重症急性胰腺炎术后并发持续性低血压一例

2018-10-30 杨婧 陈瑶 康焰 协和医学杂志

患者男性,61岁,因“反复腹痛、发热40余天,呕吐3 d ”入院。当地医院诊断为“重症急性胰腺炎(SAP)”,给予抑酸、抑制胰酶分泌、有创呼吸机辅助通气、器官功能支持等治疗后病情稳定。3 d前,患者再次出现发热,最高体温39.3 ℃,腹部增强CT提示中上腹多发包裹性积液形成,为行手术治疗转入四川大学华西医院胰腺外科。

患者男性,61岁,因“反复腹痛、发热40余天,呕吐3 d ”入院。当地医院诊断为“重症急性胰腺炎(SAP)”,给予抑酸、抑制胰酶分泌、有创呼吸机辅助通气、器官功能支持等治疗后病情稳定。3 d前,患者再次出现发热,最高体温39.3 ℃,腹部增强CT提示中上腹多发包裹性积液形成,为行手术治疗转入四川大学华西医院胰腺外科。

入院查体

体温37.8 ℃ ,脉搏76次/min,呼吸20次/min,血压109/66 mm Hg,神志清楚、消瘦。腹部外形正常,全腹柔软,上腹部压痛,无反跳痛,腹部未触及包块,余无特殊。

辅助检查

血常规示血红蛋白94 g/L,白细胞12.34×109/L。降钙素原(PCT)0.13 ng/ml。腹部增强CT示中上腹腔内多发包裹性积液形成,肠系膜上静脉及脾静脉内充盈缺损影。

入院诊断

重症急性胰腺炎伴胰腺脓肿形成;肠系膜上静脉、脾静脉血栓形成?轻度贫血。

患者诊断SAP 40余天,经外院前期治疗后病情缓解,现因前期胰腺坏死、胰液渗出而并发胰腺假性囊肿/脓肿,经局部引流效果欠佳,需手术治疗,转入我院胰腺外科。患者低热,感染指标升高,考虑患者一般情况尚可,抗感染治疗同时可先行局部引流,若局部引流效果不理想,再拟行手术治疗。

胰腺外科治疗

超声引导下局部穿刺引流,细菌培养为“大肠埃希菌”,给予亚胺培南西司他丁钠(0.5 g/d×3次, 静脉滴注)抗感染治疗1周后患者仍间断发热。遂于全麻下行“胰腺部分切除+胰腺脓肿外引流+空场造瘘+结肠穿孔修补+脾静脉修补术”,术后转入重症医学科治疗。

术后转入重症医学科

患者全麻未醒,体温36.7 ℃,脉搏75次/min,呼吸16次/min,血压76/41 mm Hg,尿量30 ml/h,腹腔引流液为暗红色血性液体,量约300 ml;床旁超声检查示剑突下下腔静脉直径1.7 cm,心腔不充盈;血气分析示钠离子(Na+)131.6 mmol/L,钾离子(K+)3.98 mmol/L,血乳酸(Lac)2.7 mmol/L;血红蛋白81 g/L, PCT 0.28 ng/ml。

予充分液体复苏,去甲肾上腺素0.25 μg/(kg·min)泵入维持血压,亚胺培南西司他丁钠抗感染,止血、输血等对症处理2 d后,患者顺利停呼吸机拔管,但血压仍需去甲肾上腺素维持。术后第6天,患者病情较前稳定,但精神欠佳,仍乏力、低热、持续低血压,升压药物不能完全撤除。

患者目前以持续性低血压为主要表现,术中发现横结肠有穿孔,故可能存在低血容量性休克及感染性休克高风险,故首先需明确是否存在休克。休克是指机体有效循环血容量减少、组织器官微循环灌注不足,以致重要生命器官细胞代谢紊乱和功能受损的病理过程,是重症患者主要死因之一。 SAP患者由于麻醉及手术渗出,常存在各种类型的休克诱因,术后多伴有血容量不足的休克表现。因手术刺激,尤其并发感染后,机体一系列应激反应可致肠道血流量减少,引起应激性溃疡而导致消化道出血,而手术创面渗血等因素可引起贫血,甚至失血性休克。SAP患者处于高代谢状态,常合并营养不良,加之术后肠道水肿、术中引流管放置不当压迫肠壁等原因可能引起消化道漏、腹腔感染;术后腹腔及腹膜后残余感染严重时可引起术后感染性休克的发生。另外,SAP长期大量释放炎性因子,感染时释放内毒素,可能导致心肌细胞受损抑制,若患者有心脏疾病史,术后可能并发心源性休克。故该患者有诱发休克的原因,有四肢湿冷、低血压表现,组织灌注指标Lac波动在1.5~2.0 mmol/L之间,不能完全排除休克的可能,但具体类型需根据病情及辅助检查进一步确认。

