维持性血液透析患者的健康教育干预与生活质量

背景：虽然终末期肾病行维持性血液透析患者的生理健康水平相对平稳,长期生存率有明显提高,但这些患者的心理健康问题并未得到相应的重视。 目的：探讨健康教育干预对于维持性血液透析患者生活质量的影响。 方法：选择维持性血液透析患者72例,其中男38例,女34例,年龄27~86岁,给予持续健康教育3个月,采用SF-36生活质量量表对患者健康教育前后生活质量进行评估,并分析影响患者生活质量的相关因素。 结果与结论：血液透析患者生活质量与年龄、家庭支持、透析时间、透析次数、费用类型、经济收入、残余尿量、合并症、每周运动时间及临床指标之间的相关系数均具有显著性意义(P均< 0.05);进一步对血透患者进行健康教育,干预后生活质量(生理健康、心理健康)较前明显改善(P < 0.05或P< 0.01)。并发现血液透析患者心理健康水平对生活质量的影响大于生理健康状况对生活质量的影响。说明对维持性血液透析患者实施健康教育可以提高其生活质量。     

高压氧预处理对冠状动脉搭桥手术后早期认知功能的影响

目的分析高压氧(HBO)预处理对冠状动脉搭桥(CABG)手术后早期认知功能的影响。方法选取82例行CABG患者临床资料,将其分为对照组(41例)、观察组(41例)。对照组术前不给予HBO治疗,观察组术前行HBO治疗,观察比较两组术后认知功能及生活质量情况。结果对照组术后Newman各指标均较术前下降(P0.05),评分较观察组低(P0.05),生理机能、精神状态、社会功能评分较观察组低(P0.05)。结论对CABG手术患者术前给予HBO治疗能有效保护患者神经系统,减少术后认知功能障碍情况发生,提高生活质量。     

血清sST2、NT-proBNP水平与血液透析患者发生心力衰竭的相关性分析

目的 观察血清可溶性st2(sST2)、N末端脑钠肽前体(NT-proBNP)表达水平与血液透析患者发生心力衰竭的相关性.方法 选取在我院血液透析中心行维持性血液透析(MHD)治疗的100例慢性肾功能不全尿毒症患者,依据是否发生心力衰竭,分为并发心衰组与未并发心衰组,比较2组一般资料、透析前后血清心肌酶[肌酸激酶同工酶...     

慢性肾衰竭血液透析患者血浆同型半胱氨酸的测定及其临床意义

目的研究同型半胱氨酸(Hcy)水平在慢性肾衰竭(CRF)诊断和治疗中的应用。方法采用免疫比浊发测定32例CRF患者血液透析前后的血浆Hcy和42例健康人血浆Hcy的含量，并进行统计分析。结果①维持性血液透析尿毒症患者血浆同型半胱氨酸水平透前及透后均明显高于正常对照组；②透析后血浆同型半胱氨酸水平较透析前有所下降﹙<0.01)，但不能降至正常。结论维持性血液透析尿毒症患者血浆同型半胱氨酸水平高于正常人，血液透析对同型半胱氨酸有清除作用，但不能使同型半胱氨酸水平降至正常。     

非体外循环冠状动脉搭桥术临床分析——附21例报告

目的评价非体外循环心脏不停跳冠状动脉搭桥术的临床价值及意义。方法回顾分析21例非体外循环冠状动脉搭桥术的临床资料,对手术方法及围手术期治疗进行分析总结。结果全组无术中需转体外循环,无围手术期急性心肌梗死,无死亡病例。术后心绞痛全部缓解,住院天数12~21d,平均14.53d。结论非体外循环冠状动脉搭桥术安全可行,且可减少输血,减轻手术创伤与并发症。远期效果有待观察。     

