人工气腹术治疗肺叶切除术后胸内残腔的护理

目的探讨人工气腹术治疗肺叶切除术后胸内残腔的护理措施。方法对389例行人工气腹术治疗肺叶切除术后胸内残腔的患者术前加强心理护理，完善术前准备；术中密切观察生命体征；术后加强吸痰护理，并保持引流通畅，维持适当的负压吸引，严密观察术后患者可能出现的相关并发症，采取相应措施。结果355例术后1周内胸内残腔消失；33例胸内残腔量〈5％，局部形成干腔；1例2周后胸内残腔量为11％，局部形成干腔。无1例出现严重人工气腹术相关并发症。结论人工气腹术治疗肺叶切除术后胸内残腔可缩短住院日，减少医疗费用，正确的护理配合是促进患者康复的重要保证。     

胸部爆震伤致兔急性呼吸窘迫综合征模型的建立及相关因素分析

目的 构建室内胸部爆震伤致兔急性呼吸窘迫综合征(ARDS)模型并分析其发生机制及早期死亡原因,为研究肺爆震伤早期预警体系和治疗方法提供依据.方法 按照不同炸药量和致伤距离所产生的压强,将60只新西兰大白兔按随机数字表法分为5个致伤组和1个无致伤对照组.伤后观察存活率和组织病理学,并监测病理生理学指标、肺含水量.结果 冲击波压强低于1 210.5 mm Hg(1 mm Hg=0.133 kPa,A、B组)时,肺损伤较轻,表现为点状肺挫伤,肺简明损伤评定分级法(ALS)均在2级内,动物伤后24 h内全部恢复,长期存活无并发症.冲击波压强高于2 036.1 mm Hg(D、E组)时,肺损伤过重,表现为广泛的肺挫伤、肺门撕裂伤和肺内大血肿,AIS均大于5级,动物于伤后1 h内全部死亡.冲击波压强为1 917.3 mm Hg(C组)时,肺表现为广泛而恒定的挫伤,累及4个肺叶以上,AIS 4～5级,伤后6 h内出现动脉氧分压下降;肺组织可见肺泡壁水肿,部分肺泡壁断裂,肺泡融合;肺泡内充满大量炎性细胞,偶见透明膜形成.与对照组比较,C组兔致伤6 h肺湿/干重比值即显著升高(6.46±0.24比3.98±0.19,P＜0.01),血浆及支气管肺泡灌洗液(BALF)中肿瘤坏死因子-α(TNF-α)和白细胞介素-6(IL-6)即明显升高[血浆TNF-α(ng/L):328.89±6.26比62.12±2.98,BALF TNF-α(ng/L):164.87±4.59比29.51±1.12;血浆IL-6(ng/L):128.51±4.13比19.32±1.53,BALF IL-6(ng/L):94.97±1.14比22.72±0.19,均P＜0.05].结论 在1 917.3 mm Hg爆炸压强的密闭环境下,冲击伤可诱导兔发生ARDS;TNF-α及IL-6参与爆震伤致ARDS的形成与发展;特定环境下,肺脏破裂致气胸为早期死亡原因,而冲击波致循环系统功能紊乱也是引起早期死亡的重要原因.

Abstract：

Objective To reproduce acute respiratory distress syndrome (ARDS) model in rabbit induced by chest blast injury and to analyze the pathogenesis and causes of early death in order to provide the basis for the early diagnosis of lung blast injury and its early-warning system to facilitate an early treatment.Methods Sixty healthy New Zealand white rabbits were divided into six groups according to the different explosion distance with the random number table method. The survival rate and its resulting pathological changes were observed and patho-physiological indexes and lung fluid content were determined at sequential time points post-explosion. Results Shock wave pressure less than 1 210. 5 mm Hg (1 mm Hg=0. 133 kPa,group A, B) resulted in limited injury to the lung within grade-2 as assessed with the abbreviated injury scale (AIS). The rabbits in these groups recovered soon and survived without any complication. Shock pressure higher than 2 036. 1 mm Hg (group D, E) caused severe injuries to the lung, including deep laceration, disruption of lung hilus and large hematoma in the lung, and the injury severity of lungs was assessed above grade-5 as assessed with AIS. All rabbits died within 1 hour post-explosion. The groups described above failed to meet the demand of an ARDS model for the present study. Shock wave pressure at 1 917. 3 mm Hg (group C) produced extensive contusion from grade-4 to grade-5 as assessed with AIS. The rabbits survived in poor general condition, and arterial partial pressure of oxygen (PaO2) lowered within 6 hours. Pathological examination showed extensive and constant multi-focal bleeding involving more than four lobes. The alveolar wall was edematous, with partial rupture and alveolar fusion in lung tissues was observed in the group C. Alveoli were filled with inflammatory cells, and hyaline membrane was formed occasionally. Compared with control group, the wet to dry weight ratio (W/D) in lungs increased obviously (6.46±0. 24 vs. 3. 98±0. 19, P＜ 0. 01) in group C within 6 hours postinjury. The contents of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in plasma and bronchoalveolar lavage fluid (BALF) were also increased distinctly compared with the control group [TNF-α (ng/L) in plasma: 328. 89± 6.26 vs.62.12±2. 98, TNF-α (ng/L) in BALF: 164.87±4.59 vs. 29. 51±1.12; IL-6 (ng/L) in plasma: 128. 51±4.13 vs. 19.32±1.53: IL-6 (ng/L) in BALF: 94.97±1.14 vs. 22.72±0. 19, all P＜0. 05]. Conclusion In an airtight environment, rabbit ARDS model can be reproduced successfully by blast injury with 1 917.3 mm Hg explosion pressure; TNF-α and IL-6 are involved in the pathogenesis and development of ARDS in blast injury. Pneumothorax as a result of lung rupture is the chief reason for early death and dysfunction of circulatory system is also an important reason in producing early death.     

