肾移植术后肺部感染28例诊治分析

目的探讨同种异体肾移植术后肺部感染的诊断和治疗经验。方法回顾性分析28例同种异体肾移植术后肺部感染患者的临床资料。结果 28例患者肺部感染发病时间为术后3个月以内6例,术后4～6个月18例,术后6个月以后4例。患者均以发热起病,早期呼吸道症状轻微,未经治疗者易发展为重症肺炎。肺部体征早期多不明显,X线胸片表现常滞后,胸部CT或磁共振成像有助于早期诊断。肾移植术后肺部感染以细菌、巨细胞病毒、真菌感染为主,混合感染常见。经给予联合使用抗感染药物、减少或者撤除免疫抑制剂、静脉应用肾上腺皮质激素(激素)、营养支持治疗,必要时辅以无创通气或者呼吸机辅助呼吸治疗等综合治疗,治愈22例,死亡6例(均为重症肺炎并发急性呼吸窘迫综合征患者)。结论肾移植术后肺部感染病情进展快,发展为重症肺炎病死率高,应及时予胸部CT或磁共振成像检查,同时加强病原体监测,确诊后及早予使用抗感染药物、调整免疫抑制剂剂量、应用激素、营养支持等治疗,以提高治愈率。     

无创正压机械通气治疗肾移植术后巨细胞病毒肺炎所致急性呼吸窘迫综合征

目的 探讨肾移植术后巨细胞病毒(CMV)肺炎合并急性呼吸窘迫综合征(ARDS)无创正压机械通气治疗效果. 方法 肾移植术后CMV肺炎合并ARDS患者10例.早期应用无创正压机械通气治疗及抗病毒、调整免疫抑制剂、加强营养支持的综合治疗.比较分析患者通气治疗前后动脉血气、生命指标及移植肾功能变化. 结果 10例患者中治愈7例.1例脱机时发生张力性气胸及广泛皮下气肿死亡;另2例治疗中病情加重改有创机械通气,治疗5、18 d无效死亡.7例治愈患者上机前与上机后、脱机前的动脉血气分析血氧分压、血氧饱和度、血二氧化碳分压比较差异有统计学意义(P<0.05);治疗前后患者血肌酐(平均15625对101.85 μmol/L)、血尿素氮(平均11.93对6.55 mmol/L)比较差异有统计学意义(P<0.05). 结论 早期应用无创正压机械通气辅以抗病毒为主的综合治疗,是提高重症CMV肺炎治愈率的重要措施.     

肾移植术后重症肺炎撤除免疫抑制剂治疗的安全性评估

目的 探讨肾移植术后重症肺炎的诊治经验.方法 回顾性分析16 例肾移植术后重症肺炎患者的临床资料.16 例患者均撤除了全部基础免疫抑制剂,经验性使用抗感染药物,并进行病原学检查,根据检查结果调整抗感染方案;同时静脉给予小剂量甲泼尼龙、营养支持治疗;如出现呼吸困难、血气分析显示低氧血症,则立即给予无创通气或气管插管治疗,评价其安全性.结果 16 例患者无一例出现急性排斥反应;重症肺炎常发生在肾移植术后3～4 个月,但移植一年以上的重症肺炎也有一定比例18.75%(3/16);发热和胸闷是最常见首发症状,仅有18.75%(3/16)的患者具有明显的咳嗽、咳痰症状;血培养、痰、咽拭子培养病原体检出率较低(43.75%).13 例重症肺炎患者治疗有效,3 例死亡,死亡病例均为移植1 年以上,有移植肾功能不全的诊断.结论 肾移植术后重症肺炎,病情严重、死亡率高.早期诊断、早期经验性抗感染治疗,撤除全部基础免疫抑制剂,静脉使用激素,进行无创通气及加强全身支持治疗,是肾移植术后重症肺炎治疗成功的关键.治疗期间全部撤除免疫抑制剂药物对患者安全有益,短期内对移植肾无害.     

肾移植术后并发肺结核感染的早期诊断和治疗(附12例报告)

目的探讨肾移植术后肺结核感染的早期诊断和治疗。方法回顾性分析12例肾移植术后肺结核感染患者的临床资料。均采取免疫抑制剂减量或停用,加大糖皮质激素剂量,异烟肼 利福平 乙胺丁醇或吡嗪酰胺三联抗结核疗法,辅以营养支持治疗。结果12例患者均在1个月左右症状缓解出院,并常规抗结核6～15个月后痊愈。结论胸部X线、痰涂片或培养、PPD、血Anti-TBAb及PCR等综合检测,结合临床表现是早期诊断的关键。调整免疫抑制方案,增加糖皮质激素用量,果断采取抗结核治疗以及营养支持治疗,将有助改善患者的预后。     

