利多卡因对脓毒症大鼠肺损伤的影响

目的 研究利多卡因对脓毒症大鼠肺损伤的影响。
方法 选择清洁级SD成年雄性大鼠30只,2月龄,体重250～300 g。采用随机数字表法将大鼠分为三组：假手术组（S组）、盲肠结扎穿孔组（C组）和利多卡因组（L组）,每组10只。S组仅打开腹腔后缝合,C组和L组采用盲肠结扎穿孔法（CLP）建立脓毒症模型。L组建立脓毒症模型后即刻给予利多卡因的负荷剂量10 mg/kg,后尾静脉持续泵注利多卡因10 mg·kg^-1·h^-1,持续3 h;S组和C组注射等量等渗氯化钠溶液。于建模后24 h处死大鼠,打开腹腔,采集下腔静脉血5 ml,采用ELISA法检测血清TNF-α、糖萼成分多配体聚糖1（Syndecan-1）、乙酰肝素酶（Heparanase）浓度。处死大鼠后采集腹主动脉血0.5 ml进行血气分析,记录PaO₂和PaCO₂。腹主动脉取血之后迅速开胸,取双肺组织,左肺组织计算肺组织湿/干重比,右肺组织采用透射电镜观察血管内皮糖萼结构。
结果 与S组比较,C组血清TNF-α、Syndecan-1和Heparanase浓度均明显升高（P<0.05）,PaO₂和PaCO₂明显降低（P<0.05）,C组肺组织湿/干重比明显升高（P<0.05）。与C组比较,L组血清TNF-α、Syndecan-1和Heparanase浓度均明显降低（P<0.05）,PaO₂和PaCO₂明显升高（P<0.05）,肺组织湿/干重比明显降低（P<0.05）。S组糖萼连续,分布均匀,结构致密;C组糖萼不连续,出现大量中断,分布不均匀,糖萼结构明显疏松;L组糖萼不连续,出现少量中断,分布不均匀,糖萼结构较疏松,但中断程度、分布不均匀程度以及疏松程度均轻于C组。
结论 利多卡因可以减少炎性因子释放、改善肺血管通透性、减轻脓毒症肺损伤,保留糖萼结构完整性。     

允许性高每搏量变异度在老年患者腹腔镜肝切除术中的应用

目的探讨允许性高每搏量变异度（SVV）在老年患者腹腔镜肝切除术中的应用效果。
方法选择2020年8月至2021年8月拟行腹腔镜肝脏切除手术的患者100例,男67例,女33例,年龄65～80岁,BMI 18～25 kg/m²,ASA Ⅱ或Ⅲ级。采用随机数字表法将患者分为两组：以SVV指导补液的研究组（S组）和以CVP指导补液的对照组（C组）,每组50例。S组：第1阶段以允许性高SVV值（13%～20%）行液体治疗,第2阶段以SVV（9%～13%）为目标进行补液;C组：第1阶段以低CVP值（0～5 cmH₂O）行液体治疗,第2阶段以CVP（5～12 cmH₂O）为目标进行补液。记录第1、2阶段持续时间、血管活性药使用情况、术中出血量、输液量、尿量、术毕乳酸浓度。记录入室、切皮、开始切肝、切肝完成、术毕的HR、MAP。持续记录术中脑氧饱和度（rSO₂）,计算术中rSO₂平均值（rSO_2mean)、术中rSO₂最小值（rSO_2min）、rSO₂较基础值下降的最大百分比（rSO_2%max）。记录术前1 d、术后1、2、3 d的肌酐（Cr）、尿素氮（BUN）。
结果S组去氧肾上腺素、硝酸甘油使用率明显低于C组（P<0.05）,S组术中出血量明显少于C组（P<0.05）,术中输液量、尿量明显多于Ｃ组（P<0.05）,术毕时S组血清乳酸浓度明显低于C组（P<0.05）。与C组比较,在开始切肝、切肝完成时S组HR明显减慢(P<0.05),MAP明显升高（P<0.05）。S组rSO_2%max明显低于C组（P<0.05）。术后1、2、3 d S组Cr明显低于C组（P<0.05）。
结论在腹腔镜肝切除术中采用允许性高SVV指导目标导向液体治疗,可减少术中出血,维持血流动力学稳定,保证重要脏器的血液灌注。     

