早期乳酸清除率评估重型颅脑创伤合并高乳酸血症患者预后的研究

目的评估重型颅脑创伤合并高乳酸血症患者6小时乳酸清除率与预后的关系。方法前瞻性研究．选取余姚市人民医院神经外科和重症医学科病房2010年6月至2012年6月人院的重型颅脑创伤合并高乳酸血症患者38例,测定治疗前及治疗后6小时动脉血乳酸,计算6小时乳酸清除率。以患者人住神经外科或重症医学科病房为研究起点,患者出院（最长随访者为28天）或死亡为研究终点,将患者分为存活组（31例）和死亡组（7例）,以6小时血乳酸清除率10％为界限分为高乳酸清除率（≥10％）维（25例）和低乳酸清除率（〈10％）组（13例）。比较存活组和死亡组6小时乳酸清除率差异,高乳酸清除率组和低乳酸清除率组之间28天死亡率差异。结果各组年龄、性别、治疗前GCS评分、APACHElI评分、基础血乳酸值均无统计学差异;存活组早期乳酸清除率显著高于死亡组[（20．68±14．67）％VS（6．21±10．40）％．P〈O．05];高乳酸清除率组28天死亡率显著低于低乳酸清除率组（8．70％VS62．5％,P〈0．05）;高乳酸清除率组生存率显著高于低乳酸清除率组（92．0％．VS615％,P〈0．05）。结论早期乳酸清除率可作为评估重型颅脑创伤合并高乳酸血症患者预后的指标。     

早期乳酸清除率评估外科严重脓毒症预后的临床价值研究

目的评估早期乳酸清除率与外科手术后严重脓毒症病人预后的关系。方法前瞻性观察并收集中山大学附属第一医院外科2004年7月至2007年6月因术后严重脓毒症进入外科重症监护病房206例病人的APACHEⅡ评分、入ICU6h动脉血乳酸清除率及病人预后的相关资料。将病人分成存活组和死亡组,高乳酸清除率组和低乳酸清除率组,比较其差异性。结果各组年龄、性别、APACHEⅡ评分和基础血乳酸值差异无显著性意义(P>0.05)。存活组乳酸清除率明显高于死亡组[(28.8±11.7)%对(15.2±11.2)%,P<0.01];高乳酸清除率组病死率均明显低于低乳酸清除率组(26.7%对51.1%,P<0.001)。结论早期乳酸清除率可用于评估外科术后严重脓毒症的预后。     

外科术后脓毒症患者血乳酸及早期乳酸清除率监测的临床观察

目的分析外科术后合并脓毒症患者动脉乳酸及乳酸清除率的变化与预后的关系。方法对68例外科术后合并脓毒症患者分别测定术前和术后6 h动脉乳酸并计算早期6 h乳酸清除率,记录患者年龄、性别及APACHEⅡ评分。将患者分成存活组及死亡组,比较2组间早期6 h乳酸清除率等指标差异性。结果死亡组动脉乳酸(11.75±2.31)明显高于存活组(5.34±2.76),死亡组患者早期6 h乳酸清除率(11.00±3.62)明显低于存活组(31.21±12.58),2组差异均有统计学意义(P<0.01)。结论早期动态监测术后脓毒症患者动脉乳酸及其早期乳酸清除率对评价和判断病情严重程度和预后较为可靠,可较好预测术后患者预后转归。     

早期乳酸清除率评估与失血性低血容量休克预后的研究

目的评估失血性低血容量休克患者早期乳酸清除率与预后的关系。方法前瞻性观察并收集因失血性低血容量休克进入外科重症监护病房92例患者的APACHEII评分、入ICU6h后动脉血乳酸清除率及患者预后。分别将患者分成存活组和死亡组,高乳酸清除率组(6h乳酸清除率10%)和低乳酸清除率组(6h乳酸清除率10%),比较各组间的差异。结果各组年龄、性别、APACHEII评分和基础血乳酸值差异无统计学意义。存活组乳酸清除率明显高于死亡组[(29.8±15.2)%vs(9.8±9.1)%,0.01];高乳酸清除率组病死率均明显低于低乳酸清除率组(11.3%vsP42.9%,P0.01)。结论早期乳酸清除率10%能准确评估失血性低血容量休克患者的良性预后。     

