Article(id=1203036772780437985, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203036770628755576, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2023.04.0476, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1636560000000, receivedDateStr=2021-11-11, revisedDate=null, revisedDateStr=null, acceptedDate=1641657600000, acceptedDateStr=2022-01-09, onlineDate=1764755917973, onlineDateStr=2025-12-03, pubDate=1682611200000, pubDateStr=2023-04-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764755917973, onlineIssueDateStr=2025-12-03, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764755917973, creator=13701087609, updateTime=1764755917973, updator=13701087609, issue=Issue{id=1203036770628755576, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='4', pageStart='367', pageEnd='488', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764755917460, creator=13701087609, updateTime=1764756108290, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1203037571086508742, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203036770628755576, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1203037571086508743, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203036770628755576, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=476, endPage=481, ext={EN=ArticleExt(id=1203036773074039273, articleId=1203036772780437985, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Research progress on the perioperative hypothermia, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Perioperative hypothermia is not rare in surgical patients, and is closely related to a variety of complications,which is not conducive to postoperative recovery of patients. At present, many studies focus on the risk factors, adverse outcomes and prevention strategies of perioperative hypothermia, and few studies analyze the changes of perioperative hypothermia from a multidimensional perspective. By summarizing and analyzing the previous research results, this paper reviews the physiology of body temperature, perioperative hypothermia, perioperative monitoring and maintenance of body temperature, and the new opinions and derived parameters of perioperative hypothermia, which is expected to bring some new perspectives for researchers and clinicians to develop better strategies for the prevention and treatment of perioperative hypothermia.

, correspAuthors=Huang Nie, authorNote=null, correspAuthorsNote=
E-mail:
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围手术期低体温是外科手术患者经常面临的问题,与多种术后并发症密切相关,不利于术后康复。目前研究多集中于围手术期低体温的危险因素、不良结局及预防策略方面,少有研究从多维度解析围手术期低体温以及不同维度定义低体温与预后的关系。本文总结分析前期研究成果,从体温的生理学、围手术期低体温、围手术期体温监测与维持、围手术期低体温的重新界定及衍生参数等方面进行综述,以期为研究人员及临床医师提供新的观点,为防治围手术期低体温提供更优的策略。

, correspAuthors=聂煌, authorNote=null, correspAuthorsNote=
聂煌,E-mail:
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张震,硕士研究生,主要从事围手术期低体温方面的研究

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张震,硕士研究生,主要从事围手术期低体温方面的研究

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张震,硕士研究生,主要从事围手术期低体温方面的研究

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围手术期低体温研究进展
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张震 , 郭海云 , 侯武刚 , 聂煌 *
解放军医学杂志 | 综述 2023,48(4): 476-481
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解放军医学杂志 | 综述 2023, 48(4): 476-481
围手术期低体温研究进展
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张震, 郭海云, 侯武刚, 聂煌*
作者信息
  • 空军军医大学西京医院麻醉与围术期医学科,陕西西安 710032
  • 张震,硕士研究生,主要从事围手术期低体温方面的研究

通讯作者:

聂煌,E-mail:
Research progress on the perioperative hypothermia
Zhen Zhang, Hai-Yun Guo, Wu-Gang Hou, Huang Nie*
Affiliations
  • Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi 710032, China
出版时间: 2023-04-28 doi: 10.11855/j.issn.0577-7402.2023.04.0476
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围手术期低体温是外科手术患者经常面临的问题,与多种术后并发症密切相关,不利于术后康复。目前研究多集中于围手术期低体温的危险因素、不良结局及预防策略方面,少有研究从多维度解析围手术期低体温以及不同维度定义低体温与预后的关系。本文总结分析前期研究成果,从体温的生理学、围手术期低体温、围手术期体温监测与维持、围手术期低体温的重新界定及衍生参数等方面进行综述,以期为研究人员及临床医师提供新的观点,为防治围手术期低体温提供更优的策略。