血管紧张素-（1-7）及其受体激动剂AVE0991治疗大鼠急性肺损伤的效果

目的 探讨血管紧张素-（1-7）［Ang-（1-7）］及其特异性受体激动剂AVE0991用于治疗大鼠急性肺损伤（ALI）的效果。
方法 选择清洁级雄性SD成年大鼠45只，6～8周龄，体重250～300 g。采用随机数字表法将大鼠分为五组：对照组（C组）、ALI组（L组）和Ang-（1-7）组（LA组）、AVE0991组（LAV组）和Ang-（1-7）抑制剂（A-779）（LAN组），每组9只。L组静脉注射脂多糖（LPS） 5 mg/kg，机械通气V_T 15 ml/kg，持续4 h；C组静脉注射与 L组等容量的生理盐水，机械通气V_T 8 ml/kg，持续4 h；LA组、LAV组和LAN组静注LPS 5 mg/kg，机械通气V_T 15 ml/kg，持续2 h后分别静注Ang-（1-7） 50 pmol·kg^-1·min^-1、AVE0991 500 pmol·kg^-1·min^-1和A-779 100 pmol·kg^-1·min^-1，继续机械通气2 h 。记录机械通气前（T₀）、机械通气 2 h（T₁）、药物处理 30 min（T₂）、60 min（T₃）、90 min（T₄）、120 min（T₅）时的肺动脉压（PAP）；T₁和T₅时取肺动脉血行血气分析，记录LA组、LAV组和LAN组的PaCO₂、PaO₂。处死大鼠，对支气管肺泡灌洗液（BALF）采用瑞氏-姬姆萨染色行白细胞分类计数，采用ELISA法检测股静脉血TNF-α浓度，采用肺组织称重法计算肺湿/干重比（W/D），采用HE染色观察肺组织病理改变并评估肺损伤程度。
结果 与T₁时比较，T₂时LA组PAP明显降低（P<0.05），T₂—T₄时LAV组PAP明显降低（P<0.05），T₅时LA组PaO₂明显升高（P<0.05）。与C组比较，L组和LAN组BALF中白细胞计数明显增多（P<0.05），L组、LA组、LAV组和LAN组血清TNF-α浓度和W/D值明显升高（P<0.05）。与L组比较，LA组和LAV组BALF中白细胞计数、血清TNF-α浓度和W/D值明显降低（P<0.05）。与LA组比较，LAN组BALF中白细胞计数、血清TNF-α浓度和W/D值明显升高（P<0.05）。C组肺组织损伤轻微，L组肺组织损伤中度，LA组和LAV组肺组织损伤轻度，LAN组肺组织损伤严重。
结论 Ang-(1-7)及AVE0991可以减轻大鼠大潮气量通气合并LPS所致ALI的炎症反应，改善肺损伤，具有肺保护作用。     

脑氧饱和度监测下控制性降压对老年高血压患者术后谵妄的影响

目的 探讨脑氧饱和度(rSO₂)监测下控制性降压对老年高血压患者术后谵妄（POD）的影响。方法 择期全麻下行鼻泪道手术的老年高血压患者110例,男53例,女57例,年龄65~85岁,ASA Ⅱ或Ⅲ级,高血压Ⅰ或Ⅱ级,采用随机数字表法分为两组：rSO₂监测组（S组）和对照组（C组）,每组55例。两组均采用乌拉地尔联合艾司洛尔控制性降压,维持MAP≥基础值的70%,且MAP≥55 mmHg;当S组rSO₂<基础值的80%或rSO₂最低值<基础值的50%,并且持续时间大于10 s,则逐步提升血压直至rSO₂恢复至≥基础值的80%或绝对值＞50%。C组rSO₂监护仪施行遮盖处理。记录入室后吸氧5 min（T0）、控制性降压15 min（T1）、30 min（T2）、控制性降压结束后5 min（T3）、拔管后10 min（T4）的HR、MAP、rSO₂;记录rSO₂基础值、术中最低值及较基础值下降的最大百分比;术后1、2、3 d采用谵妄评定方法 中文修订版（CAM-CR量表）对患者进行POD评估。结果 与T0时比较,T1—T2时两组MAP明显下降（P<0.05）,C组rSO₂明显下降（P<0.05）,T3—T4时逐渐回升至术前水平。T1—T2时S组rSO₂明显高于C组（P<0.05）,术中rSO₂最低值明显高于C组（P<0.05）,rSO₂较基础值下降的最大百分比明显低于C组（P<0.05）。术后1 d S组POD发生率明显低于C组（P<0.05）。结论 rSO₂监测下控制性降压能减少老年高血压患者鼻泪道手术后谵妄的发生,提高围术期安全性。     

