硬膜外阻滞与全身麻醉下老年患者乳酸钠林格液液体动力学比较

目的探讨硬膜外阻滞与全身麻醉老年患者乳酸钠林格液液体动力学的差别。方法择期手术病人89例,美国麻醉师协会(ASAI)-Ⅱ级老年病人,根据病情及手术所需均可选择硬膜外阻滞与全身麻醉的麻醉方法,随机分为硬膜外阻滞组43例和全身麻醉组46例。通过检测血红蛋白水平采用Matlab 6.5软件包计算扩容后一级和二级容量动力参数,采用CHMT3002型血流动力学监测仪检测扩容前后的血流动力学指标。结果两组扩容前平均动脉血压(MAP)、心率(HR)、心排量(CO)和心脏指数(CI)无显著差异(P>0.05),扩容前后的MAP、HR、CO和CI无显著变化(P>0.05),与硬膜外阻滞组比,全身麻醉组扩容后MAP、HR、CO、CI和尿量均明显降低(均P<0.05)。一级容量动力学结果显示,与硬膜外阻滞组比,全身麻醉的靶容量(V)较低,清除率较低(均P<0.05),二级容量动力学结果显示,与硬膜外阻滞组比,全身麻醉的V1、V2、K1和Kt明显降低,尿量也较低(P<0.05)。结论与硬膜外阻滞麻醉比,全麻后血浆稀释度增加,组织中的液体保留率增大,有益于老年手术患者血容量替代扩充,辅助手术顺利进行。     

氢饱和生理盐水对重症急性胰腺炎肾损伤的保护作用

目的 探讨氢饱和生理盐水对急性坏死性胰腺炎（ANP）大鼠肾损伤的保护作用及其机制.方法 雄性Wistar大鼠54只,按数字表法随机分为假手术组、ANP组和氢饱和生理盐水处理（HRS）组,每组18只.采用胆胰管逆行注射5％牛磺胆酸钠方法制备ANP模型.HRS组在造模成功后5 min尾静脉注射HRS6 ml/kg体重,并皮下滴注HRS 20 ml/kg体重.假手术组大鼠开腹后仅翻动十二指肠和胰腺后关腹.假手术组和ANP组大鼠在术后5 min经尾静脉注射生理盐水（6 ml/kg体重）,并皮下滴注生理盐水（20 ml/kg体重）.术后3、12、24 h分批处死大鼠,取血检测血淀粉酶、肌酐、尿素氮含量.取新鲜肾组织制备匀浆,检测其丙二醛（MDA）含量和超氧化物歧化酶（SOD）活性.取肾脏及胰腺组织行常规病理检查,并在透射电镜下观察肾组织的超微结构.结果 ANP组12 h时的血淀粉酶、肌酐、尿素氮水平,肾脏组织病理评分,MDA含量分别为（5396±500） U/L、（80.3±11.6） U/L、（14.1±2.1）U/L、（448.3±36.8）分、（7.03±0.85） nmol/mg,均较假手术组显著升高（P值均＜0.05）;SOD活性为（35.2±5.28） U/mg,较假手术组显著降低（P＜0.05）.HRS组的相应值分别为（5448±967） U/L、（41.9±8.6） U/L、（7.2±1.3）U/L、（315.2±39.6）分、（5.15±0.35） nmol/mg,较ANP组均显著下降,但仍显著高于假手术组（P值均＜0.05）;SOD活性为（49.1±6.79） U/mg,较ANP组显著升高,但仍显著低于假手术组（P值均＜0.05）.结论 氢饱和生理盐水对ANP大鼠的肾损伤具有一定程度的保护作用,其机制可能与抗氧化应激有关.     

