钝性分离囊袋纤维网格对心脏起搏器更换术患者囊袋出血和感染的影响

目的通过探讨不同时期起搏器更换术囊袋相关并发症的发生情况,总结更换起搏器的方法和临床经验,从而提高起搏器更换的安全性和有效性。方法回顾性分析2001年1月至2011年12月共10年间167例更换起搏器时局部囊袋处理方法的变化,即2008年以前原囊袋内周围形成的纤维网格不予以分开,仅在囊袋上部切口附近分离皮肤及组织,形成大小适中的囊袋;2008年以后尽量将原囊袋中形成的纤维网格分开,适当扩大原囊袋,并加强术后囊袋管理;同时观察起搏器更换术后囊袋感染和血肿的发生情况。结果 167例更换起搏器患者,均为起搏器电池耗竭;其中2008年1月以前更换者为77例,2008年1月以后更换者为90例。2个时间段,与起搏器囊袋并发症相关的患者和植入因素无显著不同,与2008年以前相比,2008年以后行起搏器更换术囊袋相关并发症发生率明显降低,差异有显著性(6.7%vs 27.3%,P0.01),其中局部囊袋血肿10例(5.9%),8例(80%)为2008年以前更换,局部囊袋感染17例(10.2%),13例(76.5%)为2008年以前更换。结论起搏器更换术中将由结缔组织形成的原囊袋周围钝性分开的处理方法可降低起搏器更换术囊袋相关并发症发生。     

心脏起搏器更换187例的问题分析

目的探讨起搏器系统更换的原因及更换术并发症的防治。方法回顾分析187例行起搏器系统更换术患者的临床资料,通过定期门诊或电话随访了解患者并发症的发生情况。结果所有的患者均更换了脉冲发生器,其中首次更换171例,第2次更换15例,第3次更换1例。更换原因:电池提前耗竭19例(10.16%),电池使用寿命(6.43±2.48)年;166例达到预期寿命(88.77%),使用寿命约(8.52±2.11)年;有2例由于首次植入术后囊袋破溃感染提前更换(1.07%)。更换原电极27例,更换原因:术中测试起搏电极阈值增高5例,感知障碍4例,患者认为电极使用时间较长、要求与脉冲发生器同时更换18例,原电极共使用时间(10.03±2.29)年。所有起搏器更换时的电极阻抗、R波振幅[(650±164)Ω,(11.04±4.16)m V]与初次植入时[(672±153)Ω,(10.74±4.37)m V]比较均无显著差异(P0.05)。结论起搏器更换的主要原因是脉冲发生器电池寿命正常耗竭,而更换时原电极大部分保留继续使用。严格规范的术前准备、术中操作以及术后管理,可降低起搏器更换术并发症的发生率。     

永久性起搏器更换的原因和处理方法（附685例次分析）

总结分析我院２９５例共６８５例次起搏器更换的原因和处理方法。结果显示：更换原因主要是自然寿限和故障，分别占８６．６％和９．６％，其次为术后感染，占５．１％。笔者体会：（１）更换术前应明确更换原因并行有关检查，如胸壁刺激试验；（２）术中需采取相应保护措施；（３）应常规测试原电极导线参数；（４）可采用连接器或铆接法将原电极与不匹配的新起搏器相连接；（５）对起搏器术后感染而保守治疗无效者，应尽早在对侧安置新起搏器，取出原起搏器并彻底清创缝合。     

永久性起搏器更换的原因和处理方法：附685例次分析

总结分析我院２９５例共６８５例次起搏器更换的原因和处理方法。结果显示：更换原因主要是自然寿限和故障，分别占８６．６％和９．６％，其次为术后感染，占５．１％。笔者体会：（１）更换术前应明确更换原因并行有关检查，如胸壁刺激试验；（２）术中需采取相应保护措施；（３）应常规测试原电极导线参数；（４）可采用连接器或铆接法将原电极与不匹配的新起搏器相连接；（５）对起搏器术后感染而保守治疗无效者，应尽早在对侧安     

胆道金属支架引流联合射频消融术治疗恶性胆道梗阻的围术期护理

目的总结胆道金属支架引流联合射频消融术治疗恶性胆道梗阻的围术期护理经验。方法选取我院2015年4月至2016年10月45例接受胆道金属支架引流联合射频消融术治疗的恶性胆道梗阻患者,围手术期给予系统的术前、术中及术后护理,观察本组患者治疗及预后恢复情况。结果本组患者手术操作均一次成功,术后7 d实验室检测显示肝功能逐渐好转,症状、体征有明显改善,术后无胆道穿孔、死亡病例,仅出现1例胆道出血,经局部止血、补充凝血因子等处理后好转。结论积极合理的围手术期护理有利于保证恶性胆道梗阻患者行胆道金属支架引流联合射频消融术的治疗效果和降低术后并发症发生风险。     