SICU严重脓毒症患者血降钙素原和乳酸清除率的临床分析

【摘要】〓目的〓探讨血清降钙素原(PCT)及乳酸清除在SICU严重脓毒症患者中的临床价值。方法〓研究对象来源于我院SICU从2013年6月至2015年5月收治的78例严重脓毒症患者。临床数据包括血清降钙素原、APACHE Ⅱ评分、6 h动脉血乳酸清除率及患者预后等相关资料。根据临床结局及动脉血乳酸水平,所有患者分为存活组(n=54)和死亡组(n=24);高乳酸清除率组(n=51)和低乳酸清除率组(n=27)。结果〓各组年龄、性别、APACHE Ⅱ评分和基础血乳酸值差异无显著性意义。死亡组患者的血清PCT水平明显高于存活组(P<0.05),死亡组6 h乳酸清除率较存活组明显低(P<0.05)。无论死亡组和存活组,PCT水平与患者乳酸清除率均无相关关系(r2=0.189, P>0.05;r2=0.133, P>0.05)。结论〓严重脓毒症患者血清降钙素原水平升高及乳酸清除能力降低,二者水平变化间没有相关性。     

大鼠辅助肝移植早期并发症的预防

为提高复制辅助肝移植大鼠模型的成功率，减少手术并发症，作者在Hess法的基础上对移植肝下腔静脉长度的舍取及建立门静脉血供的方式进行了改进。共做大鼠辅助肝移植手术60例，并用锝标记的植酸钠观察5例定型手术移植存活情况。结果显示：1周内大鼠肝移植物存活率为100％。文内还就如何减少术中、术后并发症进行了讨论。     

临床原位肝移植术后并发症分析

本文报道了４例临床成人原位肝移植，结合文献分析，讨论了肝移植的手术方法，手术后并发症，ＣＭＶ感染肝动脉血栓形成，胆道并发症以及急性排斥的诊断与治疗。     

肝移植术后早期并发症的防治

经历40年的发展,肝移植已成为治疗终末期肝病的有效方法。当前,国内肝移植也在蓬勃发展,但与国际水准相比,国内肝移植的质量仍有待进一步提高。虽然原发性肝脏疾病的复发和慢性排斥反应是制约肝移植远期疗效的主要因素,但术后大出血、血管并发症、胆道并发症、感染、排斥反应等并发症是导致术后近期内受体死亡的主要原因。加强     

大鼠辅助肝移植早期并发症的预防

为提高复制辅助肝移植大鼠模型的成功率，减少手术并发症，作者在Ｈｅｓｓ法的基础上地移植肝下腔静脉长度的综合舍取及建立门静脉血供的方式进行了改进，共做大鼠辅助肝移植手术６０例，并用锝标记的植酸钠观察５例定型手术移植存活情况，结果显示：１周内大鼠肝移植存活率为１００％，文内就如何减少术中，术后并发症进行了讨论。     

24例肝移植患者的术后并发症

我院自2003年4月至2004年6月共施行肝移植24例，术后多数患者出现了并发症，现将结果及我们的体会报告如下。     

Clinical significance of lactate clearance for the development of early allograft dysfunction and short‐term prognosis in deceased donor liver transplantation

