普外患者术后发生低磷血症的相关因素

目的 :探讨普外患者术后发生低磷血症的临床相关因素。方法 :检测 10 1例普外患者术前及术后第 1、4、7天的血磷浓度 ,分析各种影响因素。结果 :年龄大于 5 5岁组术后第 1、4天的血磷浓度较小于5 5岁组为低 (P <0 .0 1)。手术持续时间大于 3h组术后第 1、4天的血磷浓度较少于 3h组低 (P<0 .0 5 )。ApacheⅡ评分大于 4分的患者术后第 4、7天的血磷浓度均低于小于 4分者 (P <0 .0 5 )。术中失血量大于 30 0ml组较小于 30 0ml组术后第 1天的血磷浓度低 (P <0 .0 5 )。而性别、手术时机等因素对血磷浓度的影响无统计学差异。结论 :普外患者术后低磷血症的发生与年龄、手术持续时间、术中失血量及病情危重程度有关。     

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目的 探讨甲状腺癌手术后低钙血症的发生发展规律及治疗方法。方法 对65例因甲状腺癌而做甲状腺全切除或近全切除的病人进行术后随访，动态监测血清钙，磷，镁的变化。结果 65例病人均出现不同程度的低钙血症，其中无症状低钙血症发生率为81．5％，术后不需静脉补钙治疗。有症状低钙血症的发生率为18．5％，需静脉补钙治疗，1例病人发生永久性甲状旁腺功能低下。有症状低钙血症组血清钙浓度在术后第1，2，3，5天较无症状低钙血症组血清钙浓度明显降低（P＜0．05）。有症状低钙血症组血清磷浓度在术后第2，3天较无症状低钙血症组血清磷浓度明显增高（P＜0．05）。结论 （1）有症状低钙血症发生在手术后3天之内，甲状腺癌手术后3天应常规监测血钙，血磷和血镁，血钙低于1.81mmol/L，高度警惕低钙症状出现。（2）有症状低钙血症病人经及时补充钙剂后，症状迅速改善，并往往在术后7天内消失。（3）血钙的高低与甲状旁腺的保留量，甲状旁腺素的浓度似乎无必然联系。     

腹部手术后TPN治疗中的低血磷症及其防治

本文选择了16例腹部手术后TPN治疗的患者为观察对象,并随机分为补磷组(9例)及对照组(7例),连续测定血浆中磷水平和24小时尿中磷排出量。结果发现,对照组在TPN治疗后第4、7天血磷明显降低(P<0.01),既使无磷摄入,仍有相当的磷从尿排出;而补磷组则无低血磷现象发生。     

外科患者术后血磷浓度变化的临床观察

作者用钼兰显色法检测２５７例外科术后重症监护患者的血磷浓度。结果有１３６例血磷浓度〈０．８ｍｍｏｌ／Ｌ，称为低磷血症，发生率为５２．９％。低磷血症的发生与患者年龄、原发疾病以及术后静脉输流高渗葡萄糖溶液有关，同时可合并低血钙、低血钠、低血钾等。并且与脏器功能的受损或衰竭有关。本组４０例死亡患者中，低磷血症的有３１例。作者认为为提高外科危重患者的治疗愈率，低磷血症的及时诊和积极预防治疗是十分重要的环     

分化型甲状腺癌术后PTH变化及发生低钙血症的临床分析

目的：探讨分化型甲状腺癌不同手术方式后PTH和血钙的变化,总结手术方式与PTH及低钙血症的关系。 方法：检测2012年10月—2013年9月167例分化型甲状腺癌患者术前、术后10 min、术后第1、2天PTH水平及术前、术后第1、2、3天血钙水平变化,进行统计学分析。 结果：分化型甲状腺癌手术后,手术方式中行甲状腺近全切除+中央组淋巴结清扫者,术后低钙血症发生率均较高;术后发生低钙血症者PTH水平显著降低（P<0.05）。 结论：分化型甲状腺癌手术后均可影响甲状旁腺功能,手术越大术后发生低钙血症可能越大。PTH水平降低是术后低钙血症发生的主要因素。

