Complications of Dual Chamber Pacemaker Implantation in the Elderly

Pacemakers are frequently implanted, yet accurate prospective data on implant complications are limited. Elderly patients may be at increased risk of implant complications and are increasingly being referred for pacemaker implantation. The purpose of the present analysis was to define the incidence and possible predictors of serious complications of dual chamber permanent pacemaker implantation in the elderly. Therefore, we sought to prospectively identify the incidence and predictors of pacemaker implant complications in a large multicenter trial involving patients receiving a dual chamber pacemaker. The Pacemaker Selection in the Elderly (PASE) study was a prospective trial designed to evaluate quality of life in dual chamber pacemaker recipients age 65 years or older randomized to DDDR versus VVIR programming. In addition to being age 65 years or older, patients enrolled in this study were in normal sinus rhythm, and had standard indications for permanent pacemaker implantation. All patients received dual chamber pacemakers and were randomized to DDDR versus VVIR pacing. Pacemaker implant complications were collected on standardized forms which were completed at pacemaker implantation and during follow-up appointments. In this study of 407 patients, there were 26 complications occurring in 25 patients (6.1%). The most frequent complication was lead dislodgment which occurred in 9 patients. This was followed by pneumothorax (8 patients) and cardiac perforations (4 patients). In 18 patients (4.4%) repeat surgical procedures (including chest tubes) were required. Complications were noted prior to discharge in only 18 patients. There were no significant predictors of overall complications. Pneumothorax was more frequent in patients 75 years old, and was observed only in patients with subclavian venous access. In conclusion, complications from pacemaker implantation in the elderly are seen in 6.1% of patients and 4.4% of patients require a repeat surgical procedure. Other than advanced age and lower weight predicting for pneumothorax, there are no significant clinical predictors of complications     

Needle Embolization: Suspecting Needle Migration in Intravenous Drug Abusers

BackgroundThirteen million people inject drugs globally, making intravenous drug abuse a substantial concern worldwide. While intravenous drug users occasionally report the breaking of a needle into the skin or subcutaneous tissue, central needle migration remains a rare but potentially devastating complication.Case ReportA 27-year-old man with a history of intravenous drug abuse presented to the emergency department with the sudden onset of left-sided neck pain, chills, and subjective fever with a history of needle breaking in his left neck 3 weeks earlier while using heroin. A computed tomography scan of his chest revealed a needle lodged in the right ventricle with associated mediastinitis and mass effect on the left brachiocephalic vein, and a left internal jugular thrombus. Broad-spectrum antibiotics were initiated. This patient was managed nonsurgically for several reasons and was discharged on hospital day 12 with oral antibiotics.Why Should an Emergency Physician Be Aware of This?Intravenous drug abusers commonly use cervical veins when their peripheral vasculature has become sclerosed. This puts intravenous drug users at increased risk for intravascular embolization. Due to varied symptomology—chest pain, dyspnea, fever, or asymptomatic—and timelines—days, weeks, or months—after reported needle fragmentation, this remains a complex and likely underdiagnosed condition. Case reports describe serious complications of intracardiac needle embolization, such as cardiac perforation, constrictive pericarditis, septic endocarditis, dysrhythmias, granulomas, venous thrombosis, empyema, acute or delayed spontaneous pneumothorax, osteomyelitis, and valvular damage. In this complicated patient population, clinicians should consider needle retention and relocation in patients who report needle breaking or in those who present with chest pain, dyspnea, or fever among other complaints.     

高频振荡通气联用一氧化氮吸入在新生儿气胸中的应用

目的 探讨高频振荡通气(HFOV)联用一氧化氮(NO)吸入治疗新生儿气胸的疗效.方法 选择2003年7月-2008年10月本院新生儿科收治的37例气胸新生儿,均行床边X线胸片,提示肺组织压缩均超过60%,在出现气胸后均接受胸腔闭式引流及机械通气.37例气胸新生儿依治疗方法不同分为2组:HFOV组和HFOV+NO组.HFOV组17例,在出现气胸后机械通气模式选择HFOV治疗;HFOV+NO组20例,在给予HFOV治疗的同时吸入NO,吸入NO水平为(5～15)×10-6.2组在治疗2 h、12 h、24 h 及以后每24 h行血气分析,并详细记录呼吸机参数,计算氧合指数(OI),持续监测NO/NO2水平.结果 2组治疗后2 h氧合情况持续改善,OI值、吸入氧浓度(FiO2)、平均呼吸道压均逐渐降低,动脉血氧分压均升高,但HFOV+NO组较HFOV组改善更显著(Pa＜0.05).HFOV+NO组上机时间(88.2±19.8) h,使用FiO2≥0.8时间(5.4±3.5) h;HFOV组上机时间(105.8±22.5) h,使用FiO2≥0.8时间(15.7±8.2) h.2组在上机时间、使用高浓度氧时间方面比较,差异均有统计学意义(Pa＜0.05).结论 HFOV 联用NO吸入治疗新生儿气胸可迅速改善氧合,纠正低氧血症,缩短高浓度氧及呼吸机使用时间,提高抢救成功率.     

