80岁以上老年人长期气管切开术后并发症的原因分析

目的探讨≥80岁老年患者长期气管切开术后并发症发生的原因及防治措施。方法回顾性分析2004年2月至2011年8月我院收治的≥60岁资料完整的行气管切开术350例患者临床资料,其中就气管切开后带套管较长时间的80例≥80岁老年患者的主要并发症原因及防治进行分析。结果 80例长期带管≥80岁老年患者其并发症最多见为反复肺部感染38例(47.50%),其合并多种致病菌,致病菌以铜绿假单胞菌为主,治疗棘手,是死亡的主要原因。其后依次为拔管困难15例(18.75%)、气管内出血14例(17.50%)、伤口渗血5例(6.25%)、套管堵塞4例(5.00%)、肺大泡3例(3.75%)、气管食管瘘1例(1.25%)。结论≥80岁老年气管切开术后带套管患者由于多种疾病并存,常合并多器官功能不全,凝血机制障碍,长期带管等都是气管切开术后并发症发生的主要危险因素。针对危险因素,做好并发症预防,可延缓患者生命。     

老年病人气管切开术的特点

目的研究老年病人气管切开术的临床特点。方法对73例年龄〉70岁的老年病人的气管切开术进行回顾分析。对施行气管切开术的手术原因、手术时机、手术方式、手术条件及手术后并发症进行统计。结果长期气管插管为老年病人施行气管切开术的主要原因,喉梗阻为次要原因,手术时机在气管插管后7 d为主,复杂手术条件者在老年病人中占有较大比例（71.2%）,针对这些病人的手术方式有别于普通人群,手术后并发症有伤口出血（6.8%）、皮下气肿（4.1%）。结论老年病人的气管切开术以长期气管插管病人为主,手术时机提前,老年病人气管切开术遇到的复杂条件较多,可采用个性化的手术方案,手术后并发症发生率较低。     

幽门管过长对食管癌患者术后胸腔胃排空的影响

目的：探讨食管癌患者幽门管过长与术后胸腔胃排空障碍的关系。方法测量536例食管癌根治术患者的幽门管长度,并收集其临床资料进行分析。结果536例患者中,幽门管过长73例,术后发生胸腔胃排空障碍10例（13．70％）;幽门管正常463例,术后发生胸腔胃排空障碍15例（3．24％）。两者术后胸腔胃排空障碍发生率比较,P＜0．05。结论食管癌患者幽门管过长易发生术后胸腔胃排空障碍。     

内镜下胰管括约肌切开术后早期并发症的前瞻性研究

目的评价内镜下胰管括约肌切开术后早期并发症的发生率及相关危险因素。方法前瞻性观察2006年5月至2007年4月行ERCP的住院患者,将ERCP下行胰管括约肌切开术的患者纳入研究。在ERCP术前及术中分别将患者和操作相关情况记录在统一的观察表上;术后随访并发症的发生情况直至出院;有关数据进行统计学分析。结果在纳入观察的165例行胰管括约肌切开术的患者中,25例发生并发症（15．2％）,其中急性胰腺炎22例（13．3％,轻度15例、中度6例、重度1例）,出血1例（0．6％）,急性胆管炎2例（1．2％）,无穿孔或操作相关的死亡发生。多变量分析提示术后急性胰腺炎危险因素是：女性（OR=3．8,95％CI1．4～10．8）、复发性胰腺炎（OR=3．1,95％CI1．0-9．9）、副乳头切开术（OR=5．9,95％CI1．2—28．8）。结论与常规ERCP操作比较,内镜下胰管括约肌切开术后急性胰腺炎的发生率较高。特别是女性、复发性胰腺炎、行副乳头切开术的患者,术后更易发生急性胰腺炎。     

气管切开术手术时机的选择及并发症分析

目的：探讨气管切开术手术时机的选择,并分析其并发症。方法回顾性分析531例行气管切开手术患者的临床资料,记录其手术时机及并发症发生情况。结果531例患者中,28例（5．27％）是紧急气管切开,为了解除上呼吸道阻塞引起的呼吸困难,其余均为选择时机行气管切开术。其中33例发生并发症,包括出血12例、皮下气肿6例、纵隔气肿1例、气胸1例、气管套管脱出8例、感染1例、肉芽形成1例、气管食管瘘2例、拔管困难1例。结论上呼吸道阻塞引起的呼吸困难宜行紧急气管切开,其余可选择时机进行,并发症多为出血和气管套管脱出。     

