麻醉方式对全髋关节置换术后深静脉血栓形成的影响

目的：评价不同的麻醉方法对全髋关节置换术后下肢深静脉血栓形成(DVT)的影响。方法：84例全髋关节置换术患者随机均分为2组。硬膜外麻醉组、全麻组：术后4～7d内通过静脉造影，了解深静脉血栓发生情况。结果：硬膜外麻醉组有4例发生DVT，未见症状性DVT和肺栓塞(PE)患者。全麻组有11例发生DVT，有2例症状性DVT，未见症状性PE患者。结论：硬膜外麻醉能减少全髋关节置换术后DVT的发生率，是全髋关节置换术首选的麻醉方法。     

利伐沙班与低分子肝素在预防人工全膝关节置换术后深静脉血栓形成的分析

[目的]观察利伐沙班与低分子肝素在预防人工全膝关节置换深静脉血栓的疗效性和安全性.[方法]回顾性分析2009年5月～2011年2月行人工全膝关节置换术的患者200例,将其分为两组,利伐沙班组100例,给予利伐沙班10mg/d口服,连续14d;低分子肝素组的100例,术后给予低分子肝素5000IU/d皮下注射,连续14d.术后14d行双下肢静脉彩超检查有无深静脉血栓形成,并观察两组用药期间有无肺动脉栓塞和严重出血事件的发生.[结果]利伐沙班组深静脉血栓形成的发生率5％,显著低于低分子肝素组的9％,两组均末发生肺动脉栓塞和严重出血事件.[结论]应用利伐沙班较低分子肝素更有效预防膝关节置换术后下肢深静脉血栓的形成,出现严重出血事件很少,二者均较安全.     

硬膜外低压麻醉在髋关节置换中预防血栓性疾病的作用

目的 研究全髋关节置换术中使用硬膜外低压麻醉的有效性和安全性.方法 对993例全髋关节置换术采用硬膜外低压麻醉(平均动脉压维持在45～55 mm Hg).处理股骨侧髓腔之前2～3 min,静脉给予肝素10～15 U/kg.结果 本组平均手术时间83 min(35～268 min),平均失血量183 ml(50～1 400 ml).术后随访3个月,共有13例发生血栓性疾病,占总数的1.3％,其中确诊为下肢深静脉血栓(DVT)的有10例,发生率为1.0％.无心血管疾病、硬膜外血肿发生.随访期间无死亡病例.结论 全髋关节置换术中使用硬膜外低压麻醉安全,术中出血少,术后血栓发生率低,术后无相关的并发症.     

"低风险"人群初次人工关节置换术后的深静脉血栓

目的研究"低风险"人群在人工髋、膝关节置换术后深静脉血栓的发生情况。方法2003年2月至2005年4月,准备行选择性初次人工关节置换术的"低风险"患者136例,其中全髋关节置换术73例76髋,全膝关节置换术63例72膝,年龄46～84岁,平均68.5岁。具有深静脉血栓高危因素的患者排除在研究之外。患者术后均未采用任何方法预防深静脉血栓,于术后6～8天行静脉造影或根据临床表现急诊行静脉造影。怀疑肺栓塞的患者摄胸部X线片及CT加以确诊。结果全髋关节置换术73例76髋中,22髋(28.95%)发生深静脉血栓,其中近端栓塞14髋,远端栓塞8髋;全膝关节置换术63例72膝中,33膝(45.83%)发生深静脉血栓,其中9膝为近端栓塞,24膝为远端栓塞。全髋关节置换组与全膝关节置换组的深静脉血栓发生率比较,差异有统计学意义(!2=4.515,P<0.05);两组间近端血栓发生率比较,差异无统计学意义(!2=0.988,P>0.05);两组间远端血栓的发生率比较,差异有统计学意义(!2=11.348,P<0.05)。发生肺栓塞1例(0.74%)。临床症状对深静脉血栓的阳性预测值为52%。结论初次人工关节置换术后"低风险"人群深静脉血栓的发生率为37.16%,而临床表现并不能作为诊断深静脉血栓的可靠依据。临床上应建立起一套安全有效的方法降低深静脉血栓的发生。     

