双层手套预防骨科手术感染率的分析

目的:分析术中佩戴双层手套可有效减少内层手套破损率,从而降低感染风险。方法:统计骨科手术722台,手术人员佩戴手套3 243副,其中主刀佩戴双层手套共1 444副,一助722副,二助355副,洗手护士722副,分别对其手套破损情况进行统计,通过主刀佩戴外层手套与一助手套、主刀内层手套与一助手套、主刀外层手套与内层手套分别进行χ2检验。结果:主刀外层手套破损率明显高于一助,内层手套破损率明显低于一助,内层手套破损率亦明显低于外层。结论:佩戴双层手套,内层手套破损率明显降低,同时可有效保护术者发生医患感染风险。     

手术时间长短与术中手套破损情况的对比分析

目的:防止医护人员和患者在手术中发生交叉感染。方法:对200例手术中使用的1600只手套采用术中观察和术后手套内注水挤压方法观察A组(手术时间小于2 h)B组(手术时间大于2 h)两组手术手套破损情况。结果:显示A组手套破损发生率较低(8.00%),B组手套破损发生率较高(16.00%)。手套破损的发生与手术时间长短相关。结论:随手术时间的延长,手套破损几率增加,医护人员可能接触患者血液和其他体液的几率也会增加,为有效预防医患双方在术中发生交叉感染,术中发现手套破损应及时更换,手术时间>2 h应再次刷手更换手套。     

浅析接触化疗药物的自我防护措施

化疗药物对正常或不正常的增殖细胞均有抑制作用,大多数化疗药物都可能致机体损害。故在接触化疗药物时的自我防护是必要的,亦是非常重要的,现将防护体验总结如下。1配药液中的防护1.1操作时,穿易洗的紧袖式防护工作服(手术衣或两层隔离衣,戴厚口罩、帽子以及戴双层乳胶手套。有研究表明有内层手套的漏损率明显低于戴单层手套。因此戴双层手套是有效的防护手段。戴口罩可防止化疗药物的物末或蒸汽吸入鼻腔。1.2配药前应仔细检查注射器有无破损,漏气,如有应更换,避免在操作中药物污染注射器,针     

产科接生时手套破损发生情况分析及预防对策研究

目的:研究产科接生过程中戴单层手套或双层手套时手套破损的发生率和发现率,减少职业暴露。方法:采用灌注法对接生过程中使用的手套进行破损情况的测试,并在接生结束后询问记录人是否注意到手套的破损情况。结果:272例产科分娩,288人参与助产,85人手套发现破损,破损率为29.5%,单层手套的破损率达到29.8%,双层手套的外层破损率为24.3%,内层破损率为3.7%。接生时发现手套破损的为33.1%,接生后发现的占9.8%,灌注法测试发现的占57.1%。结论:产科接生过程中手套破损情况非常常见,但发现率较低。     

上消化道穿孔修补术中腹腔冲洗和更换器械的探讨

目的:探讨上消化道穿孔修补术中,在穿孔修补完成后并用大量温生理盐水(5000ml)冲洗后进行手术器械及术者手套更换与否对术后并发症发生率的影响。方法:对各种原因致上消化道穿孔行修补术的126例患者按术中是否行器械及术者手套更换分为两组,观察组78例,在术中于穿孔修补完成后用大量生理盐水(5000ml)冲洗后进行手术器械及术者手套更换。对照组48例,术中不行器械及术者手套更换。观察并比较两组术后并发症。结果:观察组术后各类并发症较对照组明显减少(P0.05)。结论:上消化道穿孔修补术中,在穿孔修补完成后并用大量温生理盐水(5000ml)冲洗后进行手术器械及术者手套更换可有效预防术后各类并发症的发生。     

