肝癌患者肝移植术中酸碱平衡及电解质的变化

目的 探讨肝癌病人肝移植术中血液酸碱平衡及电解质浓度变化的规律，为肝癌病人行肝移植术时针对血液酸碱及电解质紊乱治疗提供参考依据。方法系统回顾分析16例因肝癌行肝移植术病人术中血液钾、钠、钙离子浓度和pH、HCO3^-、BE值的变化规律。结果血K^ 从无肝期开始下降；开放后即刻呈现一过性升高表现，部分病人表现为暴发性高血钾。血游离钙在无肝期和新肝期降低明显。无肝期和新肝期pH、HCO3^-、BE值的变化表现为代谢性酸中毒。结论手术开始后，从无肝期就应注意纠正低血钾和低血钙，开放瞬间注意暴发性高血钾。保持血液动力学的稳定,同时进行过度通气和给予适当的碱性物质有助于减轻酸性物质的产生和酸中毒。     

肝移植围术期EPO应用的效果及安全性研究

目的 评价重组人促红细胞生成素在肝移植围术期中的效果及安全性。方法 回顾分析我院2015年9月~2016年12月原位肝移植89例患者的化验检查、用药情况及围术期输血情况,排除二次肝移植手术患者、死亡患者、术中输血＞50 U患者,根据围术期是否应用rHuEPO,分为EPO组和对照组。EPO组入院后根据围术期贫血情况皮下注射 rHuEPO 10000 U/次,1 次/d或1次/2 d;对照组入院后未用rHuEPO。观察两组患者术后血红蛋白、红细胞计数、网织红细胞计数以及输血量的对比情况。结果 ①EPO组患者经治疗后,术后3 d（T1）、术后7 d（T2）、术后15 d（T3）及术后1个月（T4）与术前基础值（T0）比较,Hb变化不大,差异无统计学意义（P＞0.05）;对照组Hb T1、T2、T3、T4与T0比较明显降低,差异有统计学意义（P＜0.01）;EPO组T0时点Hb明显低于对照组,差异有统计学意义（P＜0.01）,在T3、T4时点Hb高于对照组,差异有统计学意义（P＜0.05）。②EPO组患者经治疗后,T1、T2、T3、T4与T0比较,RBC计数差异无统计学意义（P＞0.05）;对照组RBC T1、T2、T3、T4与T0比较降低,差异有统计学意义（P＜0.05）;对照组T1、T2、T3、T4时点RBC低于EPO 组,差异有统计学意义（P＜0.05）。③EPO组患者经治疗后,网织红细胞计数（RET）T3、T4时点较对照组明显上升,差异有统计学意义（P＜0.01）; EPO组T3、T4时点与T0比较,RET升高,差异有统计学意义（P＜0.01）;对照组RET 在 T1、T2、T3、T4与T0比较差异无统计学意义（P＞0.05）;组间比较,EPO组T3、T4时点RET 明显高于对照组,差异有统计学意义（P＜0.01）。结论 肝移植贫血患者在围术期皮下注射rHuEPO,术后1个月患者的贫血改善好于对照组,提示rHuEPO对肝移植贫血的重症患者安全、有效。     

