骨科老年患者术后精神障碍风险因素识别和干预

目的观察骨科老年患者围术期发生精神障碍相关风险因素的识别和干预措施后,精神障碍的发生率。以及相关因素对降低术后精神障碍发生的临床意义。方法选择2010年1月至2012年12月在广西贵港市中西医结合骨科医院接受手术治疗的321例60岁以上老年患者,主要针对电解质紊乱、术前合并有基础病、麻醉时间、术中失血量、低血色素、低氧血症、疼痛等相关因素通过术前、术中、术后有预见性和针对性的综合预防干预。结果通过对骨科老年患者围术期发生精神障碍相关风险因素的识别和干预,术后精神障碍发生率为7．48％,控制组中麻醉时间、术后电解质失衡的发生率和低氧血症的发生率与对照组比较,差异有统计学意义（P〈0．01）。结论对骨科老年患者围术期发生精神障碍相关风险因素的识别和积极干预,能有效预防术后精神障碍的发生和降低术后各种并发症。     

老年患者冠状动脉搭桥术后血清NSE和S-100β蛋白水平的变化

目的 观察老年患者心肺转流(CPB)冠状动脉搭桥术(CABG)后血清神经元特异性烯醇化酶(NSE)及S-100β蛋白水平变化，探讨其与术后神经精神并发症的关系。方法 年龄≥65岁择期CABG患者30例，于术前、术终、术后12、24及48h五个时间点测定血清NSE和S-100β蛋白水平。评估术后急性精神障碍和脑血管意外发生情况。结果 (1)血清NSE水平在术终、术后12h及24h显著升高，血清S-100β蛋白水平仅在术终显著升高；(2)术后发生急性精神障碍患者术终、术后12h血清NSE、S-100β蛋白水平显著高于未发生者；(3)术前合并糖尿病者血清NSE水平在术终、术后12、24h及S-100β蛋白水平在术终显著高于非糖尿病患者。结论 (1)老年患者CABG后血清NSE和S-100β蛋白水平明显升高；(2)术后血清NSE和S-100β蛋白水平升高与术后急性精神障碍有关；(3)术前合并糖尿病是CABG后脑损伤和精神障碍的危险因素。     

老年患者开胸术后心肺并发症发生原因分析

目的 探讨老年重症患者开胸手术后心肺并发症的发生原因和预防措施。方法 对2001年7月至2003年12月收治的58例年龄〉65岁、术前有重要器官合并症和行大手术的开胸手术患者（实验组）进行围术期呼吸、循环监测，观察术后并发症发生情况，并与同期收治的56例（65岁开胸手术患者（对照组）进行比较。结果 实验组患者术前合并心血管和呼吸系统疾病的比率显著高于对照组，肺功能指标均较对照组差（P〈0．05）。实验组死亡4例，术后并发症、功能性并发症发生率显著高于对照组[58．6％（34／58）vs．17．9％（10／56），P=0.000；51．7％（30／58）vs．12．5％（7／56），P=0.000]，呼吸系统并发症发生率明显较对照组高。logistic回归分析显示，术前呼吸系统合并症（OR=5．4）和肥胖（OR=4．9）是术后呼吸系统并发症发生的独立预测因素。结论 术前合并呼吸系统、心血管疾病是老年患者术后易发生呼吸、心血管系统功能性并发症的主要原因。呼吸系统并发症是老年重症患者开胸手术后主要的死亡原因。术前呼吸系统合并症、肥胖是术后发生呼吸系统并发症的主要危险因素。心血管并发症主要表现为阵发性室上性心动过速，术前有心血管合并症是术后发生心血管并发症的危险因素。密切监护老年患者的呼吸循环指标及液体出入平衡变化有助于及早发现呼吸循环异常，提高老年患者开胸手术的疗效。     

老年患者术后精神障碍与麻醉手术相关因素分析

老年患者术后并发症的发生率与普通人群相比明显增高,通常对老年患者并发症的关注多集中在肺部感染、心功能不全、切口愈合不良等,对精神意识方面关注较少。本文通过回顾性调查,了解老年患者术后精神障碍的发生情况,并对相关的麻醉手术因素加以分析。     

老年食管癌患者术后严重并发症的危险因素分析

目的 总结老年食管癌患者术后发生严重并发症的危险因素及防治策略.方法 回顾性分析363例老年食管癌手术患者,并对术后发生严重并发症可能的危险因素进行单因素分析及多因素非条件Logistic回归分析.结果 Logistic回归分析显示术前长期重度吸烟史、术前有两种及以上的合并症和手术持续时间为老年食管癌患者术后严重并发症的主要危险因素.结论 对于高龄食管癌患者应做好充分的术前准备、及早戒烟、控制术前合并症和手术时间.     