同期双侧与单侧全膝关节置换治疗膝骨关节炎的比较

[目的]比较同期双侧与单侧全膝关节置换术的安全性及临床疗效.[方法]回顾性分析2000年5月～2009年5月,因骨关节炎行硬膜外麻醉下初次全膝关节置换术患者705例,按同期双侧置换(268例)和单侧置换(437例)分为两组,比较两组患者的围手术期并发症、术后失血量、输血量、住院时间、费用与KSS临床及功能评分等各项指标.[结果]存在围手术期并发症的患者比例,双侧组(15.6％)高于单侧组(7.8％),其中心血管系统并发症发生率双侧组(7.3％)高于单侧组(3.2％).感染、死亡、肺栓塞等围手术期并发症发生率,两组之间差异无统计学意义.术后失血量及输血量双侧组高于单侧组.术后2年KSS临床评分两组间差异无统计学意义,KSS功能评分,双侧组高于单侧组,差异有统计学意义.[结论]对于双侧膝骨关节炎的患者,在硬膜外麻醉下行同期双侧全膝关节置换术经济、高效,且有理想的手术疗效.术前应对患者做全面健康评估,对存在严重合并症,尤其是心血管系统疾病患者,应尽量避免行同期双侧全膝关节置换术.     

关节置换术后下肢深静脉血栓形成的解剖分布

目的 探讨初次全膝关节置换术和全髋关节置换术后下肢深静脉血栓形成的解剖分布特点.方法 回顾性分析2007年6月至2012年5月接受初次全膝关节置换术或全髋关节置换术后经下肢静脉造影诊断为下肢深静脉血栓形成的272例患者的病例资料,全膝关节置换组110例,全髋关节置换组162例.观察静脉造影中两种术式术后下肢深静脉血栓形成的部位及其差异.结果 全膝关节置换组中,中心型血栓10例、周围型血栓94例、混合型血栓6例;全髋关节置换术组中,中心型血栓3例、周围型血栓140例、混合型血栓19例.两组血栓类型的差异有统计学意义(x2=9.996,P=0.007).全膝关节置换术和全髋关节置换术后血栓最易累及部位依次为肌间静脉193例(71.0％,193/272)、胫后静脉98例(36.0％,98/272)、腓静脉85例(31.3％,85/272)、胫前静脉24例(8.8％,24/272)、腘静脉24例(8.8％,24/272)、髂股静脉20例(7.4％,20/272).周围型血栓中,全膝关节置换组比全髋关节置换组更容易累及多支静脉,两组差异有统计学意义(x2=14.712,P=0.000).在孤立性血栓中,无胫前静脉血栓形成.在多支静脉血栓中,两组均以累及胫后静脉、腓静脉、肌间静脉血栓中的两支或三支常见.结论 全膝关节置换术和全髋关节置换术后下肢深静脉血栓形成的解剖分布不同.     

人工关节置换术后并发深静脉血栓形成的危险因素评估

[目的]探讨全髋和全膝关节置换术后下肢深静脉血栓(deep venous thrombosis,DVT)形成的相关危险因素。[方法]选取2010年1月~2014年12月在本院行人工髋膝关节置换术的患者536例进行DVT的回顾性分析。选择性别、年龄、体重指数、凝血指标、吸烟史、麻醉方式、手术时长、合并慢性病史等22项与人工关节置换术后DVT形成的可能相关因素进行统计分析。[结果]216例人工膝关节置换术后发生DVT 23例,320例人工髋关节置换术患者术后发生DVT 22例,进行单因素分析表明:年龄、性别、体重指数、D-D、心肌梗死病史、深静脉血栓史是关节置换术后DVT发生的危险因素(P0.05),多因素logistic回归分析表明:年龄、深静脉血栓史使术后发生DVT的风险分别增加到1.058、6.283。[结论]年龄、性别、体重指数、D-D、心肌梗死病史、深静脉血栓史等的患者发生DVT的风险较高。尤其是高龄、深静脉血栓史与术后DVT发生密切相关,需要引起临床医生的重视。     

