心脏手术患者术前心理症状群研究

目的探讨心脏手术患者术前存在的心理症状及其构成的症状群,为心理干预提供参考。方法采用简明心境量表(BPOMSSF)对154例心脏手术前患者进行心理症状调查,采用探索性因子分析法提取症状群。结果共有30个心理症状入选,频次前5位的为紧张、焦虑、困惑、悲伤、无精打采;30个症状纳入因子分析,归为三大症状群:应激症状群(症状群1),紧张、困扰、焦虑、悲伤;精力不足症状群(症状群2),疲倦、疲惫不堪、疲乏、无精打采、精疲力竭;敌对症状群(症状群3),生气、有怨气、恼火、暴怒、脾气不好。结论心脏手术患者术前存在应激、精力不足和敌对症状群,因此,针对症状群的心理干预是解决患者心理问题的新思路。     

Respiratory gas exchange before and after cardiac operations

The changes in oxygen consumption and carbon dioxide production were measured both before and for 6 hours after a variety of cardiac operations. Core and peripheral temperatures were measured simultaneously. Oxygen consumption was initially similar to preoperative values but rose over the next 2.5 hours by an average of 31% above basal. Carbon dioxide production was initially higher than preoperative values, then declined briefly, and finally showed an average increase above basal of 29%. Core temperature rose from an initially slightly depressed level to a maximal level 4 hours postoperatively at an average rate of 0.4 degrees C/hr. It was not possible to separate cause and effect between the temperature and oxygen consumption increases, but more effective postoperative temperature control might limit metabolic demands at a critical time postoperatively.     

Patient memory before and after cardiac operations.

The memories of 20 patients undergoing elective operations on the heart were assessed by a comprehensive battery of standardized psychometric tests. Testing was conducted 1 to 2 days before, 7 to 10 days after, and 1 month after each operation. Twenty age-matched, healthy control subjects were given the same battery of tests at comparable times. Compared with healthy subjects, the patient group had significantly lower scores on 3 of 19 tests before, 10 of 19 tests 1 week after, and 5 of 19 tests 1 month after surgical intervention. The patient group had similar test performances before and 1 week after the operations and improved on 3 of 19 measures 1 month after the operations. Degrees of illness and cardiopulmonary bypass variables were significantly related to only a small subset of memory measures. Results of this study are consistent with previous reports that underscore the contribution of nonspecific aspects of surgical intervention to neuropsychologic dysfunction in the immediate postoperative period. We conclude that neither the illness nor the surgical variables are directly related to substantial variance in cognitive function after operations on the heart.     

Evoked potentials during cardiac and major vascular operations

Somatosensory evoked potentials are widely used in spine surgery to prevent injury to the spinal cord. However, their application in cardiac and major vascular surgery is largely unappreciated. This paper will review the unique stresses placed on peripheral nerves, spinal cord, and brain during these operations. In addition, the potential benefits of peri-operative somatosensory evoked potentials monitoring are described in detail.     

Prediction of perioperative cardiac complications by electrocardiographic monitoring during treadmill exercise testing before peripheral vascular surgery

ECG monitoring during treadmill exercise testing was performed in a prospective series of 105 consecutive patients with intermittent claudication scheduled for peripheral vascular surgery. ECG monitoring during the exercise test was useful in predicting perioperative cardiac complications. In 55 patients with evidence of coronary artery disease by history and ECG obtained at rest, a strong association (p less than 0.001) between an ischemic response to exercise testing and the occurrence of perioperative cardiac events was observed. ECG monitoring during the exercise test also revealed previously unsuspected ischemia or arrhythmias in six of the remaining 50 patients and predicted perioperative cardiac problems in four of these six. An ischemic response to low-level treadmill exercise testing probably indicates advanced coronary artery disease and offers valuable predictive information when a revascularization procedure is considered for the relief of intermittent claudication.     

Ultrasound evaluation and interventional therapy for peripheral vascular access stenosis in dialysis patients

