骨折并发脑型脂肪栓塞综合征诊治进展

脑型脂肪栓塞综合征是脂肪栓塞发生于中枢神经系统,尤其是脑部的一种特殊类型,其发病过程隐蔽,常伴发于严重的骨骼创伤后,症状和体征不明显,临床上容易漏诊、误诊,即使诊断明确,一般治疗效果也不令人满意.随着对这类疾患认识的深入,诊断和治疗技术不断成熟,但仍存在较多争议.该文综合回顾了骨折并发脑型脂肪栓塞综合征的一般流行病学特点、病因、发病机制、诊断和防治等方面的发展和现状.     

骨折合并颅脑损伤脂肪栓塞的诊疗体会

目的探讨创伤骨折合并颅脑损伤出现脂肪栓塞的诊断和治疗。方法对8例创伤骨折合并颅脑损伤出现脂肪栓塞综合征的病例的诊治进行分析。结果本组7例恢复良好．1例死亡。结论通过量化的指标来明确诊断指导治疗。     

原发性胆囊癌术前误诊分析及预防

目的：分析原发性胆囊癌术前误诊原因,探索有效的预防误诊的措施。方法：对收治的52例原发性胆囊癌患者的临床资料进行回顾性分析,着重分析术前误诊原因。结果：术前明确诊断19例(36.5%)。术前误诊33例(63.5%),其中误诊为胆囊结石13例,胆囊息肉样变8例,萎缩性胆囊炎4例,肝门部胆管癌3例,肝占位病变4例,Mirizzi综合征1例。术前误诊的33例术中明确诊断29例(55.8%),另有4例术后常规病理检查才明确诊断(7.7%)。误诊的原因较多,如缺乏特异性临床表现、并发胆囊其他疾病、过分依赖影像学检查、术中对可疑病灶未做快速冷冻病理检查等。结论：对存在胆囊癌高危因素的可疑者应定期进行影像学检查,必要时进行有创性检查,甚至手术探查,术中进行快速冷冻切片病理检查,可做到早发现,早治疗,有助于改善胆囊癌患者预后。     

骨科重症病人脂肪栓塞综合征的诊治

目的：探讨脂肪栓塞综合征的早期诊断和治疗。方法：对近8年来21例脂肪栓塞综合征病历资料进行回顾分析。结果：脂肪栓塞综合征并非少见病，对骨科重症病人应高度警惕其发生。21例中，1例死亡，其余20例治愈。结论：动脉血氧分压对脂肪栓塞综合征的早期诊断是一个可靠的敏感的指标；及早纠正低氧血症和早期应用大剂量激素是治疗脂肪栓塞综合征的关键。     

脂肪栓塞综合征的早期诊断及治疗

目的　探讨脂肪栓塞综合征的早期临床特点及诊治。方法　回顾分析 15例脂肪栓塞综合征患者的临床资料。结果　对股骨干骨折或合并其它骨折 ,当出现Gurd早期诊断标准中任何 1～ 2项症状并排除原发病及合并症时 ,立即按FES进行治疗 ,15例脂肪栓塞综合征患者中 ,除 1例因肺部感染、心衰死亡 ,其他患者临床症状、体征均改善或消失。结论　早期诊治是阻止脂防栓塞综合征发生、发展的重要手段。     

14例脑型脂肪栓塞综合征的治疗体会

脂肪栓塞综合征（fatembolism syndrome，FES）是严重的多发性骨折的并发症，起病急、发展快、早期诊断困难是脂肪栓塞综合征治疗不及时的主要原因，死亡率达6％～35％。脑型脂肪栓塞综合征只以嗜睡、昏迷为其主要表现，特异性不高，容易误诊。我院自1997-2007年共收治多发性骨折后并发脑型脂肪栓塞综合征14例，经积极有效治疗，取得满意疗效，现报道如下。     

时间因素对白蛋白防治脂肪栓塞综合征作用的影响

目的探讨白蛋白对脂肪栓塞综合征的防治作用。方法实验共用２１只健康杂种犬,建立脂肪栓塞综合征模型。于各时间点检测动脉血氧分压、血浆白蛋白和游离脂肪酸,并在栓塞后４８小时处死动物,取肺组织进行病理学检查和肺重量／肺系数测定。结果对照组和治疗组均有脂肪栓塞综合征发生,预防组则未发生脂肪栓塞综合征。结论白蛋白对脂肪栓塞综合征的防治作用取决于应用的时间,栓塞后早期应用白蛋白可以预防脂肪栓塞综合征的发生,栓塞１２小时以后再应用白蛋白治疗脂肪栓塞综合征是无效的。     

