经颈外静脉置入中心静脉导管术体位探讨

经外周静脉置入中心静脉导管(PICC)作为一种成熟、安全的中心静脉置管技术,近年来在国内逐渐推广和普及[1]。PICC适用于中长期静脉输液、肿瘤化疗、肠外营养及反复采血、输入血制品等。有文献报道,采用经肘部静脉(贵要静脉、肘正中静脉及头静脉)进针,有一部分病人尤其是女性病人,特别是乳腺癌术后以及幼儿病人肘部静脉状况差,缺乏可选择插管的静脉,     

三种不同经外周置入中心静脉导管固定方法临床效果的比较

目的 比较3种不同的经外周静脉置人中心静脉导管(PICC)固定方法对导管固定的临床效果.方法 将120例留置PICC导管患者采用便利抽样的方法分为3组,每组各40例,分别采用缝合固定(A组)、免缝胶带交叉固定(B组)和思乐扣免缝导管固定装置固定(C组).观察并比较3组患者置管后留置期间导管固定的牢固性、并发症发生率、固定部位皮肤损伤情况及患者的满意度.结果 B组导管移位的发生率(57.5%)明显高于A组(12.5%,P=0.000)和C组(7.5%,P=0.000),导管脱出的发生率(15.0%)亦明显高于A组(0,P=0.034)和C组(0,P=0.034).导管留置期间静脉炎的发生率在B组(25.0%)明显高于A组(7.5%,P=0.034)和C组(5.0%,P=0.012);在A组中并发穿刺部位蜂窝织炎的发生率明显高于C组(20.0%比2.5%,P=0.034).A组患者出现固定翼下的皮肤压痕的发生率(37.5%)明显高于B组(5.0%,P=0.000)和C组(5.O%,P=0.000),且A组患者皮肤破损的发生率(22.5%)也高于B组(5.0%,P=0.023)和C组(0,P=0.005);各种原因所致的皮肤刺激痛在A组(52.5%)中明显增加,高于B组(0,P=0.000)和C组(2.5%,P=0.000).患者对3组不同导管固定法的满意度在A组(12.0%)显著低于B组(62.5%,P=0.000)和C组(90.0%,P=0.000),且C组满意度最高,明显高于B组(P=0.004).结论 思乐扣免缝导管固定装置固定法可以作为胶带和缝合固定的替代,具有等同于缝合法对导管的固定作用,预防了导管移位、脱出等导管相关并发症,同时也避免了缝合固定造成的皮肤损伤.

Abstract：

Objecfive To compare the clinical effectiveness of three different fixation methods for peripherally inserted central catheter(PICC).Methods Totally 120 patients requiting PICCs were randomized into suture securement group(group A),tape securement group(group B),and sutureless adhesive-hacked device (StatIock)securement group(group C),with 40 patients in each group.Patients were followed up throughout their entire catheter course,and the securement effectiveness,catheter-related complications,risk of skin injury,and patients'satisfaction were observed.Results The rate of catheter migration without function loss in group B (57.5%)was significantly higherthan in group A(12.5%,P=0.000)and in group C(7.5%,P=0.000).Catheter dislodgment rate in group B(15.0%)was also significantly higher than group A(0,P=0.034)and group C(0,JP=0.034).Phlebitis documented during their catheter course in group B(25.0%)were more than in group A(7.5%,P=0.034)and in group C(5.0%,P=0.012).In addition,the rate of cellulitis in group A was significantly higher than group C(20.0%vs.2.5%,P=0.034).The rate of skin injury in group A 0.005).Nearly half of patients in group A (52.5%)complained irritation and/or pain at the sucure site,which was significantly higher than in other two groups ( both P = 0.000 ).The patients' satisfaction rate was significantly lower in group A (12.0% ) than in the other two groups ( both P = 0.000), documented highest in group C (90.0%) (group C vs.group B, P = 0.004).Conclusions The availability of sutureless adhesive-backed de vice StatLock provides an alternative for securement of PICCs.It performs as well as suture securement in catheterfixing.Meanwhile, it can prevent catheter-related complications such as migration and dislodgment Furthermore, it avoids skin injuries during catheter fixation or securement.     

