输血对围手术期期恶性肿瘤患者血清免疫球蛋白的影响

检测２８例围手术期恶性肿瘤患者输血前后血清免疫蛋白（Ｉｇ）的水平，结果显示输血后１０天内ＩｇＧ、ＩｇＡ、ＩｇＭ普遍降低，差异显著（分别为Ｐ〈０．０２５，Ｐ〈０．０５，Ｐ〈０．０２５）。而此后，３种Ｉｇ的发迹差异无显著性（Ｐ〉０．０５）。提示输血对围手术期恶性瘤患者体液免疫具有抑制作用。     

手术麻醉对围手术期血清激素和血糖的影响

目的：观察两种麻醉方法对普外患者围手术期内分泌激素和血糖的变化．方法：１７例普外患者随机分为硬膜外阻滞组（７例）和全麻组（１０例），前瞻性观察麻醉前至术后第５日的内分泌激素和血糖变化．结果：两组患者围术期内分泌激素变化相似，皮质醇在术中和手术当晚增高超过正常值界限，尤其是手术当晚升高更明显（Ｐ＜０．０５）；胰岛素于术后第一日增高显著（Ｐ＜０．０５）；Ｔ３，Ｔ４和ＴＳＨ均无明显变化．两组患者术中血糖均显著升高（Ｐ＜０．０１或Ｐ＜０．０５），全麻组比硬膜外组提前于手术当晚恢复．结论：术后疼痛激惹不亚于手术刺激，应激致交感－肾上腺髓质系统兴奋可减轻胰岛素升高，血糖升高并非胰岛素分泌障碍所致，而与应激、糖利用系数降低有关．     

恶性肿瘤患者围手术期输血前后体液免疫检测

目的 探讨围手术期输血对恶性肿瘤患者体液免疫的影响。方法 采用单向琼脂扩散法定量检测３８例恶性肿瘤患者围手术期输血前后ＩｇＧ、ＩｇＭ、ＩｇＡ、Ｃ３、Ｃ４的水平。结果 输血后１０天内各项指标普遍下降,ＩｇＧ Ｐ〈０．０２５,ＩｇＡ Ｐ〈０．０５,Ｃ３ Ｐ〈０．０５,Ｃ４Ｐ〈０．００２５。输血后２０天、３０天内５项指标的变化无显著性差异（Ｐ〈０．０５）。结论 围手术期输血可引起恶性肿瘤患者体液免疫暂时     

血浆内皮素—1水平在先天性心脏病体外循环围手术期的动态变化及 …

目的 观察血浆内皮素－１水平在先天性心脏病体外循环围手术期的动态变化。方法 对２０例先天性心脏病在体外循环围手术期内皮素（ＥＴ－１），血栓素Ａ２（ＴＸＡ２），前列环素（ＰＧＩ２）进行动态监测。结果 ①患者术前动脉血ＥＴ－１水平高于静脉血ＥＴ－１水平，但差异不显著（Ｐ〉０．０５），术后２周动脉血ＥＴ－１水平低于静脉血ＥＴ－１水平，且差异显著（Ｐ〈０．０５）。②血浆ＥＴ－１水平在体外循环（ＣＰＢ）期间     

肺癌患者围手术期血清sIL—2R的检测

应用ＥＬＩＳＡ双抗夹心法检测了３０例正常健康人及４０例肺癌患者围手术期ｓＩＬ－２Ｒ的方法，结果显示：肺癌组术前血清ｓＩＬ－２Ｒ水平显著高于正常对照组（Ｐ〈０．０１），手术切除后血清ｓＩＬ－２Ｒ水平明显下降（Ｐ〈０．０５），肺癌细胞分型与血清ｓＩＬ－２Ｒ水平无关（Ｐ〉０．０５）。提示血清ｓＩＬ－２Ｒ水平检测对肺癌的及病情变化，疗效观察有一定价值。     