老年胃癌患者术后出现精神障碍四例

术后精神障碍是老年人手术后一种较为常见的术后并发症，发生率约17．9％。我院2003年1月至2004年5月收治4例胃肠外科术后发生精神障碍的老年胃癌患者，现进行总结分析。     

老年胃癌患者术后严重并发症的相关因素分析

目的探讨影响老年胃癌患者术后严重并发症的主要因素。方法回顾性分析2003年1月至2008年12月期间在吉林大学中日联谊医院接受手术治疗的老年胃癌患者202例,以术后是否发生并发症及严重程度分为有和无严重并发症组,分别从临床因素和实验室检查两方面分析老年胃癌患者术后出现严重并发症的相关因素。结果在临床指标中,术前有并存症、行全胃切除、术中出血量≥800 ml、术中输血量以及联合脏器切除与手术后严重并发症相关(P<0.05)。实验室检查指标中,术前血清白蛋白值及术后第1天血糖值与手术后严重并发症相关(P<0.05)。结论术前有并存疾病、低蛋白血症以及扩大根治手术是老年胃癌患者术后出现严重并发症的危险因素。     

老年患者心理弹性和全髋关节置换术后急性精神障碍的相关性研究

目的探讨行全髋关节置换术的老年患者术前心理弹性和术后急性精神障碍的相关性。方法笔者自2014-03—2016-03采用便利抽样心理弹性量表对496例60周岁以上的需接受全髋关节置换手术的老年患者进行问卷调查,观察记录术后急性精神障碍的发生情况。结果接受全髋关节置换术的老年患者心理弹性得分为(58.59±8.77)分,低于我国社区老年人(60.17±14.28)分,差异有统计学意义(t=-3.974,P0.001)。术后出现精神障碍21例,未出现精神障碍464例。出现术后精神障碍的老年患者术前心理弹性评分为(48.67±5.651)分,未出现术后精神障碍的为(59.04±8.623)分,术后精神障碍组的心理弹性水平明显低于术后无精神障碍组,差异有统计学意义(t=5.455,P=0.021)。Pearson相关分析结果显示心理弹性和术后急性精神障碍呈负相关(r=-2.410,P0.001)。结论心理弹性较低的老年患者行全髋关节置换术后发生急性精神障碍的概率较高,应引起医护人员重视,可通过增强患者心理弹性来减少术后急性精神障碍的发生。     

老年患者择期开腹手术后感染风险因素分析

目的探讨老年患者择期开腹手术后发生感染并发症的危险因素。方法对2010年5月至2012年2月期间笔者所在医院收治的159例接受择期开腹手术的老年患者的临床资料进行回顾性分析。其中38例（23.90％）术后出现感染并发症（感染组）,121例无感染并发症（无感染组）,比较2组患者术前相关生理学指标、健康状况指标、手术指标以及术后感染并发症及死亡情况的差异。结果本组159例患者术后感染并发症发生率为23.90％（38／159）;术后死亡2例,术后病死率为1.26％。单因素及多因素logistic回归分析结果提示,患者术前的营养风险、糖尿病史和慢性呼吸系统疾病是术后感染并发症的独立危险因素。结论术前改善老年患者肺部疾病、糖尿病及营养状态,可能对降低术后感染并发症发生率有益。     

老年患者腔镜术后早期反应性精神障碍118例分析

目的 分析泌尿外科重症监护室老年患者腔镜术后早期反应性精神障碍的特点,为预防早期反应性精神障碍提供依据.方法 回顾分析近1年来我科60岁以上118例早期反应性精神障碍老年患者的临床病例资料.结果 老年患者中以前列腺增生电切术后、回肠膀胱术后、经皮肾镜碎石术后、腹腔镜下根治性肾切除术后呈集中分布,发生时间集中在术后48 h内,与基础疾病有着明显的相关性.结论 应重视高龄、基础疾病、手术方式及手术持续时间对泌尿外科重症监护室老年患者术后早期反应性精神障碍的影响,术前准确评估脏器功能、术中缩短手术时间,术后严密观察、积极预防治疗,可以减少泌尿外科重症监护室老年患者术后早期反应性精神障碍的发生,这对保证患者术后恢复具有重要意义.     