门诊与入院量动态发展变化分析

目的探讨医院门诊量与入院人次的动态发展变化规律。方法对近某院门诊量及入院人次的季节性和发展趋势进行分析。结果各月门诊与入院人次的就诊规律有明显的波动变化,门诊与住院工作量的呈上升趋势。结论应根据医院门诊和住院工作量的变化,合理安排卫生人力和医疗物资供应。     

七氟烷或丙泊酚复合瑞芬太尼麻醉在重症肌无力患者胸腺切除术中的应用

目的 探讨七氟烷或丙泊酚复合瑞芬太尼麻醉在重症肌无力患者经胸骨正中切口胸腺扩大切除术中的应用,并比较其效果.方法 搜集2008年7月—2011年6月于解放军309医院麻醉科行胸骨正中切口胸腺扩大切除术的重症肌无力患者156例,分为2组,其中应用靶控静脉输注丙泊酚和瑞芬太尼麻醉(P组)80例,应用吸入七氟烷复合静脉输注瑞芬太尼麻醉患者(S组)76例,均不加用肌松药.采用4个成串刺激(TOF)检测神经肌肉传递功能.以手术开始(切皮)前作为0时点,每30min记录1次各规定时间点的血流动力学变化,以及基础状态下与拔管后的血气分析及呼吸频率等指标,直至麻醉结束,同时记录麻醉时间、手术时间、清醒时间、麻醉恢复室(PACU)停留时间、拔管时间、输入液体及瑞芬太尼总量.结果 两组患者在不使用肌松药的情况下均顺利完成手术,S组手术开始后各时间点TOF值均明显低于P组(P＜0.05).手术后,P组pH值和PaCO2较S组显著升高(P＜0.05),PaO2则显著降低(P＜0.05).在患者清醒时间、拔管时间、PACU停留时间及瑞芬太尼用量的比较上,S组明显低于P组(P＜0.05).两组患者在血流动力学及脑电双频指数(BIS)、手术时间、麻醉时间、输入液体总量上差异无统计学意义(P＞0.05).结论 重症肌无力患者接受胸骨正中切口胸腺扩大切除术时,在不使用肌松药的情况下,应用七氟烷或丙泊酚复合瑞芬太尼麻醉安全有效.七氟烷复合瑞芬太尼对神经肌肉传递功能的抑制更具有优势,对术后呼吸功能的影响更小.     

超声诊断胎儿脑膜脑膨出合并羊膜带粘连1例

患者女,24岁,停经3月余,自测HCG(+),近来恶心、呕吐明显,伴下腹部隐痛不适,无阴道流血.二维超声:胎头位于中腹部,双顶径2.74 cm,脑中线清晰,枕部颅骨可见强回声光环连续性中断,中断处宽约1.04 cm,可见一类圆形以无回声为主囊实性团块从中断处突入羊水(图1),约2.18 cm×1.52 cm,内部及周边未探及明显血流信号;羊水中可见膜状强回声带缠绕于左上肢;胎盘位于后壁及左侧壁,厚度1.8 cm,胎盘成熟度0级;羊水暗区最大深度4.1 cm,内透声清;胎儿脐动脉多普勒阻力指数0.88,A/B 8.38;三维超声示脑膜脑膨出(图2).     

