应重视严重创伤和围术期血乳酸的监测

<正>严重创伤和围术期氧代谢障碍是外科医生经常面对的棘手问题,处理不当将导致多器官功能不全综合征(multiple organ dysfunction syndrome,MODS)的发生。研究显示,在血压、尿量正常的严重创伤和围术     

胸科手术患者围术期右心功能影响因素的研究进展

胸科手术患者围术期会因不同原因出现不同程度的右心功能下降,可持续至术后数周。围术期右心功能下降与术后右心功能不全的发展紧密相关。避免围术期右心功能下降,降低术后心血管事件的发生率,已成为目前围术期医学的研究热点。围术期多种因素会影响患者右心功能,主要包括单肺通气、手术方式、镇痛模式、液体管理等。全文对胸科手术患者围术期右心功能影响因素的研究进行简要综述,旨在更好地践行加速康复外科理念,有效保护胸科手术患者围术期右心功能,为改善患者预后提供参考。     

迷走神经刺激影响器官功能的研究进展

迷走神经是副交感神经系统的主要承担者,可以调控炎症反应及器官功能。围术期手术和麻醉等刺激可导致机体迷走神经张力相对降低,导致围术期循环、呼吸、消化、神经等系统相关并发症的发生率升高。本文就迷走神经张力降低对围术期多器官功能的影响及迷走神经刺激在器官功能中的应用做一综述,为减少围术期各种并发症的发生提供新思路。     

围手术期血压与非心脏手术后心肌损伤的研究进展

非心脏手术后心肌损伤(myocardial injury after non-cardiac surgery,MINS)作为一种心血管系统的严重并发症,是非心脏手术患者术后可归因死亡的重要原因。近来的研究发现MINS与围手术期血压显著相关,合理的围手术期血压管理策略可能减少MINS的发生。文章重点介绍了MINS的研究新进展与围手术期血压的特点,阐述了围手术期血压调控对减少MINS的潜在益处,为围手术期血压管理和MINS的预防提供新的依据。围手术期个体化血压管理策略可能成为预防MINS的新方向。     

腹部外科围手术期处理

围手术期究竟从术前几天始至术后几天止为限，迄今并无统一规定。不仅如此，参考文献的包括内容亦不一致，个人建议以本前1天，术中和术后1天为围手术期。无论上。何，围手术期内容从基础上应包括液体治疗，抗生素预防应用，营养支持，医院获得性感染防治，并存病处理和缓和手术引起的应激反应各项措施等六项。其次才是各外科病围手术期的特殊处理。本期征稿所述皆属后者，涉及基础方面则缺如。特别提出围手术期处理是在腹部手术愈做愈大，患者年龄日趋高龄，有器官功能不全和各种并存病的常见形势下才成为专题。当今对普外医师提出更高要求…     

肺癌支气管隆突成形术病人围术期护理

总结65例肺癌行支气管隆突成形术病人围术期护理.结果术后发生各类早期并发症17例,占26.2%,其中肺不张7例,胸腔感染4例,呼吸功能不全3例,心功能不全3例,均经治疗而获得痊愈.提示支气管隆突成形术手术难度大,围术期的护理要求高,积极有效的护理是提高手术成功率、减少术后并发症的重要保证.     

人工全膝关节置换围手术期护理

目的探讨人工膝关节围手术期的护理效果。方法对25例人工膝关节置换的患者进行心理、生活、功能锻炼等围手术期护理措施。结果 25例患者术后膝关节疼痛消失,功能改善明显,术后未发生并发症。结论提高围手术期护理质量,可提高全膝关节置换手术成功率,促进功能恢复。     