外科手术中术者手部细菌数量监测研究

目的对于外科手术术中外科医生的手部的细菌数量进行监控,从而为手术过程中手卫生的维持提供有效的指导依据。方法对2011年2月～2012年7月我院行40例（台）“关节置换手术”和“脊柱手术”患者的10名手术医生分别于手部消毒后1 h、2h、3 h监测手部细菌菌落的培养结果及比较不同学历、职称的外科医生的手部细菌菌落的培养结果。结果10名医生外科手消毒后1 h手部细菌菌落（1.3±0.4）cfu/cm2,消毒后2h手部细菌菌落（34±8.4）cfU/cm2,消毒后3 h手部细菌菌落（46±6.3）cfu/cm2。不同时间点外科医生手部细菌菌落培养结果之间有显著统计学差异（F=167.96,P〈 0.01）。与外科手消毒后1 h,外科医生手部菌落数相比2 h和3 h外科医生手部菌落数显著增多（P〈 0.01）。与2 h外科医生手部菌落数相比,外科手消毒后3 h时外科医生手部菌落数显著增多（P〈 0.01）。10名外科医生手部细菌菌落的培养结果与医生学历、职称无关,差异无显著性（P〉0.05）。结论手术时间越长,术者手部细菌数量越多,引起手术后感染的机会将会增加。通过此项研究,改变了医生观念,手术时间超过3 h除应用抗生素外能主动采取重新手消毒或术前戴双层手套的措施。     

手术切口感染的预防

良好的切口愈合不仅缩短病程 ,而且给病人减少不必要的痛苦和经济负担。因此 ,预防手术切口感染有利于病人早期治愈。1　内源性感染的预防1缩短病人术前住院时间 ,加强病室环境卫生清洁及管理。2在手术时切开有菌脏器 ,如消化道手术、肺支气管手术必须防止含有细菌的液体外溢 ,污染周围组织和切口 ,术中污染的器械和手套应及时更换。 3预防性抗生素的应用 :选择敏感性抗生素。根据生物学特点 ,应用抗生素最有效的时间应是在细菌受到污染之前或污染时。临床上最好在手术开始前 2～ 4h给药 ,长时间的手术宜在术中追加用药以及手术后早期给药。…     

小儿爪形手的手术和康复治疗

目的:探讨小儿手部深度烧伤后瘢痕挛缩所致重度畸形(俗称爪形手)的手术整复及康复治疗.方法:2000年1月至2006年12月对25例(39只手)患爪形手患儿进行手术整复,采用瘢痕切除、游离全厚皮移植、局部皮瓣转移和腹部带蒂真皮下血管网皮瓣转移术,并在术后采取综合康复措施.结果:33只手行瘢痕切除植皮术,术后皮片存活良好27只手,少许表皮坏死4只手,小块皮片坏死2只手,经换药后痊愈.6只手腹部皮瓣全部存活.术后随访6个月～5年,根据手部关节活动度测量,结果优28只手,良9只手,差2只手.结论:小儿手部烧伤后瘢痕挛缩爪形手畸形根据畸形程度采取不同的术式,辅以术后康复治疗,可以较好的恢复患儿手的功能.     

严重烧伤行手急诊切痂功能性治疗

目的 :提高手部深度烧伤治疗质量。方法 :将重度以上合并手深度烧伤 85例分为传统治疗组 (A组 )和改良治疗组 (B组 ) ,A组在休克期内只行必要的减压术 ,伤后 3～ 7d行手部切削痂自体皮移植术 (滚轴刀取皮 ) ;B组于伤后 8h内行手部浅层切痂异体皮或生物敷料覆盖术 ,伤后 3～ 5d进行大张自体中厚皮更植(鼓取皮 ) ,指蹼处理上将指蹼缘切开向手背提升 ,以加深指蹼 ,再行皮片插入 ,缝成曲线形 ,创面愈合后各指蹼间隔以条形疤痕贴 ,戴弹力手套并用弹力条布在手套外分指蹼加压 ,晚间应用可塑夹板或行手指牵引对抗疤痕孪缩。结果 :B组在植皮成活率、创面愈合时间等方面优于传统治疗组 ,假蹼发生率下降。结论 :严重烧伤行手部急诊切痂延期植皮为治疗手部深度烧伤较好的方法之一。     