Predictors of health-related quality of life after coronary artery bypass surgery

BACKGROUND: Little is known about the determinants of health-related quality of life after coronary artery bypass surgery. We determined the predictors of overall physical and mental health status 6 months after the operation. METHODS: We evaluated 1,973 patients enrolled in a multicenter Veterans Affairs prospective cohort study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) health status surveys. Multiple linear regression was used to identify the significant independent predictors of 6-month physical and mental component summary scores from the SF-36. RESULTS: In multivariable analyses adjusting for baseline health status, significant predictors of postoperative physical health status were a history of neurologic disease, peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, current smoking, forced expiratory volume, left ventricular ejection fraction, and serum creatinine. Significant predictors of postoperative mental health status were a history of psychiatric disease, chronic obstructive pulmonary disease, current smoking, age, and New York Heart Association functional class. CONCLUSIONS: These predictors of health-related quality of life after coronary artery bypass surgery may be useful for preoperative risk assessment and counseling of patients with regard to anticipated health status outcomes. Factors such as current smoking and psychiatric disease may be targets for interventions to improve health-related quality of life outcomes.     

老年胰十二指肠切除术术后并发症分析

目的 分析5年来实施的52例老年胰十二指肠切除术术后并发症.方法 52例老年患者实施胰十二指肠切除术,男性32例,女性20例,年龄65～76岁,中位年龄70.5岁.术后病理证实为Vater's壶腹癌及十二指肠乳头癌24例,胰腺癌16例,胆管癌12例.结果 全组病死4例(7.7%).主要并发症包括上消化道出血4例(7.7%),腹腔内出血4例(7.7%),多脏器功能衰竭(MOF)3例(5.8%),急性呼吸窘迫综合征(ARDS)2例(3.8%),胰瘘3例(5.8%),胆瘘5例(9.6%),胃瘫6例(11.5%),精神障碍8例(15.4%).结论 MOF是老年患者胰十二指肠切除术术后主要致死并发症,胃瘫和精神障碍发病率高于中青年组.

Abstract：

Objective To analyze the postoperative complications in aged patients receiving pancreaticoduodenectomy. Methods Pancreaticoduodenectomy was employed for the treatment of 52 aged patients. Of the 52 patients with a mean age of 70.5(65-76), 32 were male and 20 female. Postoperative pathological examination confirmed that 24 patients suffered from Vater,s ampullary and duodenal cancers, 16 from pancreatic carcinoma and 12 from cholangiocarcinoma. Results The mortality was 7.7%. Severe complications included bleeding (upper gastrointestinal tract or abdominal cavity),MOF, ARDS, postsurgical gastroparasis syndrome(PGS), mental disorder, pancreaticogastrostomy leak and biliary-enteric anastomotic leak et al. Conclusion MOF is the main lethal complication. Incidence of PGS and mental disorder is high.     

Cesarean section in a morbidly obese parturient with borderline personality disorder under combined spinal and epidural anesthesia

A 21-year-old morbidly obese parturient with a body mass index of 45.5 kg x m(-2) underwent an emergent cesarean section for obstructed labor under combined spinal and epidural anesthesia. At age 15, she was diagnosed as borderline personality disorder. In spite of the drug therapy, her mental status was unstable. During anesthesia and surgery, her psychiatrist attended beside her to ease her anxiety and mental stress. An experienced anesthesiologist encouraged her and maintained her in the sitting position during epidural catheterization and spinal puncture. The distance between the skin and the epidural space was about 6.5 cm at the L3-4 interspace via midline approach. An epidural catheter was inserted 5 cm cephalad. Subsequently, the L4-5 subarachnoid space was accessed at a depth of about 7.0 cm. A 3 ml bolus of 0.5% hyperbaric bupivacaine was given. The anesthetic level was T4 at the start of the operation. Throughout the surgery, sufficient analgesia was obtained and any complication such as severe hypotension or respiratory depression did not develop and her postoperative course was uneventful.     

Delayed onset refractory dystonic movements following propofol anesthesia

Neuroexcitation is an uncommon but well recognized side effect of propofol anesthesia and sedation. We present a patient who, despite an intact mental status and without any preexisting movement disorder, experienced delayed onset of involuntary dystonic movements involving head, neck and shoulder for 11 h following emergence from propofol/nitrous oxide anesthesia.     

Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery

BACKGROUND: Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. METHODS: Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. RESULTS: Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. CONCLUSION: After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.     