Complications of Tube Thoracostomy Placement in the Emergency Department

Background: Emergency medicine residents frequently perform invasive procedures, including tube thoracostomy (TT), that inherently place patients at risk for complications. Objectives: The purpose of the study was to assess the prevalence and types of complications from TT in an academic emergency department (ED). Methods: A combined prospective and retrospective, observational study of all patients who had TT between December 2002 and January 2006 was performed. Exclusion criteria included age < 15 years and tube placement at an outside facility. Complications detected in the ED were defined as immediate, whereas those discovered later were defined as delayed. Complications requiring corrective surgical intervention, administration of blood products, or intravenous antibiotics were defined as major. Bivariate and multivariate analyses were used to identify operator and patient factors associated with complications. Results: TTs were placed in 242 patients, and 90 (37%; 95% confidence interval [CI] 31.1–43.3%) experienced a complication. Major complications included one intercostal artery laceration, one retroperitoneal placement, and empyema in 2 patients. In multivariate analysis, blunt injury excluding motor vehicle accidents (odds ratio [OR] 2.57; 95% CI 1.27–5.21) and spontaneous pneumothorax (OR 3.84; 95% CI 1.80–8.18) were associated with all complications. TT size < 36 French and blunt injury excluding motor vehicle accidents were associated with immediate complications and spontaneous pneumothorax was associated with delayed complications. Conclusions: The vast majority of complications from TT in the ED were minor. The prevalence of complications was consistent with previous reports of TTs placed by non-emergency-medicine-trained physicians outside the ED. The findings can be used to identify avoidable complications and improve residency training.     

X线与CT诊断新生儿气胸临床研究

目的：研究诊断新生儿气胸时X线及CT检查方法的临床应用价值。方法：选择嘉兴市妇幼保健院2009年8月-2012年8月间120例出现气胸的新生儿患者,所有患儿均拍摄了胸部前后仰卧位X线片,116例患儿随后又进行多次胸片随访,其中20例患者还进行了胸部CT扫描。结果：进行X线检查得出41侧为少量气胸,22例需要外科引流术或者穿刺抽气;79例有多量气胸,其中71例需要进行外科处理。结论：新生儿气胸进行前后仰卧位X线胸片基本可以满足临床诊断的需要,但如果仅为一侧肺野透过度增强,膈面和心缘非常清晰锐利,则可诊断为多量气胸,对于该类患者,应用CT影像学检查可以增加诊断准确性。     

自发性气胸胸腔镜术后复发情况和影响因素分析

目的分析自发性气胸患者胸腔镜术后复发现状和影响因素。方法选取我院胸外科2009年3月至2011年3月收治的218例自发性气胸胸腔镜术后患者为研究对象,采用自编问卷对自发性气胸患者胸腔镜术后情况进行调查,应用SPSS 19.0统计软件进行描述性统计和二分类Logistic回归分析并找出其复发的影响因素。结果自发性气胸患者胸腔镜术后复发率为5.05%(11/218),多因素Logistic回归分析结果示复发性气胸(OR=2.432,P=0.000)和多发肺大疱(OR=1.918,P=0.000)是自发性气胸电视胸腔镜手术后复发的危险因素。结论自发性气胸胸腔镜术后患者复发率较高,应加强复发性气胸和多发肺大疱患者管理,减少其复发,改善患者的预后。     