肾移植术后巨细胞病毒肺炎13例报告

目的：总结肾移植术后巨细胞病毒(CMV)肺炎的防治经验,探讨有效的防治措施。方法：回顾性分析13例行同种异体肾移植术后并发CMV肺炎患者的临床资料。13例均在肾移植术后2～6个月发病,均以发热、干咳起病,胸片检查均有间质性肺炎改变。13例患者中,血CMVPP65抗原阳性9例。治疗措施包括早期抗病毒治疗、撤减免疫抑制剂用量、适时使用机械通气、加强全身支持治疗等。结果：13例患者中,治愈8例(61．5%),好转3例(23．1%),死亡2例。7例术后使用更昔洛韦预防CMV感染的患者,治愈4例,好转2例,死亡1例。结论：肾移植术后加强CMV检测有利于CMV肺炎的早期诊断。术后积极预防CMV感染,早期采取以抗病毒为主的综合治疗可提高治愈率。     

肾移植术后巨细胞病毒感染的早期诊断与治疗

目的:提高肾移植术后巨细胞病毒(CMV)感染的早期诊断率和治愈率.方法:1999年3月～2003年12月共收治152例次肾移植患者,对其中所发生的16例CMV感染患者资料进行回顾性分析.结果:根据外周血CMV IgM阳性和(或)外周血巨细胞病毒抗原(CMV-Ag)阳性诊断为巨细胞病毒活动性感染.16例肾移植术后CMV感染患者的早期临床表现不典型,一旦出现高热、干咳等症状则很快出现呼吸衰竭,对上述患者进行多次痰细菌培养及血巨细胞病毒抗体检查,结果均呈阴性5例,单纯CMV感染4例,CMV并发细菌感染6例,CMV并发真菌感染3例,CMV并发寄生虫感染1例,胸片提示为肺间质性病变12例.经治疗后治愈11例,5例死亡.结论:①CMV感染为肾移植患者术后的主要死亡原因之一.②及早诊断与早期联合治疗可提高CMV感染的治愈率.③肾移植术后CMV感染在早期抗病毒、抗细菌、抗真菌治疗同时,减少或暂停免疫抑制剂,有利于提高感染的治愈率.     

肾移植术后间质性肺炎的诊断与治疗

目的:探讨肾移植术后并发间质性肺炎的临床诊断和治疗方法。方法:回顾性分析15例肾移植患者术后并发间质性肺炎的临床资料。结果:5例血巨细胞病毒DNA阳性,4例血巨细胞病毒IgM阳性,2例找到卡氏肺孢子虫病体。经过综合治疗,12例痊愈,3例死于ARDS。结论:肾移植术后并发间质性肺炎病情凶险,寻找病原体是关键。在病原体确定前经验性使用抗生素治疗,找到病原体后改为降阶梯性治疗,撤减免疫抑制剂,使用免疫增强剂,加用甲基泼尼松龙,纠正低氧血症,效果较好。     

连续性静脉静脉血液透析滤过治疗肾移植术后并发急性呼吸窘迫综合征11例

随着新型免疫抑制剂的发展和应用，肾移植术后肾或人的存活率都得到提高，而急性呼吸窘迫综合征（ARDS）是肾移植术后最严重的并发症之一，病死率接近100％。我院2004年5月至2006年2月，早期运用连续性静脉静脉血液透析滤过（CVVHDF）救治肾移植术后并发ARDS的患者11例，现报告如下。     

肾移植术后肺部真菌感染的诊治

目的探讨肾移植术后肺部真菌感染的诊断与治疗。方法回顾性分析2008年1月至2010年12月广州医科大学附属第三医院收治的12例肾移植术后肺部真菌感染患者的临床资料。结果 12例患者中,真菌培养阳性者5例,其中白假丝酵母3例,曲霉2例。采用伏立康唑抗真菌治疗后治愈11例,死亡1例。与治疗前比较,治疗后患者呼吸频率及血二氧化碳分压降低,血氧分压及氧合指数显著升高,差异有统计学意义(均为P<0.01)。治疗前后患者的血清肌酐、尿蛋白、白蛋白、丙氨酸转氨酶水平的差异无统计学意义(均为P>0.05)。结论肺部真菌感染是肾移植术后的严重并发症,应早期明确诊断,及时使用抗真菌药物,减少免疫抑制剂用量,应用大剂量丙种球蛋白及呼吸机支持治疗。     

肾移植术后并发重症肺部感染的原因与处理

目的:探讨肾移植术后并发重症肺部感染的原因与处理措施。方法:回顾性分析29例肾移植术后并发重症肺部感染患者的临床资料。结果:29例重症肺部感染患者中17例(58.6%)救治成功,12例(41.4%)因合并急性呼吸窘迫综合征抢救无效死亡。结论:重症肺部感染是肾移植受者术后近期死亡的主要原因之一;果断减少或停用免疫抑制剂,早期联合用药抗感染治疗,尽可能早期明确病原学诊断,积极纠正低氧血症和低蛋白血症等,是成功救治的关键。     

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.     

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.