原发性肝癌外科手术过程无血切肝技术的应用

目的探讨原发性肝癌手术过程中无血切肝技术的应用及手术中失血量与预后的关系。方法回顾性统计分析1380例原发性肝癌手术切除病人的临床资料，再按照失血量分为4组，研究各组的输血量、术后并发症发生率、术后1周肝功能Child-Pugn分级、术后住院天数、术后长期存活率。结果手术过程输血量随出血量的增加而增加，各组间存在统计学差异（P〈0．01）；术后并发症的发生在出血量〉800ml时显著上升；手术后1周的肝功能（Child-Pugn评分）A级的在出血量少的前两组分别为93．7％和88．6％，而出血800～1200ml组为72．6o,4，出血〉1200ml组低至57．9％；肝功能分级组间差异非常显著（P〈0．01）；手术后住院天数随出血量增加，手术后恢复时间也增长；病人长期存活率出血量〉800ml组长期存活率显著低于出血量少组（P〈0．01）。结论无血切肝技术是控制手术过程中失血的有效方法，出血量的有效控制一定程度上预示手术后平稳恢复、长期生存。     

ASA 评分在肝癌患者外科治疗风险评估中的作用

目的：探讨ASA评分对肝癌患者外科治疗风险评估的价值。 方法：回顾2006年1月—2010年12月419例原发性肝癌肝切除患者围手术期临床资料,分析患者ASA评分与临床因素的关系,并对可能的相关因素作单因素筛选后行多因素回归分析,分析肝癌术后并发症及术中输血有关的影响因素。 结果：统计分析显示,肝癌患者术前并发症及术前血红蛋白影响ASA评分;随着ASA评分上升,患者术中失血量、输血量、术后并发症及住院天数明显高增加（均P<0.05）。多因素回归分析结果显示,ASA评分、失血量、肝硬化、年龄、丙氨酸转氨酶（ALT）水平是术后并发症发生的独立影响因素（均P<0.05）;ASA评分、手术时间、肿瘤直径是术中输血的独立影响因素（均P<0.05）。 结论：ASA评分是肝癌患者围手术期风险较好的早期预测指标。     

老年结、直肠癌术后肺部并发症危险因素分析

为探讨老年结、直肠癌患者术后肺部并发症的相关危险因素。 笔者回顾性分析近4年间手术治疗的330例60岁以上结、直肠癌患者术后肺部并发症（PPC）发生的情况。结果示330例中有72例出现PPC，发生率为21.80%，死亡5例，病死率占全组患者的1.51%，占PPC患者的6.94％。PPC发生率如下：年龄﹥80岁者为42.30%；体重指数﹥25者为27.38%；有吸烟史者为37.00%；有慢性阻塞性肺疾病（COPD）史者为33.56%；上腹部手术为37.39%；手术时间﹥2h者为24.60%。提示PPC的发生与高龄、肥胖、吸烟史、COPD史、手术部位、手术时间有明显关系，是相关的危险因素。     

肝移植围手术期的危险因素与术后肺部并发症的关系分析

目的探讨肝移植围手术期的危险因素与术后肺部并发症的关系。方法回顾性分析我院2003年4月至2007年3月行肝移植手术的终末期肝病患者107例，单因素兼多因素Logistic回归分析患者术前、术中和术后的一些因素与肝移植术后肺部并发症情况的相关性。结果本研究所有患者的肺部并发症发生率为60．8％。术前Neld评分≥25分（P=0．041），术中输液总量〉10L（P=0．026），输血液制品总量〉4L（P=0．033）是术后发生肺部并发症的危险因素，而术后前3d至少有2d的液体平衡≤-300ml（P=0．021）是保护因素。结论肝移植术前改善基础状况，术中控制输液量、减少输血液制品量，术后尽早实现液体出人量的负平衡可减少术后肺部并发症的发生率。     

大肝癌手术切除术中不同肝血流阻断方法的临床研究

目的：比较大肝癌手术切除术中3种不同的入肝血流阻断法的临床效果。
　　方法：回顾性分析2011年1月—2013年3月期间218例大肝癌（>5cm）手术患者的临床资料,术中88例采用Pringle法间断阻断全肝血流（肝门阻断组）,51例行选择性的半肝血流阻断（半肝阻断组）,79例行肝下下腔静脉阻断联合Pringle法阻断入肝血流（联合阻断组）。比较3组患者的术中与术后的相关指标。
　　结果：3组患者的术前情况、手术时间、入肝血流阻断时间及肝切除量的差异均无统计学意义（均P>0.05）;半肝阻断组与联合阻断组的术中出血量、输血量、输血率均明显低于肝门阻断组,且联合阻断组的输血量、输血率明显低于半肝阻断组（均P<0.05）;3组患者术后第1天肝功能指标差异无统计学意义（均P>0.05）,但半肝阻断组与联合阻断组第3、7天的转氨酶和总胆红素水平均明显低于肝门阻断组（均P<0.05）;3组术后并发症的发生率差异无统计学意义（P>0.05）。
　　结论：大肝癌切除术术中采用肝下下腔静脉阻断联合Pringle法阻断入肝血流不仅能够有效减少术中失血量,而且有利于术后肝功能的恢复。     

