120例产后出血的预防及护理体会

目的:总结120例产后出血的预防及护理体会.方法:通过对120例产后出血患者的一系列适宜护理,得出体会.结果:严密观察产后出血者的生命体征,根据不同原因采取相应的止血措施,抢救体克,纠正酸中毒,并应用大剂量抗生素以预防感染.结论:对产妇加强三期预防保健及产后护理,根据不同的出血原因采取相应的措施,可大大降低其发病率及死亡率.     

不同年龄患者腹腔镜胆囊切除术中肾血流量变化的比较

目的 比较不同年龄患者腹腔镜胆囊切除术中肾血流量的变化.方法 择期行腹腔镜胆囊切除术患者60例,年龄18～75岁,ASA分级Ⅰ或Ⅱ级,性别不限,体重48～78 kg,根据年龄分为2组(n=30):中青年组(18～60岁)和老年组(61 ～ 75岁).经口气管插管后置入食管超声探头,分别于气腹前、气腹1、5、10、15、20、30 min、气腹结束后1和5 min时,采用经食管超声心动图测量左肾动脉主干内径(RAD)和血流速度时间积分(VTI),计算左肾血流量(LRAF),记录最大下降时间点,计算最大下降百分比.结果 与气腹前比较,两组气腹各时点和气腹结束后1 min时RAD、VTI和LRAF降低(P＜0.05).与中青年组比较,老年组气腹前LRAF降低,最大下降时间点延迟(P＜0.05),最大下降百分比差异无统计学意义(P＞0.05).结论 中青年患者和老年患者腹腔镜胆囊手术中肾血流量均发生可逆性下降;老年患者最大下降时间延迟.     

食道静脉曲张套扎结合大剂量聚桂醇治疗体会

目的探讨在密集套扎疗法的基础上进行硬化治疗对于食管静脉曲张复发的防治作用。方法对食管静脉曲张套扎治疗后食管曲张静脉消失或基本消失的患者进行硬化剂治疗。结果套扎加大剂量聚桂醇治疗组与单纯套扎组再出血率有明显差异（P〈0.05）。结论套扎治疗后大剂量硬化剂治疗可显著减少套扎术后残留的食管曲张静脉、延缓静脉曲张的复发。     

全身热疗对全凭静脉麻醉下阿曲库铵肌松效应的影响

目的 观察全身热疗(whole body hyperthhermia,WBH)对晚期癌症患者全凭静脉麻醉(total intravenous anesthesia,TIVA)中阿曲库铵用量和作用时间的影响.方法 晚期癌症TIVA患者,分非高温组(24例),高温组(26例).监测两组患者的体温、心电图(ECG)、中心静脉...     

体外循环下小儿肌部室间隔缺损的镶嵌治疗

目的 探讨镶嵌模式(hybrid procedure)治疗小儿肌部室间隔缺损(Mvsd)的手术方法及临床应用.方法 2006年1月至2010年6月,在体外循环心内直视手术下采用手术及封堵相结合的镶嵌技术矫治小儿Mvsd 45例,其中男20例,女25例;年龄52天～12岁;体重3～32 kg.7例为单个Mvsd,38例为多发性VSD.同时合并大血管错位(D-TGA)1例、法洛四联症(TOF)2例、肺动脉狭窄(PS)3例、动脉导管未闭(PDA)6例、房间隔缺损(ASD)6例、主动脉缩窄1例.均在心脏停跳后直视下将导引钢丝经三尖瓣孔自心脏右室面穿过VSD至左室面,直视下置入导引器,然后送入封堵器,完成Mvsd封堵.多发性VSD 38例,予自体心包片修补膜周部等较大的VSD,心内其他畸形同期完成矫治.结果 42例置入单枚封堵器(直径4～10 mm)、3例置入双枚封堵器(直径4～7 mm).手术经过顺利,术前左室射血分数(EF)均在正常范围,术后1天小于8月龄组EF均值低于正常,大于8月龄组EF正常,两者差异有统计学意义.术后常规每天给予5 mg/kg肠溶阿司匹林3～6个月.术后随访超声检查示封堵器位置无偏移,无残余分流,无二尖瓣、主动脉瓣反流、Ⅲ度传导阻滞及新发心律失常等.术后因重症感染放弃治疗1例,无远期死亡病例.结论 体外循环下镶嵌技术治疗小儿 Mvsd明显降低了围手术期并发症及病死率,简化了手术过程,降低了手术风险,是一种安全、有效的方法.

