浅谈丁基胶塞在输液产品中的应用

结合丁基胶塞在输液生产中的应用及与药物相容性的考察,提出丁基胶塞在实际应用中存在的问题。     

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging,alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.     

控制成分输血输注速率提高新生儿换血疗效

目的探讨序贯调节悬浮红细胞和血浆输注速率进行新生儿换血的有效性及安全性。方法选择2006年10月至2013年9月我科收治的需要进行换血治疗的严重高胆红素血症患儿,随机分为对照组和观察组,对照组将所需红细胞与血浆按1∶1等速输注进行换血;观察组换血总量前1/3时,输注血浆速率为红细胞的两倍,中1/3时二者输注速率相等,后1/3时输注红细胞速率为血浆的两倍。换血前、中、后检测血常规、电解质、血糖及血胆红素等指标,并密切观察和记录患儿生命体征及经皮血氧饱和度(Sa O2)。结果对照组纳入40例,观察组纳入42例。两组患儿换血治疗后胆红素水平均明显降低[对照组:(222.1±30.3)μmol/L比(455.5±52.3)μmol/L,观察组:(207.3±27.8)μmol/L比(451.2±48.6)μmol/L,P<0.001],与对照组比较,观察组换血后胆红素水平更低,差异有统计学意义(P<0.05);观察组换血后血红蛋白含量明显高于对照组[(151±22)g/L比(135±26)g/L,P<0.01]。两组患儿换血相关并发症,如高血糖、血小板减少、低钙血症和低钠血症等均可在短时间内恢复正常。结论采用序贯调节悬浮红细胞和血浆的输注速率进行换血,在不增加用血量基础上,能明显降低胆红素水平和贫血的发生,且安全有效。     

动静脉同步换血换血量与胆红素水平关系的回归再分析

目的通过对加大样本量的线性回归分析,进一步研究适用于一般临床外周动静脉同步换血应用的反映换血量和总胆红素(TBIL)下降关系的回归方程。方法对75例采用外周动静脉同步换血疗法的高胆红素血症新生儿,按换血前TBIL数值高低依序分为5组,对每换血50 ml/kg进行TBIL值检测和回归分析,并对回归方程参数的95%置信区间进行分析和检验。结果 (1)每增加50 ml/kg换血量,TBIL累积换出率差异有非常显著意义(P0.01);经200 ml/kg换血后TBIL的累积换出率均值为61.5%。(2)换血过程中TBIL浓度(y)与换血量(x)呈线性相关(r值在0.96～0.98之间,P0.001)。(3)分组系列回归方程的斜率(a)与换血前TBIL浓度初始值(y0)也呈高度线性相关,其(r=0.99,P0.001)。(4)各组方程参数回归效果的方差分析检验结果均有非常显著统计学意义(P0.01)。(5)对换血回归方程参数适用区间95%置信度的检验结果有非常显著统计学意义(P0.001)。结论经分别对换血过程TBIL浓度值y与换血量x相关性依模型y=y0-ax以及对方程斜率参数a与换血前TBIL浓度初始值y0相关性依模型a=αy0+β进行的线性回归分析,可建立适用于临床指导换血用量的综合单自变量线性回归方程y=y0-ax=y0-(0.0035 y0-0.081)x。     

The placenta contributes to activation of the renin angiotensin system in twin-twin transfusion syndrome

The renin-angiotensin system (RAS) in twin-twin transfusion syndrome (TTTS) is up-regulated in the donor fetus's kidneys, but down-regulated in the recipient's. Ultrasonographic and echocardiographic features suggest that the recipient is also exposed to RAS components. In this study we investigated the role and origin of RAS components in the recipient fetus. Monochorionic diamniotic (MCDA) pregnancies were recruited from a tertiary fetal medicine service. Cord blood was collected from MCDA twins (TTTS and control non-TTTS) at delivery for renin and angiotensin II immunoassays. Placental tissue was flash-frozen for mRNA and protein expression or formalin-fixed for immunohistochemistry. Archival placenta and kidney samples were used for immunohistochemistry and in-situ hybridization. Plasma renin levels were elevated (p<0.05) in recipients (median 201pg/ml, range 54-315pg/ml) and donors (125pg/ml, 25-296) with TTTS compared to controls (2.5pg/ml, 1.1-1.5pg/ml). The same was found with angiotensin II with high levels in both recipients (300.5pg/ml, 86.1-488pg/ml) and donors (239pg/ml, 76.6-422) compared to controls (169.5pg/ml, 89-220pg/ml, p<0.05). Renin mRNA expression, and protein appeared qualitatively higher in the placental territory of the recipient compared to that of the donor and non-TTTS controls. We conclude that both fetuses in TTTS are exposed to high levels of RAS components; these appear to be produced from different sites, namely the kidney of the donor, and the placenta of the recipient. Given the markedly different phenotypes in the genetically identical fetuses with TTTS, we suggest that the source of RAS components may influence their clinical manifestations.     