糖尿病乳酸酸中毒昏迷1例

患者,女,41岁,主因发现血糖升高7年,恶心呕吐、发热4天,意识不清6小时,于2010年11月7日12：00入院。患者7年前无意中发现血糖升高（具体不详）,诊断为＂糖尿病＂,一直服用＂苯乙双胍25-50 mg,每日2次＂,根据尿糖调整药物剂量,未监测血糖。4天前无诱因出现恶心呕吐,呕吐物为胃内容物,伴发热（体温38.3℃）,     

超声诊断创伤性动静脉瘘

目的:探讨彩色多普勒超声在创伤性动静脉瘘诊治中的应用价值。方法:回顾性分析10例创伤性动静脉瘘患者的灰阶和彩色多普勒超声图像,包括动静脉瘘瘘口发生位置、瘘口大小及形态、受累静脉增宽程度、动静脉内血流表现、动静脉瘘分流的血流峰值流速、受累动脉近心端和远心端的血流频谱变化,受累静脉内频谱表现,并与手术结果或磁共振对比。术后检查,注意观察动静脉瘘口是否闭合,瘘口处动静脉的灰阶图像及血流表现。结果:动静脉瘘超声定性诊断率100%(10/10),瘘口位置诊断准确率100%(10/10),血流频谱的特异性表现为瘘口处高速、低阻及双期单向连续性血流,受累静脉内出现动脉样频谱。术后检查瘘口闭合(9/9,100%),原受累静脉内未探及动脉样频谱。结论:多普勒超声诊断动静脉瘘具有无创、简便、易行且准确率较高的优点,并具有较高的临床应用价值。     

后程三维适形放疗联合紫杉醇化疗治疗老年人乳腺癌伴脑转移癌的临床观察

Objective To evaluate the efficacy and adverse reaction of three-dimensional conformal radiation therapy (3D-CRT) combined with chemotherapy of paclitaxel in treatment of brain metastases from breast cancer in the elderly.Methods The 50 patients were randomly divided into observation group (n=26,radiation combined with chemotherapy) and control group (n= 24,simple radiation).In the early stage,both groups received common two-dimesional conformal radiation therapy.The total dose (DT) of whole brain irradiation was 30-40 Gy.In the later stage,the reduced field for the local lesion of brain metastases would be altered to 3D-CRT for the post period with 2 Gy 5 times a week.DT was added from 10-24 Gy up to total DT of 50-64 Gy.The patients were given paclitaxel 65-85 mg/m2 by intravenous drip at 1st and 8th day with synchronization of 2-4 weeks,having paclitaxel chemotherapy of 2-4 circle,28 days a circle.After 2 month treatment,the efficacy and adverse effects of the two groups were observed.follow up for 2 years,the long-term efficacy and survival rate were evaluated.Results The effective rate was 76.9% in observation group and 45.8% in control group,respectively (x2 =5.120,P＜0.05) and the KPS score was 80.8% and 54.2%,respectively.The quality of life was improved in observation group versus control group (x2 =4.059,P＜0.05).Compared with control group,hypoleukemia was significant in observation group (P＜0.05).The complications such as nausea and vomiting,hepatic dysfunction were more in observation group than in control group,but there was no statistical significance between two groups.There was statistic ally significant difference in 2-year survival rate between two groups (x2= 4.7260,P＜0.05).Conclusions The 3D-CRT combined with paclitaxel chemotherapy is a prefered choice for locally advanced brain metastases from breast cancer.More side effects and adverse reaction are observed in observation group.However,all the patients could tolerate them.It is worthy of popularization and application.     

原发性甲状腺机能减退症48例误诊分析

近年来,我院收治原发性甲状腺机能减退症（甲减）患者82例,其中误诊48例（占58．5％）。现将误诊原因分析如下。 临床资料：本组48例患者中,男8例、女40例,年龄28～70岁、平均42岁。有甲减症状38例,无甲减症状10例。     

2011年度医疗体系部队离退休及现职干部代谢综合征体检资料分析

<正>代谢综合征(metabolic syndrome,MS)是一组复杂的代谢紊乱症候群,是导致糖尿病、心脑血管疾病的危险因素,其集中发生可能与胰岛素抵抗有关。随着人类社会文明的发展,生活方式的改变,代谢综合征已成为当前影响人类健康的主要疾病之一。如何有效进行健康管理,预防干预,控制疾