围手术期低体温  /  体温  /  并发症  /  加速康复外科

Perioperative hypothermia is not rare in surgical patients, and is closely related to a variety of complications,which is not conducive to postoperative recovery of patients. At present, many studies focus on the risk factors, adverse outcomes and prevention strategies of perioperative hypothermia, and few studies analyze the changes of perioperative hypothermia from a multidimensional perspective. By summarizing and analyzing the previous research results, this paper reviews the physiology of body temperature, perioperative hypothermia, perioperative monitoring and maintenance of body temperature, and the new opinions and derived parameters of perioperative hypothermia, which is expected to bring some new perspectives for researchers and clinicians to develop better strategies for the prevention and treatment of perioperative hypothermia.

perioperative hypothermia  /  body temperature  /  complications  /  facilitating post-operative rehabilitation
张震, 郭海云, 侯武刚, 聂煌. 围手术期低体温研究进展. 解放军医学杂志, 2023 , 48 (4) : 476 -481 . DOI: 10.11855/j.issn.0577-7402.2023.04.0476
Zhen Zhang, Hai-Yun Guo, Wu-Gang Hou, Huang Nie. Research progress on the perioperative hypothermia[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (4) : 476 -481 . DOI: 10.11855/j.issn.0577-7402.2023.04.0476
维持正常体温是生命活动的必要条件。大多数外科手术患者在围手术期会出现不同程度的体温降低[1],其发生率为4%~90%[2],报道的围手术期低体温发生率差异大的原因可能是判断低体温的时机不同(闭合手术切口时或进入麻醉后监护病房时)。围手术期低体温与多种并发症密切相关[3],包括手术部位感染(surgical site infection,SSI)、凝血功能障碍、药物代谢减慢、心血管事件增加、住院时间延长等。因此,维持术中正常的体温已被许多学会(如欧洲加速康复外科学会)和机构(如英国国家健康与临床卓越研究所)纳入指南和专家共识[4-6]。目前,大多数研究集中于围手术期低体温的危险因素、低体温引发的不良结局,以及如何有效预防低体温的发生方面,鲜少有研究从多维度解析围手术期体温的变化规律,并对其与不良结局的关系进行分析。本文从体温的生理学、围手术期低体温、围手术期体温的监测与维持、围手术期低体温的新思考等方面进行综述,旨在加深对围手术期体温的认识,指导临床医务人员从不同维度分析围手术期体温变化,科学规范地管理围手术期体温,减少术后不良结局,促进患者康复。
