心脏瓣膜置换患者术后急性肾损伤风险预测模型的建立与验证

目的建立心脏瓣膜置换术后急性肾损伤(acute kidney injury, AKI)的风险预测模型并进行验证。方法选择2016年1月1日至2021年12月31日在徐州市中心医院接受心脏瓣膜置换术的患者为研究对象, 采用Logistic回归模型筛选患者发生AKI的独立危险因素, 并建立列线图预测模型。采用受试者工作特征曲线(ROC曲线)、校准曲线及决策曲线分析法(DCA)对预测模型进行验证。结果共619例心脏瓣膜置换患者入选本研究, 其中术后发生AKI 74例(11.95%)。多因素Logistic回归分析结果显示, 高龄(OR=3.826, 95%CI 2.267～6.458)、合并高血压(OR=2.376, 95%CI 1.162～4.861)、体外循环时间延长(OR=1.049, 95%CI 1.024～1.074)、血白细胞计数升高(OR=1.066, 95%CI 1.027～1.106)、血小板计数降低(OR=0.994, 95%CI 0.990～0.997)及淋巴细胞比例降低(OR=0.873, 95%CI 0.774～0.985)是心脏瓣膜置换患者术后发生AKI的独立危险...     

δ和κ阿片受体介导雷米芬太尼预处理对心脏的保护作用

目的探讨三种阿片受体(OR)在雷米芬太尼预处理对大鼠离体心脏缺血再灌注损伤保护作用中的角色。方法在Langendorff离体心脏模型,随机将64只SD大鼠心脏分为八组:对照组(CON组),雷米芬太尼预处理组(RPC组),Naltrindole组(NTD组,δOR阻断剂),norBinaltorphimine组(norBNI组,κOR阻断剂),CTOP组(μOR阻断剂),NTD RPC、BNI RPC和CTOP RPC组。RPC在缺血前给予浓度为100μg/L的雷米芬太尼5min停用5min,共重复3次。三种阿片受体阻断剂(浓度均为5×10-6mol/L)分别从RPC前10min到缺血后5min给予。观察心肌缺血梗死区(IS/AAR)、冠脉流量(CF)、乳酸脱氢酶(LDH)和HR。结果IS/AAR在RPC组减小(P<0.01),RPC这种作用被NTD和BNI消除:NTD RPC组(52.3±5.2)%,BNI RPC组(43.5±6.0)%(P<0.01);而在CTOP RPC组与RPC组差异无显著意义,与CON组差异有极显著意义(P<0.01)。相似的情况也表现在LDH。结论心脏上的δ和κ受体介导了雷米芬太尼预处理对心脏的保护作用。     

围手术期使用β-受体阻滞剂预防与手术相关的死亡率和并发症发生率：一项系统性综述和荟萃分析

背景围手术期使用β-受体阻滞剂可能减少手术后心血管死亡率、心肌缺血／梗死以及室上性心律失常的发生率。我们就围手术期使用β-受体阻滞剂对改善心脏手术及非心脏手术患者手术后转归的证据进行了回顾。方法我们检索了11个大型数据库，时间从建库到2005年11月。并查阅了多种网上资源，以便发现未发表的研究和会议摘要。我们选取了对围手术期使用β-受体阻滞剂和安慰剂或标准疗法进行比较的随机对照试验。在3680篇收集到的文献中，有69篇符合入选标准。由于并无明显的临床异质性，因此在假定存在随机效应的情况下计算了比值比（oddsratio，OR）。结果β-受体阻滞剂减少了室性快速型心律失常[OR（心脏手术）：0．28，95％CI为0．13—0．57；OR（非心脏手术）：0．56，95％CI为0．21—1．45]，心房颤动^心房扑动[OR（心脏手术）：0．37，95％CI为0．28—0．48]，其他室上性心律失常[OR（心脏手术）：0．25，95％CI为0．18—0．35；OR（非心脏手术）：0．43，95％CI为0．14—1．37]以及心肌缺血[OR（心脏手术）：0．49，95％CI为0．17—1．4；OR（非心脏手术）：0．38，95％CI为0．21—0．69]的发生率。住院时间并未减少[加权均数差（心脏手术）：-0．35天，95％CI为-0．77—0．07；加权均数差（非心脏手术）：-5．59天，95％CI为-12．22—1．04]，与之前的报道相反，β-受体阻滞剂不能减少死亡率[OR（心脏手术）：0．55，95％CI为0．17-1．83；OR（非心脏手术）：0．78，95％CI为0．33—1．87]，对围手术期心肌梗死的发生也没有影响[OR（心脏手术）：0．89，95％CI为0．53～1．5；OR（非心脏手术）：0．59，95％CI为0．25—1．39]。结论β-受体阻滞剂可降低围手术期心律失常和心肌缺血的发生，但是对心肌梗死、死亡率及住院时间没有影响。     

