摘要：Orthotopic liver transplantation can be marked by significant hemodynamic instability requiring the use of a variety of hemodynamic monitors to aide in intraoperative management. Invasive blood pressure monitoring is essential,but the accuracy of peripheral readings in comparison to central measurements has been questioned. When discrepancies exist,central mean arterial pressure,usually measured at the femoral artery,is considered more indicative of adequateperfusion than those measured peripherally. The traditional pulmonary artery catheter is less frequently used due to its invasive nature and known limitations in measuring preload but still plays an important role in measuring cardiac output(CO) when required and in the management of portopulmonary hypertension. Pulse wave analysis is a newer technology that uses computer algorithms to calculate CO,stroke volume variation(SVV) and pulse pressure variation(PPV). Although SVV and PPV have been found to be accurate predicators of fluid responsiveness,CO measurements are not reliable during liver transplantation. Transesophageal echocardiography is finding an increasing role in the realtime monitoring of preload status,cardiac contractility and the diagnosis of a variety of pathologies. It is limited by the expertise required,limited transgastric views during key portions of the operation,the potential for esophageal varix rupture and difficulty in obtaining quantitative measures of CO in the absence of tricuspid regurgitation.

摘要：The lateral hypothalamic area(LHA)plays a pivotal role in regulating consciousness transition,in which orexinergic neurons,GABAergic neurons,and melanin-concentrating hormone neurons are *** neurons have a large population in the LHA,but their anesthesia-related effect has not been ***,we found that genetic ablation of LHA glutamatergic neurons shortened the induction time and prolonged the recovery time of isoflurane anesthesia in *** contrast,chemogenetic activation of LHA glutamatergic neurons increased the time to anesthesia and decreased the time to *** activation of LHA glutamatergic neurons during the maintenance of anesthesia reduced the burst suppression pattern of the electroencephalogram(EEG)and shifted EEG features to an arousal *** of LHA glutamatergic projections to the lateral habenula(LHb)also facilitated the emergence from anesthesia and the transition of anesthesia depth to a lighter ***,LHA glutamatergic neurons and their projections to the LHb regulate anesthetic potency and EEG features.

摘要：The incidence of accidental injection or catheterization of the subdural space during performance of a neuroaxial block has recently increased. It can occur even when an experienced practitioner performs the neuraxial procedure. The presentation of numerous unexplainable clinical signs in the process of continuous epidural anesthesia, which do not fit the clinical picture of subarachnoid or intravascular injection, should envoke a high suspicion for unintentional subdural block. We report two cases of patients who achieved prolonged labor analgesia via epidural technique with only half the initial loading dose of local anesthetic. Both patients also had short episodes of hypotension. Additionally, one patient presented with severe hypoxemia and mild motor block of both upper and lower extremities. The other patient presented with transit unresponsiveness without motor block. Both patients rapidly responded to vasopressors. Desaturation in one patient, however, was persistent lasting for more than four hours. Her bedside chest X-ray was inconclusive “possible pulmonary edema” and the follow up Chest CT Scan on the second day revealed aspiration pneumonia. Based on the clinical findings, these two cases were suggestive of subdural block with cranial nerve involvement.

摘要：作为细胞中的主要运输系统,天然囊泡在物质的定点输运过程中具有至关重要的作用.高分子囊泡是与之结构相似的一种人工囊泡,具有优异的膜稳定性和胶体稳定性、高药物负载率、低膜穿透性、优异的可修饰性和长循环时间等优势,在生物医用领域具有广泛的应用前景.然而,目前该领域尚面临一系列重要挑战,如合成和制备方法较为复杂、生物相容性较难预测、功能和递送途径有限等,限制了其临床转化之路.本文从囊泡的构建模块合成、自组装技术和潜在的生物医学应用等角度,提出了设计和制备下一代高分子囊泡需要解决的五个关键科学问题,指出了未来面临的重要挑战和发展方向,例如简化设计和合成过程,优化和规范自组装过程,拓展潜在的应用前景.

摘要：对围术期或危重症病人实施个体化液体管理,需要谨慎权衡利弊,这是一项极具挑战性的日常临床工作.全世界近几十年来,羟乙基淀粉溶液一直用于围术期或危重症病人的容量复苏,然而2013年10月欧洲药品管理局提议,对于脓毒症、烧伤、肾功能不全及严重凝血功能障碍等危重症病人,一般情况下不宜使用羟乙基淀粉溶液.但这项提议基于的三个主要的随机对照试验,均因其设计方案和数据分析而倍受质疑.本文简要概述了羟乙基淀粉溶液的药代动力学和药效动力学;各代羟乙基淀粉溶液之间的不同点;围术期病人与危重症病人之间病理生理学的差异.此外,本文还对近来有关羟乙基淀粉溶液用于危重症病人和心脏手术围术期病人容量复苏的随机对照试验,进行了评论.

摘要：To the Editor： In a single-center, prospective randomized clinical study including 122 elderly patients undergoing the carotid endarterectomy （CEA）, Wang et al. showed that compared with propofol-based total intravenous anesthesia, low-dose sevoflurane inhalation along with propofol reduced the incidence of postoperative myocardial injury.

