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老年脑梗死急性期患者行急腹症手术一例麻醉处理

2019-01-07 林仙菊 项海飞 王飞 浙江临床医学

患者,女,72岁,身高157 cm,体重54kg。因“头晕、行走困难21h”于2016年10月12日入院。患者既往有高血压病史10余年。体格检查:T:37.2℃,P:100次/min,R:23次/min,BP:148/105mmHg,意识清楚,两侧瞳孔对等,对光反射灵敏,口齿含糊,额纹无变浅,鼻唇沟无变浅,口角无歪斜,伸舌居中,颈项强直(-)。右侧上肢肌力Ⅳ级,右侧下肢肌力Ⅲ级,右侧病理征阳性,左

脑梗死是临床常见的中老年缺血性脑血管疾病之一,常伴有高血压、动脉硬化、房颤史,重要脏器功能可有不同程度的损伤。再出现急腹症,病情常较重,甚至危及生命,施行手术时麻醉难度和危险性明显增加。本院为1例老年脑梗死急性期患者行急腹症手术,报道如下。
 
1.临床资料
 
患者,女,72岁,身高157 cm,体重54kg。因“头晕、行走困难21h”于2016年10月12日入院。患者既往有高血压病史10余年。体格检查:T:37.2℃,P:100次/min,R:23次/min,BP:148/105mmHg,意识清楚,两侧瞳孔对等,对光反射灵敏,口齿含糊,额纹无变浅,鼻唇沟无变浅,口角无歪斜,伸舌居中,颈项强直(-)。右侧上肢肌力Ⅳ级,右侧下肢肌力Ⅲ级,右侧病理征阳性,左侧肢体肌力Ⅴ级,左侧病理征阴性。心律绝对不齐,两肺听诊未及干湿性啰音。
 
辅助检查:心电图提示:心房颤动。MR头颅平扫+水抑制成像+DWI:左侧额叶、中脑、左侧大脑脚及脑桥脑梗死(新近出现);两侧放射冠区及半卵圆中心腔隙灶;脑白质变性。
 
入院诊断:(1)脑梗死;(2)高血压病;(3)心房颤动。入院后予拜阿斯匹林片、氯吡格雷片抗血小板聚集治疗;瑞舒伐他汀片调脂、稳定动脉斑块;丹红针、前列地尔针改善脑循环;依达拉奉针清除氧自由基等治疗。10月16日下午15点17分出现恶心呕吐1次,为少许内容物,持续腹部胀痛,无明显压痛及反跳痛。消化内科医师会诊予血尿淀粉酶、心肌酶等化验检查,解痉止泻等对症治疗。
 
10月17日下午14点出现发热至38.4℃,呼吸急促解黑色水样便,医嘱予禁食,肠减压,CT全腹部+盆腔增强:肠系膜上动脉节段性闭塞,小肠积气积液扩张。请普外科会诊,医嘱予低分子肝素应用。粪常规+隐血试验:++++;血常规+超敏CRP(急诊):超敏CRP:85.18mg/L,白细胞计数:20.1×109/L,血红蛋白:156g/L,中性粒细胞比率:88.4%;血气分析:乳酸:5.0mmol/L,钾离子:2.9mmol/L,酸碱度(PH):7.43,二氧化碳分压:28mmHg,氧分压:72mmHg;D-二聚体(急诊):4.10mg/L。
 
10月18日14点出现心室率增快至142次/min,律不齐,患者神志清,超敏CRP:163.25mg/L,白细胞计数:14.3×109/L,红细胞计数:5.34×1012/L,中性粒细胞比率:81.9%;Pro-BNP:705pg/ml;血气分析示乳酸:3.7mmol/L,酸碱度(PH):7.49,二氧化碳分压:27mmHg,氧分压:87mmHg。心脏超声检查未见明显异常,LVEF57%。
 
诊断:(1)肠系膜上动脉栓塞。(2)肠坏死。(3)脑梗死急性期。(4)高血压病。(5)心房颤动。(6)消化道出血。(7)动脉粥样硬化。(8)脓毒症。
 
经疑难危重病例全院多学科会诊讨论,充分告知剖腹手术探查的相关利弊,家属决定手术,拟行“剖腹探查手术(肠系膜上动脉取栓+小肠部分切除术)”。患者入手术室时,精神淡漠,体温38.4℃,常规监测ECG、BP、HR、SpO2。呼吸频率29次/min、房颤心律,心室率145次/min,脉搏血氧饱和度95%。局麻下建立有创动脉测压和右颈内静脉穿刺置管。有创动脉测压为126/78mmHg,血气分析:pH7.44,PCO2 32mmHg,PO2 80mmHg,K+3.5mmol/L,Lac3.4mmol/L,HCO3- 20.1mmol/L。
 
