肾移植术后脑部并发症

本文报道我院所做肾移植的患者中有6例发生了脑部并发症,结果4例死亡,1例切除移植肾后转入腹膜透析。认为肾移植术后发生脑部并发症的机理虽不太清楚,但从本组病例分析,可能与环孢素A的毒性作用、急性排斥反应、感染和糖尿病有关。     

12例体外循环心内直视术后脑部并发症的疗效探讨

目的:探讨体外循环心内直视术后脑部并发症观察的效果和护理措施。方法:回顾行体外循环心内直视术920例患者,其中12例在术后出现脑部并发症。结果:12例脑部并发症患者,2例因大面积脑梗死死亡,1例为单侧肢体活动障碍,余9例治愈。结论:回顾性分析其发病机制和危险因素,完善术后综合的护理措施,密切观察病情变化,及时发现脑部并发症,控制血压及颅内压,尽早实施脑保护是成功减少体外循环术后脑部并发症的保证。     

脑部疾患合并糖尿病急性并发症12例诊疗体会

脑部疾患合并糖尿病急性并发症病情凶险，死亡率高。我院于1990年1月~1997年9月共收治脑部疾患合并糖尿病急性并发症12例，现将诊断和治疗体会分析如下。1资料和方法1．1一般资料：男性5例，女性7例，年龄15－75岁，平均年龄50．8岁。重型颅脑损伤4例，脑内血肿3例，脑膜瘤3例，胶质瘤1例，听神经瘤1例。全部病例均人院后或术后1~7天内出现糖尿病急性并发症。其中糖尿病酮症酸中毒4例，糖尿病非酮症高渗性昏迷吕例。1．2糖尿病急性并发症的诱因：3例术前漏诊，术中。术后静脉用高糖，4例使用脱水剂与糖皮质激素，2例因严重肺部感染，3例有应…     

心脏手术后脑部并发症的防治

心脏手术后脑部并发症是一种严重的并发症，致残性及死亡率均较高，2003年3月～2004年4月，我科共发生心脏术后脑部并发症4例，经过高压氧治疗及脑神经营养药物等治疗，取得满意效果。现报告如下：     

颈内动脉内膜剥脱术治疗颈动脉硬化狭窄后早期并发症分析

目的 比较颈动脉支架置入术（CAS）及颈动脉内膜剥脱术（CEA）治疗颅外颈动脉硬化狭窄后早期并发症发生情况,为临床治疗方法的选择提供理论依据.方法 分别采用CAS（CAS组,28例）和CEA（CEA组,31例）治疗59例颅外颈动脉狭窄患者.分析两种术式治疗后7 d内脑部、心血管及局部并发症发生情况.结果 术后7 d内CAS组9例（32.1%）出现脑部并发症,3例（10.7%）出现心血管并发症,5例（17.8%）出现局部并发症;CEA组2例（6.45%）出现脑部并发症,2例（6.45%）出现心血管并发症,4例（12.9%）出现局部并发症;CAS组患者脑部并发症总发生率明显高于CEA组,差异有统计学意义（χ2＝6.402,P＝0.011）;但两组心血管、局部并发症发生率以及总并发症发生率比较差异无统计学意义（P＞0.05）.结论 对于颅外颈动脉硬化狭窄患者,CEA仍是首选治疗方式.     

MRI导向脑内多发性病灶立体定向活检

目的探讨MRI引导下立体定向病灶活检术在确定脑内多发病变的病理组织学诊断中的作用。方法使用MRI与立体定向技术相结合，进行脑部病变的活检手术共25例。结果24例获得病理学诊断．1例未能确诊．诊断率为96％。有4例出现并发症，无死亡。结论采用MRI引导的立体定向对于脑部多发性病灶活检，诊断准确率高，安全可靠，并发症少．创伤轻微，病死率低，能够有效地诊断脑内多发疑难病例。     

Stanford A型主动脉夹层涉弓手术后脑部并发症危险因素分析

目的 探讨Stanford A型主动脉夹层患者涉弓手术后发生脑部并发症的危险因素。方法 回顾性分析Stanford A型主动脉夹层进行弓部手术116例患者的临床资料，根据术后是否发生脑部并发症分为并发症组和无并发症组。采用单因素分析和多因素logistic回归分析方法，分析术后发生脑部并发症的危险因素。结果 116例患者中术后发生脑部并发症31例，发生率26.72%,其中永久性神经功能障碍(PND)7例，短暂性神经功能障碍(TND)24例；发生脑部并发症组住院期间死亡6例，无并发症组死亡5例，总住院死亡率为9.48%。单因素分析显示，弓部手术后脑部并发症的危险因素有年龄、脑卒中史、颈动脉斑块或狭窄、急诊手术、术前肾功能不全、低血压、主动脉阻断时间、深低温停循环时间、术后低氧血症、低心排综合征、输血浆>800 mL、输红细胞悬液>6 u。多因素logistic回归分析显示，深低温停循环时间>40 min、输血浆>800 mL、输红细胞悬液>6 u、脑卒中史及颈动脉斑块或狭窄是Stanford A型主动脉夹层患者弓部手术后发生脑部并发症的独立危险因素。结论 深...     

