超声引导下经皮心包穿刺置管引流术的围术期护理

目的探讨超声引导下经皮心包穿刺置管引流术的围术期护理方法。方法对25例心包积液患者实施超声引导下经皮穿刺心包置管引流术期间,认真完善术前准备及心理疏导,熟练术中配合,加强术后病情观察及引流管护理等干预。结果 25例均一次穿刺置管成功,术后引流通畅。导管留置时间4~12 d,其间1例发生导管堵塞,经肝素生理盐水冲洗后再通。未发生感染、组织脏器损伤等严重并发症。心包填塞等症状明显改善。结论心包积液患者实施超声引导下经皮穿刺心包置管引流术期间,给予科学、规范的护理,可提高穿刺成功率,减少并发症,为有效改善患者症状奠定良好基础。     

超声定位引导心包穿刺置管引流治疗心包积液的效果分析

目的观察超声定位引导心包穿刺置管引流治疗心包积液临床效果及安全性。方法对32例心包积液患者实施超声定位引导心包穿刺置管引流术,观察穿刺成功率及术后改善效果及并发症等指标。结果 32例患者均一次穿刺置管成功,穿刺过程未发生头晕、气短、心律失常等不适。术后引流通畅,2例出现穿刺孔渗液伴局部疼痛,考虑心包积液压力升高所致,经进一步抽液后痊愈,未发生引流管阻塞、脱出,继发感染,心肌、冠状动脉组织损伤等。导管留置引流时间为(6.82±2.16)d。患者临床症状均消失或明显缓解。结论采用超声定位引导心包穿刺置管引流术治疗心包积液,创伤小、操作简便,术后并发症少、症状缓解明显、安全性高,患者经济负担轻。     

心包积液超声引导经皮心包穿刺置管引流术围术期护理体会

目的总结心包积液超声引导经皮心包穿刺置管引流术期间的护理体会。方法对18例心包积液患者在接受超声引导经皮穿刺心包置管引流术期间,实施术前准备,术中医护间配合,加强术后病情监测、体位、导管引流、心理及康复指导等围术期系统护理措施。结果 18例患者一次穿刺置管成功率为100.00%,术后管道引流过程通畅。引流管留置时间5～18 d,平均12.26 d。心包填塞等症状完全消失或显著改善,无感染、计划外管道脱出等并发症出现。结论对心包积液患者实施心包积液超声引导经皮心包穿刺置管引流术的,围术期做好系统护理措施,是提高手术效果,促进患者康复的重要保障。     

心包穿刺误入右心室的急诊处理

超声引导下心包穿刺置管引流术具有实时、准确、置管快捷、方便、安全、并发症少等优点,且可在床边操作,是目前心包积液最安全、理想的诊断和治疗方法。近年来,随着心血管介入技术的发展,医源性因素导致心包压塞的比例逐渐增至7．3％～17．6％。对于已刺入心腔并放置引流导管的心包压塞患者,处理需谨慎,不具备外科开胸条件或患者身体状况不能承受外科手术时,可以考虑采用内科保守治疗措施,但对合并肺动脉高压的患者是否可以选择保守治疗目前仍无明确结论。笔者结合病例查阅文献,认为伴有肺动脉高压或活动性出血的心包穿刺致右心室穿孔破裂时首选外科修补。     

心包穿刺中心静脉导管置管引流术治疗心包积液的疗效观察

目的观察应用心包穿刺中心静脉导管置管引流术治疗心包积液的效果。方法对23例心包积液患者实施经皮心包穿刺中心静脉导管置管引流术。回顾性分析患者的临床资料。结果 23例患者均一次置管成功,留置时间6~15 d,均未发生恶性心律失常、心包内继发感染、气胸及腹部器官损伤等并发症。除1例发生导管堵塞,经肝素生理盐水冲洗后再通外,其他患者术后引流通畅,症状均获明显改善。复查B超或X线胸片,证实心包积液基本吸收后予以拔管。结论经皮心包穿刺中心静脉导管置管引流术治疗心包积液,创伤小,安全性高,疗效可靠。     

