乌司他丁对小儿体外循环手术中炎性反应和肾功能的影响

【目的】研究乌司他丁对小儿体外循环（CPB）手术中炎性反应和肾功能的影响。【方法】56例诊断为室间隔缺损的小儿患者随机分为实验组（n=28）和对照组（n=28）。实验组用乌司他丁按1．2万U／kg计算用药量,一次性加入预充液中;对照组以等量生理盐水代替。分别于体外循环前（T1）、体外循环结束后1h（T2）、4h（T3）,24h（T4）等时点采集血样,检测炎性介质和肾功能的变化。【结果】CPB前炎性介质和肾功能指标,差异均无统计学意义（P〉0．05）;CPB后炎性介质明显升高（P〈0．05）;实验组CPB后各时点IL6均明显低于对照组,T2,T3时点IL-8均明显低于对照组,T3、T4时点TNF-α明显低于对照组（均P〈0．05）。与T1相比,两组T4BUN均明显升高（P〈0．05）;与对照组相比,实验组T4BUN明显降低（P〈0．05）。【结论】乌司他丁能降低术后IL-6、TNF-α、IL-8水平,减轻炎性反应,同时对肾功能有一定保护作用。     

肺复张策略对成人瓣膜置换术后肺换气功能的影响

【目的】研究肺复张策略（RM）改善成人体外循环（CPB）心脏换瓣术后肺换气功能的作用。【方法】选择30例心阿直视换瓣手术患者,随机分成常规机械通气组（A组）、早期肺复张组（B组）、晚期肺复张组（C组）。B组在劈开胸骨后实施肺复张策略,C组在到达重症监护室（ICU）后循环稳定后实施肺复张策略。分别于术前（T1）、CPB后（T2）、到达ICU后1h（T3）、2h（T4）、12h（T5）5个时间点记录各项呼吸指标并测动脉和混合静脉血血气,并根据公式计算肺换气功能指标。【结果】B、C组在T2、T3、T4和T5时,氧合指数（OI）高于A组（P〈0．05）,而肺泡-动脉血氧分压差（PA-aO2）和肺内分流量（Os／Qt）低于A组,C组各肺换气功能指标在T4时间内与B组无统计学意义（P〉0．05）,而T5时OI高于B组（P〈0．05）,PA-aO2、Qs／Qt低于B组（P〈0．05）。【结论】肺复张策略能减轻CPB后肺损伤,且晚期肺复张策略优于早期肺复张策略。     

乌司他丁对体外循环心脏手术患者TXA2和PGI2的影响

目的观察乌司他丁（UTI）对体外循环（CPB）心脏手术患者血栓素（TXA2）和前列环素（PGI2）的影响。方法将60例CPB择期心脏手术患者随机分为实验组和对照组，分别采用UTI1．2万U／kg稀释于10ml生理盐水中和等量生理盐水中，一次性加入CPB预充液中，分别于麻醉诱导后（L）、主动脉开放30min（T2）、术毕（T3）及术后6h（T4）4个时点，抽取桡动脉血用放射免疫法测定TXB2／6-keto—PGF1a浓度。结果CPB后两组患者T2、T3、T4血浆TXB2、TKG6-keto—PGF1a浓度均较T1浓度增加（P〈0．05），但实验组增加幅度低于对照组（P〈0．05），且术后6hTXB2、6-keto—PGF1a浓度己降到或低于术前水平（P〈0．05）。结论血浆TXA2和PGI2比值升高，可能是CPB后肺损伤的机制之一。乌司他丁对CPB后肺损伤的保，护作用可能与改善花生四烯酸代谢紊乱，抑制TXA2／PGI2比值升高有关。     