采用HA130型树脂灌流器血液灌流对维持性血液透析患者微炎症的影响

背景：研究发现维持性血液透析的尿毒症患者体内存在“微炎症状态”。 目的：观察采用HA130型树脂灌流器行血液灌流对维持性血液透析患者微炎症的影响。 方法：选取维持性血液透析治疗的尿毒症患者60例,随机分为2组,灌流组采用HA130型树脂灌流器串联血液透析器进行血液灌流加血液透析治疗;透析组行单纯血液透析治疗。采集治疗前后两组患者的血清,检测高敏C-反应蛋白、肿瘤坏死因子α和白细胞介素6水平。 结果与结论：灌流组血清高敏C-反应蛋白、白细胞介素6和肿瘤坏死因子α水平治疗后较治疗前显著降低(P < 0.05);透析组治疗后上述指标较治疗前略升高,差异无显著性意义。提示血液灌流可以降低维持性血液透析患者血清高敏C-反应蛋白、白细胞介素6和肿瘤坏死因子α水平,有利于减轻其微炎症反应。     

冠状动脉旁路移植围手术期抑郁、焦虑状况调查

目的调查行冠状动脉旁路移植术(CABG)的患者围术期抑郁、焦虑的发生率及相关因素.方法2005年7月至2006年5月,以连续行择期CABG术的73例患者为研究对象,分别在术前1周内和术后出院前1天使用ZUNG氏抑郁自评量表和焦虑自评量表进行评分.结果手术前共有21例(28.8%)阳性患者,其中11例患者存在抑郁状态,7例患者同时存在抑郁和焦虑状态,3例存在焦虑状态.手术后共有34例(46.6%)阳性患者,其中18例患者存在抑郁状态,13例患者同时存在抑郁和焦虑状态,3例存在焦虑状态.SDS标准分术后(47.9±10.0)高于术前(43.7±10.0, t=3.55,P=0.001), 焦虑评分术后(41.6±8.5)高于术前(39.3±7.4, t=2.20,P=0.031).术前发生抑郁焦虑的患者受教育少(8±3/10±3年, t=2.18,P=0.032),术后焦虑抑郁组中术前就存在抑郁焦虑的比例高(16/34对5/39,χ2＝10.391, P=0.001),术前多次心肌梗死的4例都在术后抑郁焦虑组(4/34比0/39,P=0.043);术前抑郁焦虑情绪对术后围手术期恢复没有影响.术后是否发生抑郁焦虑者住院时间没有显著差别.结论CABG患者围术期抑郁焦虑状态有较高的发生率,术后情绪更差.受教育程度低是术前情绪不良的危险因素,病情重是术后情绪不良的危险因素.     

高通量透析膜对维持性血液透析过程中溶质清除及皮肤瘙痒的作用

背景：如何有效地清除尿毒症毒素,以减少透析患者的并发症,改善维持性血液透析患者生活质量及长期预后,一直是人们研究的热点。 目的：观察高通量和低通量聚砜膜血液透析器对维持性血液透析患者溶质清除及皮肤瘙痒的作用。 方法：选择皮肤瘙痒的维持性血液透析患者38例,随机分为高通量透析组和低通量透析组,每组19例。高通量透析组使用高通量透析器FX60,低通量透析组使用低通量透析器F6,均每周透析3次,每次透析4 h,观察1年;检测血尿素氮、肌酐、磷、β2微球蛋白及甲状旁腺素;观察透析前后各种溶质含量的变化,计算溶质清除率和尿素清除指数(Kt/V值);用目测类比评分法评估瘙痒程度。 结果与结论：两组患者透析后尿素氮、肌酐下降率差异无显著性意义(P > 0.05),磷和β2微球蛋白的下降率高通量透析组均高于低通量透析组(P < 0.05),两组Kt/V相比差异无显著性意义(P > 0.05);治疗1年后高通量透析组甲状旁腺素显著低于低通量透析组(P< 0.05),皮肤瘙痒与治疗前相比两组均有减轻(P< 0.05),高通量透析组瘙痒程度评分显著低于低通量透析组(P < 0.05)。提示采用高通量FX60聚砜膜透析器进行透析,不仅充分清除小分子毒素,而且增加了对于大、中分子毒素的清除,能改善维持性透析患者顽固性皮肤瘙痒症状。     

