成功抢救左心衰患者:明确病因 争分夺秒

2017-10-12 孟新科 潘景业 急危重症实战攻略---评价、推断、决策、

25岁女性患者,发热、胸闷及呼吸困难,入院时考虑“急性心肌炎”。患者急性起病,生命体征不平稳,结合心电图初步诊断为急性左心衰原因待查。进行一般处理措施的同时,尽可能快地明确引起左心衰的病因与诱因。本例最终确诊为暴发性心肌炎合并急性左心衰竭。病因如何推断?抢救成功的经验有哪些?详见本例要点——

25岁女性患者,发热、胸闷及呼吸困难,入院时考虑“急性心肌炎”。患者急性起病,生命体征不平稳,结合心电图初步诊断为急性左心衰原因待查。进行一般处理措施的同时,尽可能快地明确引起左心衰的病因与诱因。本例最终确诊为暴发性心肌炎合并急性左心衰竭。病因如何推断?抢救成功的经验有哪些?详见本例要点——

【接诊时病例资料】

患者女,25岁,因“发热、咳嗽3天,胸闷、呼吸困难2天”入院。入院前5天因劳累受凉后出现发热、咽痛伴咳嗽,自服“泰诺感冒片,清开灵”(具体用法不详)2天后体温正常,仍有咳嗽,未再服药,继续上班1天。入院前1天,开始出现胸闷、心悸,单位医务室给予吸氧、青霉素、利巴韦林治疗等治疗,补液2500ml,症状无缓解,且出现呼吸困难,不能平卧,考虑为“急性心肌炎”转入院。既往体健,入院查体:T 37.8℃,P 132次/分,R 26次/分,BP 80/49mmHg,意识清楚,急性病容,端坐位,呼吸急促,口唇及四肢发绀,颈静脉无充盈。双肺呼吸音粗,可闻及明显湿啰音,心界不大,心率132次/分,闻及奔马律,心音低钝,节律齐,A2>P2,各瓣膜听诊区未闻及杂音。腹软,肝脾未扪及,双下肢无水肿。

急诊科实验室检查:WBC 7.1×109/L,N 0.83,Hb 125g/L,HCT 38.5%,PLT 134×109/L;血生化示:CK 929U/L,CK-MB 312U/L,LDH 2810U/L,ALT 76U/L;cTnI 16.81ng/ml;肾功能、电解质正常。动脉血气分析:pH 7.31,PaO2 122mmHg,PaCO2 27mmHg,BE -4mmol/L。心电图:表现为异常Q波,前壁单向曲线ST段抬高。

【病情严重程度快速评估】

患者急性起病,突出症状为胸闷,呼吸困难(呼吸频率26次/分),不能平卧,伴发绀、血压低(80/49mmHg),生命体征不平稳,EWS评分6分以上,结合加拿大急诊类治疗标准,需立即收重症监护室治疗。体查发现双肺呼吸音粗,心率快,奔马律,A2>P2,急诊心电图:表现为异常Q波,前壁单向曲线ST段抬高。初步诊断为:急性左心衰原因待查。患者潜在风险是心力衰竭进一步加重,心源性休克难以纠正,最后出现循环衰竭,以致死亡。也要注意,患者可能发生恶性心律失常(包括窦性停搏、严重传导阻滞、室颤等)而导致心源性猝死。

【启动首轮抢救程序】

该患者首先的抢救策略是针对急性左心衰竭。处理程序包括如下四个方面:急救措施、诱因治疗、基本病因治疗、预防进一步损伤。

1.急救措施

有效的治疗应迅速开始,同时全面评估患者,首先应从可引起呼吸困难和低氧血症的病因作出较正确判断,因急性心力衰竭有许多促发因素,针对特定促发因素的治疗,是最有效的。

2.一般措施

(1)体位:

使患者取坐位或半卧位,两腿下垂,减少静脉回心血量。

(2)氧疗:

一般用鼻导管法或面罩法,流速5~6L/min,使动脉血PaO2保持80mmHg以上,湿化瓶内可放入20%~40%乙醇,或加甲基硅油消泡剂,有抗泡沫作用,如患者反应迟钝,pH>7.10;PaCO2>70mmHg,PaO2<60mmHg,即应气管内插管机械辅助间歇性正压呼吸(intermittent positivepressure breathing,IPPB),若单用IPPB而PaO2不能维持60mmHg以上时可用PEEP,可增加肺的功能残气量,减轻肺泡萎陷并可抑制静脉回流,但需注意调节,以免影响右心搏出量减少而导致左心搏出量降低和血压下降。

3.药物治疗

(1)吗啡:

无论由何种原因引起肺水肿,均可及早给予静脉注射,小剂量吗啡可减轻后负荷,对严重左心衰竭的患者可以提高每搏输出量和心输出量,吗啡使静脉血管扩张,使回心血量减少,抑制反射性呼吸中枢的兴奋性,以减少过度换气减轻呼吸困难。但有慢性肺部疾患伴有肺功能不全、肺心病、休克、颅内出血及神志不清等不宜用。吗啡用量每次2~3mg静脉注射或皮下注射5~10mg。治疗终点的判定为焦虑减轻,呼吸困难缓解。用药后应密切监测副作用如呼吸抑制和低血压。呼吸抑制可用纳洛酮0.4~1mg拮抗,但该药也可加快心率,增加心肌氧耗,拮抗吗啡良好有改善血流动力学作用。

(2)利尿剂:

呋塞米20~40mg或布美他尼1~2mg静脉注射,但并发急性心肌梗死左心衰时应慎用,因此类心衰血容量增多不明显,以免引起低血压,如病情需要时可于15~20分钟后重复注射,利尿剂可降低心脏前负荷。但要防止过度利尿导致低血钾,血容量急剧降低,也可引起休克。

(3)正性肌力药物:

多巴胺可以作为正性肌力药>2μg/(kg?min)用于急性心衰伴有低血压的患者。当静脉滴注低剂量≤2~3μg/(kg?min)时,它可以使失代偿性心衰伴有低血压和尿量减少的患者增加肾血流量,增加尿量。但如果无反应,则应停止使用。

多巴酚丁胺用于外周低灌注(低血压,肾功能下降)伴或不伴有淤血或肺水肿,使用最佳剂量的利尿剂和扩管剂无效时。多巴酚丁胺常用来增加心输出量。它的起始静脉滴注速度为2~3μg/(kg?min),无需负荷量。静脉滴注速度根据症状、尿量反应或血流动力学监测结果来调整。它的血流动力学作用和剂量成正比,速度可以增加到20μg/(kg?min)。在静脉滴注停止后,它的清除也很快,因此它是一个很方便的正性肌力药。洋地黄在急性心力衰竭,对心动过速如心房颤动诱发的心力衰竭,若其他药不能有效地控制心率,是使用洋地黄的一个指征。在急性心力衰竭时,严格控制快速心律失常的心率能缓解心力衰竭的症状。洋地黄的禁忌证包括心动过缓,二度或三度房室传导阻滞,病态窦房结综合征,颈动脉窦过敏综合征,预激综合征,肥厚梗阻型心肌病,低钾血症和高钙血症。因此在伴随急性心肌梗死的急性心力衰竭,不推荐给予具有正性肌力作用的洋地黄。

(4)血管扩张剂:

对大多数急性心衰患者,又有少尿及淤血体征,血管扩张剂常作为一线药,它可以用来开放外周循环,降低前负荷。

硝酸盐:急性左心衰时,硝酸盐在不减少每搏量和增加心肌氧耗的情况下能减少肺淤血,特别适用于急性冠脉综合征的患者。在AHF的两个随机试验证实了静脉给予硝酸盐联合呋塞米的有效性,同时也表明,静脉滴注最高血流动力学可耐受剂量的硝酸盐加低剂量的呋塞米,优于单独使用高剂量的利尿药。硝酸盐的缺点主要是很快发生耐药性,特别是静脉使用过高剂量时,使它的有效期限制在16~24小时。硝酸盐的使用剂量应取得最佳的扩管效应,降低肺动脉楔压,由此增加心脏指数(cardiac index,CI)。不当的扩管可导致血压显著下降,血流动力学不稳定。

硝酸甘油可以口服或吸入。静脉给予硝酸盐(硝酸甘油从20μg/min或硝酸异山梨酯1~10mg/h)的量应极为小心,密切监测血压,静脉滴注的剂量应防止血压下降。对于主动脉狭窄的患者,虽然在复杂情况下使用硝酸盐会有所帮助,但应特别谨慎。如果收缩压降至90~100mmHg以下,硝酸盐应减量,如果血压降得更多,则长时间停止使用。

硝普钠:对于严重心衰患者和原有后负荷增加的患者(如高血压心衰或二尖瓣反流),推荐使用硝普钠[从0.3μg/(kg?min)滴注仔细加量至1μg/(kg?min)再到5μg/(kg?min),最大极量可短时达到10μg/(kg?min)]。

硝普钠应该小心滴注,通常需要有创性动脉血压监测,密切监护。长期使用时其代谢产物硫代氰化物和氰化物会产生毒性反应,特别是在严重肝肾衰竭的患者应避免使用。急性心衰时硝普钠的使用尚缺乏对照试验,而且在AMI时使用,其结果也有争议。硝普钠应该缓慢减量以避免反跳反应。在急性冠脉综合征所致的心衰患者,硝酸盐的使用要优于硝普钠,因为硝普钠可能引起冠脉窃血综合征。

