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脱机的时机与策略

2021-08-18 赣州五院周兆斌 知行肺康复

当需要呼吸机支持的病因被去除,患者恢复自主呼吸能力时,及时撤离呼吸机对于患者恢复和减少并发症十分重要。延迟撤机将增加医疗费用和并发症发生的概率;过早撤机又可能导致脱机失败,增加再插管率与疾病死亡率。因

当需要呼吸机支持的病因被去除,患者恢复自主呼吸能力时,及时撤离呼吸机对于患者恢复和减少并发症十分重要。延迟撤机将增加医疗费用和并发症发生的概率;过早撤机又可能导致脱机失败,增加再插管率与疾病死亡率。因此,明确的脱机时机与方法对于机械通气患者来说至关重要。脱机是指从机械通气开始,逐步降低机械通气水平,逐步恢复患者自主呼吸,直至患者完全脱离呼吸机的过程。

一、脱机的时机判断

有部分精通呼吸生理知识、经验丰富的专业医师常能通过比较简单的方法预测患者能否成功撤机、如何撤机,但多数人还是通过筛查指标来指导临床撤机,从而减少对呼吸生理知识和临床经验的依赖,增加撤机的成功率,避免机械通气时间的不必要延长,避免或减少呼吸机依赖的发生。常用四大指标评估是否可以撒离呼吸机:①呼吸机支持指征的逆转;②气体交换;③自主呼吸的能力;④血流动力学稳定性。

 · 1.1. 呼吸机支持指征的逆转

撤离呼吸机最重要的指标是引起需要使用呼吸支持的原因得到纠正,这些原因除呼吸衰竭外,还包括发热,营养不良,电解质失衡,肝、肾或胃肠功能紊乱等都会对呼吸机撤离带来负面影响,因此需要纠正这些异常指标。

 · 1.2 气体交换

在开始撤机之前, 需要有良好的气体交换。吸人氧气浓度≤40%,PaO2≥60mmHg,同时呼气末正压(PEEP) ≤8cmH20是氧合能力指标。对于pH>7.30, 死腔量比值(VD /VT) <60%,分钟通气量VE<12L/min则预示脱机成功。

 · 1.3 自主呼吸能力 

要撤离呼吸机,患者必须有足够多的自主呼吸能力,即呼吸中枢驱动正常(准备脱机前需去除镇静状态,每日SAT实验);呼吸泵功能足够(MIP可较全面地评价吸气肌力量(主要是膈肌的力量) 。MIP<-25mmHg可较好地预测成功撤机, 主要用于神经-肌肉疾病和COPD慢性呼吸衰竭的评价。但长期机械通气可降低MIP的预测能力, 因为患者常有呼吸肌的失用性萎缩,即使肌力足够,但耐力下降,容易撤机失败)。

 · 1.4 血流动力学稳定

呼吸机撤离之前需要有最佳的心血管功能,及时处理心律失常、液体负荷过重和心肌收缩乏力有利于撤机成功。撤机前患者必须是在无或最小的心血管支持下(如多巴胺或多巴酚丁胺<5~10ug/(kg·min)血流动力学稳定,没有心肌缺血,没有心律失常。

二、SBT实验(自主呼吸试验)

自主呼吸试验(spontaneous breathing trial, SBT) 是临床上判断患者自主呼吸功能的有效方法。其基本方法是短期降低呼吸机支持水平或断开呼吸机后,观察患者自主呼吸情况及各项生理指标的变化,以对患者的自主呼吸能力做出判断, 并为撤机提供参考。大量研究证实,SBT可为临床判断患者能否成功撤机提供信息,能耐受SBT的患者撤机成功率高,可考虑撤机。Esteban等对546名患者研究显示,有84%耐受SBT的息者撤机成功。其他研究也证实了能耐受SBT的患者撤机成功率在77%~96%。此外, SBT的实施非常安全。目前尚无数据显示SBT可直接导致任何的不良后果。因此,具备撤机条件的患者均应进行SBT。

在预定的试验时间内,若未达终止试验标准,则表示试验成功,可考虑撤机。要值得注意的是,撤机不同于拔管。一旦患者出现脱机失败表现,应立即终止脱机,积极寻找原因,等患者稳定后可再评估。再次 SBT 需与前次间隔 24 小时,重复直至脱机。

三、机械通气常用的撤机方法

机械通气常用的撤机方法主要有:直接停机、单独T管法或T管联合CPAP法、间断停机法、SIMV法、PSV法、SIMV+PSV法等。一般为单独使用上述方法或联合、序贯使用上述几种方法完成撤机过程。