电视胸腔镜手术下应用切割缝合器和缝扎术治疗自发性气胸患者的疗效分析

目的比较观察电视胸腔镜手术(VATS)下应用切割缝合器和缝扎术治疗自发性气胸(SP)患者的临床疗效。方法选取该院2016年1月-2016年12月SP患者58例为研究对象,按随机数字表法分为观察组(n=29)和对照组(n=29),观察组采用VATS下切割缝合器治疗,对照组则采用VATS下缝扎术治疗。对两组患者的手术治疗效果进行综合评价。结果 (1)观察组患者的手术时间和术中出血量低于对照组患者(P0.05),手术费用高于对照组患者(P0.05),术后置管时间和住院时间比较无差异(P0.05);(2)两组患者术后并发症发生率无明显差异(P0.05);(3)两组患者术后疼痛评分和止疼药服用时间差异无统计学意义(P0.05);(4)观察组术后复发率明显低于对照组(P0.05)。结论两种手术方法治疗SP均安全、有效,并且预后良好,但VATS下缝合器术中出血量和手术时间优于VATS下缝扎术,且术后复发率更低,而VATS下缝扎术手术费用低,在临床上可根据实际病情需要合理选择手术方法。     

慢性阻塞性肺疾病合并自发性气胸的治疗

目的探讨慢性阻塞性肺疾病合并自发性气胸患者的治疗方式和愈后。方法回顾分析我科2007年²012年83例慢性阻塞性肺疾病合并自发性气胸的临床资料。结果治愈75例(占90.36%),死亡8例(占9.64%)。单纯胸腔穿刺38,行胸腔闭式引流术35例,开胸行肺大疤切除或肺漏气修补术10例。开胸或胸腔镜术后留置胸管时间42012年83例慢性阻塞性肺疾病合并自发性气胸的临床资料。结果治愈75例(占90.36%),死亡8例(占9.64%)。单纯胸腔穿刺38,行胸腔闭式引流术35例,开胸行肺大疤切除或肺漏气修补术10例。开胸或胸腔镜术后留置胸管时间4¹4 d(平均4.6 d),术后漏气的8例。在保证胸管引流通畅下,给予低负压吸引,术后漏气情况714 d(平均4.6 d),术后漏气的8例。在保证胸管引流通畅下,给予低负压吸引,术后漏气情况7²8 d后停止。1例术后持续漏气导致广泛皮下气肿,二次开胸修补后治愈。结论慢性阻塞性肺病并发自发性气胸起病急且不典型,误诊病死率高,在治疗中,对于突发严重呼吸困难的危重患者,应急诊床旁或急诊室行胸腔闭式引流术;外科开胸或微创治疗效果确切,可有效预防气胸复发。但要把握好手术指征,术中采用防止肺创面漏气以及促进胸膜腔粘连预防气胸复发的措施,术后加强呼吸道管理是保证手术效果的关键。     

两孔法与标准三孔法胸腔镜手术治疗原发性自发性气胸的比较

目的 探讨两孔法胸腔镜手术在治疗原发性自发性气胸中的价值.方法 分析我院127例原发性自发性气胸患者,均经胸腔镜手术治疗,其中58例采用两孔法胸腔镜手术治疗(两孔法组),69例采用标准三孔法胸腔镜手术治疗(三孔法组).比较两组的手术时间、手术出血量、伤口长度、术后胸腔闭式引流时间、术后VAS疼痛评分、术后住院时间.结果 两组患者均成功经胸腔镜完成手术,两组之间的手术时间、手术出血量、术后胸腔闭式引流时间、术后住院时间无明显差别;两孔法组伤口长度较三孔法组短,两孔法组术后VAS疼痛评分较三孔法组低.结论 两孔法胸腔镜行自发性气胸手术不增加手术操作难度,且能更有效减轻患者疼痛,减少手术创伤,增加患者满意度.     

A case of invasive Langerhans cell histiocytosis localizing only in the lung and diagnosed as pneumothorax in an adolescent female

In infants, Langerhans cell histiocytosis (LCH) is associated with poor clinical outcomes as Langerhans cells invade and damage multiple organs, a presentation that is different from that in adults. Here, we present a case of a 15-year-old female who visited ourclinic complaining of right chest pain and dyspnea. She was diagnosed with right pneumothorax by chest X-ray. Chest computed tomography showed multiple cystic changes in the bilateral lung. Additionally, bullous lesions occupying the upper lobe and multiple white tiny nodules on the surface of the lung were observed by thoracoscopy. These nodules comprised proliferating atypical CD1a/S-100-positive cells invading the pulmonary parenchyma, leading to the diagnosis of LCH. Because of the extensive invasion into the pulmonary parenchyma, chemotherapy was administered. This case of LCH was unique in that the age of onset was atypical and the tumor cells occupied a single organ, despite their malignant behavior.