目标导向循环管理策略的临床应用进展

危重患者及高危手术的不断增多,给围术期的管理带来了巨大挑战。当机体某一系统受到损害时,整个机体便会做出相应的调整代偿;当机体某一系统失代偿时,机体便会发生损伤。围术期最重要的一项工作是预防并发现机体代偿过程中出现的问题,加强器官保护,维持“脆弱”的平衡状态,改善手术患者的预后。高危患者手术持续时间长,血管内容量变化较大,术中极易出现全身氧供需失衡。组织氧合不足的后果包括伤口和吻合口破裂、器官功能障碍和死亡[1]。对于不同的手术患者,基于术后转归的要求,所选择的血流动力学监测技术及其指标、目标值也存在差异。如何确定导向目标,准确分析影响这些目标的血流动力学参数,做出准确诊断以及处理,更好地践行目标导向循环管理的理念,是麻醉科医师的重要职责。     

一例双侧全髋关节同期置换术围术期的护理

目的通过1例双侧全髋关节置换术患者围术期的护理,有效预防并发症、促进术后功能恢复。方法对2008年4月1例行双侧全髋关节同期置换术的患者进行认真的术前准备,做好心理护理,术后密切观察生命体征及病情变化,做好活动指导,防止并发症的发生,以便达到手术的预期效果。结果患者手术顺利,术后恢复快,无并发症的发生。结论认为双侧全髋关节置换术围术期的护理是手术成败的关键。     

冠心病合并认知障碍老年患者行颈动脉内膜切除术麻醉管理1例

颈动脉内膜切除术患者为脆弱脑功能患者, 围手术期易发生神经系统并发症, 且认知功能障碍增加术后神经认知功能紊乱发生的风险。该患者合并冠状动脉粥样硬化性心脏病、高血压、糖尿病、肾动脉狭窄, 围手术期多模式评估患者脑组织灌注及麻醉对脑功能的影响, 术中关注维持心脑等重要器官灌注和脑功能的维护, 采取抗炎、抗应激、体温保护和抗恶心呕吐等综合处理。患者顺利完成手术, 术后无谵妄等神经系统并发症。     

Intra-abdominal hypertension and the abdominal compartment syndrome

BACKGROUND: Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure is abnormally high in association with organ dysfunction. It tends to have a poor outcome, even when treated promptly by abdominal decompression. METHODS: A search of the Medline database was performed to identify articles related to intra-abdominal hypertension and ACS. RESULTS: Currently there is no agreed definition or management of ACS. However, it is suggested that intra-abdominal pressure should be measured in patients at risk, with values above 20 mmHg being considered abnormal in most. Abdominal decompression should be considered in patients with rising pressure and organ dysfunction, indicated by increased airway pressure, reduced cardiac output and oliguria. Organ dysfunction often occurs at an intra-abdominal pressure greater than 35 mmHg and may start to develop between 26 and 35 mmHg. The mean survival rate of patients affected by compartment syndrome is 53 per cent. CONCLUSION: The optimal time for intervention is not known, but outcome is often poor, even after decompression. Most of the available information relates to victims of trauma rather than general surgical patients.     

Treatment threshold for intra-operative hypotension in clinical practice—a prospective cohort study in older patients in the UK

Intra-operative hypotension frequently complicates anaesthesia in older patients and is implicated in peri-operative organ hypoperfusion and injury. The prevalence and corresponding treatment thresholds of hypotension are incompletely described in the UK. This study aimed to identify prevalence of intra-operative hypotension and its treatment thresholds in UK practice. Patients aged ≥ 65 years were studied prospectively from 196 UK hospitals within a 48-hour timeframe. The primary outcome was the incidence of hypotension (mean arterial pressure <65 mmHg; systolic blood pressure reduction >20%; systolic blood pressure <100 mmHg). Secondary outcomes included the treatment blood pressure threshold for vasopressors; incidence of acute kidney injury; myocardial injury; stroke; and in-hospital mortality. Additionally, anaesthetists providing care for included patients were asked to complete a survey assessing their intended treatment thresholds for hypotension. Data were collected from 4750 patients. Hypotension affected 61.0% of patients when defined as mean arterial pressure <65 mmHg, 91.3% of patients had >20% reduction in systolic blood pressure from baseline and 77.5% systolic blood pressure <100 mmHg. The mean (SD) blood pressure triggering vasopressor therapy was mean arterial pressure 64.2 (11.6) mmHg and the mean (SD) stated intended treatment threshold from the survey was mean arterial pressure 60.6 (9.7) mmHg. A composite adverse outcome of myocardial injury, kidney injury, stroke or death affected 345 patients (7.3%). In this representative sample of UK peri-operative practice, the majority of older patients experienced intra-operative hypotension and treatment was delivered below suggested thresholds. This highlights both potential for intra-operative organ injury and substantial opportunity for improving treatment of intra-operative hypotension.     