消化性溃疡急性穿孔的治疗选择

消化性溃疡穿孔在外科临床较为常见.为提高疗效,现将我院1996年1月～2001年1月经治的消化性溃疡穿孔47例资料.结合近期文献复习,着重对其治疗选择分析如下. 1 临床资料 一般资料:47例中男41例,女6例;年龄最大76岁,最小17岁.本组病例中十二指肠穿孔29例,胃幽门附近及胃窦区穿孔14例;穿孔部位不明确4例(非手术病例).发病时间:最短2h,最长36h,平均为12.25h.本组发病后12h内施行手术者30例,12h以上手术者13例.47例均有腹膜刺激征,其中板状腹40例(占85.1%),X线胸腹透视或摄片,37例提示隔下游离气体(占78.7%);23例腹腔穿刺抽出黄色或脓性渗液(占48.9%).本组31例以往有溃疡病史.全组均以消化性溃疡穿孔确诊.腹腔污染程度:所有手术病例腹腔内均有食物残渣、胃液、胆汁及脓汁等;本组半数病例腹腔污染相对较轻,脓性液体主要集中在右上腹,仅伴有穿孔部位周围的肠壁充血水肿.本组亦有21例腹内污染严重,下腹及盆腔均有较多脓液,1例还出现早期休克.     

Mechanisms of glove tears and sharp injuries among surgical personnel

OBJECTIVE.--The development of strategies to prevent exposure to blood for operating room personnel has been hampered by a lack of knowledge about the specific mechanisms of exposure. The purpose of this study was to classify the mechanisms of glove tears and sharp injuries in the operating room. DESIGN.--During a 3-month period, a nurse interviewed operating room personnel immediately after a glove tear or sharp injury had occurred. SETTING.--Yale-New Haven (Conn) Hospital is a tertiary care teaching hospital. RESULTS.--There were 249 glove tears and 70 sharp injuries. Visible skin contact with the patient's blood occurred in 156 glove tears (63%). The mechanism causing the tear could be identified in only 81 (33%). For 230 glove tears (92%), personnel were wearing single gloves. Of 70 sharp injuries, 47 (67%) were caused by needles and usually occurred during suturing. The following three mechanisms accounted for 40 sharp injuries (57%): (1) hands injured while stationary and holding an instrument, 11 (16%)-a position of risk not previously identified; (2) hands injured while retracting tissue, 12 (17%); and (3) injuries caused by sharp instruments not being used, 17 (24%). Instrument passage caused only four sharp injuries (6%). CONCLUSIONS.--The majority of glove tears have an unknown mechanism, and alteration in the manufacture or number of gloves worn may be helpful in reducing cutaneous blood exposures. The identification of specific mechanisms of sharp injuries should lead to effective strategies to prevent exposure to the human immunodeficiency virus and other blood-borne pathogens in the operating room.     

Intraoperative glove perforation—single versus double gloving in protection against skin contamination

Surgeons have the highest risk of contact with patients'' blood and body fluids, and breaches in gloving material may expose operating room staff to risk of infections. This prospective randomised study was done to assess the effectiveness of the practice of double gloving compared with single gloving in decreasing finger contamination during surgery.
In 66 consecutive surgical procedures studied, preoperative skin abrasions were detected on the hands of 17.4% of the surgeons. In the double gloving pattern, 32 glove perforations were observed, of which 22 were in the outer glove and 10 in the inner glove. Only four outer glove perforations had matching inner glove perforations, thus indicating that in 82% of cases when the outer glove is perforated the inner glove will protect the surgeon''s hand from contamination. The presence of visible skin contamination was also higher in perforation with the single gloving pattern (42.1%) than with the double gloving pattern (22.7%).
An overwhelming majority of glove perforations (83.3%) went unnoticed. Double gloving was accepted by the majority of surgeons, especially with repeated use. It is recommended that double gloves are used routinely in all surgical procedures in view of the significantly higher protection it provides.


     

远端胃癌手术消化道重建三种吻合技术的评价

目的评价远端胃癌手术分别采用单层、双层及国产吻合器吻合行消化道重建的效果。方法1995年1月至2005年1月我院对521例远端胃癌手术患者在消化道重建中分别采用了单层、双层及国产吻合器吻合三种不同的吻合方式。并观察记录手术用时、术后恢复情况以及吻合口漏及吻合口狭窄等并发症的发生率。结果单层吻合、吻合器吻合的吻合口漏发生率分别为1．11％和1．65％，均低于双层吻合5．66％（P〈0．05）。单层吻合、吻合器吻合吻合口狭窄发生率分别为1．67％和2．75％；均低于双层吻合6．92％（P〈0．05）；手术用时：吻合器组〈单层吻合组〈双层吻合组（P〈0．05）。结论单层吻合及国产吻合器吻合法较传统的双层吻合法更安全、简便；国产吻合器吻合法在节省手术时间上优势明显。     

