Postoperative hemorrhage following robotic-assisted laparoscopic prostatectomy controlled with external penile compression

We report a postoperative hemorrhage of the dorsal vein complex after transperitoneal robotic-assisted laparoscopic prostatectomy managed with external penile compression. Control of the dorsal vein required two sutures, and the estimated blood loss due to the procedure was 400 ml. Severe gross hematuria developed on postoperative day 2, but this quickly subsided with external compression at the base of the penis. Transfusions were required, but the patient refused re-exploration. A self-adherent bandage was applied circumferentially to the entire penis for 48 h. During this time there was no further hematuria, and the patient recovered uneventfully.     

全麻老年患者围术期血浆β-淀粉样蛋白1-40的变化及其意义

目的观察全麻老年患者围术期血浆β-淀粉样蛋白1-40[Aβ(1-40)]水平的变化,探讨其与手术后认知功能障碍(POCD)的关系。方法40例择期开腹手术患者按照年龄分为两组:青年组(20例,年龄在20～50岁之间);老年组(20例,年龄≥65岁)。分别在手术前一天和手术后24 h进行简易智能量表(MMSE)评分。于手术前(T1)、手术开始后2 h(T2)、4 h(T3)、24 h(T4)采集静脉血标本,用酶联免疫吸附(ELISA)法测定血浆Aβ(1-40)。结果与手术前相比,老年组手术后MMSE评分明显降低;青年组差异无统计学意义。老年组血浆Aβ(1-40)T1～T4各时点均高于青年组(P<0.05),且在T2～T4时均显著高于T1时(P<0.05)。结论老年人血浆Aβ(1-40)基础水平较高且手术开始后24 h持续维持于较高水平,可能是老年人POCD发生率高的原因之一。     

术后认知功能障碍的研究进展

术后认知功能障碍是手术麻醉后常见的中枢神经系统的并发症．在老年手术患者中发生率很高．而且不利于患者术后康复,甚至增加死亡率。但是目前术后认知功能障碍的诊断方法,发病机制不明确,没有确切的预防及治疗方法,本文就上述内容最新的研究进展作一综述,希望对今后的研究有启发意义。     

老年人骨折术后认知功能障碍

2002年1月-2005年7月,手术治疗75岁以上骨折患者105例,其中28例出现术后认知障碍,占同期手术患者的26·7%。通过对出现术后认知功能障碍的患者进行回顾性分析,探讨老年人术后认知障碍的发生原因及治疗方法。1临床资料1·1一般资料本组28例,男11例,女17例;年龄75~89岁,平均82·5     

老年人骨折术后认知功能障碍

2002年1月-2005年7月,手术治疗75岁以上骨折患者105例,其中28例出现术后认知障碍,占同期手术患者的26·7%。通过对出现术后认知功能障碍的患者进行回顾性分析,探讨老年人术后认知障碍的发生原因及治疗方法。1临床资料1·1一般资料本组28例,男11例,女17例;年龄75⁸9岁,平均82·5岁。髋部骨折21例,股骨骨折1例,股骨髁上骨折2例,胫腓骨骨折1例,肱骨外科颈骨折1例,下肢截肢2例。26例术前合并有高血压,11例合并有糖尿病,18例心电图检查异常,15例有慢性支气管炎病史,7例有脑栓塞病史,3例肝肾功能指标异常,12例贫血。13例术中或术后脑CT检查有不同程度的脑萎缩。1·2     

Postoperative cognitive decline

Memory loss and lack of concentration are symptoms that frequently occur in patients who have undergone a surgical procedure. Although cognitive function can be assessed using neuropsychological tests, reliable diagnosis of postoperative cognitive decline (POCD) appears to be difficult. Therefore, the true incidence of POCD is unknown. Severe POCD, which is apparent even without neuropsychological testing, is reported most frequently after cardiac and hip-replacement surgery. In these cases, POCD probably reflects microembolic brain injury. Apart from the nature of the surgical procedure, advanced age is the most important risk factor for POCD. The anesthetic technique is not a determinant of POCD: the risk of POCD appears to be similar after both general and regional anesthesia. This review article was invited by the Editorial Board members of the Journal of Anesthesia and was peer-reviewed as were the other articles in this journal.     

心脏手术后的认知功能障碍

大脑功能障碍是指智力下降等不同程度脑功能改变。随着心脏外科的发展，有关中枢神经系统并发症日益受到重视。 1 危险因素 术前已有中风、主动脉近端硬化、贫血与老龄化、高血压和糖尿病等均可使体外循环后中风风险增加。术中发生中风的主要风险因子是体外循环时间和反复地钳夹主动脉。其他如围术期心律失常、低心排综合征等情况也会使体外循环后认知功能障碍增加。     

术后认知功能障碍发病机制的研究进展

术后认知功能障碍(post-operative cognitive dysfunction,POCD)是术后常见的中枢神经系统并发症,目前POCD的发病机制尚不明确。本文就POCD的几种可能的发病机制进行综述,通过进一步的研究以阐明POCD的发病机制,在临床工作中对POCD进行早期预防、诊断和治疗,具有重要的医学、社会和经济意义。     