开胸术后单侧喉返神经损伤致肺炎的预防及护理

单侧喉返神经损伤是开胸术后主要并发症之一,由于左侧喉返神经的特殊解剖位置,其损伤在临床中多见[1],其主要原因是主动脉弓下淋巴结清扫损伤喉返神经结果,它的损伤会引起单侧声带完全性麻痹:患侧声带外展及内收功能均消失而出现声嘶,影响咳嗽排痰,出现进流食呛咳症状,增加了发生肺炎的危险[2],而术后并发肺炎是胸部手术后最危险的并发症之一[3]。因此,喉返神经损伤后肺炎的预防及护理十分重要,现报道如下。     

复张性肺水肿的相关临床护理对策

复张性肺水肿(Reexpansion pulmonary ede- ma,RPE)是指继发于各种原因所致的肺萎陷在肺迅速复张后所发生的急性肺水肿,多见于气、液胸患者,经大量排气排液之后,摘除胸腔巨大肿瘤,解除支气管阻塞之后以及开胸术中、术后肺复张过快等, 是临床上较为少见的非心源性肺水肿,其特点是急性间质性肺水肿。临床经过较为凶险,死亡率高达     

开胸术后气管切开患者ICU肺部感染原因分析及护理对策

目的探讨开胸手术气管切开患者ICU肺部感染与茵群的关系及其护理对策。方法对58例ICU肺部感染患者做痰液培养和药敏试验。结果细菌种类多是其特点；其原因主要有该组患者开胸术后免疫防御功能严重受损，抵抗力差．易受感染；气管切开插管后各种治疗护理增加感染机率；大量使用抗生素和多重用药使呼吸道正常茵群破坏，导致防御屏障受损；无菌观念不强．护理操作不当。结论造成开胸术后气管切开肺部感染的原因很多，其中做好气管切开术后护理显得十分重要。     

食管癌贲门癌伴糖尿病的围手术期处理

1　糖尿病的病理生理糖尿病 (ｄｉａｂｅｔｅｓｍｅｌｉｔｕｓ,ＤＭ)主要分为 2型 ,1型ＤＭ和2型ＤＭ ,1型ＤＭ一般发生在儿童、青少年和年轻人 ,2型糖尿病是老年人的常见病 ,6 0岁以上发病较为普遍。手术时 ,创伤引起的应激反应使机体内分泌代谢发生明显改变。ＤＭ患者本身就存在内分泌代谢障碍 ,其与没有ＤＭ的患者相比 ,围手术期并发症发生的危险性及死亡率大大增加。具体的并发症主要包括 :高血糖导致的高渗性利尿 ;高渗状态下可出现血液黏滞性增高 ,血栓形成和脑水肿 ;酮症和ＤＭ酮症酸中毒 ;蛋白质分解和氨基酸转运减少至伤口愈合延迟…     

双瓣式气管食管瘘修补术病人的护理

目的:总结气管食管瘘病人行双瓣式气管食管瘘修补术的护理措施。方法:总结2010年3月～2011年12月我科采用双瓣式气管食管瘘修补术治疗的气管食管瘘病人6例临床资料,术前予呼吸道及胃肠道准备、心理护理、口腔护理等,术后认真观察病情,进行针对性护理。结果:6例病人术后创伤明显减轻,无1例并发症出现。结论:做好双瓣式气管食管瘘修补术病各项护理措施,对配合病人顺利进行手术、促进病人康复起着重要作用。