围手术期液体治疗与术后呼吸系统并发症

术后肺部并发症是手术病人预后的重要影响因素。有关围手术最适合的液体治疗剂量及种类的争论,目前尚无定论。不过,近年来有关过度液体治疗会导致术后肺部并发症增加的证据在不断增多。最近有研究表明,适当的减少围手术期液体治疗量（即限制性液体治疗）能降低择期胃肠大手术的术后肺部并发症发生率。限制性液体治疗的益处,不单单是减少了晶体液的给予量,同时可能与胶体的使用有关。有文献推荐,围手术期的液体管理包括：麻醉期间不给予麻醉前的预充量;晶体仅用维持剂量,用胶体来稳定血流动力学以及保证尿量［0.5mL/（kg·h）］; 出血等液体丢失用胶体来等容替代;不推荐给予第三间隙和利尿等液体的丢失等。此外,监测血乳酸水平可早期发现和纠正限制性液体治疗所致的组织低灌注,从而减少并发症。不过,何为围手术期的最佳液体治疗种类和剂量,还需要更严密、合理的研究。     

围术期高血压处理

随着高血压病人日益增多,麻醉医师几乎每天可在术前、术中和术后遇到高血压,需要及时诊断并根据不同的病因及严重程度和紧急情况给予不同处理。按照世界卫生组织的标准,成人血压＞２１．３ｋＰａ（１６０ｍｍＨｇ）／１２．７ｋＰａ（９５ｍｍＨｇ）即诊断高血压。严重程度取决于舒张压,＞１４．７ｋＰａ（１１０ｍｍＨｇ）即为严重高血压,择期手术应推迟进行,先行治疗为宜。如舒张压＞１６ｋｐａ（１２０ｍｍＨｇ）即为高血压危象,需进行紧急处理,若延续数小时有可能出现终末器官不可逆损伤,并发心脏意外、脑卒中或肾功能衰竭。术…     

合并呼吸系统疾病病人的围手术期处理：腹部手术对呼吸功能的影响

手术后的肺部并发症是导致围手术期病死率增加的重要原因。在接受腹部手术的病人，肺部并发症远较心脏异常更为普遍，其患病率平均约为30％。手术后的肺部并发症是指引起临床明显疾病或功能障碍且病程延长的异常表现，包括肺不张、感染(支气管炎和肺炎)、需要长期机械通气的呼吸功能衰竭、慢性肺部疾病的恶化以及支气管     

跟骨骨折围手术期的处理

目的 介绍跟骨骨折围手术期的临床经验。方法 运用重建钢板、可塑形钢板、“Y”型钢板和“T”型钢板对69例77侧跟骨骨折进行治疗。骨折分型采用Sanders分型法，77侧骨折中73侧获随访，随访时间2个月一4年3个月，平均14．2个月。结果 按Maryland足部评分系统评价术后功能。本组73侧骨折中，优29侧，良40侧，可4侧，优良率94．5％。结论 对跟骨骨折围手术期的正确处理直接影响手术疗效。     

重视外科病人的围手术期处理

围手术期（perioperative period）是指从确定手术开始,直至手术有关治疗结束为止的一段时间,包括手术前、手术中和手术后3个阶段。围手术期处理不同于以往教科书上的术前准备和术后处理,而应是贯穿这3个阶段的整体过程,其目的是获得最佳的手术治疗效果。实践证明,重视围手术期处理是手术治疗成功的最关键因素之一。     

下腰椎围手术期并发症

目的: 系统回顾分析下腰椎手术中、手术后短期并发症, 并探讨其治疗方法。方法:调查1995~2003年收治下腰椎手术患者599例的临床资料, 对其2周内所发生的并发症进行分析, 其中男.367例,女232例, 平均年龄45 5岁(21~81岁), 术前诊断主要依据术前症状、体征、影像学检查, 并对不同疾患、不同手术方式进行分类、统计。结果: 599例患者中, 2周内发生并发症者62例(10 .4% ), 主要包括神经症状加重1例,神经根刺激症状32例(占并发症的48. 4%。多数患者通过对症处理、神经营养药物的应用, 于2周内缓解), 腹胀等消化道症状8例(13. 1% ), 对症处理症状缓解, 其余为切口血肿4例(6 .6% ), 脑脊液漏3例(4. 8% ), 尿潴留2例(3. 3% ), 切口感染1例( 1 .9% ), 血栓形成2例( 3. 3% ), 泌尿系感染3例( 4. 8% ), 脂肪液化6例(9 .7% ), 系统处理得以恢复。结论: 只要遵循严格的手术适应证, 操作慎重, 早期观察并及时处理, 将极大地避免相应并发症。     