Postoperative delirium following gastrointestinal surgery in elderly patients

Postoperative delirium is a common complication which can interfere with the surgical treatment and recovery of elderly patients, and is likely to prolong their hospitalization. Unfortunately, there is as yet no completely effective pre- and/or post operative technique of patient care to reduce or prevent postoperative delirium. In this study, 36 patients aged over 70 years undergoing gastrointestinal operations were assessed to examine the relationships between the preoperative cognitive state, the postoperative sleep cycle, and the occurrence of postoperative delirium. All patients were evaluated preoperatively using the revised version of Hasegawa's dementia scale (HDS-R). We correlated those test results and assessed the sleep-wakefulness disturbance postoperatively, to obtain a clinical DMS-III diagnosis of postoperative delirium. The incidence of postoperative delirium was 17% (6/36). The patients who developed postoperative delirium demonstrated preoperative cognitive impairment, and had a short sleep period during the night and a long sleep period during the day. Postoperatively, these results suggest that HDS-R is a useful method of evaluating preoperative cognition in elderly patients. Considering that sleep deficiency is likely to predispose elderly patients to postoperative delirium, techniques to prevent sleep deprivation may be of considerable value in minimizing the incidence of postoperative delirium.     

Fatal hypoglycemia with levofloxacin use in an elderly patient in the post-operative period

Background and aim Fluoroquinolones are antimicrobial agents with a broad spectrum of activity against gram-positive, gram-negative, and anaerobic organisms. They are widely used in surgical practice and are generally considered safe. Hypoglycemia because of use of levofloxacin is a rarely reported complication. This report of a case of a surgical patient highlights this potentially fatal complication. Patient An elderly, non-diabetic patient with renal impairment presented with a possible duodenal perforation. After successful surgery, the patient developed recurrent hypoglycemic episodes in the post-operative period after use of levofloxacin. Delay in recognition of the cause of hypoglycemia led to irreversible brain damage and death. Results The calculated Naranjo adverse drug reaction probability scale criteria suggest the possibility that these episodes were related to levofloxacin. The mechanism of hypoglycemia with levofloxacin relates to the potential inhibition of the K_ATP channel on the pancreatic beta cell by the drug. Conclusion The case report highlights the need to be aware of this potentially fatal complication of a drug commonly used in surgical practice.     

Postoperative Cognitive Dysfunction after Total Joint Arthroplasty in the Elderly: A Meta-Analysis

This meta-analysis consolidated the research on postoperative cognitive dysfunction (POCD) following total joint arthroplasty (TJA). Data from 17 studies that assessed cognition pre- and post-surgery in TJA patients alone (15 studies) or matched TJA and control groups (2 studies) were analysed. Results were grouped by cognitive domain (memory, attention, language, speed, general cognition) and follow-up interval (pre-discharge, 3-6 months post-surgery). The TJA data revealed small declines in reaction time and general cognition pre-discharge, but no evidence of decline 3–6 months post-surgery. Very limited TJA and Control data indicated no group differences in the changes to performance over time; however, the TJA group was cognitively compromised pre- and post-surgery compared to Controls. Further appropriately controlled research is required to clarify whether POCD commonly occurs after TJA.     

右美托咪啶对老年人术后认知功能的影响

目的:探讨右美托咪啶对老年人术后认知功能的影响及可能作用机制。方法:将择期手术治疗的腰椎骨折和髋关节置换术46例患者随机分为对照组(I组)和右美托咪啶组(II组),II组麻醉诱导前静脉输注右美托咪啶,负荷剂量0.8 ug/kg,输注时间10～15 min,以0.5 mg.kg-1.h-1的速率持续至术毕,I组给予等容量的生理盐水。于给药前(T1)、手术开始后1 h(T2)和手术结束后(T3)检测血浆皮质醇浓度,分别于术前1 d、术后1 d、术后3 d、术后7 d评估病人认知功能状态。结果:与I组比较,II组术后认知功能障碍发生率明显降低(P<0.05),皮质醇浓度在麻醉诱导后(T2)明显降低(P<0.05)。结论:右美托咪啶围术期给药,可预防老年人认知功能障碍发生,其可能机制与降低皮质醇浓度有关。     

老年患者腹部手术后认知功能障碍的高危因素分析

目的分析老年患者腹部手术后认知功能障碍(POCD)发生的高危因素。方法回顾性分析我院2000年2月至2010年10月期间60岁以上2 286例腹部手术后患者的临床资料,根据是否发生POCD将2 286例患者分为POCD组和非POCD组,其中POCD组38例,非POCD组2 248例。分析影响腹部手术后POCD发生的影响因素,包括年龄、性别、麻醉方式、术前是否用药〔地西泮和(或)阿托品或东莨菪碱〕、术前是否存在心肺疾病、术前是否有糖尿病、术前有无黄疸、术前有无贫血或低蛋白血症、手术持续时间及术后是否进行持续镇痛治疗。结果 POCD的发生与患者年龄、麻醉方式、术前是否存在心肺疾病、术前是否有糖尿病、术前有无黄疸、手术持续时间是否超过4 h、术后是否进行持续镇痛有关(P<0.05),而与患者性别、术前是否用药和术前有无贫血或低蛋白血症无关(P>0.05)。结论年龄≥70岁、全身麻醉、术前存在心肺疾病、糖尿病和黄疸、手术持续时间超过4 h、术后未进行持续有效的镇痛是腹部手术后POCD发生的高危因素。     