上消化道出血并发急性脑梗死24例临床特点分析

上消化道出血并发急性脑梗死的病例鲜见报道，应总结其临床特点。目的：探讨上消化道出血并发急性脑梗死的临床特点。方法：分析24例上消化道出血并发急性脑梗死患者的临床特点。结果：本组24例患者的平均年龄63．0岁．9例（37．5％）上消化道出血病因为肝硬化，14例（58．3％）为大出血，14例（58．3％）使用抗纤溶药物，21例（87．5％）伴高血压、高血脂、冠心病、糖尿病等与动脉硬化有关的因素。发生脑梗死的平均时间为上消化道出血后3．6d，大面积梗死多见。结论：对上消化道出血伴有与动脉硬化有关的因素（高血压、高血脂、冠心病、糖尿病等）以及既往有肝硬化史的老年患者,尤其是大出血者。应认识到并发急性脑梗死的危险，出血后3d左右脑梗死的发生率最高。治疗应禁用或慎用抗纤溶药。     

电视纵隔镜在老年肺癌分期中的应用价值

目的 探讨纵隔镜手术在老年肺癌分期中的应用价值。方法 试验组：怀疑为肺癌的老年患者10例和病理诊断已确诊为肺癌且影像学显示纵隔淋巴结肿大（≥1．0cm）的老年患者8例均行纵隔镜手术。对照组：18例怀疑老年肺癌均行手术治疗。结果 试验组：18例老年患者中，纵隔镜检查阳性12例，阴性6例。阳性者放弃手术，予以化疗；阴性者6例经开胸探查证实为肺癌。手术切除标本未发现纵隔淋巴结转移，特异性、敏感性均为100％。对照组中，8例发生并发症，并发症发生率为44．4％（8／18）；试验组中，纵隔镜术中发生出血1例，并发症发生率为5．5％（1／18）（P〈0．05）。对照组中，4例误诊，误诊率为22．2％（4／18）；试验组中，0例误诊，误诊率为0％（0／18）（P〈0．05）。对照组中，1例死亡，围手术期死亡率5．5％（1／18）；试验组中，0例死亡，死亡率为0％（P〉0．05）。结论 纵隔镜手术创伤小、安全、取材可靠，是肺癌术前病理分期最重要的方法。尤其对老年肺癌病人明确PTNM分期，确定治疗方案和判断预后具有重要意义。     

糖尿病合并肺部感染151例临床分析

目的分析糖尿病伴肺部感染的临床特点，探讨其治疗策略。方法对151例糖尿病伴肺部感染患者临床相关因素（性别、年龄、病程、血糖、并发症、痰菌等）和治疗效果进行回顾性分析。结果糖尿病伴肺部感染的发生率为26．35％，其发生与年龄、病程、血糖高低及同时存在的糖尿病其他并发症有密切关系（P〈0．05或0．01），而与性别无关；肺部感染类型以急性气管-支气管炎为主（占39．07％），其次为肺炎、慢性支气管炎、肺结核等。肺部感染以革兰阴性杆菌为主。151例中痊愈和显效106例（占70．19％），死亡19例（12．58％）。结论定期行胸部X线检查，控制血糖，预防和治疗糖尿病并发症，有效抗生素应用是防治本病的关键。     

经胰管弓式隔膜乳头预切开术和针式乳头预切开术在困难胆管插管中的应用研究

目的评价经胰管弓式隔膜乳头预切开术处理ERCP困难胆管插管的应用价值。方法回顾2006年1月至2008年7月109例ERCP胆总管插管困难患者进行经胰管弓式隔膜乳头预切开术（下称经胰管组,56例）和常规针式乳头预切开术（下称常规针刀组,53例）的临床资料,比较两种方法插管成功率及并发症发生率。结果109例患者中的97例在乳头预切开术后可成功插入胆管,经胰管组成功率96．4％（54／56）,常规针刀组成功率81．1％（43／53）,两者差异具统计学意义（P〈0．05）。109例中11例出现并发症,包括急性胰腺炎5例、出血4例、胆道感染2例。其中,经胰管组急性胰腺炎2例,常规针刀组急性胰腺炎3例,出血4例,胆道感染2例。两组比较,经胰管组总的并发症发生率低于常规针刀组（3．6％比17．0％,P〈0．05）,术后胰腺炎、出血、感染发生率也分别低于后者,但均无统计学意义。结论内镜经胰管弓式隔膜乳头预切开术超选胆总管成功率高于针式乳头预切开术,而且并发症较低,是处理选择性胆总管插管较困难患者的安全和有效的办法。     

