止血带的不同使用方法在膝关节置换术中的研究

目的探讨全膝关节置换术中止血带不同的使用方法的作用。方法2009年9月至2011年6月,对45例骨关节炎患者行单侧膝关节置换手术,根据止血带不同的使用方法分为两组,A组24例,在安装假体前至安装假体后骨水泥硬松开止血带;B组21例,在手术开始至安装假体完毕,骨水泥硬化后松开止血带,术野止血后关闭伤口。观察两组病例的手术时间、术中和术后出血量、术后患肢肿胀情况和术后HSS评分。结果手术时间（t=3．0,P〈0．05）、术中（t=9．2,P〈0．05）和术后（t=13．5,P〈0．05）出血量均有统计学差异,但是总出血量（t=0．6,P〉0．05）间的差异无统计学意义,术后患肢肿胀情况（t=2．3,P〈0．05）两组间差异具有统计学意义。结论减少使用止血带时间可能利于患者早期恢复。     

股动脉穿刺压迫止血带的研发与应用

股动脉穿刺插管后,传统上采用人工压迫止血后加压包扎方式止血,这种方式容易造成穿刺点出血、渗血和血肿形成等并发症.为此有的研究者设计了条形止血带,采用"8"字包扎方法 [1-3].这种方式较传统方法有许多优点,但其在加压包扎过程中需移动患者臀部及下肢,会发生压迫后穿刺点的出血.为有效解决上述问题,笔者自行设计了"十"字形压迫止血带,针对应用"十"字形止血带进行了临床试验,并与传统压迫止血方式进行了比较.     

小儿上肢止血带压力与收缩压和上臂周长的关系

目的探讨小儿上肢止血带的最低有效压力及其影响因素。方法检测260例上肢手术小儿使用止血带最低有效压力，并记录性别、年龄、上臂周长、上臂长度、收缩压等影响上肢止血带压力的诸多因素，测得结果代入多元线性回归方程，计算与止血带压力的关系。结果上肢止血带最低有效压力为17．3～30．4kPa（128—228mmHg），与收缩压和上臂周长的关系密切。三变量之间的关系：Y=0．5X＋3Z＋37（Y：上肢止血带压力；X：收缩压；Z：上臂周长）。结论小儿收缩压和上臂周长与上肢止血带关系密切（呈正相关）。小儿上肢止血带压公式：Y=0．5X＋3Z＋37能计算出不同年龄、不同体质小儿最低有效止血压力。     

盐酸戊乙奎醚对下肢手术患者松止血带后血清白细胞介素-6和肿瘤坏死因子-α浓度的影响

目的 观察盐酸戊乙奎醚预先给药对下肢手术患者松止血带后血清白细胞介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)浓度的影响.方法 择期行单侧下肢手术且术中应用止血带患者30例,ASA分级Ⅰ～Ⅱ级,将患者按随机数字表法分为对照组和研究组,每组15例.麻醉前30 min,研究组静脉滴注盐酸戊乙奎醚0.01～0.02 mg/kg,对照组静脉滴注相应体积的0.9％氯化钠.于止血带充气前即刻(T0)、松止血带前即刻(T1)、松止血带后30 min (T2)、松止血带后60 min(T3)抽取非患侧肢体外周静脉血,采用酶联免疫吸附法测定血清IL-6和NF-α的浓度.结果 两组松止血带后相同时间点血清 TNF-α变化量比较差异无统计学意义(P＞0.05);研究组松止血带后各时间点血清IL-6浓度均较T0下降,对照组均较T0上升,研究组与对照组T3与T0的血清IL-6浓度差比较差异有统计学意义[(-8.8±5.6)ng/L比(10.2±6.7) ng/L,P＜ 0.05].结论 盐酸戊乙奎醚预先给药能够降低下肢手术患者松止血带后血清IL-6浓度.     

锁骨骨折内固定术中应用可吸收止血绫的疗效研究

【目的】研究锁骨骨折切开复位内固定术中应用可吸收止血绫（S-100）的临床疗效。【方法】选取自2014年2月至2015年3月间本院收治的共计52例锁骨骨折患者,男38例,女14例;平均年龄44．5岁（22～78岁）。随机将患者分为试验组（采用S-100可吸收止血绫加常规方法止血）和对照组（采用常规方法止血）,每组各26例。所有患者术后临床观察2周,并出院后每月复查至术后3个月。术后2周内观察愈合过程中伤13引流、分泌物细菌培养和伤口组织恢复情况,并进行肩关节Constant评分。【结果】试验组术后平均伤13引流量为（8．3±3．6）mL,明显低于对照组的（20．2±4．3）mL,差异有统计学意义（P〈0．05）。试验组手术区域周围软组织出现充血肿胀、渗出2例（7．69％）,明显低于对照组的9例（34．6％）,差别有统计学意义（P〈0．05）。对照组发生术后感染1例,培养出金黄色葡萄球菌,试验组未发生伤13感染;术后3个月出现颈肩部疼痛,试验组1例,对照组2例并伴僵硬。试验组肩关节Constant评分优良率分别为96．2％（25／26）,但与对照组92．3％（24／26）比较差异无统计学意义（P〉0．05）。【结论】锁骨骨折内固定术中应用可吸收止血绫可减少术野渗血,避免伤口感染,并能促进伤口及周围软组织及关节功能的恢复。     