Objective To investigate the patency rate and restenosis after percutaneous transluminal angioplasty (PTA) for the treatment of arteriovenous fistula (AVF) and arteriovenous graft (AVG) stenosis in dialysis patients. Methods The patients who were successfully treated by PTA for the first time in the blood purification center of the 2nd Affiliated Hospital of Nanjing Medical University from January 2016 to June 2017, including 71 cases of AVF in the forearm, 52 cases of AVF in the upper arm and 59 cases of AVG were recorded. The data of different stenosis parts were analyzed before and after treatment and followed up for 12 months. The initial patency rate and assisted-PTA patency rate were observed at 3 months, 6 months, 9 months, and 12 months after ultrasound interventional therapy, and the initial patency time for patients who needed to reintervention among all types of pathways were recorded. Results The initial patency rates at 3 months, 6 months, 9 months and 12 months after ultrasound interventional therapy were 98.59%, 90.14%, 71.93%, 54.93% respectively in forearm AVF, 90.38%, 65.38%, 42.31%, 32.69% respectively in upper arm AVF, 91.53%, 32.20%, 6.78%, 1.69% respectively in AVG, and the PTA-assisted patency rates were 98.59%, 97.18%, 95.77%, 94.37% respectively in forearm AVF, 92.31%, 86.54%, 84.62%, 80.77% respectively in upper arm AVF, 100.00%, 98.31%, 96.61%, 93.22% respectively in AVG, while the initial patency time was (8.99±3.54) months in forearm AVF, (6.33±3.01) months in upper arm AVF, (4.80±1.40) months in AVG respectively. Conclusions Ultrasound can comprehensively evaluate the function of peripheral vascular access, guide PTA treatment, and evaluate treatment outcomes. Ultrasound intervention therapy has best initial patency rate for forearm AVF stenosis. The prognosis of upper arm AVF stenosis PTA is relatively poor due to the easy cephalic stenosis. Although AVG has a short interval of restenosis, it can achieve a better long-term patency rate through regular intervention with ultrasound intervention.     

The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients

One of the greatest risks in peripheral vascular operations is the presence of significant coronary artery disease. To assess the proper timing and demonstrate a possible protective effect of coronary artery bypass (CAB), 1093 patients who underwent one or more peripheral vascular operations in addition to CAB from 1976 through 1984 were analyzed. During that same period, 24,441 patients underwent CAB procedures, and 8530 patients underwent major vascular operations. Carotid endarterectomy (493 patients), abdominal aneurysm resection (130 patients), renal artery bypass (12 patients), aortofemoral bypass (77 patients), femoral-popliteal-tibial bypass (190 patients), and combined vascular procedures (191 patients) were included. The patients were divided into three groups according to severity of disease, which determined timing of the procedure. Group I (255 patients) underwent simultaneous CAB and peripheral vascular operation because of unstable coronary artery disease and severe vascular disease. The early mortality rate for group I was 4% (10 patients). Seven of the 10 deaths were cardiac. In group II, 279 patients had CAB and peripheral vascular operation during the same hospital admission with the same operative mortality rate (4%, 10 patients). Six deaths were from cardiac causes, three from neurologic causes, and one from hemorrhage. In group III, 559 patients underwent CAB first, then peripheral vascular operation during a separate hospital admission. There were no cardiac-related deaths and only one neurologic-related death (operative mortality rate, 0.2%). These data demonstrate the protective effect of CAB in patients who undergo elective vascular surgery. The increased risk in patients undergoing simultaneous or same admission procedures was related to the severity of the vascular and coronary artery disease and not to the combined operations. Operative complications were not increased by performing simultaneous or same admission procedures.     

Biplane translumbar aortography for evaluation of peripheral vascular disease

Complete evaluation of the aortoiliac femoropopliteal system is necessary for the proper evaluation of lower extremity peripheral vascular ischemic disease. We have used a modified infrarenal translumbar approach since it is both safely and rapidly performed. An analysis of 212 consecutive cases (the last 182 with translumbar technic) revealed that 72 per cent of patients had significant atherosclerotic involvement of the aorta or one or more common or external iliac arteries, 43 per cent had significant bilateral involvement, and it was judged that retrograde femoral catheterization would have been difficult or impossible in 38 per cent. Biplane aortoiliac evaluation was added in our last seventy-nine studies. This provided additional diagnostic help in thirty-six of these cases and revealed an abnormality not otherwise visible in six of these patients. There were no serious complications in this series.     

Algorithm of cardiac risk assessment before vascular surgery

THE OBJECT: to detect the informative value of algorithm of cardiac risk assessment recommended by American Heart Association compared with original standard enlarged protocol. Overall 456 patients underwent vascular operations. First group consisted of 198 patients who were examined according original enlarged protocol; other 258 patients (2nd group) were examined with AHA protocol. At 1st group 41% patients didn't need myocardial revascularization (according coronarography results), preventive coronary bypass surgery was performed at 32% patients. At 2nd group coronarography was performed at 133 (51%) patients according risk factors stratification and stress-examination results. Preventive coronary bypass surgery was performed at 97 patients; 27 patients refused this recommendation. Enlarged protocol increases in 2.6 times the odds of unnecessary invasive procedure. It is concluded that AHA algorithm permits to reduce in 2 times and more the number of invasive diagnostic procedures compared with standard enlarged protocol; AHA algorithm increases the clinical and economic effectiveness.     

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.     