心脏永久起搏器更换术的原因和处理

目的 探讨心脏永久起搏器更换的原因和处理方式.方法 回顾性分析2008年1月至2009年12月我院行常规起搏器更换的60例患者的临床资料,男性29例,平均年龄(68.37±12.33)岁,首次行起搏器植入的病因为病窦28例,严重房室传导阻滞29例,持续性房颤或房扑长间歇1例,双结病变2例.结果 60例更换脉冲发生器的患者中,首次更换52例,第2次更换7例,第3次更换1例,更换原因①电池提前耗竭11例(11/60,18％),电池平均使用寿命(99.36±20.61)个月,较担保寿命提前耗竭(21.09±7.94)个月.②2例由于起搏器术后囊袋破溃感染提前更换(2/60,3％).③1例发生脉冲发生器障碍只使用8个月(1/60,1.7％).④剩余46例达到担保年限(77％),平均使用寿命约(109.63±27.09)个月.同一类型起搏器的电池使用寿命在提前耗竭和常规更换患者中无差别(P＜0.05).60例中更换同类型起搏器51例,更换不同类型起搏器9例(9/60,15％).60例更换术中至起搏器更换时原电极在体内共埋置时间(107.48±31.95)个月,保留原电极48例,保留电极的患者比例为80％,更换原电极12例,更换的电极共使用(136±45.57)个月.更换电极原因:术中测试起搏电极阈值增高2例；起搏器囊袋反复破溃感染,对侧重新植入起搏器及电极1例；原起搏器电极为大接口电极,与新起搏器无法匹配1例；患者认为电极使用时间较长要求更换8例.电极最长使用时间为213个月(17.75年).结论 起搏器脉冲发生器更换的主要原因是电池耗竭或已至担保年限,脉冲发生器更换时大部分患者(80％)可以保留原电极.     

起搏器安置后远期囊袋反复破溃一例

患者男性,67岁。因病窦综合征安置了DDDR起搏器,安置术后第16个月起搏器置入部位开始出现皮肤溃破、渗出、皮肤丘疹、丘疱疹,细菌培养阴性,两次更换起搏器位置,抗感染及局部用药物治疗无效,经测试患者对多种物质过敏,考虑患者对起搏器发生排斥反应,使用激素治疗后病情好转、稳定。     

80岁以上老年人心脏起搏器植入术及减少并发症的对策

目的 探讨80岁以上老年人起搏器植入手术方式的选择,旨在减少相关并发症及提高生活质量.方法 80岁以上老年人127例植入起搏器.其中双腔起搏（包括双室三腔起搏）95例（74.8%）;单腔心室起搏32例（25.2%）.所有患者首选经头静脉放置起搏电极导线,并对寻找头静脉及电极导线植入方式做了较大的改进.电极导线的头端应固定在心腔内,切口内起搏器囊袋处的固定也十分重要.在电极导线送入心内前制作起搏器囊袋,并放置纱布压迫止血,对少数渗血较多的患者,局部适当加凝血酶或用电凝刀止血.鼓励患者术后早期下床（手术当日或次日）.结果 经头静脉送入起搏导线的成功率,在单腔起搏器为92.0%,双腔起搏器81.5%.术中及术后早期发生并发症5例（3.9%）,分别是：囊袋血肿3例（2.4%）,电极导线与起搏器连接处松动1例（0.8%）,心肌穿孔1例（0.8%）.无血气胸、电极导线脱位及起搏器囊袋感染发生.结论 经头静脉送入起搏电极导线可避免锁骨下穿刺所导致的并发症,在老年人中尤其重要;电极导线脱位主要与手术操作有关,而与早期下床活动无关;应采用适当方法达到囊袋内彻底止血,减少术后囊袋血肿及感染.     