达那唑治疗老年难治性免疫性血小板减少性紫癜疗效和安全性评估

目的观察达那唑在老年难治性免疫性血小板减少性紫癜（ITP）治疗中的作用和安全性。方法对年龄≥60岁的老年难治性ITP患者应用达那唑10～15mg·kg^-1·d^-1治疗。以血小板计数≥30×10^9／L、出血症状改善和停用糖皮质激素为治疗目标和疗效评价指标。对患者在治疗过程中的血细胞计数、生化指标、出血症状和不良反应进行随访和观察。结果：共有23例患者进入本研究，年龄60～69岁，其中男性12例，女性11例，平均（62．3±2．3）岁。8例有效，有效率34．8％（8／23），其中男性5例，女性3例，没有性别差异（P=0．673）。平均疗效出现时间（14．1±4．5）d。对缓解患者进行随访，随访中位时间7．5m（3～18m），中位维持治疗时间4m（3～6m），中位疗效持续时间6m（2～18m），平均治疗剂量（450．0±141．4）mg／d，5例合并糖皮质激素治疗，其中4例患者停药，1例患者醋酸泼尼松减到维持剂量2．5mg／d，合并药物停药率80％（4／5）。3例患者失去治疗反应，复发率37．5％（3／8）。治疗开始时，87．0％（20／23）患者存在Ⅰ-Ⅱ级出血。治疗有效的患者出血症状消失。12例患者出现肝功能异常，占52．2％（12／23），治疗有效组和无反应组分别有6例，差异无统计学意义（75．0％ vs 40．0％，P=0．193）。其他不良反应还有多毛和视物模糊。不良反应均可逆。结论达那唑是有效的治疗老年难治性ITP的药物，安全性高，老年患者耐受性好。     

Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation

BACKGROUND: Tracheostomy tube malposition is a barrier to weaning from mechanical ventilation. We determined the incidence of tracheostomy tube malposition, identified the associated risk factors, and examined the effect of malposition on clinical outcomes. METHODS: We performed a retrospective study on 403 consecutive patients with a tracheostomy who had been admitted to an acute care unit specializing in weaning from mechanical ventilation between July 1, 2002, and December 31, 2005. Bronchoscopy reports were reviewed for evidence of tracheostomy tube malposition (ie, > 50% occlusion of lumen by tissue). The main outcome parameters were the incidence of tracheostomy tube malposition; demographic, clinical, and tracheostomy-related factors associated with malposition; clinical response to correct the malposition; the duration of mechanical ventilation; the length of hospital stay; and mortality. RESULTS: Malpositioned tracheostomy tubes were identified in 40 of 403 patients (10%). The subspecialty of the surgical service physicians who performed the tracheostomy was most strongly associated with malposition. Thoracic and general surgeons were equally likely to have their patients associated with a malpositioned tracheostomy tube, while other subspecialty surgeons were more likely (odds ratio, 6.42; 95% confidence interval, 1.82 to 22.68; p = 0.004). Malpositioned tracheostomy tubes were changed in 80% of cases. Malposition was associated with prolonged mechanical ventilation posttracheostomy (median duration, 25 vs 15 d; p = 0.009), but not with increased hospital length of stay or mortality. CONCLUSION: Tracheostomy tube malposition appears to be a common and important complication in patients who are being weaned from mechanical ventilation. Surgical expertise may be an important factor that impacts this complication.     