睡眠剥夺对小鼠大肠组织炎症反应和氧化应激的影响

目的 探讨睡眠剥夺对小鼠大肠组织炎症反应和氧化应激的影响。
方法 选择SPF级雄性C57小鼠32只,8～12周龄,体重18～22 g。采用随机数字表法分为四组：空白对照组（C组）、切口组（I组）、睡眠剥夺组（A组）和睡眠剥夺+切口组（AI组）,每组8只。C组正常饲养,I组建立切口模型,A组使用睡眠剥夺箱睡眠剥夺48 h,AI组使用睡眠剥夺箱睡眠剥夺48 h后建立切口模型。取小鼠大肠组织,采用Western blot法检测白细胞介素-1β（IL-1β）、肿瘤坏死因子-α（TNF-α）、还原型烟酰胺腺嘌呤二核苷酸磷酸氧化酶2（NOX2）和超氧化物歧化酶2（SOD2）蛋白含量,超氧化物阴离子荧光探针法检测活性氧（ROS）荧光强度,免疫荧光染色法检测NOX2荧光强度。
结果 与C组比较,I组、A组和AI组大肠组织IL-1β、TNF-α和NOX2蛋白含量明显升高（P<0.05）,SOD2蛋白含量明显降低（P<0.05）,ROS和NOX2荧光强度明显增强（P<0.05）。与I组比较,A组和AI组大肠组织IL-1β、TNF-α和NOX2蛋白含量明显升高（P<0.05）,AI组大肠组织SOD2蛋白含量明显降低（P<0.05）,ROS和NOX2荧光强度明显增强（P<0.05）。与A组比较,AI组大肠组织IL-1β、TNF-α和NOX2蛋白含量明显升高（P<0.05）,SOD2蛋白含量明显降低（P<0.05）,ROS和NOX2荧光强度明显增强（P<0.05）。
结论 睡眠剥夺会引起小鼠大肠组织炎症反应和氧化应激,睡眠剥夺下行切口手术会进一步加重炎症反应与氧化应激。     

FOLFOX-肝动脉灌注化疗联合程序性死亡受体-1抑制剂和靶向药物治疗中国肝癌分期Ⅲa期肝细胞癌

目的 观察FOLFOX-肝动脉灌注化疗（HAIC）联合程序性死亡受体-1（PD-1）抑制剂和靶向药物治疗中国肝癌分期（CNLC）Ⅲa期肝细胞癌（HCC）的价值。方法 回顾性分析61例接受PD-1抑制剂+靶向药物治疗的CNLC Ⅲa期HCC患者,根据是否接受联合FOLFOX-HAIC治疗将其归入观察组（n=30）及对照组（n=31）;比较组间一般资料、治疗方案、不良反应及疗效,分析观察组方案的治疗价值。结果 组间患者一般资料及PD-1抑制剂+靶向药物方案差异均无统计学意义（P均＞0.05）;1～2级不良反应中,观察组恶心、呕吐及腹痛发生率均高于对照组（P均＜0.05）,而其余1～2级及3级不良反应组间发生率差异均无统计学意义（P均＞0.05）。观察组客观缓解率（ORR）、无进展生存期（PFS）及总生存期（OS）均高于对照组（P均＜0.05）。结论 FOLFOX-HAIC联合PD-1抑制剂+靶向药物治疗CNLC Ⅲa期HCC疗效较佳而安全性尚可。     

右美托咪定对肺癌根治术患者单肺通气相关肺损伤的影响

目的 评价右美托咪定对肺癌根治术患者单肺通气（OLV）相关肺损伤的影响。
方法 选择择期行肺癌根治手术的患者40例,男30例,女10例,年龄42～70岁,ASA Ⅰ或Ⅱ级,且术中OLV超过2 h。采用随机数字表法将患者分为两组：右美托咪定组（D组）和对照组（C组）,每组20例。麻醉诱导后,D组给予右美托咪定初始剂量0.5 μg/kg,给药时间大于10 min,继之以0.5 μg·kg^-1·h^-1的速度维持至手术结束前30 min,C组给予等容量的生理盐水。分别于给药前即刻、OLV 60、90和120 min、恢复双肺通气30 min时采集桡动脉血,测定血清肿瘤坏死因子-α（TNF-α）、白细胞介素-8 （IL-8）浓度,并进行血气分析,计算氧合指数（OI）和动态肺顺应性（Cdyn）;免疫组织化学法观察OLV前即刻、肺叶离体时肺组织肺水通道蛋白5（AQP5）的染色程度,计算免疫组织化学评分。
结果 与给药前即刻比较,OLV 60、90和120 min、恢复双肺通气30 min时两组血清TNF-α、IL-8浓度明显升高（P<0.05）,OI和Cdyn明显降低（P<0.05）。OLV 60、90和120 min、恢复双肺通气30 min时D组血清TNF-α、IL-8浓度明显低于C组（P<0.05）,OI明显高于C组（P<0.05）。OLV 90、120 min时D组Cdyn明显高于C组（P<0.05）。肺叶离体时D组AQP5蛋白染色程度明显深于C组,AQP5蛋白免疫组织化学评分明显高于C组（P<0.05）。
结论 右美托咪定降低血清TNF-α、IL-8 浓度,促使AQP5 在肺组织中表达的增强,减轻肺癌根治术患者单肺通气期间的肺损伤,改善肺功能。     

