全膝关节置换后不放置引流的相关管理策略

背景:近年来,随着全膝关节置换技术提升、手术时间缩短、术中及术后止血药的应用,其总失血量不断减少,术后引流量也逐渐减少,术后快速康复理论应运而生,引流管放置也再次成为骨科医生所热议的问题,越来越多的医生认为可以常规取消放置引流,引流似乎已可有可无。目的:旨在复习既往文献,对全膝关节置换后引流放置的相关问题归纳总结,提供围术期引流管理的相关经验。方法:检索中国知网、万方、维普、中国生物医学文献数据库等中文数据库,以及PubMed、The Cochrane Library、WebofScience、EMBASE、OVID等外文数据库,以"引流,膝关节置换术"及"totalknee arthroplasty,drainage"为检索词,检索自建库始至2020年2月为止所有与主题相关的文献,总结归纳全膝关节置换后不放置引流管围术期各方面需综合考虑的要素。结果与结论:①引流管的放置问题关乎全膝关节置换手术的最终结果,与术后出血、血肿、血栓、感染等并发症的发生关系密切;②目前全膝关节置换术后不推荐常规放置引流,但不意味着不需要管理,其实际上对临床医护在围术期各方面的管理提出更高的要求,包括但不限于术前适应证选择、手术操作、止血带使用、术中及术后药物使用、物理疗法的使用等。     

Perivascular Drainage of Amyloid-β Peptides from the Brain and Its Failure in Cerebral Amyloid Angiopathy and Alzheimer's Disease

Alzheimer's disease is the commonest dementia. One major characteristic of its pathology is accumulation of amyloid-β (Aβ) as insoluble deposits in brain parenchyma and in blood vessel walls [cerebral amyloid angiopathy (CAA)]. The distribution of Aβ deposits in the basement membranes of cerebral capillaries and arteries corresponds to the perivascular drainage pathways by which interstitial fluid (ISF) and solutes are eliminated from the brain—effectively the lymphatic drainage of the brain. Theoretical models suggest that vessel pulsations supply the motive force for perivascular drainage of ISF and solutes. As arteries stiffen with age, the amplitude of pulsations is reduced and insoluble Aβ is deposited in ISF drainage pathways as CAA, thus, further impeding the drainage of soluble Aβ. Failure of perivascular drainage of Aβ and deposition of Aβ in the walls of arteries has two major consequences: (i) intracerebral hemorrhage associated with rupture of Aβ-laden arteries in CAA; and (ii) Alzheimer's disease in which failure of elimination of ISF, Aβ and other soluble metabolites from the brain alters homeostasis and the neuronal environment resulting in cognitive decline and dementia. Therapeutic strategies that improve elimination of Aβ and other soluble metabolites from the brain may prevent cognitive decline in Alzheimer's disease.     

Post-traumatic epidural hematoma in two patients with long-standing “arrested” hydrocephalus

The occurrence of a post-traumatic epidural hematoma in two patients with long-standing arrested hydrocephalus is reported. There was a relatively long interval between the head injury and the onset of symptoms. The large hematoma was accommodated by the decrease in size of the markedly dilated ventricles. This report stresses the possibility of the presence of an epidural hematoma in the management of head injury in patients with long-standing arrested hydrocephalus.     

A contribution to the pathogenesis of respiratory disturbances associated with subarachnoid haemorrhage; an experimental approach using an animal model

Summary The present experimental work focuses on the mechanisms involved in respiratory distress observed in the course of subarachnoid haemorrhage. For this purpose, respiratory disturbances were induced in rabbits by injecting fresh autologous blood into the subarachnoid space. For six hours after this artificially induced SAH, blood PO₂ and PCO₂ as well as expiratory air CO₂ were regularly determined, while during the same period cerebral blood flow and cerebrospinal fluid pressure measurements were recorded.The results of this study suggest that pressure effects acting the brain structures that support respiration are principally involved in the pathogenesis of respiratory disturbances following SAH. A decrease in CBF and hypoxia with hypercapnia play a contributing secondary role adding to a vicious cycle phenomenon.     

