7.5%高渗盐水对腹部外科手术后液体平衡的影响

目的　探讨 7.5 %高渗盐水对腹部外科手术后液体平衡的影响。方法　 2 0例择期腹部大手术和 6例重症腹膜炎急诊手术患者 ,配对分为两组对比。术毕进入外科ICU后 ,研究组(n =13 )应用 7.5 %高渗盐水 (4ml/kg体重 ) ,后续平衡液 ;对照组 (n =13 )仅用平衡液。比较两组患者的输液量、尿量、液体平衡和体重变化。结果　与对照组相比 ,研究组术后尿量较多 ,术后第 1天和术后 48h的差异有显著性 (t =2 .6612 ,P =0 .0 2 0 7;t=3 .6863 ,P =0 .0 0 3 1) ;手术当日和术后 48h的液体正平衡量较少 ,差异有显著性 (t =2 .3 40 8,P =0 .0 2 79;t =2 .3 691,P =0 .0 2 62 ) ;术后体重增加幅度低于对照组 ,差异有显著性 (t =2 .2 761,P =0 .0 42 0 ) ;术后体重下降时间早于对照组 ,差异有非常显著性 (t =7.615 4,P =0 .0 0 44 )。结论　 7.5 %高渗盐水有明显的利尿作用 ,可动员、排出体内扣押的过多液体 ,减少腹部外科手术后液体正平衡 ,促进液体负平衡提前出现。     

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目的探讨7.5%高渗盐水对胃肠道癌术后液体平衡和临床结果的影响。方法对2003～2004年52例胃肠道癌根治性切除术病人,术毕进入外科ICU后,研究组(n=26)输注7.5%高渗盐水(4mL/kg)后续平衡液;对照组(n=26)仅输平衡液。比较两组病人的输液量、尿量、液体平衡、体重变化、动脉血氧分压/吸氧浓度分数(PaO2/FiO2)比值,以及并发症发生率和病死率。结果与对照组相比,研究组手术日和术后第1日的尿量较多,输液量减少;术后48h的液体正平衡量减少;术后体重增加幅度降低,PaO2/FiO2比值较高,总体并发症发生率和肺部感染发生率较低。结论7.5%高渗盐水有明显的利尿作用,可减少胃肠道癌术后的输液量和液体正平衡量,促进液体负平衡提前出现,并使术后总体并发症发生率和肺部感染发生率降低。     

7.5%高渗盐水对择期腹部大手术后液体平衡的影响

目的　探讨 7 5 %高渗盐水对择期腹部大手术后液体平衡的影响。方法　 2 2例择期腹部大手术患者 ,配对分为两组。术毕进入外科ICU后 ,研究组 11例应用 7 5 %高渗盐水 4ml kg ,后续平衡液 ;对照组 11例仅用平衡液。比较两组患者的输液量、尿量、液体平衡和体重变化。结果　与对照组相比 ,研究组手术日和术后第 1天尿量较多 [(2 6 5 0± 5 31)mlvs (2 0 4 6± 5 72 )ml,t=2 5 5 17,P <0 0 5 ;(2 716± 6 4 0 )mlvs (2 2 32± 4 89)ml,t=2 2 878,P <0 0 5 ];术日和术后 4 8h的液体正平衡量较少[(40 5 8± 115 9)mlvs (5 92 2± 14 93)ml,t=2 870 1,P <0 0 5 ];(492 6± 2 6 98)mlvs (76 5 6± 2 5 4 3)ml,t=2 2 2 94 ,P <0 0 5 ];术后体重增加幅度低于对照组 [(5 0± 1 9)kgvs (7 2± 1 3)kg ;t=2 80 98,P <0 0 5 ];术后体重下降时间早于对照组 [(2 4 4± 3 4 )hvs (31± 5 )h ;t =3 382 6 ,P <0 0 1]。结论　7 5 %高渗盐水有明显的利尿作用 ,可动员、排出体内扣押的过多液体 ,减少择期腹部大手术后液体正平衡 ,促进液体负平衡提前出现。     

