妇科老年患者腹腔镜截石位体位改进及效果观察

发布时间：2018-07-10 16:01

本文选题：妇科腹腔镜 + 老年患者　；参考：《郑州大学》2017年硕士论文

【摘要】：目的本研究通过对老年妇科腹腔镜手术患者术中体位的改进,探寻在充分暴露术野的情况下既能减轻老年患者体位相关并发症、又能提高其舒适度的手术体位。方法于2015年10月至2016年12月选取在郑州大学第一附属医院手术室行妇科腹腔镜手术,并符合纳入标准的100例老年患者为研究对象。依据纳入顺序采用随机数字表法分为两组,每组50例,对照组采用常规头低足高截石位,观察组采用改进的头低足高截石位。于麻醉诱导后(T1)、麻醉完成后平卧截石位(T2)、气腹并头低足高后5min(T3)、气腹并头低足高后30min(T4)及之后每30min(T5-T11)、气腹解除后恢复平卧位5min(T12)、麻醉结束恢复清醒前(T13)测量患者的眼压值;于手术全麻前摆好平卧截石体位后由患者填写手术体位舒适性量表,调查患者手术体位舒适度;并于术后24h、48h和72h对患者进行随访,调查并记录肩部疼痛情况和下肢疼痛麻木情况;术后对手术医生、麻醉医生和巡回护士进行非结构式访谈,以了解其对改进后体位安置方法的评价。采用SPSS17.0统计软件对收集的数据进行处理分析,P0.05表示差异具有统计学意义。患者一般资料中的定量资料采用t检验、Mann-Whitney U检验,定性资料采用χ2检验;两组患者术后肩痛发生率,下肢疼痛麻木发生率采用χ2检验;两组患者同一时间点的眼压值采用两独立样本t检验进行比较;多个时间点的平均动脉压和眼压值比较采用重复测量方差分析;两组患者术后肩痛、下肢疼痛程度和手术体位舒适度的数据不服从正态分布,采用Mann-Whitney U检验进行比较,访谈资料采用Colaizzi现象学资料七步分析法。结果1.两组患者平均年龄、BMI指数、术前眼压平均值差异无统计学意义(P0.05);手术相关资料手术类型、手术时间、输液量、出血量等比较差异无统计学意义(P0.05)。2.两组患者不同时间点眼压值的比较,在麻醉诱导后(T1)、麻醉完成后平卧截石位(T2)两个时间点,两组患者眼压值差异无统计学意义(P0.05)。在气腹并头低足高后5min(T3)-气腹解除后恢复平卧位5min(T12)之间的每个测量时间点两组患者眼压值差异有统计学意义(P0.05);在T12阶段两组患者的眼压值均始降低,观察组平均眼压为(19.60±0.82)mmHg,降至正常水平,而此时对照组平均眼压值为(24.40±0.98)mmHg,虽有降低但仍高出正常眼压范围(正常眼压范围10-21mmHg);在麻醉结束恢复清醒前(T13)阶段两组患者眼压值均降到正常水平。3.两组患者的平均动脉压比较,在气腹并头低足高后5min(T3),观察组患者的平均动脉压为(81.35±8.81)mmHg,对照组患者的平均动脉压为(85.17±8.08)mmHg,比较差异具有统计学意义(t=2.261,P0.05);气腹并头低足高后30min(T4),观察组患者的平均动脉压为(84.84±10.65)mmHg,对照组患者的平均动脉压为的(89.02±9.08)mmHg,比较差异具有统计学意义(t=2.105,P0.05);除去T3、T4时间点,T1、T2时间点以及T4之后的时间点,两组患者的平均动脉压比较差异无统计学意义(P0.05)。4.两组患者术后下肢疼痛麻木发生率分是对照组为12/50(24%)、观察组为4/50(8%),对照组与试验组比较差异有统计学意义(χ2=4.762,P0.05);两组发生疼痛患者的VAS疼痛评分,对照组患者为(3.20±0.82)分,观察组患者为(2.15±0.51)分,疼痛评分比较差异均有统计学意义(Z=-2.375,P0.05)。5.两组患者术后肩部疼痛发生率分别是对照组为18/50(36%)、观察组为6/50(12%),对照组与观察组比较差异有统计学意义(χ2=7.895,P0.05);两组患者发生术后肩痛的VAS疼痛评分,对照组平均得分为(4.20±1.25)分,观察组平均得分为(1.78±0.51)分,疼痛评分比较差异均有统计学意义(Z=-3.501,P0.05)。6.两组患者体位舒适度得分比较,对照组患者平均得分为(67.81±4.12)分,观察组患者平均得分为(3.18±4.38)分,比较差异具有统计学意义(Z=-5.422,P0.05)。其中在生理、心理、环境三个维度的得分差异有统计学意义(P0.05)。7.非结构式访谈结果显示手术医生、麻醉医生和巡回护士对观察组体位安置方法评价较好,观察组的体位安置方法手术野暴露良好,不会影响手术医生的操作,不会阻碍患者的呼吸。结论1.相比传统的头低足高截石位,改进头低足高截石位能有效减少老年患者术中眼压值的升高,有利于老年患者手术安全。2改进头低足高截石位患者的体位舒适度较高,能有效减少患者术后下肢并发症的发生并有利于减轻患者术后肩痛。
[Abstract]:Objective to explore the improvement of the postural position in the elderly gynecologic laparoscopic surgery, to explore the surgical posture which can reduce the body position related complications and improve the comfort of the elderly patients under the condition of full exposure of the surgical field. Methods from October 2015 to December 2016, the Department of gynaecology in the operation room, the First Affiliated Hospital of Zhengzhou University, was selected. Laparoscopic surgery was performed in 100 elderly patients, which were divided into two groups according to the order of inclusion, 50 cases in each group, and the control group adopted the normal head and low foot high osteotomy position, the observation group adopted the improved head and low foot high osteotomy position. After anesthesia induction (T1), the supine lithotomy position (T2), pneumoperitoneum after the anesthesia was completed, and pneumoperitoneum, 5min (T3) after lower foot and lower foot, 30min (T4) and 30min (T5-T11) after low foot of the lower foot, 5min (T12) of the supine position recovered after the pneumoperitoneum was relieved, and the intraocular pressure of the patients was measured before the end of anaesthesia (T13); the surgical posture Comfort Scale was filled in by the patients before the operation of general anesthesia and the comfort of the surgical posture was filled in, and the comfortable position of the patients was investigated. The patients were followed up with 24h, 48h and 72h after the operation to investigate and record the pain of the shoulders and the numbness of the pain of the lower limbs. After the operation, the surgeon, the anesthesiologist and the itinerant nurse were interviewed by unstructured interviews in order to understand the evaluation of the improved post position method. The data collected by the SPSS17.0 statistical software were processed. Analysis, P0.05 indicated that the difference was statistically significant. The quantitative data in the general data were t test, Mann-Whitney U test and chi 2 test for qualitative data. The incidence of shoulder pain in the two groups and the incidence of numbness of lower extremity pain were tested by chi 2 test, and the intraocular pressure values of the two groups were compared with two independent sample t test at the same time point. The average arterial pressure and intraocular pressure of multiple time points were analyzed by repeated measurement of variance. The data of shoulder pain after operation, the degree of pain of the lower limbs and the comfort degree of the surgical position were not subject to normal