老年人胆囊结石围手术期处理体会

胆囊结石是外科常见病、多发病 ,随着人类平均寿命的延长 ,老年人中胆囊及胆系疾病明显增多。我院于 1990年 10月～ 2 0 0 0年 5月 ,手术治疗老年人胆囊结石 2 5 6例 ,现将有关围手术期处理作如下探讨。1　临床资料全组 2 5 6例 ,男 115例 ,女 141例 ;年龄 6 0～ 91岁。伴急性胆囊炎 36例 ,慢性胆囊炎 2 2 0例 ,其中6 7例合并胆总管结石。术前并存 1种病者 16 0例(6 2 5 % ) ,包括慢性支气管炎、肺气肿、高血压、冠心病、糖尿病、脑血栓后偏瘫 ,并存 2种以上病者 4 2例(2 6 2 5 % )。行单纯性胆囊切除术 5 7例 ,其中腹腔镜手术 2 5例 ,胆…     

唇腭裂修补术围手术期并发症及处理

<正>唇腭裂是口腔颌面部常见的先天畸形,患儿数量大,多数患儿智力发育与正常儿童无异,极具治疗价值。治疗方法是以手术为主的序列综合治疗,围手术期指的是术前术后1周。为减少唇腭裂修补术围手术期易出现的并发症,增加手术的安全性和成功率,现结合18例围手术期发生的并发症讨论如下:     

合并慢性阻塞性肺病的老年直肠癌患者围手术期处理

目的探讨合并慢性阻塞性肺病(COPD)的老年直肠癌患者的围手术期处理。方法对40例中度以上COPD直肠癌患者进行静态肺功能评估,并进行正确的围手术期处理,研究其对患者术后的影响。结果术后心律失常4例,COPD症状加重8例,肺部感染6例,二重感染4例,呼吸功能衰竭2例,内科治疗后均缓解;伤口感染5例,无围手术期死亡。结论虽然合并COPD患者增加了手术风险,但正确内科治疗及处理,可以降低手术并发症发生率。     

手助式腹腔镜肾切除术围手术期并发症的处理

目的探讨手助式腹腔镜肾切除术围手术期并发症的处理方法。方法回顾性分析1998—2004年377例手助式腹腔镜肾切除术患者资料，其中根治性肾切除术206例，单纯性肾切除术91例，根治性肾、输尿管切除术49例，肾部分切除术31例，对围手术期并发症类型、发生率及处理方法进行统计分析。结果377例患者术中估计失血量平均315．6ml（30～7000m1）。术中发生脾脏损伤、难以控制的出血、肠道损伤、肾蒂血管损伤、胰腺损伤等并发症14例（3．7％）。中转开放手术13例（3．4％）。术后发生肠梗阻、肺炎、切口疝、继发性出血、冠心病发作、血管栓塞、低钠血症等并发症48例（12．7％）。死亡2例（0．5％）。有腹腔或腹膜后手术史者围手术期并发症和术式中转率高于无手术史者。结论手助式腹腔镜肾切除术仍会出现一些严重的围手术期并发症。局部粘连、肿瘤体积过大会增加并发症的发生。术中一旦出现严重出血、器官损伤等难以控制的并发症时应及时中转开放手术。充分的术前准备、正确熟练的手术操作可降低并发症的发生率。     

Postoperative pulmonary complications and their prevention

Postoperative pulmonary complications are common. Despite advances in perioperative care for patients undergoing major surgery, they are associated with increased morbidity, mortality and healthcare costs. Strategies to reduce postoperative pulmonary complications include identification of patients at risk for respiratory complications, followed by risk stratification and perioperative optimization. This article evaluates current literature on the definition of postoperative pulmonary complications, their underlying biological mechanisms, contributing risk factors and preventative measures. Of note, the wide variability in the definition of postoperative pulmonary complications highlights the importance of identifying outcome measures and standardized end points as they affect the validity of clinical trials. Validated risk prediction models are useful tools for clinicians to stratify patients at risk, however there is still a lack of consensus over which model is the best one to use. Evidence for preventative measures including smoking cessation, correction of anaemia, perioperative respiratory physiotherapy and intraoperative management including lung-protective ventilation and goal-directed haemodynamic therapy are discussed. Most importantly, perioperative care bundles demonstrate the importance of multidisciplinary involvement during different time points when a patient undergoes surgery, and a combination of interventions are found to be more beneficial than individual interventions alone.     

围手术期液体治疗对凝血机制的影响

液体治疗是围手术期处置的重要组成部分,液体治疗对机体凝血机制的影响日益受到关注。重点介绍围手术期液体治疗的目的、输液量、液体的理化性质对凝血机制的影响。     

Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery

BACKGROUND: Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. METHODS: Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. RESULTS: The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13-2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01-2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91-2.24), but increased to 2.74-fold (95% CI = 1.15-4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45-0.95) and decreased by 8% with each increasing year of age. CONCLUSIONS: This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history.     

