FloTrac/Vigileo系统监测下预扩容对TURP患者腰硬联合麻醉后血流动力学的影响

目的探讨利用Flo Trac/Vigileo监测仪观察预输入琥珀明胶扩容对经尿道前列腺电切术(TURP)患者腰硬联合麻醉后血流动力学的影响。方法择期腰硬联合麻醉下行TURP患者30例,ASAⅡ~Ⅲ级,随机分为实验组和对照组。实验组麻醉前经外周静脉输入琥珀明胶10 ml/(kg·h),对照组麻醉前经外周静脉输入乳酸钠林格液10 ml/(kg·h)。应用心电监护仪和Flo Trac监测仪观察入室后扩容前(T1)和扩容后30 min(T2)以及麻醉后5 min(T3)、10 min(T4)、15 min(T5),手术开始(T6)时的平均动脉压(MAP)、心率(HR)、心排血量(CO)、心指数(CI)、每搏量(SV)、每搏变异度(SVV)等的变化。结果两组各时间点与T1相比,麻醉后T3时MAP、CO、CI、SV值均显著降低(P0.05),实验组的MAP、CO麻醉后均高于对照组(P0.05),实验组在T3、T4时CI高于对照组,T3时SV高于对照组,而两组的SVV值与T1相比明显升高,对照组高于实验组(P0.05),研究过程中两组的心率无明显变化。结论对于行腰硬联合麻醉的高龄重症患者,输入琥珀明胶可有效改善麻醉后造成的低血压和低心排血量,在维持血流动力学的稳定性方面优于乳酸钠林格液。     

每搏输出量变异度和下腔静脉扩张指数预测全肺切除术后容量反应性的比较研究

目的:比较每搏输出量变异度(SVV)和下腔静脉扩张指数(dIVC)预测全肺切除术后患者容量变化的准确性。方法:收集2014-08-2017-04我院重症医学科收治的18例全肺切除术后机械通气下需行血流动力学监测的患者,统一采用脉搏指示连续心输出量监测仪(PICCO)监测SVV,同时应用超声测量dIVC。记录补液试验前基线血流动力学参数和补液试验(7ml/kg的羟乙基淀粉)后的血流动力学参数。以CI变化量(△CI)15%为容量治疗有反应性,将患者分为有反应组和无反应组。分别绘制SVV和dIVC的受试者工作曲线(ROC),计算曲线下面积(AUC)。结果:CVP、SVV、dIVC预测全肺切除术后机械通气患者容量反应性的AUC分别为0.604,0.893和0.863,CVP预测容量反应性无统计学意义,SVV、dIVC预测容量反应性有统计学意义(P0.05)。结论:SVV和dIVC均是全肺切除术后行机械通气患者的容量反应性评估的可靠参数,两者均有重要的临床意义,值得推广。     

犬全髋关节置换模型的构建

背景:在众多个髋关节置换动物模型中,犬因其与人类的高度相似性及易于管理、饲养的特点而倍受青睐.目的:在德国牧羊犬上建立并评价金属对金属全髋关节置换模型.方法:德国牧羊犬随机分为空白对照组,骨水泥固定组,生物固定组.空白对照组仅行手术入路操作,后两组分别行骨水泥固定与生物固定全髋关节置换.分别于术后即刻、3,6,12个月X射线观察植入物形态.结果与结论:空白对照组动物术后恢复好.骨水泥固定组中2只动物发生股骨骨折,继发伤口感染:2只动物置换后假体周围感染:1只动物骨水泥由臼底渗入盆腔.生物固定组中3只动物发生伤口及假体周围感染:1只术后反复发生脱位.其余实验组动物术后恢复好,步态堆本正常,术后即刻、3,6,9及12个月X射线片示假体位置良好.实验组手术并发症发生率9%(2/22),总感染率32%(7/22).说明犬全髋关节置换模型是一个稳定的,成功率较高,可重复的动物模型.     