辅助检查

血常规示血红蛋白85 g/L;肌钙蛋白-T:63.4 ng/L,B型尿钠肽:320 pg/ml;腹部增强CT提示肠壁轻度水肿,无明显扩张;床旁超声检查见心腔大小正常,心室充盈,收缩及舒张正常,无节段运动障碍,射血分数62%,下腔静脉直径2.1 cm,随呼吸变异度不大。

根据检查,目前可排除低血容量性、心源性和梗阻性休克,而患者低热,既往腹腔分泌物培养(+),感染性休克是最可疑诊断。感染性休克是指患者有明确的感染灶存在,经充分液体复苏后平均动脉压仍需血管活性药物作用下才能维持≥65 mm Hg,且存在微循环灌注障碍,Lac>2 mmol/L方可诊断。患者感染灶最可能是腹腔残余感染,但也不排除呼吸道、血液、消化道、泌尿系统甚至颅内感染的可能。因感染性休克的诊断包括诱发因素、临床表现、生物学指标和血流动力学参数等多方面内容,故筛查感染灶,结合血流动力学参数等综合判断后才能确诊。

感染指标筛查

血常规示白细胞10×109/L;PCT 0.03 ng/ml;血G试验及GM试验(-);痰培养及尿培养无特殊;腹部增强CT如上述;肺部CT可见双肺散在斑片条索影,较术前CT变化不大;床旁超声筛查未见全身潜在感染灶。

经充分评估,患者各类型休克诊断依据不足,持续低血压表现可能与血管本身张力有关,因此需考虑重症相关肾上腺皮质功能不全(CIRCI)可能。CIRCI可引起全身各系统反应,如发热、乏力、精神差、模糊、谵妄、昏迷、低血压、恶心、呕吐、持续低氧、低血糖、低血钠、高血钾、代谢性酸中毒等无任何特异性的表现,临床最常见表现是不明原因的持续性低血压,需小剂量血管活性药物维持,同时伴轻度电解质紊乱(低钠血症、高钾血症),最终经激素测定诊断为CIRCI。激素测定有多种方式,包括血浆随机、游离、总皮质醇(PTC)浓度,唾液PTC浓度,小剂量和大剂量促肾上腺皮质激素(ACTH)刺激试验,血流动力学对氢化可的松的反应等,以血浆随机PTC<10 μg/dl及大剂量ACTH(250 μg)刺激试验(+),即ACTH使用后,计算注射60 min(T60)PTC的最大值与注射前(T0)的差值(△Tmax<9 μg/dl)作为推荐标准。若无条件进行激素测定时,对具有高风险罹患CIRCI人群高度怀疑CIRCI时,如无激素使用禁忌证,可经验性使用激素替代治疗,但需及时评估疗效和激素带来的潜在风险。

术后第1天及第7天查ACTH及PTC均正常,故进行标准剂量(250 μg)  ACTH刺激试验,具体测量值见表1。患者ACTH刺激试验(+), CIRCI诊断明确,需进行激素替代治疗。



关于CIRCI的激素替代治疗,美国及日本内分泌指南指出,优先使用短效糖皮质激素,并可在激素分泌的早晚高峰使用,而CIRCI指南推荐使用氢化可的松(<400 mg/d,疗程≥3 d)。

结合上述两个指南的推荐意见,使用氢化可的松200 mg/d静脉泵入,患者精神、血压改善,去甲肾上腺素于术后第8天减停,后血压维持在116/68 mm Hg,遂转出重症医学科。持续应用氢化可的松至术后12 d,改为口服药物醋酸泼尼松(8:00 am 5 mg,16:00 pm 2.5 mg)至术后16 d出院,术后22 d停用激素。