高通量联合低钙透析液对维持性血透患者皮肤瘙痒的疗效分析

血液透析的普及,提高了维持性血液透析(MHD)患者的生存率,随着透析时间的延长,远期并发症发生率也随着增加,凸显普通血液透析的不足。皮肤瘙痒是尿毒症患者最常见症状之一,严重影响患者的生活质量。本研究对高通量血液透析(HFHD)联合低钙透析液对MHD患者皮肤瘙痒的影响进行了观察,并与常规透析液进行对比研究,现报道如下。     

桡动脉在全动脉化冠脉搭桥术中的临床应用

目的探讨桡动脉在全动脉化冠脉搭桥术中的临床应用效果。方法22例患者采用乳内动脉和桡动脉行全动脉化冠脉搭桥手术,"不接触血管技术"游离桡动脉,与冠状动脉对角支、钝缘支、前降支、右冠状动脉等单独或序贯吻合,共搭桥31支。术后应用钙通道阻滞剂防止桡动脉痉挛。结果22例手术均顺利完成,痊愈出院,无围术期心肌梗塞,术后心肌缺血改善,无手部缺血并发症。随访2月～3年,无心绞痛复发,手部功能正常。结论桡动脉作为血管桥材料在全动脉化冠脉搭桥术中应用效果良好。     

初次单侧全膝关节表面置换者肾功能的变化

背景：全膝关节表面置换中植入假体系统、围手术期血流动力学的改变、药物等均可能对患者肾功能产生影响。 目的：动态观察膝关节表面置换术围手术期相关处理对患者肾功能的影响。 方法：纳入膝关节表面置换患者42例,检测患者置换前后血清肌酐、胱抑素C及尿微量白蛋白水平,比较置换前后患者肾功能。 结果与结论：42例患者全膝关节表面置换均成功,在置换后1个月内未发生少尿、无尿、大量蛋白尿、肾衰竭等严重的肾脏并发症。围手术期血清肌酐水平未发生明显变化;胱抑素C水平在置换后1周内无明显变化,而在置换后1个月,较置换前下降;尿微量白蛋白水平在置换后1 d上升,自置换后3 d开始呈下降趋势,置换后7 d、1个月尿微量白蛋白水平均较置换前降低。结果说明,全膝关节表面置换对患者肾功能仅产生了轻度的一过性损伤,并且置换后1个月患者肾功能平均水平得到改善。对初次行单侧膝关节表面置换患者,围手术期积极恰当的临床处理,不致对肾功能产生严重损伤。     

Comparison between blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary surgery

This study was done to compare the protective effect of blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Sixty consecutive patients with left ventricular ejection fraction < 35% scheduled for CABG with the use of cardiopulmonary bypass without additional procedures were randomly divided into two groups. In the first group we used cold blood cardioplegia, in the second group cold crystalloid cardioplegia, both delivered only ortogradely. We measured hemodynamic data in early hours after operation, enzyme release and we collected other clinical data which could be influenced by perioperative myocardial protection. There was no death in either group. We also didn't find any significant difference in incidence of perioperative myocardial infarction, arrhythmias and use of intraaortic balloon pumping between both groups. In an early hours after operation in the group with blood cardioplegia we found significantly better hemodynamic data (LVSWI, RVSWI) and significantly lower enzyme release. We conclude, that cold blood cardioplegia shows superior perioperative myocardial protection resulting in earlier restoration of myocardial function. This difference could be important in patients with high degree of left ventricular dysfunction.     