肝移植围术期血浆一氧化氮和一氧化氮合酶活性的变化及意义

目的：动态观察肝移植围术期血浆一氧化氮（NO）水平和一氧化氮合酶（NOS）活性的变化，并探讨其意义。 方法： 30例终末期肝病患者接受原位肝移植术。用放免法、比色法分别测定肝移植围术期5个时点血浆NO2-/NO3-水平和NOS活性，观察其动态变化。同步抽取桡动脉和肺动脉血做血气分析，记录不同时期的PO2、PCO2、SO2、Hb，根据肺内分流标准模型公式计算(Qs/Qt)。并监测围术期心输出量（CO）、心率（HR）、中心静脉压（CVP）、平均动脉压（MABP）、体循环阻力（SVR）。 结果： (1) 无肝前10 min NO2-/NO3-水平明显高于麻醉后术前。无肝期30 min NO2-/NO3-显著低于无肝前10 min。新肝期30 min NO2-/NO3-显著高于麻醉后术前、无肝期30 min。（2）TNOS活性各时点无显著差异。无肝前10 min、新肝30 min时iNOS活性明显高于麻醉后术前。与无肝30 min值比较，新肝期30 min iNOS活性显著升高。（3）MABP在开放下腔静脉后1 min明显下降，CO和CVP在无肝期下降，新肝期增高。SVR在无肝期增高，新肝期明显下降。（4）Qs/Qt在无肝期下降，新肝期30 min升高。 结论： 在肝移植围术期各个时段，NO水平及iNOS活性各不相同。高NO水平可能是新肝期低阻力、肺内分流增加的原因。     

同种异体原位肝移植的围术期护理

目的：总结肝移植围术期护理特点,方法：终末期肝病患者接受同异体原位肝移植手术,术前对病人充分评估,加强心理护理,术后加强监护,各引流管的护理及感染的控制和排斥反应的观察。结果：做好围术期护理,以保证手术的成功,结论：肝移植后术时间长、务大,对术后监护包括一般护理,及时监没发症及潜在的不利因素,早期发现、及时处理。     

猪作为供体的异种肝移植的研究与进展

背景：猪易于饲养,易繁殖,器官大小与人较匹配,并且可通过基因调控技术来增强供受体器官匹配性,因此猪是最佳异种供体器官的大动物模型。 目的：总结近年来猪作为供体的异种移植研究进展。 方法：应用计算机检索PubMed数据库及万方数据库2001-01/2010-12有关以猪及非人类灵长类为供体进行异种移植的文献报道。 结果与结论：使用猪作为供体的异种移植应用于临床可能会缓解供体器官短缺的问题,然而异种移植免疫学方面还存在某些障碍,可通过基因工程技术和开发新型免疫抑制剂来解决。至此所进行的研究还不能完全克服免疫排斥反应,并且除免疫因素外,还有异种病原的感染问题,如猪内源性反转录病毒。现在还不能确定是否具有潜在的感染性,随着进一步的研究,将会彻底克服免疫排斥和病毒感染等问题。     

肝移植围手术期血浆可溶性P-选择素水平变化

目的观察肝移植围手术期血小板计数和可溶性P-选择素（sP-sel）水平的变化。方法选择20例终末期肝病患者,其中男性15例,女性5例;年龄20-61岁,平均年龄50.1岁。行肝移植治疗,分别于术前零点（T1）、无肝期15min（T2）、再灌注期60min（T3）、术后第1天（D1）4个时间点,抽取桡动脉血测定血小板数量及血浆sP-sel水平。血浆sP-sel水平检测采用酶联免疫吸附分析（ELISA）。结果血小板计数在肝移植患者T2、T3及D1各时间点显著降低,与T1相比差异有显著统计学意义（P〈0.01）。血浆sP-sel水平在肝移植患者T2、T3及D1各时间点与T1相比差异无统计学意义（P〉0.05）。结论肝移植缺血再灌注过程中血小板数量减少,而血浆sP-sel水平与再灌注内皮细胞损伤无关。     