Abstract：

Objective To summarize the technique and clinical experience of hybrid procedure under cardiopulmonary bypass (CPB) in children with muscular ventricular septal defect (mVSD). Methods From January 2006 to June 2010, 45 cases of mVSD underwent hybrid procedure with CPB. mVSDs were closed with devices under direct vision in 45 cases. Of them, there were 20 males and 25 females. They ranged from 52 days to 12 years [mean (2.05 ±2.48) year] in age and from 3 to 30 kg [(11.93 ±7.70)kg] in body weight. Preoperatively, most of children were highly susceptible to respiratory tract infections. The hybrid approach was used in all patients with CPB under the guidance of transesophageal echocardiography (TEE). The diameter of mVSDs ranged from 2 to 7 mm under TEE. Of 45 cases, 40 patients had increased rates of pulmonary blood flow. 29 patients had left axis deviation and 12 cases had sinus arrhythmia on electrocardiography (ECG). 19 had other congenital heart lesions, including transposition of great arteries in 1 case, tetralogy of Fallot in 2, pulmonary artery stenosis in 3, patent ductus arteriosus in 6, atrial septal defects in 6) and aorta coactation in 1. The quantity of VSDs were from 1 to 7 (single, in 7; two, in 24 case; three, in 8 case; four, in 5 case and seven, in lease. 37 patients were combined with pulmonary hypertension in our cohort. 38 patients with another large VSD and 19 with other congenital heart lesions were required surgical repair at sometime. Results The hybrid procedures were undertaken in all 45 cases of this cohort. All cases were successful and no deaths occurred during operation. A total of 48 devices were implanted in 45 patients, including single devices in 42 cases (device size ranged from 4 to 10 mm) and two devices in 3 cases (device size ranged from 4 -7 mm). The average time on CPB was (58.28 ±20.70) min , while aortic crossclamp time was(34. 94 ± 14.75) min. In addition, the time on mechanical ventilation postoperatively ranged from 2 hours to 6 days. Compared to the older children, 20 infante aged less than 8 monhad a significant difference in cardiac function in the early postoperative period. One infant was given up treatment because of serious infection. Anather cases recovered with the use of supportive treatment, such as using vasoactive agents, digoxin, inhaling nitric oxide, diuresis, and so on. The enteric-coated aspirin was given at dose of 5 mg ? kg -1. day -1 for a period of 3 to 6 months as usual postoperatively. All patients attended follow-up at 1 week, 1 month, 3 months, 6 months, 1 year and 2 years post-procedure. No major complications were encountered during this period. All cases were no instance of migration of any of the devices, residual shunt, aortic regurgitation, atrioventricular valve dysfunction, Ⅲo atrial-ventricular conduction block, new arrhythmia, and so on. There are no death in long-term follow-up. Conclusion Hybrid procedure is safe and effective for the closure of congenital heart defects in children.     

丙泊酚对体外高糖培养的人脐静脉内皮细胞中MDA、SOD和NF-κB的影响

目的 探讨丙泊酚对体外高糖培养的人脐静脉内皮细胞(HUMCEs)中丙二醛(MDA)含量和超氧化物歧化酶(SOD)活性及NF-κBp65表达的影响.方法 按体外培养HUMCEs的条件不同随机分为七组,葡萄糖5.5 mmol/L组(C1组)、甘露醇25 mmol/L组(C2组)、葡萄糖30mmol/L组(HG1组)、葡萄糖30mmol/L+脂肪乳90 μmol/L组(HG2组)、葡萄糖30 mmol/L+吡咯烷二硫代氨基甲酸酯(PDTC)50μmol/L组(HG3组)、葡萄糖30 mmol/L+丙泊酚25μmol/L组(HG4组)、葡萄糖30 mmol/L+丙泊酚100μmol/L组(HG5组).分别检测各组细胞的MDA含量、SOD活性及C1、HG1、HG3、HG4、HG5组中NF-κB p65表达量.结果 与C1、C2组比较,HG1组MDA含量升高,SOD活性降低,NFκB p65表达量增多(P＜0.05).与HG1组比较,HG3组、HG4组及HG5组的MDA含量均下降、SOD活性均升高、NF-κBp65表达量均降低(P＜0.05).与HG2组比较,HG3、HG4及HG5组的MDA含量均下降、SOD活性均升高(P＜0.05).与HG4组比较,HG5组MDA含量下降、SOD活性升高(P＜0.05);HG4、HG5组间NF-κB p65表达量差异无统计学意义.结论 丙泊酚与PDTC一样可抑制高糖对内皮细胞损伤,提示丙泊酚的作用与抑制NF-κB信号通路有关.     