This retrospective study evaluated lactate clearance (LC), measured at 6, 12, 18, and 24 hours after reperfusion, as a predictor of early allograft dysfunction (EAD) and short‐term outcomes in patients receiving deceased donor liver transplantation. Of 181 transplant recipients, 44 (24.3%) developed EAD and had lower LCs than those who did not develop EAD. A receiver operating characteristic analysis showed that LC determined at 6 hours showed the highest area under curve value of 0.828 (95% confidence interval [CI]: 0.755‐0.990) for predicting the development of EAD at a cutoff value of 25.8% with 76.7% sensitivity and 77.9% specificity. LC values that fell below the cutoff values were significantly associated with EAD in a multivariate analysis, with values at 6 hours having the highest adjusted odds ratio (11.891, 95% CI: 4.469‐31.639). In‐hospital and 6 month mortalities were higher in patients with LC values below the cutoffs compared with those above the cutoff values at each time point. Thus, LC calculated shortly after reperfusion of an allograft is significantly discriminative for the development of EAD and is associated with short‐term prognosis after deceased donor liver transplantation.     

High incidence of postoperative pulmonary complications after orthotopic liver transplantation in children

Postoperative pulmonary complications were investigated in a total of 41 pediatric recipients who underwent orthotopic liver transplantation (OLT) between January, 1990 and March, 1992 at the Royal Children's Hospital, Brisbane. Atelectasis was seen in 40 cases (98%) of the 41 recipients, and occurred in the left lower lobe in 28 cases (68%), and in the right upper lobe in 25 cases (61%). Radiographic pulmonary edema occurred on 23 occasions in 18 recipients (45%). Pulmonary edema was observed just after operation in 9 cases, and in the later stage from the 3rd to 25th postoperative day in 14 cases. Five recipients experienced two episodes of pulmonary edema during their ICU stay. The duration of mechanical ventilatory support was significantly longer in the patients with pulmonary edema than in those without (9.6±3.8vs 3.9±2.2 days,P<0.01). Pleural effusions were observed in 21 cases (52%), of which 18 had right-sided effusion and 3 had bilateral effusions. Pneumothorax occurred in three cases. Pyothorax, hemothorax, bronchial asthma, and subglottic granulation occurred in one case each. The present study demonstrated that postoperative pulmonary complications are frequently observed in pediatric recipients undergoing OLT.     

Bile duct complications after liver transplantation

Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.     

Predictive factors for early mortality following liver transplantation

AIMS: To retrospectively review our liver transplant performance to identify factors that influenced early outcomes and to prospectively test their validity in predicting outcomes. METHODS: Clinical records from 190 patients with liver transplants (LT; n = 200) performed between 1991 and 1997 were reviewed and the data evaluated by univariate and multivariate analyses regarding clinical outcome. The prognostic model thus obtained was prospectively evaluated in 55 patients undergoing transplant between 1999 and 2000. RESULTS: Main indication for transplant was post-necrotic cirrhosis (61%), mostly HCV(+). The majority of patients were Child-Pugh C status (46%). Post-operative mortality at 3 months was 15.3%. Risk factors predicting death were: Child-Pugh C status (OR 1.3), pre-LT renal insufficiency (OR 5.8), malnutrition (OR 2.9) and technically complex surgery requiring cross-clamping with or without bypass (OR 4.9). None of the donor factors was significant. Prospectively applied to predict outcome in the 55 patients, the model had a sensitivity of 80% and a specificity of 88.8% with a higher-than-anticipated accuracy with a positive predictive value of 61.5% and a negative predictive value of 95.3%. CONCLUSIONS: Pre-LT renal insufficiency is the most significant risk factor for early mortality and suggests that LT should be performed before evidence of irreversible renal insufficiency becomes manifest.     