先天性胆道闭锁合并卵圆孔未闭患儿肝移植围术期血流动力学及心功能变化

目的 探讨合并卵圆孔未闭的先天性胆道闭锁患儿行原位肝移植围术期血流动力学及心功能的变化。方法 回顾性分析2017年2月~2019年2月我院择期行原位肝移植术的先天性胆道闭锁患儿69例,根据心脏多普勒彩超检查结果分为卵圆孔未闭组（P组,卵圆孔＞3 mm）27例和非卵圆孔未闭组（N组,卵圆孔≤3 mm）42例,比较两组诱导插管后（T1）,门静脉阻断即刻（T2）,无肝期10 min（T3）,门静脉开放即刻（T4）,新肝期1 h（T5）,术毕（T6）时HR、MAP、CVP、SV、CO、CI、dp/dt和CCE及不良心血管事件发生率。结果 两组T4时点MAP和CI低于T1时点,差异有统计学意义（P＜0.05）;两组T2、T4时点SV和CO低于T1时点,T6时点SV和CO高于T1时点,差异有统计学意义（P＜0.05）;两组T2~T6时点CCE低于T1时点,差异有统计学意义（P＜0.05）;两组各时间点均未发生严重不良心血管事件。结论 与非卵圆孔未闭患儿比较,合并卵圆孔未闭的先天性胆道闭锁患儿行原位肝移植围术期血流动力学及心功能变化无差异,术前无明显临床症状或右向左分流致心功能不全,无需对卵圆孔未闭进行手术治疗。     

肝移植后机械通气50例分析

背景：人工机械通气是肝移植后必须经历的一个阶段,移植后机械通气与多种因素有关。 目的：探讨影响肝移植机械通气撤机的影响因素。 方法：采用回顾性方法分析机械通气时间的长短(24 h)与移植前并发症,移植中氧代谢,移植后肝、肾功能和脱机前、后血气及电解质的关系。 结果与结论：肝移植后机械通气时间的长短与移植前并发症、移植中氧代谢、移植后肝肾功能有关(P < 0.05),而与脱机前后血气及电解质无关(P > 0.05)。说明移植前并发症、移植中氧代谢、移植后肝肾功能可影响肝移植后机械通气时间。     

肝癌肝移植患者围手术期凝血功能变化的癌栓分组研究

目的在局部晚期肝癌肝移植患者中，观察癌栓患者和无癌栓患者围手术期凝血功能的变化。方法回顾性分析中山大学肿瘤防治中心2003年9月至2007年1月行肝移植的局部晚期肝癌患者31例。根据有无癌栓分为两组，比较两组患者移植前、术中无肝期、术后3d内的血小板（platelet，PLT）计数、血浆凝血酶原时间（prothrombin time，PT）、活化部分凝血酶原时间（activated paaial thromboplastin time，APTT）、血浆纤维蛋白原（fibrinogen，Fib）和血浆凝血酶时间（thrombin time，Tr）等凝血指标的测定结果，分析凝血功能的变化。结果与术前相比，两组患者PT、APTT和TT升高以及Fib和PLT降低以无肝期最为显著（P〈0．01），术后患者延长的PT、APTT、TT和升高INR逐渐回落。降低的Fib和PLT恢复较慢。组间比较，术前癌栓组患者Fib和PLT低于无癌栓组（P〈0．05）。术中无肝期及术后第1天，癌栓组患者PT、APTT和TT升高以及Fib和PLT降低程度都高于无癌栓组患者，围手术期癌栓组凝血物质的使用量多于无癌栓组。结论癌栓患者和无癌栓患者肝移植围手术期凝血功能变化趋势大致相同：癌栓患者围手术期低凝的因素较多，低凝状态在术中及术后1～2d表现更为突出，此类患者对凝血物质的需求较大，要注意补给。     

肝移植围术期血液中单核细胞TLR4表达和血清细胞因子变化的关系

目的： 探讨肝移植围术期血液中单核细胞TLR4及血清细胞因子浓度的变化。方法：采集15例肝移植患者外周静脉血，用流式细胞仪检测单核细胞TLR4的表达；ELISA法检测血清TNF-α、IL-1β和IL-8，分析TLR4表达与细胞因子的关系。结果：单核细胞TLR4在新肝期3 h、新肝24 h显著上调表达(P<005)；新肝24 h细胞因子的浓度显著高于其它各时间点 (P<001)；新肝24 h时TNF-α、IL-1β和IL-8的浓度与单核细胞TLR4的表达呈正相关(P<005)；发生急性肺损伤患者TLR4表达强且血清细胞因子水平升高。     