高渗盐水和羟乙基淀粉对腹部大手术后液体平衡影响的研究

目的探讨7．5％高渗盐水（Hs）和6％羟乙基淀粉（HES）对择期腹部大手术后液体平衡和，临床结果的影响。方法2003年6月至2005年12月江汉大学附属医院共对120例胃肠道肿瘤病人行根治性切除术。所有病人术毕进入外科ICU后分为3组，HS／HES组（n=40）输注7．5％高渗盐水（4mL／kg）后续6％羟乙基淀粉500mL，再续平衡液；HS组（n=40）输注7、5％高渗盐水（4mL／kg）后续平衡液；RL（单用平衡液）组（n=40）仅输平衡液。比较3组病人的输液量、尿量、液体平衡、体重变化、动脉血氧分压／吸氧浓度分数（PaO2／FiO2）．以及并发症发生率和病死率。结果HS／HES组、HS组与RL组相比，HS／HES组、HS组手术日尿量较多．输液量减少；术后48h的液体正平衡量减少；术后体重增加值降低，PaO2／FiO2比值较高，总体并发症发生率和肺部感染发生率较低。HS／HES组与HS组相比，HS／HES组液体正平衡量减少及术后体重增加值降低更显著。结论7．5％高渗盐水有明显的利尿作用，可减少腹部大手术后的输液量和液体正平衡量，促进液体负平衡提前出现；并使术后总体并发症发生率和肺部感染发生率降低。联合应用6％羟乙基淀粉后效果更显著。     

7.5%高渗盐水对急性弥漫性腹膜炎术后液体平衡的影响

目的 观察7.5%高渗盐水对急性弥漫性腹膜炎急诊手术后液体平衡的影响.方法 42例急性弥漫性腹膜炎急诊手术患者,术毕进入外科ICU后,实验组(n=21)输注7.5%高渗盐水(4 ml/kg体重)后续平衡液;对照组(n=21)仪输半衡液.比较两组患者的输液量、尿量、液体平衡、体莺变化以及并发症发生率和病死率.结果 与对照组比较,实验组手术日的输液量减少(P<0.05);手术日和术后第1天的尿量较多(P<0.05,P<0.05),液体正平衡量减少(P<0.01,P<0.01);术后体重增加幅度降低(P<0.01),体重下降时间提前(P<0.01);总体并发症发生率较低(P<0.05).结论 7.5%高渗盐水有明显的利尿作用,可减少急性弥漫性腹膜炎急诊手术后的输液量和液体正平衡量,促进液体负平衡提前出现,并使总体并发症发生率降低.     

用高渗盐水和胶体减少外科大手术围手术期液体正平衡量

外科大手术液体复苏后,必然出现液体正平衡以及随后的液体负平衡。液体正平衡量大的患者预后不良,并发症发生率和死亡率较高。而液体负平衡的及时出现提示预后良好。高渗盐水可通过减少毛细血管渗漏、增加血浆容量,使手术后尿量增加、输液量和液体正平衡量减少并使负平衡出现提前。羟乙基淀粉(130/0.4)可减轻炎症反应,改善微循环,增加组织氧分压。羟乙基淀粉与高渗盐水联合应用后效果更显著。     

消化性溃疡穿孔液体治疗中的正平衡

目的 探讨消化性溃疡穿孔病人液体正平衡量与病情轻重及预后的关系.方法 2007年1月至2012年6月,连续219例消化性溃疡穿孔病人分为4组,A组(n=153)为非手术治疗病例,B组(n=20)为非手术治疗后转行手术治疗病例,C组(n=41)为直接接受手术的存活病例,D组(n=5)为直接接受手术、术后死亡病例.比较4组病例入院后1～3日的液体正平衡量.结果 A组与B组入院第1日液体正平衡量差异无统计学意义(P＞0.05),A组入院第2日和第3日的液体正平衡量呈减少趋势;B组入院第2日液体正平衡量明显增加,但入院第3日液体正平衡量开始减少.A、B组与C、D组,以及C组与D组入院第1日液体正平衡量差异有统计学意义(P＜0.01).C组入院第2日和第3日的液体正平衡量呈减少趋势,D组入院第2日和第3日的液体正平衡量呈增加趋势.结论 液体正平衡量有助于判断消化性溃疡穿孔病人的病情轻重及预后,动态监测液体正平衡量还有助于判断治疗效果、调整治疗策略.     

尿微量白蛋白对腹部大手术后病人预后预测价值研究

目的 研究尿微量白蛋白与腹部大手术后病人预后的关系。方法 选择江汉大学附属医院2007年9月至2009年4月期间收治的118例腹部大手术病人,连续动态监测腹部大手术后48h内尿微量白蛋白/尿肌酐值（ACR）、入ICU时动脉血乳酸值（LAC）、PaO2/FiO2值和术后各种并发症的发生。ROC曲线比较ACR、POSSUM评分、LAC、PaO2/FiO2值预测术后并发症的价值。结果 术后13例（11%）出现并发症,并发症组入ICU后0、6、12、18、24和48h ACR值显著高于无并发症组（P≤0.001）,相关分析显示入ICU后24h 、48h ACR与POSSUM评分（r=0.374, P＜0.001,r=0.390, P＜0.001）、LAC（r=0.381, P<0.001,r=0.296, P=0.001）呈正相关,与PaO2/FiO2值（r=-0.27, P=0.003,r=－0.251, P=0.006)存在负相关。ROC曲线显示24h ACR ROC曲线为0.857,48h ACR ROC曲线为0.946,而POSSUM评分ROC曲线为0.89,24h ACR值取临界值5.0g/mol时,其预测敏感度86.7%, 特异度33.3％,死亡的阳性预测值16.9%,阴性预测值94.1%。结论 动态监测尿微量白蛋白可作为预测术后并发症的可靠指标。     

