全凭静脉麻醉下保留自主呼吸行胸腔镜手术的安全性评估

目的：观察保留自主呼吸全凭静脉麻醉对胸腔镜手术围术期机体生理变化的影响，并进一步探讨其有效性及安全性。方法：2016年5—11月择期行胸腔镜手术患者64例，随机分为自主呼吸全麻组（40例）及气管插管全麻组（24例）。自主呼吸全麻组以右美托咪定、舒芬太尼、丙泊酚静脉诱导，以右美托咪定、瑞芬太尼、丙泊酚辅以术侧胸腔镜下肋间神经及胸内迷走神经阻滞进行术中维持麻醉。观察并记录术前、开胸前、开胸时、开胸后15 min、开胸后30 min、关胸前、关胸后30 min、关胸后60 min等时间点的心率（HR）、平均动脉压（MAP）、呼吸频率（RR）、指脉氧饱和度（SPO2）、脑电双频谱指数（BIS）以及相应时间点动脉血酸碱度（pH）、二氧化碳分压（PCO2）、氧分压（PO2）、氧合指数、剩余碱（BE）、碳酸氢根（HCO3-）、二氧化碳总量（TCO2）、电解质等指标的变化，并进一步观察探讨其与气管插管全麻组患者在术前麻醉、拔管呛咳、呕吐、复苏室停留时间、咽喉痛、肺部感染及总住院天数等方面是否有差异。结果：自主呼吸全麻组患者HR、RR、MAP开胸前较术前有所下降（P < 0.05），RR在开胸后30 min、关胸前时间点较开胸前有所增加（P < 0.05）。开胸时MAP较开胸前进一步下降（P < 0.05），于开胸后15 min、开胸后30 min、关胸前时间点逐渐上升，与开胸前时间点比较差异无统计学意义（P＞0.05）。SPO2在开胸后15 min、开胸后30 min相比开胸前有所降低（P < 0.05），在关胸后30 min、关胸后60 min恢复到术前水平（P＞0.05）。pH、PO2、氧合指数在开胸后30 min及关胸前较开胸前降低（P < 0.05），PCO2在开胸30 min、关胸前较开胸前升高（P < 0.05），PO2、氧合指数在关胸后30 min时恢复到开胸前水平（P＞0.05），pH、PCO2在关胸后60 min时恢复到开胸前水平（P＞0.05）。BE在关胸后30 min较开胸前降低（P < 0.05）。HCO3-、TCO2、Na+、K+、iCa2+、Glu、Hb等指标各时间点无明显差异。此外自主呼吸全麻组在术前麻醉时间、复苏室停留时间、拔管呛咳及咽喉痛的发生率均低于气管插管全麻组（P < 0.05）。结论：自主呼吸全凭静脉麻醉行胸腔镜手术安全可行，患者生理指标在可接受范围内发生变化，且在关胸后短时间内恢复。     

Confocal scanning laser Doppler flowmetry of the optic nerve in smokers

The many smoking-induced changes are diffuse and include, but are not limited to, coronary artery disease and cerebrovascular accidents. Cigarette smoking has even been suggested to be an important risk factor in the development of nonarteritic anterior ischemic optic neuropathy. The purpose of the present investigation was to compare confocal scanning laser Doppler flowmeter parameters between otherwise healthy smokers and healthy nonsmokers. Confocal scanning laser Doppler flowmeter parameters were assessed in 58 healthy non-smokers and 20 otherwise healthy smokers in a middle-aged population. An analysis of covariance (covariate: age) disclosed decreased values for all confocal scanning laser Doppler flowmeter parameters (`Volume': p&lt;0.036; `Flow': p&lt;0.019; `Velocity': p&lt;0.023) in smokers. The present study suggests that healthy smokers might have reduced confocal scanning laser Doppler flowmeter parameters at the optic nerve.     

A Case of Catamenial Pneumothorax with Diaphragmatic Fenestrations

Background: Considerable controversy exists with regards to the physiopathogenesis of catamenial pneumothorax. The rarity of catamenial pneumothorax makes understanding of its pathophysiology and verification of etiological mechanisms difficult. Objective: To contribute evidence to the knowledge base on the pathogenesis of catamenial pneumothorax. Case Report: We describe a case of catamenial pneumothorax with images that substantiate the pore hypothesis as a cause of recurrence of air in the pleural cavity in this patient. Conclusion: Our case report contributes evidence that transperitoneal migration of endometrial implants may occur through diaphragmatic fenestrations. Surgical options may be more viable to prevent recurrent pneumothoraces in such patients.     