鼻唇沟皮瓣修复鼻尖及鼻翼缺损的效果

目的 探讨在鼻尖及鼻翼缺损治疗中应用鼻唇沟皮瓣修复的效果。方法 选取2018年6月-2022年 6月我院收治的82例鼻尖及鼻翼缺损患者作为研究对象,均采用鼻唇沟皮瓣修复术治疗,观察并发症发生 情况及治疗满意度,并对患者治疗前后的生活质量进行比较。结果 82例患者皮瓣成活状况均良好,未出 现静脉回流障碍、皮瓣血供障碍等并发症,治疗满意度为96.34%;治疗后躯体功能、躯体角色、活力、社 会功能、情绪角色、心理健康、总健康评分均高于治疗前,差异有统计学意义（P ＜0.05）。结论 鼻唇沟 皮瓣修复鼻尖及鼻翼缺损的效果良好,可有效改善患者的生活质量,且术后并发症发生几率较小,患者满 意度较高。但由于个体差异不同,手术治疗时还需根据患者自身情况制定科学的、合理的治疗方案。     

The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair

Background: The impact of anesthetic choice on postoperative mortality and morbidity has not been determined with certainty.

Methods: The authors evaluated the effect of type of anesthesia on postoperative mortality and morbidity in a retrospective cohort study of consecutive hip fracture patients, aged 60 yr or older, who underwent surgical repair at 20 US hospitals between 1983 and 1993. The primary outcome was defined as death within 30 days of the operative procedure. The secondary outcomes were postoperative 7-day mortality, postoperative myocardial infarction, postoperative pneumonia, postoperative congestive heart failure, and postoperative change in mental status. Numerous comorbid conditions were controlled for individually and by several comorbidity indices using logistic regression.

Results: General anesthesia was used in 6,206 patients (65.8%) and regional anesthesia in 3,219 patients (3,078 spinal anesthesia and 141 epidural anesthesia). The 30-day mortality rate in the general anesthesia group was 4.4%, compared with 5.4% in the regional anesthesia group (unadjusted odds ratio = 0.80; 95% confidence interval = 0.66-0.97). However, the adjusted odds ratio for general anesthesia increased to 1.08 (0.84-1.38). The adjusted odds ratios for general anesthesia versus regional anesthesia for the 7-day mortality was 0.90 (0.59-1.39) and for postoperative morbidity outcomes were as follows: myocardial infarction: adjusted odds ratio = 1.17 (0.80-1.70); congestive heart failure: adjusted odds ratio = 1.04 (0.80-1.36); pneumonia: adjusted odds ratio = 1.21 (0.87-1.68); postoperative change in mental status: adjusted odds ratio = 1.08 (0.95-1.22).     

前列腺增生电切术配合同期不同碎石术治疗前列腺增生合并膀胱结石的疗效及对其症状积分、生活质量的影响

目的 探讨前列腺增生（BPH）电切术配合同期不同碎石术治疗BPH合并膀胱结石的疗效及对其症状积分、生活质量的影响。方法 以本院2015年12月至2017年6月期间收治的92例BPH合并膀胱结石患者为研究对象。根据患者给予的治疗方式将其分为两组，观察组（经尿道前列腺增生电切术联合钬激光碎石术）46例，对照组（经尿道前列腺增生电切术联合气压弹道碎石治疗）46例。观察患者手术前后前列腺症状国际评分（IPSS）、最大尿流率（Q_max）、残余尿量（RUV）、生理状态、心理状态、主观判断评分情况；统计比较两组患者术后并发症发生情况。结果术前两组患者的IPSS评分、Q_max、RUV、生理状态、心理状态、社会功能状态、主观判断评分比较差异无统计学意义（P>0.05）；术后两组患者的IPSS评分、RUV均低于术前，且观察组患者IPSS评分、RUV与对照组相比明显较低（P<0.05），Q_max、生理状态、心理状态、社会功能状态、主观判断评分与术前相比明显提高，且观察组患者较对照组明显升高，组间差异有统计学意义（P<0.05）。观察组术后并发症发生率与对照组比较，差异有统计学意义（P<0.05）。结论 前列腺增生电切术联合钬激光碎石术治疗BPH合并膀胱结石的疗效显著，术后并发症发生率较低，对患者生活质量有所提高，可推广应用。     

全膝关节置换术前心理状态与术后早期膝关节功能的相关性研究

  目的 探讨全膝关节置换术前患者心理状态与术后膝关节功能的相关性。方法 2010年7至10月接受全膝关节置换且符合纳入标准的骨关节炎患者 111例（155膝）,按照医院焦虑抑郁量表（Hospital Anxiety and Depression Scale,HADS）对术前心理状态进行评估。HADS≥8分（有焦虑、抑郁）者纳入心 理组（21例）,HADS0.05）;与术后6个月膝关节疼痛呈正相关（r=0.613,0.530,0.500,0.473;P0.05）。结论 患者术前的焦虑、抑郁状态对全膝关节置 换术后膝关节功能的恢复有负面影响。