单中心心脏死亡和脑死亡供肺肺移植临床经验总结

目的 总结单中心脑死亡器官捐赠(DBD)和心脏死亡器官捐赠(DCD)的供肺获取以及肺移植的临床经验.方法 11例潜在器官捐献供者进行了术前评估,所有供者均进行痰培养、床旁支气管镜、胸部X线片及血液气体分析等检查.11例供者中,6例为DCD供者,5例为DBD供者.1例DCD和2例DBD供者因两肺广泛炎症浸润,氧合指数差未行供肺获取;1例DCD供者因心跳停止时间过长未行供肺获取;其余7例临床评估供肺良好,按照临床器官捐赠相关规定流程,在气管插管机械通气下完成供肺获取.7例供、受者术前淋巴细胞毒交叉配合试验均为阴性,供、受者ABO血型相同,供肺大小匹配.结果 7例肺移植均在体外膜肺氧合辅助下完成,包括5例双肺移植和2例右侧单肺移植,受者手术顺利.1例术后并发严重感染,术后39 d死亡;1例术后第9天死于多器官功能衰竭.2例分别于术后30 d、19 d并发急性排斥反应,治疗后好转.3例术后无严重并发症,恢复顺利,肺功能得到极大改善,出院后接受长期随访,术后平均存活23.3个月(3～51个月).结论 应该严格按照临床器官捐献相关规定的要求进行器官捐赠工作.在全面评估供肺质量的前提下,DCD和DBD供肺肺移植的效果可靠.     

心脏死亡器官捐献供肝获取术的临床配合及管理

目的总结心脏死亡器官捐献(DCD)供肝获取术的临床配合和管理经验。方法回顾性分析113例供体器官获取手术的临床资料,总结手术配合体会。结果术前准备做好手术人员和常用器械准备、灌注管路和液体的准备和术中药品的准备。手术配合包括器官获取前工作、器官获取、分离供体肝、肾。所有器官获取过程顺利,后续完成102例经典原位肝移植手术。其中4例由于供肝质量问题弃用,7例供肝分配至其他移植中心。结论对于DCD供肝获取术,良好的手术配合及管理有助于提高手术成功率。     

心脏死亡供者供肺移植三例报告

目的 总结心脏死亡供者供肺获取以及应用于临床肺移植的经验.方法 共进行3例心脏死亡供者供肺获取及肺移植.3例供者平素健康,因发生严重颅脑外伤或脑肿瘤,经严格医学检查后均被明确判定为脑死亡,并被确定为潜在心脏死亡供者.供者的近亲亲属均知情同意心脏死亡器官捐献,临床评估供肺良好,供者在停止呼吸机,心脏停跳5 min后,确定为心脏死亡,并在全身麻醉下切取供肺.3例受者术前淋巴细胞毒交叉配合试验均为阴性,供、受者ABO血型相同,身高相近,体重相差均在20％以内,胸腔大小匹配.结果 利用3例心脏死亡供者供肺成功进行了2例双肺移植和1例单肺移植,3例供肺的热缺血时间分别为23、27和32 min.3例受者手术顺利,在ICU的监护时间分别为31、18和26 d,术后肺功能得到极大改善,例1和例2分别于术后30和19d发生急性排斥反应,经皮质激素冲击治疗后好转,3例受者均未发生感染等并发症,随访期间生活质量良好.结论 在现有条件下,严格按《中国心脏死亡器官捐献工作指南》开展心脏死亡器官捐献应用于临床肺移植的工作,正确维护好潜在心脏死亡供者,在全面评估供肺质量的前提下,心脏死亡供肺可作为肺移植的主要供肺之一.     

后腹腔镜活体供肾切取术的护理配合

目的 介绍肾移植手术中经腹腔镜活体供肾切取的方法和手术配合要点.方法 对3例腹腔镜下活体供肾切取术患者进行术中护理.结果 3例均顺利完成手术,未出现中转开腹的情况,术中术后未发生任何并发症,移植效果满意.结论 经腹腔镜活体供肾切取术成功的关键除供肾者术前准备充分和术者技术娴熟以外,手术室仪器设备的功能良好、准备齐全,器械护士和巡回护士的熟练配合是该手术取得满意效果的决定性因素之一.     

