肢端肥大症并发扩张性心肌病患者行前列腺粒子植入术的麻醉管理1例

2019-10-19 吴洁 马艳辉 王天龙 麻醉安全与质控

患者,男,66岁,身高178 cm,体质量70kg,因“前列腺癌”入院。既往垂体瘤病史40余年(间断服用溴隐亭),扩张性心肌病病史7年,高血压病史7年,血压(BP)最高180/120mmHg,口服利血平、美托洛尔和贝那普利控制血压,平时BP控制在120/80mmHg左右,曾有心衰病史,经内科治疗好转,目前心功能Ⅱ级。27年前行右眼外伤手术,目前右眼失明。

1.患者资料
 
患者,男,66岁,身高178 cm,体质量70kg,因“前列腺癌”入院。既往垂体瘤病史40余年(间断服用溴隐亭),扩张性心肌病病史7年,高血压病史7年,血压(BP)最高180/120mmHg,口服利血平、美托洛尔和贝那普利控制血压,平时BP控制在120/80mmHg左右,曾有心衰病史,经内科治疗好转,目前心功能Ⅱ级。27年前行右眼外伤手术,目前右眼失明。
 
入院查体:BP130/80mmHg、心率(HR)80次/min、呼吸频率(RR)20次/min、体温(T)36.2℃。患者肢端肥大样面容,四肢活动好,双手足粗大,鼻唇肥厚,无双下肢水肿。辅助检查:心电图显示窦性心动过缓,T波改变;胸片示双肺纹理重;心脏多普勒超声示左室增大(左室舒张内径62mm),左室壁肥厚,主动脉瓣、二尖瓣、三尖瓣轻度反流,左室收缩及舒张功能减低,射血分数(EF)48%。
 
头颅磁共振显示鞍区占位病变,垂体瘤可能性大,大小1.01 cm×1.53 cm×1.65 cm,双侧基底节区及双侧脑室旁多发腔隙性脑梗死。术前脊柱磁共振示L1-4椎体膨出、L4-5椎间盘突出伴局部椎管狭窄、L1椎体血管瘤、双髋退行性改变、双髋关节积液及周围滑囊形成。
 
实验室检查:术前生长激素(GH)10.70ng/mL(正常范围0.003~0.971ng/mL);动脉血氧分压(PaO2)67.9mmHg,动脉血二氧化碳分压(PaCO2)46.5mmHg;术前甲状腺功能、生化检查、凝血及血细胞分析未见明显异常。拟于全麻下行前列腺放射性粒子植入术。
 
患者入室后建立上肢静脉通路,连续监测心电图(ECG)、HR、无创血压、脉搏血氧饱和度(SpO2)、脑电双频谱指数(BIS)、体温、呼气末二氧化碳分压(PETCO2),局麻下行右侧桡动脉穿刺置管术,监测有创动脉压,连接FloTrac/Vigileo传感器(美国Edwards公司),监测心输出量(CO)、心指数(CI)、每搏输出量(SV)、每搏量指数(SVI)、每搏量变异度(SVV)。
 
术前对患者进行气道评估(术前请耳鼻喉科行喉镜检查、评估患者甲颏距离、马氏分级、张口度、头颈活动度等),判断无困难气道,选择静脉快速顺序诱导。以6L/min氧流量持续面罩吸氧5min后,开始麻醉诱导,依次静注咪达唑仑1.5mg、依托咪酯8mg,舒芬太尼10μg,待患者入睡后,静注罗库溴铵50mg,1min后置入双管喉罩,连接呼吸机进行机械通气,设定潮气量8mL/kg,吸呼比1∶1.5,调整呼吸频率维持PETCO235~40mmHg。
 
