临床执业医师《外科学》复习讲义.doc

2014年临床执业医师外科学复习讲义输血输血的适应证、输血技术和注意事项(一)适应证1.大量失血 补充的血量、血制品种类应根据失血的多少、速度和病人的临床表现确定。凡一次失血量低于总血容量10%(500m1)者，不必输血。当失血量达总血容量的 10%20%(500l 000m1)时，若病人可表现为活动时心率增快，出现体位性低血压，但HCT常无改变。可以输入少量血浆代用品。若失血量达总血容量20%(1 000m1)时，应输入浓缩红细胞。原则上，失血量在30%以下时，不输全血。2.贫血或低蛋白血症3.重症感染4.凝血异常输血的并发症及其防治(一)发热 反应是最常见的早期输血并发症之一，多发生于输血开始后15分钟2小时内。主要表现为畏寒、寒战和高热，血压多无变化。【治疗】 对于症状较轻的发热反应可先减慢输血速度，病情严重者则应停止输血。畏寒与寒战时应注意保暖，出现发热时可服用阿司匹林。伴寒战者可肌肉注射异丙嗪25mg或哌替啶50mg。(二)过敏反应 多发生在输血数分钟后，表现为皮肤局限性或全身性瘙痒或荨麻疹。治疗 当病人仅表现为局限性皮肤瘙痒或荨麻疹时，不必停止输血，可口服抗组胺药物如苯海拉明25mg，并严密观察病情发展。反应严重者应立即停止输血，皮下注射肾上腺素(1：l 000，0.5lml)和(或)静脉滴注糖皮质激素(氢化可的松100mg加入500ml葡萄糖盐水)。(三)溶血反应 是最严重的输血并发症。最早征象是不明原因的血压下降和手术野渗血。典型的症状为腰背酸痛、乃至血压下降、休克，随之出现血红蛋白尿和溶血性黄疸。【治疗】 当怀疑有溶血反应时应立即停止输血，对病人的治疗包括：抗休克。保护肾功能：可给予5%碳酸氢钠250ml，静脉滴注，使尿液碱化。(四)大量输血的影响 大量输血后(24小时内用库存血细胞置换病人全部血容量或数小时内输入血量超过4 000m1)，可出现：低体温;碱中毒(枸橼酸钠在肝转化成碳酸氢钠);暂时性低血钙;高血钾(一次输入大量库存血所致)及凝血异常(凝血因子被稀释和低体温)。体内钾的异常正常血钾浓度为3.55.5mmol/L。(一)低钾血症【临床表现】 最早的临床表现是肌无力，先是四肢软弱无力，以后可延及躯干和呼吸肌。典型的心电图改变为早期出现T波降低、变平或倒置，随后出现ST段降低、QT间期延长和U波。低钾性碱中毒时患者的尿却呈酸性(反常性酸性尿)。【治疗】 补钾量可参考血钾浓度降低程度，约每天补氯化钾36g。静脉补充钾，有浓度及速度的限制，每升输液中含钾量不宜超过40mmol(相当于氯化钾3g)。待尿量超过40ml/h后，再静脉补充钾。(二)高钾血症 血钾浓度超过5.5mmol/L。【临床表现】 高钾血症，特别是血钾浓度超过7mmol/L，都会有心电图的异常变化。典型的心电图改变为早期T波高而尖。QT间期延长，随后出现QRS增宽，PR间期缩短。【治疗】1.停用一切含钾的药物或溶液。2.降低血钾浓度，可采取下列几项措施：(1)促使K+转入细胞内：输注碳酸氢钠溶液。输注葡萄糖溶液及胰岛素。10%葡萄糖酸钙，对抗心脏毒性。(2)阳离子交换树脂的应用。(3)透析疗法。2014年临床执业医师外科学复习讲义北京京师杏林医考教育撰写发布Winger Tuivasa-Sheck, who scored two tries in the Kiwis' 20-18 semi-final win over England, has been passed fit after a lower-leg injury, while Slater has been named at full-back but is still recovering from a knee injury aggravated against USA.Both sides boast 100% records heading into the encounter but Australia have not conceded a try since Josh Charnley's effort in their first pool match against England on the opening day.Aussie winger Jarryd Hayne is the competition's top try scorer with nine, closely followed by Tuivasa-Sheck with eight.But it is recently named Rugby League International Federation player of the year Sonny Bill Williams who has attracted the most interest in the tournament so far.待添加的隐藏文字内容2The Kiwi - with a tournament high 17 offloads - has the chance of becoming the first player to win the World Cup in both rugby league and rugby union after triumphing with the All Blacks in 2011."I'd give every award back in a heartbeat just to get across the line this weekend," said Williams.The (lack of) air up there Watch mCayman Islands-based Webb, the head of Fifa's anti-racism taskforce, is in London for the Football Association's 150th anniversary celebrations and will attend City's Premier League match at Chelsea on Sunday."I am going to be at the match tomorrow and I have asked to meet Yaya Toure," he told BBC Sport."For me it's about how he felt and I would like to speak to him first to find out what his experience was."Uefa has opened disciplinary proceedings against CSKA for the "racist behaviour of their fans" during City's 2-1 win.Michel Platini, president of European football's governing body, has also ordered an immediate investigation into the referee's actions.CSKA said they were "surprised and disappointed" by Toure's complaint. In a statement the Russian side added: "We found no racist insults from fans of CSKA." Baumgartner the disappointing news: Mission aborted.The supersonic descent could happen as early as Sunda.The weather plays an important role in this mission. Starting at the ground, conditions have to be very calm - winds less than 2 mph, with no precipitation or humidity and limited cloud cover. The balloon, with capsule attached, will move through the lower level of the atmosphere (the troposphere) where our day-to-day weather lives. It will climb higher than the tip of Mount Everest (5.5 miles/8.85 kilometers), drifting even higher than the cruising altitude of commercial airliners (5.6 miles/9.17 kilometers) and into the stratosphere. As he crosses the boundary layer (called the tropopause),e can expect a lot of turbulence.The balloon will slowly drift to the edge of space at 120,000 feet ( Then, I would assume, he will slowly step out onto something resembling an Olympic diving platform.They blew it in 2008 when they got caught cold in the final and they will not make the same mistake against the Kiwis in Manchester.Five years ago they cruised through to the final and so far history has repeated itself here - the last try they conceded was scored by England's Josh Charnley in the opening game of the tournament.That could be classed as a weakness, a team under-cooked - but I have been impressed by the Kangaroos' focus in their games since then.They have been concentrating on the sort of stuff that wins you tough, even contests - strong defence, especially on their own goal-line, completing sets and a good kick-chase. They've been great at all the unglamorous stuff that often goes unnoticed in the stands but not by your team-mates.It is as though their entire tournament has been preparation for the final.In Johnathan Thurston, Cooper Cronk, Cameron Smith and either Billy Slater or Greg Inglis at full-back they have a spine that is unmatched in rugby league. They have played in so many high-pressure games - a priceless asset going into Saturday.The Kiwis are a lot less experienced but winning a dramatic match like their semi-final against England will do wonders for their confidence.They defeated Australia in the Four Nations final in 2010 and the last World Cup, and know they can rise to the big occasion.