PCEA对老年前列腺摘除病人围手术期应激反应的影响

目的 研究硬膜外自控镇痛（ＰＣＥＡ）对前列腺摘除病人围术期应激反应的影响。方法 ２０例在硬膜外阻滞下行前列腺摘除老年病人，其中１０例术后给予ＰＣＥＡ（ＰＣＥＡ组）另１０全铡为对照组。结果 ＰＣＥＡ组术后镇痛效果满意，ＣＯＲ、ＰＲＬ、ＧＬＵ与麻醉前比较无显著升高（均Ｐ〉０．０５），对照组术后２４ｈＣＯＲ、ＰＲＬ、ＧＬＵ显著升高（Ｐ〈０．０５或０．０１），术后４８ｈ ＣＯＲ、ＧＬＵ仍显著升高Ｐ〈０．０     

小切口与传统切口胆囊切除术的比较

作者自１９９３年３月至１９９４年６月共采用５ｃｍ小切口胆囊切除术（ＭＣ）３０例。与同期施行的６３例传统切口胆囊切除术（ＣＣ）比较，切口平均长度ＭＣ组５．５ｃｍ，ＣＣ组１１．５ｃｍ（Ｐ〈０．０１）；术后平均排气时间ＭＣ组为３０ｈ，ＣＣ组为５４ｈ（Ｐ〈０．０１）；术后平均住院天数ＭＣ组为８天，ＣＣ组为１２天（Ｐ〈０．０５）。术中出血量和手术时间两组比较无意义（Ｐ〉０．０５）。提示ＭＣ手术较ＣＣ手术腹壁     

胸膜外手术治疗小儿动脉导管未闭的研究

为探讨小儿动脉导管未闭胸膜外手术结扎方法的疗效和优点，将３￣１４岁小儿动脉导管未闭７３例随机分为胸膜外组４０例和剖胸组３３例，均采用动脉导管结扎方法。结果；２组患儿的年龄、动脉导管直径基本相同（Ｐ〉０．０５），但２组的输血率（Ｐ〈０．００１），并发症发生率、术后住院时间均有显著性差异（Ｐ〈０．０５），提示：胸膜外手术治疗小儿动脉导管未闭，手术创伤小，输血少，肺部并发症少，术后恢复快，是一种安全值得     

大肠癌患者手术前后血清胃泌素含量研究

应用放射免疫分析法测定了４３例大肠癌患者手术前后和２０例对照组空腹血清胃泌素（ＳＧ）水平。结果表明：大肠癌患者ＳＧ显著高于对照组（Ｐ〈０．０１）；Ｄｕｋｅｓ Ｃ、Ｄ期大肠癌患者ＳＧ显著高于Ｄｕｋｅｓ Ａ、Ｂ期（Ｐ〈０．０５）；不同肿瘤组织学类型之间ＳＧ差异无显著性；根治性大肠癌切除术后ＳＧ较术前显著降低（Ｐ〈０．０１）；姑息性手术前后ＳＧ差异无显著性。提示ＳＧ水平与大肠癌生长密切相关，ＳＧ测定有助     

原发性肝癌患者手术前后血浆T—SOD Mn—SOD CuZn—SOD活性含量的变化

测定了２４例原发性肝癌患者治疗前后血浆Ｔ－ＳＯＤ、Ｍｎ－ＳＯＤ、ＣｕＺｎ－ＳＯＤ活性，同时测定４５名正常对照者血浆的含量。经统计学分析，肝癌患者血浆Ｔ－ＳＯＤ、Ｍｎ－ＳＯＤ活性与正常对照组比较有显著性差异（Ｐ〈０．０５），手术治疗前与术后有显著性差异（Ｐ〈０．０５）；术前Ｔ－ＳＯＤ、Ｍｎ－ＳＯＤ活性明显高于正常对照组和术后，而术后两项均逐渐恢复正常，即与正常对照组无显著性差异（Ｐ〉０．０５），说明     

Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group.

