肠内营养在腹部手术中的应用

目的　探讨肠内营养在腹部手术中的应用价值。方法　 30例接受腹部手术的患者 ,术后 2 4～ 2 8h开始实施肠内营养 ,观察营养指标和免疫功能的变化及与肠内营养的关系。结果　通过肠内营养 ,患者的体重、血红蛋白、血浆蛋白、前白蛋白、血清白蛋白均有不同程度的提高 ,其中血浆蛋白和前白蛋白上升最明显 (P <0 .0 5 ) ,营养前后免疫指标IgA ,IgG ,IgM ,淋巴细胞计数差异有显著意义 (P <0 .0 1) ,且无严重并发症的发生。结论　肠内营养能够显著改善腹部手术患者的营养状况 ,明显提高患者的免疫功能 ,有效保障肠粘膜屏障功能的稳定性 ,防止细菌移位 ,避免了因此而引起的严重并发症的发生     

特殊营养素在外科患者中的应用

某些特殊营养素如谷氨酰胺、精氨酸、ω-3脂肪酸等具有治疗和调节机体代谢与免疫功能作用．可降低手术患者感染性并发症发生率,缩短住院时间。本文介绍药理营养或免疫营养概念以及其在胃肠道手术患者中的应用。     

生长激素联合免疫肠内营养在大肠癌患者围手术期的应用

目的:探讨大肠癌患者术后应用重组人生长激素(rhGH)联合免疫肠内营养Supportan的安全性、有效性.方法:将大肠癌患者72例随机、单盲分为治疗组(肠内营养+rhGH)21例,肠内营养对照组26例,肠外营养对照组25例.比较行大肠癌根治手术前后三组患者的营养、免疫指标.观察术后并发症发生率及随访3年结果.结果:术后第14天治疗组PALB值已经恢复至术前水平之上,肠内营养组较肠外营养组有明显恢复但仍未达到术前水平,而肠外营养组仍处于术前水平以下.治疗组术后第8天、14天CD4+/CD8+值较PN组明显上升.治疗组并发症发生率明显低于对照组(P<0.05).结论:大肠癌根治术后联合使用GH与免疫型肠内营养制剂改善了患者术后的营养状况和免疫功能,减少了术后并发症,对其生存率和肿瘤复发率没有明显的影响.对能手术根治的大肠癌术后短期小剂量使用rhGH联合Supportan是安全有效的,可作为术后较为合理的营养支持方法.     

合并营养不良的胃肠道恶性肿瘤患者术后应用肠内免疫营养的临床研究

目的探讨术后应用肠内免疫营养对伴营养不良的胃肠道肿瘤患者术后炎性反应和免疫功能的影响。方法前瞻性收集2008年1月至2010年6月间河北省沧州市人民医院普通外科106例合并营养不良的胃肠道恶性肿瘤手术患者．按随机数字表法分为肠内免疫营养组（53例）和普通肠内营养组（53例）。于术前5d、术后1d和9d分别进行免疫学指标和急性相反应蛋白的检测。结果两组患者手术情况及术前免疫学指标的差异均无统计学意义（均P〉0．05）。术后9d,免疫营养组免疫学指标C04、CD4／CD8、IgG、淋巴细胞、NK细胞及补体c3、c4和CH50水平均高于普通营养组：血清C反应蛋白水平则低于普通营养组,差异均有统计学意义（P〈0．05）。免疫营养组术后感染并发症发生率为3．8％（2／53）,明显低于普通营养组的15．1％（8／53）（P〈0．05）：术后住院时间为（8．1±1．1）d,明显短于普通营养组的（9．2±2.1）d（P〈0．05）。结论对于合并营养不良的胃肠道恶性肿瘤患者．应用肠内免疫营养可减轻术后创伤和炎性反应．改善机体免疫功能,从而降低术后感染并发症发生率。     

肠内生态免疫营养在结直肠癌围手术期的应用

目的 了解肠内生态免疫营养在结直肠癌围手术期的临床应用。方法 复习国内外文献,进行总结归纳,并加以综述。结果 围手术期早期给予肠内生态免疫营养能大大改善结直肠癌患者的营养状态,提高患者的免疫功能,重建肠道菌群,减少并发症的发生。结论 肠内生态免疫营养在结直肠癌围手术期的应用可明显改善患者的营养状况,提高免疫功能,减少应激反应,改善其预后,但其使用的最佳剂量还需进一步研究。     

免疫营养与梗阻性黄疸

梗阻性黄疸（obstructive jaundice）是肝胆外科的常见疾病，围手术期易发生感染、败血症、多器官功能障碍综合征（MODS）等并发症，严重影响患者预后。患者免疫功能低下是主要原因之一。而免疫营养在补充机体所需营养的同时可以改善患者免疫功能。本文对免疫营养、梗阻性黄疸以及免疫营养对梗阻性黄疸的影响综述如下。     

胃肠外营养在严重多发性创伤病人中的应用

目的研究胃肠外营养支持在治疗严重多发性创伤的效果.方法从110例严重多发性创伤患者中随机选择46例进行胃肠外营养支持治疗,比较营养指标,免疫功能指标变化.结果治疗10天后,患者营养指标及免疫功能指标均明显增高.结论胃肠外营养对严重多发性创伤患者有营养支持和提高免疫功能作用,可减少并发症发生率和降低死亡率.     

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术前营养不良是影响手术预后的重要原因。老年外科病人增多使得外科营养问题更为突出,但外科医师的临床营养知识和对外科营养的重视程度仍有待提高。在加速康复外科模式下,围手术期营养的观念和原则也有了很大改变。临床证据表明,围手术期应用某些特殊营养底物具有抗炎、免疫调控和器官保护作用,并改善外科病人的预后,即"免疫营养"。外科营养的地位已从"营养支持"向"营养治疗"转变。     

免疫营养在胃肠道恶性肿瘤围手术期中的应用

胃肠道恶性肿瘤发病率较高, 且有40%～80%的胃肠道肿瘤患者存在营养不良, 肿瘤疾病本身的代谢机制及以手术为主的治疗方式导致围手术期应激反应可进一步加重营养不良。因此, 对有营养风险或营养不良的围手术期肿瘤患者应常规进行营养支持。长期以来, 以谷氨酰胺、ω-3脂肪酸、精氨酸及核苷酸等为主的免疫营养素在围手术期肿瘤患者中的治疗备受关注。围手术期免疫营养治疗不仅可以改善营养缺乏, 纠正营养不良;还能维持机体免疫功能和减轻炎症反应;以及维护肠屏障完整性, 减少术后并发症发生率和缩短术后住院时间等。然而, 近年来随着免疫营养在临床上的广泛应用与深入研究, 其在胃肠道恶性肿瘤围手术期的应用仍存在争议。笔者就胃肠道恶性肿瘤患者围手术期免疫营养素的药理机制与临床应用、免疫营养素围手术期联合应用、免疫营养应用时机等方面进行综述, 为其临床应用提供依据。     

肠内营养及微生态免疫营养在围手术期的应用

近年来,围手术期营养干预在外科重症病人中应用越来越受到重视,选择合理的围手术期营养干预将有助于提高病人预后。给予围手术期病人肠内营养(enteral nutrition,EN)可保护病人肠黏膜、促进营养吸收以及增强免疫功能等,因此EN已成为外科重症病人围手术期一种重要的营养支持。不仅如此,在肠道微生态重要性日益凸显的背景下,微生态免疫营养的临床研究也越来越广泛。本文将论述围手术期肠内营养及微生态免疫营养的应用。     

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.     

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.     

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.