经股腘静脉抽吸治疗下肢深静脉继发下腔静脉血栓

目的探讨经股静脉入路放置滤器治疗继发于下肢深静脉血栓(DVT)的下腔静脉血栓的可行性及安全性,评价滤器保护下血栓抽吸术的有效性。方法收集109例下肢DVT患者,其中11例血栓累及下腔静脉。于路径图引导下经健侧股静脉入路放置Aegisy滤器,打开但不解脱;再次穿刺股静脉,以8F指引导管抽吸下腔静脉内血栓;若血栓脱落于滤器内,尽量取出滤器内血栓后收回滤器,清洗后重新放置。经腘静脉入路抽吸髂股静脉内血栓,应用球囊或支架治疗髂静脉病变。14天内取出滤器。结果对11例DVT合并下腔静脉血栓者均成功取出髂股静脉及下腔静脉内血栓,8例术中发生血栓脱落;置入髂静脉支架5例,球囊扩张6例;8例取出滤器,3例永久植入滤器。随访6~35个月,下腔静脉及支架通畅,患者无活动后酸沉、肿胀,无色素沉着、静脉曲张等。结论经股静脉放置滤器治疗DVT合并下腔静脉血栓安全可行;在滤器保护下应用血栓抽吸术经股腘静脉入路治疗血栓快速、有效。     

永久性下腔静脉滤器置入后相关并发症探讨

目的　探讨永久性下腔静脉滤器置入术后 ,相关并发症出现的原因和预防措施。　方法　 1999年 12月～ 2 0 0 3年 6月 ,71例经彩色超声确诊下肢深静脉血栓 (deepveinthrombosis,DVT)置入永久性下腔静脉滤器 (venacavafilter ,VCF) ,其中急性下肢DVT 4 0例。术中常规行下腔静脉造影 ,确定下腔静脉和滤器释放途径静脉无血栓形成 ,将滤器放置平于肾静脉开口之下的下腔静脉。应用的滤器包括Titan -Greenfield滤器、Simon -Nitinol滤器、LGM滤器和TrapEase滤器。术后常规肝素和华法令抗凝。　结果　本组VCF均释放成功。术后 1～ 4 1个月随访 ,下腔静脉滤器放置部位血栓形成 2例 ,滤器倾斜 5例 ,倾斜角度 <15°。无滤器释放不全、穿孔、脱落、移位、出血和滤器释放通路血栓形成 ,无肺栓塞 (pulmonaryembolism ,PE)发生。　结论　不同类型滤器出现并发症的种类和发生率不同。滤器置入术前行彩色超声检查和术中下腔静脉造影 ,了解下腔静脉和VCF放置通路的情况 ,术中操作要点的实施 ,以及术后严格的抗凝治疗 ,是确保VCF放置成功、有效预防PE发生、避免或降低并发症的关键。     

临界型下肢深静脉血栓的治疗:附23例报告

目的探讨临界型下肢深静脉血栓早期诊断及治疗的效果。方法回顾分析23例临界型下肢深静脉血栓患者的临床资料。所有患者经彩色多普勒证实下肢深静脉内暴风雪征阳性,并行股、腘静脉轴流及暴风雪征中心流速测定。比较治疗前后的血流动力学指标,分析治疗效果。结果患者均于基础抗凝、扩容治疗5～7 d后出院。治疗后患者股、腘静脉轴流流速峰增加(均P<0.01),暴风雪征消失或减轻。结论临界型下肢DVT的彩色多普勒筛查和早期干预有助于防止病变向固体化血栓转化,从而避免了不必要的外科手术干预(包括取栓和下腔静脉滤器的植入等)以及长期抗凝或溶栓所带来的风险和副作用。     

超声引导下腔静脉滤器置入术的临床应用

目的探讨彩色多普勒超声引导下下腔静脉滤器置入术的临床应用价值。方法对我院收治的16例单侧下肢深静脉血栓（DVT）患者,在彩色多普勒超声经腹扫查实时动态引导下,行经健侧股静脉下腔静脉滤器置入术。结果 16例患者均在实时彩色多普勒超声引导下,置入VenaTechTMLP永久型下腔静脉滤器16只。术中出血少,无肺栓塞发生及滤器误置入其他血管。术后伤口均恢复良好,术后1周至半年超声及X线随访示滤器无变形、移位,无肺栓塞发生。结论超声引导下经皮穿刺下腔静脉滤器置入术是一种安全、可靠、简便、经济、无辐射的方法 ,具有较高的临床应用价值。     