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??Risk factors for operative management with blunt liver injury: A report of 102 cases HUANG Chao??ZHANG Kun??JIANG Yi. Department of Hepatobiliary Surgery??Fuzong Medical College of Fujian Medical University??Fuzhou General Hospital of Nanjing Military Command, Fuzhou 350025, China
Corresponding author??ZHANG Kun??E-mail??zhangkun73@aliyun.com
Abstract Objective To investigate the risk factors for operative management with blunt liver injury. Methods One hundred and two cases of blunt liver injury admitted in the Fuzhou General Hospital of Nanjing Military Command between October 1??2003 and May 1??2016 were reviewed retrospectively. The grading of the liver injury was verified by using surgical operation or CT scans. According to whether were operative management??and depending on the American Association for the Surgery of Trauma-organ injury scale (AAST-OIS) and imaging Becker rating??all the cases were divided into operative management group and non-operative management group??including 23 cases of grade ??33 cases of grade ??24 cases of grade ??18 cases of grade ????and 4 cases of grade ??. Univariate and multivariate Logistic analysis were performed to investigate correlative factors of operative management with blunt liver injury to identify independent risk factors of operative management with blunt liver injury. Using receiver operating characteristic curse??it determined the threshold of independent risk factors of operative management with blunt liver injury. Results Univariate analysis showed that correlative factors of operative management with blunt liver injury include alanine aminotransferase??aspartate aminotransferase??hemoglobin??hematocrit??serum potassium??heart rate??systolic blood pressure??the American Society for Surgery of Trauma-organ injury scale??peritoneal irritation??merger intraperitoneal other organ damage. Pearson product-moment correlation coefficient analysis showed that levels of serum potassium and sodium were correlated negatively??levels of blood pressure and heart rate were correlated negatively??levels of alanine aminotransferase and aspartate aminotransferase were correlated positively??and the liver grading and peritoneal irritation were correlated positively in both groups. Alanine aminotransferase??serum potassium and systolic blood pressure of the best threshold of operative management with blunt liver injury were 171.5 U/L??3.625 mmol/L??96.5 mmHg ??1 mmHg=0.133 kPa??respectively by the ROC curve. Logistic multivariate regression analysis showed that blood pressure <96.5mmHg??serum potassium <3.625 mmol / L??merger intraperitoneal other organ damage and peritoneal irritation were independent risk factors for operative management with blunt liver injury. Conclusion Blood pressure <96.5 mmHg??serum potassium <3.625 mmol/ L??merger intraperitoneal other organ damage and peritoneal irritation were the high risk factors of operative management with blunt liver injury.     