术中及术后血液回收在骨科的临床应用

目的探讨术中及术后血液回收在骨科无菌手术中的应用。方法 1996年 6月～ 2000年 4月,在 117例骨科手术中使用术中血液回收,其中 29例全髋关节置换术联合使用术后血液回收。记录回收的血液量及并发症。结果术中血液回收共计 70 965 ml,占总输血量的 41.61％,平均每人 606.54 ml,其中 29例全髋关节置换术患者术后血液回收共计 12 330 ml,平均每人 425.17 ml。 2例有一过性血红蛋白尿, 8例出现一过性发热反应,无其他并发症。结论术中及术后血液回收是安全且有效的自体输血方式,可以节省异体血的用量,并且避免血液传播性疾病的发生。     

输血对大肝癌切除术后近远期预后的影响

目的研究输血对大肝癌切除术后近期并发症和远期存活率的影响。方法回顾性分析177例大肝癌切除术病例，结合随访分析输血对近期并发症和远期存活率的影响。结果本组大肝癌围手术期输血率为74．6％。近5年输血量及输血率较5年前显著减少（P〈0．01）。不输血组并发症率低于输血组（P〈0．05）。单因素分析显示，年龄、肝门阻断、术中出血量、输血量以及手术时间与术后并发症发生有关。多因素分析显示，年龄、肝门阻断、输血量以及手术时间是决定术后并发症的4个独立的预测指标。本组大肝癌1、3、5年总存活率为67％、44％和34％，1、3、5年无瘤存活率为51％、31％和31％。不输血组和输血组的总存活率以及无瘤存活率无显著差别。结论输血是决定大肝癌切除术后并发症发生的独立危险因素之一，但输血对大肝癌切除术后存活率无显著影响。肝脏外科医生应积极采取各种方法尽可能避免大肝癌切除术围手术期的输血。     

吸气肌的锻炼可减少CABG术后肺部的并发症

肺部并发症（PPC）是冠脉搭桥术（CABG）术后主要并发症和死亡原因，可增加患者的住院时间和医疗资源消耗。而术前进行吸气肌锻炼（IMT）以降低CABG术后PPC发生率的临床疗效还不明确。荷兰一项单盲随机临床研究表明，IMT可降低CABG患者术后PPC发生率。     

食管癌手术围术期肺部感染的高危因素分析及预防

目的探讨食管癌手术围术期发生肺部感染的高危因素及其预防措施。方法回顾性分析2009～2012年广元市中心医院258例食管癌手术患者的临床资料,按食管癌术后是否发生肺部感染将258例食管癌手术患者分为两组,肺部感染组：86例,男62例、女24例,平均年龄65.1（45～84）岁,食管癌手术后均发生肺部感染;对照组：172例,男124例、女48例,平均年龄60.2（43～78）岁,为随机抽取的同期食管癌手术后未发生肺部感染者。比较两组患者的术前肺功能、年龄、吸烟量、吻合口位置、手术出血量、术前、术后其它合并症及管状胃代食管肺部感染发生率的差异,并采用logistic多因素回归分析食管癌手术围术期肺部感染的高危因素。结果单因素分析结果显示,肺部感染组肺功能中重度障碍、吸烟（≥400支/年）、高龄（≥65岁）、喉返神经损伤、围手术期失血量（术中出血＋术后24 h胸腔、腹腔引流量≥1 000 ml）、手术时间≥4 h、术前合并糖尿病的比率均高于对照组（P〈0.05）。Logistic多因素回归分析结果显示,肺功能中重度障碍（P=0.022）、吸烟（≥400支/年,P=0.000）、高龄（≥65岁,P=0.026）、喉返神经损伤（P=0.002）、围手术期失血量（术中出血＋术后24 h胸、腹腔引流量≥1 000 ml,P=0.020）是食管癌患者术后发生肺部感染最主要的危险因素。结论肺功能中-重度障碍、吸烟（≥400支/年）、高龄（≥65岁）、喉返神经损伤、围手术期失血量（≥1 000 ml）是食管癌术后发生肺部感染的高危因素;术前戒烟、加强呼吸功能锻炼、呼吸道准备、严密止血、注意保护喉返神经等措施可预防肺部感染的发生。     

食管癌围术期液体管理对肺部并发症影响的回顾性队列研究

目的了解食管癌手术围术期液体管理对术后肺部并发症发生的影响,找出最佳的补液方案。方法选取2014年6~12月间四川大学华西医院胸外科行食管癌切除,胃代食管术的75例食管鳞癌患者进行回顾性队列研究。肺部并发症的界定采用修订后的Kroenke术后肺部并发症分级系统。将所有出现Ⅱ~Ⅳ级肺部并发症的患者作为肺部并发症组[n=13,男12例、女1例,年龄(64.62±8.64)岁],其他患者作为无并发症组[n=62,男50例、女12例,年龄(60.55±8.73)岁],对比组间各临床指标和围术期出入量的差距。结果并发症组与无并发症组组间相比,存在差异的指标包括术后输注白蛋白,术中净入量、总入量、术中公斤体重净入量、术中公斤体重总入量、术中公斤体重小时净入量、术中公斤体重小时总入量(术中输液速度)、术后1~3 d总入量、术后1~3 d公斤体重总入量。其中,术中输液速度和术后1~3 d总入量对于预测肺部并发症的截点值分别为12.07 ml/(kg·h)和178.57 ml/kg。结论术中补液速度和术后前3 d的补液量是影响术后肺部并发症发生的重要因素,为降低术后并发症发病率,术中输液速度最好不超过12.07 ml/(kg·h),术后前3 d补液不超过178.57 ml/kg。在此范围之内,适当增加补液量有助于改善患者体验。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.