围手术期利用乳酸林格氏液积极补液预防经内镜逆行胰胆管造影术术后胰腺炎的Meta分析

目的 评价围手术期使用乳酸林格氏液（lactated Ringer''s solution,LRS）积极补液对降低经内镜逆行胰胆管造影（ERCP）术后胰腺炎（post -ERCP pancreatitis,PEP）发病率的价值。 方法 检索中国期刊全文数据库（CNKI）、维普、万方数据库、PubMed、Embase、Cochrane图书馆,收集LRS积极补液治疗预防ERCP术后胰腺炎的随机对照试验（RCT）,检索时限为建库至2018年6月。由2名研究者按纳入及排除标准独立选择试验、提取资料和评估方法学质量,采用Revman 5.3软件进行Meta分析,各纳入研究间的异质性分析采用Q检验及I2检验,采用漏斗图、偏倚风险图、偏倚风险总结图进行偏倚评价。 结果 纳入10篇随机对照试验,共1 727例患者,Meta分析结果显示：10篇文献之间无明显异质性（P=0.10,I2=39%）,利用LRS积极补液可以降低PEP的发病率(OR = 0.37,95%CI: 0.26~0.53,P <0.000 01)。有6篇文献记录了高淀粉酶血症的发生率,结果显示利用LRS积极补液可降低高淀粉酶血症（hyperamylasemia,HA）的发生率(OR = 0.41,95%CI: 0.27~0.64,P <0.000 01)。有4篇文献对比了试验组与对照组间ERCP术后出现上腹痛的发生率,结果显示利用LRS积极补液可降低上腹痛的发生率(OR = 0.32,95%CI: 0.15~0.68,P =0.003)。 结论 利用乳酸林格氏液积极补液能有效预防经内镜逆行胰胆管造影术后胰腺炎等并发症的发生。     

急性胰腺炎的内科治疗

急性胰腺炎分轻重两型,轻型者胰腺有组织水肿,无或有少许组织坏死,临床有自限性,多于1～2周痊愈。重型者胰腺有出血、坏死,病变可累     

急性胰腺炎的外科治疗

急性胰腺炎的外科治疗山东省立医院（２５００２１）吴泰璜徐健ＡＰ，特别是急性出血坏死型胰腺炎（ＡＨＮＰ）的病死率很高，手术彻底是降低其病死率的关键措施之一。我们认为，凡有以下情况者应积极手术：①确诊或高度怀疑ＡＨＮＰ，伴有休克、弥漫性腹膜炎、血性腹水、...     

BISAP评分系统对急性胰腺炎严重程度评估的荟萃分析

目的评估BISAP评分系统在预测急性胰腺炎（AP）严重程度的临床应用价值。方法计算机检索Medline、EMBASE、ScienceDirect、Springerlink、CBM、中国知网、万方以及维普数据库2000年1月至2013年3月的文献,按照严格的纳入标准收集BISAP评分系统预测AP严重程度的文献,采用QUADAS量表进行文献质量评价,利用Meta—Disc1．4统计软件进行异质性分析和定量合成,计算汇总的敏感度、特异度、阳性似然比、阴性似然比和受试者特征性工作（ROC）曲线下面积（AUC）,结果均采用95％可信区间（95％CI）表示。结果共纳入文献11篇,包括7篇中文论著和4篇英文论著。按QUADAS量表进行分级,其中A级4篇,B级5篇,C级2篇。6篇文献以BISAP2分为cutoff值、9篇文献以BISAP3分为cutoff值（4篇文献采用两个cutoff值）预测SAP。前者汇总的诊断比值比为8．03（95％C15．66～11．38）,后者为7．49（95％C15．35～10．49）,两组文献均存在中等程度的异质性（I^2=63．3％,P=0．018;I^2=56．1％,P=0．019）。以BISAP2分为cutoff值预测AP严重程度的汇总的敏感度、特异度、阳性似然比、阴性似然比和AUC分别为59％（95％CI56％-63％）、82％（95％CI80％-83％）、3．50（95％CI 2．96～4．14）、0．45（95％CI 0．36～0．56）和0．82;以BISAP3分为cutoff值时分别为44％（95％CI41％～47％）、90％（95％CI89％-91％）、4．59（95％CI3．31-6．37）、0．64（95％C10．61-0．68）和0．64。前者有较高的敏感度,较低的特异度,AUC较大;后者敏感度低,特异度高,AUC较小。结论BISAP预测SAP的最佳的cutoff值为2分。其漏诊率较低,且误诊率在可接受范围内,适合在临床应用及推广。     