130例次埋藏式永久起搏器术后随访的临床分析

目的研究埋藏式永久起搏器植入后并发症的发生率、相关因素以及防治方法。方法对接受永久性心脏起搏治疗的130例患者术后进行临床随访6个月~20年,随访内容包括临床资料、并发症、起搏器囊袋的状态、起搏器电极位置和各参数测量。结果原有的晕厥、头晕、乏力、心悸等与心动过缓有关的症状完全消失或减低82例;更换起搏器脉冲器术后切口处反复皮肤破溃1例;囊袋血肿3例;出现起搏器膈肌刺激症状1例;起搏电极移位3例;单纯电池耗竭更换脉冲发生器20例次;死亡2例,1例随访2年后发生脑出血死亡,另1例随访6年后因突发心力衰竭死亡,此2例患者死前检测起搏器功能正常;所有病例术后随访期间未出现其他起搏治疗相关并发症。结论永久性人工心脏起搏作为症状性心动过缓的惟一标准的治疗方法,其疗效确切,安全性好,同时坚持定期的随访,及时发现和处理与起搏器相关的并发症及排除起搏故障是非常重要的。     

58例起搏系统相关感染的临床特征与处理

目的 回顾性分析起搏器相关感染的临床特征,评价起搏系统感染的治疗方法及其预后.方法 选择自2002年1月至2009年12月的所有因“起搏系统相关感染”入院的患者,回顾性分析起搏器相关感染的临床特点、治疗及预后.结果 共58例起搏器相关感染的患者纳入研究.单纯起搏器囊袋局部感染52例,合并全身感染6例.与同期住院的所有起搏器患者相比较,起搏器感染的发生率为0.93％,其中起搏器首次植入感染的发生率为0.69％,更换后的感染发生率为1.96％( P＜0.01).治疗上,6例仅静脉使用抗生素及局部换药；其余52例患者,38例行局部清创(清创组)；14例行整个起搏系统移除与清创(导线拔除组).结果发现清创组21例(55.2％)感染复发,导线拔除组仅1例(7.7％)复发,(P＜0.001).40例患者在起搏器移除后再次评价,其中16例(40％)未再植入新的起搏器.结论 起搏系统相关感染是起搏器植入的严重并发症,起搏器更换为感染的危险因素之一.单纯局部清创感染复发风险很高,导线拔除并移除整个起搏系统是最佳的治疗方法.术后须进一步评价患者的起搏器适应证.     

永久性心脏起搏器植入术后并发囊袋相关并发症的原因及预防措施

目的分析永久性心脏起搏器植入术后并发囊袋相关并发症的主要原因及预防措施。方法收集2008年10月—2013年7月我院收治的行永久性心脏起搏器植入患者69例,回顾性分析其临床资料,观察术后囊袋相关并发症发生情况、原因及预防措施。结果 69例患者中,8例(11.5%)发生并发症,其中1例(1.4%)起搏器囊袋感染合并脉冲器外露、2例(2.9%)囊袋感染、5例(7.2%)囊袋积血。结论对永久性心脏起搏器植入患者,加强术前评估、提高术中操作水平及术后病情观察,有利于预防并减少相关并发症,促进病情康复。     

A High Blood Pressure Predicts Bleeding Complications and a Longer Hospital Stay after Elective Coronary Angiography Using the Femoral Approach

Aim: The aim of this study was to assess risk factors for bleeding complications after elective coronary angiography (CA).
Methods and results: We consecutively included 1,000 patients scheduled for elective diagnostic CA using the femoral approach. A bleeding complication was defined as formation of a hematoma ≥5 cm, severely oozing or pulsating bleeding through the skin, development of a pseudoaneurysm, or a bleeding demanding blood transfusion. We found a bleeding complication in 88 patients. In the multivariate analysis, only female gender and systolic blood pressure were associated with a bleeding complication.
Conclusion: We conclude that systolic blood pressure and female gender are independent predictors of bleeding complications and that a high systolic blood pressure should be reduced before elective CA.     

永久性心脏起搏器植人术后感染患者的临床资料分析

目的回顾性分析永久性心脏起搏器植入术后感染患者的临床特点,并对不同治疗方法进行评价。方法纳入2005年8月~2013年3月植入心脏起搏器[包括双腔及三腔起博器（CRT）]后发生感染的患者12例,分析感染者的临床特点,同时比较不同抗感染治疗（包括抗生素＋局部换药;抗生素＋原囊袋清创消毒＋起搏器原侧换位植入;起搏器及导线拔除＋抗生素＋起搏器对侧植入）方案的疗效差异。结果12例患者中植入双腔起搏器11例（91.6%）,CRT 1例（8.3%）,感染出现的中位时间为4.5个月,平均随访（33.0±19.0）个月。12例患者中有10例（83.3%）患者合并1种或以上其他疾病（包括糖尿病、心功能不全、慢性阻塞性肺病、结缔组织病等）,4例（33.3%）患者体内有2根以上的电极导线。10例首选保守治疗（应用抗生素＋局部换药,或抗生素＋原囊袋清创消毒＋起搏器原侧换位置入）中有8例感染复发,其中6例通过去除整个起搏系统治愈,1例起搏器消毒后重新置入治愈,1例形成窦道持续换药;2例首选去除起搏系统的患者均痊愈。结论起搏器感染多发生在合并危险因素的患者,一旦感染累及起搏系统,去除整个起搏系统是合理的。     

Drug-Induced Bleeding of Gastric Leiomyoma

Gastrointestinal bleeding is a major sign by which smooth muscle tumors are brought to medical attention. Bleeding usually occurs from an ulceration on the mucosal surface of the tumor. Agents such as nonsteroidal antiinflammatory drugs and steroids may damage the gastric mucosa, thus becoming predisposed to bleeding. Three patients presenting with ulcerated or bleeding leiomyomas while on either nonsteroidal antiinflammatory drugs or steroid therapy are herein reported.     

