胃食管折迭术治疗食管静脉曲张出血

目的解决门脉高压食管静脉曲张出血断流术后复发和再出血问题。方法用贲门周围血管离断加Ｎｉｓｓｅｎ氏胃底成形术治疗门脉高压并食管静脉曲张出血６０例。结果急症手术全部立即止血。术中食管测压１０例，包裹折迭部压力在４．０～５．３３ｋＰａ之间；术后食管测压３６例，食管下段压力范围为２．５３～４．６７ｋＰａ，平均３．５３±０．５５ｋＰａ。出院的５５例术后随访３个月至１０年，仅２例再出血。结论只要正确掌握折迭缝合的松紧度，本术式是一种治疗门脉高压食管静脉曲张出血的有效方法。     

经皮肝穿胃左静脉栓塞联合部分脾栓塞术治疗门脉性上消化道出血

目的探讨经皮肝穿胃左静脉栓塞联合部分脾栓塞术治疗门脉性上消化道出血的临床效果。方法分析25例门脉高压引起的上消化道大出血患者资料,经皮肝穿刺门静脉,造影确认胃左静脉后经导管注入无水酒精栓塞食管胃底曲张静脉,再用钢圈栓塞胃左静脉主干。采用Seldinger’s技术穿刺右侧股动脉行部分脾栓塞术。术后1个月随访观察患者临床症状改善情况、外周血象、门脉压力变化和有无并发症等。结果25例患者全部栓塞成功,即时止血率达100％,上消化道出血症状消失,临床症状减轻,外周血象改善,白细胞及血小板数量增加,门脉压力减低,术中、术后均未出现严重并发症。结论经皮肝穿胃左静脉栓塞联合部分脾栓塞术治疗门脉性上消化道出血创伤较小,即时止血效果好,是一种安全有效的治疗方法。     

Postpartum Cerebral Angiopathy Mimicking Hypertensive Putaminal Hematoma: A Case Report

Objective: To present an emerging clinical entity which may mimick another common entity. Methods: A 31 year-old woman complained of sudden severe headache and collapsed. She had delivered by Cesarean section one week previously. She had a normal antenatal history and did not have any evidence of hypertension. Results: Clinical examination revealed her to be in altered sensorium, GCS E2V2M5 with reduced movements on the left side. CT scan showed a large right putaminal hematoma with mass effect and midline shift. MRI also showed the hematoma but the MRV was normal. Despite antiedema measures and hyperventilation, the patient continued to deteriorate and so underwent right hemicraniectomy. MRA was done postoperatively and showed diffuse spasm of both middle cerebral arteries. A diagnosis of postpartum cerebral angiopathy was made and she was put on methylprednisolone and other antiedema measures were continued. With this she improved significantly. At one year she had residual hemiparesis but had returned to work. Four-vessel angiogram repeated 1 year later showed no arterial spasm. She later had cranioplasty to cover the defect. Conclusions: This case is presented to show that in a postpartum patient, if she presents with putaminal hematoma, postpartum angiopathy needs to be suspected and appropriate investigations and treatment, including steroids, should be given as the overall prognosis is good.     

Removal of the Prehospital Tourniquet in the Emergency Department

BackgroundLife-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place.DiscussionAn interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient.ConclusionThese steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.     

左旋18-甲基炔诺酮用于药物流产后出血50例观察

目的探讨左旋18-甲基炔诺酮对改变药物流产后出血量的作用。方法将100例药物流产后B超证实无宫内残留的40岁以下妇女,随机分为试验组、对照组,比较不同用药对出血时间及出血量的影响。结果药物流产后应用左旋18-甲基炔诺酮者出血时间及出血量、月经周期恢复时间与对照组间差异均有显著性意义(P<0.05)。结论左旋18-甲基炔诺酮对药物流产后阴道出血时间长、出血量多有很好的治疗作用,从而减少生殖道感染机会,同时起到调节女性内分泌功能的作用。     