奈西立肽(nesiritide):这是一类新的血管扩张剂,近期被用以治疗AHF。它是人脑型利钠肽(BNP)的重组体,是一种内源性激素物质。它能够扩张静脉、动脉、冠状动脉,由此降低前负荷和后负荷,在无直接正性肌力的情况下增加心输出量。

(5)β受体激动剂:

多巴酚丁胺,如前述及,本品仅供静脉使用,药效作用出现快,15分钟后心排血量增加,左室舒张末压,外周血管阻力、肺毛细血管楔嵌压均下降,本药半衰期短,剂量范围2.5~10μg/(kg?min)可增加心肌收缩力,同时降低后负荷,增加心排血量,此剂量对血压无影响,这就可能增加冠脉和心肌灌注。

4.诱因治疗

急性左心衰的发生常在心脏病的基础上合并某些诱因。最常见者有感染、心动过速、输液过多、急性心肌缺血或心肌梗死、肺栓塞、甲亢或严重贫血。需积极寻找诱因并予以针对性治疗。注射抗心律失常药无效,可及时电击复律。高血压危象采用硝普钠静滴。

5.心电监护

包括监测心率(律)、脉搏和血氧饱和度;必要时监测中心静脉压,漂浮导管监测心功能。抢救同时及时书写病程记录,记录抢救经过情况,开病危通知书,随时向患者家属通报病情变化情况。

6.急性心力衰竭的基础疾病和并发症的治疗

急性冠脉综合征(不稳定心绞痛或心肌梗死)并发AHF时,需要进行冠状动脉造影急诊经皮冠状动脉介入(percutaneous transluminal coronary intervention,PCI)应尽早考虑,如有适应证应及时进行。如果既没有PCI又无外科条件需要长时间等待,则推荐及早行溶栓治疗。

急性主动脉夹层(特别是Ⅰ型)可能表现为心力衰竭症状伴或不伴疼痛。疼痛过后,心力衰竭可能成为主要症状。急性心力衰竭通常与高血压危象或急性主动脉关闭不全有关。及时诊断和外科会诊是必需的。手术干预的速度通常是生死攸关的。

高血压危象相关的急性心力衰竭几乎总表现有肺淤血,其程度可能为轻度至重度的肺水肿不等。由于它发作迅速所以被称作“闪电(flash)肺水肿”。必须给予快速针对性的治疗。高血压急性肺水肿治疗的目标是降低左室前后负荷,减轻心肌缺血,保持足够的通气以利肺水肿的消除。

对于严重肾衰竭和顽固性体液潴留患者可发生急性左心衰,持续静-静脉血液滤过(continuous venous-venous hemofiltration,CVVH)可能是必要的。联用正性肌力药可增加肾血流,改善肾功能并恢复利尿剂的疗效。

缓慢性心律失常急性心力衰竭时,通常首先应用阿托品0.25~0.5mg静脉注射,必要时重复使用。在房室阻滞伴心室率低下时,可以考虑应用异丙肾上腺素2~20μg/min,但在缺血状态下应当避免使用。在药物治疗无效时应当置入临时起搏器。室上性心动过速室上性快速心律失常可能是急性心力衰竭的原因或并发症。急性心力衰竭合并室上性快速心律失常治疗建议:急性心力衰竭伴心房颤动时控制心室率是很重要的,特别是患者存在舒张功能不全时。应根据需要迅速控制心室率或复律。

【病因思考快速扫描】

首先急性左心衰需与支气管哮喘鉴别,后者常有以往反复发作史,出汗和发绀不太明显,肺部哮鸣音常为高调,鼾音和湿性啰音较肺水肿为少。大量粉红色泡沫痰和心尖部舒张奔马律有助于诊断肺水肿。近年BNP和NT-proBNP的临床广泛应用,为鉴别呼吸困难是否为心源性提供了一个敏感性、特异性均较高的实验室指标,有条件的单位应该合理应用。患者入院后立即进行急性左心衰的一般处理措施,同时重点应积极治疗原发病,对于病情的缓解及挽救生命有很大的意义。因此应尽可能以最快的速度明确引起左心衰的病因与诱因。

1.急性重症心肌炎

该患者为25岁年轻患者,发病前有发热,上呼吸道症状,随后出现胸闷,呼吸困难,入院时左心衰,休克的表现,心电图表现为异常Q波,前壁单向曲线ST段抬高支持暴发型心肌炎的诊断。需动态检查心电图和心肌损伤生化标志物、肌钙蛋白等心肌损伤标志物,综合分析可作出正确诊断。

2.急性心肌梗死(AMI)