麻醉诱导前先补充200ml晶体溶液,诱导药物:咪达唑仑3mg,舒芬太尼30μg,罗库溴铵40mg缓慢静脉注射,采用滴定法给药,诱导开始前即刻启动输注去甲肾上腺素0.05μg/(kg·min),插管前经声门喷入2%利多卡因60mg,气管插管顺利,设定潮气量350ml,呼吸次数15次/min,PEEP5 cmH2O,吸呼比1:2,维持PETCO2 34~38mmHg,脉搏血氧饱和度99%~100%。麻醉维持:静脉输注异丙酚2mg/(kg·h)、瑞芬太尼4~8μg/(kg·h)、吸入七氟醚及间断静脉注射罗库溴铵。
 
采用脑电监测仪监测BIS,维持BIS在42~53,动态监测中心静脉压及液体治疗,维持CVP12~13mmHg,维持酸碱水电解质平衡,补充10%氯化钾1.5g,25%硫酸镁2.5g,使用去乙酰毛花甙0.4mg控制房颤心室率在105~125次/min,不断调整去甲肾上腺素0.05~0.15μg/(kg·min),维持有创平均动脉压在80~100mmHg。手术历时6h,共输入乳酸钠林格注射液3050ml,尿量450ml。
 
手术结束时患者有创动脉血压130/80mmHg,房颤心律,心室率110次/min,SpO2 100%,血气分析:pH7.32,PCO2 40mmHg,PO2 185mmHg(Fio2 0.5),K+3.8mmol/L,Na+137mmol/L,血糖6.5mmol/L,Lac3.2mmol/L,Hct34%,带气管导管送入ICU继续监测和治疗。患者在入ICU45min后麻醉转醒,对指令配合,四肢肌力同术前。夜间继续镇静至第2天上午8点钟顺利拔除气管导管。1周后随访原有脑梗死症状轻度好转,1个月后脑梗死症状明显好转出院。
 
2.讨论
 
本例患者急性脑梗死发生于术前6d,具有明显的高危因素,如房颤。且房颤时形成的附壁血栓可能在围术期任何不确定的时间段内脱落,栓塞在身体的不同部位而引起不同的临床后果。为防止脑组织局灶性水肿和颅内压增高等病理过程的发展,除非病情危及生命,一般不宜施行非脑部手术。
 
本例患者的麻醉难点:(1)老年患者急性脑梗死后,伴有右半身瘫痪,遭遇麻醉后易发生血管张力严重降低,血压难以调控;且感染性休克的基本病理生理原因由于中枢及外周组织灌注不良,从而引起组织细胞存在缺氧状态。致病菌毒素的释放激活机体的免疫系统,从而引起中性粒细胞、内皮细胞、细胞因子等炎性递质的释放,导致血管扩张、毛细血管通透性增加、心肌抑制等,这些因素均可导致麻醉后血压急剧下降。(2)急性脑梗死后,难于纠治的低血压易诱发广泛性脑梗死。(3)患者高龄合并房颤,与低血压互为影响,低血压易诱发脏器低灌注性损伤甚至衰竭。(4)因血管张力改变导致的低血压,给容量管理困难。因此,术中怎样维持血流动力学稳定,避免血压剧烈波动和心律失常的进一步加重,维持脑氧供需平衡,降低脑细胞代谢率,是这类患者手术麻醉中的关键。
 
作者认为麻醉中应注意:
 
(1)麻醉诱导:诱导前补充200ml晶体溶液,先准备单次使用苯肾上腺素、麻黄碱和连续输注去甲肾上腺素,诱导药物选择对循环抑制较轻的咪达唑仑,舒芬太尼,罗库溴铵,避免使用异丙酚、因其具有显著心肌和循环抑制作用。采用滴定法给药,诱导开始前即刻启动输注小剂量去甲肾上腺素0.05μg/(kg·min),插管前经声门喷入2%利多卡因60mg,使麻醉诱导药物用量可以适当减少,又可避免气管插管出现较大的血流动力学波动。
 
(2)麻醉维持:使用异丙酚、瑞芬太尼微泵静脉注射、吸入七氟醚和间断静脉注射罗库溴铵维持麻醉。动物试验证明,七氟醚对颅内压影响轻微,对脑代谢抑制较强。而丙泊酚的脑保护作用也极其复杂,是多途径、多位点交互作用的结果。
 
(3)麻醉监测:该脓毒症患者麻醉过程中除进行常规监测外,如ECG、SpO2、无创血压、PETCO2、气道压力、呼吸波形和尿量等。术中还进行连续有创动脉血压监测和CVP监测以指导液体治疗,动态监测血糖、动脉血气、血乳酸、血常规、血电解质,以维持水电解质平衡。而且还特别推荐麻醉深度监测,以更准确使用麻醉药,避免麻醉过深带来的并发症。血乳酸水平的恢复一直是指南推荐的液体治疗目标,是反映组织灌注及液体治疗效果的良好指标。
 
