手术后猝死8例临床与尸解分析

手术后猝死是医患双方都最不愿看到的结局，也是医疗纠纷的原因之一。为了预防并减少手术后猝死的发生，现将8例手术后猝死病例的临床与尸解结果分析如下。     

猝死76例尸检分析

0引言 尸体解剖在确认主要疾病及死因等方面有着极其重要的作用,即使现代医学技术已相当先进,但有些疾病的临床确诊仍较困难,甚至误诊．尤其是猝死病例,由于其生前无明显症状或病史短,若不进行尸体解剖,根本无法确诊主要疾病及死因．为此,我们收集和整理76例猝死病例尸检资料,探讨其死因和病理学特点,为医疗部门的医疗决策提供参考．     

反复胸闷、气急、猝死(第45例)

1 病史摘要 患者,女,47岁,因反复胸闷、气急5年余,加重3周入院。患者5年前无明显诱因出现胸闷、气急,活动后加剧,休息后好转,无明显胸痛、心悸症状,B超示肝硬化,脾肿大,腹水,后者为渗出性,细菌培养(-),TB-DNA(-),亦未找到肿瘤细胞。胃镜示食管胃底静脉曲张,予地高辛、呋塞米、螺内酯、卡托普利处理,腹水引流5000ml后缓解。入院前3个月又出现胸闷、气急症状,且不断加重,夜间不能平卧,伴有咳嗽、咳泡沫痰,腹围进行性增大,为进一步诊治于2001年     

上腹部疼痛、猝死(第44例）

1　病史摘要患者 ,男性 ,4 2岁。因持续上腹部疼痛 1小时余来院急诊。患者 2 0 0 0年 8月 2 2日 2 2时无诱因突然出现上腹部胀痛 ,并呕吐两次 ,呕吐物为少量胃内容物。晚餐正常进食 ,饮少量啤酒。以往曾有类似发作史。既往有可疑高血压病史。胆囊已切除。入院体检 :急性痛苦面容 ,双肺 (- ) ,心率6 0次 / m in,律齐 ,S1 ↓ ,各瓣膜未闻及杂音 ,腹略膨隆 ,腹软 ,剑突下压痛 ,无反跳痛。 Bp 12 0 / 70 mm Hg (1mm Hg=0 .133k Pa)。心电图 :窦性心律 ,左室高电压 ,余正常。超声检查 :肝、肾未见异常 ,胰腺回声不均匀。给予阿托品、奥曲肽(善…     

胃癌切除术后猝死(第46例)

1 病史摘要 患者男,59岁,入院前2个月感中上腹持续隐痛,期间偶有恶心、呕吐、腹胀、黑便和发热.发病后胃纳差,体重减轻.查体:消瘦面容,中上腹轻度压痛、反跳痛和肌卫.胃镜提示为"胃底贲门癌",病理检查为"黏液性腺癌".于4月17日8:00于全麻下行贲门癌根治术,术中见肿瘤约7 cm×5 cm,位于贲门区并向小弯侧浸润性生长,未见转移.行全胃切除术,食管、空肠R-Y吻合术,手术于16:40顺利结束.术后患者无不适主诉,体温39℃,因伤口渗血较多,给予肝素1支,生命体征平稳.4月18日4:00患者主诉略有腹胀,腹腔引流物淡血性.     

1749例儿童猝死病理解剖分析

本文对我国２２所医学院校病理教研室（科）或法医系登记的１９５０年至１９８９年间１４岁以下猝死尸检病例１７４９例进行分析，其结果表明：男性１０４０例，女性７０９例，男女比为１．５：１，平均年龄为２．５７岁，年龄小于２９天的病例最多，其６１３例（３５．０％），儿童猝死的主要原因依次是：呼吸系统疾病（３１．２％），新生儿疾病（２５．８％）传染病（１８．６％）最常见的三种疾病排位是小叶性肺炎，大量吸入综合     

70例猝死者法医尸检资料分析

本文解剖了70例猝死尸体,男性(81.4%)显著高于女性(18.6%),白天发病(67.2%)多于夜间(32.8%),中年组(57.0%)显著高于青年组和老年组(各21.5%)。主要死因:①冠心病(44.8%);②其它心脏疾患(17.1%);③脑疾患(14.2%);④急性出血坏死性胰腺炎(12.8%);⑤其它疾患(11.1%)。其中急性出血坏死性胰腺炎所占比例较大,在非冠心病心性猝死中原发性心肌病、病毒性心肌炎所占比例较大(75.0%),与文献报道不相一致。     

