滤除白细胞异体血对围术期患儿细胞免疫功能的影响

目的 评价滤除白细胞异体血对围术期患儿细胞免疫功能的影响.方法 选择术中行异体输血的患儿359例,年龄3个月～14岁,体重5～74 kg,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其随机分为2组:对照组(C组,n=163)术中输注未滤除白细胞的异体血;滤除白细胞异体血组(D组,n=196)术中输注滤除白细胞的异体血.分别于输血前、输血后2和6d时,采外周静脉血样,采用流式细胞仪测定CD3+、CD4+、CD8+、CD56+的水平,计算CD4+/CD8+.记录术中输血量、手术时间、术后引流时间、抗生素使用时间、住院时间和术后感染的发生情况.结果 与C组比较,D组输血后6d时CD3+、CD4+、CD4+/CD8+和CD56+的水平升高,引流时间、抗生素使用时间和住院时间缩短,术后感染发生率降低(P＜0.05).两组CD8+水平、术中输血量和手术时间差异无统计学意义(P ＞0.05).结论 输注滤除白细胞的异体血有助于改善围术期患儿的细胞免疫功能.     

围手术期异体输血对胃癌患者CD95L表达的影响

本研究以T淋巴细胞的CD95L表达水平作为检测指标 ,对胃癌患者异体输血后的免疫功能进行评估。资料与方法1 一般资料 :选择胃癌患者 30例 ,均经术前胃镜活检或术后病理证实。随机分为 3组 :A组为对照组 ,男 7例 ,女3例 ,年龄 39～ 79岁 ,体重 4 8～ 83kg ,手术时间 (182± 2 9)min ,围手术期不输血 ,输注 6 %羟乙基淀粉维持血容量 ;B组为去白细胞组 ,男 8例 ,女 2例 ,年龄 4 1～ 80岁 ,体重 4 5～ 75kg,手术时间 (190± 37)min ,术中或术后 12h内输入去白细胞的全血 ;C组为全血组 ,男 7例 ,女 3例 ,年龄 36～ 76岁 ,体重 4 4～ 86kg ,手术…     

等容血液稀释自体输血对肿瘤病人围术期T淋巴细胞亚群、NK细胞影响的比较

目的：探讨异体输血和等容血液稀释自体输血对围术期T淋巴细胞亚群,NK细胞的变化。方法：选择直肠癌,结肠癌格或胃癌根治术病人30例,随机均分为2组。H组术中输异体全血400ml;A组于手术切皮前放血400ml,同时输入等量羟乙基淀粉。术中自体血回输给病人。分别于术前,输血前,术后第1d,第5d抽取静脉血,用流林细胞仪测定T细胞亚群和NK细胞的数量。结果：两组术后第1dCD3^ ,CD4^ ,CD4^ /CD8^ ,NK细胞较术前显著减少（P＜0．05或0．01）,异体输血组较自体输血组减少更明显（P＜0．05）。术后第5d异体输血组CD3^ ,CD4^ ,CD4^ /CD8^ ,NK细胞仍较术前显著减少,自体输血组基本恢复正常。结论：围术期输异体血严重抑制病人免疫,因液稀释自体输血免疫抑制轻微,且术后免疫功能很快恢复。     

氟比洛芬酯联合吗啡镇痛对胃癌患者T淋巴细胞亚群及自然杀伤细胞的影响

目的 观察氟比洛芬酯联合吗啡镇痛对胃癌根治术患者罔术期外周血T淋巴细胞亚群及自然杀伤(NK)细胞的影响.方法 40例择期全麻下行胃癌根治术患者随机分为氟比洛芬酯组(A组)和吗啡组(B组),每组20例,分别于术前0.5 h静注氟比洛芬酯或安慰药英脱利匹特,术后距第一次给药6 h再次静注氟比洛芬酯或英脱利匹特.两组患者术后均行患者自控静脉镇痛(PCIA).于麻醉前、手术开始后2 h、术后24、48、120 h五个时点用流式细胞仪检测T淋巴细胞亚群(CD3+、CD4+、CD8+)及NK细胞(CD3+CD6+CD56+).结果 与麻醉前比较,两组CD3+、CD4+、CD4+/CD8+和NK细胞在手术2 h、术后24、48 h均明显降低(P<0.05);术后120 h CD3+CD16+CD56+仍未恢复至麻醉前水平(P<0.05).与B组比较,A组CD3+、CD4+、CD4+/CD8+在术后24 h下降幅度较小(P<0.05),而NK细胞则在手术2 h和术后24 h下降幅度较小(P<0.05).结论 胃癌根治术患者围术期用氟比洛芬酯联合吗啡镇痛较单用吗啡镇痛对T淋巴细胞亚群和NK细胞有保护作用.     