个体化呼气末正压通气对肥胖患者腹腔镜胃减容术后肺部并发症的影响

目的 研究个体化呼气末正压（PEEP）通气策略对肥胖患者腹腔镜胃减容术后肺部并发症（PPCs）的影响。
方法 选择行全身麻醉腹腔镜胃减容术的成年肥胖患者40例,男15例,女25例,年龄18～44岁,BMI 35～55 kg/m²,ASA Ⅱ或Ⅲ级。采用随机数字表法分为两组：个体化PEEP组（I组）和固定PEEP组（C组）,每组20例。I组在诱导插管后依据肺动态顺应性（Cdyn）个体化滴定最佳PEEP并维持此PEEP进行术中通气,C组以PEEP 8 cmH2O进行术中通气。记录插管后5 min、气腹后1 h的氧合指数、分流率以及气道峰压、气道平台压、驱动压、Cdyn等呼吸力学参数,记录术中低血压发生情况、输液量、血管活性药用量、机械通气时间和术后住院时间,记录术后第1天、第2天、第3天、第8天PPCs的发生情况以及术后8 d内PPCs累积发生率。
结果 I组PPCs累积发生率明显低于C组 ［13例（65%） vs 19例（95%）, P＜0.05］。气腹后1 h 时I组氧合指数、气道峰压、气道平台压、Cdyn均明显高于C组（P<0.05）,I组驱动压明显低于C组（P<0.05）。两组术中低血压发生率、输液量、去氧肾上腺素用量、机械通气时间和术后住院时间差异无统计学意义。
结论 个体化PEEP能够降低腹腔镜胃减容术患者PPCs发生率,并在不影响血流动力学稳定性的同时降低术中驱动压,改善氧合。     

不同浓度罗哌卡因竖脊肌平面阻滞在腹腔镜下胃癌根治术中的应用效果

目的 观察不同浓度罗哌卡因竖脊肌平面阻滞（ESPB）对腹腔镜下胃癌根治术患者术中镇痛效果和炎性因子的影响。
方法 择期行腹腔镜胃癌根治术患者80例,男54例,女26例,年龄40～65岁,BMI 18～25 kg/m²,ASA Ⅰ或Ⅱ级,采用随机数字表法将患者分为四组,每组20例。S1、S2、S3组行双侧ESPB,每侧分别注射0.25%、0.375%、0.5%罗哌卡因,随后行全身麻醉;C组行单纯全身麻醉。术中采用全凭静脉麻醉,术毕行舒芬太尼PCIA。记录阻滞起效时间和持续时间;记录术后2、8、12、24、48 h静息和运动时VAS疼痛评分;记录术中舒芬太尼用量、术后48 h内镇痛泵有效按压次数和舒芬太尼追加情况。记录术后2、8、12、24 h血清IL-6和IL-10浓度;记录术后呼吸抑制、恶心呕吐、局麻药中毒等不良反应情况。
结果 与S1组比较,S2组、S3组阻滞起效时间明显缩短（P<0.05）;与S2组比较,S3组阻滞起效时间明显缩短（P<0.05）。三组阻滞持续时间差异无统计学意义。与C组比较,S1组、S2组、S3组术后2、8、12 h静息和运动时VAS疼痛评分明显降低（P<0.05）;与S1组比较,S2组、S3组术后8 h静息和运动时VAS疼痛评分明显降低（P<0.05）。与C组比较,S1组、S2组、S3组术中舒芬太尼用量和术后48 h内镇痛泵有效按压次数明显减少（P<0.05）。与S1组比较,S2组、S3组术后48 h内镇痛泵按压次数明显减少（P<0.05）。与C组比较,S2、S3组术后追加舒芬太尼例数明显减少（P<0.05）。与C组比较,术后8、12 h S1组、S2组、S3组IL-6浓度明显降低,IL-10浓度明显升高（P<0.05）。四组术后呼吸抑制、恶心呕吐发生率差异无统计学意义。S3组术后有1例（5%）出现肌肉震颤的局麻药中毒反应。
结论 超声引导下0.375%罗哌卡因ESPB可减少腹腔镜下胃癌根治术的围术期阿片类药物用量,镇痛效果确切,同时减轻胃癌患者术后炎症反应。     