类风湿关节炎膝关节置换后深静脉血栓发生情况及溶栓效果研究

[目的]探讨类风湿关节炎患者行全膝关节置换术后深静脉血栓的发病率及溶栓效果研究。[方法]2009年2月～2011年5月手术治疗类风湿关节炎24例,其中男性4例,女性20例;年龄29～74岁,平均58.2岁。双膝关节置换术6例(分两次手术),6例行左膝关节置换术,12例行右膝关节置换术。全膝关节置换术后行下肢深静脉造影诊断是否有深静脉血栓形成,术后深静脉血栓形成患者使用系统性溶栓治疗。[结果]深静脉造影术后,类风湿关节炎行全膝置换术后深静脉发生率为26.7%;系统性溶栓后,临床有效率为100%。分别在术后3、6个月随访两次。[结论]类风湿关节炎行全膝关节置换术后深静脉血栓发生率不低,值得在今后的临床工作中注意;下肢深静脉造影是关节置换术后诊断深静脉血栓形成的必要手段。     

康复操在预防全髋关节置换术后并发症方面的应用与初步体会

[目的]介绍本科自行研究设计的康复操在预防全髋关节置换术后并发症的应用.[方法]对155例行全髋关节置换术围手术期的患者,根据病情采取有针对性的康复操锻炼,每天3次.[结果]术后按Harris评分标准,优(90～100分)105例,良(80～89分)39例,可(70～79分)10例,优良率为92.90％；便秘发生率为19.35％、深静脉血栓发生率为3.22％、压疮发生率为1.29％等.[结论]加强康复操在全髋关节置换术围手术期的应用,可降低患者术后并发症发生的概率,是保证患者髋关节术后疗效的方法之一.     

原发性深静脉瓣膜功能不全对全膝关节置换术后下肢深静脉血栓形成的影响

目的 探讨原发性深静脉瓣膜功能不全(PDVI)对全膝关节置换术(TKR)术后深静脉血栓形成的影响.方法 126例TKR患者,术前行彩色多普勒超声检查,记录股总静脉有无反流并记录反流时间,反流时间>1s为静脉瓣膜功能不全(有PDVI组),无反流或反流时间≤1 s为静脉瓣膜功能正常(无PDVI组);术后7 d再对全部患者进行下肢静脉彩色多普勒超声复查,观察有无下肢深静脉血栓(DVT)发生.对两组计量资料采用成组资料χ2检验的方法进行统计学分析.结果 126例患者中,有PDVI组54例,无PDVI组72例,共有50例患者术后发生下肢DVT,总发生率39.7%(50/126).其中,有PDVI组33例患者术后发生下肢DVT,发生率61.1%(33/54);无PDVI组17例患者术后发生下肢DVT,发生率23.6%(17/72);PDVI组下肢深静脉血栓的发生率高于瓣膜功能正常组,两组差异有统计学意义(χ2=21.227,P<0.05).结论 原发性PDVI是TKR术后下肢深静脉血栓发生的危险因素.     

The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy

The occurrence of deep vein thrombosis (DVT) was studied by the 125-I-fibrinogen uptake test in 38 patients subjected to retropubic prostatectomy. The patients were randomly allocated to two groups: continuous lumbar epidural analgesia for up to 24 hours and general anaesthesia with intermittent positive pressure ventilation. Two of the 17 patients in the epidural group (12%) developed DVT in contrast 11 of the 21 patients in the general anaesthetic group (51%). The difference between the groups was significant. It is concluded that epidural analgesia offers a protection against postoperative DVT and is worth further investigation.     

骨科围手术期监测D-二聚体和同型半胱氨酸的临床意义

[目的]探讨骨科围手术期D-二聚体及同型半胱氨酸的变化对监测深静脉血栓形成的临床意义.[方法]选择55例骨科大手术患者,分别于术前24h,术后24、48、72 h静脉血检测其D-二聚体及同型半胱氨酸的水平,将并发深静脉血栓组与未发生组比较及分别与正常对照组比较,分析它们对监测深静脉血栓形成的早期诊断价值.[结果]手术前24h患者D-二聚体和同型半胱氨酸的浓度,并发深静脉血栓组与未发生组比较结果无显著性差异(P＞0.05),且分别与正常对照组比较差异无显著性(P＞0.05);手术后24、48、72 h,同时间两组比较,并发深静脉血栓组D-二聚体和同型半胱氨酸的浓度明显高于未并发深静脉血栓组,有显著性差异(P＜0.05);并发深静脉血栓组手术后24、48、72hD-二聚体和同型半胱氨酸的浓度与正常组比较,有显著性差异(P＜0.05);未并发深静脉血栓组手术后24hD-二聚体与正常组比较,有显著性差异(P＜0.05),而手术后48、72 h与正常组比较,无显著性差异(P＞0.05);未并发深静脉血栓组手术后24、48、72 h同型半胱氨酸浓度与正常组比较,无显著性差异(P＞0.05);且D-二聚体和同型半胱氨酸血浆浓度升高与手术后深静脉血栓的发生呈显著正相关(P＜0.05);[结论]动态联合监测D-二聚体及同型半胱氨酸的水平对早期诊断骨科大手术后并发深静脉血栓具有重要意义.     