1,25-二羟基维生素D3对致死剂量脂多糖攻击的大鼠CD_4~＋CD_（25）~＋Treg细胞的调节作用

目的：观察不同剂量1,25-二羟基维生素D3（1,25-（OH）2D3）短期应用对大鼠受致死剂量脂多糖（LPS）攻击后的保护作用,并探讨此保护作用是否与1,25-（OH）2D3对CD4＋CD25＋Treg细胞的调节作用有关。方法：将大鼠分成3个剂量组,每组20只。分别给予1,25-（OH）2D3 0.125μg/只、0.25μg/只、1μg/只灌胃,3次/周,共2周。另设对照组给予赋形剂。给药后第15天腹腔注射致死剂量LPS（10mg/kg）,每组10只用于观察96 h内的死亡率;其余10只大鼠注射LPS 6 h后抽取外周血并留取脾脏标本。流式细胞仪检测大鼠外周血及脾脏CD4＋CD25＋Treg细胞数量,实时定量PCR检测脾脏Foxp3mRNA水平,ELISA检测外周血IL-10和TGF-β水平。结果：用1,25-（OH）2D3预处理的各组大鼠死亡率均显著低于对照组,用药各组外周血及脾脏CD4＋CD25＋Treg细胞数量、脾脏Foxp3mRNA表达水平、外周血IL-10及TGF-β水平也显著高于对照组。结论：1,25-（OH）2D3能够有效保护大鼠抵抗致死剂量LPS的攻击,这种保护作用可能与1,25-（OH）2D3上调CD4＋CD25＋Treg细胞的数量和功能有关。     

活体肝移植术后Ⅴ、Ⅷ段肝静脉淤血的临床及影像学观察

目的 评价活体肝移植(living donorlivertransplantation,LDLT)术后Ⅴ、Ⅷ段肝静脉淤血(hepatic venous congestion,HVC)的MSCT表现及其对患者术后肝功能恢复的影响.方法83例在天津市第一中心医院移植外科施行活体右半肝移植的患者纳入本研究,所有患者均于术后早期(≤1个月)和术后中晚期(≥3个月)进行MSCT平扫和增强检查,记录淤血区的MSCT表现和患者术后1～7 d丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TB)及凝血酶原时间(PT).比较淤血组和无淤血组上述指标之间的差异.结果 20例患者(24.10%)LDLT术后1个月内出现Ⅴ、Ⅷ段HVC,淤血区体积和淤血率分别为(218.25±130.29)cm3和16.68%±8.81%.淤血区于MSCT平扫及动脉期多呈低密度,门静脉期多呈混杂密度或高密度,增强后动脉期及门静脉期呈持续低密度者预后不良.淤血组与无淤血组患者术后1～7 d各项肝功能化验指标差异均无统计学意义(均P＞0.05).结论 MSCT是评价LDLT术后Ⅴ、Ⅷ段HVC的有效方法,多数HVC对LDLT术后患者肝功能恢复没有影响.