术前急性高容量血液稀释对病人血气和电解质的影响

目的比较乳酸钠林格液、万汶和佳乐施用于术前急性高容量血液稀释对病人血气和电解质的影响。方法30例择期脑膜瘤手术病人随机分为乳酸钠林格液组（Ⅰ组）、万汶组（Ⅱ组）和佳乐施组（Ⅲ组），每组10例。麻醉诱导前，分别用相应液体以20ml／（h．kg）的速度AHHD30min，诱导时及以后继续用相应液体20ml／（h．kg）的速度AHHD30min后手术。并于AH—HD前（T1）、AHHD毕（T2）、AHHD后60min（T3）、AHHD后120min（T4）采集动脉血待测血气指标及电解质。结果三组AHHD后，HCT在T2、13、T4点均较T1点降低P〈0．01，AHHD毕与AHHD前比较乳酸钠林格液组HCT降低8．9％，万汶组降低24．8％，佳乐施组降低17．1％。三组病人AHHD后与AHHD前比较，PH、K^＋无明显变化P〉0．05，HCO3-PaGO2均降低P〈0．01。AHHD毕与AHHD前比较，Na^＋、CL均升高P〈0．01，Ca^2^＋的变化万汶组和佳乐施组均降低P〈0．01。结论术前AHHD能维持血流动力学的稳定，用万汶和佳乐施扩容效果优于乳酸钠林格液，且万汶优于佳乐施；AHHD对血气指标无明显影响；三组AHHD后CL^-均增加，而万汶组和佳乐施组AHHD后Ca^2^＋降低，应予以注意，必要时及时补充钙离子。     

量子氧合血对肝缺血再灌注损伤的保护作用

作者建立了兔肝脏缺血再灌注模型,于阻断入肝血流前输注量子氧合血(QOB),与对照组比较,观察肝脏缺血前后肝静脉、下腔静脉血气变化及组织SOD、MDA含量变化.结果表明,对照肝脏缺血25min时肝静脉血表现为极严重的酸中毒,肝脏几乎处于无氧状态,而QOB组仅表现为轻度酸中毒,肝组织内仍维持足够的氧供.另外,QOB组肝组织内SOD总活力明显提高,肝组织内MDA的生成也明显得到抑制,与对照组比较差异极显著(P<0.01).本研究认为,肝切除前或手术中应用QOB,具有较强的抗肝脏缺血再灌注损伤的防治效应.     

Quadrupole mass filtering for registration of blood gas partial pressures

Summary With a newly developed quadrupole mass spectrometer several blood gas partial pressures are recorded simultaneously and continuously. In the mass filter the separation of the ions to be detected takes place in a hyperbolic electric field with variable direct and alternating voltages with a constant frequency of 2.4 MHz.For blood gas analysis a fully relaxed experimental animal was artificially ventilated and provided with arterial and venous catheters. Each catheter consisted flexible steel tubing (external diameter 0.6 mm) slotted near the end and covered with a silicone rubber membrane. The distance from the measuring tip to the mass spectrometer was 150 cm. Experiments with blood, in vivo equilibrated with gas mixtures, showed good reproducibility; the mean error of the helium partial pressure, for example, was less than 4%.During respiration using a gas mixture with 40% argon, the time constantt _63% was found to be 55 s for the whole experimental arrangement including the experimental animal.Supported by the Bundesministerium für Forschung und Technologie     