Prevention of deep vein thrombosis after total hip replacement. The effect of low-molecular-weight heparin with spinal and general anaesthesia.

Enoxaparin, a low-molecular-weight heparin, has been used together with spinal or general anaesthesia in a prospective, randomised study of 188 consecutive elective hip replacements. Bilateral venography was performed on all patients on day 13 after operation. Group I (65 patients) received spinal anaesthesia and no immediate injection of enoxaparin. Group II (61 patients) received spinal anaesthesia and 20 mg of enoxaparin one hour after the onset of anaesthesia. Group III (62 patients) was operated on under general anaesthesia and received 40 mg of enoxaparin 12 hours prior to surgery. This group acted as the control group. In all three groups, 40 mg of enoxaparin was given 12 hours after the end of surgery and continued on a once-daily basis. Proximal DVT occurred in 6% of group I, 6.7% of group II and 6.5% of group III, not a significant difference. Distal DVT was present in 11% of group I, 5% of group II and 0% of group III; this was a highly significant difference (p = 0.007). Tolerance was good and the incidence of bleeding low in the three groups. Our results confirm the low rate of DVT in patients operated on under general anaesthesia with the standard procedure of 40 mg of enoxaparin on a once-daily basis started pre-operatively. The 40 mg-dose is also safe and effective in association with spinal anaesthesia if half the dose (20 mg) is injected an hour after the lumbar puncture.     

A Controlled Study on the Effect of Epidural Analgesia with Local Anaesthetics and Morphine on Morbidity after Abdominal Surgery

A hundred patients scheduled for elective abdominal surgery were randomized to either general anaesthesia (low-dose fentanyl) and systemic morphine for postoperative pain or combined general anaesthesia and epidural analgesia with etidocaine 1.5% intraoperatively (T4-S5) and bupivacaine 0.5% 5 ml/4 h for 24 h and morphine 4 mg/12 h for 72 h. Postoperative pain was better controlled by the epidural regimen (P less than 0.0001). We found no significant reduction in postoperative mortality (6% to 2%), pneumonia (28% to 20%), cardiac dysrhythmia (10% to 5%) and wound complications (14% to 11%) by the epidural analgesic regimen. The incidence of deep venous thrombosis (125I-fibrinogen scan) was 32% after general anaesthesia and low-dose heparin and 34% after epidural analgesia with no prophylactic antithrombotic treatment (P greater than 0.9). Postoperative weight loss and decrease in serum-albumin and serum-transferrin, as well as the reduction in haemoglobin and the need for postoperative transfusions, were similar in the two groups. Convalescence, as assessed by postoperative fatigue, restoration of bowel function (flatus, bowel movement and food intake) and the time until the patients were self-aided at their preoperative level, was not reduced by epidural analgesia. Since 50% of the patients in each group suffered from one or more of the above-mentioned postoperative complications, this epidural regimen was not effective in reducing postoperative morbidity after major abdominal surgery despite the achievement of adequate pain relief.     