人体具有完善的体温调节系统,可适应正常生命活动的需要。体温一般分为核心体温与外周体温,前者是核心组织(躯干和头部)的平均温度,其中肺动脉血液温度最能代表核心组织的平均温度[7];后者如手臂、腿部和皮肤等的温度随环境因素及外周灌注情况而变化。生理状态下,健康成人的核心体温维持在37 ℃左右,女性的核心体温通常较男性略高,外周体温较核心体温一般低2~4 ℃[8]。体温随昼夜节律而波动,通常在凌晨3:00左右最低(36.5 ℃),下午3:00左右最高(37.5 ℃),波动幅值一般不超过1 ℃。绝经前妇女的体温会随月经周期变化而变化,在黄体期稍高。小儿和老年人因代谢速率与成人不同,体温也有所差异。
人体体温调节系统主要由感觉传入、中枢调节、自主性调节及行为性调节组成[9]。视前区下丘脑前部是体温调节的高级中枢,体温调节的次级中枢则包括延髓、脊髓等部位。另外,大脑皮质对体温的行为性调节也起到调控作用[8]。位于外周皮肤的各种感受器可感知温度,然后传入中枢系统进行处理,最后使机体做出相应的调节。值得注意的是,瞬时感受器电位蛋白(transient receptor potential proteins,TRPVs)在温度感知中发挥着重要作用,其中TRPV受体1-4被热激活,而TRPM8和TRPA1被冷激活[7]。自主性体温调节包括热调节(毛细血管前扩张和出汗)及冷调节(动静脉分流血管收缩和寒战)。婴儿产热主要是非颤抖产热,主要发生在褐色脂肪中。作为一种最有利的调节方式,行为性体温调节可使机体在面对不同的环境时,采取主动调节体温的行为,包括环境温度寒冷时主动添加衣物或使用取暖设备,而炎热时着装清凉或使用制冷设备。行为性体温调节使人类能够适应所居住的各种环境。
温度调节具有阈值效应[7]。出汗与血管收缩阈值之间的温度定义为正常核心温度,通常约为37 ℃。出汗是机体在炎热条件下唯一的散热途径,可激活毛细血管前血管扩张,将热量传递至皮肤表面并散失到环境中。寒战阈值较血管收缩阈值低1 ℃;当出现寒战时,体温已经相当低。根据阈值效应,“调定点”学说是目前主要被认可的体温中枢调节机制[10]。该学说认为,在体温调节中枢内存在一个调定点,类似于恒温器,机体围绕着该调定点来调控体温。当体温偏离调定点时,由反馈系统(温度感受器)将偏差信息传输到中枢系统(视前区下丘脑),然后进行综合分析,最后通过对效应器(产热和散热)的调控将中心温度维持在调定点附近水平。
作为经典的生命体征之一,体温异常可导致机体患病,也预示着疾病的发生。绝大多数麻醉药物会损害体温调节系统[7],特别是降低寒战防御的阈值,即动静脉分流收缩和寒战。体温调节受损,加之较低的手术室环境温度和手术暴露,几乎所有未保暖的外科手术患者都会体温过低。传统上,这种非医疗计划导致的手术患者核心温度低于36 ℃称为围手术期低体温(perioperative hypothermia)[4]
目前的主要观点认为,围手术期体温变化经历了以下3个阶段[11]:首先,麻醉药物影响体温调节中枢,降低血管收缩及寒战阈值,引起血管扩张,导致核心温度重新分布;其次,术中机体的产热不足以补充流失的热量,导致体温缓慢下降;最后,低体温达到血管收缩阈值,核心温度流失减少,机体产热与散热达到平衡。但麻醉药物影响体温调节的具体机制尚不清楚,如同麻醉药物如何使人类意识消失一样,仍是一个需要解决的科学问题。
现有的研究表明,围手术期低体温发生的危险因素包括患者自身因素[如年龄≥60岁、体重指数(body mass index,BMI)<22 kg/m2等]、麻醉因素[如美国麻醉医师协会(ASA)分级>Ⅱ级、麻醉时间>2 h、麻醉药物、联合麻醉等]、手术因素[如手术类型(开腹手术暴露或者腹腔镜手术中CO2带走腹腔的大量热量)、手术时间>2 h、术中用药、术中大量冲洗液或输注液未加温等]及其他因素(如手术室环境温度较低、未积极采取保温措施等)[12-13]
鉴于机体维持正常的新陈代谢和细胞功能都离不开合适的温度,围手术期低体温与各种围手术期并发症的发生密切相关。但不同研究确定低体温的时机不同,多数研究将手术结束时的温度低于36 ℃视为低体温。按照该标准,即使患者术中经历了低体温,但手术结束时体温正常则不属于低体温范畴,这一部分“体温正常”的患者与手术全程体温正常患者相比是否存在并发症增多的风险,仍需要进一步研究。此外,不同研究中低体温程度的不同也可能造成研究结果不一致。
