本文選題：關(guān)節(jié)成型術(shù) + 置換��； 參考：《重慶醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的：探索骨水泥型膝關(guān)節(jié)表面置換術(shù)術(shù)中心腔內(nèi)超聲栓子的發(fā)生率、發(fā)生時(shí)段和程度、及其對(duì)呼吸循環(huán)系統(tǒng)的影響。 方法：對(duì)13例擇期在全麻下行單側(cè)膝關(guān)節(jié)表面置換術(shù)的患者進(jìn)行研究。手術(shù)假體全部為后交叉韌帶替代型骨水泥固定人工膝關(guān)節(jié)假體(美國(guó)DePuy公司RP或RPF假體)。手術(shù)時(shí)氣囊止血帶壓力均調(diào)整為350mmHg（不使用驅(qū)血帶），全采取內(nèi)側(cè)髕旁入路，先行脛骨截骨，再行股骨遠(yuǎn)端截骨，在股骨鉆孔后立即予負(fù)壓吸引管抽吸骨髓組織，并予50ml生理鹽水沖洗、抽吸干凈后再插入帶凹槽的髓內(nèi)定位桿，在脛骨鉆孔、打入龍骨沖后予負(fù)壓吸引管抽吸干凈。所有病例未行髕骨面置換。所有手術(shù)在75分鐘內(nèi)完成。用多維TEE成人探頭（VividS6TEE）插入食管，調(diào)整探頭于合適的位置，分別于止血帶充氣前1min至止血帶開(kāi)始充氣、止血帶開(kāi)始充氣后3分鐘內(nèi)、股骨開(kāi)始鉆孔后3分鐘內(nèi)、開(kāi)始植入假體后5分鐘內(nèi)、止血帶開(kāi)始放氣后15分鐘內(nèi)，約在食道中段獲取心臟四腔室圖像。分別于止血帶充氣前5分鐘、止血帶開(kāi)始充氣后5分鐘、股骨開(kāi)始鉆孔時(shí)、開(kāi)始植入假體后5分鐘、止血帶準(zhǔn)備放氣時(shí)、止血帶開(kāi)始放氣后5分鐘、術(shù)畢，記錄心率（HR）、橈動(dòng)脈收縮壓（SBP）和舒張壓（DBP）、脈氧飽和度（SpO2）、呼氣末二氧化碳（ETCO2）。分別于止血帶充氣前、股骨開(kāi)始鉆孔后5分鐘、止血帶開(kāi)始放氣后5分鐘、術(shù)畢，從橈動(dòng)脈采集血液進(jìn)行動(dòng)脈血?dú)夥治鲆粤私庋鹾现笖?shù)（PaO2/FiO2）、二氧化碳分壓（PCO2）的變化。不同時(shí)段右心TEE栓子的等級(jí)程度采用Friedman秩和檢驗(yàn)，兩兩間的比較采用兩相關(guān)樣本的非參數(shù)檢驗(yàn)（Wilcoxon符號(hào)秩和檢驗(yàn)），不同時(shí)間點(diǎn)血流動(dòng)力學(xué)指標(biāo)采用單因素重復(fù)測(cè)量方差分析（repeatedmeasures ANOVA),多重比較采用LSD法（Least Significant Difference)。相關(guān)性分析采用Spearman秩相關(guān)分析。 結(jié)果：所有的入選病例都順利完成了麻醉、手術(shù)、以及術(shù)中監(jiān)測(cè)，所有患者于術(shù)中TEE監(jiān)測(cè)均未發(fā)現(xiàn)卵圓孔未閉等先天性心臟結(jié)構(gòu)異常。在止血帶充氣前、止血帶充氣后3min內(nèi)均未發(fā)現(xiàn)栓子影像；有2例在股骨髓內(nèi)定位時(shí)開(kāi)始監(jiān)測(cè)到栓子，在植入假體時(shí)有4例監(jiān)測(cè)到栓子。所有患者釋放止血帶后均監(jiān)測(cè)到栓子，成一個(gè)先上升后逐漸下降的高峰。栓子在止血帶開(kāi)始放氣后1分鐘內(nèi)最明顯，約40s時(shí)達(dá)到高峰，所有病例5分鐘內(nèi)栓子基本消失，若再次活動(dòng)膝關(guān)節(jié)，部分病例會(huì)再次出現(xiàn)細(xì)小栓子。有3例患者在止血帶釋放后監(jiān)測(cè)到3級(jí)強(qiáng)回聲栓子，大小約2.0×2.0cm2，如棉花團(tuán)樣漂過(guò)右心房和右心室，所有觀察到的栓子在右側(cè)心房及心室短暫存留后隨血流進(jìn)入肺動(dòng)脈。全程所有觀察時(shí)間點(diǎn)上HR、SpO2、ETCO2、DBP、PCO2無(wú)顯著變化（P0.05）；止血帶開(kāi)始放氣后5分鐘SBP和PaO2/FiO2與止血帶開(kāi)始充氣前相比顯著下降（P0.05）；各時(shí)間段栓子的等級(jí)程度與SBP、PaO2/FiO2呈負(fù)相關(guān)；大部分病人能耐受SBP及PaO2/FiO2的變化，，但有2例患者需給予升壓藥物及調(diào)高給氧濃度干預(yù)處理，這2例均為出現(xiàn)3級(jí)超聲栓子的患者。 結(jié)論：1.骨水泥型膝關(guān)節(jié)表面置換術(shù)（使用止血帶）中，心腔內(nèi)可出現(xiàn)微栓子現(xiàn)象，個(gè)別患者在止血帶放氣后會(huì)出現(xiàn)大栓子；2.栓子在止血帶開(kāi)始放氣后1分鐘內(nèi)十分明顯；3.止血帶放氣后往往伴有收縮壓及氧合指數(shù)的下降，可能大多數(shù)病人能夠耐受這種變化；4.TEE可作為監(jiān)測(cè)TKR術(shù)中心腔內(nèi)栓子的一個(gè)手段。
[Abstract]:Objective: To investigate the incidence, duration and degree of intravascular ultrasound embolus in cemented total knee arthroplasty and its effect on the respiratory and circulatory system.