麻醉维持:持续输注丙泊酚2~4mg/(kg·h)和瑞芬太尼0.1~0.15μg/(kg·min),术中维持BIS45~60。持续输注去甲肾上腺素0.02~0.05μg/(kg·min)及多巴胺2~5μg/(kg·min)维持血流动力学稳定,麻醉期间CO变化趋势见图1。手术历时83min,出血约5mL,静脉输注乳酸钠林格氏液500mL。术毕患者清醒拔除喉罩,安返病房,术后8d好转出院。


图1 患者术中CO变化趋势
 
2.讨论
 
本例患者拟行前列腺放射性粒子植入术,可选择椎管内麻醉或全身麻醉,由于患者术前核磁共振成像(MRI)检查提示明显腰椎病变,为避免椎管内麻醉相关并发症的发生,麻醉方式选择喉罩全身麻醉。放置喉罩对患者刺激小、插管反应轻,更适用于心血管病患者,此外,对于气管插管困难患者,喉罩也是一种重要的通气设备。肢端肥大症患者生存时间较对照组平均减少10年,且病死率增加2.0~2.5倍,GH分泌过度主要是对心血管系统、呼吸系统等产生严重不良影响,因此,该类患者在麻醉管理中需要考虑以下问题。
 
2.1心脏功能评估和循环管理
 
肢端肥大症主要是由于GH分泌过度引起,GH在心脏发生、发展和维持中均占有作用,正常分泌的GH通过GH和胰岛素样生长因子在心肌上的受体参与心脏结构和功能的调节。GH过度分泌可直接对心脏产生不利影响,GH可通过胰岛素样生长因子直接或间接发挥对心肌正性肌力作用,使得心肌细胞相对增加而导致心室壁向心性增厚,称之为肢端肥大症性心肌病。
 
研究表明,GH腺瘤病史超过10年者,心脏并发症发生率较病史在10个月~10年的患者高3倍,其中左室肥厚风险增加9.9倍,心室舒张功能减退风险增加4.8倍,且肢端肥大症患者发生高血压(1.4~1.7倍)、心律失常(4.9倍)及其他心脏功能障碍的风险要明显高于非肢端肥大症患者。对于未经控制的肢端肥大症患者的死亡率较治疗的肢端肥大症患者增加1.72~1.9倍,其中导致死亡的主要原因是心血管疾病(>60%)。对于年龄<40岁且合并3~7年功能性肢端肥大症的患者中有54%的患者存在左室肥大,41~60岁合并5~15年病史的患者则高达72%。
 
本例患者垂体瘤病史40余年,术前心脏彩超提示左房增大、室间隔增厚,此外发现扩张性心肌病7年,既往有心衰病史,目前心功能Ⅱ级。因此,围术期发生心功能不全的风险很高。
 
2.2围术期诱发心衰的因素
 
2.2.1心脏前负荷过重
 
心室舒张回流的血液过多可使心室舒张期负荷过重,导致心衰。围术期液体输注过多或过快,回心血量增多,左心室、右心室舒张期负荷加重,可能诱发心力衰竭。该患者术中除常规监测外,还进行了动脉压力波形心排量法(APCO)监测。此外,本例患者术中采用SVV来指导术中液体管理,维持SVV<13%,以避免术中液体过度输注,维持前负荷在合适状态,避免了因前负荷增加而诱发心衰的可能。
 
2.2.2后负荷过重
 
围术期血压增高,心脏后负荷增加,可诱发心衰,因此,术中避免麻醉过浅引起的交感神经系统兴奋,心脏负荷加重。本例患者于麻醉诱导后,CO和CI逐渐降低,通过静脉输注正性肌力药多巴胺后,CO等逐渐恢复至术前水平。该患者高血压并发腔隙性脑梗死,平时BP维持在120~130mmHg/70~80mmHg,建议血压维持在术前平静血压的基线水平值+20%范围内。
 