超声溶栓治疗下腔静脉滤器安放后血栓形成14例体会

近年来，下肢深静脉血栓形成（deep venous thrombosis，DVT）引起的肺栓塞（pulmonary embolism，PE）明显增加，为防止DVT患者发生PE，下腔静脉滤器的作用在不断被重视，虽然下腔静脉滤器可以有效地防止PE发生，但个别DVT患者却在放置下腔静脉滤器后仍发生了下腔静脉血栓形成，造成滤器下腔静脉闭塞。我们于2001年5月至2007年5月应用超声溶栓治疗了14例滤器安放后下腔静脉血栓形成患者，现报告如下。     

术前筛查下肢血栓对防止肺栓塞的意义

目的：探讨术前彩色多普勒超声（CDFI）筛查骨折患者下肢静脉血栓对防止肺栓塞的意义。方法：回顾性分析2010年1月至12月,因创伤致下肢骨折入院,拟行切开复位术的2000例患者,男1140例,女860例;年龄18～94岁,平均（54.78±21.45）岁。所有患者入院时伤肢肿胀明显,均经外敷和口服中药治疗,伤肢肿胀好转后（3～14d）,行骨折复位术,手术前1d筛查骨折患者下肢血栓,并对其临床资料（性别、年龄、骨折部位、病程）进行回顾性分析。结果：①2000例创伤骨折患者术前经CDFI筛查,证实并发深静脉血栓（deepveinthrombosis,DVT）共128例（6.4%）。血栓类型：髂-股静脉血栓52例,腘-胫静脉血栓20例,小腿肌肉静脉血栓56例。对胫静脉以上DVT72例采取溶栓治疗或放置下腔静脉滤网,溶栓有效20例,放置下腔静脉滤网17例,溶栓失败和未放置腔静脉滤网患者28例,这65例均实施了骨折复位术,另外7例采取保守治疗。1例术中发生肺栓塞,经及时溶栓治疗获得成功。小腿肌肉静脉血栓56例中51例未行特殊处理,实施了复位术;另5例行保守治疗。②DVT发生与性别无关;血栓发生最小年龄22岁,41岁以上组血栓发生率高于40岁以下年龄组;多发骨折、股骨骨折高于胫骨、腓骨骨折;血栓发生病程最短3d,病程越长,血栓发生率越高。结论：创伤骨折患者无论是否存在形成DVT的高危因素,骨折复位手术前均应常规行CDFI筛查DVT,对降低麻醉、手术风险,防止致命性肺栓塞有重要意义。     

以手术为主综合治疗急性下肢深静脉血栓形成

目的探讨急性深静脉血栓形成手术取栓,并行大隐静脉或胫前静脉插管持续给药的疗效。方法2004年12月～2006年3月,对13例下肢深静脉急性血栓形成患者行手术为主的综合治疗。其中男5例,女8例;年龄24～49岁。发病至手术时间24～120h,平均70h。13例均为左下肢患病,4例为髂股型,其余均为混合型。左下肢明显水肿,肢体皮肤颜色无改变,尚无动脉供血障碍。术前均经彩色超声多普勒或静脉顺行造影确诊,提示患肢深静脉不显影或长段低回声血栓影,上界达髂股静脉水平。患肢增粗,周径比对侧增粗3～6cm。术前均未放置下腔静脉滤器。术后经大隐静脉或胫前静脉持续给予肝素与尿激酶。结果13例手术均顺利,无术中及术后死亡,亦无症状型肺栓塞发生。术后患肢均迅速消肿。术后2周行下肢静脉彩色超声多普勒检查,10例全程基本通畅,3例存在髂股静脉短段闭塞。获随访3～18个月,平均9个月,13例均恢复劳动。除3例外髂骨静脉短段闭塞者外,其余下肢无肿胀及浅静脉曲张。结论对急性深静脉血栓形成取栓是必要的,术后持续给予溶栓抗凝药静脉通畅率较高。     