先心病体外循环术后肺损伤情况及应用乌司他丁的临床效果分析

[目的]分析先天性心脏病体外循环(CPB)术后肺损伤情况及乌司他丁防治效果.[方法]选择2013年1月至2016年12月淮安市第一人民医院收治的CPB下拟行心脏手术先天性心脏病患儿80例,将患儿随机分为观察组与对照组,每组各40例.观察组CPB前给予乌司他丁干预,对照组则行等容量盐水注射,比较两组切皮前(T0)、主动脉开放即刻(T1)、停机后4 h(T2)、停机后24 h(T3)相关炎症因子、肺功能参数及手术前后不同时间点心肌酶变化情况.[结果]两组T1、T2、T3时间点血清白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)及基质金属蛋白酶-9(MMP-9)水平均明显高于T0时间点(均P<0.05);观察组T1、T2、T3时间点IL-6、TNF-α、MMP-9水平均明显低于对照组(均P<0.05).两组T1、T2、T3时间点氧合指数(OI)明显小于、呼吸指数(RI)明显大于T0时间点(均P<0.05);观察组T1、T2、T3时间点OI明显高于对照组、RI明显低于对照组(P<0.05).两组术后24 h、72 h时磷酸肌酸激酶(CK)、磷酸肌酸激酶同工酶(CK-MB)水平均明显高于术前(P<0.05);观察组术后24 h、72 h时CK、CK-MB水平均明显低于对照组,差异有统计学意义(P<0.05).[结论]先天性心脏病CPB术后可能出现肺损伤,乌司他丁对CPB术后肺功能有一定的保护作用,其作用机制可能与其抑制炎症反应、减轻心肌损伤等有关.     

乌司他丁对体外循环肺静脉血炎性介质的影响

目的探讨乌司他丁对体外循环患者肺静脉血中炎性介质CD11bI、CAM-1、NE、ET-1的影响。方法选择40例主动脉阻断时间30 min以上的心内直视手术患者,分成乌司他丁实验组(U组)和氯化钠溶液对照组(C组),每组20例。实验组(U组)于麻醉诱导后静脉注射乌司他丁1.2×104U/kg,氯化钠溶液对照组(C组)不用乌司他丁,用等量氯化钠溶液代替。分别在麻醉诱导后(T1)、主动脉开放10 min(T2)、停机后10 min(T3)和1h(T4)测定肺静脉血黏附分子CD11bI、CAM-1、NE、ET-1浓度,流式细胞仪测定中性粒细胞CD11b活性表达,ELISA法测定肺静脉血ICAM-1、NE、ET-1浓度。结果 (1)麻醉诱导后两组患者肺静脉血CD11bI、CAM-1、NE、ET-1水平差异无统计学意义(P>0.05)。(2)CPB开始后各时点CD11b、NE、ET-1的水平明显上升(P<0.05)。U组明显低于C组(P<0.05)。(3)停机后1 h(T4),肺静脉ICAM-1值逐渐上升并超过基础值,两组比较U明显低于C组(P<0.05)。结论 (1)体外循环可引起静脉中炎性介质CD11bI、CAM-1、NE、ET-1水平升高,导致肺损伤。(2)乌司他丁通过抑制炎性介质CD11b、ICAM-1、NE、ET-1表达,减轻肺部炎症反应,对体外循环所致肺损伤提供保护作用。     

乌司他丁对心肺转流心脏手术器官保护的临床研究

目的：研究乌司他丁对心肺转流（CPB）心脏手术中缺血一再灌注损伤的器官保护作用。方法：择期CPB心内直视手术20例随机均分为乌司他丁组（U组）和对照组（C组）。U组分别于阻断主动前和开放主动脉后给予乌司他丁各5000μ／kg，C组同时段给予生理盐水，分别于麻醉诱导，阻断主动脉30min，开放主动脉30min，开放主动脉1h，开放主动脉2h采集静脉血，用ELISA法测定样本中肿瘤坏死因子-α（TNF—α），白细胞介素-6（IL-6），白细胞介素-8（IL-8）的水平。结果：两组中各项指标在麻醉诱导期无显著差异（P〉0．05）；两组中各项指标在阻断主动脉30min，开放主动脉30min、1h、2h与麻醉诱导期比较有明显增加（P〈0．05和P〈0．01）；U组中血浆TNF-α、IL-6、IL-8的浓度在阻断主动脉30min，开放主动脉30min，1h、2h与C组比较有显著差异（P〈0．05）。结论：乌司他丁能抑制机体炎症反应，减轻缺血一再灌注损伤，从而达到保护重要脏器的作用，但不能完全阻断炎症反应所致的中性粒细胞增加。     

血凝酶对体外循环心内直视术患者血液的保护作用

目的研究血凝酶对体外循环（CPB）心内直视术患者血液的保护作用。方法将30例室间隔缺损患儿随机分为血凝酶组（n=15）与空白组（n=15）。血凝酶组于麻醉诱导后至CPB前经中心静脉缓慢静注血凝酶1000U,另1000U加入预充液中随机转入体内;空白组以等容量生理盐水代替血凝酶。监测2组患儿主动脉阻断时间、CPB时间以及切皮前（T1）、CPB开始后30min（T2）、鱼精蛋白中和肝素后20min（T3）、CPB后1h（T4）的Hb、PLT、PT、APTT、D-dimer;记录术后1、3、6h心包纵隔引流量（mL）。结果Hb、PLT值血凝酶组T2、T3、T4显著高于空白组（P〈0．05）;PT、APTT值血凝酶组值T3、T4显著低于空白组（P〈0．01或P〈0．05）;D-dimer值血凝酶组T2、T3、T4显著低于空白组（P〈0．05）;心包纵隔引流量2组术后1h无明显差异（P〉0．05）,术后3、6h血凝酶组显著低于空白组（P〈0．05或P〈0．01）。结论血凝酶对体外循环心内直视术患者血液具有积极的保护作用。     