胃癌根治术中自体输血病人围术期血清新喋呤和白细胞介素-2浓度的变化

目的探讨自体输血胃癌根治术病人围术期血清新喋呤、白细胞介素-2(IL-2)浓度的变化。方法拟行胃癌根治术病人60例,随机分为2组:异体输血组(H组)术中输异体全血400 ml;自体输血组(A组)麻醉诱导后采集自体血400ml,同时输入琥珀酰明胶500ml,术中将采集的自体血进行回输。分别于麻醉诱导前(术前)、术毕拔管后(术毕)、术后第5天抽取静脉血,用ELISA法检测血清新喋呤和IL-2浓度。结果与术前比较,H组术毕和术后第5天时血清新喋呤、IL-2浓度降低,A 组术毕血清新喋呤浓度降低(P<0.05或0.01),术后第5天时恢复至术前水平,IL-2浓度无明显变化(P>0.05)。与H组比较,A组术毕和术后第5天时血清新喋呤浓度升高,IL-2浓度术后第5天时升高(P<0.01)。H组和A组新喋呤和IL-2浓度的相关系数分别为0.071和-0.29(P>0.05)。结论自体输血对胃癌根治术病人术后机体细胞免疫功能抑制较轻,与IL-2相比,血清新喋呤可更敏感的反映病人术后免疫功能。     

扁桃体间充质干细胞免疫学特性的初步研究

目的 探讨扁桃体间充质干细胞(tonsil mesenchymal stem cells,TMSCs)的免疫学特性及机制.方法 取慢性扁桃体炎患儿的扁桃体组织,分离、培养TMSCs,通过流式细胞术检测HLA-Ⅰ、HLA-Ⅱ、CD80、CD86等免疫分子的表达情况.以牙周膜干细胞作为对照,观察TMSCs能否引起同种异体外周血单个核细胞(peripheral blood mononuclear cells,PBMCs)的增殖,以及TMSCs对混合淋巴细胞反应(mixed lymphocyte reaction,MLR)和植物血凝素(phytohemagglutinin,PHA)引起的淋巴细胞增殖的影响.建立TMSCs+PHA+异体PBMCs、TMSCs+MLR的培养体系,测定细胞上清液中的犬尿氨酸浓度.在上述反应体系进行中和实验,观察被TMSCs抑制了的淋巴细胞重新发生增殖的情况.每个实验重复3次,每组6个佯本.统计学方法采用方差分析,P ＜0.05为差异有统计学意义.结果 TMSCs表达HLA-Ⅰ,但不表达HLA-Ⅱ和共刺激分子CD80、CD86.TMSCs与异体PBMCs共培养5d后,刺激指数为1.38±0.26,而单纯PBMCs培养5d后的刺激指数为1.22±0.28,2组差异无统计学意义(P＞0.05),证实TMSCs不会引起异体PBMCs增殖.TMSCs与异体PBMCs、PHA共培养5d后,刺激指数分别为1.49±0.29(TMSCs∶ PBMCs为0.5∶1)和1.23±0.22(TMSCs∶ PBMCs为1∶1),而PBMCs+PHA组培养5d后的刺激指数为4.60±0.81,2组之间的差异均有统计学意义(P＜0.05),说明TMSCs能够抑制PHA引起的淋巴细胞增殖.TMSCs与MLR共培养5d后,刺激指数分别为1.29±0.23(TMSCs∶ PBMCs为0.5∶1)和1.26±0.27(TMSCs∶ PBMCs为1∶1),而MLR培养5d后的刺激指数为3.04±0.66,2组之间的差异均有统计学意义(P＜0.05),说明TMSCs能够抑制MLR引起的淋巴细胞增殖.在TMSCs+PHA+异体PBMCs、TMSCs+MLR的培养体系中,犬尿氨酸浓度显著升高,分别为(26.0±2.3) μmol/L和(23.5±4.5)μmol/L.中和实验发现,1-甲基-L-色氨酸基本恢复了被TMSCs抑制的淋巴细胞增殖.结论 TMSCs具有低免疫原性和免疫抑制特性,有望进行同种异体移植.     

