重症先天性心脏病围术期氧供量和氧耗量的变化

目的了解重症先天性心脏病围术期的氧合状态.方法测定了22例心脏复跳后连续应用多巴酚丁胺或米力农情况下体外循环中、停体外循环后30min、手术结束、术后2h、术后16h的心脏指数(CI)、氧输送量(DO2)、氧耗量(VO2)和氧摄取率(ERO2).结果(1)体外循环中和体外循环结束DO2和VO2有高度正相关性(P＜0.01),相关系数分别为0.861,0.811;(2)体外循环中与体外循环后30min各数据比较CI、DO2、VO2前者明显低于后者(P＜0.05或0.01),ERO2无显著性差异;(3)体外循环结束后各点数据比较,CI能维持在3L@min-1@m-2以上,DO2能维持在550ml@min-1@m-2以上(术后16h最高,明显高于手术结束,P＜0.05),VO2能维持在120ml@min-1@m-2以上术后16h最低,术后2h最高,且明显高于体外循环后30min和术后16h(P＜0.05).结论(1)重症先天性心脏病围术期存在病理性氧供依赖;(2)心脏复跳后应用多巴酚丁胺能改善组织对氧的摄取和利用;(3)体外循环后连续应用多巴酚丁胺或米力农很难进行DO2、VO2、CI的超正常值维护,但CI高于ShoemakerWC提出的在治疗心源性休克所需维护的水平,即应不小于3L@min-1@m-2;(4)手术后16h循环功能尚未完全恢复,仍需继续加强正性肌力药的治疗.     

Ca sensitizer superior to catecholamine during myocardial stunning?

BACKGROUND: After open-chest cardiac surgery, ventricular function remains depressed (myocardial stunning). Catecholamines (epinephrine) improve ventricular function by increasing the intracellular Ca(2+) concentration. In parallel, the oxygen consumption is increased, so that the hitherto intact myocardium can be jeopardized. In the very insufficient ventricle, epinephrine can even become ineffective. Since Ca(2+) sensitizers provide another therapeutic avenue, the effects of epinephrine and levosimendan on postischemic hemodynamics were investigated. METHODS: After hemodynamic steady state, isolated, blood (erythrocyte-enriched Krebs-Henseleit solution)-perfused rabbit hearts were subjected to 25 min normothermic, no-flow ischemia and 20 min reperfusion. Heart rate (HR), cardiac output (CO), left ventricular pressure (LVP), coronary blood flow (CBF), and arterio-venous oxygen difference (AVDO(2)) were recorded during reperfusion and after administration of either epinephrine (n=16; 0.03 micromol), or levosimendan (n=11; 0.75 micromol) or epinephrine plus levosimendan (n=5). RESULTS: Epinephrine increased HR (19%, p=0.01) and improved hemodynamics in terms of CO (62%, p=0.0006), stroke volume SV (46%, p=0.02), stroke work W (158%, p=0.01), LVP(max) (58%, p=0.0001), maximal pressure increase dP/dt(max)(140%, p=0.0004), minimal pressure increase dP/dt(min) (104%, p=0.0002), LVP(ed) (-26%, p=0.02), and increased coronary resistance CR (31%, p=0.05). Epinephrine impaired hemodynamics in terms of AVDO(2) (+63%, p=0.003), myocardial oxygen consumption MVO(2) (+67%, p=0.0003) and MVO(2)/beat (+36%, p=0.01). External efficiency eta was increased by 92% (p=0.02). Levosimendan in postischemic hearts increased HR (32%, p=0.009) and improved hemodynamics in terms of CO (85%, p=0.01), SV (44%, p=0.03), W (115%, p=0.04), LVP(max) (95%, p=0.04), dP/dt(max) (133%, p=0.009), dP/dt(min) (121%, p=0.007), LVP(ed) (-63%, p=0.0006), and CR (-17%; n.s., p=0.1). It altered hemodynamics in terms of AVDO(2) (+7.0%; n.s., p=0.3) and MVO(2) (+32%, p=0.007) and MVO(2)/beat (+2.3%; n.s., p=0.4). External efficiency was increased by 307% (p=0.04). In five additional extremely dysfunctional rabbit hearts, epinephrine was ineffective. Additional levosimendan increased hemodynamics in terms of HR (56%; n.s., p=0.1), CO (159%, p=0.04), SV (89%, p=0.03), W (588%, p=0.02), LVP(max) (168%, p=0.03), dP/dt(max) (102%, p=0.005), dP/dt(min) (78%, p=0.006), LVP(ed) (-98%, p=0.0006), and CR (-50%, p=0.02). It altered hemodynamics in terms of AVDO(2) (-11%; n.s., p=0.05), MVO(2) (+131%, p=0.04) and MVO(2)/beat (+171%, p=0.03). External efficiency was increased by 212% (p=0.04). CONCLUSION: In contrast to epinephrine, levosimendan improves ventricular function without increasing oxygen demand, thereby considerably improving external efficiency. Even during epinephrine resistance in extremely dysfunctional hearts, levosimendan successfully improves ventricular function.     