2.2.3心肌收缩力
 
手术期间使用的麻醉药物均有不同程度的心肌抑制作用,使得心脏收缩力减弱,建议术中尽可能使用对心肌抑制作用小的麻醉药物。
 
2.3困难气道评估和呼吸功能管理
 
肢端肥大症患者多伴有厚唇增厚、高宽鼻子、下颌骨前伸宽大、舌体肥厚、声门增厚及声门下狭窄,因此,气管插管可能遇到困难。该类患者在麻醉诱导中易发生严重呼吸道梗阻、通气困难,导致缺氧和PaCO2升高,应选用大号口咽通气管和喉镜,避免因其长度不够而遇到声门显露困难。
 
气管插管时的注意事项包括:(1)清醒气管插管;(2)对预估插管困难病例,采用纤维光导喉镜或支气管镜完成插管;(3)肢端肥大症患者声门及声门下可能存在肥厚狭窄,应选择内径稍细的气管导管,减少对声门和气管壁的损伤。
 
对于手术时间短、预计插管困难的患者(如肢端肥大症患者)可首先考虑使用喉罩来降低气管插管困难的风险。肢端肥大症患者由于呼吸系统疾病导致死亡的发生率占25%。肢端肥大症患者由于结缔组织增生,全身内脏增大增厚,肺容量增大,血管壁增厚,可能存在通气/血流比例失调。对于全麻患者术中行常规机械通气,通常设定通气量为10mL/kg。术中都应动态监测血气分析,随时调整呼吸参数,以尽量符合生理状态。术毕拔管指征:吸空气下通气量接近术前水平,PETCO2<35mmHg、SpO2>95%或达术前水平、肌力恢复、完全清醒、不存在呼吸道梗阻隐患以及吞咽反射良好。
 
2.4术后管理
 
患者在手术室内清醒拔管返回泌尿外科病房。术后随访患者,未发生恶性心律失常、心力衰竭、脑血管意外及猝死等事件。患者于术后第5天,痊愈出院。术后应注意血容量及液体调整,患者如能自由进食应避免过多液体输注。同时加强监测,及时观察患者病情变化,防止心衰的发生。
 
总结本例患者麻醉管理体会,对于合并肢端肥大症患者,术前访视时应注重:(1)患者心血管合并症的评估,评估的内容包括心功能的状态、有无心脏结构病变以及心律失常,术前完善相关检查(超声心动图和心电图),充分治疗并存疾病,尽可能改善个体系统功能和心脏功能,同时应根据患者及手术的具体情况制定一个完善的麻醉管理方案;(2)术前做好困难气道评估,提高手术安全性;(3)术中麻醉管理应该避免浅麻醉、注重术中液体管理和心功能监测,通过完善的监测维持血流动力学平稳,必要时给予血管活性药物和正性肌力药物预防和避免心衰的发生;(4)手术后加强监测液体容量管理,避免术后心衰事件,保障患者良好的转归。
 
原始出处:

吴洁,马艳辉,王天龙.肢端肥大症并发扩张性心肌病患者行前列腺粒子植入术的麻醉管理1例[J].麻醉安全与质控,2018,2(05):278-280.