创伤早期全身炎症反应综合征血液生化指标及血气变化分析

目的:探讨创伤早期发生全身炎症反应综合征(SIRS)的外周血液生化指标及血气变化特点,提高对伤情的早期判断和救治水平。方法: 从2003年8月-2004年2月我科收治的创伤患者中随机抽取88例,按AIS-ISS90进行创伤评分,分为重伤组和轻伤组,总结两组患者入院时的体温、脉搏、呼吸频率、血糖、外周血白细胞、血红蛋白及动脉血气参数(PaO₂、PaCO₂、HCO₃^-、AG),经统计学处理比较两组间上述指标的差异,并比较SIRS发生率及预后的差异。结果: 88例患者中,创伤早期符合SIRS诊断标准者49例,其中12例在轻伤组,37例在重伤组。重伤组患者脉搏、呼吸频率、白细胞计数、血糖、AG及SIRS发生率明显高于轻伤组;PaO₂、HCO₃^-明显低于轻伤组;PaCO₂>45 mmHg或<35 mmHg的发生率明显高于轻伤组(P<0.01);两组间体温、血红蛋白无明显差别(P>0.05)。重伤组中有13例发生了多器官功能不全综合征(MODS),死亡2例。轻伤组无MODS病例,无死亡病例。结论:应用AIS-ISS90进行创伤评分结合SIRS相关外周血液生化指标及血气变化的检测有利于对创伤患者病情的早期判断和及时处理。     

Interpretation of arterial blood gas

Disorders of acid–base balance can lead to severe complications in many disease states, and occasionally the abnormality may be so severe as to become a life-threatening risk factor. The process of analysis and monitoring of arterial blood gas (ABG) is an essential part of diagnosing and managing the oxygenation status and acid–base balance of the high-risk patients, as well as in the care of critically ill patients in the Intensive Care Unit. Since both areas manifest sudden and life-threatening changes in all the systems concerned, a thorough understanding of acid–base balance is mandatory for any physician, and the anesthesiologist is no exception. However, the understanding of ABGs and their interpretation can sometimes be very confusing and also an arduous task. Many methods do exist in literature to guide the interpretation of the ABGs. The discussion in this article does not include all those methods, such as analysis of base excess or Stewart’s strong ion difference, but a logical and systematic approach is presented to enable us to make a much easier interpretation through them. The proper application of the concepts of acid–base balance will help the healthcare provider not only to follow the progress of a patient, but also to evaluate the effectiveness of care being provided.     

Effects of conjugated equine oestrogens with and without the addition of cyclical norgestrel on serum and urine electrolytes, and the biochemical indices of bone metabolism and liver function

Serum and urine electrolytes, and biochemical indices of bone metabolism and liver function were measured in 51 post-menopausal women treated with two hormone replacement therapy regimens for 24 wk. Twenty-six of the women were treated continuously with conjugated equine oestrogens (0.625 mg/day) and the remainder were treated as above with the addition of norgestrel (0.15 mg/day) during the last 12 days of each 28-day cycle.

Both treatment regimens affected electrolytes in a similar manner. The most consistent effect was a reduction in serum sodium levels and a reduction in urinary sodium/creatinine ratios. The combined regimen appeared to have a greater effect on sodium reabsorption.

Both regimens decreased all the biochemical indices of bone metabolism measured, viz serum calcium (corrected for albumin), phosphate and alkaline phosphatase and urinary calcium/creatinine and hydroxyproline/creatinine ratios. The preparations used decreased the parameters by similar amounts over the 24 wk indicating that both were equally effective in reducing bone turnover. The data suggested, however, that the combined regimen had a more profound effect on bone metabolism during the early phase of treatment.

The two treatment regimens had broadly the same effects on the biochemical indices of liver function, reducing albumin levels and all the liver enzymes. Judging by these indices neither regimen had a deleterious effect on liver function.

We conclude that the two hormone replacement regimens have similar effects on the biochemical indices measured, but there are subtle differences between the two treatments which merit further research.     

脐动脉血气对新生儿窒息诊断价值的探讨

目的探讨新生儿脐动脉血气检查在新生儿窒息诊断中的价值。方法前瞻性统计2008年1月1日至2009年7月31日期间在北京市海淀区妇幼保健院出生的全部新生儿18429例。低Apgar评分103例,统计脐动脉血气的参考值及脏器损伤的发生率及分析脐动脉血气与脏器损伤的相关性。结果窒息后可导致多脏器受损,脏器损伤中以呼吸系统受损最常见。脐动脉血气pH〈7.00脏器损伤率为100%。结论单凭低Apgar评分诊断窒息易导致误诊,脐动脉血气应被纳入新生儿窒息诊断标准。     

Use of liquid heparin for blood gas sampling in pediatric intensive care unit: A comparative study of effects of varying volumes of heparin on blood gas parameters

Background and Aims:

Pre-analytical errors in sample collection affect the reliability of blood gas (BG) analysis. Amount of liquid heparin as anticoagulant in samples for BG can affect results by its dilutional direct binding and compositional effects. The aim of this study was to examine the effect of varying amounts of heparin in blood samples on results.