足月妊娠脐带绕颈胎儿猝死2例

1　病例资料例 1,女 ,38岁。怀孕 9+ 个月 ,阵发性腹痛 4小时 ,于1998年 12月 2 6日入院。G1PO。查体 :一般情况好 ,心肺(- ) ,宫体足月妊娠大 ,胎心 14 0次 /分 ,宫缩 30 '5 - 6 '。肛诊 :宫口开大 2cm ,诊断为 38+ 2 周妊娠临产 ,入产房待产。给予胎心监护 :基线 130次 /分 ,变异良好 ,无减速 ,10分钟后胎心音突然消失 ,误认为探头滑脱 ,寻找仍无 ,考虑胎儿猝死 ?B超确诊为死胎。于 8小时后自然分娩一 340 0 g死婴 ,外观发育正常 ,脐带长 4 5cm ,绕颈 1周 ,紧 ,颈部有压迹 ,胎盘未见异常。例 2 ,女 ,2 6岁。怀孕 9+ 个月 ,羊水少 ,于 1…     

渐进性排尿困难,手术,猝死(第45例)

1 病史摘要 患者,男,65岁,渐进性排尿困难3年,加重2个月,以前列腺增生症于1998年9月21日收住入院.入院时患者感排尿费力,尿线变细,射程变短,夜尿增多(4～5次/晚).查体:T 37℃,P 80次/min,R 20次/min,BP 22/12 kPa.一般情况好,心肺无异常,腹软、无压痛,肾区无扣击痛,膀胱区不充盈、无压痛,尿道口无红肿及溢脓,外生殖器无异常.前列腺肛检:大小为5 cm×4.5 cm×4.0 cm,质中等,表面光滑,无结节,中央沟消失.实验室检查:肝肾功能、乙肝表面抗原、核心抗原、e抗原及三大常规均未见异常.X线胸片:心、肺、膈均未见异常.腹部平片+静脉肾盂造影:前列腺增大,双肾功能正常.心电图:窦性心动过速,ST段轻度压低,V1～V6 T波轻度压低.B超检查:前列腺增生.血PSA(前列腺特异抗原)20.9 μg/L. 既往史:有高血压病史6年,1992年曾行左腹股沟斜疝修补术.无会阴外伤及尿路感染史.     

Early parental responses to sudden infant death, stillbirth or neonatal death

OBJECTIVE: To examine the mental health of parents after stillbirth (SB), neonatal death (NND) or sudden infant death syndrome (SIDS). DESIGN: The sampling frame from southeast Queensland was observed over 2.5 years. Control families were matched for birth date, sex of child, hospital and health insurance status. SETTING: Home interviews, by specially trained social workers, took place two months after the death of the infant. PARTICIPANTS: Results were based on 918 responses from 260 bereaved families (99 SB, 109 NND, 52 SIDS) and 252 control families, with a 63.6% overall participation rate. MAIN OUTCOME MEASURES: Questionnaires included standardised measures of anxiety, depression, biographic and demographic data. It was hypothesised that subject families would show more symptoms of anxiety and depression than control families, with mothers and parents affected by SIDS having the highest levels. RESULTS: Affected parents report significantly more psychological symptoms than controls, mothers more than fathers (P less than 0.001). Parents affected by SIDS showed more symptoms than other affected parents. High levels of anxiety were 14 times more likely in mothers affected by SIDS than controls (95% confidence interval, 5.4-36.6), with depression 12 times more likely (95% confidence interval, 3.8-43.5). Anxiety for groups affected by SB and NND were respectively 3.9 (2.1-10.5) and 6.5 (2.6-16.3) times more likely than for controls, and depression 6.9 (2.1-22.5) and 8.5 (2.7-26.7) times more likely. Differences were less marked for fathers, except for fathers affected by SIDS. CONCLUSIONS: Parents affected by stillbirth, neonatal death or sudden infant death syndrome manifest high levels of anxiety and depression two months after the death. Mothers have more symptoms than fathers, and parents affected by SIDS have the most symptoms of anxiety and depression.     

