后腹腔镜治疗肾上腺嗜铬细胞瘤围手术期观察与护理

总结了39例经后腹腔镜手术治疗肾上腺嗜铬细胞瘤患者围手术期的病情关察与护理方法,重点是加强患者术前心理护理,观察血压及心率的变化,做好高血压危象的观察与预防;术后加强血压的观察,做好腹腔镜术后并发症尤其是高碳酸血症及皮下气肿观察与护理。39例病人均无护理并发症,手术成功率100%,无1例高血压危象发生,4例轻度高碳酸血症及5例皮下气肿经积极治疗护理后痊愈。严密的病情观察和有效的治疗护理措施是手术成功的重要保障。     

Sex differences in circadian timing systems: Implications for disease

Virtually every eukaryotic cell has an endogenous circadian clock and a biological sex. These cell-based clocks have been conceptualized as oscillators whose phase can be reset by internal signals such as hormones, and external cues such as light. The present review highlights the inter-relationship between circadian clocks and sex differences. In mammals, the suprachiasmatic nucleus (SCN) serves as a master clock synchronizing the phase of clocks throughout the body. Gonadal steroid receptors are expressed in almost every site that receives direct SCN input. Here we review sex differences in the circadian timing system in the hypothalamic–pituitary–gonadal axis (HPG), the hypothalamic–adrenal–pituitary (HPA) axis, and sleep–arousal systems. We also point to ways in which disruption of circadian rhythms within these systems differs in the sexes and is associated with dysfunction and disease. Understanding sex differentiated circadian timing systems can lead to improved treatment strategies for these conditions.     

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.     

术前戒烟干预对患者术后戒烟的影响

目的评估麻醉医师术前戒烟干预对患者术后戒烟影响的有效性及安全性。方法选择当前吸烟男性择期手术患者182例,年龄18~79岁,ASAⅠ~Ⅲ级,按1∶1比例及手术大小分层随机分为对照组和干预组,每组91例。在术前访视时实施戒烟干预,措施为:吸烟对麻醉影响宣教、戒烟宣传资料(包括吸烟危害文字部分、吸烟所致器官损害图片、北京朝阳医院戒烟门诊热线电话及微信公众号),记录麻醉方式、手术时间、PACU治疗时间和术中术后并发症发生情况,术后30d电话随访戒烟率、吸烟下降率、戒烟门诊或戒烟热线随访率。结果在182例患者中,失访16例,最后纳入分析166例。术后30d两组戒烟率差异无统计学意义;术后30d干预组自报吸烟下降率(36.9%)明显高于对照组(22.0%);在术后30d自报戒烟患者中,干预组术前呼气末CO值为轻度吸烟者占83.3%,对照组占40.0%(P0.05);两组术中术后并发症发生率差异无统计学意义。结论麻醉医师术前实施戒烟干预具有安全性,可使患者术后30d吸烟量下降,并提高轻度吸烟患者术后30d戒烟率。     

乌司他丁对脊柱手术患者围术期凝血功能的影响

[目的]观察胰蛋白酶抑制剂乌司他丁对脊柱手术患者围术期凝血功能及血小板聚集率的影响.[方法]选择36例无血液疾病及凝血功能障碍、肝肾功能异常或未服用影响血小板功能药物的择期脊柱手术患者(ASAⅡ～Ⅲ),随机分为乌司他丁组(W组,5000 U/kg,n=18)和生理盐水组(C组,n=18)；分别于注射前(T0)、注射后1 h(T1)、注射后2 h(T2)、注射后3 h(T3)抽出静脉血测定凝血酶原时间(PT)、部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(FIB)、国际标准化比值(INR)、及血小板1 min,5 min和最大聚集率(PAG1、PAG5、PAGM),并记录两组手术出血量.[结果]注射乌司他丁组后1h,W组APTT,PT较注射前明显延长(P＜0.05),用药后2h,TT较注射前明显延长(P＜0.05),用药后3h,APTT,PT,TT差异无统计学意义(P＞0.05).与C组比较,注射后1h,APTT显著性延长(P＜0.01),用药后2h,PT显著性延长(P＜0.05),用药后3h,APTT,PT,TT差异无统计学意义(P＞0.05).两组注射前后及组间比较PAgT差异无统计学意义(P＞0.05).两组患者出血量比较差异无统计学意义(P＞0.05).[结论]围术期应用5000 U/kg乌司他丁可改善脊柱手术患者术中患者的凝血状态,减少术中微血栓综合征,预防术中术后血栓形成.     

右美托咪定对功能性鼻内窥镜手术患者苏醒期质量的影响?