常温不停跳冠状动脉搭桥术对机体氧供需的影响

目的：研究常温心脏不停跳冠状动脉搭桥术对机体氧供需平衡的影响。方法：16例冠心病患者，在咪唑安定，芬太尼，丙泊酸，维库溴铵及异氟醚静吸复合麻醉下，心脏不停跳行冠状动脉搭桥手术，术中监测ECG，SpO2及血液动力学指标。于冠脉血管吻合前后，分别取挠动脉及肺动脉血，测定血红蛋白（Hb)和动脉血氧饱和度（SaO2)，并计算全身氧供需平衡，结果：冠状动脉搭桥前后CaO,CvO2,DO2,VO2,O2ER,A-aDO2等均无明显变化（P＞0．05），CO搭桥后比搭桥前增加，但无显著性差异，结论：常温心脏不停跳冠状动脉搭桥手术对全身氧供需平衡没有明显影响。     

Effect of coenzyme Q10 supplementation on mitochondrial function after myocardial ischemia reperfusion.

BACKGROUND: Coenzyme Q10 (CoQ10) protects myocardium from ischemia-reperfusion (IR) injury as evidenced by improved recovery of mechanical function, ATP, and phosphocreatine during reperfusion. This protection may result from CoQ10's bioenergetic effects on the mitochondria, from its antioxidant properties, or both. The purpose of this study was to elucidate the effects of CoQ10 supplementation on mitochondrial function during myocardial ischemia-reperfusion using an isolated mitochondrial preparation. METHODS: Isolated hearts (n = 6/group) from rats pretreated with liposomal CoQ10 (10 mg/kg iv, CoQ10), vehicle (liposomal only, Vehicle), or saline (Saline) 30 min before the experiments were subjected to 15 min of equilibration (EQ), 25 min of ischemia (I), and 40 min of reperfusion (RP). Left ventricular-developed pressure (DP) was measured. Mitochondria were isolated at end-equilibration (end-EQ), at end-ischemia (end-I), and at end-reperfusion (end-RP). Mitochondrial respiratory function (State 2, 3, and 4, respiratory control index (RCI, ratio of State 3 to 4), and ADP:O ratio) was measured by polarography using NADH (alpha-ketoglutarate, alpha-KG)- or FADH (succinate, SA)-dependent substrates. RESULTS: CoQ10 improved recovery of DP at end-RP (67 +/- 11% in CoQ10 vs 47 +/- 5% in Vehicle and 50 +/- 11% in Saline, P < 0.05 vs Vehicle and Saline). CoQ10 did not change preischemic mitochondrial function. IR decreased State 3 and RCI in all groups using either substrate. CoQ10 had no effect in the mitochondrial oxidation of alpha-KG at end-I. CoQ10 improved State 3 at end-I when SA was used (167 +/- 21 in CoQ10 vs 120 +/- 10 in Saline and 111 +/- 10 ng-atoms O/min/mg protein in Vehicle, P < 0.05). Using alpha-KG as a substrate, CoQ10 improved RCI at end-RP (4.2 +/- 0.2 in CoQ10 vs 3.2 +/- 0.2 in Saline and 3.0 +/- 0.3 in Vehicle, P < 0.05). Using SA, CoQ10 improved State 3 (181 +/- 10 in CoQ10 vs 142 +/- 9 in Saline and 140 +/- 12 ng-atoms O/min/mg protein in Vehicle, P < 0.05) and RCI (2.21 +/- 0.06 in CoQ10 vs 1.85 +/- 0.11 in Saline and 1.72 +/- 0.08 in Vehicle, P < 0.05) at end-RP. CONCLUSIONS: The cardioprotective effects of CoQ10 can be attributed to the preservation of mitochondrial function during reperfusion as evidenced by improved FADH-dependent oxidation.     