因CIRCI激素使用与感染性休克治疗有类似之处,该疾病也需与感染性休克进行鉴别,故需了解感染性休克的激素使用方式,以免引起误解。感染性休克的激素使用,无论使用方式是静脉推注还是持续泵入,激素的类型(地塞米松、氢化可的松、甲强龙)对死亡率均无影响;但对于休克的逆转而言,氢化可的松较其它类型更具优势。对于激素使用剂量,研究已表明小剂量长疗程(200 mg,5~7 d)较大剂量短疗程(>500 mg,2~3 d)可降低感染性休克28 d死亡率。因单用氢化可的松对感染性休克死亡率仍存在争议,目前指南推荐小剂量长疗程氢化可的松用于经液体复苏和血管活性物质仍不能纠正的感染性休克。但近期研究表明,若氢化可的松联用氟氢可的松治疗感染性休克,可改善患者病死率,故期待激素在感染性休克中的使用在未来有新进展。

出院1个月随访,患者已停用激素,血压恢复正常,无乏力、恶心、呕吐、低血压等PTC缺乏症状。

该患者确诊为CIRCI,激素替代治疗效果理想,因指南推荐激素治疗疗程≥3 d,未推荐具体疗程,故使用激素替代治疗直至皮质醇缺乏症状消失后停用。关于CIRCI的激素使用方案,仍需不断完善临床研究。