摘要：Cholangiocarcinoma(CCA)is characterized by heterogeneous mutations and a refractory ***,the development of a model for effective drug screening is urgently *** the established therapeutic testing models for CCA are often ineffective,we fabricated an enabling three-dimensional(3D)-bioprinted CCA-on-a-chip model that to a good extent resembled the multicellular microenvironment and the anatomical microstructure of the hepato-vascular-biliary system to perform high-content antitumor drug ***,cholangiocytes,hepatocytes,and vascular endotheliocytes were employed for 3D bioprinting of the models,allowing for a high degree of spatial and tube-like microstructural ***,it was possible to observe CCA cells attached to the surfaces of the gelatin methacryloyl(GelMA)hydrogelembedded microchannels and overgrown in a thickening manner,generating bile duct stenosis,which was expected to be analogous to the in vivo *** 4000 differentially expressed genes were detected in the CCA cells in our 3D coculture model compared to the traditional two-dimensional(2D)*** screening revealed that the CCA cells grown in the 3D traditional model were more sensitive to the antitumoral prodrug than those in the 2D monoculture due to drug biotransformation by the neighboring functional *** study provides proof-of-concept validation of our bioprinted CCA-on-a-chip as a promising drug screening model for CCA treatment and paves the way for potential personalized medicine strategies for CCA patients in the future.

摘要：背景控制血管手术后心脏不良事件的策略在不断改进。早期发现和处理心肌缺血是提高手术后生存率的关键因素。心肌肌钙蛋白Ⅰ（cTnⅠ）的筛查是监测手术后心肌缺血性损伤的有效方法，并具有长期的预后价值。方法我们设计了一个马尔柯夫决策分析模型来评估手术后第0、1、2、3天常规监测cTnⅠ的成本效益，其目的还在于将手术后cTnⅠ〉1．5ng/ml的患者移入重症监护病房观察5天，严格控制目标心率（60～65次／分），并进行严密监测和冠状动脉监护。根据已发表的文献所输入的主要变量如下：心肌梗死的概率0．049；监测cTnⅠ的成本为357美元；干预的成本和效率分别为13145美元和0．55。以寿命为时间轴，目标人群是平均年龄为65岁的行择期开腹腹主动脉手术的患者。此研究分析的费用来自第3方。结果相对于没有监测cTnⅠ的对照组，每个生命质量调整年用于监测cTnⅠ增加的成本效益为12641美元。单因素方差分析显示心肌梗死的可能性和干预的效能会影响成本效益。采用二次合并蒙特卡罗模拟分析行多因素敏感性分析显示，在每个生命质量调整年用低于50000美元的费用监测cTnⅠ，其获益率可达到90．75％。结论对于择期行开腹腹主动脉手术的住院患者，加强cTnⅠ监测并早期积极地使用β-受体阻滞剂会带来成本效益。

摘要：目的:全麻中两种以上的药物合并应用比单一麻醉剂更为有效。本研究是为确定中国成年患者全麻期间合并应用七氟醚与瑞芬太尼时药物相互作用的方式,并以反应曲面模型法对其进行表述。方法:1.试验设计:研究采用平行实验设计,65例病人(ASAI级,各项指标正常,无长期服用阿片类药物史)入选本次试验,随机选定并维持一定的呼末七氟醚浓度[≤2MAC(0.3 %-3.4 %)] ,逐渐增加靶控输注的瑞芬太尼浓度(≤10 ng/mL) ,观察不同浓度组合时患者对喉镜置入刺激的反应以确定麻醉是否完全。2.反应曲面模型法进行药物动力学/药效动力学分析:两药合用的效果通过对喉镜置入时的反应进行评估,0和1分别代表有或没有体动反应。以下面的药效学模型表述体动反应消失的概率(P)其中Us ,Ur分别为标准化的七氟醚与瑞芬太尼水平;U50为达最大效应一半时的药物综合标准化水平;r为形状因子;I(Q)为药物相互作用的强度函数。模型通过作图、目标函数改变以及参数的生理/临床学的合理性等几方面进行评价。P=[U50/I((QU)s]+r+U(r)Urs+Ur)r结果与结论:研究表明瑞芬太尼与七氟醚合用时为协同式相互作用,上述反应曲面模型与实际观测值有较好的拟合。应用NONMEM得到喉镜置入刺激时的参数(RSE%)为U50=6.62(10.6) ,C50 ,sevo=1.71 %(12.9) ,C50 ,remi=12.4 ng/mL(19.0) ,Imax=2.31 ,Qmax=0.706。所得数值的加权残差均小于3。结果表明与传统方法相比,反应曲面模型法可以得到较好的拟合质量,为药物相互作用的研究提供了一种新颖思路和有效手段。

摘要：女性患者，64岁，因慢性膝关节退行性病变伴疼痛在全身麻醉下行全膝关节成形术（TKA），既往有哮喘和高血压病史。按照研究设计，手术中采用经食道超声（TEE）对手术引发的栓子进行定量监测。