一家族4例脑型肝豆状核变性的MRI诊断

目的 探讨肝豆状核变性的脑部MRI表现及其临床应用价值。方法 对一家族4例经临床化验证实的肝豆状核变性患者的脑部MRI表现进行分析。结果 患者脑部MRI主要改变为铜沉积所致的继发性双侧大致对称性的长T1长T2信号,增强无强化;发病部位依次为壳核4例,苍白球4例,丘脑3例,尾核头2例,齿状核1例,中脑1例,出现脑萎缩3例。结论 肝豆状核变性脑部改变以继发为主,MRI表现有一定的特征性,且与临床症状有一定的相关性。     

经人工血管行股动脉插管在主动脉夹层手术中的应用

目的：探讨经股动脉插管行主动脉夹层动脉瘤手术的结果。方法：对159例主动脉夹层动脉瘤经股动脉插管进行手术,并观察其疗效。159例主动脉瘤中：StanfordA型89例,StanfordB型70例,90例全心转流,其中31例深低温停循环,69例左心转流。结果：7例（4．4％）在术中出现假腔灌注;7例（4．4％）出现脑部并发症,4例死亡,2例广泛脑缺氧,5例脑栓塞;12例（9．0％）皮肤切口延迟愈合,局部感染2例（1．5％）,无插管侧下肢缺血或股动脉血栓形成。采用经人工血管行股动脉插管有效地降低了股动脉狭窄,血栓形成和下肢缺血的发生,股动脉插管主动脉逆行灌注造成的脑部并发症在本组发生率较低,但后果严重。结论：经股动脉插管行体外循环或左心转流手术治疗主动脉夹层动脉瘤的方法是非常有效的。     

老年人脑部手术的评估及围手术期处理

目的 探讨老年患者脑部手术的危险因素、手术时机和围术期管理.方法 2001年2月～2009年12月对老年患者行58例脑部手术,其中开颅脑肿瘤切除术21例,侧脑室腹腔分流术14例,外侧裂池开放术10例,经鼻蝶入路垂体腺瘤切除术4例,慢性硬膜下血肿钻孔引流术9例.结果 术后出现并发症17例(29.3%),早期死亡5例(8.6%).术前慢性阻塞性肺病和冠心病以及高龄患者是术后早期死亡和并发症的独立危险因素(P<0.05).结论 老年人脑部疾病能够保守治疗的尽量保守,必须手术的需要严格掌握手术适应证,以便达到临床效果满意.     

Outcome of rationing access to open-heart surgery: effect of the wait for elective surgery on patient outcome.

OBJECTIVE: To assess the effect of the waiting period before elective open-heart surgery on patient outcomes. DESIGN: Retrospective analysis. SETTING: The Montreal Heart Institute, a referral centre in cardiology and cardiac surgery. PATIENTS: All 568 patients who underwent open-heart surgery on an elective basis or following urgent admission or interhospital transfer between October 1991 and February 1992. MAIN OUTCOME MEASURES: In-hospital death rate, incidence of postoperative complications, length of stay in the intensive care unit (ICU) and total length of hospital stay. RESULTS: A total of 206 patients (151 men and 55 women with an average age of 59.0 [standard error of the mean (SEM) 1] years) underwent elective surgery, and 362 patients (264 men and 98 women with an average age of 62.0 [SEM 1] years) underwent urgent surgery. The mean wait for elective surgery was 2.8 (SEM 0.2) months. There was no significant difference between the two groups in the in-hospital death rate (4% v. 4%), the average length of stay in the ICU (4.4 [SEM 0.2] days v. 5.8 [SEM 1] days) or the average total length of hospital stay (9.0 [SEM 0.4] days v. 9.1 [SEM 1] days). As would be expected, postoperative complications developed in significantly more patients in the urgent group (27%) than the elective group (18%) (p = 0.02). Eight patients were admitted on an urgent basis for surgery owing to worsening symptoms or acute myocardial infarction after a mean wait of 4.6 months. One patient died suddenly at home 1 month after medical investigation while awaiting repeat coronary artery bypass grafting. Among the 206 patients who underwent elective surgery there was no relation between waiting time and adverse clinical outcomes after surgery. CONCLUSIONS: The results suggest that the wait before elective open-heart surgery had no effect on patient outcome after surgery in our institution. A policy of a short waiting period before elective open-heart surgery for patients whose condition is stable is safe and acceptable only if rapid access to medical and surgical treatment is available should it become necessary.     