超声引导穿刺置入微导管法治疗恶性心包积液的评价

目的探讨超声引导下穿刺置入微导管法在恶性心包积液治疗中的价值.方法13例恶性心包积液在超声引导下进行心包穿刺,置入硬膜外麻醉导管（微导管）,通过导管抽出心包积液并注入化疗药物.结果13例均成功穿刺并顺利置入微导管,引流积液400～780 ml,平均530 ml.治疗后3、12、24个月存活率分别为92%（12/13）,78%（7/9）和60%（3/5）,无心包积液复发.结论超声引导穿刺置入微导管法治疗恶性心包积液安全、微创、有效、可行.     

心包穿刺引流部位与安全性及引流程度关系的探讨

目的探讨心包穿刺引流部位与安全性和引流程度的关系。方法对46例中等量以上心包积液患者，11例选取左肋缘与剑突左缘交角下1伽为穿刺点；28例选取左侧第4肋间距胸骨左缘1-2cm处为穿刺点；7例选取左侧第4肋间心浊音界内侧1-2cm为穿刺点，留置引流导管直至积液消失。结果46例患者均一次穿刺、置管成功，无相关并发症；选取左侧第4肋间距胸骨左缘1—2cm处为穿刺点时进针深度最小；引流导管位于心包底部几率最高；采用反复抽送导引钢丝的方法能有效区分穿刺针是在心包腔内还是心腔内。结论选取左侧第4肋间距胸骨左缘1—2cm行心包穿刺置管引流术操作简便，安全、有效；采用多种预防措施可有效减少相关并发症的发生。     

今又生联合顺铂治疗恶性心包积液近期疗效分析

目的评价今又生联合顺铂化疗治疗恶性心包积液的疗效。方法 20例恶性心包积液患者行彩超引导下心包穿刺置管引流术后,心包腔内注射rAD-p53 1×1012VP及顺铂。结果临床总有效率（CR＋PR）为70%,毒性反应主要为自限性发热。结论今又生联合化疗控制恶性心包积液疗效好。     

超声引导锥形套管针穿刺在心脏压塞救治中的应用

目的探讨超声引导下锥形套管针穿刺在心脏压塞救治过程中的应用价值。方法 1998年3月~2015年10月,在超声引导下使用锥形套管针(专利号:ZL 2006 2 0132265.8)对28例大量心包积液(心包积液宽度≥17 mm)引起的心脏压塞进行心包穿刺,置入引流管引流。选择Seldinger法心包置管治疗心脏压塞患者28例作为对照组,比较2组的置管时间。结果所有心脏压塞患者均一次穿刺成功并置入引流管,锥形套管针组置管时间(6.2±1.1)min,比Seldinger组(15.0±1.1)min明显缩短(t=-27.844,P=0.000),引流后患者心脏压塞症状均消失。结论在大量积液引起的心脏压塞患者的救治过程中,超声引导下锥形套管针穿刺置管操作简便,创伤小,快速安全,疗效确切,也为后续治疗提供了保障。     

超声引导下经皮穿刺引流术治疗胰腺炎局部并发症70例

目的:探讨超声引导下经皮穿刺置管引流术治疗胰腺炎局部并发症的临床应用价值。方法:采用超声引导经皮穿刺引流术治疗70例胰腺炎局部并发症患者,术后随访1~20个月,观察患者腹部症状,引流液的量及性状,CT复查胰腺及周围情况等。结果:70例共穿刺置管82支,由于液体腔分隔同时置入2支导管12例;腹部疼痛减轻或消失,腹胀改善,全身炎症反应减轻;2例拔管后复发,再次穿刺引流。结论:超声引导下经皮穿刺引流术治疗胰腺炎局部并发症,安全、成功率高、治疗效果佳。     

Uremic pericardial effusion. Treatment by catheter drainage and local nonabsorbable steroid administration.