阿片受体介导心肌缺血/再灌注损伤保护作用的研究进展

心肌缺血/再灌注损伤(myocardial ischemia/reperfusion injury, MI/RI)是心肌梗死后冠状动脉血管再通常见的并发症, 严重影响患者的康复, 甚至威胁患者生命安全。而阿片类药物不仅具有镇痛作用, 还具有心脏保护作用, 此作用依赖于阿片受体(opioid receptor, OR)的激活。κ-OR、δ-OR的激活直接参与心肌保护, 而μ-OR的作用及其作用机制尚存在争议。此外, 不同激动剂对3种OR亚型的不同亲和力使得"OR介导的心脏保护"这一结论具有争议。文章就内源性阿片肽类物质及外源性阿片类药物(如吗啡、芬太尼、瑞芬太尼、布托啡诺、美沙酮)对MI/RI的保护作用进行综述, 讨论不同OR介导MI/RI保护作用的机制及其与G蛋白耦联受体(G protein-coupled receptor, GPCR)家族其他成员的串扰, 以及可能的上下游信号通路, 以便为未来开发改善心肌、挽救心肌的药物提供参考。     

急性肾损伤定义及分期系统评估心脏手术患者预后的临床价值

目的了解心脏手术后急性肾损伤(AKI)的发病及预后情况,探讨急性肾损伤网络(AKIN)会议推荐的AKI分期预测患者院内死亡的应用价值。方法将2004年1月至2007年6月上海交通大学医学院附属仁济医院收治的所有成年心脏手术患者1 056例纳入研究,采用AKIN推荐的AKI定义及分期标准评估心脏手术后AKI的发病率及住院病死率,并采用单因素和logistic多因素回归分析法对术前、术中、术后与AKI发生可能相关的危险因素进行分析。结果在1 056例行心脏手术的患者中,328例发生AKI,发生率为31.06%;AKI患者的住院病死率显著高于非AKI患者(11.59%vs.0.69%,P<0.05)。Logistic多因素回归分析显示:年龄每增加10岁(OR=1.40)、术前高尿酸血症(OR=1.97)、术前左心功能不全(OR=2.53)、冠状动脉旁路移植术(CABG)加心瓣膜手术(OR=2.79)、手术时间每增加1 h(OR=1.43)和术后循环血容量不足(OR=11.08)是心脏手术后发生AKI的独立危险因素。AKIN分期预测患者院内死亡的ROC曲线下面积为0.865,95%可信区间为0.801-0.929。结论随着AKIN分期的上升,心脏手术患者住院病死率逐步升高。年龄高、术前高尿酸血症、术前左心功能不全、CABG加心瓣膜手术、手术时间延长和术后循环血容量不足是心脏手术后并发AKI的独立危险因素。AKIN分期可以有效预测心脏手术患者发生院内死亡的风险,为及早对高危人群采取有效的预防干预措施提供依据。     

心肺转流下心脏瓣膜术后急性肾损伤的危险因素分析

目的探讨成人心肺转流(cardiopulmonary bypass,CPB)下心脏瓣膜手术后急性肾损伤(acute kidney injury,AKI)的危险因素。方法回顾性分析1 349例心脏瓣膜手术患者的临床资料,采用多因素Logistic回归分析心脏瓣膜术后AKI的危险因素。结果 1 349例心脏瓣膜手术患者AKI发生率为28.4%,多因素Logistic回归分析显示,每增加1岁(OR=1.05,95%CI 1.03~1.06,P0.001)、糖尿病史(OR=2.11,95%CI 1.22~3.68,P=0.008)、贫血(OR=1.50,95%CI1.05~2.21,P=0.026)、术前血清肌酐(Scr)值每增加1mg/dl(OR=1.01,95%CI 1.01~1.02,P=0.001)、手术时间每增加1h(OR=1.28,95%CI 1.15~1.41,P0.001)、术中输注血浆(OR=1.50,95%CI 1.14~1.97,P=0.004)是心脏瓣膜术后发生AKI的独立危险因素。结论心肺转流下心脏瓣膜术后急性肾损伤的独立危险因素是高龄、糖尿病史、贫血、术前肌酐高、手术时间长以及术中输注血浆。     