间接测热法和反向Fick氏法测定心脏手术病人术后氧耗量的比较

目的 采用反向Fick氏法和间接测热法测定心脏手术后病人的全身氧耗,并比较两种测量方法的相关性和准确性。方法8例心脏手术术后病人,分别在入ICU后2h和6h时同时采用反向Fick氏和间接测热法测定病人的全身氧耗量。结果 间接测热法和反向Fick法测得氧耗分别是(16±30)ml·min-1·m-2和(127±23)ml·min-1·m-2,前者的测定结果显著高于后者(P<0.01)。相关分析显示两者有较好的相关性(r=0.92,P<0.01)。采用Bland和Altman统计分析提示两种测定结果的平均偏离值为(35.5±13.4)ml·min-1·m-2,其95％的分布范围是(9～62)ml·min-1·m-2,提示两种测量结果间的一致性较差。结论 两种方法测定心脏病人术后全身氧耗的结果有明显差异,其中反向Fick氏法的测定结果误差大、准确性差,而间接测热法是较好的临床选择。     

Cost reduction of perioperative coagulation management in cardiac surgery: value of ‘bedside’ thrombelastography (ROTEM)

Objective: Demographic changes and aggressive platelet inhibition have resulted in a marked increase in blood- and coagulation product expenditure and costs in cardiac surgery. We analyzed ‘bedside’ coagulation test (ROTEM) in order to verify clot forming quality for the purpose of finding a cost-effective treatment path. Methods: Annual treatment costs of all cardiosurgical patients were analyzed before (729 patients) and after (693 patients) implementation of ‘bedside’ ROTEM. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and coagulation factors: pooled coagulation concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. Number of resternotomies and early mortality was assessed and compared in both periods. Results: After ROMTEM implementation cumulative RBC expenditure showed 25% decrease while PltC exhibited 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (−80%) while rFVIIa were entirely omitted. Fibrinogen, however, increased two-fold. Cumulative average monthly costs of all blood products decreased from 66,000€ to 45,000€ (−32%). Coagulation factor average monthly costs decreased from 60,000€ to 30,000€ (−50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1.580€. Total number of resternotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. Conclusion: Cumulative costs for treatment of perioperative coagulation disorders can be reduced by ‘bedside’ ROTEM analysis to achieve a selective substitution management. Saved costs for blood- and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.     

亚甲蓝对感染性休克患者术中氧代谢的影响

目的 探讨亚甲蓝对感染性休克患者术中氧代谢的影响.方法 行急诊手术的感染性休克患者40例,ASA分级Ⅱ或Ⅲ级,年龄38～64岁,体重48～75 kg,随机分为2组(n=20):去甲肾上腺素组(NE组)和亚甲蓝组(MB组).人室后NE组静脉输注去甲肾上腺素0.5～2.0μg·kg-1·min-1至术毕,MB组静脉输注亚甲蓝0.5～1.0 mg·kg-1·h-1至术毕.静脉注射咪达唑仑-依托咪酯-舒芬太尼-维库溴铵麻醉诱导,经口气管插管行机械通气,术中吸入七氟醚,间断静脉注射维库溴铵和舒芬太尼维持麻醉.于麻醉诱导前(T0)、手术开始前(T1)、手术开始后30 min(T2)、60 min(T3)、90 min(T4)及术毕时(T5)记录HR、SvO2、MAP、CVP、每搏量,计算外周血管阻力指数(SVRI)、CI.于上述时点采集桡动脉和颈内静脉血样行血气分析,并测定动脉血乳酸(Lac)浓度,计算氧供指数(DO2I)、氧耗指数(VO2I)和氧摄取率(ERO2).结果 与NE组比较,MB组MAP、HR、CVP、SVRI、DO2I、VO2I和ERO2升高,CI和Lac降低(P＜0.05).与T0时比较,T2～5时MB组MAP、HR、CVP、SVRI、VO2I、DO2I和ERO2升高,CI和Lac降低,NE组CI和Lac降低,SVRI、VO2I和ERO2升高(P＜0.05),DO2I差异无统计学意义(P＞0.05).结论术中应用0.5～1.0 mg·kg-1·h-1亚甲蓝不仅可改善感染性休克患者术中血液动力学,还可改善机体氧代谢.     