超声引导下不同入路髂筋膜间隙阻滞用于老年患者股骨近端防旋髓内针内固定术围术期镇痛效果的比较

目的 比较超声引导下腹股沟韧带上髂筋膜间隙阻滞（S-FICB）与腹股沟韧带下髂筋膜间隙阻滞（I-FICB）在行股骨近端防旋髓内针内固定术老年患者围术期的镇痛作用。
方法 限期行股骨近端防旋髓内针内固定术的股骨粗隆间骨折患者80例,男43例,女37例,年龄65～85岁,ASA Ⅰ—Ⅲ级,随机分为两组：S-FICB组（S组）和I-FICB组（I组）,每组40例。S组和I组分别注射0.4%罗哌卡因40 ml行S-FICB和I-FICB。记录阻滞操作时间、股神经及股外侧皮神经阻滞起效时间及阻滞效果。记录术后2、6、12、24、48 h静息及运动时VAS疼痛评分、自控镇痛按压次数及补救镇痛情况。记录术后不良反应的发生情况。
结果 两组阻滞操作时间、股神经阻滞效果差异无统计学意义。S组股神经及股外侧皮神经阻滞起效时间明显短于I组（P<0.05）,股外侧皮神经阻滞效果明显优于I组（P<0.05）。S组术后2、6、12 h运动时VAS疼痛评分明显低于I组（P<0.05）。两组术后自控镇痛、补救镇痛及不良反应发生率差异无统计学意义。
结论 与I-FICB比较,S-FICB阻滞起效更快,股外侧皮神经阻滞效果更好,患者术后变换体位时镇痛效果更好。     

门静脉高压犬肝缺血再灌注时肺循环血液动力学及NO/ET和PGI2/TXA2的变化

目的 评价门静脉高压犬肝缺血再灌注时肺循环血液动力学及肺循环一氧化氮(NO)/内皮素(ET)和前列腺素I2(PGI2)/血栓素A2(TXA2)的变化.方法 健康家犬12只,雌雄不拘,体重10～18 kg,随机分为2组(n=6):对照组和模型组.模型组采用部分结扎门静脉的方法 建立犬门静脉高压模型,12周后完全阻断门静脉、肝后下腔静脉30 min,再灌注60 min制备肝缺血再灌注模型.于第2次麻醉后即刻、肝缺血前即刻、缺血5、30 min、再灌注前即刻、再灌注5、10、15、30和60 min(T1-10)时记录心率(HR)、心输出量(CO)、中心静脉压(CVP)、肺动脉楔压(PAWP)和平均肺动脉压(MPAP),计算心脏指数(CI)、肺血管阻力(PVR)和肺血管阻力指数(PVRI),并计算T2-10时CI、CVP、MPAP、PAWP和PVRI相对于T1的变化幅度;于T2、T4和T9时测定肺动脉血浆NO、ET、TXA2和PGI2的浓度,并计算NO/ET和PCI2/TXA2比值.结果 两组肝缺血时CI、CVP、PVRI、PAWP和MPAP均降低,且模型组CI、CVP、PAWP、MPAP降低幅度低于对照组,两组再灌注时CVP、PAWP、MPAP和PVRI均升高,且模型组PAWP和PVRI升高幅度高于对照组(P<0.05或0.01);模型组肝缺血再灌注时肺动脉血浆NO浓度、NO/ET比值和肝缺血时肺动脉血浆TXA2浓度、PGI2/TXA2比值均低于对照组(P<0.01).模型组PVR与肺动脉血浆NO浓度呈负相关(r=-0.567,P<0.05).结论 门静脉高压犬肝缺血再灌注时肺动脉压升高,可能与肺循环NO水平降低、NO与ET失衡有关.     

The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial

BACKGROUND CONTEXTTranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction.PURPOSEThe primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects.STUDY DESIGNProspective, double-blinded, randomized controlled trial.PATIENT SAMPLEA total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study.OUTCOME MEASURESThe primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL.METHODSPatients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo.RESULTSThe mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1–786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6–763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL.CONCLUSIONSA multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.     