1996年Kurz等[14]The New England Journal of Medicine发表的研究指出,结肠肿瘤手术患者术中核心温度的降低增加了手术部位的感染风险,延长了住院时间,自此,围手术期低体温与SSI的关系备受关注。此后,相继有研究也得到了围手术期低体温导致SSI的结论[15-16]。但后续研究对围手术期维持正常体温可减少SSI提出了质疑。如Baucom等[17]从不同维度的低体温定义出发,未发现结肠肿瘤患者围手术期低体温与SSI有关。Kurz等[14]研究中的低温组是人为造成的,平均术中最终核心温度为34.7 ℃,而Baucom等[17]的病例对照研究中保温措施更普遍,发生SSI患者的平均最终核心温度为36.3 ℃(未发生组为36.1 ℃),严重低温的情况明显减少;此外,Kurz等[14]的研究中低温组输血比例远高于正常体温组(没有排除这一混杂因素),可能是这两项研究得出不同结论的原因。另一项采用美国国家外科质量提升计划数据库资料的巢式病例对照研究在控制了患者因素和其他手术因素后分析发现,围手术期维持正常核心体温与胃肠手术后SSI降低没有独立相关性[18]。此外,有Meta分析发现,围手术期低体温与SSI无明显相关性[19-20]。后续仍需要更多的循证医学证据证实二者之间的关系。
围手术期低体温可能会引起凝血功能障碍[21],这是由于体温降低造成凝血因子活性、血小板功能、纤溶系统功能等受损所致。体温过低引起的凝血障碍也增加了输血的需求。Rajagopalan等[22]的Meta分析显示,核心温度每降低1 ℃,失血量约增加20%,输血的相对风险增加约22%。最近一项在体外不同温度下进行血样本血栓弹力图检测的研究发现,与37 ℃相比,35 ℃时外源性和内源性途径血块形成时间均明显延长[23]
温度对酶的活性有重要影响,低体温会延长多种药物的作用时间[3]。通过影响药物代谢,围手术期体温过低与麻醉苏醒延迟和麻醉后监护病房(post anesthesia care unit,PACU)内停留时间延长有关。
由于肌松药物的使用,全麻患者术中出现寒战非常少见,但术后寒战却很常见。寒战是一种自主性的体温调节方式,可产生热量以补偿体温过低。寒战对患者来说极其不适,可通过多种药物进行有效治疗,包括哌替啶、可乐定、右美托咪啶和氯胺酮等[24]。热不适(thermal discomfort)是核心温度下降1 ℃以上时产生的一种不适感,与热舒适(thermal comfort)一起被认为是愉悦-痛苦情绪的特殊方面[25],也是围手术期低体温患者的一种主观不良感受[7]。对体温过低患者进行主动皮肤加温可显著提高其热舒适性,同时加快复温速度,但预防体温过低显然是更好的治疗策略。
围手术期低体温会导致心血管事件增加[26],如心肌缺血、心肌梗死、心脏停搏等。体温降低可能通过增高血液中去甲肾上腺素的浓度、促进血管收缩、影响冠脉灌注等而导致血压降低、心律失常、心肌损害甚至心跳停止等不良心血管事件。一项观察性研究发现,正常体温组缺血性心血管事件发生率为1.4%,而低体温组为3.1%(风险调整后OR=0.60,95%CI 0.41~0.92)[27]
世界卫生组织安全手术指南指出,手术期间需要维持正常体温[28]。目前的共识是当全身麻醉时间超过30 min时应测量核心体温。虽然体温监测设备种类较多,但用于围手术期体温监测的设备只有4种,即热敏电阻温度计、热电偶温度计、红外线温度计和零热流量温度计[29]
热敏电阻是简单的半导体,其电阻随温度呈非线性变化,因此可将电阻转换为绝对温度。大多数临床体温计都是基于热敏电阻设计的。热电偶是双金属结构,会产生随温度非线性变化的微小热电电压;对于给定的金属组合,电压随温度变化的关系是一致的,同样可将电压转换为绝对温度。红外线温度计则通过对物体自身辐射的红外能量进行测量,得到准确的表面温度,但测量深部温度的能力有限。在临床背景下,一些组织温度如手术过程中器官表面的温度,可在没有直接接触和污染风险的情况下进行测量。零热流量温度计根据热量只能沿温度梯度流动的定律,由两个温度计及其中间的绝缘体构成。该技术目前多用于接受椎管内麻醉的患者[30],未来随着科技的发展,有望用于监测全身麻醉患者的核心温度。