关节置换手术低分子肝素预防深静脉栓塞使用时机的初步研究

目的探讨低分子肝素预防深静脉栓塞（deep vein thrombosis,DVT）的使用时机。方法单侧初次关节置换164例,其中全髋关节置换术（totalhip replacement,THR）103例,术前开始使用低分子肝素32例,术中开始使用28例,术后43例;全膝关节置换术（totalknee replacement,TKR）61例,术前开始使用低分子肝素23例,术中开始使用16例,术后开始使用22例。比较DVT的发生率,并引入隐性失血量,计算总失血量,评价安全性。结果①THR患者术前开始使用低分子肝素组总失血量平均为1626ml,术中开始使用组平均为1857ml,术后开始使用组平均为1366ml;TKR患者术前开始使用组失血量平均为1530ml,术中开始使用组平均为1780ml,术后开始使用组平均为1258ml。比较THR和TKR术前开始使用与术中、术后开始使用低分子肝素三者的总失血量均有统计学意义。②术前使用组DVT的发生率为20.0%,术中使用组DVT发生率为18.2%,术后使用组DVT发生率为24.6%,差异无统计学意义。结论术前和术中使用低分子肝素预防DVT有效,但出血量明显增多;术后使用低分子肝素失血量少,且DVT的发生率和术前、术后使用低分子肝素效果相当。     

mPCNL并发出血的原因及防治

目的：总结微创经皮肾镜取石（mPCNL）术中、术后出血的发生原因及其预防和处理方法。方法：回顾性分析本院2005年7月～2009年10月57例次mPCNL术并发术中、术后出血患者的临床资料。结果：本组患者并发术中出血43例,其中38例经处理出血停止,继续手术,5例活动性出血,予放置肾造瘘管,改行二期mPCNL;术后出血14例,其中8例经夹闭造瘘管,绝对卧床及使用止血药后出血停止,3例经穿刺窦道Foley’s管球囊压迫止血后成功止血,2例行介入治疗栓塞出血血管,1例予缝扎造瘘口2针后出血停止。结论：mPCNL是一种安全、有效的微创手术,但有可能术中、术后出现严重出血的并发症,预防和处理的关键为合理选择患者、操作轻柔、严密观察病情、及时恰当处理。     

去氧孕烯炔雌雌醇片隆用于药物流产后临床观察

目的探讨妈富隆用于药物流产后的临床效果。方法对2007年3月至2007年9月药物流产患者随机分为2组,服妈富隆为实验组138例,服益母草为对照组148例,对两组进行对照分析。结果实验组及对照组平均出血天数为（9.6±6.7）d、（15.2±7.8）d,P〈0.01,出血量比月经量多者分别占10.29%、20.42%,出血量比月经量少分别为7.35%、3.52%,完全流产、不全流产、失败率分别为97.1%、1.45%、1.45%,91.22%、6.76%、2.02%,月经复潮时间（26±4.6）d、（33±7.5）d。结论妈富隆可以减少药流后出血时间及出血量,减少不全流产率,促进卵巢功能恢复。     

外伤性脾破裂合并腹腔内大出血急诊手术的护理配合

目的:探讨外伤性脾破裂出血并腹腔内大出血急诊手术的配合。方法:回顾69例外伤性脾破裂并腹腔内大出血患者资料,应用气管插管全麻64例、硬膜外麻醉5例,并对术前、术中护理配合进行总结。结果:本组病例中,真性脾破裂64例,被膜下破裂5例,行全脾切除术64例,全脾切除加自体脾片移植术1例,69例均经手术治疗全部抢救成功。结论:在手术过程中,医护密切配合是手术成功的重要保证。     

生长抑素垂体后叶素治疗食管静脉曲张破裂出血的疗效观察

目的 比较生长抑素和垂体后叶素治疗肝硬化患者急性食管静脉曲张破裂出血的疗效和安全性.方法 生长抑素8肽(奥曲肽Octreotide成都天台山制药有限公司)组30例,静推0.1mg后,然后以每小时25ug 静脉滴注,维持48小时.垂体后叶素组28例,垂体后叶素30u最初10分钟之内,每分钟1u,其后每分钟0.1u维持静滴3～4天.观察两种药物的止血率,再出血率和副作用.结果 生长抑素8肽组治疗有效率(90.00%),垂体后叶素组有效率(64.30%);两组再出血率分别为13.30%和39.30%.垂体后叶索组副作用发生率为46.40%,生长抑素8肽无明显副作用.结论 生长抑素8肽是治疗急性食管静脉曲张破裂出血的一线有效药物.