Outcome of anaemic monochorionic single survivors following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome

Objective  To evaluate the outcome of severely anaemic monochorionic (MC) twins surviving the death of their co-twin following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome (FFTS).
Study design  We reviewed all MC pregnancies complicated with FFTS following primary management, in which a single intrauterine fetal death (IUFD) was diagnosed with certainty within 24 hours between January 1999 and December 2006. We included MC survivors who presented ultrasound or Doppler features of fetal anaemia following the death of their co-twin. Intrauterine transfusion (IUT) was given to all survivors who were anaemic.
Results  Nineteen MC twin pregnancies presented a single intrauterine death (IUD) associated with an anaemic co-twin. Median gestational age at IUD was 23 [20–28] weeks. The median interval between IUD and IUT was 12 [8–24] hours. There were 58% (11/19) healthy survivors. Perinatal death rate was 26% (5/19) including 16% (3/19) intrauterine and 10% (2/19) neonatal deaths. Abnormal prenatal cerebral findings developed in 21% (4/19) cases, always within 1 month after the death of the co-twin. Considering occlusive techniques and other management separately, there were 64% (7/11) and 50% (4/8) healthy survivors, respectively, and perinatal death occurred in 36% (4/11) and 12.5% (1/8) of fetuses, respectively. Prenatal fetal cerebral lesions developed in 9% (1/11) of cases following occlusive techniques and in 37.5% (3/8) of fetuses when managed differently. The median gestational age at delivery in the survivors was 31 [25–38] weeks.
Conclusion  In cases of FFTS with single anaemic survivors, early IUT could be offered following extensive counselling and close follow up.     

红细胞输注效果的影响因素分析

目的分析红细胞输注无效的原因,为临床红细胞的安全有效输注提供依据。方法回顾性总结分析本院半年内无效输血与可能因素之间的关系。结果红细胞无效输注与性别、年龄无关,多见于血液病和地贫患者,与既往输血次数(妊娠一次计算为一次输血)、红细胞制品贮存时间以及红细胞制品品种有关。结论尽量减少输血次数,正确选用新鲜的红细胞制品可降低红细胞输注无效率。     

关节腔内使用氨甲环酸对同期双侧人工全髋关节置换术后失血量的影响

目的:探讨关节腔内注射氨甲环酸(TXA)对同期双侧人工全髋关节置换(THA)术后失血量的影响.方法:同期双侧THA患者42例,关节腔内使用TXA 21例为观察组,使用生理盐水21例为对照组,比较两组患者术后24 h引流量、输血量、术后血红蛋白水平、总失血量、隐性失血量,纤维蛋白原(Fbg)、凝血酶原时间(PT)和活化部分凝血酶原时间(APTT),并观察患者3月内是否发生深静脉血栓(DVT)及肺栓塞(PE).结果:观察组术后总的失血量、术后24 h引流量、隐性失血量、输血量低于对照组,血红蛋白水平高于对照组,差异均有统计学意义(P＜0.05);两组患者的凝血3项指标比较差异无统计学意义(P＞0.05).未发现深静脉血栓及肺栓塞病例.结论:THA关节腔内使用TXA能明显降低患者术后失血量并减少输血率,不增加术后PE及VTE的发生率.     

加强抗菌药物合理使用降低门诊输液使用率的实践

目的：为医院降低门诊输液使用率提供参考。方法：结合我院采取的各种加强门诊抗菌药物合理使用的举措,分析实施前后门诊处方各项指标。结论：通过加强对抗菌药物合理使用的培训和管理,并充分运用计算机信息技术等办法,确实能减少门诊输液的使用率,使临床用药更安全、有效和经济。     

慢性活动性肝炎治疗探讨

本文总结了我科自1982～1988年共收治的101例慢性肝炎治疗的疗效观察,其中慢活肝53例,临床治愈86.7％,好转13.3％,无1例死亡,有效率100％;慢重肝48例,临床治愈31.2％,好转14.5％,无效26例,有效率45.8％。本组资料提示,慢活肝应用任何药物组合治疗,疗效都较好;慢重肝对各组治疗方法的疗效,与病情严重程度、有无并发症和MOSF有关。目前慢重肝病死率仍在50％以上,我们认为,在综合性治疗上加用FLC输注,可提高其存活率。此外,防治并发症与MOSF的发生也不可忽视。这常是治疗成败的关键。