Methods: a total of 13 patients undergoing elective unilateral knee replacement under general anesthesia were studied. All the surgical prostheses were fixed to the prosthesis of the posterior cruciate ligament (DePuy RP or RPF prosthesis). The pressure of the airbag tourniquet was adjusted to 350mmHg during the operation. On the road, the tibial osteotomy was performed before the distal femur osteotomy, and the bone marrow tissue was sucked immediately after the drilled femur, and the bone marrow tissue was pumped by the negative pressure suction tube immediately after the drilled of the femur. 50ml physiological saline was used to rinse the bone, then the intramedullary positioning rod with a groove was inserted into the tibia, and then the tibia was drilled and the suction tube was pumped into the bone. All cases were not replaced by the patellar surface. All hands were not replaced. All hands were not replaced by the patellar surface. The operation is completed within 75 minutes. Insert the multidimensional TEE adult probe (VividS6TEE) into the esophagus and adjust the probe to the appropriate position. The tourniquet begins to inflate 1min to the tourniquet before the tourniquet is inflated. The tourniquet begins to inflate within 3 minutes. The femur begins to drill 3 minutes after the start of the drill, and within 5 minutes after the implant is implanted, the tourniquet begins to deflate for 15 minutes, about 15 minutes. The four chamber image of the heart was obtained in the middle segment of the esophagus, 5 minutes before the tourniquet was inflated and 5 minutes after the tourniquet began to be inflated. When the femur began to drill, it began to implant the prosthesis for 5 minutes. The tourniquet began to deflate, and the tourniquet began to deflate for 5 minutes. The heart rate (HR), radial systolic pressure (SBP) and diastolic pressure (DBP), pulse oxygen saturation (DBP), and pulse oxygen saturation (DBP) were recorded at the end of the operation. SpO2), the end of the expiratory carbon dioxide (ETCO2). Before the tourniquet was inflated, the femur began to drill 5 minutes after the start of the drill, and the tourniquet began to deflate 5 minutes. After the operation, the blood gas was collected from the radial artery to analyze the oxygen index (PaO2/FiO2) and the change of the partial pressure of carbon dioxide (PCO2). The degree of the right heart TEE emboli at different time periods was Fried Man rank sum test, the 22 comparison used the non parametric test of two related samples (Wilcoxon symbol rank and test). The hemodynamic indexes at different time points were analyzed by single factor repeated measurement variance analysis (repeatedmeasures ANOVA), and multiple comparison using LSD (Least Significant Difference). Correlation analysis adopted Spearman rank correlation score. Analysis.
Results: all the selected cases successfully completed the anesthesia, operation, and intraoperative monitoring. All patients did not find congenital cardiac structural abnormalities such as oval foramen in all patients during the TEE monitoring. Before the tourniquet was inflated, the embolus was not found in 3min after the tourniquet was inflated; 2 cases began to monitor the embolus in the femoral bone marrow location. The embolus were monitored in 4 cases. All the patients released the tourniquet after releasing the tourniquet to monitor the embolus and become the highest peak. The embolus was most obvious within 1 minutes after the tourniquet began to deflate. At about 40s, the embolus reached the peak. The embolus disappeared basically within 5 minutes of all cases. If the knee joint was reactivated again, the cases of partial disease appeared again. Small emboli. 3 patients monitored the 3 strong echoes after the tourniquet release, the size of which was about 2 * 2.0cm2, such as the right atrium and right ventricle. All the observed embolus entered the pulmonary artery after the temporary retention of the right atrium and ventricle. All observed HR, SpO2, ETCO2, DBP, PCO2 did not change significantly (P0. 05): 5 minutes after the tourniquet began to deflate, SBP and PaO2/FiO2 were significantly lower than before the tourniquet began to inflate (P0.05); the level of the embolus in each time period was negatively correlated with SBP and PaO2/FiO2; most patients were able to tolerate the changes of SBP and PaO2/FiO2, but 2 patients need to be given the booster drugs and the high oxygen concentration intervention treatment, these 2 cases. A patient with a 3 stage supersonic embolus.
Conclusion: in 1. bone cement type knee replacement surgery (using tourniquet), there can be a micro embolus phenomenon in the intracardiac, and a few patients appear large embolus after the tourniquet deflation; 2. embolus are very obvious within 1 minutes after the tourniquet begins to deflate, and the 3. tourniquet often has a decrease of systolic pressure and oxygen index after the release of the tourniquet. The patient can tolerate this change; 4.TEE can be used as a means of monitoring intracavity embolus in TKR.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R687.4

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 張陽(yáng);錢(qián)齊榮;吳海山;李曉華;吳宇黎;祝云利;劉宏濱;;股骨髓腔吸引對(duì)全膝關(guān)節(jié)置換術(shù)中減少栓塞的影響[J];骨科;2010年03期

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