虽然急性心肌梗死多在有冠心病的基础上发病,以中老年发病多见,但是近年来,心肌梗死的发病有年轻化的倾向,特别是临床上有很多暴发性心肌炎的发病酷似心肌梗死,造成误诊。因此该患者还需与急性心肌梗死鉴别。重症病毒性心肌炎有以下特征:①常见于青壮年,发病前或发病时常有呼吸道、消化感染史,且常伴发热,三度房室传导阻滞及阿-斯综合征发生率较高。②心肌炎心肌损伤生化标志物的改变并没有心肌梗死显著,即使是暴发性心肌炎其CPK也中度升高,范围在200~1000U/L。③心电图损伤性改变显著,病理性Q波常呈一过性可逆性改变,经适当治疗一般2~3天内消失。④ST段抬高和无对应性ST段压低。⑤病理性Q波与ST抬高发生的导联“不吻合”,且不能用某支冠状动脉阻塞来解释。而AMI其病理性Q波逐渐加深、加宽、范围扩大或出现等电位性Q波,其心电图主要以异常Q波和ST段抬高为主,同时伴有明显的胸痛、低血压、休克等临床症状。ST段抬高时,常存在镜像改变或对应性ST段改变。心内膜下心肌损伤导致心内膜下心电图上ST段抬高,非缺血的心外膜电图出现对应ST段下移。ST段抬高时,对应性ST段压低在梗死发生时的几小时内ST段压低明显,不同部位的急性心肌梗死伴发的对应部位不同。急性心肌梗死时,典型的心电图能够可靠地预测出相关“责任”血管。

3.肺栓塞

肺栓塞的临床表现无特异性,各年龄层次均可发病,当肺栓塞面积达50%~60%时可导致肺动脉压明显增高,临床上出现类似心绞痛的剧烈胸痛。由于心排血量的急剧下降,患者出现烦躁不安、恶心、呕吐、心慌、发绀、出冷汗及血压下降等休克的表现。还有急性发作不能解释的呼吸困难:肺栓塞导致的呼吸困难主要表现为气短和呼吸频率加快,超过25次/分。呼吸困难可为一时性的,也可持续存在,但端坐呼吸并不多见,这与心衰的表现不同,肺栓塞患者查体上表现为心率、呼吸频率加快,肺部体查无明显异常发现,血压可下降,心电图表现为SIQIIITIII,心肌损伤生化标志物可不升高,D-二聚体有助于筛查

【实战经过真实回放】

入院后立即进行心电图、血压、脉搏、呼吸频率和SpO2监测,心肌损伤生化标志物示:CK 929U/L,CK-MB 128U/L,LDH 810U/L,ALT 76U/L;cTnI 14.81ng/ml;血常规及肾功能、电解质均正常;BNP 6349pg/ml;动态复查12导联心电图,床旁胸片示:心腰饱满,右房增大,肺淤血表现。患者入院时呼吸急促,不能平卧,BP 80/49mmHg,SpO2 77%,四肢湿冷,脉搏细速,HR 143次/分,律齐,心音低钝,两肺广泛湿啰音。诊断为:重症心肌炎;急性心力衰竭;心源性休克;心功能Ⅳ级。开始给予面罩高流量吸氧,建立双静脉通路,一路为升压药维持血压,一路为扩血管药物,减轻心脏前后负荷,同时予以抗感染、抗病毒等药物治疗一天,患者呼吸困难仍不能改善,血压一直偏低,第2天转入ICU,行经鼻气管插管机械通气,给予PEEP 12cmH2O、吸入氧浓度(FiO2)100%机械通气支持,改善缺氧与肺水肿。考虑到暴发性心肌炎,给予甲泼尼龙240mg减轻心肌水肿与炎症,共用3天。行肺动脉漂浮导管(Swan-Ganz导管)测中心静脉压(central venous pressure,CVP)6cmH2O,肺毛细血管嵌压(pulmonary capillary wedge pressure,PCWP)38mmHg,混合静脉血氧饱和度(SvO2)45%,心排血指数(CI)1.6L/(min?m2),在血流动力学监测下积极扩容,维持CVP 12~15cmH2O,同时予大剂量升压药维持血压,治疗上改扩血管药为rh-BNP(新活素),采用负荷剂量1.5μg/kg静脉推注新活素,随后按维持剂量0.0075μg/(kg?min)进行微量泵注射。连续使用5天后,胸闷及呼吸困难症状明显好转,血压正常,血流动力学指标基本正常,停漂浮导管监测,并逐渐撤除升压药,复查BNP 4271pg/ml;同时逐步下调PEEP。第7天停呼吸机拔管,生命体征渐趋稳定。

本病例最后诊断——暴发性心肌炎合并急性左心衰竭

诊疗经过剖析与总结】

1.急性左心衰竭的病因推断

针对急性左心衰竭的病因治疗是改善预后的重要环节,因此在进行一般的抢救措施的同时,重视患者的病因推断是本例抢救成功的经验总结。患者呼吸困难,胸闷,心动过速,异常Q波与ST段抬高,心肌损伤生化标志物改变,但鉴于患者年轻女性,发病前有上呼吸道感染病史,仍首诊急性重症心肌炎。若不和急性心肌梗死鉴别,误诊为急性心肌梗死,对其进行抗凝与药物溶栓,甚至行PCI,将有可能造成不良的后果。并且对于急性心梗的患者,使用肺动脉导管的许多回顾性研究显示使用肺动脉导管能增加死亡率。