输去白红细胞血对肿瘤患者围术期细胞免疫功能的影响

目的　探讨输去白红细胞血对胃癌、结肠癌患者围术期T淋巴细胞亚群及自然杀伤(NK)细胞的影响。方法　 30例胃癌、结肠癌手术患者 ,随机分为三组 :输盐水组 (Ⅰ组 ) ,输全血组(Ⅱ组 ) ,输去白红细胞组 (Ⅲ组 ) ,每组 10例 ,分别于术前、术后第 1、5天抽取外周静脉血 ,用流式细胞仪测定血T淋巴细胞亚群CD3+ 、CD4 + 、CD8+ 、CD4 + /CD8+ 比值及CD5 6 + 的变化。结果　与术前相比 ,术后第 1天三组患者CD3+ 、CD4 + 、CD8+ 、CD4 + /CD8+ 及CD5 6 + 均显著降低 (P <0 0 5 )。术后第 5天Ⅱ组CD3+ 、CD4 + 、CD8+ 、CD5 6 + 明显低于术前水平 (P <0 0 5 ) ;而Ⅰ组及Ⅲ组各指标均接近术前水平 (P >0 0 5 )。结论　围术期异体输血严重抑制患者的免疫功能。输去白红细胞血对机体的免疫抑制轻 ,术后免疫功能较快恢复。因此 ,在确实要输异体血时 ,最好滤除白细胞 ,以减轻异体血对肿瘤患者免疫功能的抑制作用。     

围术期外周血单核细胞β2整合素表达的变化

目的 动态观察围术期患者外周血单核细胞β2整合素族的白细胞功能相关抗原(LFA-1即CD11a/CD18)和巨噬细胞分化抗原(Mac-1即CD11b/CD18)阳性表达率的变化情况,并比较不同手术创伤对其表达的影响。方法 选择择期手术患者24例,其中髋关节置换手术为Ⅰ组(n=10),下腹部手术为Ⅱ组(n=14)。所有患者均采用腰硬联合麻醉,且阻滞效果确切。分别于术前、术毕、术后第1天、术后第3天采集外周静脉血,采用免疫荧光流式细胞检测术,测定外周血单核细胞膜上CD11a/CD18、CD11b/CD18阳性表达率(％)。另选14位健康志愿者作对照测定正常值。结果 与正常对照值相比,两组围术期各时点CD11b/CD18差异均显著性增高30％-45％(P<0.01),而CD11a/CD18差异无显著性(P>0.05)。与术前相比,两组在术毕及术后第1天CD11b/CD18均显著性增高(P<0.05),术后第3天差异无显著性。CD11b/CD18在术后第1天Ⅰ组较Ⅱ组有显著性增高(P<0.05)。结论 围术期患者外周血单核细胞CD11b/CD18阳性表达率显著性上调,髋关节置换手术患者在术后24h的阳性表达上调较下腹部手术患者更显著;单核细胞可能主要通过CD11b/CD18介导而发挥多种功能。     

胃肠肿瘤根治术对炎性细胞因子和应激激素影响的研究

目的探讨围手术期细胞因子和应激激素的变化规律及其临床意义。方法 96.3～96.12中山一院外科Ⅱ、Ⅲ期胃癌(A 组)13例,低位直肠癌(B 组)13例和食管贲门癌(C 组)11例,均接受根治性切除术,对照组(10例)为择期小手术。所有患者于术前1日、术后2小时、术后1日和术后6日取血,测定血浆中 IL-6,IL-8,ACTH,Cortisol 含量。结果 A、B、C 三组患者术后2小时 IL-6、IL-8、ACTH、Cortisol 含量显著升高(P<0.05),但各组上升幅度不同,术后1日则显著下降。出现并发症患者 IL-6和 IL-8呈过度升高,而对照组仅ACTH 显著升高(P<0.05)。结论围手术期细胞因子和应激激素的变化具有显著时效性,监测其变化有利于判断手术创伤程度和予后,具有显著临床意义。     