微白蛋白尿在腹部手术后病人的液体治疗中的价值

目的 探讨腹部手术后微白蛋白尿的变化与手术创伤应激程度、液体正负平衡的关系.方法 腹部择期手术病人191例,根据手术类型分为4组:腹腔镜胆囊切除术组(Ⅰ组),开腹胆囊切除胆道手术组(Ⅱ组),结直肠癌根治性手术组和胃癌根治术(Ⅲ组)、胰十二指肠切除术组(Ⅳ组),手术创伤应激评分(SSS)评判手术创伤严重度.术后动态监测尿微白蛋白的变化,方差分析比较4组术后0、6 h平均尿微白蛋白/尿肌酐比值(ACR)的差异,对ACR与SSS评分进行相关性分析.在肿瘤手术两组监测术后体重变化,计算手术日24 h液体正平衡量,观察手术日24 h液体正平衡量与0、6 h ACR变化值(△ACR)的相关性,比较ACR恢复至正常或术前水平与体重达峰值的时间差异.结果 4组术后ACR均升高,Ⅰ组ACR的升高幅度最小,ACR0:(14.36±14.39)mg/mmol,ACR6:(8.62±6.03)mg/mmol,在Ⅱ组ACR0:(28.94±8.31)mg/mmol,ACR6:(12.66±3.92)mg/mmol和Ⅲ组ACR0:(30.46±13.74),ACR6:(11.67±5.55)mg/mmol升高幅度居中,Ⅳ组ACR的升高幅度最大,ACR0:(40.84±8.80),ACR6:(21.47±3.68)mg/mmol.方差分析:4组0、6 h ACR差异均有统计学意义(P＜0.001).0、6 h ACR值与SSS评分呈正相关.Ⅳ组手术日液体正平衡量较Ⅲ组明显增加,0、6 h△ACR与手术日液体正平衡量正相关,表明液体正平衡量与创伤程度正相关.ACR恢复至正常或术前水平较体重达峰值的时间提前.结论 腹部手术后病人的ACR的升高与手术创伤、液体正平衡量正相关,能反映手术的创伤程度.ACR恢复正常或术前水平较体重达峰值的时间提前,预示其是负平衡出现较体重测定更敏感的指标.

Abstract：

Objective To evaluate the relationship among the microalbuminuria, surgical stress and postoperative fluid balance after abdominal surgery. Methods A total of 191 patients undergoing an elective abdominal operation were studied. According to the extent of operative trauma, all patients were divided into 4 groups. Group Ⅰ: laparoscopic cholecystectomy ( n = 64); Group Ⅱ: laparotomy of cholecyst and biliary tract ( n = 36); Group Ⅲ: radical surgery of colorectal cancer ( n = 43 ); Group Ⅳ: distal subtotal gastrectomy (D2) or total gastectomy ( D3 ) or pancreaticoduodenectomy ( n = 48 ). The operative severities were predicated by surgical stress score (SSS). Urine albumin-creatinine ratio (ACR) was measured at both pre-and post-operation. The levels of ACR were compared by ANOVA among these 4 groups. The correlation of ACR and SSS was analyzed. In Groups Ⅲ and Ⅳ, body weight was measured by weight-bed simultaneously. The correlation of variation of ACR at 0 and 6 hours post-operation (△ACR) and the volume of positive fluid balance in the first 24 hour post-operation were studied. We also compared the varied durations of ACR levels returning to normal or the pre-operative level and body weight reaching peak values.Results The levels of ACR increased in all groups. The level of ACR was the highest in Group Ⅳ and the lowest in Group Ⅰ , significantly different from the levels of group Ⅱ and Ⅲ. There was a significant positive correlation between the increase in ACR and the severity of surgical trauma as measured by SSS. A positive correlation was observed between the volume of positive fluid balance in the first 24 hour post-ooeration and△ACR at 0 and 6 hours post-operation. The varied duration of ACR levels returning normal or the preoperative level was earlier than that of reaching the peak values. Conclusion ACR has a positive correlation with the extent of surgical stress and volume of positive fluid balance. The fact that the ACR comes earlier than the change of body weight indicates that the change of ACR is a more sensitive and simpler parameter than body weight to predict the onset of negative fluid balance.     