OBJECTIVE--To determine the long-term (2-year) cardiac prognosis of high-risk patients undergoing noncardiac surgery and to determine the predictors of long-term adverse cardiac outcome. DESIGN--Prospective cohort study. Historical, clinical, and laboratory data were collected during the in-hospital period, and at 6 months, 1 year, and 2 years following surgery. Data were analyzed using proportional hazards models. SETTING--University-affiliated Veterans Affairs medical center. POPULATION--A consecutive sample of 444 patients with or at high risk for coronary artery disease who had undergone elective noncardiac surgery and were discharged from the hospital in stable condition. MAIN OUTCOME MEASURES--Cardiac death, myocardial infarction, unstable angina, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty, and new unstable angina requiring hospitalization. RESULTS--Forty-seven patients (11%) had major cardiovascular complications during a 728-day (median) follow-up period: 24 had cardiac death; 11, nonfatal myocardial infarction; six, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty; and six, new unstable angina requiring hospitalization. Thirty percent of outcomes occurred within 6 months of surgery and 64% within 1 year. Five independent predictors of long-term outcome were identified. Three predictors reflected the preexisting chronic disease state: (1) the presence of known vascular disease (hazard ratio, 6.1; 95% confidence interval [CI], 2.5 to 15.0; P less than .0001); (2) a history of congestive heart failure (hazard ratio, 5.0; 95% CI, 2.0 to 12.0; P less than .0005); and (3) known coronary artery disease (hazard ratio, 3.7; 95% CI, 1.7 to 8.0; P less than .0007). Two predictors reflected acute postoperative ischemic events: (1) myocardial infarction/unstable angina (hazard ratio, 20; 95% CI, 7.5 to 53.0; P less than .0001) and (2) myocardial ischemia (hazard ratio, 2.2; 95% CI, 1.1 to 4.3; P less than .03). Patients surviving a postoperative in-hospital myocardial infarction had a 28-fold increase in the rate of subsequent cardiac complications within 6 months following surgery, a 15-fold increase within 1 year, and a 14-fold increase within 2 years (95% CI, 5.8 to 32; P less than .00001). Seventy percent of all long-term adverse outcomes were preceded by in-hospital postoperative ischemia that occurred at least 30 days (median, 282 days) before the long-term event. The development of congestive heart failure or ventricular tachycardia (without ischemia) during hospitalization was not associated with adverse long-term outcome. CONCLUSIONS--The incidence of long-term adverse cardiac outcomes following noncardiac surgery is substantial. At increased risk are patients with chronic cardiovascular disease; at highest risk are patients with acute perioperative ischemic events. We conclude that survivors of in-hospital perioperative ischemic events, specifically myocardial infarction, unstable angina, and postoperative ischemia, warrant more aggressive long-term follow-up and treatment than is currently practiced.     

Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery.The Study of Perioperative Ischemia Research Group.

OBJECTIVE--To identify predictors of postoperative myocardial ischemia in patients scheduled to undergo major noncardiac surgery. DESIGN--Historical, clinical, laboratory, and physiological data were obtained prospectively before and during surgery to identify potential univariate predictors of postoperative myocardial ischemia, which then were entered into multivariate logistic models. Continuous two-lead electrocardiograms before, during, and after surgery were used to identify episodes of myocardial ischemia. SETTING--Department of Veterans Affairs tertiary care hospital. PATIENTS--A consecutive sample of 474 men at high risk for or with coronary artery disease who were scheduled to undergo major noncardiac surgery (95% compliance rate). MAIN OUTCOME MEASURE--Significant variables identified by multivariate logistic models that are associated with postoperative myocardial ischemia. RESULTS--Five major preoperative predictors of postoperative myocardial ischemia were identified: (1) left ventricular hypertrophy by electrocardiogram; (2) history of hypertension; (3) diabetes mellitus; (4) definite coronary artery disease; and (5) use of digoxin. The risk of postoperative myocardial ischemia increased progressively with the number of predictors present: in 22% of patients with no predictors, in 31% with one predictor, in 46% with two predictors, in 70% with three predictors, and in 77% with four predictors. CONCLUSION--Patients subgroups who are at high risk for developing postoperative myocardial ischemia and who might benefit the most from intensive Holter monitoring in the postoperative period now can be identified preoperatively.     