Materials and Methods:

The prospective study was conducted on 15 children at a pediatric intensive care unit (PICU). Three different heparinized syringes were used containing minimal, 60 IU and 120 IU of heparin. A total volume of 1 ml blood in each syringe was taken and was analyzed by blood gas analyzer. Statistical analysis used related samples Friedman''s test and Wilcoxon signed ranks test for paired comparisons. The observed bias was also compared with the desirable bias according to specifications by Ricos et al.

Results:

There was a significant difference (P < 0.05) in values of pH, pCO₂, HCO₃⁻, Hb and Na⁺ in the three syringes. The pCO₂, HCO₃⁻ and Na⁺ levels decreased with the increasing amount of heparin. The observed percentage bias was more than desirable percentage bias specifications for pCO₂, HCO₃⁻, Hb, Na⁺, K⁺ and Cl⁻ levels.

Conclusions:

Syringes with minimal liquid heparin are most appropriate for studying BG parameters as they have the least effect on these parameters. There is a need to standardize the procedure of syringe preparation for BG analysis. Further studies are needed to compare minimal amounts of heparin with commercially available dry balanced heparin syringes.     

暴发性肝功能衰竭大鼠肺血管壁通透性、血气的变化及其与内毒素血症的关系

本实验对硫代乙酰胺所致暴发性肝损伤大鼠肺血管壁通透性及血气的变化进行了观察。结果表明,肝损伤大鼠出现暴发性肝功能衰竭症状时,其肺血管对伊文思蓝的通透性增加(P<0.05),血浆内毒素水平亦较正常动物为高(P<0.05)。血气分析表现为动脉血CO_2分压增高(P<0.05);pH降低,且其水平与血浆内毒素浓度呈负相关(r=-0.730,P<0.05),70%大鼠出现混合性酸中毒,但动脉血氧分压及血氧饱和度无变化。     

Regulation of hepatic blood flow in patients with liver cirrhosis and after liver transplantation

We studied liver blood flow at rest and its regulatory changes after exercise and food intake in ten patients with advanced liver cirrhosis and in 14 patients more than 10 months after orthotopic liver transplantation. The results were compared with those obtained in ten healthy volunteers. Sorbitol steady state infusion was employed to measure functional liver blood flow (FLBF). Thirty minutes of half-maximal muscular work, performed on a supine position ergometer and consumption of a standard meal were used as stimuli to study regulatory changes in hepatic perfusion. Results: FLBF at rest was reduced in end stage cirrhosis (mean 1257±105 ml/min in cirrhosis vs. 1707±76 ml/min in controls; P<0.01). After liver transplantation FLBF at rest was normalized (mean 1922±169 ml/min) in patients with stable graft function. Muscular exercise led to a reduction in FLBF, which in the transplanted patients was the same range as in normal controls (−26.7±3.7%; −24.7±0.7, respectively), but was reduced in cirrhosis (−19.1±2.1%; P<0.05). After ingestion of a standard meal FLBF increased substantially in normal controls (+40.2±2.3%), while in patients with cirrhosis this increase was rather small (+10.1±1.9%; P<0.001). After transplantation the food-induced increase in FLBF(+20.5±3.6%) was larger than in cirrhosis (P<0.05) but remained smaller than in the controls (P<0.01). We conclude that in cirrhosis FLBF is reduced and adaptive changes after exercise or food intake are impaired. After transplantation FLBF is normalized, but blood flow regulation, especially after food intake remains abnormal.