开胸心脏术后机械通气时间延长影响因素分析

目的探讨开胸心脏术后机械通气时间延长的围术期影响因素,为临床护理工作提供参考。方法使用自行设计的资料收集表,收集2014年10月至2016年6月222例入住心脏外科的开胸心脏手术患者的社会人口学资料,开胸手术前后心、肺及肾功能指标,手术基本资料和术后机械通气时间,筛选机械通气时间延长的影响因素。结果成人心脏手术后机械通气时间延长(24 h)发生率25.2%。Logistic回归分析显示,机械通气时间延长的影响因素包括NYHA分级Ⅳ级(OR=37.266,P=0.002)、既往有心脏手术史(OR=4.755,P=0.020)、术中红细胞输注量(OR=1.192,P=0.010)、术后发生室性心律失常(OR=12.068,P=0.000)、应用1种血管活性药物(OR=5.139,P=0.000)、应用3种或以上血管活性药物(OR=8.677,P=0.002)。结论成人心脏手术后机械通气时间延长的发生率高,其围术期影响因素较多,需加强危险因素评估,加强针对性护理,以缩短机械通气时间,减少术后并发症。     

冠状动脉架桥术后手术室内拔管并无好处

虽然心脏手术病人早期拔除气管内导管(TE)安全且节省费用,但心脏手术病人术后多早TE为宜尚未定论。本文作者对择期冠脉架桥手术(CABG)在手术室(OR)内TE的病人与在重症监测治疗病房(ICU)早期TE的病人进行比较。以判断OR内TE是否有益。     

血栓前状态分子标志物在老年冠心病非心脏手术患者围术期的变化及意义

目的研究血栓前状态(PTS)分子标志物在老年冠心病患者腹部手术围术期的变化及意义。方法选择60~75岁择期行腹部手术的老年冠心病患者128例,分别于手术当天及术后1、2、3d测量血浆D-二聚体(D-D)、血栓前体蛋白(TpP)、P-选择素(CD62P)及血管性血友病因子(vWF)水平,分析其与心脏不良事件发生的相关性。结果共有128例患者纳入本研究,其中心脏不良事件29例(22.7%)。与手术当天比较,术后1、2、3d患者血浆D-D、TpP、CD62P和vWF水平明显升高(P0.01)。女性(OR=22.5,95%CI 2.9~174.55)、合并糖尿病(OR=97.77,95%CI11.51~830.42)、手术时间延长(OR=1.08,95%CI 1.03~1.13)以及术前PTS分子标志物升高是心脏不良事件发生的危险因素,但都不是独立危险因素。结论 PTS分子标志物水平升高对于老年冠心病非心脏手术患者围术期心脏不良事件的发生有一定的预测价值。     

再次心脏瓣膜手术325例临床分析

目的总结再次心脏瓣膜手术患者的外科治疗经验,探讨其危险因素。方法回顾性分析1998年1月至2008年12月第二军医大学长海医院共施行再次或多次心脏瓣膜手术325例的临床资料,其中男149例,女176例;年龄(47.1±11.8)岁。收集患者术前合并症、术前心功能状态、再次手术原因及手术方式、术后早期死亡及并发症发生情况等相关临床资料,并与同期首次心脏瓣膜手术患者相关临床资料进行对比;通过多因素logisitic回归分析导致再次心脏瓣膜手术围术期死亡的相关危险因素。结果全组患者再次手术的主要原因为二尖瓣闭式扩张术后失败及新发其他瓣膜病变;全组术后早期在院死亡28例,总病死率为8.6%(28/325),主要死亡原因为低心排血量综合征(LCOS)和急性肾功能衰竭;与首次心脏瓣膜手术相比,再次心脏瓣膜手术患者术前合并慢性阻塞性肺疾病(COPD)、心功能分级(NHYA)Ⅲ～Ⅳ级及心房颤动者较多,体外循环时间及主动脉阻断时间较长,术后发生LCOS、急性肾功能衰竭、急性呼吸窘迫综合征(ARDS)等并发症也较多。多因素logistic分析结果显示:术前危重状态(OR=2.82,P=0.002)、体外循环时间>120 min(OR=1.13,P=0.008)、同期行CABG(OR=1.64,P=0.005)、术后发生LCOS(OR=4.52,P<0.001)、ARDS(OR=3.11,P<0.001)、急性肾功能衰竭(OR=4.13,P<0.001)为再次心脏瓣膜手术围术期死亡的相关独立危险因素。结论再次心脏瓣膜手术是难度较大、风险较高的一类手术,但只要术前充分了解瓣膜病变情况、准确把握手术时机及加强围术期监护,仍可降低手术死亡率和并发症发生率。     

