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[医护心情] rextao的华西麻醉研究生成长历程—我也开博(就在这个麻醉的天堂)

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1#
发表于 2008-10-30 10:48:27 | 只看该作者 回帖奖励 |倒序浏览 |阅读模式
老张还是很有创意的,想出了论坛博客这个东东。自己之前没有弄过博客,前一阵子自己的QQ空间弄的倒是不错,可是自从上了临床忙了起来,那个也就不顾了。新青年麻醉论坛我是常客,因为自己是版主,加上对麻醉事业的热爱。现在这个地盘就是我在论坛开博的地方,欢迎大家过来做客,聊聊工作学习或者生活上的一些···的话题!
发几张照片,作为开博的见证!!

[ 本帖最后由 rextao 于 2008-10-31 10:33 编辑 ]

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2#
 楼主| 发表于 2008-10-30 10:56:26 | 只看该作者
先对过去的一年做个小结!研究生一年级的上学期就是上课,主要为科研做准备,一天还是很清闲,在成都这个休闲舒服的城市,逐渐变得懒散了···。下学期开始上临床,真正的麻醉生活开始了,每天都是早出晚归,懒散的习惯顿时消失,上了临床3各月开始排我们研究生值班,可以遇到各种急症的抢救与麻醉!华西是训练魔鬼的天堂,之所以没有说成地狱,是因为虽然是魔鬼训练,但是真的可以学到好多的东西,为自己今后的麻醉道路打好夯实的基础!大家一起加油,为了我们伟大的麻醉事业!

[ 本帖最后由 rextao 于 2008-11-7 13:57 编辑 ]

活动公告:做任务得积分和权限(新手奖励计划) (←点击查看详情)

3#
 楼主| 发表于 2008-10-30 14:03:24 | 只看该作者
这几天一直在忙选题的事情,所以下了临床,可以有大量的时间在论坛徜徉,一边查文献一边看论坛的更新,给自己的板块评分,觉得还是很充实的。我准备做脑外麻醉的课题,跟输血有关的。是什么暂时保密!觉得自己这几天也上出网瘾了,等老张回来我也得收敛一下了(老张最近在戒网瘾),呵呵!

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4#
 楼主| 发表于 2008-10-30 18:50:45 | 只看该作者

Autologous transfusion

Summary points

    * Autologous transfusion reduces the need for allogeneic transfusion and is most widely used in elective surgery
    * Autologous transfusion is one of several techniques used to reduce the need for allogeneic transfusion
    * The three main techniques are predeposit transfusion, intraoperative haemodilution, and intraoperative and postoperative salvage
    * Evidence from clinical trials shows that autologous transfusion is more cost effective than allogeneic transfusion and that clinical outcomes are improved

Predeposit autologous transfusion entails repeated preoperative phlebotomy (fig 2). Blood collection begins three to five weeks before elective surgery, depending on the number of units required, usually 2-4 units (about 1-2 litres). The last donation takes place at least 48-72 hours before surgery to allow for re-equilibration of the blood volume. On each occasion, about half a litre of the patient's own blood is taken and put into sterile plastic bags. Anticoagulation is maintained with citrated glucose solution, and the blood is stored until the time of surgery.Advantages
Predeposit autologous transfusion virtually eliminates the risks of viral transmission and immunologically mediated haemolytic, febrile, or allergic reactions. These adverse effects range in frequency from 1 in 1 000 000 (HIV) to as high as 5% (febrile reactions). In addition, it may decrease the risk of postoperative infection and recurrence of cancer because immunomodulation as a result of transfusion is avoided.2–4 Immunomodulation refers to decreases in cellular immune function that have been documented after allogeneic, but not autologous, transfusions.7

Disadvantages
Up to half of the blood that is collected may be discarded because the amount drawn off needs to exceed the median routinely needed to avoid additional allogeneic transfusions. Leftover blood can rarely be used for other patients because most autologous donors do not meet the stringent health requirements for allogeneic blood donation. This wastage of blood and the costs of administering autologous programmes result in collection costs that are higher than those for allogeneic transfusion. Volume overload, bacterial contamination, and ABO haemolytic reactions to the transfusion resulting from administrative or clerical errors are further risks.

Suitability of patients
Predeposit autologous donation is practical only for elective surgery. Patients must be willing and able to travel to a donation centre before their operation, which can be inconvenient and stressful and may decrease their productivity at work. Because preoperative donation results in perioperative anaemia (which may not be completely resolved before surgery) blood volume, venous access, packed cell volume, and haemodynamic stability are important determinants of who is an appropriate candidate for the procedure. Children who weigh less than 30-40 kg are usually not suitable, but adult patients are deferred from donation only if they have severe haemodynamic problems, active systemic infections, or a history of serious reactions to donation (such as seizure). Patients with diarrhoeal illnesses in the days or weeks before donation should not donate as they may be at increased risk of bacterial contamination of their donated blood. Although autologous donors have a higher incidence of reactions such as fainting or dizziness than voluntary donors (presumably because they are inexperienced donors and not as young and fit), their reactions are seldom severe.

Intraoperative acute normovolaemic haemodilution

Acute normovolaemic haemodilution (“haemodilution”) is a type of autologous donation that is performed preoperatively in the operating theatre or anaesthetic area. It is usually restricted to patients in whom substantial blood loss is predicted (>1 litre or 20% of blood volume). Whole blood (1.0-1.5 litres) is removed, and simultaneously intravascular volume is replaced with crystalloid or colloid, or both, to maintain blood volume. The anticoagulated blood is then reinfused in the operating theatre during or shortly after surgical blood loss has stopped. The blood sparing benefit of haemodilution is the result of the reduced red cell mass lost during surgical bleeding.

