肺栓塞患者行多层螺旋CT检查的护理

对85例疑肺动脉栓塞和治疗后复查患者采用多层螺旋CT行薄层肺动脉造影和间接法深静脉造影.结果 85例患者均顺利完成检查,45例疑肺动脉栓塞中24例确诊为急性肺动脉栓塞(双肺动脉栓塞14例、左肺动脉栓塞3例、右肺动脉栓塞7例),肺部感染8例,肺结核2例,肺癌2例,胸腔积液8例,肺动脉黏液性恶性纤维组织细胞瘤1例;深静脉血栓9例.提出加强患者心理护理,完善检查前准备,严格操作规程,掌握熟练的穿刺技术并积极预防并发症是保证检查成功,获得具有诊断价值的肺动脉及深静脉造影图像的重要措施.     

Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism.Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.     

急性肺动脉栓塞的介入治疗

目的探讨急性肺动脉栓塞的介入治疗效果。方法 2009年10月～2011年5月对19例急性肺动脉栓塞行下腔静脉滤器植入,肺动脉造影,导管碎栓、抽栓、溶栓治疗,其中12例术中应用球囊辅助碎栓,术后处理联合应用低分子肝素和华法林,调整凝血酶原国际标准化率在2～3。结果术中即刻造影显示8例主干完全开通,11例部分开通。术中16例肺动脉压下降至16～37 mm Hg,3例肺动脉压升高至39～62 mm Hg,考虑末梢血管痉挛所致。基本治愈8例,显效5例,有效3例,无效3例。19例随访2～26个月,平均18个月,未见复发。结论急性肺动脉栓塞的介入治疗可以迅速恢复肺灌流量且相对于外科手术微创、简单,与全身静脉溶栓比较更迅速、有效。     

Chronic Obstructive Pulmonary Disease in Patients With Acute Symptomatic Pulmonary Embolism

BackgroundThe diagnosis of pulmonary embolism (PE) is often complicated by the presence of chronic obstructive pulmonary disease (COPD). Some studies have suggested that patients with PE and concomitant COPD have a worse prognosis than patients without COPD.Patients and MethodsOutpatients diagnosed with acute symptomatic PE at a university tertiary care hospital were prospectively included in the study. Clinical characteristics, time between onset of symptoms and diagnosis, and outcome were analyzed according to presence or absence of COPD. The primary endpoint was all-cause deaths at 3 months.ResultsOf 882 patients with a confirmed diagnosis of acute symptomatic PE, 8% (95% confidence interval [CI], 6%-9%) had COPD. Patients with COPD were significantly more likely to have a delay in diagnosis of more than 3 days and to have a low pretest probability of pulmonary embolism according to a standardized clinical score. The total number of deaths during 3 months of follow-up was 128 (14%; 95% CI, 12%-17%). Factors significantly associated with mortality from all causes were a history of cancer or immobilization, systolic blood pressure less than 100 mm Hg, and arterial oxyhemoglobin saturation less than 90%. COPD was significantly associated with PE-related death in the logistic regression analysis (relative risk, 2.2; 95% CI, 1.0-5.1).ConclusionsPatients with COPD and PE more often have a lower pretest probability and a longer delay in diagnosis of PE. COPD is significantly associated with PE-related death in the 3 months following diagnosis.     

Review of Acute Pulmonary Embolism in a General Hospital

Purpose Acute pulmonary embolism (APE) is a serious cardiovascular disease associated with high mortality rates. We analyzed the clinical characteristics, treatment, and outcome of patients with APE in a general hospital in Japan. Methods The subjects were 14 patients with APE: 6 with out-of-hospital onset and 8 with in-hospital onset. Results The incidence of APE in hospitalized patients was 0.03% (95% confidence interval, 0.01%–0.05%). Eight patients suffered shock and three patients suffered cardiac arrest. Advanced age, deep vein thrombus (DVT), cancer, fracture, obesity, and surgery were common risk factors. In the hospitalized patients, surgery was a major risk factor: APE developed perioperatively in five (63%) of eight patients. Nine patients were treated with heparin alone, three were treated with thrombolysis, and two underwent surgical embolectomy for right heart thrombi. Three of the patients who suffered shock died during hospitalization and another died of recurrence 2 months after the first episode. Overall in-hospital and 3-month mortality rates were 21% and 29%, respectively, and the in-hospital mortality rate of the patients with shock was 38%. Conclusion Acute pulmonary embolism was associated with high mortality rates and surgery was the most common risk factor predisposing to APE in hospitalized patients. Thus, standardized prophylaxis against DVT is essential for patients undergoing surgery.     

Pulmonary Embolectomy In Acute And Recurrent Massive Embolism

A series of seven patients surviving an acute massive embolization or with severe recurrent emboli of the lung were considered as embolectomy candidates and closely followed in pump stand-by. Embolectomy and caval ligation was performed in three of four patients with acute massive embolism. Two of them were saved and free from symptoms at follow-up. One patient died after embolectomy because of complications of her primary disease; at autopsy all pulmonary arteries were patent. The fourth patient was not embolectomized because of absence of persistent arterial hypotension until sudden death.

Three patients had recurrent massive embolism during 4 to 6 months. Embolectomy was not performed in one patient because of arterial normotension. Sudden death occurred without leaving time for embolectomy. Autopsy revealed that the emboli could easily have been removed. The second patient with cor pulmonale and occlusion of most pulmonary arterial branches was prepared for embolectomy but she died just before the planned operation. Autopsy showed that a sizable part of the occluding masses could have been removed at surgery. The situation was similar in the third patient with only one segmental artery patent in each lung and severe cor pulmonale. Thromboembolectomy restored blood flow to large parts of both lungs. Recovery was amazingly good.

The experiences seem to favour an active attitude to removal of both acute and recurrent massive pulmonary emboli.     

Detection of Pulmonary Embolism in the Postoperative Orthopedic Patient Using Spiral CT Scans

Orthopedic surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). This study was performed to compare the clinical presentations of a suspected versus a documented PE/DVT and to determine the actual incidence of PE/DVT in the post-operative orthopedic patient in whom CT was ordered. All 695 patients at our institution who had a postoperative spiral CT to rule out PE/DVT from March 2004 to February 2006 were evaluated and information regarding their surgical procedure, risk factors, presenting symptoms, location of PE/DVT, and anticoagulation were assessed. Statistical analysis was performed using an independent samples t test with a two-tailed p value to examine significant associations between the patient variables and CT scans positive for PE. Logistic regression models were used to determine which variables appeared to be significant predictors of a positive chest CT. Of 32,854 patients admitted for same day surgery across all services, 695 (2.1%) had a postoperative spiral CT based on specific clinical guidelines. The incidence of a positive scan was 27.8% (193/695). Of these, 155 (22.3%) scans were positive for PE only, 24 (3.5%) for PE and DVT, and 14 (2.0%) for DVT only. The most common presenting symptoms were tachycardia (56%, 393/695), low oxygen saturation (48%, 336/695), and shortness of breath (19.6%, 136/695). Symptoms significantly associated with DVT were syncope and chest pain. A past medical history of PE/DVT was the only significant predictor of a positive scan. Patients who have a history of thromboembolic disease should be carefully monitored in the postoperative setting.