上海市普通外科住院病人静脉血栓栓塞症诊治现状调查分析

目的调研了解上海市二级甲等及以上医院普痛外科有关静脉血栓栓塞症(VTE)院内防控体系建立情况、医生相关知识掌握,住院病人发病情况。方法2019年9月1—12日以上海市普通外科临床质量控制中心为平台,设计问卷并以质量控制中心官方邮件及微信平台共同推送二维码形式对上海市二级甲等及以上医院普通外科进行电子问卷调查。问卷内容设计严格按照国内外普通外科领域VTE防治指南为标准。结果共69家医院普通外科参与调研,回收有效问卷112份,肺动脉栓塞(PE)确诊例数占住院手术例数的0.06%(5/7843),深静脉血栓形成(DVT)确诊例数占1.02%(80/7843)。上海市二级及以上医院已有88.39%(99/112)的科室建立VTE防控体系;84.82%(95/112)的科室有VTE和PE的联合会诊团队;96.43%(108/112)的科室入院时为病人做VTE风险评估,74.11%(83/112)的科室在病人手术后评估VTE风险,38.39%(43/112)的科室出院前为病人评估VTE风险。有53.57%(60/112)的科室为VTE高风险病人进行术前抗凝,至术前12 h停药。34.61%(18/52)的科室因顾虑出血,以及23.07%(12/52)的科室认为外科手术前无须抗凝,而术前不予抗凝治疗。在术后抗凝治疗中,对良性疾病病人,43.75%(49/112)的科室对予术后抗凝3~5 d,23.21%(26/112)予抗凝至出院前,4.46%(5/112)予抗凝至可自由行走,2.68%(3/112)予抗凝至术后28 d,25.89%(29/112)术后未予常规预防性抗凝;对于恶性疾病病人,47.32%(53/112)科室予抗凝至出院前,23.21%(26/112)予术后抗凝3~5 d,仅有8.04%(9/112)根据规范推荐抗凝至术后28 d。院内预防中有96.43%(108/112)的科室选择低分子肝素;院外预防中有43.75%(49/112)的科室使用阿司匹林,16.07%(18/112)使用低分子肝素,24.11%(27/112)使用新型口服抗凝药,15.18%(17/112)使用华法林。结论与2年前对比,上海市普通外科VTE防治的理念和实践有了很大的进步,但对照先进国家的防治实践,存在较大差距,尤其在为病人选择正确用药及恶性肿瘤等VTE高危病人的预防上仍有改善空间。     

脊柱疾病术后静脉血栓栓塞症的危险因素研究进展

<正>静脉血栓栓塞症(VTE)包括深静脉血栓栓塞症(DVT)和肺动脉血栓栓塞症(PE)。DVT是指深静脉腔内血液的病态凝结,这种血块可留在原位,或移至肺动脉导致PE。DVT和PE是VTE在不同部位和不同阶段的2种临床表现形式。VTE是骨科术后常见的并发症,有较高的致残率及致死率。VTE在脊柱手术后发生率与关节手术相似~([1])。确定围手术期VTE的危险因素将有助于评估患者形成VTE的风险程度。术前进行风险评估和危险分层,筛选     

院内防控体系在普通外科围手术期静脉血栓栓塞症防治中的意义

对住院病人进行全面的静脉血栓栓塞症(VTE)风险评估,识别VTE高危病人,及时进行预防,可以显著减少院内VTE的发生。包含医院防治管理组、医院防治专家组和科室防治小组的管理体系,防治流程中各个环节的明确性、时效性、可操作性、监督性,质量控制管理的全程化、个性化、精细化等院内防控体系的建立,对普通外科围手术期VTE防治有重要意义。     

上海市普通外科住院病人静脉血栓栓塞症防治管理规范

正为规范普通外科住院病人静脉血栓栓塞症(VTE)的预防和治疗,指引临床医护人员的诊疗过程,最大限度地减少诊疗过程中的失误,改善病人预后,根据国家卫计委《医疗技术临床应用管理办法》、《执业医师法》和《医疗机构管理条例》的有关规定,结合我国普通外科住院病人VTE防治管理的实际情况,制定本规范。本规范为参与本项目的医疗机构及其医护人员进行普通外科住院病人VTE防治的基本要求。     