Abstract：

Objective To evaluate MSCT appearance and impaction of Ⅴ, Ⅷ segments' hepatic venous congestion ( HVC ) on hepatic functional recovery in living donor liver transplantation (LDLT).Methods In this study, 83 patients undergoing LDLT in our hospital were included, all subjects received plain and contrast MSCT examinations at early stage (within 1 month) and later stage (3 months later) after LDLT. MSCT appearance of HVC was recorded, at the same time, gutamic pyruvic transaminase ( ALT),glutamic oxalacetic transaminase (AST), total bilirubin (TB) and prothrombin time (PT) of 1 to 7 days after LDLT between congestion group and non-congestion group were recorded and compared.Results Segments Ⅴ and Ⅷ congestion was identified by after LDLT CT scanning in 20 patients (24. 10% ). Congestion volume and congestion ratio was (218. 25 ± 130. 29) cm3 and 16. 68% ±8. 81%,respectively. HVC often appear as hypoattenuation on plain CT scan and arterial phase, mixed or hyperattenuation on portal vein phase. There was no significant difference of ALT, AST, TB and PT after LDLT between congestion group and non-congestion group (P ＞ 0. 05). Conclusions MSCT is a valuable method to evaluate Ⅴ, Ⅷ segments' HVC after LDLT, most HVC has no impaction on hepatic functional recovery in LDLT patients.     

OSAS患者右美托咪啶和舒芬太尼辅助表面麻醉用于纤维支气管镜引导经鼻气管插管效果的比较

目的 比较阻塞性睡眠呼吸暂停综合征(OSAS)患者右美托咪啶和舒芬太尼辅助表面麻醉用于纤维支气管镜(纤支镜)引导经鼻气管插管的效果.方法 全麻下行择期手术的OSAS患者30例,性别不限,ASA分级Ⅱ或Ⅲ级,年龄32 ～ 58岁,体重75 ～ 105 kg.采用随机数字表法,将患者随机分为2组(n=20):舒芬太尼组(S组)和右美托咪啶组(D组).2组均应用2％利多卡因咽喉喷雾表面麻醉,环甲膜穿刺注射1％丁卡因3 ml.S组经60 s静脉注射舒芬太尼0.1μg/kg,给药后3 min开始实施纤支镜引导经鼻气管插管,D组静脉输注右美托咪啶0.1μg·kg-1·min-1 10 min时开始实施纤支镜引导经鼻气管插管,记录气道阻塞评分.记录麻醉诱导开始至气管插管后3 min内MAP和HR的最大值,计算MAP和HR的变化率、RPP＞ 22 000以及呼吸抑制等的发生情况.分别于麻醉前、纤支镜通过鼻后孔、窥视会厌、气管插管成功时、气管插管后1 min、气管插管后3 min时记录灌注指数(PI)和Ramsay镇静评分.术后24h随访患者,记录声音嘶哑和咽喉疼痛的发生情况.结果 与S组比较,D组气道阻塞评分、呼吸抑制的发生率降低,PI、Ramsay镇静评分、MAP变化率＞30％、HR变化率＞30％、RPP＞ 22 000、咽喉疼痛和声音嘶哑的发生率差异无统计学意义(P＞0.05).结论 与舒芬太尼比较,右美托咪啶辅助表面麻醉用于OSAS患者纤支镜引导经鼻气管插管不抑制呼吸,可提供良好的气管插管条件.     

颈段食管癌的外科治疗

目的总结外科治疗颈段食管癌的经验体会。方法综合分析1993年12月至2005年12月在河南省肿瘤医院胸外科和头颈外科接受外科治疗的82例颈段食管癌患者的临床资料。结果本组患者1997年以前以单纯手术治疗为主（27例）；1997年后，除5例早期癌患者外，50例常规采用半量放疗后再手术的综合治疗模式。非开胸食管切除73例．开胸食管切除9例；同期行单侧或双侧区域性颈淋巴结清扫14例；联合脏器切除12例。单纯手术组和综合治疗组保喉率分别为81．3％和95．8％，差异无统计学意义（P〉0．05）。无术中或术后大出血、气管和（或）支气管撕裂及围手术期死亡者；并发症发生率为19．5％；术后病理证实上切缘阳性5例，均为单纯手术组；淋巴结转移14例（17．1％）。全组5年总生存率43％：其中综合治疗组50．2％，高于单纯手术组的33．9％（Χ^2=7．17；P=0．007）；开胸食管切除者、同期行单侧或双侧区域性颈淋巴结清扫者和联合脏器切除者的5年生存率分别为36．5％、45．8％和33．3％。结论颈段食管癌患者半量放疗后再手术．可明显减少肿瘤上切缘阳性的发生率，提高保喉率和5年生存率。手术方式以非开胸游离食管为首选，联合脏器切除或双侧颈部淋巴结清扫应非常谨慎。