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目的　探讨手术中、手术后短时间高浓度氧疗对腹部污染手术切口感染的影响。方法　 2 0 0 1年 1月至 2 0 0 3年 4月行腹部污染手术 196例 ,随机分组。手术开始至术后 2h内观察组 (98例 )用防漏面罩供氧 (FiO26 0 % ) ,对照组 (98例 )用鼻导管供氧 (FiO2 2 8% )。除阑尾手术外术后 2h抽股动脉血测定血气分析 ,均测定末梢动脉血氧饱和度 ,记录有无氧中毒表现。观察切口至术后 15d ,切口丙级愈合为切口感染。结果　两组无氧中毒表现。术后 2h动脉血气分析 ,观察组PaO2 为 (16 5 3± 38 6 )mmHg ,对照组为 (118 1± 2 9 4 )mmHg ,两组比较 P<0 0 0 1。术后末梢动脉血氧饱和度两组均正常。观察组切口感染 5例 (5 1% ) ,对照组 14例 (14 3% ) ,两组比较P <0 0 5。结论　手术中、手术后短时间高浓度氧疗可减少腹部污染手术切口感染。     

消化道穿孔围手术期液体治疗中的正平衡

目的　探讨消化道穿孔 (DTP)急诊手术病例围手术期液体正平衡与APACHEⅡ评分的关系。方法　根据APACHEⅡ评分 ,将连续 3 72例DTP病例分为轻症 ( <8分 )、重症 ( 8-19分 )和危重病例 (≥ 2 0分 )三组 ,比较三组病例手术前、手术日和术后第 1日的液体正平衡量。结果　轻症、重症和危重病例术前的液体正平衡量分别为 112 6.91± 414 .80ml、2 3 60 .89± 85 7.0 3ml和 3 494.97± 995 .65ml(P <0 .0 1) ;手术日液体正平衡量分别为 2 10 3 .71± 72 8.99ml、40 5 0 .5 6± 10 3 6.3 7ml和 5 743 .95±12 5 6.2 1ml(P <0 .0 1) ;术后第 1日液体正平衡量分别为 916.81± 5 5 9.62ml、12 11.43± 679.85ml和15 87.0 9± 73 3 .3 8ml(P <0 .0 1)。结论　无论是术前、手术当日或术后第 1日 ,DTP病例的液体正平衡量与其APACHEⅡ评分正相关。APACHEⅡ评分可估测DTP病例的液体正平衡量 ,指导其围手术期的液体治疗。     

钠钾镁钙葡萄糖注射液扩容对术中血糖、电解质和酸碱平衡的影响

目的比较钠钾镁钙葡萄糖注射液和复方乳酸钠注射液扩容对术中血糖、电解质及酸碱平衡的影响。方法择期行胃肠道手术患者30例,采用随机数字法分为研究组(n=16)和对照组(n=14),研究组使用钠钾镁钙葡萄糖注射液扩容,对照组使用复方乳酸钠注射液扩容,分别在入室后以15ml·kg-1·h-1的速度输注相应液体。分别于输液前(T0)、输液量为10ml/kg(T1)、20ml/kg(T2)和30ml/kg(T3)时检测患者血糖、血乳酸、电解质及pH值等。结果输液后研究组血糖明显升高(P<0.05),血乳酸无明显变化,血pH明显降低(P<0.05);对照组血乳酸明显升高(P<0.05);两组电解质水平均无明显变化。结论钠钾镁钙葡萄糖注射液在扩容、维持电解质及酸碱平衡方面与复方乳酸钠注射液效果相当,可避免大量输入复方乳酸钠注射液所致的乳酸升高,但当大量输注钠钾镁钙葡萄糖注射液时可导致一定程度的血糖升高。     