     

外科手术与低磷血症相互关系的实验研究

目的 通过研究大鼠腹部手术前后血磷等指标的变化，探讨手术与低磷血症的关系，低磷对机体的影响以及补磷治疗的效果。方法 雄性ＳＤ大鼠６４只，分成２组，一组饮用配制液造成体内磷缺乏，另组饮清水作为对照。３周后行胆总管结扎术，观察血磷及其它生化指标的变化。然后每组再分为补磷组及不补磷组，观察４组大鼠生化指标、生存率及重要器官电镜结构的变化。结果 手术后各组大鼠均有不同程度的血磷下降；术前磷缺乏组血磷及平均     

大块肝切除的低磷酸血症

1979～1989年 Sloan-Kettering 癌肿中心施行49例右肝叶或扩大右肝叶切除。本文对其中记录完整的44例进行回顾研究,计14例(32%)有19种严重并发症,均预先有低磷酸血症。术后第10天,血清无机磷值均见下降,平均下降1.91mg/dl。第2天出现低无机磷血症,平均持续5天。44例中,32例的血磷值在第2或第3天最低。2例的血磷值下降不明显,其余42例的低无机磷血症分为三组:中度(磷为2.5～1.6 mg/dl)19例,其中5例发生5个并发症;重度(1.5～1.1mg/dl)15例,其中3例发生4个并发症;极重(<1.0mg/dl)8例,其中6例发生10个,并发症显著增高(P<0.005)。半数以上病例服用制酸剂,如30ml 的铝制酸剂,服用铝制酸剂病人(n=25)的血清无机磷值比不服用者明显增高。中度组病人多在早期辅充磷酸盐,而重度和极重度组则较少辅充。21例在术前一日补充磷酸盐,23例未予补充。无机磷的平均最低值分别为1.72和1.33     

外科脓毒血症病人血磷水平变化的初步研究

目的:研究外科危重病人在全身炎症反应综合征(SIRS)、脓毒血症和脓毒性休克阶段血磷水平变化的趋势。方法:回顾性研究2003年1月到2003年4月在瑞金医院外科ICU连续入住病人的血磷值,比较不同病程阶段(非重症、SIRS、脓毒血症和脓毒性休克)病人的血磷水平。结果:在外科ICU非重症病人中,血磷水平都正常;而在SIRS阶段病人,部分标本的血磷水平降低(占标本数30.4%),但平均值仍属正常。脓毒血症阶段病人的血磷水平则明显降低,平均为(0.66±0.17)mmol/L,显示低磷血症的标本数占90.9%;脓毒性休克时病人的血磷降低更为明显,平均为(0.48±0.22)mmol/L。方差分析显示各组间两两比较都有显著差异。结论:外科危重病人中,随着疾病从SIRS加重到脓毒性休克,其血磷降低程度亦逐渐加重。     

18例腹部外科重危病人低磷血症的临床研究

本文对18例并发低磷血症的腹部外科重危病人进行回顾性分析,发现腹部严重感染、各种消化道瘘致胃肠道液体大量丢失是引起低磷血症的常见原因。且后者更易导致重症低磷血症。肌无力、肌肉疼痛、低氧血症、感染异常、恐惧感、轻度黄疸、合并感染或原有的感染难以控制等是重症低磷血症的主要临床表现。作者认为该症的早期诊断关键在于充分认识其发病原因和临床表现、及时定期监测血磷浓度的变化。     

脑血管意外病人家属焦虑的调查分析

应用焦虑自评量表(SAS)对300例脑血管意外病人的300名家属进行焦虑状况调查和评定.结果家属的SAS评分显著高于国内常模(P<0.01),女性高于男性(P<0.01),高年龄段高于低年龄段(均P<0.05),文化程度越低评分越高(均P<0.05),配偶评分显著高于父母或子女、旁系及其他角色(均P<0.05);家属SAS评分与年龄呈正相关(P<0.01),与文化程度呈负相关(P<0.01).提示护理人员应重视家属的心理疏导与支持,尤其应针对其中的女性、高年龄者、文化程度较低者及其配偶,以避免其不良心理影响病人.     