全髓关节置换骨水泥注入前后无创血流动力学参数监测

目的:观察全髋关节置换应用骨水泥充填前后心脏和外周血管功能的变化,并比较无创心功能监测仪与传统肺动脉漂浮导管监测血流动力学指标变化的作用及差异.方法:选择2006-03/2007-07沈阳市骨科医院收治的心功能I-Ⅱ级,择期行全髋关节置换60例患者,分为骨水泥组30例和非骨水泥组30例.全部采用连续硬膜外麻醉,右侧颈内静脉穿刺,放置动脉漂浮导管,连接监测仪,监测心输出量、外周血管阻力.多功能监护仪监测心电图,动脉血压,脉搏氧饱和度.连接无刨血流动力学监测仪,测定心输出量、外周血管阻力、心脏加速度指数、胸腔液体总量等血流动力学参数.同时做血气分析,测定动脉血氧分压、氧饱和度、二氧化碳分压.结果:[1]骨水泥组动脉血氧分压、动脉血氧饱和度、收缩压和舒张压在注入骨水泥后10,15 min时显著下降(P<0.05).动脉血二氧化碳分压没有明显变化.[2]两种方法监测骨水泥组注入骨水泥后10,15 min 的心输出量、外周血管阻力均低于注入骨水泥前(P<0.05).胸腔液体总量在注入骨水泥后10,15 min 高于注入骨水泥前(P<0.05).[3]在各时间点通过肺动脉漂浮导管和无创血流动力学检测系统测定心输出量值和外周血管阻力均有很好的偏性和相关性(P<0.05).结论:全髋关节置换应用骨水泥充填对心脏收缩功能及外周血管功能有明显的抑制作用.无创血流动力学检测系统与肺动脉漂浮导管所测得血流动力学参数在每个时间点都具有很好的偏性和相关性.     

骨水泥型人工半髋与全髋关节置换治疗高龄股骨颈骨折的比较

背景：采用人工半髋关节置换治疗老年股骨颈骨折还存在一些争议。 目的：观察骨水泥型人工半髋关节置换治疗高龄股骨颈骨折的临床治疗效果,并与人工全髋关节置换对比。 方法：回顾性分析2009年1月至2010年6月的23例高龄股骨颈骨折行人工关节置换患者的临床资料,其中采用骨水泥型人工半髋关节置换的患者11例,人工全髋关节置换的患者12例。比较骨水泥型人工全髋关节置换与人工半髋关节置换患者的下床活动时间、Harris评分,以及围手术期并发症的发生率。 结果与结论：所有患者均获得12-18个月随访,骨水泥型人工半髋关节置换组治疗后主动直腿抬高角度、治疗后下床时间、治疗后早期并发症发生率、治疗后1周Harris评分优于人工全髋关节置换组;治疗后6周、3个月、6个月的Harris评分两组间差异无显著性;但骨水泥型人工半髋关节置换组远期髋关节疼痛的发生率高于人工全髋关节置换组。因此,作者认为高龄股骨颈骨折患者应用骨水泥型人工半髋关节置换后近期疗效较好,但远期综合疗效尚需进一步验证。     

人工关节置换治疗老年转子间骨折患者的临床疗效对比

目的探讨人工关节置换治疗老年转子间骨折的临床疗效。方法回顾性分析老年股骨转子间骨折患者内固定组、骨水泥置换组和非骨水泥置换组各43例,分析3组患者的手术时间,术中出血量、术后开始下地时间,根据Harris评价术后功能恢复程度以及术后6个月内并发症发生情况。结果股骨近端抗旋髓内钉(PFNA)固定组与人工关节置换组相比,手术时间和术中出血量明显减少,术后开始下地时间明显延长,差异有显著性(P<0.05);骨水泥置换组与非骨水泥置换组比较,手术时间延长、术中出血量多,差异有显著性(P<0.05),但术后开始下地时间差异无显著性(P>0.05);人工关节置换组患者髋关节功能恢复情况明显优于PFNA内固定组,差异有显著性(P<0.05);但骨水泥置换组与非骨水泥置换组比较差异无显著性(P>0.05);PFNA固定组深静脉血栓、尿路感染、褥疮和肺部感染等并发症的发生例数明显增多,与人工关节置换组相比差异有显著性(P<0.05);骨水泥置换组合非骨水泥置换组比较差异无显著性(P>0.05)。结论人工关节置换术对治疗老年转子间骨折患者有较好的疗效,术中出血量少,手术时间短,关节功能恢复迅速,能够减少并发症的发生,更适用于高龄患者。     