Thoracic duct lymph and PEEP studies in anaesthetized dogs

PEEP impedes thoracic duct drainage (LF). This can be counteracted by a thoracic duct fistula. Consequently, lung oedema (LOE) should develop during PEEP more slowly with LF at atmospheric pressure (LF_AP) than with LF against jugular venous pressure (LF_JVP). In 12 anaesthetized dogs LOE was produced by Ringer's solution i.v. (2.5 ml/min per kg) for 6 h during PEEP (10 mmHg) with either LF_AP or LF_JVP. Ringer's+PEEP greatly increased aortic, pulmonary artery and wedge pressures, JVP, and cardiac output. Colloid osmotic pressures in plasma and lymph were drastically reduced, pulmonary effective filtration pressure (EFP) rose by about 20 mmHg. LF_JVP increased 7-fold, LF_AP about 19-fold, the respective loss of plasma proteins was 1.83 and 1.06 g/kg during 6 h. Thermal-dye extravascular lung water showed an increment of 68 with LF_JVP versus 43 l/h/g per mmHg with LF_AP. Final lung water content was at any EFP (12.8–31.9 mmHg) lower with LF_AP than with LF_JVP amounting 512 with LF_JVP versus 377 l/g/per mmHg with LF_AP. LF_AP decreased the development of LOE during PEEP by bypassing the PEEP-induced high JVP and thus facilitating the removal of interstitial fluid. It is hypothesized that a thoracic duct fistula might aid the treatment of patients with LOE due to ARDS and therefore requiring high levels of PEEP.     

肝脓肿治疗模式的临床研究

目的探讨肝脓肿的治疗方式和减少并发症的途径。方法对117例肝脓肿的各种治疗方法进行回顾性总结。结果非手术治疗12例,经腹切开引流46列,B超引导下经皮穿刺抽脓或置管引流59例,全部治愈。介入超声治疗组术后平均住院日比手术引流组少6.2d(P<0.01),并发症明显减少(P<0.01)。结论经皮穿刺抽脓或置管引流术简便、安全、住院时间短、费用少,并发症和病死率低,可用于治疗大多数肝脓肿。     

脑室出血的治疗

目的探讨脑室出血的治疗方法。方法选择原发性脑室出血19例,继发性脑室出血21例,其原发出血灶血肿量严格限制在30ml以下,全部病人均采用双侧侧脑室双腔管引流,尿激酶脑室灌注及间断腰穿放液。结果死亡7例,死亡率17．5％,明显低于内科治疗80％的死亡率。结论双腔管双侧脑室引流尿激酶脑室灌注和间断腰穿放液等为目前治疗脑室出血的较为有效的方法。     

急性后颅窝血肿的微创穿刺术治疗

目的：探讨应用IL－2型特种针进行微创穿刺术治疗后颅窝血肿的可行性及临床应用。材料及方法：回顾性分析我们自1995年9月至1999年9月对28例后颅窝高血压性或外伤性脑内血肿及硬膜外血肿进行微创穿刺引流治疗的病例。结果：28例病例中除1例于穿刺成功后死于脑干功能衰竭外,其余病例均获成功,病人无后遗症,痊愈出院,其中1例伴发再出血,经血肿腔内止血药冲洗引流治疗再出血停止,结论：此穿刺针特点为针钻一体,解决了针在颅骨上固定问题,也解决了立体定向不能留置针管问题,微创穿刺方法治疗后颅窝血肿可避免传统后颅窝开颅手术,安全性高,疗效良好,操做简便,费用较低,易于在各级医院普遍开展,具有较大推广使用价值。     

Hematoma subdural intracraneal tras punción dural accidental: caso clínico

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.     

胆总管探查内置自行脱落J管一期缝合与T管引流治疗胆总管结石的临床分析

目的 比较腹腔镜胆总管探查放置自行脱落J管一期缝合与T管引流的临床疗效,探讨胆总管一期缝合放置自行脱落J管引流的可行性。方法 回顾性分析2019年3月至2020年10月西安交通大学附属咸阳市中心医院肝胆外科156例行腹腔镜下胆囊切除联合胆总管探查患者的临床资料。按手术方式分为自行脱落J管组（n=80）和T管引流组（n=76）,比较两组患者基线资料、术中术后情况及并发症等。结果 两组手术总时间、术中出血量、术后并发症情况无统计学差异（P＞0.05）。自行脱落J管组较T管引流组术后下床活动时间[（18.2±7.2）h vs（22.1±8.3）h,t=3.139,P=0.002]、术后排气时间[（1.7±0.9）d vs（2.1±1.3）d,t=2.244,P=0.026]、补液总量[（5 634.1±432.8）mL vs（6 351.4±547.9）mL,t=13.56,P＜0.001]、拔管时间[（8.7±3.3）d vs（47.1±13.0）d,t=14.966,P＜0.001]、住院时间[（7.9±2.8）d vs（9.4±3.3）d,t=3.067,P=0.003]、住院总费用[（15 489.2±2 217.1）元 vs（18 136.4±2 251.3）元,t=7.398,P＜0.001]差异有统计学意义。结论 严格掌握手术适应证前提下,自行脱落J管引流扩大了胆总管一期缝合适应证,安全有效,相比T管引流具有加速康复、减少住院费用、缩短住院时间等优势。