闭合性肝损伤手术治疗危险因素102例分析

目的 探讨闭合性肝损伤手术治疗的危险因素。方法 回顾性分析2003-10-01至2016-05-01南京军区福州总医院收治的102例闭合性肝损伤病人临床资料,通过腹部CT检查或手术中探查确定肝损伤的程度分级。按是否手术治疗,并根据影像学Becker分级及美国创伤外科学会-器官损伤分级（AAST-OIS）,分为手术组51例,非手术组51例,肝损伤分级包括Ⅰ级23例、Ⅱ级33例、Ⅲ级24例、Ⅳ级18例、Ⅴ级4例。采用单因素分析和多因素Logistic回归法分析肝损伤手术治疗的相关因素,确定肝损伤手术治疗的独立危险因素。通过受试者工作特征曲线（ROC曲线）确定肝损伤治疗独立危险因素的阈值。结果 单因素分析显示,闭合性肝损伤手术治疗的相关因素有丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、血红蛋白（Hb）、血细胞比容（HCT）、血清钾（K+）、心率（HR）、收缩期血压（SBP）、美国创伤外科学会-器官损伤分级、腹膜刺激征、合并腹腔其他器官损伤。Pearson积差相关系数分析提示血清K+和血清钠（Na+）的水平在两组中呈负相关,SBP和HR的水平在两组中呈负相关,ALT和AST的水平在两组中呈正相关,肝损伤程度分级和腹膜刺激征在两组中呈正相关。通过ROC曲线评估得出ALT、血清K+、SBP的手术治疗最佳阈值分别为171.5 U/L、3.625 mmol/L、96.5 mmHg（1 mmHg=0.133 kPa）。多因素Logistic回归分析发现SBP<96.5 mmHg、血清K+<3.625 mmol/L、合并腹腔其他器官损伤、腹膜刺激征是闭合性肝损伤手术治疗的独立危险因素。结论 SBP<96.5 mmHg、血清K+<3.625mmol/L、合并腹腔其他器官损伤、腹膜刺激征为闭合性肝损伤手术治疗的高危因素。     

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a devastating condition for the critically unwell patient. Initially described as solely affecting surgical patients, ACS is now also recognized in the medical intensive care setting. Without prompt and definitive treatment mortality rates approach 70% as multi-organ failure develops. Over the past decade our understanding, recognition and management of ACS has evolved. The World Society of Abdominal Compartment Syndrome published updated guidelines in 2012 to draw consensus and improve patient outcomes. ACS is the end sequela of raised intra-abdominal pressure (IAP), defined as a sustained IAP >20 mmHg with or without an abdominal perfusion pressure <60 mmHg and associated with new organ dysfunction. Intravesical measuring of IAP is the gold standard diagnostic technique. Surgical decompressive laparotomy and open abdomen with temporary abdominal closure measures is the definitive treatment. This article summarizes the updated consensus definitions, pathophysiology, diagnostic investigation and management to help the junior surgical trainee faced with ACS.     

Perioperative fluid therapy

Precise physiological systems ensure normal fluid and electrolyte homeostasis in health. These mechanisms can be disrupted by illness and injury (including surgery). Disruption results in altered cellular and organ function. An understanding of this physiology is therefore crucial to provide safe and effective fluid management for these patients. Effective fluid management is required to cover the full perioperative period and there is increasing evidence to support the use of cardiac output monitoring to guide fluid therapy. The ultimate aim is to ensure preoperative, intra-operative and postoperative fluid optimisation to maximise cardiac output and oxygen delivery at the cellular level. Such ‘goal directed’ fluid therapy tailors management to individual patient physiology, associated co-morbidity and the degree of surgical insult and subsequent stress response with the aim of reducing mortality, morbidity and reducing the length of postoperative stay.     

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is a devastating condition for the critically unwell patient. Initially described as solely affecting surgical patients, ACS is now also recognized in the medical intensive care setting. Without prompt and definitive treatment, mortality rates approach 70% as multiorgan failure develops. Over the past decade our understanding, recognition and management of ACS has evolved. The World Society of Abdominal Compartment Syndrome published updated guidelines in 2012 to draw consensus and improve patient outcomes. ACS is the end sequala of raised intra-abdominal pressure (IAP), defined as a sustained IAP >20 mmHg with or without an abdominal perfusion pressure <60 mmHg and associated with new organ dysfunction. Intravesical measuring of IAP is the gold standard diagnostic technique. Surgical decompressive laparotomy and open abdomen with temporary abdominal closure measures is the definitive treatment. This article summaries the updated consensus definitions, pathophysiology, diagnostic investigation and management to help the junior surgical trainee faced with ACS.     