肺动脉最能反映核心温度的真实情况,但由于监测困难,很少选择其作为监测点。目前常见的用于反映核心温度的监测部位包括远端食管、鼻咽和鼓膜。采用食管内温度探头时,应将其放置在心音最大的位置或更远的位置,以避免呼吸带来的影响。鼻咽部的探头则需要插入鼻孔后10~20 cm,才可准确地估算成人核心温度[31]。鼓膜部位的监测常由于探头插入的距离不够远,导致对核心温度的估计不准确。上述几种体温监测设备都是基于热敏电阻或热电偶的温度探头,可在术前放置于对应的部位进行体温持续监测。红外线耳温仪不能接近鼓膜,主要用于测量皮肤温度,因此很难估计核心温度。此外,核心温度也可从摄入的胶囊中获得,这些胶囊可将温度传送到带有接收装置的可穿戴背心上,在研究体温的昼夜节律时非常有价值,但很少用于日常监测。相比之下,膀胱和直肠温度的可靠性较低,因为这两个部位的血流灌注都很差,温度变化明显滞后于核心温度[7]。但小儿的膀胱和直肠温度滞后可能较小,对于2岁以下小儿可将直肠或者膀胱作为核心温度的监测部位。麻醉恢复期患者可采取口腔或者腋窝测温,也能很好地估算核心温度。皮肤温度远低于核心温度,且受环境因素影响较大,因此简单地在皮肤温度上增加固定的补偿(如2 ℃),不能可靠地估计核心温度。大多数情况下,如何选择合适的监测部位来估算或反映核心温度至关重要,决定精确度和准确度的是测量部位,而不是监测设备。
围手术期体温的维持对于减少术后并发症具有重要意义,也是加速康复外科(enhanced recovery after surgery,ERAS)24个核心临床路径要素中的重要一环[32]。ERAS强调了维持正常体温的必要性,目的是减少低体温带来的并发症,从而促进术后快速康复[33]。有Meta分析显示,维持围手术期正常体温可改善患者预后,且当与其他ERAS要素一起实施时,对促进患者术后康复具有显著的效果[34-35]。目前临床上常用的维持体温的方式包括被动保温(如常规使用手术单、棉毯或反光毯等可有效减少手术患者的热量损失)、主动保温[如使用加温设备(加热毯)进行体表加温及应用加温的输液液体(37 ℃)、灌洗液(38~40 ℃)等可有效预防低体温的发生]、维持手术室环境温度(不低于21 ℃)以及使用药物干预(如苯肾上腺素、果糖、氨基酸可减少热量再分布及增加代谢产热等)。详细描述参见代子一等[11]的综述。目前使用最多的主动保温措施是充气加温(forced-air warming),加热毯的使用也很常见。推荐联合应用多种保温措施以维持术中正常体温。
围手术期低体温可引起多种不良结局,严重影响患者的生活质量,增加医疗费用,加重社会负担。随着ERAS理念的推广,多数指南建议外科手术中应监测患者核心温度,并使之维持在正常水平,但正常核心温度的定义尚无明确的描述。目前的研究大都以不同时间点核心温度<36 ℃作为围手术期低体温的标准,但很少涉及时间维度。考虑到手术时长、麻醉时长是导致围手术期低体温的危险因素,将时间因素引入围手术期体温的分析,可能有助于发现新的规律。随着连续体温监测的应用越来越广泛,这一想法也成为可能。
2011年Egan等[36]首次提出了基于时间维度的体温界定,即TWA,其计算方式为曲线下面积/体温监测时间,有别于传统的术中平均温度(=监测温度总和/监测次数)不同;该研究还比较了体下阻力加热系统与充气加温系统在开腹手术中的保温效果,发现二者并无明显差别。2018年Schacham等[37]评估了术中最终温度、术中TWA与心肌损伤的关系,发现术中最终温度、术中TWA与心肌损伤无明显相关性,分析原因为该研究的最终体温平均为36.5 ℃,高于早期的研究,该程度的低温没有造成明显的心肌损伤。2020年Walters等[38]以TWA和术中最终温度作为暴露因素,探讨了其与结直肠肿瘤患者术后30 d感染的关系,发现术中TWA低于35.5 ℃与结直肠手术后的严重感染并发症相关;当TWA为35.5~36.5 ℃时,与术后感染并发症没有明显关联。这对将36 ℃作为维持正常体温临界值的传统观点提出了挑战。同时术中最终核心体温与严重感染、浅表感染、住院时间等均无关。该研究结果表明,基于时间维度的术中平均体温而非术中最终体温与术后切口感染存在密切关系。2021年Ju等[39]根据术中TWA将患者分为常温组(36.0~37.5 ℃)、轻度低温组(35.0~36.0 ℃)与重度低温组(<35 ℃),分析术中体温与胰十二指肠切除术后胰漏的相关性,结果显示,术中重度低温与胰漏明显相关,而轻度低温与胰漏无明显相关性。因此,未来的研究应重点关注围手术期低体温的界定,从不同维度分析其与术后不良结局的关系,以制定更好的围手术期体温管理目标。