MDCT of the central airways: comparison with bronchoscopy in the evaluation of complications of endotracheal and tracheostomy tubes

OBJECTIVE: To evaluate the accuracy of multidetector row computed tomography (MDCT) compared with bronchoscopy in the assessment of airway complications related to endotracheal and tracheostomy tubes. MATERIALS AND METHODS: A review was performed of all consecutive patients undergoing computed tomography (CT) and bronchoscopy for symptomatic complications of endotracheal or tracheostomy tubes during an 18-month period. MDCT imaging was performed according to a standard protocol and interpreted by an experienced thoracic radiologist before bronchoscopy. After bronchoscopy by an experienced interventional pulmonologist, CT and bronchoscopic findings were reviewed jointly, and the accuracy of CT was determined using bronchoscopy as the "gold standard." RESULTS: The study population was comprised of 32 patients (range: 26 to 88 y, mean 55.6) with a total of 47 airway complications: tracheal stenosis (n=25), tracheomalacia (n=8), tracheal granulation tissue (n=8), tracheal cartilage fracture (n=4), tracheal perforation (n=1), and tracheostomy tube disruption (n=1). CT accurately diagnosed 42 of 47 airway complications (sensitivity 89.4%, specificity 95.2%, positive predictive value 85.7%, negative predictive value 96.5%). False negative findings at CT occurred in 5 (11.1%) of 47 cases. Contributing technical factors were identified in 3 (60.0%) of 5 false-negative cases, including the presence of tracheostomy tube during imaging and patient inability to complete the CT protocol. CONCLUSIONS: MDCT of the central airways is highly accurate for detecting symptomatic airway complications of endotracheal and tracheostomy tubes, particularly when technical limitations to the performance of CT are minimized.     

Cardiovascular abnormalities in Turner's syndrome: What prevention?

Cardiovascular complications in Turner's syndrome are the most common cause of excess early mortality, with a life expectancy that may be reduced by more than 10 years. Congenital cardiac abnormalities are described in approximately one third of patients. These abnormalities are mostly left heart obstructions, the most common of which are bicuspid aortic valve (16%) and coarctation of the aorta (11%). Dilatations of the ascending aorta are often described and may occur in isolation from any heart disease, suggesting a vasculopathy specific to the syndrome, probably predisposed to by extracardiac risk factors such as oestrogen deficiency, diabetes, dysplidaemia and overweight. The most feared complication is aortic dissection with around a 100 cases, described at average age of approximately 35-years-old. This is believed to complicate 2% of induced pregnancies. Hypertension (HBP) usually essential, affects up to 50% of patients with Turner's syndrome. This is an important risk factor for cardiovascular complications and justifies aggressive treatment. On the other hand, retrospective studies have not demonstrated adverse cardiological effects due to growth hormone treatments. Patients with Turner's syndrome merit regular cardiology follow-up from childhood onwards, particularly if they have treated heart disease. The merits of preventative treatments for aortic dilatation have not been demonstrated in Turner's syndrome and justify prospective trials.     

Semi-skeletonized internal mammary artery grafts and sternal wound complications

This study aimed to evaluate the risk factors for sternal wound complications in patients undergoing myocardial revascularization using bilateral semi-skeletonized internal mammary arteries. Prospectively collected data on 751 patients undergoing coronary artery surgery from September 1994 to August 2002 were analyzed. The mean age of the patients was 56 years, 633 (84%) were male, 44 (6%) were over 66 years of age, and 170 (23%) were diabetic. Forty-four (5.9%) patients developed sternal wound complications. Among these cases, sternal infection occurred in 22 (2.9%) patients, of which 15 (2.0%) had sternal infection with mediastinitis and 7 (0.9%) had sternal infection alone. Independent risk factors for any sternal wound complications were peripheral vascular disease, diet-controlled diabetes, and delayed sternal closure. The risk factors for sternal infection were diabetes, postoperative pulmonary complications, and postoperative stroke. The perioperative mortality rate was 1.5% (11 patients), including 2 patients who had sternal wound complications. The use of bilateral semi-skeletonized internal mammary artery conduits carries a comparable sternal wound complication rate as conduits harvested by other techniques.     

Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention

Intrapulmonary placement of small-bore nasogastric feeding tubes caused pneumothoraces in four patients. Review of the literature discloses another 106 cases of the same complication. Risk factors for intrapulmonary complications include endotracheal intubation or tracheostomy (60% of reported cases [95% confidence interval, 44% to 80%]), and altered mental status (36% of reported cases [95% confidence interval, 24% to 53%]). We propose a simple, two-step method of feeding tube insertion designed to prevent such complications in high-risk patients.     