带蒂肌瓣转移联合负压吸引一期重建治疗心脏术后复杂性纵隔感染

目的总结心脏术后复杂性纵隔感染的外科治疗经验,探讨最佳治疗策略。方法回顾性分析首都医科大学附属北京安贞医院心外科2006年6月至2012年12月期间,应用带蒂肌瓣转移填充及负压吸引一期重建治疗心脏直视术后复杂性纵隔感染18例的临床资料。其中男12例、女6例,平均年龄（65．5±8．2）岁。心脏手术与肌瓣重建时间间隔（12．5±5．8）d。彻底清创,拔除全部钢丝,游离双侧胸大肌瓣向中线牵拉,填充胸骨间隙并覆盖胸骨,无张力缝合肌瓣,纵隔及皮下置引流管负压吸引,关闭创口。胸骨缺损较大者,需游离一侧腹直肌瓣上提填充缺损,再按上述方法一期重建。结果1例患者术后早期死于纵隔感染复发,脓毒血症及多器官功能衰竭。17例患者术后过程顺利,创口一期愈合。重建术后住院时间（18．6±7.2）d,创口愈合时间（4．5±2．4）周。17例患者随访6个月以上未见纵隔感染复发,工作生活质量良好。结论带蒂肌瓣转移联合负压吸引一期重建治疗心脏术后复杂性纵隔感染效果确切,手术简单,易于推广。     

The postoperative care of adult patients exposed to deep hypothermic circulatory arrest

Deep hypothermic circulatory arrest with cardiopulmonary bypass is indicated for complex surgical operations in adult patients involving the aortic arch, thoracoabdominal aorta, cerebral vasculature, and tumors extending into the vena cava and heart. Understanding the principles of ischemic-reperfusion injury and the effects of hypothermia in attenuating this process is fundamental to the delivery of effective postoperative care. Neurologic injury is the most troublesome adverse effect after the use of deep hypothermic circulatory arrest and cardiopulmonary bypass, presenting as either a transient neurologic deficit (5.9% to 28.1%) or an irreversible neurologic injury (1.8% to 13.6%). In patients with neurological injury, early postoperative mortality is markedly increased (18.2%), and for those patients that survive, long-term cognitive disability is still evident 6 months later. Early postoperative support of organ function, along with timely diagnosis and treatment of organ injury, is essential in minimizing perioperative morbidity, particularly neurologic morbidity. Meticulous management of fluids, maintaining stable cardiovascular hemodynamics with particular attention to systolic blood pressure, optimizing oxygen delivery, limiting ventilator-associated lung injury, intensive insulin therapy for control of blood glucose levels, and avoidance of hyperthermia are essential in limiting organ injury and reducing perioperative morbidity and mortality.     

Perioperative implications of retrograde flow in both the subclavian arteries in an adult undergoing surgical repair of coarctation of aorta

During surgical repair of coarctation of aorta (CoA), management of spinal cord ischemia and prevention of paraplegia is an important issue. The risk factors for paraplegia include level and duration of aortic-clamping, clamping of left subclavian artery (SCA), intraoperative temperature, variability of collateral circulation to the spinal cord, cerebrospinal fluid pressure, upper body arterial pressure, and aortic pressure beyond the aortic clamp. A short clamp time (<30 min), and distal aortic pressure>60 mmHg, minimizes the risks of spinal cord injury. In an adult patient during surgical repair of CoA, the arterial pressure in the femoral artery remained around 45 mmHg and repair took 83 min of aortic-clamping. Neurological assessment on regaining consciousness showed no deficit of lower limbs. Aortic root angiogram had shown retrograde filling of both SCAs. A unique situation in which clamping of SCAs would increase flow to the spinal cord as their clamping would stop stealing of blood and aortic-clamping proximal to CoA will further increase collateral flow; because of these reasons, the patient tolerated prolonged aortic-clamping despite low distal aortic pressure without neurological deficit. However, aortic-clamping increased left ventricular after-load and the patient developed worsening of mitral regurgitation and pulmonary hypertension during aortic clamping.