The effects of preexisting medical comorbidities on mortality and length of hospital stay in acute burn injury: evidence from a national sample of 31,338 adult patients

OBJECTIVE: To determine whether and to what extent preexisting medical comorbidities influence mortality risk and length of hospitalization in patients with acute burn injury. SUMMARY BACKGROUND DATA: The effects on mortality and length of stay of a number of important medical comorbidities have not been examined in acute burn injury. Existing studies that have investigated the effects of medical comorbidities on outcomes in acute burn injury have produced inconsistent results, chiefly due to the use of relatively small samples from single burn centers. METHODS: Records of 31,338 adults who were admitted with acute burn injury to 70 burn centers from the American Burn Association National Burn Repository, were reviewed. A burn-specific list of medical comorbidities was derived from diagnoses included in the Charlson Index of Comorbidities and the Elixhauser method of comorbidity measurement. Logistic regression was used to assess the effects of preexisting medical conditions on mortality, controlling for demographic and burn injury characteristics. Ordinal least squares regression with a logarithmic transformation of the dependent variable was used to assess the relationship of comorbidities with length of stay. RESULTS: In-hospital mortality was significantly predicted by HIV/AIDS (odds ratio [OR] = 10.2), renal disease (OR = 5.1), liver disease (OR = 4.8), metastatic cancer (OR = 4.6), pulmonary circulation disorders (OR = 2.9), congestive heart failure (OR = 2.4), obesity (OR = 2.1), non-metastatic malignancies (OR = 2.1), peripheral vascular disorders (OR = 1.8), alcohol abuse (OR = 1.8), neurological disorders (OR = 1.6), and cardiac arrhythmias (OR = 1.5). Increased length of hospital stay among survivors was significantly predicted by paralysis (90% increase), dementia (60%), peptic ulcer disease (53%), other neurological disorders (52%), HIV/AIDS (49%), renal disease (44%), a psychiatric diagnosis (42%), cerebrovascular disease (41%), cardiac arrhythmias (40%), peripheral vascular disorders (39%), alcohol abuse (36%), valvular disease (32%), liver disease (30%), diabetes (26%), congestive heart failure (23%), drug abuse (20%), and hypertension (17%). CONCLUSIONS: A number of preexisting medical conditions influence outcomes in acute burn injury. Patients with preburn HIV/AIDS, metastatic cancer, liver disease, and renal disease have particularly poor prognoses.     

The effect of pulmonary hypertension on inpatient outcomes of laparoscopic procedures

The purpose of our analysis was to assess the effects of pulmonary hypertension (PH) on clinical outcomes of patients undergoing laparoscopic procedures. Pulmonary hypertension alters physiologic patterns that has the potential to complicate laparoscopic procedures, however, an in-depth analysis evaluating survival outcomes, complications, and associated comorbidities has not been done before. Data from the National Inpatient Survey were used to identify 179,663 patients without PH and 1453 patients with PH undergoing laparoscopic procedures from the years 2003–2013. In patients with pulmonary hypertension, the presence of the following comorbidities, congestive heart failure (OR 3.56) diabetes with chronic complications (OR 3.74) fluid and electrolyte disorders (OR 7.34) metastatic cancer (OR 14.42) and peripheral vascular disease (OR 3.12) increased in-patient mortality. In regards to post-operative complications, patients with PH were more likely to have cardiac complications defined as cardiac arrest, cardiac insufficiency, cardiorespiratory failure, or heart failure (OR 3.74). Patients with PH were also more likely to develop iatrogenic pneumothorax (OR 4.13) iatrogenic pulmonary embolism (OR 7.65) and post-operative urinary complications (OR 1.92). Overall, the comorbidity with the highest association with in-patient mortality was metastatic cancer and of all complications, patients with PH were most likely to develop iatrogenic pulmonary embolism. Preparing for these adversities, notably in patients with certain associated conditions has the potential to improve patient outcome.     