 · 3.1 直接停机法

指不经过任何器械和辅助撤机方法完成整个撤机过程,对于外科手术机械通气不超过24h的患者非常容易完成早期撤机和拔管。Quasha等发现冠状动脉搭桥术后2h拔管与术后18h拔管心、肺并发症的发病率无差异。对于机械通气时间不需要超过24h的患者,如补液过度和高血压导致的心源性肺水肿、速发型支气管哮喘、某些药物过量、痰堵和咯血窒息患者,因病因迅速去除,患者的自主呼吸能力迅速恢复或呼吸阻力迅速降低,一般也可直接停机。

 · 3.2 T管撤机法

指气管插管或气管切开患者经T形塑料管呼吸湿化、温化的气体,自主呼吸稳定后的撤机方法。与其他撤机技术(如SIMV、PSV撤机) 比较, T管撤机属于完全自主性呼吸, 撤机后不容易发生心、肺功能紊乱。1.基本要求①应用T管撤机时,必须充分抽出导管气囊内的气体,且应从辅助通气开始,而不是从控制通气开始,以免引起患者的不适应。②试验过程中,若出现呼吸肌疲劳的表现就应停止,而不应该根据“所谓的”“预先设定的训练时间的长短及频率”终止。③如果撤机失败,在随后的24h内无须尝试其他撤机方案。

 · 3.3 SIMV撤机法

SIMV撤机法是经典撤机方法之一,其过程包括逐渐减少通气次数和逐渐增加自主呼吸次数。指令性辅助通气与自主呼吸相互交替,有益于逐渐完成撤机过程。对于机械通气患者,每30min/1小时减少flmv,flmv达4次/分,患者呼吸稳定2—4小时,并维持良好的气体交换功能,可考虑撤机。

 · 3.4 PSV撤机法

PSV属自主性通气模式, 其支持压力还能对抗气管插管和呼吸管路所增加的呼吸功,补充导管阻力增大所致的自主呼吸不足,使患者更为舒适,有助于提高患者的依从性和撤机成功率。若支持压力降低至5-7cmH2O,维持4-6H,说明患者自主呼吸能力能够克服通气阻力,可考虑脱机。

四、 脱机失败

机械通气>24h尝试撤机失败的患者,应寻找所有可能引起撤机失败的原因,尤其是一些潜在的、可逆的原因。常见的原因包括:①神经系统因素:代谢性或药物性因素导致呼吸中枢和(或)外周神经功能失常,②呼吸系统因素。呼吸肌方面包括失用性肌萎缩,严重的神经性肌病或药物导致的肌病等;③代谢因素:营养、电解质和激素都是影响呼吸机功能的代谢因素。④心血管因素:对心功能储备较差的患者,降低通气支持可诱发心肌缺血或心力衰竭。⑤心理因素:恐惧和焦虑是导致撤机失败的非呼吸因素。

当SBT失败的原因纠正后, 每日进行一次SBT试验, 没有必要一天内多次反复进行SBT。呼吸系统异常很少在数小时内恢复, 一天内频繁行SBT对患者没有帮助。研究表明, SBT失败的原因常是呼吸系统机械力学的异常,而这些异常不能迅速恢复。SBT失败后机械通气应选择恒定的支持水平, 以保证患者的呼吸肌充分休息, 这可以大大地缩短训练的时间。所以在SBT失败后的24h应该让肌肉休息、舒适(包括使用镇静剂) 和避免并发症, 而不是积极地降低通气支持的水平。 

参考文献:

[1]机械通气/朱蕾主编.-4版.上海:上海科学技术出版社,2017.1(2019年重印)

[2]呼吸内科急危重症/梁名吉主编.一北京:中国协和医科大学出版社,2018.1(临床实用急危重症系列丛书)ISBN 978-7-5679-0741-6

[3]机械通气学:生理学与临床应用/(美) 凯罗(Cairo,J.M.) 主编;卞金俊,邓小明译.一北京:人民卫生出版社,2014ISBN 978-7-117-19688-8

[4]机械通气精要/(美) 迪恩R.赫斯(Dean R.Hess) 原著;袁月华主译.一北京:人民卫生出版社,2016ISBN 978-7-117-22752-0

[5]危急重症急救技术规范和实践/黄东胜,杨向红主编.一杭州:浙江大学出版社,2017.5(2017.7重印)ISBN 978-7-308-16319-4

来源:知行肺康复

作者:赣州五院周兆斌

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    收藏

    0

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    2021-08-18 ms3000000797286593

    学习了

    0

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    2021-08-18 1244c0ebm28暂无昵称