急性DeBakey I型主动脉夹层手术的围麻醉期管理

目的回顾总结深低温停循环下DeBakeyI型主动脉夹层血管置换手术38例,探讨其围麻醉期管理方法。方法 38例急性DeBakeyI型主动脉夹层患者,全身麻醉深低温停循环（DHCA）下完成手术,术中实施多脏器保护。结果该组患者均顺利完成手术,麻醉诱导、维持平稳;平均体外循环时间（192.39±29.76）min,深低温停循环时间为（48.2±13.5）min,选择性脑灌注时间为（46.42±11.25）min;30例病人8～24h完全苏醒,顺利脱机拔管,8例出现短暂神经功能异常,通过术后脑保护措施,72h完全苏醒拔管,1例病人双下肢肌力减退,5d后完全恢复;肾功能衰竭6例;手术3d后死亡4例,2例死于肾功能衰竭,1例死于肺栓塞,1例死于呼吸功能衰竭,死亡率为10%;全部患者无麻醉死亡。结论充分的术前准备、术中麻醉管理、重要脏器的保护是提高主动脉弓动脉瘤血管置换手术成功率的关键。     

输尿管软镜碎石术围手术期肾彩色多普勒超声血流动力学评价

目的　彩用彩色多普勒超声（CDFI）对单发肾结石患者输尿管软镜碎石术围手术期肾血流动力学的评价。 方法　分析2016年7月至2018年6月共61例输尿管软镜碎石手术的单发肾结石患者,应用CDFI观察围手术期术侧肾叶间动脉血流参数,记录术前1 d、术后1 h内及术后5 d叶间动脉血流参数,并进行统计学分析。 结果　围手术期肾叶间动脉血流参数整体分析,收缩期峰值流速（Vmax）、舒张末期流速（Vmin）及阻力指数（RI）数值差异分别具有统计学意义（P<0.05）。与术前血流参数相比,术后1 h叶间动脉Vmax及Vmin均减低,RI增高（P<0.017）,术后5 d复查,Vmax及Vmin较术后1 h升高、RI较术后1 h减低（P<0.017）,与术前测值相比差异无统计学意义（P>0.017）。 结论　CDFI可以观察并量化输尿管软镜碎石术围手术期肾内动脉灌注,快速评价术侧肾血流动力学变化,手术后会出现短期、可逆性肾叶间动脉流速减低、RI增高。     

Retrospective analysis of the clinical trends and current indications for perioperative intraaortic balloon pumping in high-risk coronary artery bypass surgery

We clinically evaluated the current indications for perioperative intraaortic balloon pumping (IABP) in high-risk patients undergoing coronary artery bypass grafting (CABG). Over the past 22 years, 196 CABG patients received perioperative IABP at our institution. We divided the 22 years into periods I–IV (earliest to latest) and investigated the annual changes in the indications for and mortality from IABP. In periods I and II, IABP was mainly employed for postoperative low-output syndrome (LOS) or perioperative myocardial infarction (PMI). The hospital mortality rate was 13.2%–18.5%. In period III, the mortality rate was markedly reduced by the use of preoperative scheduled IABP. In period IV, however, scheduled IABP was used less often for high-risk CABG, and IABP was mainly employed in patients having emergency CABG for acute coronary syndrome (ACS). The hospital mortality rate was reduced to 3.7%. In the last 2 years, 19 (65.5%) of 29 patients who received preoperative IABP had emergency CABG for ACS, while 27 high-risk CABG patients with poor left ventricular (LV) function or left main trunk (LMT) disease were treated successfully without scheduled IABP. There were no significant differences between the IABP and non-IABP patients in age, sex, number of bypasses, and aortic cross-clamp time. Because of improvements in anesthesia, operative techniques, perioperative management, and cardioplegic solutions, preoperative support with IABP is less often needed for high-risk CABG, except in patients undergoing emergency surgery for ACS.     

输尿管软镜碎石术围手术期肾彩色多普勒超声血流动力学评价

目的　彩用彩色多普勒超声（CDFI）对单发肾结石患者输尿管软镜碎石术围手术期肾血流动力学的评价。 方法　分析2016年7月至2018年6月共61例输尿管软镜碎石手术的单发肾结石患者,应用CDFI观察围手术期术侧肾叶间动脉血流参数,记录术前1 d、术后1 h内及术后5 d叶间动脉血流参数,并进行统计学分析。 结果　围手术期肾叶间动脉血流参数整体分析,收缩期峰值流速（Vmax）、舒张末期流速（Vmin）及阻力指数（RI）数值差异分别具有统计学意义（P<0.05）。与术前血流参数相比,术后1 h叶间动脉Vmax及Vmin均减低,RI增高（P<0.017）,术后5 d复查,Vmax及Vmin较术后1 h升高、RI较术后1 h减低（P<0.017）,与术前测值相比差异无统计学意义（P>0.017）。 结论　CDFI可以观察并量化输尿管软镜碎石术围手术期肾内动脉灌注,快速评价术侧肾血流动力学变化,手术后会出现短期、可逆性肾叶间动脉流速减低、RI增高。     