Twenty-year audit of percutaneous liver biopsy in a major Australian teaching hospital

Background: To examine the changes in indications, patient characteristics, safety and outcomes in consecutive patients undergoing percutaneous core liver biopsies in a major Australian teaching hospital over a period of two decades. Methods: A retrospective audit was carried out on all percutaneous core liver biopsies from a single institution between 1996 and 2005. This was combined with 10 years of data already reported on for the years 1986–1995 to detect trends in indications and outcomes. Results: Medical records from 1398 patients were included for analysis. Over a 20‐year period, the most common indications for liver biopsy were hepatitis C (37.8%), hepatitis B (26.4%) and abnormal liver function tests (22.2%). Twelve major complications (1.0%) were seen; 10 episodes of haemorrhage, 1 bile leak and 1 visceral perforation. Seven of these patients had an abnormal baseline coagulation profile; a significant risk for major haemorrhage (P < 0.001), resulting in three deaths. All deaths occurred in inpatients with major comorbidities. Minor complications occurred in 13.6% of patients, with multiple passes a significant risk factor. Whereas the overall major and minor complication rates were independent of operator experience inadequate specimens were more frequently obtained by the registrar. Conclusion: This large series extending over two decades shows that despite advances in biopsy techniques, the rates of both minor and major complications remain significant. Of particular concern are the procedure‐related deaths. Identifying factors that may increase risk requires further scrutiny and careful patient selection needs to be undertaken.     

Risk factors for complications after performance of ERCP

BACKGROUND: ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS: Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS: Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS: The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.     

Angiographic predictors of femoral access site complications: implication for planned percutaneous coronary intervention.

This study examined the relationship between the femoral arteriotomy location and the risk of femoral access site complications after diagnostic and interventional cardiac catheterization procedures. One of the most common complication of cardiac catheterization and percutaneous coronary intervention (PCI) involves the vascular access site. The femoral approach is the most frequent site of vascular access during invasive cardiac procedures. This approach is associated with vascular complications, such as retroperitoneal bleeding, which can be life-threatening. If angiographic predictors of retroperitoneal bleeding can be identified, this complication could be avoided. A prospective cohort of 33 patients with femoral access site complications was subgrouped based on the angiographic arteriotomy site. Concurrent patients without complications were randomly selected to form a control group. Study and control patients were compared on presenting risk factors and outcomes. Logistic regression analysis was used to identify independent predictors for femoral access site complications. Arteriotomy location above the most inferior border of the inferior epigastric artery in patients undergoing PCI was associated with 100% of all retroperitoneal bleeds (P < 0.001). Low, high middle, and high femoral arteriotomy sites were associated with 71% of all vascular access complications. The combination of these locations for the femoral arteriotomy was an independent predictor of adverse vascular access site complications beyond traditional risk factors (odds ratio = 28.7; CI = 6.73-122.40; P < 0.0001). Vascular complications occurred more frequently in patients who were of older age (72 vs. 66 years; P < 0.001). The location of the femoral arteriotomy site assessed by a femoral angiogram is predictive of life-threatening complications. Patients undergoing PCI with an arteriotomy above the most inferior border of the inferior epigastric artery are at an increased risk for retroperitoneal bleeding. This complication may be avoided by risk-stratifying patients prior to intervention with a femoral angiogram.     

Complications of percutaneous liver biopsy in children.

To determine the frequency and nature of complications after liver biopsy and whether risk factors could be identified to predict these complications, the medical records of all patients (age, 1 week to 28 years) who underwent a percutaneous liver biopsy at Children's Hospital over a 6-year period (1981-1986) were reviewed. Data were collected from 469 (97%) of 483 eligible charts. Twenty-one patients (4.5%) experienced major complications including bile leak (n = 3, 0.6%), prolonged drainage of ascitic fluid (n = 1, 0.2%), pneumothorax (n = 1, 0.2%), bleeding requiring transfusion (n = 13, 2.8%), and death (n = 3, 0.6%). A subgroup of patients (n = 37) with cancer or bone marrow transplantation was found to be at a nearly fivefold greater risk for transfusion than patients with other diagnoses (P = 0.02). All three deaths in previously stable patients occurred in this same high-risk group of patients with cancer or bone marrow transplantation (P less than 0.001). Two deaths resulted from disseminated intravascular coagulation and one from bleeding. Diagnosis, age, number of percutaneous passes, and prebiopsy coagulation studies were not predictive of subsequent complications. It is concluded that bleeding that requires transfusion is the most common liver biopsy complication and that it occurs more frequently in children than previously reported. Children with cancer or those who have undergone bone marrow transplantation are at a greater risk for bleeding and death following percutaneous liver biopsy.