急性胰腺炎的综合治疗

急性胰腺炎的综合治疗山东省立医院（２５００２１）杨崇美朱菊人ＡＰ综合治疗的目的是维持体内营养及生理状态，限制胰酶的进一步自身破坏作用。１抑制或减少胰液分泌禁食及胃肠减压不仅可减少胃酸及食物对胰液分泌的刺激，还可减轻呕吐与腹胀，除此之外，临床常用以下药...     

急性胰腺炎肝损伤的发病机制和治疗

急性胰腺炎(acute pancreatitis,AP)是临床常见的急腹症,常常引起胰外器官损伤,肝脏是主要受损器官之一,其损害的不断加重可导致胰腺炎病情恶化,目前认为肝脏损伤的机制主要有细胞因子、胰酶、氧化应激、微循环障碍、细胞凋亡和胰腺炎相关性腹水等.目前AP肝损伤的治疗也主要从上述各方面着手,但更多的方法仍仅仅局限于动物实验,临床应用还需进一步研究.     

急性胰腺炎误诊分析

目的通过对我院10年来急性胰腺炎误诊病例分析，总结经验教训，旨在提高对本病的正确诊断。方法对我院22例急性胰腺炎病例，仔细分析误诊原因。结果误诊病例多因对疾病认识不足，检查条件不具备或不全面所致。结论加强对本病的学习，详细询问病史，认真查体，较全面的辅助检查，对可疑患者，必要时反复检查减少对本病的误诊。     

Lactated Ringer's vs normal saline for acute pancreatitis: An updated systematic review and meta-analysis

IntroductionRecent studies have evaluated and compared the efficacy of normal saline (NS) and lactated Ringer's (LR) in reducing the severity of acute pancreatitis (AP) and improving outcomes such as length of stay, the occurrence of the systemic inflammatory response syndrome (SIRS), ICU admission and mortality. We performed an updated systematic review and meta-analysis of the available studies to assess the impact of these fluids on outcomes secondary to AP.MethodsWe systematically searched the following databases: PubMed/Medline, Embase, Cochrane, and Web of Science through February 8th, 2021 to include randomized controlled trials (RCTs) and cohort studies. Random effects model using DerSimonian-Laird approach was employed and risk ratios (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated for binary and continuous outcomes, respectively.Results6 studies (4 RCTs and 2 cohort studies) with 549 (230 in LR and 319 in NS) were included. The overall mortality (RR: 0.73, CI: 0.31–1.69) and SIRS at 24 h (RR: 0.69, CI: 0.32–1.51) was not significantly different. The overall ICU admission was lower in LR group compared to NS group (RR: 0.43, CI: 0.22–0.84). Subgroup analysis of RCTs demonstrated lower length of hospital stay for LR group compared to NS group (MD: 0.77 days, CI: 1.44 –0.09 days).ConclusionOur study demonstrated that LR improved outcomes (ICU admission and length of stay) in patients with AP compared to NS. There was no difference in rate of SIRS development and mortality between LR and NS treatments.     

Hemodilution with lactated Ringer's solution causes hypocoagulability in rabbits.