Advantages
Haemodilution provides the advantages of predeposit autologous donation and some additional benefits. It may be used before any type of surgical procedure, and systemic infection does not preclude its use. The patient is under anaesthesia during the procedure, which reduces stress, and the anaesthetist can ensure expert monitoring of blood circulation. Blood is stored at room temperature for a short time, so deterioration of clotting factors and cells is minimal. Additional advantages include a lower cost than for predeposit transfusion (because testing and cross matching are not usually required) and minimal wastage, as most or all blood is reinfused. Blood is maintained at the point of care, incurring little or no administrative expense, and the risk of ABO incompatibility because of administrative or clerical error is further minimised.

Disadvantages
The circulating red cell mass is lowered appreciably and acutely. If colloid is used for volume replacement the risk of allergic reactions or haemostatic abnormalities increases. Other disadvantages are the additional expense of, and inconvenience to, the anaesthetist who performs the procedure. The procedure may require additional training and experience on the anaesthetist's part. No large studies have investigated morbidity or mortality that may occur with acute anaemia, so the general belief that haemodilution is safe is largely anecdotal at this time.

Suitability of patients
Elective operations with typical blood losses of 1-2 litres are particularly suitable for haemodilution (for example, replacement of cardiac valves, revision of hip arthroplasty, or spinal reconstruction). The major limiting factor in choosing candidates for haemodilution is the patient's ability to tolerate a low volume of red blood cells. Patients with severe anaemia are usually poor candidates.

Salvage autologous transfusion

Intraoperative red blood cell salvage entails the collection and reinfusion of blood lost during surgery. Shed blood is aspirated from the operative field into a specially designed centrifuge. Citrate or heparin anticoagulant is added, and the contents are filtered to remove clots and debris. Centrifuging concentrates the salvaged red cells, and saline washing may be used. This concentrate is then reinfused. Devices used can vary from simple, inexpensive, sterile bottles filled with anticoagulant to expensive, sophisticated, high speed cell washing devices. Postoperative salvage refers to the process of recovering blood from wound drains and reinfusing the collected fluid with or without washing.

:victory:advantage
Salvage is considered a safe and efficacious alternative to allogeneic red cell transfusion, but fewer data are available about clinical outcomes than for predeposit autologous donation or haemodilution.1 These techniques offer advantages similar to those of haemodilution but do not require infusions of crystalloid or colloid to preserve blood volume. Many litres of blood can be salvaged intraoperatively during extensive bleeding, far more than with other autologous techniques.

Disadvantages
Although the oxygen transport properties and survival of red cells are similar to that of allogeneic blood, salvaged blood is not haemostatically intact compared with blood derived by haemodilution. Coagulation in the wound leads to consumption of coagulation factors and platelets. Salvaged blood that is not washed contains raised concentrations of various tissue materials. Uncommon complications of extensive intraoperative salvage include disturbances to pH and electrolytes, systemic dissemination of non-sterile material, infectious agents or malignant cells, air or fluid embolism, and dilutional coagulopathy. A “salvaged blood syndrome” has been described, which entails multiorgan failure and consumption coagulopathy.8

Suitability of patients
Intraoperative salvage is used extensively in cardiac surgery, trauma surgery, and liver transplantation. Contraindications to its use are bacterial infection or malignant cells in the operative field, and use of microfibrillar collagen or other foreign material at the operative site. Salvage can be one of the most expensive autologous techniques because costly capital equipment and disposables are used, and it is usually restricted to procedures resulting in substantial blood loss (>1-2 litres).

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5#
发表于 2008-10-30 21:20:55 | 只看该作者
除了羡慕,还能有什么呢!

有奖活动:我为论坛出谋划策!! ←点击查看详情

6#
发表于 2008-10-30 22:27:42 | 只看该作者
惭愧之外,为前进,务必加油呀!否则就挨打屁股喔。

有奖活动:我为论坛出谋划策!! ←点击查看详情

7#
 楼主| 发表于 2008-10-31 00:15:39 | 只看该作者

没有什么羡慕一说哈,大家努力作一名合格的麻醉医生就是最终的目标!从学习中进步,在进步中学习···

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8#
发表于 2008-10-31 00:40:38 | 只看该作者
终于看到帅小伙本人啦!:lol :lol

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9#
 楼主| 发表于 2008-10-31 10:36:07 | 只看该作者
原帖由 orexin 于 2008-10-31 00:40 发表
终于看到帅小伙本人啦!:lol :lol

那是在研一 现在不行了 上了临床工作强度很大,压力也大,憔悴了许多,脸上也长痘痘了 呵呵!

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10#
发表于 2008-10-31 12:31:37 | 只看该作者
自体输血因其可避免和减少因异体同种输血引起的副作用,正逐步受到临床医生的广泛重视。血液黏滞度下降;静脉回流增加;末梢阻力下降,心输出量增加。稀释后的血液黏滞度明显下降,红细胞容易通过毛细血管,脑微循环灌流良好,有利于防止脑缺血及脑血栓形成。总之,稀释性自体输血不仅解决了手术中输血问题,还避免了输异体血的不良反应。
这个课题?

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