气腹对呼吸、循环系统的影响

随着腹腔镜技术的广泛应用。为了给术者提供一个清晰术野。气腹是施行腹腔镜手术的重要前提条件。腹腔内充人一定压力的某种气体。无疑会对膈肌及腹内脏器产生机械压迫和神经内分泌改变等作用，从而影响呼吸及循环等系统功能。甚至带来严重不良后果。气腹对患者所产生的各种病理生理学改变已引起众多研究学者的重视。目前CO2是气腹的首选气体，CO2因不易燃爆，且在血液及组织中溶解度高，形成气栓的可能性小，但因可引起高碳酸血症，或呼吸性酸中毒，加重气腹对心肺功能的影响。因此，要求腹腔镜手术医师及麻醉医师对气腹引起的呼吸和循环等系统的改变，以及气腹所致的相关并发症，应有一个较全面的认识。     

腹腔镜下手术体位的改变对呼吸循环的影响

目的探讨腹腔镜下手术体位的改变对呼吸循环的影响。方法回顾性分析本院近年来收治的138例腹腔镜下妇科手术患者的临床资料,监测记录MAP、HR、PETCO2、潮气量、呼吸频率。结果138例腹腔镜下妇科手术患者,气腹后的MAP、HR、PETCO2、潮气量、呼吸频率均有所增加,经统计学分析,P〈0．05,差异有统计学意义,改变体位后,各项指标均有显著性变化,P〈0．01;改换体位气腹后、恢复体位排气后各项指标明显降低,但仍高于气腹前水平。结论腹腔镜手术时,由于体位改变导致的高气腹压力对患者呼吸循环系统影响较为明显,术中应避免体位改变,以维持呼吸循环功能的稳定。     

腹腔镜术后肩痛的原因分析及护理研究进展

腹腔镜手术在越来越广泛地应用于妇产科临床，它具有损伤小、出血少、并发症发生率低、住院时间短、恢复快等优点，因而目前的妇科良性疾病广泛采用腹腔镜手术治疗。但术后肩痛、腹胀等并发症也同时引起了临床上的关注，尤以肩痛明显。有报道指出肩痛的发生率高达63．7％～80％，其原因主要有几个方面：腹腔内二氧化碳产生的酸性物质对膈神经、膈肌的刺激，术中气腹压力及体位影响，精神心理因素等。临床护理工作中对术后肩痛逐渐认识，并针对形成原因采取了术前宣教缓解精神压力、术中气腹控制及体位控制、术后氧疗、饮食及呼吸方式指导、局部按摩等处理措施。     

综合护理干预对妇科腹腔镜术后并发症的效果观察

目的:探讨妇科腹腔镜术后综合护理干预的效果。方法:将108例妇科腹腔镜手术患者随机分为对照组和观察组,对照组采用常规护理干预方法,观察组则采用综合护理干预,包括术中调节气腹压力、术后6 h膝胸卧位、早期床上运动及功能康复操的锻炼。结果:观察组术后CO2气腹并发症包括恶心、呕吐、腹胀、腹痛、肩痛、膈下疼痛等发生率低于对照组,差异有统计学意义(P<0.01或P<0.05)。结论:综合护理干预可显著降低CO2气腹并发症的发生,促进排气、排便,优于常规护理干预。     

CO_2气腹对妇科腹腔镜手术患者呼吸循环的影响

妇科腹腔镜手术中大多是采用全麻和CO2气腹,但是术中CO2气腹对机体的生理反应有一定影响,尤其对呼吸循环系统影响较大.2007年1月～2008年9月作者对42例妇科腹腔镜手术患者的呼气末CO2分压和血气进行了检测,旨在了解CO2气腹对妇科腹腔镜手术患者呼吸和循环系统的影响.     

全麻下妇科腹腔镜手术对呼吸循环功能的影响

妇科腹腔镜手术与传统开腹式手术比较，具有创伤小，术后疼痛轻，并发症少及恢复快等优点，但由于该技术特殊的气腹和体位，对患者呼吸、循环功能会产生不同的影响，本文观察50例的妇科患者全麻下腹腔镜手术对呼吸循环功能的影响观察报告如下。     

腹腔镜术中CO2气腹压力对合并老年COPD患者呼吸功能的影响

目的:探讨腹腔镜手术中二氧化碳(CO2)气腹压力对老年慢性阻塞性肺病(COPD)患者呼吸功能的影响及合适气腹压力的选择。方法:将行腹腔镜手术的75例COPD患者随机分成A、B、C三组各25例,A组气腹压力设定为10～12 mm Hg(1 mm Hg=0.133 kPa),B组气腹压力13～15 mm Hg,C组气腹压力设定为16～18 mm Hg,比较手术医生对腹部操作空间的满意度,患者围麻醉期血气、气道压和苏醒、麻醉时间。结果:B、C组医生满意度高于A组、手术时间短于A组(P<0.05),C组苏醒时间、拔管时间长于A、B组(P<0.05);C组术后呼吸功能与A、B组比较差异有统计学意义(P<0.05)。结论:腹腔镜术中气腹压力对COPD患者呼吸功能的影响随压力增加而明显,13～15 mm Hg压力可保证满意的手术视野和操作空间,且对患者呼吸功能无明显影响。     

CO2气腹对妇科腹腔镜手术患者呼吸循环的影响

妇科腹腔镜手术中大多是采用全麻和CO2气腹，但是术中CO2气腹对机体的生理反应有一定影响，尤其对呼吸循环系统影响较大。2007年1月-2008年9月作者对42例妇科腹腔镜手术患者的呼气末CO2分压和血气进行了检测，旨在了解CO2气腹对妇科腹腔镜手术患者呼吸和循环系统的影响。     

体位和气腹压力对腹腔镜术后肩痛的影响

目的 探讨腹腔镜不同手术体位和气腹压力对术后肩痛的影响.方法 随机选择腹腔镜手术277例,术中采取头高足低位142例,气腹压力设定A组14 mm Hg,B组10 mm Hg.头低足高位135例,气腹压力设定C组14 mm Hg,D组10 mm Hg.比较4组患者术后肩痛的发生率.结果 两种手术体位对术后肩痛发生率有显著差异(P<0.05),低气腹压力组术后肩痛发生率明显低于高气腹压力组.结论 体位和气腹压力均对腹腔镜术后肩痛有影响,高气腹压力或头低足高位可致腹腔镜术后肩痛.     

等比通气对腹腔镜下老年患者呼吸力学及白细胞介素6的影响

正由于腹腔镜技术的发展及社会的老龄化,越来越多的老年患者要求进行微创治疗。但是,老年人心肺储备功能降低,出现低氧血症、肺不张、肺损伤等并发症的风险更大。腹腔镜手术时CO_2气腹及头低足高位增加腹内压、抬高膈肌,使肺容量减少、胸肺顺应性下降、气道阻力增加、肺不张发生,老年患者会加重上述损害~([1])。调节机械通气参数可在某种程度上降低二氧化碳潴留和低氧血症发生率,但仍有气压伤等导致肺损伤发生,因此,通气模式的选择显得尤为重要。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.