Aortofemoral bifurcation bypass--effect of anesthesia procedure (NLA, thoracic continuous catheter peridural anesthesia) on circulation, respiration and metabolism. Hemodynamic changes caused by peridural anesthesia and anesthesia induction

In 50 patients scheduled for infrarenal aortic bypass surgery the cardiovascular effects of two anaesthetic regimes were investigated prior to surgery. A Swan-Ganz-catheter was used for haemodynamic measurements. These patients, having been randomized into two groups, were optimally volume loaded (PCWP 10 mmHg) before anaesthesia. In 24 patients a thoracic epidural was induced with 12-15 ml 0.25% plain bupivacaine. When segmental anaesthesia had extended from T4/5 to L1/2 general anaesthesia was additionally applied (flunitrazepam 1.5-2 mg, pancuronium bromide 0.1 mg/kg). In 26 patients neuroleptanaesthesia was induced (droperidol 0.1-0.2 mg/kg, fentanyl 0.01 mg/kg, pancuronium bromide 0.1 mg/kg, and thiopentone 100-150 mg. Haemodynamic measurements were made before injection into the epidural catheter, after complete spread of anaesthesia, before commencing general anaesthesia and 10-15 min thereafter. Results: Neither of the two procedures were associated with severe haemodynamic alterations. In the epidural group HR fell slightly during latency of complete spread and increased to the same extend following general anaesthesia. The epidural caused MAP (104 to 88 mmHg), mean PAP (20 to 14 mmHg), PCWP (10 to 7.5 mmHg), and RAP (4.5 to 2.5 mmHg) to decrease moderately but no further changes were effected by the subsequent general anaesthesia. SVR and PVR were not influenced by either epidural or by general anaesthesia. CI (3.6 to 3.41 . min-1 . m-2), LVSWI (67 to 52 p . m-1), and cardiac minute work index (55 to 40 J . min-1 . m-2) decreased during latency of complete spread but were no further influenced by general anaesthesia. The haemodynamic changes of neuroleptanaesthesia were almost identical to those of the combined epidural-general anaesthesia. For the operation which followed, a continuous infusion of 0.125 per cent plain bupivacaine (0.25 ml/kg X h) via epidural catheter (in combination with N2O/O2-anaesthesia) was sufficient for complete analgesia in the epidural group. These findings lead to the conclusion that a small bolus volume and a low concentration of bupivacaine result in good anaesthesia while avoiding serious haemodynamic alterations.     

Effects of lumbar epidural analgesia and general anaesthesia on flow velocity in the femoral vein and postoperative deep vein thrombosis

The effect of lumbar epidural analgesia and of general anaesthesia on the peroperative velocity of flow in the femoral vein was measured with Doppler ultrasound technique in 38 patients undergoing retropubic prostatectomy. The patients were randomly allocated to the epidural or the general procedure. The 125I-fibrinogen test was used to detect deep vein thrombosis (DVT). Epidural analgesia was associated with a significant (ca. 120%) increase in the femoral venous flow velocity. The peak flow showed a moderate (47%) increase, whereas the minimum flow was greatly increased (188%). The increase was significant already 2 min after induction of the analgesia and the rate continued to rise for about 11 min. General anaesthesia significantly reduced the flow velocity in the femoral vein. Immediately after induction of the anaesthesia the velocity approached zero, but gradually rose, and after about 8 min was stabilized at level 40% below the preoperative velocity. The peak flow velocity in all patients of this group fell by 24 to 40%. Only 2 of 17 patients with epidural analgesia, but 11 of 21 with general anaesthesia had postoperative DVT. In the 11 patients with DVT the mean minimum velocity of flow was decreased (by 85%), but in the 10 without DVT it was increased (by 175%). The difference was not statistically significant. Increased velocity of flow in the femoral vein, especially of minimum flow, seems to counteract development of DVT.     

Intra- and post-operative blood loss and haemodynamics in total hip replacement when performed under lumbar epidural versus general anaesthesia