Releasing the Tourniquet in Carpal Tunnel Surgery

The purpose of this study was to determine if letting down the tourniquet prior to closure after carpal tunnel release decreases the amount of post-operative ecchymosis and subsequent post-operative pain. We prospectively studied 18 consecutive patients who were undergoing bilateral open carpal tunnel releases. The side done first was randomized and the tourniquet was released to obtain hemostasis prior to closure on this side only. The second side was completed, closed, and dressed prior to letting the tourniquet down. The patients’ pre-operative and post-operative pain scores were recorded, as was an ecchymosis score at the 10-day follow-up visit. The results showed no significant difference between the two groups in either pain or ecchymosis. We conclude that the added surgical time required for letting the tourniquet down and obtaining hemostasis prior to closure in a carpal tunnel is unnecessary.     

Heterogeneity in Surveillance after Endovascular Aneurysm Repair in the UK

Objectives

Surveillance after Endovascular Aneurysm Repair (EVAR) is considered mandatory, but the optimal regimen remains controversial. The aim of the present study was to report the nature of routine post-EVAR surveillance protocols in the UK, in order to identify the degree of variation in national practice and from the manufacturer’s instructions for use (IFU).

Methods

A telephone survey was administered to 41 centres with 10 years’ experience in EVAR to identify their standard surveillance protocol after EVAR. Data were collected regarding the number of surveillance CT or ultrasound performed up to 5 years postoperatively.

Results

12/41 centres used CT as the primary mode of surveillance, 14/41 centres used USS as the primary mode of surveillance, and 15/41 centres used a combination of CT and USS. The mean ± s.d. number of CT scans performed cumulatively up to 1 year and 5 years post surgery were 1.1 ± 0.6 and 3.5 ± 2.9 respectively. The mean ± s.d. ultrasound scans performed at 1 year and 5 years post surgery were 0.5 ± 0.9and 4.7 ± 3.6 respectively.

Conclusions

Significant heterogeneity exists in surveillance after EVAR in the UK. Efforts should be made to establish consensus towards a national surveillance protocol.     

瑞芬太尼及丙泊酚静脉用药对高龄患者术后认知功能恢复的影响

目的探讨瑞芬太尼及丙泊酚对高龄患者静脉麻醉后认知功能恢复的影响。方法2009年1月-2013年1月我院行食管癌根治术患者32例,年龄70-80岁,ASAⅠ-Ⅱ级,随机分为两组,分别采用瑞芬太尼＋丙泊酚＋卡肌宁（瑞芬太尼组,n=16）及芬太尼＋丙泊酚＋卡肌宁（芬太尼组,n=16）行麻醉诱导维持。术后记录自主呼吸恢复时间、呼之睁眼时间、拔管时间及自我陈述时间,分别于术前24h、术后2h、24h应用简易精神状态量表评估患者认知功能。结果两组自主呼吸恢复时间未见显著差异（P〉0．05）,瑞芬太尼组呼之睁眼时间、拔管时间及陈述自己姓名时间均明显早于芬太尼组（P〈0．05）。术后2h两组简易精神状态量表评分均较术前明显降低（P〈0．05）,术后24h评分两组较术前均无统计学差异（P〉0．05）。结论瑞芬太尼与丙泊酚合用对高龄患者术后认知功能影响小,值得临床推广应用。     

吸入麻醉药与老年人认识障碍

吸入麻醉药通过对大脑海马多种神经递质．受体以及脑神经营养因子（BDNF）表这的影响,改变突触可塑性,抑制长时程增强（LTP）的形成．从而对学习记忆功能产生广泛作用。因此,研究吸入麻醉药对学习记忆的影响．将对术后认知障碍（POCD）的产生机制作进一步的解释．并为临床指导用药提供理论依据。     

Current techniques in the post-operative monitoring of microvascular free-tissue transfers

Accurate assessment of the perfusion of free-tissue transfers has always been a challenge for surgeons undertaking microvascular reconstructive procedures. Microvascular free-tissue transfer today has a high success rate, which is partly due to the monitoring of flap circulation post-operatively. Recent advances in technology and improvements in surgical technique have led to reported success rates of between 95% and 98%. The aim of post-operative surveillance is the early recognition of flap compromise to improve chances of flap salvage and lower morbidity and mortality rates. There is extensive literature available on post-operative monitoring, and, although many techniques to assess flap perfusion have been described, a standard, reliable, universally accepted method, other than bedside clinical observation by the medical and nursing staff, remains elusive. This review outlines the current clinical and experimental flap monitoring methods available.