Bleeding complications associated with cardiopulmonary bypass

Bleeding after CPB has been difficult to characterize and its treatment equally difficult to standardize. The complexity of this problem is related to the hemostatic process, the technical variations in the operative procedures, and the many uncontrolled variables associated with CPB, including the effects of anesthetic or pharmacologic agents, the nature of the priming solution, hemodilution, hypothermia, the type of oxygenator, and the use of transfused blood products. Although there are multiple and generally predictable complex changes in the hemostatic mechanism during CPB, the temporary loss of platelet function is the most common and clinically relevant. This transient platelet dysfunction occurs in all patients undergoing CPB; however, it only causes excessive bleeding in a small percentage of patients. Unfortunately, it has not yet been possible to predict which patients will develop hemorrhagic complications, although prolonged pump times are a contributing risk factor. Over the past decade there has been extensive investigation into the management of bleeding associated with CPB, provoked primarily by the increased awareness of transfusion-transmitted viral diseases and the inappropriately excessive use of homologous blood products. Several approaches to autotransfusion of shed blood and autologus blood donation have been developed to minimize perioperative homologous blood transfusion. Pharmacologic agents such as desmopressin, aprotinin, and topical fibrin glues have also been introduced to improve hemostasis during CPB. The protease inhibitor aprotinin is particularly promising in the reduction of bleeding associated with CPB when given prophylactically. Aprotinin may provide new insights into the mechanism of CPB-induced platelet dysfunction. Desmopressin is indicated only for the treatment of bleeding after CPB. The management of bleeding associated with CPB will undoubtedly     

Dacron-woven pacemaker pouch. Influence on long-term pacemaker mobility.

Pacemaker migration can interfere with correct pacing system function and patient comfort. A Dacron pouch has been developed which may prevent these problems. To assess the efficacy of the pouch, we measured various factors of pacemaker mobility in 100 patients after long-term follow-up. The patients were divided into three groups on the basis of their dictated operative reports: group 1, no pouch or anchoring stitch; group 2, pouch only; group 3, anchoring stitch to pacemaker header or pouch. The average age of the study population was 74.3 +/- 11 years. Total follow-up time was 42 +/- 28 months (group I, 53 +/- 32 months; group 2, 36 +/- 23 months; group 3, 34 +/- 25 months). There were no significant differences when pacemakers were measured for movement in the inferosuperior and lateromedial directions, nor was there any difference in the distance between the incision scar and the pacemaker header in any group. There was a significant difference between group 1 and groups 2 and 3 when the degree of tilt of the pacemaker off the chest wall was compared. This was 46 degrees +/- 34 degrees for group 1 and 27 degrees +/- 26 degrees and 26 degrees +/- 27 degrees for groups 2 and 3, respectively (p less than 0.02 for both). These data suggest that the Dacron pouch does not restrict pacemaker mobility parallel to the chest wall during long-term follow-up but does reduce the angle to which the pacemaker can be tilted relative to the chest wall.     

Bleeding Complications in Lower-Extremity Peripheral Vascular Interventions: Insights From the NCDR PVI Registry

ObjectivesThis study sought to assess periprocedural bleeding complications in lower-extremity peripheral vascular interventions (PVIs).BackgroundFew studies have examined the incidence, predictors, or outcomes of periprocedural bleeding after lower-extremity PVI.MethodsThe study examined patients undergoing PVI at 76 hospitals in the National Cardiovascular Data Registry PVI registry from 2014 to 2016. Post-PVI major bleeding was defined as any overt bleeding with a hemoglobin (Hb) drop of ≥3 g/dl, any Hb decline of ≥4 g/dl, or blood transfusion in patients with pre-procedure Hb >8 g/dl within 72 h of their procedure. Hierarchical multivariable logistic regression was used to identify factors independently associated with post-PVI bleeding. The study also examined adjusted in-hospital mortality among patients with or without major bleeding complications.ResultsAmong 18,289 PVI procedures, major bleeding occurred in 744 (4.10%). Patient characteristics independently associated with bleeding included age, female sex, heart failure, pre-procedural hemoglobin <12 g/dl, nonelective PVI, and critical limb ischemia on presentation. Procedural characteristics associated with bleeding included nonfemoral vascular access, use of thrombolytic therapy, PVI of the aortoiliac segment, and multilesion interventions, whereas use of closure devices was associated with less bleeding. All-cause in-hospital mortality was higher in patients who experienced bleeding than in those who did not (6.60% vs. 0.30%; p < 0.001; adjusted hazard ratio: 10.9; 95% confidence interval: 6.9 to 17.0).ConclusionsMajor bleeding occurred in 4.10% of lower-extremity PVI procedures and was associated with several patient and procedural characteristics, as well as in-hospital mortality. These insights can be incorporated into strategies to reduce periprocedural bleeding after PVI.     