艾司洛尔治疗冠心病心肌缺血的疗效观察

目的比较冠心病(CHD)患者冠状动脉不同病变程度与发生心肌缺血的关系,探讨超短效β阻滞剂艾司洛尔缓解冠心病心肌缺血的效果。方法利用冠状动脉造影确定(CHD患者)冠脉病变支数和狭窄程度;应用动态心电图(DCG)记录,分析不同程度冠脉病变CHD患者心肌缺血的发作阵次、持续时间、ST段下移幅度和发作时心率;对心肌缺血患者常规使用硝酸酯、吗啡等药物后未能完全缓解者,给予盐酸艾司洛尔注射液,以用药前和用药后4h作为评价时间点,评价指标主要包括症状评分、心电图ST段压低、心率和血压。结果 163例中有126例出现缺血性ST段改变,在不同程度冠脉病变支数和狭窄程度间比较差异有统计学意义(P<0.05或P<0.01);采用艾司洛尔治疗的103例患者中有86例有效,治疗有效率为83.5%,其中,59例显效患者用药(68±21)min后症状完全缓解(P<0.01),心率和血压均显著下降(P<0.01),心电图ST段基本恢复至基线(P<0.01)。结论冠脉病变支数、狭窄程度与心肌缺血的发生率有关;艾司洛尔可迅速、安全、有效缓解冠脉病变所致心肌缺血。     

冠脉搭桥术围术期心肌损伤相关指标和血小板活化研究

目的:探讨非体外循环冠脉搭桥术患者围术期心肌损伤相关指标和血小板活化的变化规律。方法:选取2011年5月～2012年6月进行体外循环冠脉搭桥术治疗的27例患者为对照组,同期进行非体外循环冠脉搭桥术治疗的27例患者为观察组,后将两组患者肝素化前、术后即刻、术后2h及12h的血清心肌损伤、心功能相关指标及血小板活化指标进行比较。结果:观察组肝素化前至术后即刻、术后2h及12h的血清心肌损伤、心功能相关指标及血小板活化指标波动幅度均小于对照组(P均<0.05),有显著性差异。结论:非体外循环冠脉搭桥术对患者围术期的心肌损伤和血小板活化指标不良影响更小。     

胸段硬膜外阻滞(TEA)对冠心病患者围手术期心肌保护的观察

目的:比较单纯全麻和全麻复合胸段硬膜外阻滞(TEA)对冠心病患者非开胸手术围术期心肌保护作用的观察。方法:38例非开胸手术患者随机均分为两组。A组仅采用单纯全身麻醉,B组术中采用TEA复合全身麻醉,观察两组围术期平均动脉压、心率、ST-T段的变化及TnT的水平。结果:各个时间点A组患者的平均动脉压、心率明显高于基础值(P<0.05),B组各时点无差异(P>0.05);两组患者心肌缺血改善A组总有效率为31.5%,B组总有效率为84.2%;TnT含量在术后1h开始升高(P<0.05),24h明显升高(P<0.05),24h时B组TnT水平低于A组(P<0.05)。结论:胸段硬膜外阻滞复合全麻组患者的血流动力学稳定,心肌缺血、缺氧改善明显,有效地减轻了心肌损伤。     