不同剂量乌司他丁对体外循环患者炎症反应及呼吸功能的影响

目的 研究不同剂量乌司他丁在体外循环(CPB)心脏直视手术中对肺损伤的保护作用机制.方法 采用前瞻性随机对照研究方法,选择42例心脏瓣膜置换术患者,随机分为对照组、乌司他丁8 kU/kg组(U1组)及乌司他丁12 kU/kg组(U2组),3组分别于麻醉诱导后术前(T1)及停止CPB 1 h(T2)、4 h(T3)、24 h(T4)取静脉血,检测血浆肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、IL-10的浓度;同时测定动脉血气,对比观察氧合指数(PaO_2/FiO_2)及呼吸指数(RI).结果 ①3组患者T1时血浆TNF-α、IL-6和IL-10比较差异均无统计学意义(P均>0.05),T2～4时则均显著升高(P<0.05或P<0.01).与对照组比较,U1、U2组T2～4时血浆TNF-α、IL-6浓度降低,IL-10浓度升高,且U2组变化较U1组明显(P<0.05或P<0.01).②3组患者T1时PaO_2/FiO_2、RI比较差异均无统计学意义(P均>0.05),T2～4时则出现PaO_2/FiO_2减少、RI值增大(P<0.05或P<0.01).与对照组比较,U1、U2组T2～4时PaO_2/FiO_2增大、RI值减小,且U2组变化较U1组更为显著(P<0.05或P<0.01).结论 在CPB过程中,乌司他丁能明显抑制促炎因子TNF-α、IL-6的产生,上调抗炎因子IL-10的释放,减轻肺损伤,改善CPB术后肺功能,并呈剂量-效应关系.     

体外循环心脏直视手术中乌司他丁对肝脏的保护作用

目的：探讨乌司他丁（ulinastatin，UTI）在体外循环（camiopulmonary bypass，CPB）心脏手术期间对肝脏的作用，为乌司他丁在体外循环心脏手术中的应用提供临床依据。方法：30例体外循环心脏直视手术患者随机分为实验组（A组，n=15）和对照组（B组，n=15）。A组预冲液中加入UTI 1．5万U／kg，B组不加UTI。分别于术前、主动脉及心脏插管完毕后30min、开放升主动脉后1h、6h及术后24h，从中心静球插管采集血标本，典5次。放免法检测血中TNR-α、IL-6、IL-8含量，全自动生化分析仪检测血中丙氨酸氨基转移酶（ALT）、总胆红素（TB）水平变化。结果：两组患者血中TNF-α、IL-8、IL-6、ALT、TB在插管30min后避渐升高，A组术中及术后各时段各项指标均低于B组，且两组同时段有显著差异（P〈O．05或P〈0．01）。结论；乌司他丁在体外循环心脏直视手术期间对肝脏具有保护作用。     

乌司他丁与氨溴索合用对婴幼儿体外循环术后的肺保护作用

[目的]探讨低体重婴幼儿体外循环（CPB）手术围术期联合应用乌司他丁与氨溴索的肺保护效果。[方法]以60例体重7奴及以下的先天性心脏病室间隔缺损患儿为研究对象,随机分四组（每组15例）：氨溴索组（A组,氨溴索20mg／kg·d）、乌司他丁组（U组,乌司他丁1～2万U／d）,联合组（AU组）按A、U组方案联合应用氨溴索和乌司他丁,对照组（C组）为空白对照,仅予以常规处理。以动态肺顺应性（Cd）、静态肺顺应性（Cs）以及呼吸指数（RI）来评价术后早期肺功能改变。[结果]手术后1h,AU组Cd优于A组、C组,RI优于A组、U组;手术后24h,AU组Cd和RI优于其他组,Cs优于A组、U组。[结论]围术期联合应用乌司他丁和氨溴索可抑制婴幼儿CPB术后炎症反应,改善术后肺功能,其效能大于其中任一药物单用。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.