2.抢救成功的经验

该例患者发病短期内即出现严重心源性休克,心功能衰竭器功能障碍,病情进展十分迅速。患者因心搏出量减少及严重的全身有效循环血量不足,导致全身组织灌注不足,需积极扩容以阻止多脏器功能障碍发展;但积极补液可加重肺水肿,且严重的肺水肿难以在短时间内靠药物缓解,全身组织缺氧将进一步加重。对采用高PEEP机械通气来减少回心血量,减轻压力性肺水肿,改善氧合,并使其耐受积极扩容。Swan-Ganz导管是血流动力学监测的有效手段。利用Swan-Ganz导管监测CVP、PAP、PCWP、CO、SvO2等指标可以指导积极且精确的输液扩容,以及各种血管活性药物的准确应用,并了解心功能和组织缺氧状态的动态变化。

【相关问题深层次解读

1.急性心衰的分类(2008ESC指南)

急性心力衰竭可发生在原有心脏病基础上或作为第一症状首次发作。其临床分类没有统一的标准,以往多根据病因分类。在AHA指南中,将急性心衰按起病的形式分为3类。

(1)代偿期慢性心衰的突然恶化(占住院急性心衰的70%)。

(2)新发的急性心衰(如在急性心肌梗死后;左室舒张功能减退的基础上血压的突然升高(占急性心衰住院的25%)。

(3)晚期心衰(顽固性心衰)伴心功能进行性恶化(占急性心衰住院的5%)。这一分类较为笼统,对于治疗没有指导意义。

ESC将急性心衰按其临床特征进行了更详细的分类,共分为6类。

(1)失代偿性心衰(新发或慢性心衰失代偿),伴有急性心衰的症状、体征,轻到中等度心衰,未达到心源性休克,肺水肿或高血压危象的标准。

(2)高血压型急性心衰:急性心衰的症状和体征,同时伴有血压升高,左室功能部分失代偿,胸片提示符合急性肺水肿的改变。

(3)肺水肿(X线证实):伴有严重的呼吸困难,双肺湿啰音和端坐呼吸,未吸氧时氧饱和度<90%。

(4)心源性休克:指在纠正前负荷的情况下,由于心衰导致的组织低灌注。尽管对这一型心衰的血流动力学指标没有明确的定义,但心源性休克通常表现为血压下降(收缩压<90mmHg,或平均动脉压下降>30mmHg)和(或)少尿[<0.5ml/(kg?h)],脉搏>60次/分,伴或不伴器官充血的证据。低心排量综合征与心源性休克呈连续性变化,缺乏明确的界线。

(5)高心排量心衰:指心排量增加,通常伴有心率增快(由心律失常、甲亢、贫血、佩吉特病、医源性或其他机制),外周组织温暖,肺充血,在感染性休克时,有时可出现血压下降。

(6)右心衰:特点为低心排量,颈静脉压增加,肝大和低血压。

2.急性心衰患者的器械检查和监测
到达急诊室后,急性心衰患者应尽快接受监护,同时应进行相关的检查以尽早明确原发病因。监测的内容与严密程度取决于患者的病情、治疗反应和急诊室的条件。

(1)无创监测:

所有危重患者常规监测内容包括:体温、呼吸、心率、血压及心电图。有些实验室检查应反复重复,动态观察,如电解质、心肌损伤生化标志物、肌酐、血糖、感染指标或其他代谢性疾病指标。必须严格控制高血钾或低血钾,这些指标都可通过自动检测仪快速准确的监测。监测的频率应随病情变化而调整。在心衰失代偿期间,应进行心电监测(心律和ST段),特别是由于缺血和心律失常导致的心衰加重的患者。

在治疗过程中,血压监测非常重要,需要定时测量(比如每5分钟一次),直到血管活性药物、利尿剂以及正性肌力药物剂量稳定后。在血管收缩不严重及心率不很快时无创血压测量是可靠的。指脉搏血氧监测是测量动脉氧与血红蛋白结合饱和度的无创装置(SpO2)。指脉搏血氧计测得的SpO2通常与联合血氧计测量结果相差在2%以内,但伴有休克时这一误差增大。在接受吸氧治疗的不稳定患者应连续监测指脉搏血氧饱和度。在任何急性失代偿期心衰接受氧气治疗的患者应连续监测末梢血氧饱和度。

(2)有创监测

1)动脉置管:

置入动脉导管的指征是因为血流动力学不稳定需要连续监测动脉血压或需要多次动脉血气分析。置入导管型号为20号,2英寸(5.1cm)长的桡动脉导管时并发症最低。

2)中心静脉置管:

中心静脉置管连通中心静脉循环,所以可用于输注液体和药物,也可监测CVP及静脉氧饱和度(SvO2)(上腔静脉或右心房处),后者可以评估氧的运输情况。在分析右房压力时应慎重,避免过分强调右房压力,因为在急性心衰患者右房压力与左房压力几乎没有关系,因而与左室充盈压也无关。CVP也会受到重度三尖瓣关闭不全及PEEP的影响。

3)肺动脉导管:

肺动脉导管(pulmonary artery catheter,PAC)是一种漂浮导管,用于测量上腔静脉(SVC)、右房、右室、肺动脉压力、肺毛细血管楔压以及心输出量。现在的导管能半连续的监测心输出量、混合静脉氧饱和度、右室舒张末容积和射血分数。根据这些资料可对血流动力学进行综合分析。尽管肺动脉导管置入对急性左心衰诊断不是必需的,但对伴有复杂心肺疾病的患者,它可用来鉴别是心源性机制还是非心源性机制,肺动脉导管监测肺毛细血管楔压及心输出量对指导严重弥漫性肺部疾病患者或持续血流动力学障碍患者的治疗有重要价值。但应记住,在二尖瓣狭窄、主动脉关闭不全、高气道压或左室僵硬(左室肥厚、糖尿病、纤维化、使用正性肌力药物、肥胖、缺血)的患者,肺毛细血管楔压能准确反映左室舒张末压。通常在严重急性左心衰的患者合并有严重三尖瓣反流,而三尖瓣反流对热稀释法测定的心输出量有高估或低估的影响。对于急性心梗的患者,使用肺动脉导管的许多回顾性研究显示使用肺动脉导管能增加死亡率,其实PAC本身对患者并无伤害,而是由于导管的不当操作(右室采用了不恰当的方式)而对患者不利。因此,PAC应主要用于对传统治疗未产生预期疗效的血流动力学不稳定患者,以及合并有淤血和低灌注的患者。在这些情况下,置入肺动脉导管以保证左室最恰当的液体负荷量,并指导血管活性药物和正性肌力作用药物的使用。因为长时间插管增加并发症,只有当需要获得特殊数据时(通常与患者的血容量状态有关),才维持插管,当插管没有更多帮助时(如当利尿剂和血管扩张药达到理想效果时)应立即拔管。在心源性休克和持续严重低心输出量状态时,建议测量肺动脉的混合静脉氧饱和度,从而估计氧释放(利用)情况(SpO2-SvO2)。在急性左心衰时,应使肺静脉SvO2>65%。

3.机械通气在急性左心衰中的治疗作用

近年来,随着无创呼吸机的广泛应用,对患者早期采用无创呼吸机正压给氧已成为基本治疗原则。急性左心衰时患者常表现为严重的呼吸困难,患者为维持适当的肺泡通气,常产生非常大的胸腔负压,从而增加左室跨壁压,左室后负荷增加,导致心输出量进一步下降,同时也更易发生呼吸肌疲劳。即便给予充分补氧和适当药物治疗,有些急性左心衰患者仍发生顽固性低氧血症和高碳酸血症,这部分患者是由于氧输送仍不能满足机体需要所致。迅速有效地纠正缺氧是抢救急性左心衰竭的关键。机械通气可迅速纠正低氧血症,机械通气不仅改善气体交换,而且直接改善心功能。可能机制为:

(1)改善气体交换,提高PaO2:

①增加肺泡内和肺间质静水压,有利于肺泡和肺间质液回流入血管腔,改善肺泡内和肺间质水肿;②BiPAP使肺泡毛细血管周围压力升高,而对肺泡外毛细血管影响较小,促进水分由肺泡区向肺间质区移动;③扩张陷闭肺泡;④增加功能残气量和改善肺组织顺应性,总体上减少肺血流量,改善通气/血流比例。

(2)改善心功能:

①降低左心室后负荷,即左心室跨壁压(跨壁压:心室内压-胸腔内压),BiPAP呼吸机通气使胸腔内压升高,心室跨壁压下降,必然伴随心输出量增加,这是BiPAP改善心功能的主要机制,与用药治疗有很大不同,能在不降低动脉血压的情况下降低后负荷;②前、后负荷的降低必然伴随心肌张力的下降,使冠状动脉供血改善。

急性左心衰竭发生时,左心排血量急剧减少左室舒张末期容积增加,导致舒张末压急剧增高肺静脉回流不畅产生肺淤血,肺淤血是急性左心衰竭引起低氧血症的主要原因。因缺氧可加重肺淤血,诱发缺血性脑病及肝肾功能损害。故积极纠正缺氧是抢救急性左心衰竭的关键,机械通气是纠正低氧血症有效的方法之一。在呼吸机支持下,联合使用利尿、扩血管、强心、镇静等治疗效果更好。