Abdominal aortic aneurysms. Is there an association between surgical volume, surgical experience, hospital type and operative mortality? Members of the Norwegian Abdominal Aortic Aneurysm Trial

The effects of number of operations, experience of the surgeon, and type of hospital on operative mortality have been studied in 444 patients treated for abdominal aortic aneurysms. In the elective group (n = 279) there was a significant difference in mortality between hospitals in which more than 10 such operations were done compared with those in which less than 10 were done during the study period (p = 0.05; odds ratio (OR) 2.7). In the ruptured group there was no statistically significant difference (p = 0.14; OR 1.9). In the elective group, units with vascular surgical experience had an operative mortality of 4.8% compared with 11.3% for other units (p = 0.05; OR 2.6). In the ruptured group the figures were 52.5% and 73.3% respectively (p = 0.03; OR 2.5). There was no difference in operative mortality between university, county and local hospitals. Outcome of treatment after operations for abdominal aortic aneurysm was related to number of operations carried out and experience, whereas the type of hospital seemed less important.     

Minimally invasive operating suite in the 21st century: Endo‐Lap operating room

Although a number of innovative and futuristic operating room (OR) designs have been proposed, the challenge to implement the OR of the future has never been fulfilled. We believe the setting of future OR should be an integration of the entire spectrum of surgical care: from diagnostic to preoperative planning, and from intraoperative navigation to education. Besides overcoming the deficiencies of today’s OR, it should also create a platform that allows easy inclusion of upcoming innovation. The opening of the brand new, innovative operating room in the Pamela Youde Nethersole Eastern Hospital, the Endo‐Lap OR, is considered a benchmark in the territory. As minimally invasive surgery continues to flourish, we believe the concept and vision behind this Endo‐Lap OR will help to shed light on the future development of OR.     

Fracture Risk Associated with Use of Nonsteroidal Anti-Inflammatory Drugs, Acetylsalicylic Acid, and Acetaminophen and the Effects of Rheumatoid Arthritis and Osteoarthritis

We studied the effects of various nonmorphine pain medications as well as rheumatoid arthritis and osteoarthritis on fracture risk in a nationwide case-control study. Cases were all subjects with any fracture sustained during the year 2000 (n = 124,655) in Denmark. For each case, three controls (n = 373,962) matched on age and gender were randomly drawn from the background population. The primary exposure variables were use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetylsalicylic acid (ASA). Adjustments were made for several confounders. The effect of dose was examined by stratifying for cumulated dose (defined daily dose, DDD). For acetaminophen, a small increase in overall fracture risk was observed with use within the last year (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.41–1.49). For ASA, no increase in overall fracture risk was present with recent use. Significant heterogeneity was present for the NSAIDs; e.g., ibuprofen was associated with an increased overall fracture risk (OR = 2.09, 95% CI 2.00–2.18 for <20 DDD), while celecoxib was not (OR = 0.76, 95% CI 0.51–1.13 for <20 DDD, 2P < 0.01 for comparison). Osteoarthritis was associated with a decreased risk of any fracture if the diagnosis had been made more than 1 year ago (OR = 0.70, 95% CI 0.67–0.72). Rheumatoid arthritis was associated with an increase in overall fracture risk if the diagnosis had been made within the last year (OR = 1.86, 95% CI 1.68–2.07). Weak analgesics may be associated with fracture risk in a varying way. The effects in most cases were small. Falls may be one reason for the increase in fracture risk with some NSAIDs.     

Bedeutung der Materiallogistik im Schnittstellenmanagement der Operationsabteilungen

The implementation of diagnosis-related groups (DRGs) sharply increased economic pressure on hospitals. Hence, process optimization was focussed on cost-intensive areas, namely the operation room (OR) departments. Work-flow in the OR is characterized by a mandatory interlocking of the job functions of many different occupational groups and the availability of a variety of different materials. Alternatives for staff assignment optimization have been published in numerous publications dealing with the importance of OR management. In this connection the issue of material logistics in the context of OR management has not been frequently addressed. In order to perform a surgical procedure according to plan, one depends on personnel and on timely availability of the materials needed. Supply of sterilized materials is of utmost importance, because in most hospitals sterilized surgical devices constitute a critical resource. In order to coordinate the OR process with the production flow of sterilized materials, an organizational connection to the OR management makes sense. Hence, in a German university hospital the Department of Hospital Sterile Supplies was integrated into the OR management of the Department of Anesthesiology. This led to a close coordination of work-flow processes, and concomitantly a significant reduction of production costs of sterile supplies could be achieved by direct interaction with the OR. Thus, hospital sterile supplies can reasonably be integrated into an OR management representing a new interesting business area for OR organization.     