低潮气量联合不同阶段呼气末正压通气对老年患者开腹术后肺功能的影响

目的观察术中低潮气量联合不同阶段呼气末正压通气(positive end expiratory pressure,PEEP)对老年患者开腹术后肺功能及并发症的影响。方法选择择期全麻下行开腹手术的老年患者60例,男21例,女39例,年龄≥65岁,ASAⅠ或Ⅱ级,随机分为三组,每组20例。A组手术开始后1h联合PEEP 10cm H_2O持续1h,B组术毕拔除气管导管前1h联合PEEP 10cm H_2O持续1h,C组手术全程联合PEEP 10cm H_2O。分别于术前、术后1、24h行血气分析测PaCO_2、PaO_2和A-aDO_2,计算氧合指数。记录术前、术后24、72h的气道分泌物评分。结果与术前比较,术后1h三组PaCO_2明显升高,B组PaO_2明显下降,A组A-aDO_2明显升高(P0.05);术后24hB组、C组PaCO_2明显升高,B组氧合指数明显下降(P0.05)。与术后1h比较,术后24hA组PaCO_2明显下降,A组A-aDO_2明显下降(P0.05)。术后三组气道分泌物评分差异无统计学意义。结论术中低潮气量联合不同阶段PEEP能够改善术后肺的氧合功能,但对术后肺部并发症无明显影响。     

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??Microalbuminuria as predictor of outcome after major abdominal surgery ZHU Guo-chao, LI Rong??QUAN Zhuo-yong??et al.Department of Surgery , the Affiliated Hospital of Jianghan University, Wuhan 430015,China
Corresponding author : LI Rong??E-mail: rongman@163.com
Abstract Objective To evaluate microalbuminuria as predictor of outcome after major abdominal surgery. Methods Microalbuminuria (ACR) was measured in 48 hours post-operation and arterial lactate, PaO2/FiO2 ratio at ICU admission. Receiver-operator curves (ROC) were constructed to compare ACR, physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) score, LAC and PaO2/FiO2 ratio to predict outcome. Results A total of 13 postoperative complications were recorded in 118 patients (11%). ACR at ICU admission and 6, 12, 18, 24 and 48 hours at ICU was significantly higher in patients with postoperative complications than in those without complications ??P≤0.001??. ACR at 24 and 48 hours were positively correlated with POSSUM ??r=0.374, P??0.001??r=0.390, P??0.001????LAC??r=0.381, P<0.001??r=0.296, P=0.001??and LAC ??r=0.381, P<0.001??r=0.296, P=0.001??and inversely correlated with mean PaO2/FiO2??r=-0.27, P=0.003??r=-0.251, P=0.006). The area of ROC of ACR at ICU 24, 48 hour and POSSUM to morbidity was statistically higher than 0.5 (0.857 vs 0.946 vs 0.89). Using a cutoff for ACR at ICU 24 hour of 5.0g/mol. The sensitivity for complication was 86.7%, with specificity of 33.3% and the positive predictive value of death was 16.9%, with negative predictive value of 94.1%. Conclusion ACR is a valuable predictor of in-hospital outcome after major abdominal surgery.     

Continuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants

BACKGROUND: Lung injury after cardiopulmonary bypass is a serious complication for infants with congenital heart disease and pulmonary hypertension. Excessive neutrophil sequestration in the lung occurring after reestablishment of pulmonary circulation implies that interaction between neutrophils and pulmonary endothelium is the major cause of lung injury. METHODS: Thirty infants with either ventricular septal defect or atrioventricular septal defect and with pulmonary hypertension were enrolled in this study. We performed continuous pulmonary perfusion during total cardiopulmonary bypass on 16 patients (perfused group) and conventional cardiopulmonary bypass on 14 patients (control group). PaO2/FiO2 and neutrophil counts were assessed from immediately before surgery to 24 hours after termination of cardiopulmonary bypass. RESULTS: PaO2/FiO2 was higher in the perfused group than in the control group, and the difference was significant throughout the study period. Neutrophil counts decreased below prebypass values in both groups at 30 minutes after aortic unclamping, and the difference was significant in the control group but was not in the perfused group. Duration of postoperative ventilatory support was significantly less in the perfused group. CONCLUSIONS: Our study demonstrates that arrested pulmonary circulation during cardiopulmonary bypass is the major risk factor of lung injury and that continuous pulmonary perfusion is effective in preventing lung injury.     