Intraoperative video angioscopy compared with arteriography during peripheral vascular operations

In a prospective study, we assessed the diagnostic and therapeutic applications of intraoperative angioscopy for peripheral vascular procedures. Sixty-seven vessels and 17 bypass grafts were examined with a flexible, multichannel, fiberoptic endoscope (outer diameter 2.8 mm), with video projection of a magnified image used during the following operations: femoropopliteal or femorotibial bypass (14), aortofemoral (six), axillopopliteal bypass (one), and femoral embolectomy (three). Preoperative angiograms were compared with the findings at prebypass intraoperative angioscopy. Immediately after bypass, angioscopic appearances of the graft, anastomosis, and distal runoff artery were compared with a completion angiogram. Significant disparity between angioscopy and arteriography occurred in five patients (21%), with resultant change of management in three (12.5%). In comparison to angioscopy, the arteriograms gave a false negative rate of 12.5% (3 of 24) and a false positive rate of 8% (2 of 24). Angioscopy was accurate for assessment of anastomoses in all cases and was particularly beneficial for monitoring balloon catheter embolectomy. Complications were limited to three instances of vasospasm when the scope was used in narrow vessels. No embolization, intimal trauma, infection, or vessel perforation occurred. We conclude that angioscopy promises to be a safe and accurate alternative technique for intraoperative assessment, monitoring anastomotic results and controlling therapeutic procedures.     

Prevention of cardiac complications in peripheral vascular surgery

The prevalence of severe coronary artery disease in peripheral vascular patients exceeds 50 per cent. It is therefore not surprising that complications of coronary artery disease are the most common causes of mortality following peripheral vascular operations. If the incidence of cardiac complications is to be reduced, it is first necessary to identify patients at risk through screening tests that will reliably detect hemodynamically important coronary occlusive disease. The operative risk can then be reduced by modifying the magnitude of the procedure, taking measures that can enhance the tolerance for a specific operation, or employing a combination of both. Screening methods in current use include risk factor analysis, exercise testing, routine coronary angiography, and dipyridamole thallium-201 scintigraphy. The risk factor approach has the advantage of being widely applicable since it makes use of historical, physical, and electrocardiographic findings that are already familiar to surgeons and anesthesiologists. It is also inexpensive. However, it may overlook the patient who has no symptoms of coronary artery disease, possibly as a result of the sedentary lifestyle imposed by complications of peripheral vascular disease. The electrocardiographically monitored stress test will identify the asymptomatic patient with occult coronary disease and is helpful in predicting operative risk. However, a meaningful test is dependent on the patient's ability to exercise--an activity that is frequently limited by claudication, amputation, or arthritis. Exercise testing also suffers from a lack of sensitivity and specificity when compared with coronary arteriography. Routine preoperative coronary angiography overcomes the exercise limitation of treadmill testing but is not widely applicable as a screening test for reasons of cost and inherent risk. Dipyridamole thallium-201 scanning, on the other hand, is safe and of relatively low cost and does not require exercise. Further, it has a high degree of sensitivity and specificity when compared with coronary arteriography. It appears to be an accurate predictor of postoperative cardiac complications.     

Initial evaluation of absorbable polydioxanone suture for peripheral vascular surgery

The long-term integrity of an autogenous vascular anastomosis is primarily dependent on the strength of tissue healing; therefore permanent mechanical support of an autogenous anastomosis with sutures is unnecessary. In this study we evaluated monofilament absorbable polydioxanone as an alternative to polypropylene for suturing autogenous vascular tissue during adult peripheral vascular operations. We used polydioxanone suture for 21 vascular procedures in 20 patients. We evaluated suture handling characteristics during operation and then followed patients with clinical assessments and serial duplex scans to monitor for pseudoaneurysms, anastomotic narrowing, and vessel patency. Indications for surgery included limb salvage (67%), dialysis access (23%), traumatic arteriovenous fistula and claudication (5% each). The operative procedures included infrainguinal bypass (57%), arteriovenous fistula formation (24%), thromboembolectomy (14%), and arteriovenous fistula repair (5%). Polydioxanone sutures were placed in 39 separate test sites (35 arterial, 4 venous). No deaths occurred during operation. Polydioxanone suture was found to have handling characteristics similar to polypropylene. During mean patient follow-up of 7.2 +/- 0.6 months, we found no cases of anastomotic narrowing or pseudoaneurysms. Actuarial test site patency at 1, 3, and 6 months was 97%, 97%, and 86%, respectively. Polydioxanone suture has handling properties that are acceptable for use in vascular applications, and it provides adequate mechanical support for sutured vessels to heal. A randomized trial comparing polydioxanone with polypropylene suture will be necessary to determine whether the lack of permanent foreign material in vascular anastomoses can improve long-term patency.