SINGLE-VERSUS MULTIPLE–DOSE ANTIMICROBIAL PROPHYLAXIS FOR MAJOR SURGERY: A SYSTEMATIC REVIEW

Background: Single-dose antimicrobial prophylaxis for major surgery is widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple–dose antimicrobial prophylaxis for major surgery and across surgical disciplines. Methods: Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 × 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple–dose regimens and low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed. Results: Combined OR by both fixed (1.06,95% CI, 0.89–1.25) and random effects (1.04, 95% CI, 0.86–1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple–dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other). Conclusions: Continued use of single–dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.     

The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG: a meta-analysis

PURPOSE: Coronary artery bypass graft surgery (CABG) is associated with cardiac complications, including ischemia, acute myocardial infarction (AMI), and death. Volatile anesthetics have been shown to have a preconditioning-like effect. This systematic review assesses the effects of volatile anesthetics on cardiac ischemic complications and morbidity after CABG. METHODS: Data were obtained, without language restriction, from searches of MEDLINE, Science Citation Index, PubMed, and reference lists. We included only prospective randomized controlled trials evaluating volatile anesthetics during CABG. Two reviewers independently abstracted data on myocardial ischemia, acute myocardial infarction (AMI), and death. Treatment effects were calculated as odds ratio (OR) with 95% confidence intervals (CI) for binary data, and weighted mean difference (WMD) with 95% CI for continuous data. PRINCIPAL FINDINGS: Thirty-two studies (2,841 patients) were included. In comparison with iv anesthesia, volatile anesthetics were associated with reduced all-cause mortality (OR, 0.65; 95% CI, 0.36-1.18; P = 0.16). Enflurane was associated with increased AMI (OR, 1.34; 95% CI, 0.68-2.64; P = 0.40), whereas sevoflurane and desflurane reduced cardiac troponin I (cTnI) at six hours, 12 hr, 24 hr [WMD, -1.45; 95% CI (-1.73, -1.16); P < 0.00001], and 48 hr after operation. CONCLUSION: This meta-analysis demonstrates sevoflurane and desflurane reduce the postoperative rise in cTnI. Sevoflurane-mediated reduction in cardiac troponin was associated with improved long-term outcomes in one study. This meta-analysis was not able to show that these positive effects on troponin were translated into improved clinical outcomes. Well-designed large randomized control trials are needed to further elucidate the differential cardio-protective effects of volatile anesthetics.     

策略性增加手术单元时间以扩充手术室容量不应基于手术室利用率

背景当决定扩充手术室容量时,选择让外科亚专业接受增加的手术单元时间以填充手术室容量是一项战术性决策。这样的决策大约每年出炉1次。然而,通常在手术前的数月,又会出现第2方案,即根据预期的工作量来分配手术室的时间以及亚专业人员的时间。实践中,在已计划好的手术单元时间内不可能安排手术,手术应安排到有人员配置的时间内。本文回顾了有关扩充手术室容量的战术性决策的文献。当增加的手术室容量可以利用时,应该分配给那些单位手术时间利润额最大的亚专科的亚专业,它们具有发展潜力,并且对有限资源的需求小,如重症监护室（ICU）床位。有许多原因可以解释为什么安排附加手术单元时间不应基于当前或过去的利用率。     

Prediction of surgical outcome for thoracoabdominal aortic aneurysm

Prediction model for lethal outcome after operation for thoracoabdominal aortic aneurysm (TAAA) has been constructed based on assessment of preoperative risk factors. The main risk factors of lethal outcome at TAAA repair are: Crawford's operation (OR 12.25), deep hypothermia and circulatory arrest (OR 10.86), renal failure (OR 6.8), coronary heart disease (OR 2.49), chronic non-specific lung diseases (OR 2.29), age >50 years (OR 2.18), TAAA of II type by Crawford (OR 2.12). The prognostic system permits to access individual risk with high accuracy including at the patients with combination of different risk factors.