Intravenous fluid and postoperative nausea and vomiting after day-case termination of pregnancy

Background : Deprivation of oral fluid before minor surgery has been alleged to cause postoperative nausea. We examined the effect of intraoperative fluid load on postoperative nausea and vomiting over 3 d after day-case termination of pregnancy.
Methods : In a randomized study, 100 patients were allocated into one of two groups; receiving 1000 ml of compound sodium lactate solution during surgery or no intraoperative fluid. Propofol and alfentanil was used to induce and maintain anaesthesia with nitrous oxide (67%) and oxygen (33%). Visual analogue scores for nausea and pain, the time and frequency of emetic episodes, analgesic and antiemetic consumption were recorded for 3 d postoperatively.
Results : The scores of nausea were significantly lower in the fluid group ( P <0.05) compared with the control group at 1, 2, 4 h and during 24–48 h following surgery. The incidence of emesis was lower ( P <0.01) after discharge, and the time to first oral fluid was shorter ( P <0.05) in the fluid group. There was no difference in pain score or analgesic consumption between the groups. Five patients (10%) in the control group requested antiemetic medication compared with none in the fluid group.
Conclusion : Intraoperative fluid administration may offer some benefit in decreasing the incidence of postoperative nausea and vomiting following day-case surgery.     

多发骨折手术时机与机体炎性变化及临床结果的关系

目的 探讨对于多发骨折的患者,行股骨干内固定手术的时机与术后机体炎性变化及临床结果间的关系.方法 进行前瞻性非随机队列研究.按入选标准选取2005年4月至2007年8月78例患者.分为多发骨折伴有股骨干开放骨折组26例(A组)、多发骨折伴股骨干闭合骨折组23例(B组)、单纯股骨干闭合骨折组29例(C组).A组实施伤害控制骨科学(damage control orthopaedics,DCO)处理行分期手术,B、C组均早期行骨折确定性内固定术(＜24 h).各组患者术前、术后血液IL-6、TNF-α浓度作为炎性反应水平的指标,PaO2/FiO2、总胆红素、肌酐等项目作为了解各器官功能损害的指标,并统计各组术后并发症的发生率.对各组患者术前、术后炎性反应程度的变化以及多器官功能损害情况和术后并发症率进行比较分析.结果 A组二期术后IL-6平均升高了59 ng/L,TNF-α平均升高了85 ng/L,而B组分别平均升高了154 ng/L和250 ng/L,两组之间IL-6、TNF-α升高的值均有显著差异(P＜0.01).A组一期术后、C组术后IL-6、TNF-α平均升高的程度也均明显小于B组(P＜0.01).相应的,B组术后中出现PaO2/FiO2＜250 mm Hg(1 mm Hg=0.133kPa)的比例、总胆红素出现异常的比例、肌酐出现异常的比例均大于A组两期手术术后(P＜0.05),在人工通气时间、ICU时间、正性体液平衡时期上也均高于A组二期术后(P＜0.01).与A组一期手术比较,B组术后人工通气时间略高(P＜0.05),而ICU时间、正性体液平衡时期无明显差异(P＞0.05).C组术后在以上各个项目上也均小于B组(P＜0.01).术后统计栓塞和MODS的发生率,A组(11.5%)与B组(13.0%)比较无明显差异,但均高于C组(P＜0.01).结论 多发骨折股骨干早期髓内钉固定,可引起机体炎性反应的显著变化,并引起各器官亚临床的改变,而晚期手术引起的上述改变较小.因此,选择多发骨折早期股骨干髓内钉固定手术时机仍需要谨慎.     

Hypertonic saline (7.5%) decreases perioperative weight gain following cardiac surgery

OBJECTIVE: To compare the effects of 7.5% hypertonic saline (HS) and 0.9% normal saline (NS) on perioperative weight gain in cardiac surgical patients. DESIGN: Prospective, randomized study. SETTING: University teaching hospital. PARTICIPANTS: Patients (n = 72) scheduled for elective coronary artery bypass graft surgery. INTERVENTIONS: Patients were randomly assigned to receive either 7.5% HS (36 patients) or 0.9% NS (36 patients) as a single dose of 4 mL/kg over 30 minutes during the postoperative rewarming phase in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Weight gain until the first postoperative morning was significantly greater in the NS group than in the HS group (1.9 plus minus 1.4 kg, median, 2.1 kg; 0.8 plus minus 1.5 kg, median, 0.8 kg; p = 0.005). One-hour diuresis after the fluid infusion was significantly greater in the HS group compared with the NS group (501 plus minus 282 mL and 237 plus minus 173 mL; p < 0.001). In the linear regression model, the 2 most important factors affecting the perioperative weight gain were the volume of fluid infused postoperatively in the intensive care unit (4,098 plus minus 916 mL in the HS group and 4,589 plus minus 1,344 mL in the NS group) and the total diuresis after surgery (3,351 plus minus 1,035 mL in the HS group and 2,942 plus minus 846 mL in the NS group). CONCLUSIONS: HS had an intense diuretic effect, which reduced intraoperative fluid retention. This effect was confirmed by the lesser increase in body weight measured on the first postoperative morning.