重症高血压脑出血外科治疗及体会

目的 探讨采用钻颅、血肿穿刺加引流方法对重症高血压基底节出血外科治疗的疗效。方法 根据CT诊断确定手术适应证后，采用钻颅、血肿穿刺加引流方法治疗。结果 48例患者，临床痊愈4例，好转10例，死亡34例。结论 通过对重症高血压基底节出血患者，采用钻颅、血肿穿刺加引流方法治疗，可以达到提高疗效，减少或减轻脑出血后遗症，降低死亡率的目的。     

钻颅引流血肿抢救进展性高血压脑出血并发脑疝

目的探讨快速钻颅抽吸引流血肿减压在急性进展性高血压脑出血并发脑疝术前急救的临床疗效。方法对24例高血压脑出血并发脑疝者,先行快速钻孔抽吸引流血肿减压,尽快完成术前准备后行骨瓣开颅清除血肿。结果钻颅后一侧瞳孔缩小或恢复正常13例,双侧瞳孔缩小4例,瞳孔无变化7例,钻颅后GCS评分好转11例。出院时GOS:良好5例,中残9例,重残7例,植物生存1例,死亡2例。结论快速钻颅抽吸引流血肿减压对高血压脑出血并发脑疝患者术前急救有明显疗效,且可降低病死率,改善预后。     

颅内血肿微创清除术治疗290例高血压性颅内血肿的护理体会

高血压性颅内血肿患者具有起病急，病情重，病程复杂，预后差等特点，发病后1个月的病死率为32．0％～55．0％，而且一半以上死于48h以内，存活的患者中常留下严重后遗症。2000年8月～2006年8月，我们对290例急性高血压性颅内血肿，在YL-1型颅内血肿穿刺针微创钻颅血肿穿刺抽吸引流手术前后，加强护理，取得满意的效果，现总结如下。     

细孔钻颅抽吸血肿注入尿激酶引流治疗高血压性脑出血的护理

为提高高血压性脑出血病人的抢救成率，根据ＣＴ图象，采用细孔钻颅抽吸血肿注入尿激酶引流治疗６５例，有效率达８１．５。护理要点１严密观察志组为瞳孔，生命体征，肢体功能变化，及时发现脑疝先兆；２保持呼吸道通畅；３保健情绪稳定及大便通畅，预防再出血；４控制中枢性主热；５加强营养，防止消化道出血。     

微创硬通道钻颅治疗各型颅内血肿的临床应用(附40例分析)

目的 研究颅内血肿微创穿刺,并建立硬通道,液化,引流血肿方法在治疗各型颅内血肿的临床效果。方法 微创硬通道钻颅血肿清除技术,即CT定位,“经皮颅内血肿粉碎穿刺针”穿刺,液流冲碎血肿,并建立自锁硬通道,注射液化剂,引流清除血肿。结果 治疗40例,存活34例,死亡6例。存活,6月后日常活动能力ADLI-3级31例,ADL4级3例。结论 微创硬通道钻颅血肿清除技术操作简便,对治疗颅内血肿有满意的临床效果。     

锥颅抽吸血肿腔引流治疗自发性小脑出血46例临床分析

目的：观察锥颅抽吸血肿腔引流治疗自发性小脑出血的疗效。方法：采用头颅CT定位，锥颅置管血肿腔抽吸引流和用生理盐水置换冲洗，并在血肿腔注射麻黄素，尿激酶治疗46例自发性小脑出血，结果：治愈27例，好转12例，死亡7例，结论：早期行锥颅抽吸血肿腔引流术，能明显提高病人生存率及功能恢复，该疗法操作简单，定位准确，细针穿刺创伤小，不受年龄及重要脏器功能限制，可在局麻下完成，便于基层医院开展。     

钻颅治疗创伤性非急性硬膜外血肿

本文报道１２例临床表现为延迟过程的硬膜外血肿，受伤至临床征象出现时间超过４天。这些病例的临床过程轻微并且预后比急性好。本文资料显示亚急性、慢性硬膜外血肿的位置，位于额及额－颞区发生率高（９１．７％）。全部病例均采用钻颅、吸除、冲洗及引流的方式施术。手术效果令人满意。ＧＯＳ均为５分。本文还对具体手术方法和该方法的病理学基础作详细的讨论。     

锥颅置管引流治疗硬膜外血肿32例分析

目的探讨锥颅置管注人尿激酶引流治疗硬脑膜外血肿的临床疗效。方法在CT定位下锥颅穿刺血肿置引流管注入尿激酶使血肿液化后引流清除血肿。结果32例手术均成功,临床症状均明显好转或消失,复查CT示血肿消失或基本消失,无并发症。结论锥颅置管引流治疗硬膜外血肿方法安全、微创、简便、临床效果满意。     

穿刺抽吸尿激酶引流治疗高龄高血压脑出血分析

目的探讨穿刺抽吸纤溶引流治疗高龄高血压脑出血的疗效。方法回顾本院2008年6月至2010年5月间高龄（70～85岁）高血压基底节区脑出血、意识状态在Ⅱ～Ⅳ级的患者89例,其中意识状态在Ⅱ～Ⅲ级的61例,意识状态在Ⅳ级的28例。44例行穿刺抽吸纤溶引流,另外45例作为对照组,采取内科保守治疗和开颅血肿清除术,对生存患者3个月的ADL评分进行比较。结果术后恢复按ADL评分：其中意识状态在Ⅱ～Ⅲ级：穿刺抽吸纤溶引流组较内科保守治疗组、开颅血肿清除组患者ADL评分明显提高,死亡率下降;意识状态Ⅳ级：采用穿刺抽吸纤溶引流术与开颅血肿清除术比较患者ADL评分、死亡率均无统计学差异。结论对意识状态分级为Ⅱ～Ⅲ级的高龄患者行穿刺抽吸尿激酶引流治疗疗效较好,疗程短。对于意识状态分级为Ⅳ级患者,采用任何手术方法均不能明显降低患者的死亡率。     

单孔钻颅双管血肿引流治疗慢性硬膜下血肿

慢性硬膜下血肿较为常见，钻颅血肿引流为常用的治疗方法，预后良好，但治疗不当仍会产生各种并发症。本院自１９９２年至１９９８年共收治该类病人９６例，其中采用单孔钻颅双管引流７０例，取得了较为满意的效果。现报告如下。资料与方法１．临床资料：本组７０例，男４８例，女２２例；年龄３８～７８岁，平均６２岁。有明确外伤史５０例，受伤至确诊时间１月～２年。首诊症状分别为：头痛４３例，头晕１３例，行走不稳８例，痴呆、精神异常６例，不同程度偏瘫２４例。CT检查多为颅板下半月形占位、等密度或低密度灶，其中有混杂小片状…     

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.