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    2021-11-12 湘雅科教

    已拜读,受益匪浅。

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  2. 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GetPortalCommentsPageByObjectIdResponse(id=1758172, encodeId=f7fc1e581720a, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Feb 06 03:28:00 CST 2020, time=2020-02-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1684810, encodeId=a27716848100e, content=<a href='/topic/show?id=794754e74f4' target=_blank style='color:#2F92EE;'>#扩张#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54774, encryptionId=794754e74f4, topicName=扩张)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=699d28086811, createdName=lsj637, createdTime=Mon Feb 10 02:28:00 CST 2020, time=2020-02-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1804054, encodeId=f38818040549d, content=<a href='/topic/show?id=2b99e6207fd' target=_blank style='color:#2F92EE;'>#粒子植入术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76207, encryptionId=2b99e6207fd, topicName=粒子植入术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat May 16 08:28:00 CST 2020, time=2020-05-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=374373, encodeId=259f3e437331, content=牛逼, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/10/21/e031c1d6c6115cbe1737b2149e602c1d.jpg, createdBy=3c105212218, createdName=147612bem32暂无昵称, createdTime=Fri Oct 25 10:15:39 CST 2019, time=2019-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1664769, encodeId=d3f71664e6969, content=<a href='/topic/show?id=65b5818609b' target=_blank style='color:#2F92EE;'>#肢端肥大#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81860, encryptionId=65b5818609b, topicName=肢端肥大)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1cad25837873, createdName=654699882_84926994, createdTime=Fri Jul 10 23:28:00 CST 2020, time=2020-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1271195, encodeId=43ef12e119513, content=<a href='/topic/show?id=391f8186168' target=_blank style='color:#2F92EE;'>#肢端肥大症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81861, encryptionId=391f8186168, topicName=肢端肥大症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1520622, encodeId=3e541520622c5, content=<a href='/topic/show?id=7a736264553' target=_blank style='color:#2F92EE;'>#植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62645, encryptionId=7a736264553, topicName=植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1622415, encodeId=3c96162241553, content=<a href='/topic/show?id=b9578094833' target=_blank style='color:#2F92EE;'>#肌病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80948, encryptionId=b9578094833, topicName=肌病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1069574, encodeId=e5da10695e48e, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Fri Nov 12 10:42:51 CST 2021, time=2021-11-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1968930, encodeId=028b196893024, content=<a href='/topic/show?id=cd63e6206b2' target=_blank style='color:#2F92EE;'>#粒子植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76206, encryptionId=cd63e6206b2, topicName=粒子植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Sat Feb 22 21:28:00 CST 2020, time=2020-02-22, status=1, ipAttribution=), 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createdName=lsj637, createdTime=Mon Feb 10 02:28:00 CST 2020, time=2020-02-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1804054, encodeId=f38818040549d, content=<a href='/topic/show?id=2b99e6207fd' target=_blank style='color:#2F92EE;'>#粒子植入术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76207, encryptionId=2b99e6207fd, topicName=粒子植入术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat May 16 08:28:00 CST 2020, time=2020-05-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=374373, encodeId=259f3e437331, content=牛逼, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/10/21/e031c1d6c6115cbe1737b2149e602c1d.jpg, createdBy=3c105212218, createdName=147612bem32暂无昵称, createdTime=Fri Oct 25 10:15:39 CST 2019, time=2019-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1664769, encodeId=d3f71664e6969, content=<a href='/topic/show?id=65b5818609b' target=_blank style='color:#2F92EE;'>#肢端肥大#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81860, encryptionId=65b5818609b, topicName=肢端肥大)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1cad25837873, createdName=654699882_84926994, createdTime=Fri Jul 10 23:28:00 CST 2020, time=2020-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1271195, encodeId=43ef12e119513, content=<a href='/topic/show?id=391f8186168' target=_blank style='color:#2F92EE;'>#肢端肥大症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81861, encryptionId=391f8186168, topicName=肢端肥大症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1520622, encodeId=3e541520622c5, content=<a href='/topic/show?id=7a736264553' target=_blank style='color:#2F92EE;'>#植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62645, encryptionId=7a736264553, topicName=植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1622415, encodeId=3c96162241553, content=<a href='/topic/show?id=b9578094833' target=_blank style='color:#2F92EE;'>#肌病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80948, encryptionId=b9578094833, topicName=肌病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=)]