The effects of lumbar epidural anaesthesia and two types of general anaesthesia on blood loss and haemodynamics during and after hip replacement were compared in three groups of patients. One group (n = 14) received continuous lumbar epidural anaesthesia, another group (n = 10) was given inhalational anaesthesia and spontaneous breathing after endotracheal intubation, and the third group (n = 14) received artificial ventilation after intubation and pancuronium and fentanyl intermittently i.v. Intra-operative blood loss in patients under epidural anaesthesia was 950 +/- 300 ml (mean +/- SD) and blood loss during the following 24 h-i.e. as long as the epidural anaesthesia was maintained-was 370 +/- 80 ml. These figures were significantly lower than the intra- and post-operative blood losses in patients under general anaesthesia with narcotics as post-operative pain treatment: 1140 +/- 200 ml (inhalational anaesthesia) followed by 480 +/- 70 ml and 1540 +/- 340 ml (artificial ventilation) followed by 500 +/- 110 ml. The intra-operative blood loss in the general anaesthesia group with spontaneous breathing was significantly smaller than the blood loss in the artificially ventilated group, whereas the post-operative blood loss in the two general anaesthetic groups was similar. Haemodynamic differences explain these differences in blood loss. Thus epidural anaesthesia induced hypotension on the arterial and venous sides. Intra-operatively, inhalational anaesthesia also induced hypotension on the arterial and venous sides compared with general anaesthesia using artificial ventilation. Post-operatively, the general anaesthesia groups behaved haemodynamically similarly and no differences in blood loss were seen. The reduction in blood loss, notably associated with lumbar epidural anaesthesia, is beneficial in decreasing the hazard and cost of blood transfusion.     

PKP治疗老年骨质疏松性椎体压缩骨折的手术时机

[目的]比较不同时机经皮穿刺椎体后凸成形术(PKP)治疗老年骨质疏松性腰椎压缩骨折的临床效果。[方法]2014年12月~2016年12月,对114例老年单节段骨质疏松性椎体压缩骨折(OVCF)患者,均采用PKP术治疗,根据骨折至手术时间分为<7 d组55例,7~14 d组35例,15~28 d组24例。比较三组患者围手术期、随访与影像资料。[结果]所有患者均顺利完成手术,三组患者在手术时间、住院时间和骨水泥使用量的差异均无统计学意义(P>0.05)。7~14 d组骨水泥渗漏率为5.71%,显著低于<7 d组的14.55%以及15~28 d组的12.50%,差异具有统计学意义(P<0.05)。所有患者均随访24个月以上,随时间推移,三组患者VAS评分、ODI指数均显著降低,而JOA评分显著升高(P<0.05)。术后3 d,<7 d组疼痛VAS评分、ODI指数显著低于7~14 d组和15~28 d组,差异具有统计学意义(P<0.05);相应时间点,三组间JOA评分差异无统计学意义(P>0.05)。末次随访所有患者均无明显疼痛症状,活动功能恢复良好,无邻椎骨折或伤椎再骨折发生。影像测量方面,三组患者术后Cobb角均显著小于术前,而伤椎前缘高度均显著大于术前(P<0.05)。术后24个月,15~28 d组Cobb角大于<7 d组和7~14 d组,而伤椎前缘高度比(RAH)显著低于<7 d组和7~14 d组,差异具有统计学意义(P<0.05)。[结论]PKP术治疗老年OVCF能获得满意的近远期疗效,但骨折至手术时间<7 d疼痛改善效果更佳,手术时间7~14 d骨水泥渗漏率最低,手术时间15~28 d容易出现远期矫正丢失。     

人工全髋关节置换术后下肢深静脉血栓形成的多因素分析

目的:分析影响人工全髋关节置换术(THA)后下肢深静脉血栓形成(DVT)的危险因素。方法:对98例(112个关节)人工全髋置换术术后DVT发生情况进行分析。其中男55例,女43例;平均年龄59.12岁(41～81岁)。术前及术后7～10d均用彩色多普勒检查双下肢深静脉血流通畅情况及DVT的发生。对17项临床因素与人工关节置换术后DVT形成的相关性进行了分析。结果:术后发生DVT41例,DVT发生率为41.84%(41/98),其中无症状DVT患者占58.54%(24/41)。经Logistic多因素回归分析,与DVT相关的因素有5个,其中年龄、肥胖及肢体延长大于2cm使术后发生DVT的风险分别增加到1.952、3.349及7.376倍(P<0.05);硬膜外麻醉和踝泵练习使术后发生DVT的可能性减少到原来的0.132和0.265(P<0.01)。结论:年龄、肥胖及肢体延长大于2cm是人工关节置换术后发生DVT的危险因素,而硬膜外麻醉和踝泵练习是减少术后发生DVT的保护因素。关节置换术后无症状DVT的大量存在,提示术后最好常规行双下肢彩色多普勒检查,一旦有DVT发生,及时治疗,防止发生致命性肺栓塞。