经皮冠状动脉腔内成形术对冠心病患者QT离散度的影响

目的通过分析经皮冠状动脉腔内成形术(percutaneoustransluminalcoronaryangioplasty,PTCA)中缺血和再灌注时QT离散度的变化。评价成功的PTCA术对改善QT离散度的临床意义。方法22例冠心病患者行成功的PTCA术治疗,其中男17例,女5例,年龄43～79岁,平均年龄(59.8±9.0)岁,记录PTCA术中及当日同步十二导联动态心电图。分别于术前、首次球囊扩张期间、首次球囊扩张后即刻、术后2h及12h测定QT间期和RR间期,QTd=QTmax-QTmin。结果QTd在首次球囊扩张期间与扩张前比较明显增大(P<0.05),在术后2h及12h均较术前减小(P<0.05),且术后12h与术后2h比较差异有统计学意义(P<0.05);首次球囊扩张后即刻与扩张前比较差异无统计学意义(P>0.05)。结论PTCA球囊扩张期间,由于产生一过性短暂的心肌缺血使QTd增加,而成功的PTCA术可降低冠心病患者的QT离散度,从而可能预防恶性室性心律失常的发生。     

应用心脏远程监护技术分析静息性心肌缺血

目的应用心脏远程监护技术分析静息性心肌缺血的冠状动脉痉挛和冠状动脉严重狭窄心肌耗氧量增加两种机制各占的比例,统计静息性心肌缺血在不同人群中的发病率。方法查阅患者病历记录,根据冠状动脉造影结果及冠状动脉成形术结果筛选入选患者,查阅入选患者心脏远程监护记录及动态心电图诊断报告,计算静息性心肌缺血两种机制各占的比例及静息性心肌缺血在不同人群中的发病率,并作统计学分析。结果冠心病患者静息性心肌缺血发生率≥21.3%,冠状动脉有一定程度狭窄,但未达到冠心病诊断标准患者静息性心肌缺血发生率≥58.3%(P<0.05)。冠状动脉痉挛在所有发生静息性心肌缺血的机制中所占比例≥73.3%,非冠状动脉痉挛的原因所占比例≤26.7%(P<0.05)。结论冠状动脉造影可以鉴别诊断导致静息性心肌缺血的冠状动脉痉挛和冠状动脉狭窄心肌耗氧量增加的两种机制;静息性心肌缺血发生机制中冠状动脉痉挛所占的比重大;冠状动脉有一定程度的狭窄但未达到冠心病诊断标准的患者比冠心病患者更易发生静息性心肌缺血;心脏远程监护技术的连续监测对于静息性心肌缺血的诊断具有重要意义。     

肢体缺血预适应增强脂联素对心功能的保护作用

目的:研究肢体缺血预适应对缺血大鼠心肌是否具有保护作用。方法:健康雄性SD大鼠,体重220~280 g,随机分为3组(n=10),假手术组(sham组)只穿线,左冠状动脉前降支不予处理;心肌缺血2 h组(MI2h组):心脏冠状动脉左前降支实施缺血2 h;肢体缺血预适应组(LIPC组):肢体缺血5 min,再灌注5 min,连续预适应3天,第4天实施缺血2 h。RM6240记录实验各组心功能指标,Elisa检测血清脂联素。结果:MI2h组大鼠血清中脂联素的含量、LVSP和±dp/dtmax与sham组比较均降低明显(P<0.05);LIPC组大鼠血清中脂联素的含量、LVSP和±dp/dtmax较MI2h组升高(P<0.05);与sham组相比,MI2h组LVEDP明显升高(P<0.05),与MI2h相比LIPC组LVEDP数值降低显著(P<0.05);血清脂联素水平与心收缩功能指标呈显著正相关。结论:脂联素与肢体缺血预适应作为正性调节因素,共同在心肌缺血损伤心肌病变的发生、发展中起作用。     

Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group.