小剂量高渗氯化钠羟乙基淀粉40对自然杀伤细胞和血小板CD41的影响

目的 观察术中高渗氯化钠羟乙摹淀粉40注射液(HSS40)对恶性肿瘤患者体内自然杀伤细胞(NK细胞)和血小板活化分子CD41影响.方法 将76例手术患者随机分两组:输血组(A组)38例、HSS40组(B组)38例.于麻醉前1 h、术后1、3、7 d抽取外周血,细胞检测仪检测CD56和CD41含量;以乳酸脱氢酶释放法检测NK细胞活性.结果 组间比较:CD56术后第3、7天B组高于A组,差异显著(25.560±11.026比15.648±6.729;29.040±10.221比15.035±6.758,P<0.01),NK细胞活性术后第7天两组比较差异有统计学意义(19.939±6.994比15.307±5.107,P<0.05);CD4,术后l d B组明显低于A组(7.740 4-4.101比10.752 4-5.493,P<0.01).组内比较:A组术后第3天NK细胞活性下降(P<0.05),术后第7天下降明显,与术前比较差异有统计学意义(P<0.01),B组术后第7天NK细胞活性与术前比较差异有统计学意义(P<0.05),CD56术后第3天有所上升(P<0.05),术后第7天上升明显,与术前比较差异有统计学意义(P<0.01).两组CD41术后1～7 d均明显高于术前水平(P<0.01).结论 手术和输血可导致术后NK细胞活性降低,血小板CD41含量明显升高,术中输注HSS40,术后NK细胞活性及数目不同程度升高,且降低血小板CD41含量.     

Crystalloids,colloids, blood,blood products and blood substitutes

Understanding the physiology of fluid distribution within the human body is fundamental to the practice of anaesthetists and intensivists of all grades. There is a necessity to recognize the range of actions and consequences of the commonly infused intravenous fluids if safe patient care is to be provided. There are many historical and on-going trials surrounding fluid therapy and it is important for the physician to keep up to date with current guidelines.There is a continued drive to improve the safety of donor blood and prevent transfusion errors. Knowledge of how blood products are collected separated and stored is essential to prevent harm to patients through transfusions. Work in producing blood substitutes is progressing, but to date, trials have failed to market a product in Europe and the USA with an acceptable risk profile.     

Perioperative blood and blood component therapy

This overview examines blood, blood components, their indications and contra-indications, from an anaesthetist's viewpoint. The dangers of any blood transfusion, including infection transmission and immune suppression, as well as the risks of massive and rapid transfusions, are discussed. Autologous predonation, intraoperative haemodilution and salvage are described to help prevent some of the risks of homologous blood transfusion. Preoperatively an acceptable individualised haemoglobin concentration should be calculated for each patient and a history for potential bleeding problems taken. In most patients perioperative anaemia does not adversely influence patient morbidity and mortality. However, if blood is required, 4 ml.kg-1 body weight of packed red blood cells will raise the patient's haemoglobin concentration by 1 g.dl-1. The bleeding time as a test of platelet function does not predict perioperative blood loss. However, it remains a useful test in patients with a known bleeding problem or in operations where even small amounts of bleeding increase the surgical difficulty and patient morbidity. If bleeding is due to thrombocytopaenia it is usually slow enough to allow time to check platelet number and function before ordering and transfusing them. Fresh plasma is a much overused product which should mainly be used for coagulation factor replacement, in adequate volumes (4-8 packs in dilutional coagulopathy). The well-informed anaesthetist should be better able to use blood products which, while they may be life saving, are neither innocuous nor inexpensive.     

Crystalloids,colloids, blood,blood products and blood substitutes

The choice of fluid in a given clinical scenario relies on knowledge of the physiology and pharmacology of the fluid. A broad range of fluids are discussed in this article, with particular emphasis on problems associated with excess administration of 0.9% saline. Colloids, blood, blood products and blood substitutes are also discussed. Balancing the risks of allogenic blood transfusion for a patient and transfusion thresholds are considered. The potential of haemoglobin substitutes are still yet to be realized; however PolyHeme is currently in a phase 3 pre-hospital trauma trial.     

