术前;术后48 h,两组患儿血清CRP、IL-6均下降,接近术前水平。结论:腹腔镜小儿腹股沟斜疝高位结扎术对患儿机体创伤较小,值得临床推广应用。     

超声引导下低位前锯肌平面阻滞对上腹部手术患者术后镇痛及炎症反应的影响

目的 评价超声引导下低位前锯肌平面阻滞(SAPB)对上腹部手术患者术后镇痛及炎症反应的影响.方法 择期上腹部手术患者120例,男69例,女51例,年龄18～65岁,ASAⅠ或Ⅱ级.随机分为三组:对照组(C组,n=39),不行神经阻滞;常规SAPB组(SAPB组,n=40),全麻诱导前超声引导下双侧腋中线第5肋水平前锯肌...     

二次全膝关节置换术对老年患者术后早期认知功能的影响

目的 通过观察首次及二次全膝关节置换术术后早期认知功能及炎性细胞因子的变化,探讨二次全膝关节置换术对老年患者术后早期认知功能的影响. 方法 择期行全膝关节置换术患者96例,年龄≥65岁,ASA分级Ⅰ、Ⅱ级,按手术次数分为一次手术组和二次手术组,每组48例.采用简易精神状态检查(mini-mental state examination,MMSE)量表于术前及术后1、3、5、7d进行认知功能评估.术后MMSE评分较术前降低大于或等于一个标准差为发生术后认知功能障碍(postoperative cognitive dysfunction,POCD).根据是否发生POCD分为POCD组和NPOCD组.于麻醉诱导前、术后24h抽取外周静脉血,应用ELISA测定IL-1、IL-6和IL-10的浓度. 结果 二次手术组患者术后3、5 d POCD的发生率(56.3％、10.4％)显著高于一次手术组(25.0％、2.1％)(P＜0.05).与NPOCD组比较,POCD组术后IL-6的水平较术前明显增加,术后IL-10的水平较术前明显降低,差异有统计学意义(P＜0.05).与术前比较,一次手术组和二次手术组POCD患者术后24 h IL-6的水平明显增加(P＜0.05)、IL-10的水平明显降低(P＜0.05);与一次手术组POCD患者比较,二次手术组POCD患者术后24 h IL-6的水平明显升高(P＜0.05)、IL-10的水平明显降低(P＜0.05). 结论 二次全膝关节置换术老年患者术后早期POCD发生率增加,可能与血液中IL-6浓度升高及IL-10浓度降低有关.