OBJECTIVE--Transesophageal echocardiography (TEE) and 12-lead electrocardiography (ECG) are sophisticated techniques that are increasingly being used to monitor for myocardial ischemia during noncardiac surgery. We examined whether the routine use of these techniques has incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes when compared with preoperative clinical data and intraoperative monitoring using continuous two-lead bipolar ECG. DESIGN--Cohort study. SETTING--Veterans Affairs medical center. PATIENTS--A total of 332 men undergoing noncardiac surgery who had or were at high risk for coronary artery disease. INTERVENTIONS--TEE, 12-lead ECG, and two-lead ECG were performed continuously during noncardiac surgery (47% vascular, 53% nonvascular). Monitoring results were not available to anesthesiologists or surgeons, and data were blindly analyzed after surgery. MAIN OUTCOME MEASURE--Perioperative ischemic outcomes (cardiac death, nonfatal myocardial infarction, unstable angina). RESULTS--In a subset of 285 patients who were adequately studied by all three techniques, 111 patients (39%) were identified as having intraoperative myocardial ischemia (by one or more monitoring techniques). By univariate analysis, intraoperative ischemia was associated with all perioperative cardiac outcomes, including ischemic outcomes, congestive heart failure, and ventricular tachycardia (P less than or equal to .02 for each of the three monitoring techniques). However, when monitoring results for TEE and 12-lead ECG were added to a multivariate model that included preoperative clinical data and continuous two-lead ECG results, the incremental value of TEE was small (odds ratio, 2.6; 95% confidence interval [CI], 1.2 to 5.7; P = .02) and that of 12-lead ECG was not significant (odds ratio, 1.5; 95% CI, 0.6 to 3.8). Furthermore, when the multivariate analysis was repeated with only ischemic outcomes, neither TEE nor 12-lead ECG retained significant associations (odds ratio, 2.2; 95% CI, 0.5 to 9.4, and odds ratio, 1.1; 95% CI, 0.2 to 6.1, respectively). CONCLUSION--When compared with preoperative clinical data and intraoperative monitoring using two-lead ECG, routine monitoring for myocardial ischemia with TEE or 12-lead ECG during noncardiac surgery has little incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes.     

WHBE兔痰瘀证心肌缺血模型的建立

目的利用高脂喂养结合冠脉结扎建立WHBE兔痰瘀证心肌缺血模型。方法 18只WHBE兔随机分成正常对照(NC)组、心肌缺血模型(MI)组和痰瘀证心肌缺血模型(PBSS-MI)组,每组6只,MI组和PBSS-MI组均采用冠脉结扎法建立心肌缺血,然后NC组和MI组饲喂普通饲料,PBSS-MI组饲喂高脂饲料,连续造模4周,制备痰瘀证心肌缺血模型,分别通过测定动物的体重、心肌酶指标、血脂水平、血液流变学和心肌梗死面积(MIS)来评价模型的建立和痰瘀证的病理进程,用Pearson法进行相关性分析。结果与NC组比,MI组体重略有降低,但血清CK、LDH、TG、血浆粘度、卡松粘度和心肌梗死面积均明显升高(P0.05,P0.01),PBSS-MI组体重降低不明显,但血清CK、LDH、TC、TG、LDL-C、HDL-C、全血粘度、血浆粘度、红细胞电泳时间、卡松粘度、心肌梗死面积均显著升高(P0.05,P0.01);与MI组比,PBSS-MI组TC、LDL-C、HDL-C、高切全血粘度、红细胞电泳时间和心肌梗死面积均高于MI组(P0.05,P0.01)。相关分析显示,MI组MIS与TC、TG和HDL-C指标密切相关(P0.01);而PBSS-MI组MIS与TC、TG、HDL-C、LDL-C、LDH、CK、高切和低切全血粘度、红细胞电泳时间和卡松粘度密切相关(P0.05,P0.01)。结论高脂喂养结合冠脉结扎法在WHBE兔体内可成功建立痰瘀证心肌缺血模型,且缺血程度与血脂、血液流变学有相关性变化,这些可反映了中医"痰瘀互结"的相关生物学基础。