BiPAP通气操作简单、副作用少,可减少有创通气的相关并发症。只要患者神志清醒,能配合呼吸,痰液不多,在开始应用时设置IPAP水平在6~10cmH2O,EPAP水平在3~5cmH2O,逐渐上调,同时给予患者充分的解释、安慰,大多能收到较好的效果。一旦出现病情无改善、神志不清或呼吸浅慢等情况要及时转为气管插管通气;或患者用无创通气半小时以上症状无缓解,SpO2不升高,应停用无创通气。早期应用双水平正压无创通气(BiPAP)救治急性左心衰竭,合理掌握适应证及禁忌证有较好的临床效果。

4.血液净化与急性左心衰

急性心力衰竭患者存在严重血流动力学的不稳,组织灌注差,造成内环境紊乱,如代谢性酸中毒,电解质紊乱,并使肾素-血管紧张素-醛固酮系统激活,儿茶酚胺分泌过多,导致心率增快以增加心输出量外周血管收缩,血压升高,后负荷加重,同时肾血管血流减少,尿量减少,这些变化造成恶性循环,心衰进一步加重。通过血液净化可以清除体内多余水分,明显减轻水肿,从而减轻心脏前负荷,增加心排血量,心功能得到改善。随着心功能的改善,肾血流量增加,肾淤血减轻,肾功能恢复,尿量增多。同时被激活的肾素-血管紧张素-醛固酮系统活性恢复正常,减轻了心脏前、后负荷,进一步促进心功能的改善。血液净化能在短时间内快速纠正电解质及酸碱平衡紊乱、清除肌酐、尿素氮等代谢产物,故对有高血钾、低血钠、高血钠、酸中毒明显、肾功能不全的患者的效果更好。研究表明,血液净化过程脱水速度较慢,体外血流速度小,每次超滤脱水在较长时间内逐渐完成,患者能够适应对容量的清除,故对患者血流动力学影响小,血压、脉搏较稳定,可耐受的脱水量更大,对于血压偏低、高龄、伴有严重感染性疾病者更安全有效。血液净化还能清除如激素、炎性介质、肾素等物质,有助于原发病治疗及心衰的控制。以纠正心衰为治疗目的,血流量不宜过大(<15ml/min),血液净化超滤不宜过快,1次超滤脱水量不宜过多。总之,通过血液净化治疗纠正酸中毒和电解质紊乱减少了心律失常的发生,并恢复了机体对儿茶酚胺的敏感性,避免了儿茶酚胺的过度分泌所致的恶性循环,清除部分炎症介质及多余水分,减轻心脏的前负荷,减少心肌的耗氧,减轻肺水肿,改善氧合,从而使心功能得到改善心衰症状迅速减轻,缩短住院时间,降低住院费用,而且同时恢复肾脏血液,恢复患者对利尿剂的敏感性,减少肾衰的发生。因此,血液净化是急性心力衰竭行之有效的治疗方法。

5.脑钠素在心力衰竭中的临床应用

近年来临床研究表明,正常状态下血浆脑钠素(brainnatriureticpeptide,BNP)在心室肌中储备很少,BNP与心功能关系密切,随着心衰的发展,心脏分泌BNP随之增加,血浆BNP的浓度可作为心衰的诊断、治疗评估和预后的判断标志物,且在心衰的治疗中显示效果良好。2000年美国FDA正式批准血浆BNP为临床诊断心衰的血清标志物,当心室容量与压力负荷增大,室壁张力增高时,即可导致BNP快速合成并释放入血,可以敏感而特异地反映心室功能的改变。BNP是促尿钠排泄铵酸系统(NPS)中的一员,是肾素-血管紧张素-醛固酮系统(RAAS)唯一的天然拮抗剂,具有扩张血管、排钠、降低醛固酮水平、降低RAAS活性及降低交感系统活性的作用。另有研究表明,BNP调节自主神经系统,阻止心肌纤维化和血管平滑肌细胞增殖,抑制血管内皮细胞组织因子和纤维蛋白酶原激活物抑制剂的表达,阻止充血状态下的血栓形成。

(1)BNP在诊断中的应用:

心衰是一种常见的临床综合征,预后差,以往主要依赖临床症状、心电图、X线和心脏彩超诊断和鉴别诊断,临床缺乏灵敏性和特异性,因而误诊率较高。近年来国内外很多研究发现,心衰患者血浆中BNP浓度显著升高,重症心衰时BNP升高更明显,BNP和左室舒张末压、左室射血分数(LVEF)以及心功能(NYHA)分级密切相关,是诊断心衰较为敏感的指标。呼吸困难是急性充血性心力衰竭最常见的症状,但呼吸困难也可由肺部疾病等非心源性原因引起,BNP可用于排除或确定急诊室呼吸困难患者是否为充血性心力衰竭。目前60岁以下人群采用100pg/ml作为NBP的分割点,300pg/ml作为NT-proBNP的分割点,但要在老年患者中BNP随年龄变化,脑部疾病、肾功能异常等疾病也会影响BNP预测心衰的准确性。此外还应注意,血清BNP升高只能反映出患者室壁张力增高,BNP合成亢进,但患者的主要矛盾却并不一定是心衰。例如肺心病患者因呼吸困难就诊,血清BNP水平升高并不一定提示患者呼吸困难的症状是由心衰导致。严重肺部感染,肺大疱破裂和长期卧床形成下肢静脉血栓后发生肺栓塞等情况都有可能导致呼吸困难,而此时患者BNP升高可能是既往肺心病的结果,也可能是其他疾病导致心功能恶化的结果,决不能见到BNP升高,就想当然地认为患者存在的主要矛盾是心衰。即便如此,由于血浆BNP浓度测定简单、方便、准确和客观,有望成为心衰患者简单易行的常规筛查项目。

(2)BNP在心力衰竭中的治疗作用:

BNP具有利钠、利尿、提高肾小球滤过率、扩张血管、降低外周循环阻力、对抗肾上腺素、抑制RAAS的作用,参与人体血压、血容量及水盐平衡的调节。2001年美国FDA批准SCDS公司生产的Natrecor(nesiritide)生物工程合成基因重组rh-BNP(奈西利肽)上市以来,rh-BNP已用于治疗急性失代偿性心衰。已有的研究显示rh-BNP在改善失代偿性心衰患者的临床症状及血流动力学作用优于硝酸甘油等传统的血管活性药物,耐受性更好,为心衰的治疗带来了美好的前景。近几年的临床实践表明,重组人B型利钠肽可迅速、有效地改善急性左心衰患者的血流动力学,而不激活甚至降低神经内分泌系统的活性。研究表明rh-BNP在降低PCWP、PAP方面明显优于硝酸甘油,并且在用药后15分钟就表现出疗效,这将为 CHF急性发作的患者带来特殊益处。rh-BNP于2001年已在美国上市,2005年欧洲心脏病学会将其列入CHF的治疗指南。

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    2017-10-23 虈亣靌

    谢谢分享知识

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  2. 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  3. 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createdName=yuanming7, createdTime=Sat Oct 14 13:35:00 CST 2017, time=2017-10-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471301, encodeId=2b3914e1301fd, content=<a href='/topic/show?id=ac13558e9cb' target=_blank style='color:#2F92EE;'>#抢救#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55879, encryptionId=ac13558e9cb, topicName=抢救)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=be1a7117101, createdName=lfyang, createdTime=Sat Oct 14 13:35:00 CST 2017, time=2017-10-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252780, encodeId=98d8252e80c4, content=学习一下谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Sat Oct 14 07:23:58 CST 2017, time=2017-10-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252625, encodeId=a6b1252625eb, content=学习了谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Fri Oct 13 18:35:19 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252465, encodeId=57032524654a, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Fri Oct 13 08:05:46 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252456, encodeId=b2a1252456e5, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Fri Oct 13 08:04:06 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252422, encodeId=7c7225242238, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-14 lfyang
  4. 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createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Sat Oct 14 07:23:58 CST 2017, time=2017-10-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252625, encodeId=a6b1252625eb, content=学习了谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Fri Oct 13 18:35:19 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252465, encodeId=57032524654a, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-14 三生有幸9135

    学习一下谢谢分享

    0

  5. 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createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzaiabIFicf63hKvVMjL6aJlx4yX4UcXmzX9DyibCRcicq0QtCRWMaQKh8MYjE1D3EKUBopgiaGWYuqbeR/0, createdBy=0c2b1999806, createdName=三生有幸9135, createdTime=Sat Oct 14 07:23:58 CST 2017, time=2017-10-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252625, encodeId=a6b1252625eb, content=学习了谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Fri Oct 13 18:35:19 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252465, encodeId=57032524654a, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-13 虈亣靌

    学习了谢谢作者分享!

    0

  6. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Fri Oct 13 08:05:46 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252456, encodeId=b2a1252456e5, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Fri Oct 13 08:04:06 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252422, encodeId=7c7225242238, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-13 刘煜

    谢谢分享.阅读

    0

  7. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-13 Y—xianghai

    学习了新知识

    0

  8. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-13 飛歌

    学习了很有用不错

    0

  9. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Oct 13 07:14:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252416, encodeId=b11c25241631, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Oct 13 07:12:14 CST 2017, time=2017-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=252381, encodeId=a5da25238188, content=生命就是争分夺秒, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Fri Oct 13 06:13:32 CST 2017, time=2017-10-13, status=1, ipAttribution=)]
    2017-10-13 明月清辉

    谢谢分享.学习了

    0

  10. 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    2017-10-13 yjs木玉

    生命就是争分夺秒

    0