Prolonged stimulation with low‐intensity ultrasound induces delayed increases in spontaneous hippocampal culture spiking activity

Ultrasound is a promising neural stimulation modality, but an incomplete understanding of its range and mechanism of effect limits its therapeutic application. We investigated the modulation of spontaneous hippocampal spike activity by ultrasound at a lower acoustic intensity and longer time scale than has been previously attempted, hypothesizing that spiking would change conditionally upon the availability of glutamate receptors. Using a 60‐channel multielectrode array (MEA), we measured spontaneous spiking across organotypic rat hippocampal slice cultures (N = 28) for 3 min each before, during, and after stimulation with low‐intensity unfocused pulsed or sham ultrasound (spatial‐peak pulse average intensity 780 μW/cm²) preperfused with artificial cerebrospinal fluid, 300 μM kynurenic acid (KA), or 0.5 μM tetrodotoxin (TTX) at 3 ml/min. Spike rates were normalized and compared across stimulation type and period, subregion, threshold level, and/or perfusion condition using repeated‐measures ANOVA and generalized linear mixed models. Normalized 3‐min spike counts for large but not midsized, small, or total spikes increased after but not during ultrasound relative to sham stimulation. This result was recapitulated in subregions CA1 and dentate gyrus and replicated in a separate experiment for all spike size groups in slices pretreated with aCSF but not KA or TTX. Increases in normalized 18‐sec total, midsized, and large spike counts peaked predominantly 1.5 min following ultrasound stimulation. Our low‐intensity ultrasound setup exerted delayed glutamate receptor‐dependent, amplitude‐ and possibly region‐specific influences on spontaneous spike rates across the hippocampus, expanding the range of known parameters at which ultrasound may be used for neural activity modulation. © 2016 Wiley Periodicals, Inc.     

Outcome predictors of cirrhotic patients with spontaneous bacterial empyema

Background: Spontaneous bacterial empyema (SBE) is a complication of cirrhotic patients in which a pre‐existing pleural effusion becomes infected. This retrospective study was designed to investigate the bacteriology and outcome predictors of SBE in cirrhotic patients. Methods: Medical records of cirrhotic patients treated in a tertiary care university hospital from December 2004 to December 2008 were retrospectively reviewed. Results: Of 3390 cirrhotic patients seen during the study period, 81 cases of SBE were diagnosed. The incidence of SBE was 2.4% (81/3390) in cirrhotic patients and 16% (81/508) in patients with cirrhosis with hydrothorax. There were 46 monomicrobial infections found in 46 SBE patients. Aerobic Gram‐negative organisms were the predominant pathogens (n=29, 63%), and Escherichia coli (n=9, 20%) was the most frequently isolated sole pathogen. The mortality rate of SBE was 38% (31/81). Univariate analysis showed that Child–Pugh score, model for end‐stage liver disease (MELD)–Na score, concomitant bacteraemia, concomitant spontaneous bacterial peritonitis, initial intensive care unit (ICU) admission and initial antibiotic treatment failure were predictors of poor outcomes. Multivariate regression analysis demonstrated that the independent factors related to a poor outcome were initial ICU admission [odds ratio (OR): 4.318; 95% confidence interval 1CI) 1.09–17.03; P=0.037], MELD–Na score (OR: 1.267; 95% CI 1.08–1.49; P=0.004) and initial antibiotic treatment failure (OR: 13.10; 95% CI 2.60–66.03). Conclusion: Spontaneous bacterial empyema in cirrhotic patients is a high mortality complication. The independent factors related to poor outcome are high MELD–Na score, initial ICU admission and initial antibiotic treatment failure. High MELD–Na score may be a useful mortality predictor of SBE in cirrhotic patients.     

张力性气胸术后严重并发症的护理体会

目的:探讨张力性气胸引流术后并发严重并发症的有效的护理方法。方法:回顾性分析31例张力性气胸治疗过程中6例出现严重并发症后采取的针对性护理方法,归纳总结针对这类疾病有效的护理方案。结果:31例患者中1例出现短暂纵膈摆动及心律失常(频发室性早搏),4例出现广泛皮下气肿,其中2例合并纵膈气肿,1例出现皮下气肿及复张性肺水肿,采取床边严密心电监护、吸氧、控制引流速度、排痰及其它对症处理,患者均顺利恢复,无不良后果。结论:针对不同病情患者采取针对性护理措施能有效挽救患者生命,促使患者早日康复,意义重大。