下腔静脉滤器置放术在深静脉血栓-肺栓塞演变中的临床应用

目的探讨下腔静脉滤器(IVCF)在预防深静脉血栓(DVT)-肺栓塞(PE)演变中的临床应用价值。方法经造影和(或)彩色多普勒超声证实为下肢深静脉广泛血栓30例,其中有肺部临床表现21例,胸部影像学证实19例,DSA显示下腔静脉内血栓6例。溶栓介入治疗前置放IVCF 30例,下腔静脉内血栓形成未放IVCF 1例。置放IVCF后经患肢足背静脉滴注尿激酶或经导管血栓内抽吸、局部溶栓、导丝搅拌增加溶栓接触面积;经非患肢静脉给予抗凝、抗生素治疗。结果本组30例放置5种构型滤器32枚,其中2枚为临时滤器,置入取出均顺利,滤器无移位,术中无并发症。痊愈9例,有效14例,改善6例,无效1例。因没有及时置入IVCF进行溶栓治疗,深静脉血栓导致下腔静脉血栓6例,后置入IVCF 5例疗效良好,未放IVCF 1例,12天后因肺栓塞死亡。结论下腔静脉滤器对预防深静脉血栓向肺栓塞演变具有一定价值,其置放术安全可靠,便于临床及时溶栓抗凝治疗,但其应用价值需进行综合评价和进一步探讨。     

Celect可回收滤器在骨折合并下肢深静脉血栓治疗的应用

目的探讨Celect可回收腔静脉滤器在骨折合并下肢深静脉血栓形成(DVT)患者中的应用,并对滤器植入路径及回收方法进行总结。方法对2013年6月至2014年6月77例骨折合并DVT患者的临床资料进行回顾性分析,选择经股静脉(71例)及右侧颈内静脉(6例)路径放置Celect滤器。结果技术成功率100%,滤器在体内留置时间为10~111天,平均37.5天。2例(2.6%)发生症状性肺栓塞(PE),无致命性PE。64例患者进行了滤器回收,62例(96.9%)成功取出,2例取出失败。27例(42.2%)捕获大量血栓,经导管溶栓后二期回收。左侧股静脉路径放置时滤器倾斜可能性大于右侧股静脉(P0.01)。结论 Celect滤器用于骨折合并DVT的患者可有效预防PE。滤器于股静脉路径植入时无明显前跳及回缩现象,定位良好,安全性高;颈内静脉路径植入可能有0~2cm回缩距离。捕获大量血栓也可在溶栓后顺利回收,最大程度提高了滤器可回收率,鉴于不可预知的远期风险,建议在PE风险可控时及早回收。     

下肢骨折术后并发深静脉血栓形成的治疗与护理

目的:探讨下肢骨折术后深静脉血栓形成患者经下腔静脉滤器置入留置导管溶栓的疗效与护理.方法:对31例下肢骨折术后患者采用彩色多普勒超声检查仪检查,在DSA引导下阻断患肢浅静脉经足背静脉留置针注入碘比醇20ml,观察深静脉阻塞的程度及血栓的范围.采用Seldiinger技术,经皮健佣股静脉穿刺置人导管鞘先行下腔静脉造影,经5F猪尾导管以20ml/s速度注入碘比醇30ml,了解双侧肾静脉开口位置,于双侧肾静脉开口下方置入下腔静脉滤器;然后经导管鞘送入溶栓导管,将溶栓导管头端置于血栓内,用肝素冒封好溶栓导管尾瑞,每8小时经溶栓导管推注10万单位尿漱酶溶液50ml(将10万单位尿激酶溶液50ml生理盐水中),常规抗凝并给予真对性护理干预.结果:31例患者治疗3～10天血栓完全溶解,血管通畅,所有患者于滤器置入第10～14天内取出.性别、年龄、骨折部位及有无合并高血压、糖尿病的骨折患者术后下肢深静脉血栓形成有显著性差异(P<0.01).结论:下腔静脉滤器置入留置溶栓导管治疗下肢深静脉血栓形成的患者,做到严密观察、细致护理,对减少并发症的发生具有积极临床意义.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.