Laparoscopic surgery in children is associated with an intraoperative hypermetabolic response

Background Laparoscopic surgery is thought to be associated with a reduced metabolic response compared to open surgery. Oxygen consumption ( ) and energy metabolism during laparoscopic surgery have not been characterized in children. Methods We measured respiratory gas exchange intraoperatively in children undergoing 19 open and 20 laparoscopic procedures. Premature infants and patients with metabolic, renal, and cardiac abnormalities were excluded. Anesthesia was standardized. Unheated carbon dioxide was used for insufflation. was measured by indirect calorimetry. Core temperature was measured using an esophageal temperature probe. Results We found a steady increase in during laparoscopy. The increase in was more marked in younger children and was associated with a significant rise in core temperature. Open surgery was not associated with significant changes in core temperature or . Conclusions Laparoscopy in children is associated with an intraoperative hypermetabolic response characterized by increased oxygen consumption and core temperature. These changes are more marked in younger children. M. C. McHoney and L. Corizia contributed equally to the study, analysis, and writing of the paper     

2013-2015年北京佑安医院销售金额前10位药品应用的合理性分析

目的 分析首都医科大学附属北京佑安医院药物使用及分布情况、用药现状及趋势,为促进合理用药提供参考依据.方法 采用回顾性分析方法,对2013-2015年销售金额排序前10位药物的销售金额、用药频度(DDDs)、日均费用(DDC)等进行统计、分析.结果 2013-2015年销售金额前10位的药品主要包括抗病毒药、抗肿瘤药、抗炎保肝药物、抗纤维化药及免疫调节药物.2013-2015年抗病毒药销售金额分别为10 163万元、11 334万元和11 653万元.在各年度销售金额中,抗病毒药物均为首位,抗炎保肝类药物为第2位.在DDDs排序中,恩替卡韦片或恩替卡韦分散片始终居于首位,替比夫定为第3或4位.2013-2015年DDC排序中,康艾注射液排名均位于首位,复合辅酶为第2位.结论 佑安医院临床用药以抗病毒药和抗炎保肝药物为主,使用药物与主要诊疗疾病相符.     

曲靖中海拔烟区土壤—烤烟钼含量状况及对烟叶感官质量的影响*

采用野外调查与室内分析相结合的方法分析了云南曲靖烟区土壤有效钼含量和烤烟钼含量状况及其相互关系,结果表明：(1)曲靖中海拔烟区土壤有效钼含量整体较为适宜,平均含量为0.199 mg/kg,变幅为痕量~1.966 mg/kg,变异系数高达93.23% ,土壤有效钼含量不足的样本所占比例过高;地区间差异明显;(2)曲靖烟区烤烟钼含量平均为0.227 mg/kg,变幅为痕量~2.687 mg/kg,变异系数为71.45%,地区间差异显著;(3)烤烟钼含量随着土壤有效钼的增加而增加,回归方程为 =0.4829x+0.0907;(4)烤烟钼含量对烤烟感官质量评分影响显著,与质量特征、风格特征、烟气特征均具有较为明显相关性;(5)烤烟钼含量对烤烟常规化学成分和其他矿质元素影响显著,与烟叶总糖(0.200)、总氮(0.257)、烟碱(0.333)和淀粉(0.259)呈极显著正相关;与烟叶钾(-0.227)、硫(-0.208)、铁(-0.316)、锰(-0.278)和硼(-0.14)营养呈极显著负相关;与烟叶镁(0.41)、磷(0.259)含量呈极显著正相关。曲靖烟区50%面积表现缺钼,应注意补施钼肥。