★ 通过对本病的诊治,笔者经验如下 ★

(1)SAP术后并发症较多,如出血、腹腔及腹膜后残余感染、急性呼吸窘迫综合征、消化道漏等,均可导致患者休克,故当SAP术后患者出现低血压时需要及时鉴别、治疗。

(2)因SAP术后患者机体病理生理改变涉及CIRCI发病的任一机制,当患者SAP术后出现持续低血压时需考虑CIRCI,及时安排激素测定。

(3)当PTC测定正常,而高度怀疑CIRCI时,可安排ACTH刺激试验协助诊断。

(4)一旦确诊CIRCI后,尽早进行激素替代治疗,改善症状,有效缩短患者重症医学科住院时间,促进患者早期康复。

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#插入话题
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  2. [GetPortalCommentsPageByObjectIdResponse(id=1941921, encodeId=f426194192179, content=<a href='/topic/show?id=774a95943de' target=_blank style='color:#2F92EE;'>#重症急性胰腺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95943, encryptionId=774a95943de, topicName=重症急性胰腺炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=07f7192, createdName=waiwai3030, createdTime=Thu Dec 27 21:16:00 CST 2018, time=2018-12-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1922584, encodeId=7477192258434, content=<a href='/topic/show?id=3f3156324ff' target=_blank style='color:#2F92EE;'>#持续性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56324, encryptionId=3f3156324ff, topicName=持续性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2c31495, createdName=liuyg0228, createdTime=Wed Jun 26 16:16:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758044, encodeId=5bbe1e580443c, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, 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=Sat Nov 24 14:16:00 CST 2018, time=2018-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367377, encodeId=ca5c136e377d1, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Thu Nov 01 09:16:00 CST 2018, time=2018-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=351001, encodeId=3531351001ec, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/09/18/bcfe87f9039c0d40a4bcafd6476c1418.jpg, createdBy=10f02444712, createdName=Zzzzxs, createdTime=Wed Oct 31 00:03:37 CST 2018, time=2018-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350989, encodeId=2c49350989da, content=很好的病历分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhRvIvBCic3jbz4PVDcMREDl6iaWw7opPo99JEXWc0tmIrGaXGPP0y58DKDiajZfV2qR3qXdCgwIyhVq/0, createdBy=d71a1955931, createdName=QFXL123456, createdTime=Tue Oct 30 21:45:31 CST 2018, time=2018-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350985, encodeId=16cf350985f4, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Oct 30 20:57:39 CST 2018, time=2018-10-30, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1941921, encodeId=f426194192179, content=<a href='/topic/show?id=774a95943de' target=_blank style='color:#2F92EE;'>#重症急性胰腺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95943, encryptionId=774a95943de, topicName=重症急性胰腺炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=07f7192, createdName=waiwai3030, createdTime=Thu Dec 27 21:16:00 CST 2018, time=2018-12-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1922584, encodeId=7477192258434, content=<a href='/topic/show?id=3f3156324ff' target=_blank style='color:#2F92EE;'>#持续性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56324, encryptionId=3f3156324ff, topicName=持续性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2c31495, createdName=liuyg0228, createdTime=Wed Jun 26 16:16:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758044, encodeId=5bbe1e580443c, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, 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=Sat Nov 24 14:16:00 CST 2018, time=2018-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367377, encodeId=ca5c136e377d1, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Thu Nov 01 09:16:00 CST 2018, time=2018-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=351001, encodeId=3531351001ec, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/09/18/bcfe87f9039c0d40a4bcafd6476c1418.jpg, createdBy=10f02444712, createdName=Zzzzxs, createdTime=Wed Oct 31 00:03:37 CST 2018, time=2018-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350989, encodeId=2c49350989da, content=很好的病历分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhRvIvBCic3jbz4PVDcMREDl6iaWw7opPo99JEXWc0tmIrGaXGPP0y58DKDiajZfV2qR3qXdCgwIyhVq/0, createdBy=d71a1955931, createdName=QFXL123456, createdTime=Tue Oct 30 21:45:31 CST 2018, time=2018-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350985, encodeId=16cf350985f4, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Oct 30 20:57:39 CST 2018, time=2018-10-30, status=1, ipAttribution=)]
    2018-11-24 丁鹏鹏
  4. [GetPortalCommentsPageByObjectIdResponse(id=1941921, encodeId=f426194192179, content=<a href='/topic/show?id=774a95943de' target=_blank style='color:#2F92EE;'>#重症急性胰腺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95943, encryptionId=774a95943de, topicName=重症急性胰腺炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=07f7192, createdName=waiwai3030, createdTime=Thu Dec 27 21:16:00 CST 2018, time=2018-12-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1922584, encodeId=7477192258434, content=<a href='/topic/show?id=3f3156324ff' target=_blank style='color:#2F92EE;'>#持续性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56324, encryptionId=3f3156324ff, topicName=持续性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2c31495, createdName=liuyg0228, createdTime=Wed Jun 26 16:16:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758044, encodeId=5bbe1e580443c, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, 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=Sat Nov 24 14:16:00 CST 2018, time=2018-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367377, encodeId=ca5c136e377d1, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Thu Nov 01 09:16:00 CST 2018, time=2018-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=351001, encodeId=3531351001ec, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/09/18/bcfe87f9039c0d40a4bcafd6476c1418.jpg, createdBy=10f02444712, createdName=Zzzzxs, createdTime=Wed Oct 31 00:03:37 CST 2018, time=2018-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350989, encodeId=2c49350989da, content=很好的病历分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhRvIvBCic3jbz4PVDcMREDl6iaWw7opPo99JEXWc0tmIrGaXGPP0y58DKDiajZfV2qR3qXdCgwIyhVq/0, createdBy=d71a1955931, createdName=QFXL123456, createdTime=Tue Oct 30 21:45:31 CST 2018, time=2018-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350985, encodeId=16cf350985f4, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Oct 30 20:57:39 CST 2018, time=2018-10-30, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1941921, encodeId=f426194192179, content=<a href='/topic/show?id=774a95943de' target=_blank style='color:#2F92EE;'>#重症急性胰腺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95943, encryptionId=774a95943de, topicName=重症急性胰腺炎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=07f7192, createdName=waiwai3030, createdTime=Thu Dec 27 21:16:00 CST 2018, time=2018-12-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1922584, encodeId=7477192258434, content=<a href='/topic/show?id=3f3156324ff' target=_blank style='color:#2F92EE;'>#持续性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56324, encryptionId=3f3156324ff, topicName=持续性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2c31495, createdName=liuyg0228, createdTime=Wed Jun 26 16:16:00 CST 2019, time=2019-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758044, encodeId=5bbe1e580443c, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, 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=Sat Nov 24 14:16:00 CST 2018, time=2018-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367377, encodeId=ca5c136e377d1, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Thu Nov 01 09:16:00 CST 2018, time=2018-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=351001, encodeId=3531351001ec, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/09/18/bcfe87f9039c0d40a4bcafd6476c1418.jpg, createdBy=10f02444712, createdName=Zzzzxs, createdTime=Wed Oct 31 00:03:37 CST 2018, time=2018-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350989, encodeId=2c49350989da, content=很好的病历分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/icyLhIGqru6gIknBJqfuPhRvIvBCic3jbz4PVDcMREDl6iaWw7opPo99JEXWc0tmIrGaXGPP0y58DKDiajZfV2qR3qXdCgwIyhVq/0, createdBy=d71a1955931, createdName=QFXL123456, createdTime=Tue Oct 30 21:45:31 CST 2018, time=2018-10-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=350985, encodeId=16cf350985f4, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Tue Oct 30 20:57:39 CST 2018, time=2018-10-30, status=1, ipAttribution=)]
    2018-10-31 Zzzzxs

    谢谢分享

    0

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    2018-10-30 QFXL123456

    很好的病历分享,学习了

    0

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    2018-10-30 医者仁心5538

    学习了

    0

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