Correlation of cleft type with incidence of perioperative respiratory complications in infants with cleft lip and palate

BACKGROUND: A retrospective survey of 339 infants who had undergone primary plastic surgery for cleft lip and palate was performed to evaluate the concomitant preoperative assessment based on severity grading of the common cold and the correlation of cleft type with the incidence of perioperative respiratory complications. METHODS: We assessed the severity of common cold symptoms in the preoperative period using the Common Cold Score, which comprises 10 symptoms and findings. We then determined the association of the incidence of perioperative respiratory complications with the increasing severity of common cold symptoms and also compared the complication incidence in the three cleft types in healthy infants without a common cold. RESULTS: The incidence of perioperative respiratory complications was greater in the group with a suspected presence of a common cold. Infants with severer cleft, who had bilateral cleft lip and palate, even without common cold symptoms, had a significantly higher incidence of perioperative respiratory complications (8.9%) than infants with simple cleft lip (1.7%, P < 0.05). CONCLUSIONS: Clinicians should consider postponing primary plastic surgery for cleft lip and palate in infants with a suspected presence of a common cold. Our results also suggest that the presence of a wide cleft is a risk factor for causing perioperative respiratory complications in infants with cleft lip and palate. We believe that a careful preoperative assessment of common cold symptoms in these infants can decrease the incidence of perioperative respiratory complications.     

Childhood body mass index and perioperative complications

BACKGROUND: Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children. METHODS: This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children. RESULTS: There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children. DISCUSSION: Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.     

呼吸功能不全病人代谢特点及围手术期营养治疗

呼吸功能不全病人的病理生理特点决定其在疾病的不同阶段会发生不同程度的营养问题。在围手术期治疗中,及时合理的营养治疗是救治病人的重要环节,运用得当会明显改善预后,否则会导致病情恶化。合理的营养治疗是提高呼吸功能不全病人手术耐受性和成功率的重要方面。     

重视普通外科围手术期静脉血栓栓塞症规范化防治

普通外科围手术期病人是静脉血栓栓塞症(VTE)的高发人群,近年来国内外已经日益重视普通外科围手术期VTE的预防,但是在开展预防的前提下普通外科围手术期VTE仍时有发生,目前国内围手术期的风险评估和预防实施率仍不高,因此有必要重视普通外科围手术期VTE的规范化防治。规范化预防包括采用Caprini评分进行VTE风险评估以及在此基础上结合出血评估采用相应的机械预防和药物预防措施。规范化治疗主要是请血管外科和呼吸科专科医师协助根据指南对深静脉血栓形成(DVT)和肺动脉栓塞(PE)进行及时的诊断和治疗。治疗首选抗凝,其次根据病人病情和危险分层可进行溶栓、腔内治疗。同时植入滤器应严格按照指征。     

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食管胃结合部腺癌(AEG)的首要治疗方式是手术切除,但根治性切除病例中5年内复发率或病死率均超过50%,提示AEG围手术期放化疗的多学科综合治疗的必要性。近年来AEG的新辅助治疗受到较多关注,当前认为术前新辅助放疗能够提高术后5年总体存活率。而且欧洲癌症研究与治疗组织亦制定了AEG术前新辅助放疗的共识性指南,其对临床实践有很好的指导意义。术前新辅助化疗对提高R0切除率有重要意义,但需与术后辅助化疗序贯应用以提高总体存活率。术后辅助化疗和胃癌相同,NCCN推荐的多药方案为经典的ECF或改良ECF方案,而单药S1的试验结果也有不错的远期存活率。目前术中和术后放疗的证据令人遗憾,并不能提高远期存活率。因此,目前来说术前同步新辅助放化疗联合术后序贯辅助化疗应该是较为理想的方式。     

腹腔镜下胃旁路手术应注意的关键技术问题

目的 探索腹腔镜下胃旁路手术术中意外情况发生的原因及处理方法,寻求术中关键技术,从而减少术后并发症的发生.方法 南京医科大学第一附属医院普外科自2010年6月至2013年6月完成腹腔镜下胃旁路术150例,按时间顺序分为三组,复习所有患者完整手术录像,记录术中并发症发生的类型,处理的方法,回顾患者的病历资料,统计术中并发症的相关因素.结果 149例胃旁路术患者均在腹腔镜下完成,1例中转开腹,无术中大出血,无术后死亡病例,无术后大出血及肠梗阻、吻合口梗阻等严重并发症,150例患者发生术中并发症17例（11.7％）23次,主要集中在损伤、错断胃囊两大类,三阶段中第三阶段并发症发生率明显低于其他两阶段（P＜0.01）.并发症的发生与体质量指数（BMI）呈正相关（P＜0.01）.结论 腹腔镜下胃旁路术术中并发症的发生与术者学习曲线相关,与患者的BMI相关.术中测漏以及可靠的缝合技术是发现和处理并发症的关键.