间质性肺疾病患者行不同活检方式后出血风险及其出血严重程度的相关因素研究

背景现有证据表明,经支气管冷冻肺活检(TBCB)在间质性肺疾病(ILD)诊断中极具潜力,但不同活检方式的诊断效能及安全性鲜见报道。目的比较ILD患者行经支气管镜钳夹活检(TBFB)、TBCB后出血风险及其出血严重程度的相关因素。方法选取2015年3月至2019年2月在湖北医药学院附属太和医院呼吸与危重症医学科就诊的ILD患者729例,排除临床资料不完整的11例患者,最终纳入718例患者,将其随机分为TBFB组和TBCB组,每组359例。TBFB组患者经支气管钳抽取肺组织并进行活检,TBCB组患者经支气管镜低温冷冻抽取肺组织并进行活检。比较两组患者临床资料、肺组织活检情况、术后出血发生率、术后出血严重程度及气胸发生率,TBFB组和TBCB组出血患者出血严重程度的影响因素分析采用单因素分析。结果TBCB组患者凝血酶原时间长于TBFB组,取样数量少于TBFB组,多肺叶活检者所占比例低于TBFB组(P<0.05)。TBCB组患者术后出血发生率高于TBFB组,出血严重程度重于TBFB组(P<0.05)。在TBFB组中,中重度出血患者中服用阿司匹林者所占比例低于轻度出血患者(P<0.05)。在TBCB组中,中重度出血患者中年龄≥65岁、服用阿司匹林者所占比例高于轻度出血患者(P<0.05)。TBCB组患者气胸发生率为6.13%(22/359),高于TBFB组患者的1.67%(6/359)(P<0.05)。结论与TBFB相比,ILD患者行TBCB后出血和气胸发生风险更高;服用阿司匹林可能与ILD患者行TBFB后出血严重程度相关,年龄≥65岁、服用阿司匹林可能与ILD患者行TBFB后出血严重程度相关。     

高血压脑出血术后再出血的原因及预防

目的分析高血压脑出血患者术后再出血的原因及预防措施。方法选取2009年8月—2013年8月我院收治的高血压脑出血患者120例,根据其有无再出血情况分为研究组(再出血患者)和对照组(未出血患者),各60例。分析再出血发生的原因及相关预防措施。结果研究组患者年龄≥60岁、出血距离手术时间6 h、手术前后血压≥120/180 mm Hg、凝血块形状不规则、血管与脑组织受损以及术后出现躁动等不良情绪所占比例均高于对照组(P0.05)。结论对高血压脑出血患者进行再出血相关原因的分析,并及早采取预防措施,可有效提高手术效果,降低患者临床病死率。     

Endoscopic Sclerotherapy for Control of Bleeding Varices in Children

Thirty-three children with esophageal varices due to portal hypertension underwent injection sclerotherapy over a period of 6 yr. Thirty-one completed the sclerotherapy course, and the varices were eradicated in all. In nine, the procedure was performed as an emergency because of continued bleeding and, in each case, a gastric fundal varix was the source of the blood loss. Sclerotherapy successfully controlled the bleeding in four of these, whereas five required surgical underrunning of the fundal varix. After surgery, these five continued sclerotherapy until the esophageal varices were eradicated. Complications included transient pyrexia (39%), retrosternal discomfort (30%), esophageal ulceration (18%), and esophageal stricture (12%). Rebleeding before initial eradication of the varices occurred in 12 patients but, thereafter, was very uncommon and always small in amount. Esophageal varices recurred after initial eradication in 33% of cases but were easily sclerosed with further injections. This study demonstrates that sclerotherapy is effective in reducing bleeding frequency in children with portal hypertension, but emphasizes the need for regular follow-up endoscopy after initial eradication of esophageal varices.