This article reports the management of thirty elderly patients of septic shock during anesthesia. Twenty-four of them received continious epidural anesthesia, five of them were under intravenous general anesthesia with endotracheal intubation, and onr patients recerived intravenous ketamine anesthesia. The effects of these patients on enesthesia wer satisfactory. Twenty-four patients recouverd after roperation. Six patients died. The authors atresses the high risk of anesthetic management in these patients. Experiences are introduced in per-anesthetic preparation and medication selection and maintenance of anesthesia, monitoring and treatment during anesthesia and postoperative care of septic shock of the elderly.
Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.
目的 探討早期堿剩余對感染性休克患者病情嚴重程度的預測價值。 方法 對2009年2月－2011年2月資料完整入院的感染性休克患者60例進行回顧性分析，按死亡及存活進行分組，對最初24 h的堿剩余值差異及血乳酸清除率情況進行對照研究。 結果 死亡組堿剩余值變化及乳酸清除率低于存活組（P＜0.05）。治療后堿剩余≤?6 mmol/L較堿剩余＞?6 mmol/L的患者病死率明顯增加，尤其是治療后24 h 堿剩余仍≤?6 mmol/L病死率高達92.23%。 結論 早期堿剩余有助于感染性休克預后評估和指導臨床治療。
目的 探討特發性結腸穿孔的治療方法及成因。方法 結合文獻分析2001～2009年期間我院收治的特發性結腸穿孔患者的診治經過。結果 共收治特發性結腸穿孔9例，占同期結腸穿孔患者的28.1%（9/32），其中5例穿孔（5/9）發生在乙狀結腸。修剪破口后直接縫合者2例，行結腸雙腔造瘺者7例。術后死亡3例。結論 特發性結腸穿孔好發于乙狀結腸，與其解剖和生理上的特點有關。不明原因結腸穿孔的患者要想到本病的可能。及時、合理的手術治療，仔細周到的術后管理是治療成功的關鍵。
目的 探討孤立腎腎結石經皮腎鏡取石（PCNL）術并發感染性休克的護理。 方法 回顧性分析2010年3月－2012年10月5例孤立腎腎結石患者行PCNL術后并發感染性休克的臨床資料，對患者術后出現的休克及時補足血容量，使用有效的抗生素，早期足量應用激素、血管活性藥物，同時加強心理疏導、健康教育等護理措施。 結果 5例患者體溫均在3 d內降至正常；血管活性藥物平均使用時間為1.8 d （2～4 d）；1例因血氧飽和度＜80%，血壓＜85/50 mm Hg（1 mm Hg=0.133 kPa）轉往重癥監護病房行呼吸機輔助呼吸2 d后呼吸循環功能改善；另1例同時出現少尿無尿，及時行血液透析，第4天尿量逐漸恢復；5例患者均痊愈出院。 結論 感染性休克是PCNL術后最危險的并發癥之一，對其采取積極預防、及早發現、及時有效的治療和護理等措施，可有效促進患者康復。
ObjectiveTo investigate the influence of norepinephrine on pulmonary vessel pressure in animal model of septic shock. MethodsTwelve health mongrel dogs were randomly divided into a control group (n=5, intravenously injected with normal saline 1 mL/kg) and an endotoxin group(n=7, intravenously injected with lipopolysaccharide 1 mg/kg). When the systemic blood pressure decreased by more than 40% of baseline before administration, the dogs in two groups were intravenously injected with NE 0.5, 1.0, 2.0, 5.0μg·kg-1·min-1. The interval of each dose was more than 10 minutes. The changes of the pulmonary arterial pressure (PAP), pulmonary venous pressure (PVP), and systemic arterial rressure (SAP) were recorded and compared between two groups. ResultsIn the control group, PAP didn't change significantly after administration (P < 0.05), however, PVP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.01). In the endotoxin group, PAP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), while PVP didn't change significantly (P > 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). There were significant differences in SAP (P < 0.05), not in PAP and PVP (P > 0.05), between two groups after NE administration at dose of 1.0, 2.0 and 5.0μg·kg-1·min-1. The PVP/SAP and PAP/SAP values didn't change significantly after administration in the control group (P > 0.05). In the endotoxin group, the PVP/SAP and PAP/SAP values increased significantly after LPS administration, and decreased slightly after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). ConclusionsNE administration in septic shock can not increase the angiotasis of the pulmonary vein. NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 can cause the increase of PAP and SAP, but the increase of PAP is lower than the increase of SAP.