(4)循环管理:急性脑梗死后大脑自主调节能力损害,脑自主调节压力窗缩窄;低血压易造成大脑本身的低灌注,易致急性脑缺血性损害加重。脓毒症患者术中循环管理应兼顾患者的容量状况和心脏功能,实行目标导向液体治疗策略,进行合理的输血输液和使用血管活性药物,维持血流动力学稳定。
 
研究报道,在治疗感染性休克时,去甲肾上腺素(NE)可有效改善患者的血压状况。对患者的心率影响少,对肾功能也无明显影响,推荐去甲肾上腺素作为首选升压药物。NE选择性激活α受体,对β作用较弱,在使用中升压效果明显,且可反射性减慢心率,降低心肌氧耗。有研究报道,手术前、后肾功能指标和术中尿量均无明显变化,由此认为,NE可改善肾脏灌注,增加肾小球滤过率,可能有肾脏保护功能。
 
本例患者入手术室时心电图显示房颤,心室率达145次/min,心室率过快可导致血流动力学发生改变,出现心功能不全或加重、心肌缺血加重、左房血栓脱落致动脉系统栓塞及心脏性猝死等严重并发症。因此,尽快控制房颤患者的快心室率显得更加迫切。洋地黄是治疗心力衰竭的经典用药,也广泛用于快速性心律失常,如室上速、房扑、房颤。西地兰能延长房室结的有效不应期,抑制房室传导,减慢心室率,从而改善临床症状。
 
术中通过连续有创动脉血压监测和CVP监测,充分的液体复苏CVP至12~13mmHg,不断调整去甲肾上腺素0.05~0.15ug/(kg·min),使用西地兰控制房颤心室率,不断调整内环境,手术历时6h,共输入乳酸钠林格注射液3050ml,维持有创平均动脉压80~100mmHg,尿量450ml。
 
(5)呼吸管理:脓毒症患者术中需采用肺保护性通气策略,避免机械通气相关性肺损伤。本例患者术中采用小潮气量(6ml/kg)、PEEP 5 cmH2O和肺复张策略等肺保护性通气策略,维持SpO2 99%~100%,PETCO2 35~38mmHg。另外,脑梗死急性期患者常有不同程度的偏瘫和肢体感觉障碍等,术前应仔细了解病情,以便术后对照。本例患者通过严密的监测和精心的麻醉方案设计和麻醉管理,安全渡过围术期。
 
原始出处:

林仙菊,项海飞,王飞.老年脑梗死急性期患者行急腹症手术一例麻醉处理[J].浙江临床医学,2018,(1):183-184.

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#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
    2019-01-10 jyzxjiangqin

    老年脑梗死急性期患者的治疗。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
    2019-01-09 qblt
  5. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
    2019-01-09 zhaojie88
  6. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
    2019-01-08 糖糖的男神

    各位老师,此病例术中可以给胶体吗

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1952604, encodeId=17641952604c0, content=<a href='/topic/show?id=c905103053c1' target=_blank style='color:#2F92EE;'>#麻醉处理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103053, encryptionId=c905103053c1, topicName=麻醉处理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2b4297, createdName=徐岩, createdTime=Fri Sep 13 03:44:00 CST 2019, time=2019-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1678270, encodeId=2a0116e827073, content=<a href='/topic/show?id=12025231333' target=_blank style='color:#2F92EE;'>#急性期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=108, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52313, encryptionId=12025231333, topicName=急性期)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b8027680692, createdName=feifers, createdTime=Mon Sep 30 12:44:00 CST 2019, time=2019-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357737, encodeId=ab0835e73785, content=老年脑梗死急性期患者的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Jan 10 08:04:51 CST 2019, time=2019-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1428563, encodeId=016a1428563a1, content=<a href='/topic/show?id=8d2b525354a' target=_blank style='color:#2F92EE;'>#急腹症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52535, encryptionId=8d2b525354a, topicName=急腹症)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=07ae4095227, createdName=qblt, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1465135, encodeId=a264146513595, content=<a href='/topic/show?id=2dea8489010' target=_blank style='color:#2F92EE;'>#脑梗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84890, encryptionId=2dea8489010, topicName=脑梗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Wed Jan 09 09:44:00 CST 2019, time=2019-01-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357598, encodeId=786935e5986f, content=各位老师,此病例术中可以给胶体吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLVddVxRRGG7yq68dfU0nBF9bMwVPNxjn3gISDKZcrxkZETibsX0cgPjOcI1cBAn2rR5xFszUXYd9Q/132, createdBy=b0502315675, createdName=糖糖的男神, createdTime=Tue Jan 08 23:21:31 CST 2019, time=2019-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357505, encodeId=2bad35e5058b, content=可惜了,没有手术记录, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b3f2513785, createdName=124c5476m20暂无昵称, createdTime=Tue Jan 08 01:46:19 CST 2019, time=2019-01-08, status=1, ipAttribution=)]
    2019-01-08 124c5476m20暂无昵称

    可惜了,没有手术记录

    0

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