Alcohol intemperance and sudden death

Ten years after a health screening examination was offered to 50 year old men 32 of the 2322 participants and 12 of the 454 nonparticipants had died of ischaemic heart disease. Of these, 26 and 11 respectively had suffered sudden death, for which necropsy was performed. Half of the men who had died suddenly had been registered for alcohol intemperance up to 1973, which was four times the prevalence of such registrations in the general population. Registration at both the Swedish Temperance Board and the Bureau of Social Services was associated with an odds ratio of 3.74 for sudden death as compared with not being registered at either. Logistic analysis including the classical risk factors for ischaemic heart disease together with registration for alcohol intemperance and at the Bureau of Social Services showed only the two types of registration and systolic blood pressure to be independent risk factors. On the other hand, there was no overrepresentation of subjects entered in the registers among those surviving a myocardial infarction. For non-fatal myocardial infarction blood pressure and serum triglyceride concentration were significant risk factors and serum cholesterol concentration, smoking, and body mass index probable risk factors; the two types of registration were not independent risk factors. Alcohol intemperance is strongly associated with an increased risk of sudden death after myocardial infarction.     

体力活动、锻炼与女性心脏性猝死

背景：通常认为锻炼能够降低人们患心血管疾病的危险，也可能短暂性升高室性心律失常的风险。但锻炼与女性心脏性猝死风险之间的近期和远期关系尚不明确。目的：对比中至高强度体力活动时与低强度至无体力活动时的女性心脏性猝死风险；评价中至高强度体力活动与心脏性猝死的远期关系。设计、地点和参与者：对护士健康研究（1980-2004年）中的288例心脏性猝死患者进行前瞻性巢式病例交叉研究；对1986--2004年间随访的69693例既往无心血管疾病的参与者进行前瞻性队列分析。主要观察指标：与中至高强度体力活动相关的心脏性猝死风险。结果：与中至高强度体力活动相关的心脏性猝死绝对风险极低，仅为每3．65×10’h体力活动中1h。在病例交叉分析中，与低强度或无体力活动时的风险相比，中至高强度体力活动时的心脏性猝死风险有短暂性升高（RR2．38，95％CI1．23—4．60，P：0．01）。习惯性中至高强度体力活动可缓解这种短暂性风险升高（相互比较P：0．005），在每周至少锻炼2h的人群中风险无显著升高。队列分析表明，在排除了生物学因素并校正年龄的多元模型中，中至高强度运动增加与心脏性猝死远期风险降低相关（趋势P=0．006）。考虑到生物学因素时这种相关性降低（趋势P：0．06）；然而，每周锻炼至少4h的女性与不锻炼的女性相比，风险降低仍具有显著性（校正RR0．41，95％CI0．20。0．83，P=0．01）。     

Physical exertion, exercise, and sudden cardiac death in women

Context  Exercise is associated with a lower risk of cardiovascular events but may transiently increase the risk of ventricular arrhythmias. Its short-term and long-term associations with risk of sudden cardiac death among women are unclear. Objectives  To compare the risk of sudden cardiac death in women during moderate to vigorous exertion with the risk of sudden cardiac death during lighter or no exertion; and to assess the long-term association between moderate to vigorous exercise and sudden cardiac death. Design, Setting, and Participants  Prospective, nested case-crossover study of 288 cases of sudden cardiac death within the Nurses' Health Study (1980-2004); and a prospective cohort analysis of 69 693 participants without prior cardiovascular disease followed up from 1986-2004. Main Outcome Measure  Risk of sudden cardiac death associated with moderate to vigorous exertion. Results  The absolute risk of sudden cardiac death associated with moderate to vigorous exertion was exceedingly low at 1 per 36.5 million hours of exertion. In case-crossover analyses, the risk of sudden cardiac death was transiently elevated during moderate to vigorous exertion (relative risk [RR], 2.38; 95% confidence interval [CI], 1.23-4.60; P = .01) compared with the risk during lesser or no exertion. Habitual moderate to vigorous exertion modified this transient risk (P = .005 for interaction) and the risk was no longer significantly elevated among those who exercised 2 or more hours per week. In the cohort analyses, an increasing amount of moderate to vigorous exercise was associated with a lower long-term risk of sudden cardiac death in age-adjusted and multivariable models that excluded biological intermediates (P = .006 for trend). This relationship was attenuated when biological intermediates were included (P = .06 for trend); however, the reduction in risk remained significant among women who exercised 4 or more hours per week (adjusted RR, 0.41; 95% CI, 0.20-0.83; P = .01) compared with women who did not exercise. Conclusions  These prospective data suggest that sudden cardiac death during exertion is an extremely rare event in women. Regular exercise may significantly minimize this small transient risk and may lower the overall long-term risk of sudden cardiac death.