    学习学习

    0

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    2021-08-18 小火龙111

    学习到了

    0

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    2021-08-18 小火龙111

    很详细

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1009428, encodeId=8b0a10094282f, content=收藏, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2822321865, createdName=DR Yao, createdTime=Thu Aug 19 11:42:24 CST 2021, time=2021-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009273, encodeId=b2ed10092e347, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=12515511056, createdName=ms3000000797286593, createdTime=Wed Aug 18 21:47:54 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009081, encodeId=041810090817b, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e8212476654, createdName=1244c0ebm28暂无昵称, createdTime=Wed Aug 18 14:44:07 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009060, encodeId=eb7610090604e, content=学习到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:48 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009059, encodeId=87cb10090591a, content=很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:44 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009058, encodeId=8a8d100905821, content=很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:38 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009057, encodeId=0011100905e9c, content=不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:31 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009056, encodeId=36891009056a3, content=好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:27 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009055, encodeId=5eec1009055cd, content=cnice, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:22 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009054, encodeId=1e9a100905488, content=nice, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:20 CST 2021, time=2021-08-18, status=1, ipAttribution=)]
    2021-08-18 小火龙111

    很有用

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1009428, encodeId=8b0a10094282f, content=收藏, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2822321865, createdName=DR Yao, createdTime=Thu Aug 19 11:42:24 CST 2021, time=2021-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009273, encodeId=b2ed10092e347, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=12515511056, createdName=ms3000000797286593, createdTime=Wed Aug 18 21:47:54 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009081, encodeId=041810090817b, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e8212476654, createdName=1244c0ebm28暂无昵称, createdTime=Wed Aug 18 14:44:07 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009060, encodeId=eb7610090604e, content=学习到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:48 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009059, encodeId=87cb10090591a, content=很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:44 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009058, encodeId=8a8d100905821, content=很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:38 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009057, encodeId=0011100905e9c, content=不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:31 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009056, encodeId=36891009056a3, content=好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:27 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009055, encodeId=5eec1009055cd, content=cnice, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:22 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009054, encodeId=1e9a100905488, content=nice, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:20 CST 2021, time=2021-08-18, status=1, ipAttribution=)]
    2021-08-18 小火龙111

    不错

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1009428, encodeId=8b0a10094282f, content=收藏, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2822321865, createdName=DR Yao, createdTime=Thu Aug 19 11:42:24 CST 2021, time=2021-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009273, encodeId=b2ed10092e347, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=12515511056, createdName=ms3000000797286593, createdTime=Wed Aug 18 21:47:54 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009081, encodeId=041810090817b, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e8212476654, createdName=1244c0ebm28暂无昵称, createdTime=Wed Aug 18 14:44:07 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009060, encodeId=eb7610090604e, content=学习到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:48 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009059, encodeId=87cb10090591a, content=很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:44 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009058, encodeId=8a8d100905821, content=很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:38 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009057, encodeId=0011100905e9c, content=不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:31 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009056, encodeId=36891009056a3, content=好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:27 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009055, encodeId=5eec1009055cd, content=cnice, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:22 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009054, encodeId=1e9a100905488, content=nice, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:20 CST 2021, time=2021-08-18, status=1, ipAttribution=)]
    2021-08-18 小火龙111

    好的

    0

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    2021-08-18 小火龙111

    cnice

    0

  10. [GetPortalCommentsPageByObjectIdResponse(id=1009428, encodeId=8b0a10094282f, content=收藏, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2822321865, createdName=DR Yao, createdTime=Thu Aug 19 11:42:24 CST 2021, time=2021-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009273, encodeId=b2ed10092e347, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=12515511056, createdName=ms3000000797286593, createdTime=Wed Aug 18 21:47:54 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009081, encodeId=041810090817b, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e8212476654, createdName=1244c0ebm28暂无昵称, createdTime=Wed Aug 18 14:44:07 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009060, encodeId=eb7610090604e, content=学习到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:48 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009059, encodeId=87cb10090591a, content=很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:44 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009058, encodeId=8a8d100905821, content=很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:38 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009057, encodeId=0011100905e9c, content=不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:31 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009056, encodeId=36891009056a3, content=好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:27 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009055, encodeId=5eec1009055cd, content=cnice, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:22 CST 2021, time=2021-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1009054, encodeId=1e9a100905488, content=nice, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210817/23cddf8b4fd64eb993e1ce0dc039919a/a5d2416ef1744efb8a761e2b41df007f.jpg, createdBy=f9635507778, createdName=小火龙111, createdTime=Wed Aug 18 14:25:20 CST 2021, time=2021-08-18, status=1, ipAttribution=)]
    2021-08-18 小火龙111

    nice

    0

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