Cardiovascular surgery in chronic hemodialysis patients

 Renal failure increases the morbidity and mortality of patients undergoing cardiac surgery. To investigate the adequacy of perioperative management and intraoperative techniques for cardiac operations, we retrospectively analyzed data from 25 patients (4 women and 21 men, with a mean age of 57.4 ± 7.7 years) with chronic renal failure who underwent cardiovascular surgery. The hospital mortality rate was 8.0%. Eleven postoperative complications were observed in 25 patients. The main complications were low cardiac output syndrome (with intraaortic balloon pump insertion in 4 cases), postoperative gastrointestinal tract bleeding (3 cases), and mediastinitis (2 cases). These results demonstrate that preoperative chronic renal failure increases mortality and morbidity; however, good operative outcome can be obtained with careful perioperative management. Received: February 23, 1999 / Accepted: July 16, 2002 Correspondence to:H. Shimpo     

Effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter after polymyxin B-immobilized fiber column therapy of septic shock

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently ends in death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in Japan in 1994 and has since been used for the treatment of septic shock. On the other hand, the effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA- CHDF) for critically ill patients has also been reported. We treated 27 septic shock patients by DHP-PMX. The patients, except for the nine in whom CHDF was not performed after DHP-PMX, were divided into two groups: namely, a group in which PMMA-CHDF therapy was added after DHP-PMX (11 cases), and a group in which continuous hemodiafiltration using a polyacrylonitrile membrane hemofilter (PAN-CHDF) therapy was added after DHP-PMX (7 cases). The outcomes in the two groups were compared. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score were not significantly different between the two groups. The PMMA-CHDF group showed significantly better outcomes, with significant improvements of the serum PAI-1, protein C, IL-6 and N-arachidonoylethanolamine (AEA) levels. We conclude that PMMA-CHDF may be more effective than PAN-CHDF in the management of septic shock.     

高龄患者开胸手术围术期心功能不全相关因素分析及处理体会

目的通过高龄患者开胸术后围术期生命体征的临床观察及处理体会,探讨心功能不全等并发症的相关因素及防治措施。方法回顾性分析了2006年1月~2006年12月我科全麻下行开胸手术的151例高龄患者的临床资料。结果发生心功能不全9例,均发生于术后2~3d。术后第3d、第2d尿量较前一天明显增多。术前有合并症组术后血压较无合并症组高,心率快。年龄在75岁以上组心率较75岁以下组有增快趋势。结论开胸术后心功能不全与高龄、合并症、手术创伤、术后2~3d第三间隙液回吸收有关。对高龄患者应严格掌握手术适应证,充分术前准备,加强围手术期监护,适时应用利尿剂以防治心功能不全。     

Use of ventricular assist devices in patients with postcardiotomy shock.

Over the last three years, we have used ventricular assist devices (VAD) in 7 patients. Of these 7, four patients with combined aortic and mitral valvular disease underwent double valve replacement; one patient with annuloaortic ectasia underwent a Cabrol's operation; another had aortic valve replacement; the last patient had triple coronary artery bypass grafts. The only patient who could be weaned from CPB developed cardiogenic shock after the operation. LVADs supported 6 patients for 4 to 8 days and a BVAD supported one patient for 9 days. All patients survived the weaning procedure. Three were discharged from the hospital and survived 7 to 21 months. The 4 other patients died of multiple organ failure. Three of these four suffered from both renal failure and infection, while one patient had arrhythmia and died of ileus. These data suggest that renal failure and major infection can be serious detrimental complications to VAD support.