Hypophosphatemia after major hepatic resection.

METHODS. We performed a retrospective study of 44 patients who underwent right or extended right hepatic lobectomy to determine the incidence and significance of hypophosphatemia after major hepatic resection. RESULTS. The postoperative serum phosphate level (measured as inorganic phosphorus) dropped in all 44 patients studied. Profound hypophosphatemia (less than 1.0 mg/dl) was significantly (p less than 0.001) associated with the frequent development of major postoperative complications (cardiorespiratory, five cases; infections, four cases; hemorrhage, one case; and liver failure, one case). Factors such as extent of liver resection, blood loss, blood or plasma transfusion, postoperative bilirubin level, and preexisting liver diseases showed no significant correlation with the nadir inorganic phosphorous level. Use of aluminum-containing antacids caused a further drop of the serum values (p less than 0.05). Early phosphorous replacement showed a significant protective effect (p less than 0.05), with higher serum levels and fewer major complications. CONCLUSIONS. These observations affirm the importance of frequent monitoring and replacement of phosphate after major hepatic resection.     

Techniques for hepatectomies without blood transfusion, focusing on interpretation of postoperative anemia

HYPOTHESIS: Transient postoperative anemia is partially a physiologic phenomenon, and variations in blood transfusion rates after liver resection in different series in part are due to different interpretations of postoperative anemia. Based on the hypothesis that transient postoperative anemia is partially a physiologic phenomenon, we analyzed serum hemoglobin and hematocrit values in patients who underwent liver resection without blood transfusion to check fluctuations. DESIGN: Prospective cohort study. SETTING: Community hospital. PATIENTS: Forty-six consecutive patients with primary and metastatic liver tumors. INTERVENTIONS: Surgical treatment consisting of dissection technique performed under intermittent warm ischemia, using intraoperative ultrasonography, and without blood transfusion. MAIN OUTCOME MEASURES: Hematocrit and hemoglobin concentrations in serum sampled preoperatively and on the first, third, fifth, and seventh postoperative days. RESULTS: No postoperative mortality and major morbidity were observed. No patient received a blood transfusion. The hematocrit and hemoglobin concentrations in serum were significantly lower on the third postoperative day than on the first, fifth, and seventh postoperative days; differences among the first, fifth, and seventh postoperative days were not significant. CONCLUSIONS: The fluctuations of hemoglobin and hematocrit levels after liver resection showed a steady and significant decrease until the third postoperative day and then an increase. Therefore, a decrease in the hemoglobin and hematocrit levels between first and fifth postoperative days without evidence of active bleeding from drain discharge or any other possible source of bleeding does not justify blood administration.     

Reduced function of neutrophils during routine postoperative glucose infusion

Postoperative infusion of carbohydrate solution leads to moderate fall in the serum concentration of inorganic phosphate. The possible significance of this fall for cellular function as expressed by the neutrophils was investigated in 16 patients undergoing elective cholecystectomy. On postoperative day 2 all received 1 l 10% glucose intravenously to which in eight (randomly chosen) cases 10 mmol phosphate buffer/l had been added. Blood was sampled preoperatively and before and after the infusion. The group without phosphate supplement showed the expected significant fall in serum phosphate during the glucose infusion. The phosphate supplement prevented this fall. The hypophosphatemia was associated with significant reduction of neutrophil phagocytosis, intracellular killing, consumption of oxygen and generation of superoxide during phagocytosis. No parameter expressing neutrophil function was affected in the group with phosphate supplement. The obligatory fall in serum concentration of inorganic phosphate during postoperative carbohydrate infusion was concluded to be a cause of cellular dysfunction, the clinical importance of which is unknown.     