氨甲环酸不同静脉给药方式对青少年特发性脊柱侧凸后路矫形术中出血量的影响

目的 对比氨甲环酸(TXA)不同静脉给药方式对青少年特发性脊柱侧凸(AIS)后路矫形术中出血量的影响及安全性.方法 2017年1月—2020年3月,廊坊市第四人民医院采用脊柱后路矫形术治疗AIS患者120例,按照随机数字表法分为3组,每组40例.A组切开皮肤前15 min静脉滴注TXA 30 mg/kg;B组切开皮肤前15 min静脉滴注TXA 15 mg/kg,术中给予TXA 10 mg/(kg·h)维持至术毕;C组围手术期不使用TXA.比较3组手术时间、术中出血量、异体血输注量、晶体输注量、胶体输注量、术后输血率、术后引流量及手术前后血红蛋白(Hb)水平、D-二聚体(D-D)水平等指标,并记录并发症发生情况.结果 所有手术顺利完成.A、B组术中出血量、异体血输注量、胶体输注量、术后输血率、术后1 d引流量低于C组,术后各时间点Hb水平高于C组,差异均有统计学意义(P<0.05);以上指标A、B组组间比较,差异无统计学意义(P>0.05).3组术后各时间点D-D水平均较术前明显升高,术后1 d达到最高值,之后逐渐下降;术后各时间点A、B组D-D水平低于C组,差异均有统计学意义(P<0.05);A、B组组间比较,差异无统计学意义(P>0.05).所有患者切口愈合良好,术后双下肢血管超声检查未见深静脉血栓形成.术后电话随访均未出现相关并发症.结论 术前TXA足够剂量静脉滴注可取得与首次负荷量联合术中维持量静脉滴注相同的止血效果,无安全隐患,术前单剂量静脉滴注在操作上更为简便,值得推广应用.     

Kidney fibrosis induced by various irrigation pressures in mouse models of mild and severe hydronephrosis

Objective

We want to study whether the degree of fibrosis in the mild and severe hydronephrosis is different, and whether the irrigation pressure will affect the fibrosis of the hydronephrosis.

Methods

Animal models of mild and severe hydronephrosis in the left kidney were established: 72 healthy C57BL/6 mice were randomly divided into nine groups (eight in each group). The N group was used as a control group, and 0 mmHg pressure perfusion was given. The M and S groups were used as mild and severe hydronephrosis groups, respectively. The mild and severe hydronephrosis groups were subdivided into eight subgroups, M0–M3 and S0–S3. Among them, groups 0, 1, 2, and 3 were perfused with 0 mmHg, 20 mmHg, 60 mmHg, and 100 mmHg, respectively. We investigated the effects of irrigation pressures on renal fibrosis in mild (group M) and heavy (group S) hydronephrosis by quantitative real-time polymerase chain reaction, Western blot analysis, Masson staining and immunohistochemistry staining in mouse models.

Results

Compared with group N, EMT and ECM deposits were significantly aggravated in both the mild and severe hydronephrosis groups, TGF-β signaling pathway-related molecules significantly changed too. In terms of ECM deposition, S2 and S3 are significantly increased compared to S0.The EMT of M2 and M3 changed significantly compared with M0; the EMT of S1, S2 and S3 changed significantly compared with S0.The molecules related to TGF-β signaling pathway also changed: M0 and S0 changed significantly compared with N; M1, M2 and M3 changed significantly compared with M0; compared with S0, S1, S2 and S3 changed significantly.

Conclusion

Compared with mild hydronephrosis, renal fibrosis in severe hydronephrosis is more severe and its tolerance to perfusion pressure is lower. These changes may be related to the TGF-β signalling pathway.

     