心内直视术l490例次血气检测结果临床分析

目的正确评价心内直视术中机体代谢变化的特点。方法对２２５例心内直视术１４９０例次血气检测结果进行分析。结果ＰＯ_（２）１３．３ＫＰａ的占６８．１％,ＰＣＯ_（２）在正常范围的占７２．４％;ｐＨ值正常范围和硷质血症分别占４２．３％和４９．２％,实际碳酸氢盐和剩余硷高于正常的分别占４８．５％和５９．９％电解质多在正常范围。结论正确使用呼吸机,合理进行氧治疗,及时发现、处理并发症：酌情应用碳酸氢钠,及时补充血容量和钾离子,减少术后早期硷质血症的发生,以提高手术疗效。     

缺氧性脑病3例临床病理报告

三例不同病因所致缺氧性脑病的尸检材料表明脑部损害共同性的神经病理改变是急性缺血性神经元改变,普金野细胞尼氏体溶解或消失及胶质反应。选择性的改变:苏满氏段锥体细胞消失仅见死于癫痫连续状态的病人。每例皮质中均可找到弥散性急性神经元肿胀变化,为可逆性的,如及时认识及适当治疗,有益于防止神经细胞死亡。     

体外循环浅低温心脏不停跳心内直视手术的临床研究

目的:探讨体外循环浅低温心脏不停跳心内直视手术的方法、疗效评价及其对心肌保护作用。方法:总结2004年3月～2008年12月间12例施行浅低温心脏不停跳心内直视手术病例,并行循环不阻断主动脉,鼻咽温维持在32～35℃,阻断上、下腔静脉,完成心内直视手术。结果:全组无围手术期死亡,心脏手术结束能顺利停机,术后血流动力学平稳,无严重心律失常,血尿发生率0%,无1例发生空气栓塞。1例心房切口缝合针眼渗血,行再次开胸止血,1例术后第32h发生急性肺梗塞,均经治疗痊愈。结论:浅低温心脏不停跳心内直视手术技术安全可行,是一种接近生理状态的心肌保护方法,可避免再灌注损伤,有较理想的心肌保护效果。     

异氟醚与丙泊酚预处理在小儿体外循环心脏直视手术中脑保护作用的比较研究

目的比较异氟醚和丙泊酚预处理在小儿体外循环心脏直视手术中对脑的保护作用。方法将40例年龄不超过4岁的先天性心脏病患儿随机分为异氟醚组(n=20)和丙泊酚组(n=20),在手术前(T1)、体外循环开始后5min(T2)、阻断主动脉时(T3)、体外循环后30min(T4)、体外循环术毕(T5)、停止体外循环后6h(T6)、停止体外循环后24h(T7)7个时间点采集血样,采用酶联免疫吸附测定(ELISA)法检测血清中S-100β蛋白的表达,头颅CT检测术前、术后患儿的脑部情况。结果两组患儿术前S-100β蛋白的差异无统计学意义(P>0.05),两组S-100β蛋白的表达在体外循环开始后均上升,术后下降至术前水平(P>0.05)。异氟醚组患儿T4和T5时间点的S-100β蛋白表达水平比T1时间点显著升高(P<0.05),丙泊酚组患儿T4、T5和T6时间点的S-100β蛋白表达水平比T1时间点显著升高(P<0.05)。在T4、T5、T6及T7时间点,丙泊酚组患儿S-100β蛋白的表达水平显著高于异氟醚组(P<0.05)。丙泊酚组患儿术后并发症的发生率高于异氟醚组(P<0.05),而两组患儿脑水肿的检出率差异无统计学意义(P>0.05)。结论异氟醚预处理在体外循环小儿心脏直视手术中的脑保护效果方面优于丙泊酚预处理。     