术中最低温度、术中最终温度、术中平均温度是3种比较常见的温度模式。Seamon等[40]探讨了创伤后开腹患者术中低体温与伤口感染的关系,发现术中最低体温的预测价值最大。Baucom等[17]探讨了4种可能的低体温定义(包括术中最低体温、术中平均体温、体温最低点时间百分比和体温低于36.0 ℃的时间百分比)在接受节段性结肠切除术的患者中与30 d SSI的关系,但未发现体温过低与30 d SSI之间存在关联。目前手术患者多常规使用保温设备和其他预防低温的措施,术中出现体温下降的程度远低于10年前的研究,这可能是与既往研究得出不同结论的原因之一。
考虑到不同方法界定的低体温与术后并发症的关系可能不同,针对不同的并发症高危人群,基于不同时间点和方法判断低体温可能更有意义。如轻度的低体温即可损害凝血功能,这一影响与持续时间密切相关,因此TWA可能更有意义。对于有凝血功能障碍或大出血倾向的患者应实施更为精细的体温管理,而不应仅满足于术中最终体温>36 ℃。对于易发生心肌损害的患者,则手术结束时的低体温更有意义,因为围手术期心肌损害多发生在术后,这与苏醒后机体对低体温的反应密切相关。值得注意的是,对于不同类型的手术,临床医师关注的预后结局不同,其低体温界定也可能不同。从不同维度细化分析术中的体温变化模式,有利于进一步了解体温与术后并发症的关系。未来的研究应将以下几种不同界定方式的术中低体温及其衍生参数(图1)推广应用于其他类型的外科手术中,以获取更多的循证医学证据来指导精准的围手术期体温管理。
围手术期低体温是外科手术的常见现象,与多种并发症相关,不利于患者的康复。目前关于围手术期低体温的研究大都以单一时间点的测量值或者多次测量的平均值展开,没有将时间因素纳入分析中,忽略了体温动态变化与术后并发症的关系。连续体温监测为计算TWA等提供了契机,未来的研究应考虑以这一指标判断是否发生了可导致不良结局的低体温。此外,以36 ℃作为标准来判断是否发生低体温是否适用于所有手术类型仍值得考量。研究者应该综合考虑各种因素,将手术类型、患者的基础疾病等与围手术期的体温变化规律联系起来,权衡临床获益和成本,采取精细化、个体化的围手术期体温管理策略,以改善患者预后。
  • 国家自然科学基金(81971226)
  • 国家自然科学基金(81901079)
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2023年第48卷第4期
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doi: 10.11855/j.issn.0577-7402.2023.04.0476
  • 接收时间:2021-11-11
  • 首发时间:2025-12-03
  • 出版时间:2023-04-28
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  • 收稿日期:2021-11-11
  • 录用日期:2022-01-09
基金
National Natural Science Foundation of China(81971226)
国家自然科学基金(81971226)
National Natural Science Foundation of China(81901079)
国家自然科学基金(81901079)
作者信息
    空军军医大学西京医院麻醉与围术期医学科,陕西西安 710032

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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