含抗生素骨水泥股骨柄与非骨水泥髋臼金属托结合全髋置换治疗中老年股骨颈骨折内固定失败19例

背景：中老年股骨颈骨折内固定失败后的治疗充满挑战性,最佳治疗方法尚未达到一致。目的：观察含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节置换治疗股骨颈骨折内固定失败的效果。方法：纳入股骨颈骨折内固定失败后行人工全髋关节置换患者19例,假体均为含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节。髋臼侧采用生物性假体压配固定,股骨侧采用带抗生素骨水泥假体固定。12例选取金属-聚乙烯承重界面,7例选取陶瓷-聚乙烯承重界面。置换后随访,定期摄片监测假体位置,并指导功能锻炼,记录髋关节功能恢复状况。结果与结论：手术时间（110±55）min,术中出血量（510±60）mL,置换后出血量（310±40）mL。切口均一期愈合,未见局部红肿,脓性渗出。双下肢畸形恢复,长度相差均小于1cm。19例全部获得随访,随访期间所有病例均未见假体松动征象。置换后1年随访Harris髋关节评分显著高于置换前（P〈0.05）,其中优10例,良8例,中1例,差0例,优良率为94.7%。提示全髋关节置换治疗股骨颈骨折内固定失败有一定困难,采用含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合,可加强围手术期处理以及针对性的功能锻炼,患者关节疼痛以及活动度可得到明显改善。     

含抗生素骨水泥股骨柄与非骨水泥髋臼金属托结合全髋置换治疗中老年股骨颈骨折内固定失败19例

背景:中老年股骨颈骨折内固定失败后的治疗充满挑战性,最佳治疗方法尚未达到一致。目的:观察含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节置换治疗股骨颈骨折内固定失败的效果。方法:纳入股骨颈骨折内固定失败后行人工全髋关节置换患者19例,假体均为含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节。髋臼侧采用生物性假体压配固定,股骨侧采用带抗生素骨水泥假体固定。12例选取金属-聚乙烯承重界面,7例选取陶瓷-聚乙烯承重界面。置换后随访,定期摄片监测假体位置,并指导功能锻炼,记录髋关节功能恢复状况。结果与结论:手术时间(110±55)min,术中出血量(510±60)mL,置换后出血量(310±40)mL。切口均一期愈合,未见局部红肿,脓性渗出。双下肢畸形恢复,长度相差均小于1cm。19例全部获得随访,随访期间所有病例均未见假体松动征象。置换后1年随访Harris髋关节评分显著高于置换前(P<0.05),其中优10例,良8例,中1例,差0例,优良率为94.7%。提示全髋关节置换治疗股骨颈骨折内固定失败有一定困难,采用含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合,可加强围手术期处理以及针对性的功能锻炼,患者关节疼痛以及活动度可得到明显改善。     

胃肠道手术中每搏量变异监测对液体管理的指导作用

目的比较每搏量变异（SVV）和中心静脉压（CVP）监测对胃肠道手术患者术中输液管理及预后的影响。方法选择2012年3月至2012年12月行择期全麻下胃肠道手术患者80例,随机分为CVP组和SVV组,每组加例。CVP组术中监测CVP及桡动脉压,sVV组术中SVV及心输出量。记录并比较两组病人术前、术中、术后的输血、输液量、手术时间、住院时间、排气排便时间、术后进食时间等。结果SVV组患者术中输液量明显少于CVP组（P〈0．05）;SVV组患者术中出血量明显少于CVP组（P〈0．05）;术后3天输液总量、术中尿量及患者术后排便时间差异无统计学意义（P均〉0．05）;SVV组术后肛门排气时间、术后进食时间、住院时间明显短于CVP组（P均〈0．05）。术后并发症CVP组9例,SVV组5例,两组并发症发生率差异无统计学意义（P〉0．05）。结论sVV指导输液可以减少术中输液量,缩短住院时间,有利于手术患者的康复。     

双侧全髋关节置换一期完成与术后关节功能同步恢复的探讨

目的探讨同时完成双侧全髋关节置换治疗双髋病变的临床效果与术后关节功能同步恢复等问题。方法31例双髋关节病变患者在全麻下行后外侧切口入路,同期置换全髋关节,采用进口全髋26例,国产5例,骨水泥型14例,非骨水泥型13例,混合型4例,随访6～26个月。结果所有患者双全髋关节一期置换手术顺利,无感染及其他并发症,手术时间相对较长,但比分次完成费用明显降低。术后关节功能同步恢复好,且时间短,双下肢肢体均等长。结论有条件的医院和技术操作熟练的医师,选择合适的病例,一期完成双髋关节置换术,具有诸多优点。     

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.