腹腔镜筋膜内子宫切除术与经腹全子宫切除术效果比较

目的: 比较腹腔镜筋膜内子宫切除术(classic intrafascial supracervical hysterectomy,CISH)与经腹全子宫切除术的效果。方法: 将126例良性子宫病变患者随机分为CISH组64例和剖腹组62例,比较两组术中、术后情况。结果: CISH组的手术时间、术中出血量、术后出血、排气时间、病率、住院时间较经腹组显著减少(P<0.005~P<0.001)。结论: 应用CISH效果明显优于传统的经腹全子宫切除术。     

双极等离子电切与普通电切治疗前列腺增生的疗效比较

目的对双极等离子电切术（PKRP）与普通电切术（TURP）治疗前列腺增生的疗效指标进行比较,探讨两种术式的临床价值。方法收治106例良性前列腺增生患者,其中48例行前列腺经尿道PKRP,58例行前列腺经尿道TURP,比较两组的手术时间、术中出血量、手术并发症及两组术前与术后的国际前列腺症状评分（IPSS）、生活质量评分（QOL）及最大尿流率（Qmax）。结果两组患者手术无一例中转为开放手术;与TURP组比较,PKRP组术中出血量明显减少;PKRP组无一例发生前列腺包膜穿孔,TURP组有2例发生包膜穿孔;两组患者术后IPSS、QOL、Qmax均较术前好转。结论虽然PKRP与TURP治疗前列腺增生的手术疗效相似,但PKRP能减少术中出血量,具有较高的安全性。     

手助腹腔镜与腹腔镜直肠癌根治术的对比研究

目的：通过手助腹腔镜与腹腔镜直肠癌根治术的对比研究,了解两种手术方式的的临床应用价值。方法对比手助腹腔镜和腹腔镜手术的直肠癌患者各52例的基本临床资料、手术切口、术中出血量、手术时间、术后恢复、病理结果、近期疗效等,并进行统计学分析。结果手助腹腔镜组平均手术时间明显优于腹腔镜组,平均切口长度长于腹腔镜组,平均出血量多于腹腔镜组,差异均有统计学意义（P＜0.05或0.01）。两组在术后平均止痛时间、术后静脉高营养使用时间、术后平均引流量、术后排气时间、术后进食流质时间等方面并无统计学差异（均P＞0.05）,手助腹腔镜组患者术后平均住院时间短于腹腔镜组,差异有统计学意义（P＜0.01）。结论腹腔镜与手助腹腔镜直肠癌根治术都是安全的微创手术方式,都具有住院时间短、进食及肠道恢复快,疼痛减轻,出血量较少,手术彻底性良好的特点。     

开放与腹腔镜修补术治疗胃十二指肠穿孔术的比较

目的研究胃十二指肠溃疡穿孔行开腹及腹腔镜手术治疗效果。方法收集70例胃十二指肠溃疡穿孔行开腹修补术及腹腔镜下修补术,比较两组患者的临床治疗效果。结果腹腔镜手术组在手术时间,术中出血量,住院时间及术后并发症等方面明显优于开腹组（P〈0.01）.结论腹腔镜下胃十二指肠溃疡穿孔修补术较传统开腹手术具有创伤小、恢复快及术后并发症少等优点,值得推广。     

宫腔镜手术的麻醉及电解质、血糖等监测对预防TURS的临床意义

目的：探讨宫腔镜手术的麻醉方法,了解电解质、血糖等在宫腔镜手术中的变化。方法：80例行寓腔镜手术的患者,随机分为GA组(静脉吸入复合全身麻醉组．n=36)和EA(硬膜外麻醉组．n=44)。所有的病人均于术前、术中、术后检测电解质(Na^ 、K^ 、Cl^-)、血糖和血气(HCO3^-、PaCO2、pH、Hb、Hct),同时记录下所用灌流液多少及手术时间。结果：两组术中血糖、术后血糖均较术前显著上升,术后血糖较术中血糖有所上升。电解质中以血钠变化明显,术中、术后较术前显著下降。组间比较无显著差异。两组灌流液量无明显差异。结论：宫腔镜手术中,静脉吸入复合全麻和硬膜外麻醉均可安全使用。电解质、血糖等监测是不可缺少的手段之一。