    2020-02-06 丁鹏鹏
  4. [GetPortalCommentsPageByObjectIdResponse(id=1069574, encodeId=e5da10695e48e, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Fri Nov 12 10:42:51 CST 2021, time=2021-11-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1968930, encodeId=028b196893024, content=<a href='/topic/show?id=cd63e6206b2' target=_blank style='color:#2F92EE;'>#粒子植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76206, encryptionId=cd63e6206b2, topicName=粒子植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Sat Feb 22 21:28:00 CST 2020, time=2020-02-22, status=1, ipAttribution=), 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createdName=lsj637, createdTime=Mon Feb 10 02:28:00 CST 2020, time=2020-02-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1804054, encodeId=f38818040549d, content=<a href='/topic/show?id=2b99e6207fd' target=_blank style='color:#2F92EE;'>#粒子植入术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76207, encryptionId=2b99e6207fd, topicName=粒子植入术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat May 16 08:28:00 CST 2020, time=2020-05-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=374373, encodeId=259f3e437331, content=牛逼, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/10/21/e031c1d6c6115cbe1737b2149e602c1d.jpg, createdBy=3c105212218, createdName=147612bem32暂无昵称, createdTime=Fri Oct 25 10:15:39 CST 2019, time=2019-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1664769, encodeId=d3f71664e6969, content=<a href='/topic/show?id=65b5818609b' target=_blank style='color:#2F92EE;'>#肢端肥大#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81860, encryptionId=65b5818609b, topicName=肢端肥大)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1cad25837873, createdName=654699882_84926994, createdTime=Fri Jul 10 23:28:00 CST 2020, time=2020-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1271195, encodeId=43ef12e119513, content=<a href='/topic/show?id=391f8186168' target=_blank style='color:#2F92EE;'>#肢端肥大症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81861, encryptionId=391f8186168, topicName=肢端肥大症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1520622, encodeId=3e541520622c5, content=<a href='/topic/show?id=7a736264553' target=_blank style='color:#2F92EE;'>#植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62645, encryptionId=7a736264553, topicName=植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1622415, encodeId=3c96162241553, content=<a href='/topic/show?id=b9578094833' target=_blank style='color:#2F92EE;'>#肌病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80948, encryptionId=b9578094833, topicName=肌病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=)]
    2020-02-10 lsj637
  5. [GetPortalCommentsPageByObjectIdResponse(id=1069574, encodeId=e5da10695e48e, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Fri Nov 12 10:42:51 CST 2021, time=2021-11-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1968930, encodeId=028b196893024, content=<a href='/topic/show?id=cd63e6206b2' target=_blank style='color:#2F92EE;'>#粒子植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76206, encryptionId=cd63e6206b2, topicName=粒子植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Sat Feb 22 21:28:00 CST 2020, time=2020-02-22, status=1, ipAttribution=), 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createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/10/21/e031c1d6c6115cbe1737b2149e602c1d.jpg, createdBy=3c105212218, createdName=147612bem32暂无昵称, createdTime=Fri Oct 25 10:15:39 CST 2019, time=2019-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1664769, encodeId=d3f71664e6969, content=<a href='/topic/show?id=65b5818609b' target=_blank style='color:#2F92EE;'>#肢端肥大#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81860, encryptionId=65b5818609b, topicName=肢端肥大)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1cad25837873, createdName=654699882_84926994, createdTime=Fri Jul 10 23:28:00 CST 2020, time=2020-07-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1271195, encodeId=43ef12e119513, content=<a href='/topic/show?id=391f8186168' target=_blank style='color:#2F92EE;'>#肢端肥大症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81861, encryptionId=391f8186168, topicName=肢端肥大症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d7db99, createdName=chg121, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1520622, encodeId=3e541520622c5, content=<a href='/topic/show?id=7a736264553' target=_blank style='color:#2F92EE;'>#植入#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62645, encryptionId=7a736264553, topicName=植入)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1622415, encodeId=3c96162241553, content=<a href='/topic/show?id=b9578094833' target=_blank style='color:#2F92EE;'>#肌病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80948, encryptionId=b9578094833, topicName=肌病)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Mon Oct 21 01:28:00 CST 2019, time=2019-10-21, status=1, ipAttribution=)]
  6. 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    2019-10-25 147612bem32暂无昵称

    牛逼

    0

  7. 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  8. 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  9. 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