distribution in the two groups, compared with the Mann-Whitney U test, and the interview data were analyzed by the seven step analysis of the Colaizzi phenomenology data. Results the results of the 1. two groups were flat. The average age, BMI index, and preoperative intraocular pressure (IOP) mean difference was not statistically significant (P0.05); there was no significant difference in operation related data, operation time, infusion volume, bleeding volume, etc. (P0.05) the comparison of intraocular pressure at different time points in the.2. two groups, after anesthesia induction (T1), and two time points for the supine lithotomy position after the anesthesia was completed, There was no significant difference in intraocular pressure between the two groups (P0.05). There was a significant difference in the intraocular pressure between the two groups of two groups of patients after the recovery of 5min (T12) after the release of the lower foot of the pneumoperitoneum (T3) and the relieving of the pneumoperitoneum (P0.05). In the T12 stage, the intraocular pressure of the two groups was reduced, and the average intraocular pressure of the observation group was (19.60 + 0.82) mm. Hg, to the normal level, and at this time the average intraocular pressure of the control group was (24.40 + 0.98) mmHg, although there was a decrease but still higher the range of normal intraocular pressure (normal intraocular pressure range 10-21mmHg); the intraocular pressure of two groups of patients in the two groups before the end of the anesthesia recovery (T13) were all lower to the normal level of the.3. two group, and 5 after the lower foot of the pneumoperitoneum. Min (T3), the average arterial pressure of the patients in the observation group was (81.35 + 8.81) mmHg, the average arterial pressure of the control group was (85.17 + 8.08) mmHg, and the difference was statistically significant (t=2.261, P0.05), and the average arterial pressure of the patients in the observation group was (84.84 + 10.65) mmHg, and the average arterial pressure of the control group was 89.02 (89.02) (89.02). The difference was statistically significant (t=2.105, P0.05), and the average arterial pressure in the two groups was not statistically significant (P0.05) except T3, T4 time point, T1, T2 point and time after T4 (P0.05). The incidence of numbness in the lower limb pain in the two groups was 12/50 (24%), the observation group was 4/50 (8%), and the control group. Compared with the experimental group, the difference was statistically significant (x 2=4.762, P0.05); the VAS pain score in two groups of pain patients was (3.20 + 0.82), and the patients in the observation group were (2.15 + 0.51), and the difference in pain score was statistically significant (Z=-2.375, P0.05) in group.5. two, the incidence of shoulder pain was 18/5 in the control group, respectively. 0 (36%), the observation group was 6/50 (12%), the control group was significantly different from the observation group (x 2=7.895, P0.05); the two groups of patients had the pain score of shoulder pain after operation, the average score of the control group was (4.20 + 1.25) points, the average score of the observation group was (1.78 + 0.51) scores, and the difference of pain score was statistically significant (Z=-3.501, P0.05).6. two group. The score of the patient's body position comfort was compared, the average score of the control group was (67.81 + 4.12). The average score of the patients in the observation group was (3.18 + 4.38), and the difference was statistically significant (Z=-5.422, P0.05). The difference of score difference between the three dimensions of physiology, psychology and environment was statistically significant (P0.05).7. non structural interview results showed surgery Doctors, anesthesiologists and itinerant nurses have better evaluation of the placement of the observation group. The position of the observation group is well exposed in the surgical field, which does not affect the operation of the surgeon and does not obstruct the patient's respiration. Conclusion 1. compared with the traditional head and low foot high lithotomy position, the improvement of the head low foot high osteotomy position can effectively reduce the intraoperative eye of the elderly patients. The increase of pressure value is beneficial to the operation safety of the elderly patients with.2 to improve the comfort degree of the patients with low foot and high stone position, which can effectively reduce the incidence of postoperative complications of the lower extremities and reduce the shoulder pain after operation.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.6

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