创伤性脂肪栓塞综合征的医护配合与协作

目的提高脂肪栓塞综合征治疗过程中医生和护理人员之间的配合与协作水平,提高疾病治疗疗效。方法总结我科11例脂肪栓塞综合征的临床表现、诊断、治疗及疗效。结果2例暴发型病人抢救无效死亡,1例完全型病例留下严重后遗症,其余8例治愈。结论早期诊断、早期处理、积极预防以及医生和护理人员之间的良好配合与协作是疾病治疗疗效的关键。     

脂肪栓塞综合征早期诊断与救治中有关问题探讨

目的：探讨创伤后脂肪栓塞综合征的首发症状与主要临床表现，分析各项临床监测指标，提高该综合征的诊疗水平。方法：通过观察27例创伤后脂肪栓塞综合征的首发症状与主要症状，结合患者临床监测指标的变化，确定该综合征的早期诊断指标与治疗方案。结果：严重创伤、多发骨折的患者脂肪栓塞综合征发生率高，早期多以无诱因高热、呼吸困难、意识障碍为首发症状，血氧分压、血氧饱和度、血色素及红细胞压积早期常呈进行性下降。结论：通过对脂肪栓塞综合征的早期诊断而进行早期治疗，有效地提高了该综合征的治愈率。     

骨折并发脑脂肪栓塞的临床诊治研究

目的　探讨骨折后并发脑脂肪栓塞的发病机理、诊断及治疗措施。方法　回顾性分析 1 6例骨折后并发的以意识障碍、偏瘫及皮肤出血点为主要症状的脑型脂肪栓塞综合征 (FES)。该组均采取以激素和高压氧为主的综合治疗。结果　 1 6例中 1 5例于 3～ 1 5d内清醒 ,神经功能缺失症状于 1 5～ 35d内恢复 ;1例呈植物生存状态。结论　脑脂肪栓塞为排他诊断 ,应以临床诊断为主 ,明确诊断后及早行以激素和高压氧为主的综合治疗 ,疗效明显 ,治愈率高     

Case report: Acute postoperative neurological impairment from fat embolism syndrome

PURPOSE: To describe a case of fat embolism syndrome (FES) following elective tendon contracture release in a patient with myotonic dystrophy, to highlight the importance of considering this entity in the differential diagnosis of acute postoperative neurocognitive dysfunction. CLINICAL FEATURES: A 34-yr-old man with myotonic dystrophy underwent uneventful tendon contracture release under regional anesthesia. In the immediate postoperative period, neurological and respiratory complications developed, requiring intensive care support. The patient showed the classical clinical triad of hypoxemia, neurological impairment and a petechial rash associated with the FES. A diagnosis of FES was made and, despite therapy including fluid and inotropic support, the patient succumbed to the condition. There was no demonstrated intracardiac shunt, suggesting a physiological intrapulmonary shunt was responsible for the development of systemic manifestations of FES. CONCLUSIONS: Postoperative neurological dysfunction is a difficult condition with numerous possible causes. All possible etiologies, including FES, need to be considered in the differential diagnosis and postoperative management of patients developing acute postoperative neurological impairment and hypoxemia.     

创伤后脂肪栓塞综合征的诊治分析

目的 探讨创伤后脂肪栓塞综合征（FES）的诊治问题。方法 总结分析我院1997年3月至2001年3月所收治的9例临床资料。结果 9例按Sevitt分型：暴发型2例，完全型2例，亚临床型5例。除2例暴发型死亡外其余7例因早期发现并及时正确治疗均治愈。结论 正确认识该病的临床表现和诊断标准，早期及时正确的治疗有助于进一步提高疗效。加强创伤后复苏抢救措施可明显降低FES的发生率。     

Early diagnosis of the fat embolism syndrome

One hundred consecutive cases of trauma with associated fractures of the lower limb long bones were studied for the subsequent development of the fat embolism syndrome (FES). This is to be differentiated from the intravascular fat embolism which often occurs without clinical FES becoming manifest. Seventeen of the patients developed the clinical picture, with a further 16 patients being considered to have had the syndrome subclinically. Clinical and biochemical features were studied to determine pointers to the early diagnosis and patient "at risk" of developing FES. Young males under the age of 30 with significant hypoxemia occurring early in the course of the disease were considered the most likely candidates "at risk" for developing FES. These results favor the concept that FES is essentially a form of respiratory insufficiency syndrome similar to that which occurs following trauma in other situations, e.g., shock lung.     

Massive fat emboli syndrome after unsuccessful unreamed nailing of the tibia

A patient is presented in whom massive fat emboli syndrome (FES) developed after the unsuccesful treatment of a solitary tibial fracture with an unreamed tibial nail. Ultimately, a reamed tibial nail was inserted. Several risk factors for the development of FES were identified retrospectively in this particular case: a very small medullary canal, a large-diameter unreamed tibial nail, reaming of a small medullary canal and insertion of a thick reamed tibial nail. Even in the presence of patients with solitary lesions and without obvious risks for FES, one should always take this dangerous complication into account.     