Hemodilution (HD) has been associated with hypercoagulability. It was hypothesized that HD with lactated Ringer's solution (LR) would result in hypercoagulability in rabbits. Sedated rabbits (n = 12) underwent HD with LR (40% estimated blood volume replaced with five volumes of LR) via ear vessels. Key procoagulants and anticoagulant activities were assessed prior to and 3 h after HD. Hemostatic function was assessed with the activated coagulation time and platelet-inhibited thrombelastography. Circulating tissue factor activity was much more diluted (-67.2% from baseline) than tissue factor pathway inhibitor (-45.2%) or antithrombin (-9.5%) activities after HD. HD significantly decreased factor VIII complex activity (-31.5%) more than protein C activity (-5.9%), and factor X activity (-29.2%) was more diluted than antithrombin activity. The activated coagulation time and thrombelastography demonstrated a significant decrease in hemostatic function after HD. Hemodilution with LR caused hypocoagulability in the rabbit. A greater decrease in circulating procoagulant activity than anticoagulant activity appears to be the mechanism underlying HD-mediated decreases in hemostasis.     

Use of hypertonic saline/dextran versus lactated Ringer's solution as a resuscitation fluid after uncontrolled aortic hemorrhage in anesthetized swine.

STUDY OBJECTIVE: We tested the hypothesis that following aortotomy, administration of hypertonic saline/dextran increases hemorrhage and mortality. We also compared hypertonic saline/dextran with the standard therapy of attempting to replace three times the amount of lost blood with lactated Ringer's solution. DESIGN: In this model of uncontrolled arterial hemorrhage resulting from aortotomy, 24 anesthetized Yorkshire swine underwent splenectomy, stainless steel wire placement in the infrarenal aorta, and instrumentation with Swan-Ganz and carotid artery catheters. The wire was pulled, producing a 5-mm aortotomy and spontaneous intraperitoneal hemorrhage. INTERVENTIONS: The animals were randomly assigned to one of three study groups: control; hypertonic saline/dextran group in which six minutes after aortotomy a 4-mL/kg mixture of IV 7.5% NaCl and 6% Dextran-70 was given over one minute; or lactated Ringer's group in which six minutes after aortotomy 80 mL/kg IV lactated Ringer's was given over nine minutes. MEASUREMENTS AND MAIN RESULTS: The volume of hemorrhage and the mortality rate in hypertonic saline/dextran-treated animals were significantly greater than in the nonresuscitated controls (1,340 +/- 230 mL versus 783 +/- 85 mL and five of eight versus zero of eight, respectively; P less than .05). Although the mortality rate in the lactated Ringer's group was not significantly different from the hypertonic saline/dextran group, survival time was significantly shorter than in the hypertonic saline/dextran group. CONCLUSION: In this model of uncontrolled hemorrhage, immediate IV administration of hypertonic saline/dextran significantly increased hemorrhage volume and mortality. However, the accentuation of hemorrhage and reduction in survival were not as great as that produced by the standard practice of attempting to replace the lost blood with three times that volume of lactated Ringer's.     

Myocardial protection during cardiac ischemia by coronary perfusion with cold lactated Ringer's solution plus mannitol

This experimental and clinical study evaluates the degree of myocardial protection afforded by coronary perfusion with cold lactated Ringer's solution plus mannitol. In the experimental study, diluted blood at 30 degrees C (Control G.), lactated Ringer's solution at 4 degrees C (G. A), 1,000 ml lactated Ringer's solution plus 200 ml of 20% mannitol at 4 degrees C (G. B), and 1,000 ml lactated Ringer's solution plus 500 ml of 20% mannitol at 4 degrees C (G. C) were used for coronary perfusion. The myocardial-protecting effect of each perfusate was evaluated by examining serum isoenzymes (CPK-MB, LDH1+2), left ventricular function (Vmax, LVEDP, CO), and the ultrastructure of myocardium. there were no significant differences in myocardial changes between the control group, G. A and G. B. Left ventricular enddiastolic pressure increased significantly in G. A and a significant increase in CPK-MB was seen in G. C. Mitochondrial scores for each group were 98 (Control G.), 86 (G. A), 93 (G. B), and 51 (G. C). Minimal myocardial change was seen in G. B. In the clinical study aortic root perfusion with cold lactated Ringer' s solution (400 m Osm) under aortic cross clamping (27-144 min) was employed in 25 patients. They all survived and CPK-MB returned to preoperative values within 49 hours after operation. In 6 cases, the ultrastructure of left ventricular papillary muscle was examined. It was confirmed that no significant mitochondrial changes developed during aortic cross-clamping.     

JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

The basic principles of the initial management of acute pancreatitis are adequate monitoring of vital signs, fluid replacement, correction of any electrolyte imbalance, nutritional support, and the prevention of local and systemic complications. Patients with severe acute pancreatitis should be transferred to a medical facility where adequate monitoring and intensive medical care are available. Strict cardiovascular and respiratory monitoring is mandatory for maintaining the cardiopulmonary system in patients with severe acute pancreatitis. Maximum fluid replacement is needed to stabilize the cardiovascular system. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with necrotizing pancreatitis. Although the efficacy of the intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional measures, blood purification therapy and continuous regional arterial infusion of a protease inhibitor and antibiotics, depending on the patient’s condition.     

Comparison of normal saline versus Lactated Ringer's solution for fluid resuscitation in patients with mild acute pancreatitis,A randomized controlled trial

Background/Objectives

Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. However, there are few studies which focus on types of fluid therapy.

JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis

The currently used diagnostic criteria for acute pancreatitis in Japan are presentation with at least two of the following three manifestations: (1) acute abdominal pain and tenderness in the upper abdomen; (2) elevated levels of pancreatic enzyme in the blood, urine, or ascitic fluid; and (3) abnormal imaging findings in the pancreas associated with acute pancreatitis. When a diagnosis is made on this basis, other pancreatic diseases and acute abdomen can be ruled out. The purpose of this article is to review the conventional criteria and, in particular, the various methods of diagnosis based on pancreatic enzyme values, with the aim of improving the quality of diagnosis of acute pancreatitis and formulating common internationally agreed criteria. The review considers the following recommendations:

• — Better even than the total blood amylase level, the blood lipase level is the best pancreatic enzyme for the diagnosis of acute pancreatitis and its differentiation from other diseases.
• — A pivotal factor in the diagnosis of acute pancreatitis is identifying an increase in pancreatic enzymes in the blood.
• — Ultrasonography (US) is also one of the procedures that should be performed in all patients with suspected acute pancreatitis.
• — Magnetic resonance imaging (MRI) is one of the most important imaging procedures for diagnosing acute pancreatitis and its intraperitoneal complications.
• — Computed tomography (CT) is also one of the most important imaging procedures for diagnosing acute pancreatitis and its intraabdominal complications. CT should be performed when a diagnosis of acute pancreatitis cannot be established on the basis of the clinical findings, results of blood and urine tests, or US, or when the etiology of the pancreatitis is unknown.
• — When acute pancreatitis is suspected, chest and abdominal X‐ray examinations should be performed to determine whether any abnormal findings caused by acute pancreatitis are present.
• — Because the etiology of acute pancreatitis can have a crucial influence on both the treatment policy and severity assessment, it should be evaluated promptly and accurately. It is particularly important to differentiate between gallstone‐induced acute pancreatitis, which requires treatment of the biliary system, and alcohol‐induced acute pancreatitis, which requires a different form of treatment.

     

JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis

Gallstones, along with alcohol, are one of the primary etiological factors of acute pancreatitis, and knowledge of the etiology as well as the diagnosis and management of gallstones, is crucial for managing acute pancreatitis. Because of this, evidence regarding the management of gallstone-induced pancreatitis in Japan was collected, and recommendation levels were established by comparing current clinical practices with optimal clinical practices. The JPN Guidelines for managing gallstone-induced acute pancreatitis recommend two procedures: (1) an urgent endoscopic procedure should be performed in patients in whom biliary duct obstruction is suspected and in patients complicated by cholangitis (Recommendation A); and (2) after the attack of gallstone pancreatitis has subsided, a laparoscopic cholecystectomy should be performed during the same hospital stay (Recommendation B).