【目的】研究术中输注右美托咪定对功能性鼻内窥镜手术(FESS)患者苏醒期质量的影响。【方法】选取40例年龄为30~60岁择期全身麻醉下行 FESS 的患者。将入选患者随机分为两组(每组20例)：对照组(C组)和右美托咪定组(D组)。常规麻醉诱导气管插管后,D组给予1μg/kg 右美托咪定10 min内静脉输注完毕,随后以0.2μg/(kg·h)速率输注至手术结束前30 min。C 组以同样方式输注等量生理盐水。两组麻醉维持均采用静脉持续输注异丙酚,七氟醚吸入,适时静注顺式阿曲库铵。当患者平均动脉压(MAP)和心率(HR)较基础值增加超过15%时单次追加芬太尼1.5μg/kg。比较两组患者麻醉前、手术结束时、拔管时、离开麻醉恢复室(PACU)时的 HR、MAP;入 PACU 后的 Riker 躁动评分、VAS 疼痛视觉模拟评分;拔管时间、滞留PACU时间以及术后不良反应情况。【结果】与麻醉前比较,C 组患者拔管时 HR 明显增快(P <0.05)。入PACU后D组 Riker躁动评分和 VAS疼痛视觉模拟评分均低于 C组(P <0.05)。两组拔管时间、滞留PACU时间的差异均无显著性(均P >0.05)。D组术后寒战发生率低于 C 组(P <0.05)。【结论】术中输注右美托咪定可明显改善 FESS患者苏醒期质量。     

心脏机械瓣膜置换术后输尿管中下段结石的手术及围术期处理

探讨心脏机械瓣膜置换术后输尿管中下段结石的手术方法选择及围手术期抗凝药物的使用及其安全性。【方法】8例心脏机械瓣膜置换术后罹患输尿管中下段结石患者,长期口服华法林抗凝治疗,入院后停用华法林,改用普通肝素0．5 mg／kg ,q4 h 静脉注射,调整凝血酶原时间（PT ）至正常范围之内,于手术前24 h 停用抗凝药物。手术方式采用全麻下输尿管硬镜气压弹道碎石加 D‐J 管内置术,手术时间控制在30 min 之内,术后24～48 h 口服华法林并与肝素重叠使用,3 d 后停用肝素,单服华法林并维持国际标准化比率（INR）于治疗范围之内。【结果】8例患者均顺利渡过围术期,一次性碎石排石率100％。【结论】针对心脏机械瓣膜置换术后输尿管中下段结石患者,在合理调整抗凝药物种类、剂量及用法,掌握合适的抗凝强度,并注意术中操作及术后处理的前提条件下,输尿管镜碎石＋ D‐J 管内置术,其疗效确,安全可靠。     

猪肝移植术中无肝期前后的护理

目的探讨原位猪肝移植无肝期前后的病理生理变化 ,并提出相应的护理措施。方法共行 5 5例原位猪肝移植 ,在无肝期前和无肝期后 (包括无肝期和新肝期 )检测体温、血流动力学、血气、生化、肝肾功变化情况。结果平均动脉压 (MAP)、中心静脉压 (CVP)以及心排出量 (CO)在无肝期后下降明显 (与无肝期前相比 ,P <0 .0 5 )。无肝期后出现明显的代谢性酸中毒、低血糖、低体温 ,供肝复流后出现一过性高血钾。新肝期谷草转氨酶 (AST)、谷丙转氨酶 (ALT)、总胆红素 (TB)升高明显 (与无肝期前相比 ,P <0 .0 1)。结论　猪原位肝移植术中受者经历了一系列的病理生理变化。明确以上危险因素的发生发展 ,并给予正确的护理 ,可以极大地提高手术成功率 ,延长术后存活时间     

左半结肠癌急性梗阻一期切除吻合36例临床分析

本院自1999年9月至2005年12月共收治左半结肠癌急性梗阻患者36例,均行一期切除吻合术,取得满意的疗效,现报告如下。1资料与方法1.1一般资料本组共36例。其中男性22例,女性14例;年龄29~79岁。结肠脾曲癌12例、降结肠癌13例、乙状结肠癌6例、直肠乙状结肠交界处癌5例。病程最长63     

快速二期大动脉调转术的围术期管理

[目的]总结超龄完全性大动脉转位(D-TGA)患儿在一期肺动脉环缩和体肺分流术后,行快速二期大动脉调转术(ASO)的围术期管理要点.[方法]回顾14例D-TGA行快速二期ASO的患儿围术期管理情况.术中使用舒芬太尼,咪达唑仑,丙泊酚和罗库溴铵,辅以七氟醚吸入诱导和维持麻醉.主动脉开放后持续输注多巴胺,米力农和肾上腺素.体外转流停机前,所有患儿复温至36℃,积极调整凝血功能,根据血气分析结果补充电解质并维持酸碱平衡.[结果]本组14例患儿中12例完成快速二期ASO手术.ASO术前间隔期血管活性—正性肌力药评分(VIS)中位数值16.75(P25,P75:13.125,25.75),ASO术后VIS评分中位数值22.5(P25,P75:18.375,31.125).术后死亡2例(16.7％),低心排量综合征7例(58.3％),低氧血症2例(16.7％),无麻醉相关并发症.[结论]围术期维持和改善左心功能是D-TGA患儿行快速二期ASO手术麻醉成功的关键.术中选择适合新生儿和小婴儿的麻醉诱导和维持药物,体外转流后增强心肌收缩,降低后负荷和肺循环阻力,改善凝血功能是围术期管理的要点.