喷他佐辛对止血带致下肢缺血/再灌注后心肌肌钙蛋白Ⅰ的影响

目的 观察喷他佐辛对下肢缺血/再灌注(ischemia/reperfusion,I/R)后心肌肌钙蛋白Ⅰ(cardiac troponin Ⅰ,cTnⅠ)的影响及其与降钙紊基因相关肽(calcitonin gene-related peptide,CGRP)的关系. 方法 选取择期在蛛网膜下腔麻醉下行单侧下肢骨科手术使用止血带患者60例,按照随机数字表法分为对照组(C组)和喷他佐辛组(P组),每组30例.止血带充气前P组患者给予喷他佐辛0.5 mg/kg静脉滴注,C组在相同时刻给予等量生理盐水.在止血带充压前(To)及止血带释压后0.5 h(T0、24 h(T2)时采集输液对侧肘静脉血5 nl,采用ELISA法检测血清中cTnⅠ和CGRP的含量. 结果 两组患者一般资料比较,差异无统计学意义(P＞0.05).与To时cTnⅠ[(0.2 1±0.06)μg/L]比较,C组cTnⅠ在T1时无明显变化(P＞0.05),在T2[(0.28±0.10) μg/L]时明显升高(P＜0.05),P组cTnⅠ在T1、T2时无明显变化(P＞0.05);与To时CGRP[(16.9±2.2) ng/L]比较,C组CGRP在T1、T2时均无明显变化(P＞0.05),P组CGRP在T1[(17.9±2.7) ng/L]、T2[(18.8±2.8) ng/L]时均明显升高(P＜0.05).与C组在T1、T2时cTnⅠ[(0.23±0.12)、(0.28±0.10) μg/L] 、CGRP[(16.9±1.9)、(16.7±2.6) ng/L]比较,P组的cTnⅠ在T1时无明显变化(P＞0.05),T2[(0.22±0.06) μg/L]时明显降低(P＜0.05),P组的CGRP在T1、T2时均明显升高(P＜0.05). 结论 喷他佐辛可以减轻下肢使用止血带诱发I/R后的cTnⅠ升高,可能与内源保护性神经肽CGRP有关.     

Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff �C a questionnaire study

INTRODUCTION

Pneumatic tourniquets are used frequently in orthopaedic theatres to provide a bloodless field whilst operating on the extremities. Their use has given rise to complications and preventable damage due to over-pressurisation and prolonged application. We designed a questionnaire to assess the knowledge on tourniquet use among operating department assistants (ODAs) and specialist registrars (SpRs) in orthopaedic surgery.

SUBJECTS AND METHODS

A questionnaire was constructed using set guidelines from the Association of periOperative Registered Nurses (AORN) for recommended practice of tourniquet application. This was distributed to orthopaedic registrars with varying levels of experience and ODAs from five different NHS hospitals. The unpaired, two tailed t-test was used to test for statistical significance of results.

RESULTS

A total of 54 completed questionnaires were collected for analysis. The study population included 29 orthopaedic SpRs and 25 ODAs. The mean score for the orthopaedic SpRs as a group was 41.3% (SD 6.85; range, 29.0–54.8%). The mean score for the ODAs was 46.7% (SD 9.64; range, 23.3–62.9%) with a P-value of 0.024.

CONCLUSIONS

Most surgeons are taught how to use pneumatic tourniquets by their senior colleagues as no formal teaching is given. Most of the complications are infrequent and preventable. However, their consequences can be devastating to the patient with medicolegal implications. Our results show suboptimal knowledge of tourniquets and their use among SpRs and ODAs. This study highlights the need for amendments in training to improve the knowledge and awareness of medical practitioners on the application and use of tourniquets to prevent adverse events and improve patient safety.     

止血带与全膝关节置换术肺脂肪栓塞风险的实验研究

目的探讨止血带对全膝关节置换术（TKA）肺脂肪栓塞产生的影响。方法16只杂种犬随机分为两组。实验组：模拟TKA截骨、扩髓,插入髓内杆,术中使用止血带;对照组：术中操作同实验组,术中不使用止血带。术中监测不同时间动脉血气分析、凝血指标和血管内皮损伤指标,术后进行肺脏病理检查并采用病理学评分计算肺损伤程度。结果血气分析监测发现在释放止血带后5min内实验组氧分压下降值高于对照组（P〈0．05）。凝血酶原时间和活化部分凝血活酶时间两组问的差异无统计学意义。术后实验组组织型纤溶酶原激活物低于对照组（P〈0．05）,血管性血友病因子和血栓调节蛋白均高于对照组（P〈0．05）。肺损伤总分实验组高于对照组（5．6±2．3）υs（3．2±1．4）,（P〈0．05）。结论TKA术中使用止血带可能损伤血管内皮,止血带释放时可能干扰呼吸系统功能,增加肺脏脂肪栓塞的发生风险。     

Femoral,saphenous nerve palsy after tourniquet use: a case report

Persistent motor and sensory abnormalities after surgery may affect the rehabilitation process. Patients with continued weakness may be perceived as lacking motivation by health care providers. However, there may be an underlying pathophysiologic abnormality preventing patients from progressing through their rehabilitation programs. We report a case of a 20-year-old man who underwent surgical repair of multiple knee structures with the use of a pneumatic tourniquet. Several weeks after surgery, electromyographic evaluation was done because he was having difficulty in his rehabilitation because of persistent weakness. An electromyography and nerve conduction study (NCS) revealed femoral and saphenous nerve palsies. Our report is the first on tourniquet-induced saphenous nerve injury as well as on abnormal femoral NCSs caused by tourniquet use. A review of the literature indicates that tourniquet-induced nerve palsies are not a rare event. Further evaluation should be considered if patients who are having persistent weakness or sensory findings after surgery have used a tourniquet.