Pericardial drainage via percutaneous catheter placement and local nonabsorbable steroid instillation was employed as definitive therapy for uremic patients who had intractable pericardial effusions. Twelve patients are reported. Prior daily dialysis, and in one case systemic steroids, were not curative. 11 of 12 cases suffered severe tamponade requiring pericardiocentesis. One patient had an organized pericardial effusion, making pericardiocentesis impossible. He required pericardiectomy with prolonged hospitalization (2 weeks) due to postoperative complications. There were no complications in the 11 patients where catheter drainage and local steroid instillation were employed. No patient had recurrence of his pericardial effusion (followed from 2 weeks to 32 months). Instillation of a relatively nonabsorbable steroid through an indwelling pericardial catheter provides immediate and lasting relief without either the inconvenience or postoperative complications and prolonged hospitalization associated with the surgical procedure of pericardial fenestration. This report offers initial evidence that the percutaneous approach may be a safe and effective alternative to pericardial fenestration in most uremic patients with pericardial effusion.     

Thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer; report of a case

We performed thoracoscopic pericardial fenestration for persistent pericardial effusion after radiotherapy for esophageal cancer. An 85-year-old man who had radiation therapy (70.2 Gy) for esophageal cancer was admitted for shortness of breath. Chest computed tomography showed a pericardial effusion. During the 6 months prior to this admission, the patient had undergone percutaneous pericardial drainage 3 times for cardiac tamponade. We performed thoracoscopic partial pericardiectomy with creation of a pleuropericardial window via one access port. Histopathologically, no malignant cells were found in either the resected pericardium or the pericardial effusion. Therefore, we believe the persistent pericardial effusion was secondary to radiotherapy. There was no recurrence of the pericardial effusion for 7 months postoperatively. In summary, thoracoscopic pericardial fenestration is useful in both the diagnosis and treatment of persistent pericardial effusion.     

Clinical experience with subxiphoid drainage of pericardial effusions

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.     

超声引导经皮穿刺治疗肝脓肿

目的:探讨B超引导下介入治疗肝脓肿的临床应用价值。方法:对22例肝脓肿患者实施B超引导下经皮肝穿刺置管、药物冲洗引流术。结果:穿刺及置管均获成功,22例患者均痊愈。结论:超声引导下穿刺诊治肝脓肿是一种安全、简便、经济、高效的方法,可作为临床治疗细菌性肝脓肿的首选微创治疗方法。     

Comparison of open subxiphoid pericardial drainage with percutaneous catheter drainage for symptomatic pericardial effusion

BACKGROUND: The optimal therapy for symptomatic pericardial effusions remains controversial. This paper compares outcomes after the two most commonly used techniques, percutaneous catheter drainage and operative subxiphoid pericardial drainage. METHODS: We performed a 5-year retrospective, single-institution study to analyze outcomes after either percutaneous catheter drainage or subxiphoid open pericardial drainage for symptomatic pericardial effusions. RESULTS: Symptomatic pericardial effusions in 246 patients were treated by open pericardiotomy and tube drainage (n = 150) or percutaneous catheter drainage (n = 96). Drainage duration, total drainage volume, and duration of follow-up (2.6 years) were similar in both groups. Effusions were classified malignant in 79 (32%) patients and benign in 167 (68%) patients. No direct procedural mortality occurred, but the hospital mortality was 16 patients (10.7%) in the open group and 22 (22.9%) in the percutaneous group (p = 0.01) The 5-year survival rate was 51% in the open group versus 45% in the percutaneous group, despite a greater percentage of the open group having a preoperative malignant diagnosis (35% versus 28%). Symptomatic effusions recurred in 16.5% of the percutaneous group compared with 4.6% in the open group (p = 0.002), and sclerosis did not appear to reduce recurrence rates (10.7% with sclerosis versus 15.6% without; p > 0.05). The diagnosis of malignancy was confirmed in 16 of 27 (59%) percutaneous procedures performed on patients with known malignancy. In the open group, cytologic and pathologic evaluation of the pericardial specimen revealed malignancy in 32 of 52 (62%) patients with known malignancy. CONCLUSIONS: Subxiphoid and percutaneous pericardial drainage of symptomatic pericardial effusions can be performed safely; however, death occurs from underlying disease. Open subxiphoid pericardial drainage with pericardial biopsy appears to decrease recurrence but does not improve diagnostic accuracy of malignancy over cytology alone.     

Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage

BACKGROUND: Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS: Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS: Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS: Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.     

How soon should drainage tubes be removed after cardiac operations?

Pericardial effusion frequently occurs after cardiac operation. Despite its high incidence, the etiological process of postoperative pericardial effusion remains unclear. Residual blood or thrombus has often been suggested as a possible cause, implying that the occurrence of pericardial effusion could be related to the effectiveness of postoperative thoracic drainage. This possible relationship, however, has never been studied. We found that prolonging the duration of thoracic drainage by 24 hours often increases total chest tube output considerably but does not affect the incidence of postoperative pericardial effusion: approximately 55% of 100 patients in this study were shown by two-dimensional echocardiography to have pericardial effusion on the sixth postoperative day, regardless of the duration of postoperative drainage. Because of this, and because a long period of drainage causes discomfort for the patient, mechanical irritation to the heart and the pericardium, and an increased risk of infection, we recommend removing drains as soon as their efficacy has peaked, preferably on the first postoperative day.     

Difficult preoperative diagnosis in a case of rapidly progressive carcinomatous pericarditis

A 54-year-old woman initially diagnosed with stage IIIb squamous cell carcinoma of the uterine cervix was treated with chemotherapy and radiation therapy. After 8 months, she developed dyspnea, leg edema, pleural effusion, pericardial effusion, and liver congestion. Her cardiac ejection fraction was normal and cardiomegaly was not evident. Metastatic carcinomatous pericarditis or pleurisy was suspected, but laboratory findings, including tumor markers, were normal. She was transferred to our hospital for the repair a cardiac injury caused by a pericardial drainage procedure. Emergency surgery was performed for the misplaced drainage catheter in the right atrium and for an abnormal mass in her right and left atria. The clinical diagnosis of carcinomatous pericarditis was made; however, her condition rapidly deteriorated, and she died 6 days postoperatively. At autopsy, metastasis was identified in a large area of the pericardium and myocardium.     

Massive primary chylopericardium: a case report

A large pericardial effusion was discovered in an asymptomatic 12-year-old boy admitted for an elective orthopedic procedure. On physical examination, heart rate was 96 and blood pressure was 130/70 without paradox. The neck veins were not distended, but heart tones were distant. Chest roentgenogram (CXR) showed an enlarged cardiac silhouette. Echocardiogram showed a massive pericardial effusion compressing the right atrium, with depressed ventricular contractility. Pericardiocentesis yielded 450 mL of chylous fluid. A percutaneous pericardial drain was placed and drained another 400 mL of chyle. Pericardial fluid reaccumulated even though the patient was on a low-fat diet, and 1 week after admission left thoracotomy was performed with partial pericardiectomy and pericardial window. There was 1 L of chyle in the pericardial sac; frozen section of the pericardium showed lymphangiectasia. Chest tube drainage diminished rapidly and the patient was discharged. Follow-up CXR at 1 week showed fluid in both pleural spaces requiring bilateral tube thoracostomies again draining chyle. Even with total parenteral nutrition (TPN), 500 mL/d of chyle drained from the pleural tubes. Right thoracotomy with ligation of the thoracic duct was performed after 1 week of TPN. Pleural drainage abruptly dropped, and there has been no reaccumulation in either the pleural spaces or pericardium at 6-month follow-up. This case dramatically supports early thoracic duct ligation and partial pericardiectomy as the treatment of choice for primary massive chylopericardium.