下腔静脉滤器在合并静脉血栓栓塞症普通外科手术病人中的合理应用

正合并有静脉血栓栓塞症(venous thromboembolism,VTE)的病人进行普通外科大手术,应积极面对血栓复发、脱落、肺血栓栓塞症(pulmonary embolism,PE)加重等风险,采取有效措施,减少病人围手术期出现严重致死性PE的发生,提高手术安全。本文主要阐述下腔静脉滤器在PE预防中的作用及其在合并VTE的普通外科手术病人中的合理应用,以及植入后管理及常见并发症处理。1下腔静脉滤器在PE预防中的地位下腔静脉滤器可以有效预防下肢深静脉血栓(deep venous thrombolism,DVT)脱落导致的PE,目前临床上常用     

中国创伤骨科患者围手术期静脉血栓栓塞症预防指南(2021)

静脉血栓栓塞症(venous thromboembolism,VTE)是创伤骨科患者的常见并发症,也是导致患者围手术期死亡的主要原因之一。对创伤患者施以有效的预防措施,可以降低VTE的发生风险,减轻患者痛苦,减少医疗费用。因此,参照2016版"中国骨科大手术静脉血栓栓塞症预防指南"、2018版"中国血栓性疾病防治指南"及最新的循证证据,在2012版"中国骨科创伤患者围手术期静脉血栓栓塞症预防的专家共识"基础上,制定本指南。     

本期导读

静脉血栓栓塞症(venous thromboembolism,VTE)是创伤骨科患者的常见并发症,也是导致患者围手术期死亡及医院内非预期死亡的主要原因之一。对创伤骨科患者施以有效的抗凝预防措施,可以降低VTE的发生风险,减轻患者痛苦,减少医疗费用。虽然目前国内已有2016版"中国骨科大手术静脉血栓栓塞症预防指南"、2018版"中国血栓性疾病防治指南"等循证证据,但是创伤患者有其独特的临床特点,中华医学会骨科学分会创伤骨科学组等4家组织及《中华创伤骨科杂志》编辑部着眼于创伤骨科患者VTE的预防,在上述指南和2012版"中国骨科创伤患者围手术期静脉血栓栓塞症预防的专家共识"基础上,邀请全国多位创伤骨科知名专家进行讨论研究,并于2020年11月召开了指南制定专家定稿会,最终形成"中国创伤骨科患者围手术期静脉血栓栓塞症预防指南(2021)"。     

中国普通外科围手术期血栓预防与管理指南

正随着人口老龄化不断进展和心血管疾病发病率上升,血栓栓塞性疾病的防治和处理逐渐受到各学科关注和重视。静脉血栓栓塞症(venous thromboembolism,VTE)包括肺血栓栓塞症(pulmonary embolism,PE)和深静脉血栓形成(deep vein thrombosis,DVT),PE和DVT是同一疾病不同阶段和不同部位的两种临床表现,二者统称为VTE。外科病人术前活动减少、术中制动和术后长期卧床均     

从重症监护角度思考普通外科围手术期静脉血栓栓塞症防治

普通外科围手术期病人,尤其是重症监护病人存在多种容易导致血栓形成的高危因素,因而较之其他病人,具有更高的静脉血栓栓塞症(VTE)发病风险,在该类人群中切实做好VTE防治工作刻不容缓。准确评估发病风险,是做好VTE的防治工作的关键第一步。目前常用的Caprini模型对于预测围手术期病人的血栓风险具有较高的敏感度,临床上将血浆标记物与该模型相结合,可进一步提高重症监护病人VTE风险的预测价值。重症病人的VTE预防及治疗须强调个体化,综合评价血栓与出血的风险,兼顾有效性及安全性,选择最佳策略和最优剂量,改善病人预后。     

脊柱术后急性肺栓塞溶栓治疗1例报道及文献复习

静脉血栓栓塞症(venous thromboembolism, VTE)是骨科手术比较常见的并发症,包括深静脉血栓(deep venous thrombosis, DVT)与肺栓塞(pulmonary embolism, PE),其中急性肺动脉血栓栓塞症(acute pulmonary thromboembolism,...     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