Biliary complications after orthotopic liver transplantation in rats

P = 0.0001). The nonarterialized bile duct, which becomes ischemic soon after liver transplantation, appears to be susceptible to infections. Such opportunistic infections may prevent the development of arterial collaterals, causing bile duct necrosis and the subsequent leakage of bile juice. When biliary complications frequently occur after nonarterialized liver transplantation in rats, the possibility of an opportunistic infection should thus be considered. (Received for publication on May 7, 1998; accepted on Mar. 11, 1999)     

原位肝移植术后胆道并发症治疗经验

目的总结原位肝移植术后胆道并发症的治疗经验。方法1999年2月至2004年2月,我中心采用胆总管-胆总管端端吻合术施行原位肝移植236例,96例采用置“T”管引流的胆管间断吻合;39例采用未置“T”管的胆管间断吻合技术;101例采用未置“T”管、前壁间断后壁连续的胆管吻合。结果全组术后32例(13·3%)发生胆道并发症,其中胆管狭窄24例(10·0%),胆漏6例(2·5%),胆管结石2例(0·8%)。3组胆道并发症发生率分别为17·7%、15·4%和7·9%,其中肝门部/肝内胆管狭窄发生率分别为8·3%,2·6%和1·0%。第3组胆道并发症发生率和胆管狭窄发生率显著降低(P<0·05)。20例胆管狭窄患者接受放射和/或内镜介入治疗,其中单纯吻合口狭窄治愈率90%,肝门部/肝内胆管狭窄治愈率60%。结论弃用“T”管的胆管前壁间断后壁连续的吻合方式能显著减少胆道并发症;非缺血相关性胆管吻合口狭窄和单纯肝门部胆管狭窄应首选介入治疗。     

肝移植患者术后早期精神并发症28例临床分析

目的探讨肝移植术后早期精神并发症的病因及防治措施。方法回顾性分析28例肝移植术后发生精神并发症患者的临床资料。结果 28例精神并发症患者表现为躁狂12例（43%）,焦虑伴失眠（睡眠障碍）7例（25%）,抑郁3例（11%）,恐惧2例（7%）,癫2例（7%）,幻觉1例（4%）,自杀倾向1例（4%）。11例躁狂患者在减少抗排斥药物及小剂量使用抗精神病药物（奥氮平、氟哌啶醇）后症状缓解,未见后遗症,另1例给予氟哌啶醇后出现抑郁状态,随着肝功能的逐渐恢复而好转。1例恐惧患者经医师及家属耐心劝导并给予镇静治疗后逐渐缓解。2例癫患者经头颅CT检查未见异常,在停用抗生素后逐渐好转。3例焦虑伴失眠患者经血培养证实合并败血症,焦虑症状日益严重,给予抗菌和镇静治疗后仍效果不佳,终因多脏器功能衰竭于术后2周内死亡。余患者均在2～3周内随着肝功能的逐渐好转,精神症状逐渐消失。结论肝移植术后早期精神并发症可能由患者自身因素,手术、环境及药物等因素引起,大部分症状较轻,预后良好,但精神症状严重者或并存器质性病变者病死率较高。针对不同病因及时进行治疗有助于改善患者的预后。     

Analysis of postsurgical complications in 75 living liver transplantation donors

Seventy-five living donor liver hepatectomies were performed at our transplantation center between April 1990 and December 2004. We collected the data from patient charts, files, and the Baskent University Liver Registry. There were 39 male and 36 female donors (mean age, 35.1 +/- 9.3 years). We have performed 29 (38.6%) left hepatic lobectomies, 18 (24%) left lateral segmentectomies, 26 (34.6%) right lobectomies, and two (2.6%) donors had simultaneous living donor nephrectomy plus left lobe hepatectomy. The mean remnant liver volume was 598 +/- 168 cm(3) (range, 410-915 cm(3)). The mean percentage of remnant liver for the donor was 55.2%. Mean postoperative hospital stay was 10 +/- 4.4 days. After surgery, there was no mortality or reoperation. We saw 15 (20%) postsurgical complications in 14 donors. Intra-abdominal collection was seen in five (6.6%) patients. Biliary leak was seen in four patients. Portal vein thrombosis was seen in one patient, and a pulmonary embolus developed in one liver donor. Patient safety must be the primary focus in living-donor liver transplantation. These donors face significant risks, including substantial morbidity and death. More experience, improved surgical techniques, and meticulous donor evaluation will help minimize morbidity and mortality for both living liver donors and recipients.