左心房压和肺动脉楔压监测在心脏术后的应用

目的评价心脏直视术后合并肺动脉高压患者经颈内静脉安置左心房测压管和肺动脉漂浮导管对于成人心脏外科术后患者监护的可行性、安全性及准确性。方法前瞻性选择2010～2012年于武汉亚洲心脏病医院行心内直视手术的18岁以上患者100例,男43例、女57例,年龄46～65（47±16）岁。将患者分为两组：合并淤血性重度肺动脉高压患者行瓣膜置换术50例（A组）,合并淤血性轻中度肺动脉高压患者行瓣膜置换术50例（B组）。两组患者均经颈内静脉入路置入ARROW5Fr三腔导管,尖端经房间隔穿刺行持续左心房压（LAP）监测;同时经同侧颈内静脉安置ARROW 8Fr高流量鞘管放置肺动脉漂浮导管,入室即监测LAP和肺动脉楔压（PAWP）。观察两组患者中LAP和PAWP的相关性及准确性。结果两组患者均成功行持续LAP及PAWP监测,无严重导管相关并发症发生。A组和B组患者手术时间和体外循环时间差异无统计学意义（P〉0．05）,术后机械通气时间和ICU留置时间差异有统计学意义（P〈O．05）。A组患者平均肺动脉压（PAPMean）、平均左心房压（LAPmean）、平均肺动脉楔压（PAWPmean）、PAWP与LAP差值平均值（PAWP-LAPmean）均显著高于B组（P〈0．01）。两组患者中PAWP与LAP均具有良好相关性,A组患者相关性低于B组,差异有统计学意义（P〈0．01）。结论经颈内静脉入路行LAP监测及肺动脉漂浮导管监测是安全、可行的。PAWP不能准确反映左心室前负荷,在合并淤血性重度肺动脉高压的患者中使用LAP监测对于判断左心室前负荷更准确。     

Tranexamic acid is effective in lower doses with infusion in total knee arthroplasty

ObjectiveTo identify the most effective intravenous regimen with reduced doses of tranexamic acid (TXA).MethodsWe retrospectively evaluated the two most frequently used TXA regimens (infusion and divided-dose regimens) in total knee arthroplasty in comparison with patients not treated with TXA, in three groups. Group NO (n = 134; 19 men and 115 women; mean age: 66.48 ± 7.66) (patients who were not treated with TXA); group DIV (n = 158; 14 men and 144 women; mean age: 65.67 ± 7.98) (total dose of 10 mg/kg intravenous TXA divided into two doses: 15 minutes before tourniquet inflation and 15 minutes before tourniquet deflation), an extra 5 mg/kg intravenous TXA dose was administered 2 hours after surgery in the orthopedic ward, if needed; and group INF (n = 193; 33 men and 160 women; mean age: 67.08 ± 7.2) (10 mg/kg TXA perioperative intravenous infusion starting 15 minutes before surgery until closure of the wound, and 5 mg/kg additional intravenous dose was administered 12 hours after surgery). Pre-postoperative hemoglobin (Hb) and hematocrit (Htc) difference, total blood loss (TBL), number of transfused packed red blood cells (pRBC), and length of hospital stays (LOS) were compared between the groups.ResultsTBL was lower in group INF (531.61 ± 316.76 mL) in comparison with group DIV (999.91 ± 352.62 mL). TBL was statistically significantly higher in Group NO (1139.23 ± 43 mL). The mean number of transfused pRBC was significantly higher in the control group (1.22 ± 0.58 units) than the in the other TXA groups. The mean number of transfused pRBC was significantly lower in INF group (0.33 ± 0.56 units) than DIV group (0.75 ± 0.63 units). The number of patients requiring transfusion was significantly lower in INF group (28.5%) than DIV group (65.2%). Group NO had the highest number of patients requiring transfusion (96.3%). Pre-postoperative Hb and Htc difference was significantly lower in INF group (?1.19 ± 0.9 gr/dL and ?3.74 ± 2.96%). The mean LOS of the control group, group DIV and group INF were 7.16 ± 2.29, 6.93 ± 2.39 and 5.06 ± 1.24 days, respectively. Group INF had the lowest hospital stay time in comparison with the other groups (p < 0.005). There was no statistically significant difference between the control group and group DIV in the LOS.ConclusionA total dose of 10 mg/kg of TXA perioperative intravenous infusion starting 15 minutes before the surgery until wound closure can significantly decrease TBL. Intraoperative infusion regimen is more effective than the divided-dose regimen.Level of EvidenceLevel III, Therapeutic Study.     

Wedging the pulmonary artery catheter: changes in left atrial and pulmonary artery pressures and risk for perforation