磷酸肌酸钠对胃癌术后疲劳综合征患者免疫功能的影响

目的：观察磷酸肌酸钠对胃癌术后疲劳综合征患者免疫功能的影响。方法：将165例胃癌患者分为两组,在手术后1～3 d治疗组85例静脉滴注磷酸肌酸钠,对照组80例静脉滴注等容积生理盐水;记录术前及术后第1、3、5、9 d疲劳评分（VAS评分）,检测术前及术后第1、3、5、9 d两组免疫球蛋白IgA、IgG、IgM及免疫细胞亚群CD3＋、CD4＋、CD4＋/CD8＋水平。结果：两组患者术后VAS评分较术前显著升高,治疗组升高程度低于对照组（P＜0.05）;术后血清IgA、IgG、IgM、CD3＋、CD4＋、CD4＋/CD8＋水平均明显下降,对照组降低更为明显（P＜0.05）。结论：磷酸肌酸钠能够明显减轻患者胃癌术后疲劳综合征,改善免疫状况,有利于改善生活质量。     

全膝关节置换术治疗甲型血友病膝关节病变的疗效分析

目的 评价全膝关节置换术治疗甲型血友病膝关节病变的疗效、手术特点、假体选择及凝血因子替代治疗的有效性和安全性.方法 2003年6月至2009年4月,采用全膝关节置换术治疗甲型血友病膝关节病变患者19例(25膝);年龄18～54岁,平均33.4岁.Ⅷ因子替代治疗方案为手术当天补充至100%,术后3 d内80%以上,术后3 d至一周60%以上.术后进行以持续被动活动器(CPM)为主的功能锻炼,锻炼时机为Ⅷ因子输注后6 h内.观察比较手术前后膝关节HSS评分、疼痛、活动度及并发症.结果 18例(24膝)患者得到随访,随访时间7～54月,平均31个月.术前患者HSS评分为平均(51±14)分(31～64),术后HSS评分为平均(86±9.5)分(62～110).关节活动度由术前平均55°±26.3°(10°～100°),改善为术后平均82°±18.6°(60°～100°).屈曲畸形由术前平均19°±13°(0°～45°),改善为术后平均2.7°±3.2°(0°～10°).所有患者术后1～5 d时间内检测的平均Ⅶ因子浓度为74.07%.术后1例发生关节出血,1例发生腓总神经麻痹,1例患者术后17个月因假体感染行翻修术.结论 在合理补充凝血因子条件下,全膝关节置换术是治疗血友病膝关节病变的有效方法,可明显改善膝关节症状和活动度.     

胸腔镜手术对创伤性血气胸患者临床指标的影响

目的:研究胸腔镜手术对创伤性血气胸患者临床指标的影响。方法:选取2014年1月至2015年3月治疗的92例血气胸患者作为研究对象,按照随机数字表对患者进行编号,随机分为观察组与对照组,每组46例,观察组采用胸腔镜治疗,对照组行开胸手术。对比两组患者一般资料、手术情况、并发症及不同时间段内C反应蛋白(C-reactive protein,CRP)水平。结果:术前及术后第1天,两组患者CRP水平差异无统计学意义(P0.05);术后第3天、第5天,观察组CRP水平均低于对照组;观察组术后第1天、第3天CRP水平高于术前,第5天低于其他时段;对照组术后第1天、第3天、第5天的CRP水平均高于术前,差异有统计学意义(P0.05)。两组患者手术时间、术后并发症差异无统计学意义(P0.05),观察组胸管引流量、引流时间、住院时间均少于对照组,差异有统计学意义(P0.05)。结论:胸腔镜手术创伤小,痛苦小,术后恢复时间短,且无严重并发症,是安全、有效的术式。     

Changes of serum phosphorus levels in hepatic resections and implications on patients' outcomes

Life-threatening hypophosphatemia has been reported after major liver resections with a significant impact on postoperative outcome. Regeneration of the liver may play a crucial role, but the underlying mechanism has not yet been elucidated. This study aims at assessing the effect of vascular control and resected volume of the liver on postoperative phosphorus levels. The study included 30 patients that underwent liver resection. Sixteen patients were operated on without any vascular control and 14 with selective vascular exclusion. Correlation between serum kinetics of phosphorus to resected liver volume and warm ischemia was carried out. All patients experienced low postoperative phosphorus levels. The lowest levels were observed on the second postoperative day, when 40% developed life-threatening hypophosphatemia (< or = 1.1 mg/dl). Warm ischemia and major resections aggravated hypophosphatemia compared with patients operated on without vascular occlusion and with those with minor resections. Vascular exclusion and major resections aggravate hypophosphatemia. Patients who developed hypophosphatemia < or = 1.5 mg/dl were more prone to complications and longer hospital stays compared with counterparts who had serum phosphorus levels > or = 1.6 mg/dl.     