自制中药膏剂外敷治疗静脉留置针致静脉炎

目的 介绍肾移植手术中经腹腔镜活体供肾切取的方法和手术配合要点。方法 对3例腹腔镜下活体供肾切取术患者进行术中护理。结果 3例均顺利完成手术，未出现中转开腹的情况，术中术后未发生任何并发症，移植效果满意。结论 经腹腔镜活体供肾切取术成功的关键除供肾者术前准备充分和术者技术娴熟以外，手术室仪器设备的功能良好、准备齐全，器械护士和巡回护士的熟练配合是该手术取得满意效果的决定性因素之一。     

脑死亡供肺获取并双肺移植1例

目的 初步总结适应我国国情的国际标准化脑死亡供肺的获取经验,探讨一套适用于我国临床肺移植的脑死亡供肺获取标准和规范.方法 对1 例机械通气16 d的志愿捐献者经脑死亡和供器官功能评估后,根据国际标准进行双肺及其他脏器的获取术.获取的双侧供肺为1例34岁的终末期矽肺患者进行了双肺移植.结果 顺利获取脑死亡供者双肺及其他器官.双肺移植受者术后恢复良好,43 d顺利出院,术后随访至2009年2月生活质量良好,肺功能极大改善.结论 本例脑死亡供肺顺利获取以及移植成功,为今后我国脑死亡供肺及其他脏器按国际标准获取积累了经验.     

活体右半肝原位辅助肝移植术的围手术期配合体会(1例报告)

目的总结活体右半肝原位辅助肝移植术前与术中护理配合的体会。方法回顾性分析1例暴发性肝衰竭患者辅助性原位肝移植术前与术中的临床资料,总结护理体会。结果术前制定相应的管理程序,包括供体、手术环境、常规用品和特殊器械物品的准备。做好术中配合,包括供体供肝切取时的配合、受体病肝部分切除时的配合、供受体术中超声吸引刀使用时的配合、受体供肝植入的手术配合等。供受体手术过程顺利,术后无发生手术相关并发症。结论原位辅助性肝移植是一项操作过程极为复杂的手术,完善而充分的术前准备,熟练而准确的术中配合,可以保障手术的顺利进行和减少与手术相关的并发症。     

新生儿巨大肺囊肿切除术的手术配合

对1例新生儿巨大肺囊肿行切除术.手术过程顺利,术后恢复好.新生儿巨大肺囊肿切除术要求高水准的手术、麻醉和护理技术,手术成功取决于团队的默契配合.完善的术前准备、术中娴熟的配合及严密管理是手术成功的关键.     

小鼠原位左肺移植模型的建立

目的 建立稳定的小鼠左肺移植模型.方法 取近交系雄性Balb/c小鼠40只作为肺移植的供、受者,每对供、受者间大小和体重基本匹配,采用三套管法进行原位左肺移植.术后1个月,取受鼠进行胸部CT检查,取阻断右肺门前、后的移植左肺静脉血进行血液气体分析,取移植肺组织进行病理学检查.结果 实验共行肺移植20例,除1例因肺静脉撕裂导致手术失败外,其余19例均成功进行手术,手术成功率为95％(19/20).成功模型的套管吻合均一次成功,术后1例受鼠因发生感染而死亡,死亡率为5.2％(1/19).套管准备时间为(2.0±0.5)min,供肺切取时间为(5.0±1.3) min,供肺冷缺血时间为(35.6±5.9)min,热缺血时间为(25.3±7.2)min,供、受者血管套管耗时(21.0±5.6)min,受者手术耗时(30.0±4.2)min,建立模型总耗时(85±15) min.术后1个月,显微CT检查结果显示,受鼠移植肺野清晰,支气管套管通畅;血液气体分析结果显示,阻断前、后的氧气分压分别为(106.9±5.8) mm Hg(1mm Hg=0.133 kPa)和(105.0±8.7) mm Hg,二者比较,差异无统计学意义(P＞0.05);移植肺组织的病理学检查显示,移植肺结构正常,肺间隔正常,肺泡通气良好.结论 采用三套管法建立的小鼠肺移植模型具有操作简便易行,支气管吻合口径更大,手术成功率高,以及模型稳定等特点,这对于推动肺移植的基础实验研究有重要意义.     

国际标准化脑死亡供肺的临床应用3例报告

目的总结适应我国国情的国际标准化脑死亡供体肺的获取以及应用于肺移植的经验。方法 3例机械通气分别达到3d、16d、12d的志愿捐献者经脑死亡和供体器官功能评估后,行国际标准化肺获取术。获取的双侧供肺分别为32岁、34岁、61岁的终末期肺病患者进行了双肺移植。结果利用3例脑死亡供肺成功进行了3例双肺移植,1例患者手术后第9日死于多器官功能衰竭,另外2例双肺移植患者术后恢复良好,顺利出院,术后随访生活质量良好,肺功能极大改善。结论在我国的条件下,严格按国际标准化获取脑死亡供肺,可作为肺移植的主要供肺来源之一。     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.