腹膜后神经鞘瘤1例报告并文献复习

目的报告1例腹膜后神经鞘瘤,并复习相关文献,分析其临床诊治现状。方法通过对1例腹膜后神经鞘瘤的诊断、治疗方法及术后病理、随访的回顾,结合国内外有关文献报道,综合分析腹膜后神经鞘瘤的诊断及治疗状况。结果本例行手术治疗,术后病理证实为腹膜后神经鞘瘤,随访半年无复发。结论腹膜后神经鞘瘤诊断困难,影像学检查无特异性,确诊依靠病理检查,理想的治疗方法是通过外科手术完整切除肿瘤,其预后良好,早期复发率低。     

Fat Embolism Syndrome

Fat embolism syndrome (FES) was first described in 1862, but its frequency today is still unclear. A diagnosis of FES is often missed because of a subclinical illness or coexisting confusing injuries or disease. Fat embolism syndrome develops most commonly after orthopedic injuries, but it has also been reported after other forms of trauma such as severe burns, liver injury, closed-chest cardiac massage, bone marrow transplantation, and liposuction. Although FES usually presents as a multisystem disorder, the most seriously affected organs are the lung, brain, cardiovascular system, and skin. Fat embolism syndrome is a self-limiting disease and treatment should be mainly supportive. Many drugs have been used to treat FES, but the results are inconclusive.     

Fat embolism syndrome and elective knee arthroplasty

PURPOSE: To report a case of fat embolism syndrome (FES) following elective left knee arthroplasty and review the diagnosis, investigation, prevention and perioperative management of this condition. CLINICAL FEATURES: A 76-yr-old lady presented for left total knee arthroplasty under general anesthesia. After an uneventful anesthetic and initial recovery, she developed respiratory and neurological complications six hours postoperatively necessitating supportive care in the intensive care unit. Following extensive investigation, a clinical diagnosis of FES was made 48 hr postoperatively supported by the development of diffuse encephalopathy, thrombocytopenia, hypoxemia, chest petechiae and chest x-ray changes. A magnetic resonance imaging scan five days postoperatively confirmed this diagnosis. Her postoperative course showed gradual improvement consistent with a slowly resolving encephalopathy. Previous published cases of FES associated with knee arthroplasty present either with intraoperative cardiorespiratory collapse or, as with this patient, in the postoperative period with respiratory, cardiovascular and/or cerebral dysfunction. CONCLUSIONS: The clinical diagnosis of FES is essentially one of exclusion, supported by laboratory and radiological investigations. Preoperative identification of at-risk patients, use of appropriate invasive perioperative monitoring and modified surgical techniques may minimize the development of the syndrome. Treatment is supportive.     

Functional Electrical Stimulation in Spinal Cord Injury:: From Theory to Practice

This article outlines steps to practical application of functional electrical stimulation (FES) within activity-based restorative therapy (ABRT). Drawing from current evidence, specific applications of FES intended to help restore function lost to spinal cord injury and associated neurologic disease are discussed. The medical and therapeutic indications, precautions, and contraindications are reviewed to help participants with appropriate patient selection, treatment planning, and assessment. Also included are the physiological implications of FES and alterable parameters, including dosing and timing, for a desired response. Finally, approaches to improve cortical representation and motor learning and to transition emerging movement into functional tasks are reviewed.     

Efficacy of physical therapeutic modalities in women with proven bladder overactivity

OBJECTIVE: To assess the efficacy of physiotherapeutic treatment modalities in women with proven bladder overactivity. METHODS: One hundred and twelve women received ambulatory urodynamics. Based on both urodynamic variables of ambulatory cystometry (ACM) and the micturition diary, the Detrusor Activity Index (DAI) for each patient was calculated. After randomization, 68 women with a DAI> or =0.50 were defined as having proven bladder overactivity. In a single blinded RCT patients were randomized over four treatment groups, i.e. lower urinary tract exercises (LUTE); office- and home-based functional electrostimulation (FES); office-based FES and LUTE; no treatment. Patients treated received nine treatment sessions, once weekly. The primary outcome variable was the DAI, measured before randomization and, as soon as possible within a maximum of 14 days after the end of the study period. RESULTS: Intention to treat analysis in the group of 68 patients showed a statistically significant decrease of DAI-scores in the FES group (p=0.032) in comparison with no treatment, while this decrease was not statistically significant in the LUTE group (p=0.105) and the LUTE+FES group (p=0.672). CONCLUSIONS: Our conclusion is that, based on the DAI, in the homogeneous set of 68 patients, only FES seemed to be effective.