Prevention of hypophosphatemia during postoperative routine glucose administration

The main study comprised 16 patients undergoing colon surgery. On the day of operation and the 3 following days 100 g of glucose was infused at the rate of 0.3 g/kg/h. Half the patients had 10 mmol of phosphorus added to each 1 000 ml 10% glucose solution. The investigation demonstrated that two different kinds of hypophosphatemia occur in the immediate postoperative period. A significant decrease in fasting plasma phosphate was found at the first, second and the third postoperative morning, most pronounced at the second day (1.20 +/- 0.05 to 0.78 +/- 0.07 mmol/l). A significant correlation between these changes and the corresponding 24-hour phosphorus balance was demonstrated (r = 0.61, p < 0.001). The falls in fasting phosphate could not be prevented by phosphorus addition because an amount of phosphorus corresponding to the amount added was excreted in excess in the urine. The plasma phosphate was decreased furthermore during and even 4 hours after the 5-hour glucose infusion (from 0.76 +/- 0.05 to 0.49 +/- 0.07 nmol/l at the end of the infusion at the second day). This hypophosphatemia was prevented by the phosphorus addition.--In average 3% of the infused sugar was lost in the urine. The solitary examples of higher losses (10-20%) were not followed by a higher urinary production. It is therefore concluded that 0.3 g glucose/kg/h is a suitable infusion rate in the immediate postoperative period.     

Hepatic resection-related hypophosphatemia is of renal origin as manifested by isolated hyperphosphaturia

OBJECTIVE: The objective of this study was to elucidate and define the pathophysiological mechanism(s) responsible for the clinically relevant phenomenon of posthepatic resection hypophosphatemia. SUMMARY BACKGROUND DATA: Although biochemically significant hypophosphatemia has been described after major hepatic resection, no mechanism or validated scientific explanation exists. The phenomenon is of considerable clinical relevance because numerous patients, after hepatic resection, develop significant hypophosphatemia requiring large doses of phosphate replacement to maintain metabolic homeostasis. This event has previously been empirically ascribed to amplified phosphate utilization of regenerating hepatocytes, although no rigorous data attest to this postulate. Recent data identifying a novel mechanism of phosphaturia in X-linked hypophosphatemic rickets, autosomal-dominant hypophosphatemic rickets, and oncogenic osteomalacia demonstrate that elevated levels of novel circulating phosphaturic factors such as fibroblast growth factor 23 (FGF-23) and PHEX are responsible for phosphate wasting. We hypothesize that posthepatectomy hypophosphatemia reflects a derangement of normal hepatorenal messaging and is the result of a disruption of renal phosphate handling consequent on aberrations in the metabolism of an as yet unrecognized chemical messenger(s) responsible for tubular phosphate homeostasis. This postulate has not previously been proposed or examined. METHODS: Twenty patients undergoing hepatic resection were studied prospectively with respect to serum phosphate, phosphate requirements, as well as renal phosphate handling. Fractional excretion of phosphate was calculated on a daily basis. To confirm the relationship between phosphate loss and a circulating renal-targeted messenger, the plasma levels of the circulating phosphaturic factor FGF-23 were measured using a c-terminal assay both pre- and postoperatively. RESULTS: All patients developed hypophosphatemia with a nadir on postoperative day 2 (average drop of 47% despite phosphate administration). This phenomenon was associated with hyperphosphaturia (mean +/- standard error) with high fractional excretion of phosphate. A consistent change in FGF-23 was not identified. CONCLUSION: Hypophosphatemia after hepatic resection is a frequent occurrence. Transient isolated hyperphosphaturia and not increased phosphate utilization is the predominant cause of this phenomenon, although the identity of the agent involved remains to be identified.