Ambulatory blood pressure monitoring: mean blood pressure and blood pressure load

Ambulatory blood pressure monitoring (ABPM) is commonly used to diagnose pediatric hypertension. Using ABPM, hypertension is usually defined as a mean BP greater than the 95th percentile for height. A BP load >30% (% of BP readings greater than the 95th percentile) is also used for the diagnosis of hypertension. The objective of this study was to determine the agreement between mean BP greater than the 95th percentile and 30% BP load for the diagnosis of hypertension using ABPM. All ABPM records (n =1,009) of patients referred for hypertension to a pediatric center were retrieved. Scans were excluded if: age was >19 and height <115 cm or >185 cm. Mean BP and BP loads were calculated for 728 scans. Agreement between mean BP greater than the 95th percentile for height and various BP loads were calculated using the kappa coefficient. The kappa coefficient of agreement between mean BP greater than the 95th percentile and 30% BP load was 0.56 and 0.57 for daytime systolic and diastolic BP, respectively. The agreement between mean night-time BP greater than the 95th percentile and 30% BP load was 0.70 and 0.66 for systolic and diastolic BP, respectively. Agreement between mean BP greater than the 95th percentile and 30% BP load is only moderate to good. Maximum agreement between mean BP greater than the 95th percentile and BP load is achieved at 50% BP load.     

Worldwide supply of blood and blood products

Blood services have achieved a high degree of sophistication, but there remain serious logistic problems which interfere with the adequacy of blood supplies. Many countries have not been able to implement modern component therapy. Supplies of certain specialized products, such as factor VIII, are insufficient almost everywhere. There is a lively international trade in blood products, and corresponding evidence of disease transmission when the rate of infection is relatively high in the exporting region. The answer to these problems lies in the development everywhere of effective blood programs, based on the organization of nonremunerated blood donors.

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Resumen Los servicios de banco de sangre han alcanzado un alto grado de sofisticación, pero hay todavía serios problemas logísticos que interfieren con la debida provisión. Muchos países no han logrado organizar programas de terapia con componentes sangurneos. La provisión de ciertos productos especializados, tales como el factor VIII, es insuficiente casi en todas partes. Existe un activo comercio internacional de productos sanguíneos con la correspondiente evidencia de transmisión de enfermedades cuando la tasa de infección es relativamente alta en la región exportadora. La respuesta a estos problemas recae en el desarrollo universal de programas efectivos de banco de sangre basados en la organización de donantes no remunerados.

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Résumé Les services de transfusion sanguine ont atteint un haut degré d'organisation mais des problèmes logistiques persistent en particulier en ce qui concerne les sources de sang. Dans de nombreux pays il n'a pas été possible de mettre en oeuvre l'emploi de constituants isolés du sang. L'approvisionnement en certaints produits spécialisés tels que le facteur VIII est insuffisant presque dans le monde entier. Il existe par ailleurs un actif commerce international de produits sanguins avec pour conséquence la transmission possible de maladies, lorsque le taux de l'infection est relativement élevé dans le pays exportateur. La réponse adéquate à ces problèmes consiste dans le développement dans chaque pays d'un programme autonome basé sur le recrutement de donneurs volontaires non rémunérés.

     

Anaemia and blood transfusion incorporating patient blood management

Chronic anaemia in the stable patient carries a small risk in non-haemorrhagic surgery. Where bleeding is anticipated, anaemia can be treated medically to avoid transfusion. Both intravenous (IV) iron and erythropoiesis stimulating agents (ESA) are gaining popularity to raise the haemoglobin (Hb) in anaemic patients. Bleeding causes acute anaemia requiring maintenance of blood volume and only transfusion to keep the haematocrit (Hct) >21% and Hb >74 g/L in low-risk patients without coronary artery disease (CAD) and Hct 24–27% or Hb >80 g/L in high-risk patients. Both anaemia and transfusion increase the morbidity and mortality associated with surgery. The most significant impact on adverse outcomes is major bleeding (MB). Medical, surgical and anaesthetic management should focus on correcting anaemia and avoidance of bleeding to prevent adverse outcomes for the patient.