缺氧对肾小管上皮细胞分泌外泌体的影响

目的    观察缺氧对肾小管上皮细胞分泌外泌体的影响,探讨外泌体在缺氧致肾脏损伤中的作用及机制。 方法    （1）常氧（21% O₂）及缺氧（1% O₂）分别处理大鼠肾小管上皮细胞（NRK-52E）48 h,收集细胞上清液并使用高速梯度离心法分离外泌体。采用透射电镜、纳米示踪分析、Western印迹、蛋白浓度定量鉴定并比较两组外泌体的基本特性。（2）在共培养实验中,以不同浓度（1、10、50、100、300 mg/L）的常氧外泌体、缺氧外泌体分别干预脂多糖（LPS）诱导的大鼠原代腹腔巨噬细胞,使用实时荧光定量PCR与酶联免疫吸附试验（ELISA）法分别检测巨噬细胞白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、诱导型氮氧化物合酶（iNOS）水平;使用Western印迹法检测巨噬细胞磷酸化（p）STAT/STAT及细胞因子信号传导抑制蛋白1（SOCS1）的蛋白表达;最后,使用实时荧光定量PCR法检测常氧外泌体与缺氧外泌体中炎性反应相关微RNA（microRNA,miR）的表达差异。 结果    （1）离心得到的囊泡具有外泌体典型的结构,粒径小于150 nm,表达外泌体标志蛋白CD63,说明分离得到外泌体。缺氧对肾小管上皮细胞分泌的外泌体形态、粒径分布比例无明显影响,但提高了外泌体的分泌量。（2）缺氧外泌体相比于常氧外泌体促进了LPS诱导的M1型巨噬细胞IL-6、TNF-α、iNOS 的表达和分泌（均P＜0.01）,同时提高STAT的磷酸化水平并减少SOCS1的蛋白表达（均P＜0.01）;对炎性反应相关microRNA检测发现缺氧外泌体中miR-155、miR-27a表达量较常氧外泌体明显升高（P＜0.05）。 结论    缺氧可改变外泌体的生物学功能,表现为协同促进LPS诱导的M1型巨噬细胞的表型转化,这可能是慢性肾脏病微炎性反应状态持续的原因之一。     

In Vitro Function and Durability Assessment of a Novel Polyurethane Heart Valve Prosthesis

Abstract While flexible-leaflet, central-flow prosthetic heart valves promise relief from anticoagulation therapy, they continue to be restricted by inadequate durability. In consequence, a novel trileaflet valve, made entirely from polyurethane, has been developed. A batch of 6 consecutively manufactured polyurethane valves was subjected to hydrodynamic function and accelerated fatigue testing. Computerized data acquisition and control systems have been introduced to improve valve testing methodologies. In terms of hydrodynamic function, the polyurethane valve demonstrates transvalvular pressure gradients similar to those for a bioprosthetic valve (Carpentier-Edwards) and levels of retrograde flow significantly less than those for either the bioprosthetic valve or a bileaflet mechanical valve (St Jude Medical). The equivalent of 10 years of cycling without failure has been exceeded by all 6 polyurethane valves in accelerated fatigue tests with 2 valves remaining intact after 674 million cycles (equivalent to approximately 17 years) in continuing tests. Highspeed photography revealed considerable differences in leaflet motion between valves cycled at accelerated and physiological rates.     

Negative pressure ventilation vs. spontaneous assisted ventilation during rigid bronchoscopy: A controlled randomised trial

Background: Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). Methods: Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre-and intra-operative arterial blood gases and O₂ flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. Results: Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 ± 1.8 (μg · kg^?1· h^?1 vs. 6.6 ± 4.8 μg · kg^?1· h^?1), a lower O₂ supply (3.3 ± 2.8 1/min vs. 11.6 ± 3.4 1/min), a shorter recovery time (5.4 ± 2.9 min vs. 9.8 ± 7.1 min) and no manually assisted ventilation (0 ± 0 vs. 1 ± 1.1 nd?/procedure). Intraoperative PaCO₂ was higher in the SAV (8.1 ± 1.3 kPa) than in the INPV group (5.0 ± 1.6 kPa) and intraoperative pH differed in the two groups (7.26 ± 0.05, SAV vs. 7.47 ± 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). Conclusions: As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces 02 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.