Open-heart surgery in elderly patients

Between March 1975 and March 1980, 50 patients aged 70 to 78 years underwent open-heart surgery at the Montreal Heart Institute. Coronary bypass was performed in 23 patients, valve replacement in 16 and combined coronary and valve surgery in 11. There were four early deaths, all due to cardiac causes. Early postoperative complications occurred in 58% of the patients. There were seven late deaths, five in the valve replacement groups and two in the isolated coronary bypass group. The cumulative survival rate 5 years after surgery was estimated at 76%. While 82% of the survivors were in functional class III or IV before surgery, 90% were in class I or II when last seen, after an average postoperative follow-up of 3 years. Nonfatal late complications occurred in eight of the survivors, one of whom suffered a major hemorrhage due to anticoagulant therapy. Thus, open-heart operations can be offered to the elderly, with a low risk of operative death. The late clinical improvement, with a return to a normal lifestyle, justifies a surgical approach for patients in otherwise good general condition.     

中低温低流量体外循环在婴儿心内直视手术的临床研究

目的：探讨先天性心脏病婴儿进行心内直视手术时,应用中低温低流量体外循环的安全性和可行性。方法：40例因先天性心脏病行心内直视手术患儿,随机分为观察组（n=20）：应用中度低温低流量的灌注技术;对照组（n=20）：应用浅低温高流量的灌注技术。记录转机时间、手术时间、降温时间、复温时间、不良反应的发生,对两组术中血气、术后脑功能进行对比。结果：中低温低流量灌注时静脉血氧饱和度均在80％以上,无缺氧酸中毒的血气表现,血乳酸值也未升高,观察组与对照组各时间点的动一颈内静脉血的乳酸浓度差无明显变化（P〉O．05）,术后恢复良好,术后无明显体外循环相关并发症。结论：对婴儿进行心内的直视手术时,采用中低温低流量体外循环,能够满足脑组织的氧供,而且减少血液的破坏,保持术野的清晰,有利于减少长时间高流量灌注的不良反应,为临床开展婴儿复杂型先心手术的脑保护提供新手段。     

Effets de la chirurgie á coeur ouvert sur les mécanismes de défense contre lea infections bactériennes

Extracorporeal circulation during open-heart surgery may damage cellular and humoral factors in the blood. Phagocytic functions of circulating polymorphonuclear leukocytes were investigated in 10 patients 1 day before, then 1 hour, 2, 4 and 10 days after open-heart surgery. Transient diminutions in the phagocytic capacity of polymorphs was found for Staphylococcus aureus and Escherichia coli in one patient, and E. coli only in two patients up to the 4th postsurgical day. A positive correlation was found between the duration of extracorporeal circulation and the transient diminutions in phagocytic capacity for these three patients. However, the bactericidal capacity of polymorphs and their capacity to reduce nitroblue tetrazolium were normal in all patients. The serum concentrations of total hemolytic complement, C3, IgG and IgM were generally diminished up to the 4th day after surgery, but the opsonic power of the serum was almost normal in all the patients.     

Asepsis in the Operating Theatre

In the investigation of several blood stream infections following open-heart surgery, sutures and other material that had been exposed and handled in the sterile field were examined bacteriologically. One hundred and seventy-five open-heart operations were carried out during the study period and a high percentage of the specimens cultured yielded viable staphylococci and diphtheroids. Glove powder, textile fibres, and skin squames were found in the dust that collected in the room during the operations and staphylococci were frequently recovered from this source, and from the floor. Although the air supply to the theatre appeared to be of good quality, it is suggested that air currents within the room had caused dissemination of this foreign material and had probably contributed to wound infections.     

新生儿心内直视手术的体外循环管理

目的：总结36例新生儿心内直视手术的体外循环（cardiopulmonary bypass,CPB）管理经验。方法：回顾性总结2009年2月～2011年1月新生儿心内直视手术36例,其中,男28例,女8例;年龄3～28 d,平均（22.07±6.76）d;体重2.0～5.0 kg,平均（3.60±0.47）kg。其中常温2例,浅低温14例,中低温11例,深低温低流量4例,深低温停循环选择性脑灌注5例。深低温患儿应用pH稳态、甲基强的松龙和甘露醇。CPB中监测平均动脉压﹑心率﹑静脉混合血氧饱和度﹑尿量、鼻咽温、肛温和中心静脉压。全组心肌保护采用高钾晶体液停跳液。术中和停CPB后应用平衡超滤与改良超滤。结果：全组患儿CPB转流时间40～158 min,平均（80.19±35.43）min;主动脉阻断时间0～85 min,平均（45.02±22.03）min;所有病例均自动复跳,5例发生并发症,1例死亡,其余均痊愈出院。结论：CPB中应用个体化管理和采用综合措施是新生儿心内直视手术成功的保障。