OBJECTIVE: Clinical and experimental data indicate that when there is lung disease, wedging the pulmonary artery catheter (PAC) could cause decreases in cardiac output and systemic arterial blood pressure and an increase in mean pulmonary artery pressure (PAP). The authors studied whether wedging would alter mean left atrial pressure (LAP), and report perforations with PACs in their unit since 1975. DESIGN: Observational study. SETTING: University hospital operating room and intensive care unit. PARTICIPANTS: Ten adult patients undergoing cardiac surgery. INTERVENTIONS: Placement of epidural catheters in the left atrium and pulmonary artery, and a PAC. MEASUREMENTS AND MAIN RESULTS: After weaning from cardiopulmonary bypass, mean LAP, mean PAP, and cardiac output were measured before and during wedging with the chest open and closed. Mean LAP decreased during wedging, from 13.5 +/- 2.8 (SD) mmHg to 13.0 +/- 3.0 mmHg (open chest) and from 15.8 +/- 3.2 mmHg to 15.3 +/- 3.1 mmHg (closed chest; p < 0.001), and mean PAP increased, from 18.8 +/- 3.5 mmHg to 19.7 +/- 3.5 mmHg (open chest) and from 21.3 +/- 4.3 mmHg to 21.9 +/- 4.2 mmHg (closed chest; p < 0.001). Mean PAP-mean LAP increased by 20% to 25%. Wedge pressure did not differ from mean LAP. Cardiac output and systemic arterial pressure did not change. Four perforations due to PACs occurred since 1975. CONCLUSIONS: In adult patients undergoing cardiac surgery, wedging of a PAC resulted in a small decrease in mean LAP and a small increase in mean PAP. The wedging maneuver carries a small risk. How wedging is performed could influence the risk for perforation.     

Effects of pneumonectomy on pulmonary input impedance

The long-term effects of pneumonectomy on the pulmonary circulation quantifiable through pulmonary input impedance analysis were studied. Excision of the left lung was performed in purebred beagle dogs aged 6 to 10 weeks (n = 6 group I) or 1 year (n = 8 group II). Unoperated beagles served as controls (n = 8 group III). When the dogs were 5 years of age, pulmonary pressure and flow were measured and the impedance spectra calculated. Characteristic impedance (Zo) (indicative of changes in proximal vessel physical properties) and pulmonary vascular resistance (PVR) (indicative of the distal response) were estimated. In group III the cardiac output (CO) was 1.7 +/- 0.4 L/min, mean pressure 16 +/- 5 mm Hg, PVR 605 +/- 448 dyne-sec/cm, and Zo 204 +/- 76 dyne-sec/cm. Group I results exhibited bimodal distributions that were not statistically different from results of groups II or III; four dogs had spectra comparable to those of group III, while two dogs had developed moderate hypertension and high PVR and Zo. Group II results were more normally distributed, and comparison with group III indicated statistically significant differences (P less than 0.05) in CO (1.1 +/- 2 L/min), PVR (1396 +/- 573 dynes-sec/cm), and Zo (543 +/- 273 dynes-sec/cm). Doubling of PVR and Zo in group II indicated that proximal vessel compliance and peripheral perfusion radius had not increased following pneumonectomy in adult beagles. Group I results indicate that marked facilitory adaptation can occur when pneumonectomy is performed in puppies; however, the adaptation may not be based on true lung growth and, therefore, may not be sustained indefinitely.     

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundPostoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.MethodsThis study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.ResultsTotal blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).ConclusionCSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.     

人工低温对猪肺血管阻力的影响

目的 模拟人工低温,并对低温后的血流动力学变化进行分析.方法 体表降温法建立人工低温模型,降温到32℃.检测降温前后主动脉压、中心静脉压、左房压、肺动脉压、肺动脉血流量等指标.比较37℃、32℃各项指标.按"肺血管阻力=80×(肺动脉平均压-左房平均压)/心输出量"公式计算肺血管阻力.结果 37℃时,肺血管阻力为(42.100±22.290)kPa·s/L,32℃时为(61.463±29.454)kPa·s/L(P＜0.01).结论 低温治疗能够引发肺血管阻力升高,进而引发肺功能障碍.

Abstract：

Objective Hypothermia is widely used in clinical work. We want to study the pulmonary vascular resistance when induced hypothermia on healthy individuals, in order to facilitate the protection of lung function. Methods Thirty Swedish domestic pigs with a mean weight of 50 kg (range 48-52 kg) were included in the study. A median sternotomy was performed, Open pericardium, put a blood probe around pulmonary artery. Put one catheter in left atrium sinistrum, put one catheter in pulmonary artery for blood pressure measurements and blood sampling. Values of T, HR, AP, CVP, LAP, PAP, PBF will be recorded. We cooled the pigs by surface cooling with ice packs to 32 ℃ core temperature. Count PVR use formula "PVR = 80 × (mean pulmonary arterial pressure-mean left atrial pressure ) /cardiac output". Data are expressed as means ± SEM,analysis were done by SPSS 12. 0. Results 37 ℃ ,PVR: (42. 100 ±22. 290)complications and dysfunction of ventilation.