术中应用临时起搏器的价值研究

发布时间：2018-04-15 15:00

本文选题：临时起搏器 + 非心脏外科手术　；参考：《天津医科大学》2014年硕士论文

【摘要】：目的在非心脏外科手术的患者中,时常有些患有冠心病、窦性心动过缓、房室传导阻滞的患者,手术时需安置临时起搏器渡过术中风险。但在部分患者中,临时起搏器在围手术期中并未发挥起搏功能,且安装临时起搏器存在静脉穿刺损伤、心脏内导联的机械刺激作用、起搏器导联的电活动、血肿、感染或血栓形成、起搏失败等一系列并发症,增加了病人的风险,且造成医疗资源的浪费。本文通过回顾性分析非心脏手术前安装临时起搏器治疗的患者多项临床资料,评价临时起搏器在术中和术后的使用情况,为临床围术期临时起搏应用提供参考。方法选择我院非心脏外科手术前安装临时起搏器的缓慢性心律失常患者274例,根据术中起搏器工作情况,分为起搏组与备用起搏组,其中起搏组90例,备用起搏组184例,用SPSS18.0软件进行统计分析,比较上述指标的水平在组中差异是否有统计学意义(以P0.05为差异有统计学意义)。结果不同心律失常下起搏器工作情况不同,合并窦缓及Ⅲ度AVB、房颤伴长间歇、快慢综合征的患者临时起搏器工作状态多(P0.05),而合并Ⅱ度AVB、双束支阻滞、完全左后分支阻滞、完全性左束支阻滞的患者临时起搏器工作状态较少(P0.05)。不同年龄阶段起搏器工作情况不同,年龄大于70岁的缓慢性心律失常患者术中临时起搏器工作状态多(P0.05),年龄小于70岁的缓慢性心律失常患者术中临时起搏器工作状态少(P0.05)；合并不同心脏疾病时起搏器工作状态不同,其中在合并扩心病、病毒性心肌炎等情况时起搏器工作状态明显较高(P0.05),而在合并冠心病(稳定性心绞痛)、高心病时的起搏器的工作状态较少(P0.05)。麻醉方式对临时起搏器工作状态无影响(P0.05)。中小手术临时起搏器工作状态少,而大手术时高(P0.05)。结论 1.对于合并有严重窦缓(心率50次/分)及Ⅲ度AVB、双束支阻滞、房颤伴长间歇、快慢综合征的患者,术前植入临时起搏器可降低手术中危及生命的缓慢性心律失常的发生,使手术顺利进行。 2.对年龄大于70岁且合并心脏基础疾病的缓慢性心律失常患者术前植入临时起搏器可降低术中恶性心律失常事件的发生,合并有扩心病、病毒性心肌炎的患者术前植入临时起搏器可有效预防恶性心律失常事件的发生；对于合并有冠心病、高血压性心脏病的患者术前植入临时起搏器保护意义不大。 3.虽然全身麻醉下临时起搏器工作状态所占比例较局部麻醉和腰麻高,但麻醉方式对临时起搏器工作状态的影响无统计学差异。 4.中小手术临时起搏器工作状态少,而大手术时高。老年患者行非心脏手术前,如果存在以下情况时,不论手术大小、麻醉方式如何,最好先行临时起搏器植入术：(1)严重窦性心动过缓及Ⅲ度房室传导滞；(2)房颤伴长间歇(2s)；(3)快慢综合征。当患者存在如下情况并合并扩心病、病毒性心肌炎时,在行大手术、全麻时可先行临时起搏器植入术以保证手术安全：Ⅱ度房室传导阻滞、双束支阻滞、完全左后分支阻滞。
[Abstract]:objective
In non heart surgery patients, some patients suffering from coronary heart disease, sinus bradycardia, atrioventricular block patients, surgery need temporary pacemaker through intraoperative risk. But in some patients, temporary pacemaker pacing does not play a function in the perioperative period, and the installation of temporary pacemaker venous puncture injury. The inside of the heart lead mechanical stimulation, electrical activity, pacemaker leads hematoma, infection or thrombosis, pacing failure and other complications, increase the patient's risk, and cause the waste of medical resources. This article through retrospective analysis of clinical data of patients with multiple non cardiac surgery before the installation of temporary cardiac pacemaker therapy, evaluation of temporary pacemaker the use of intraoperative and postoperative, to provide reference for clinical perioperative application of temporary pacing.
Method
Our hospital non heart surgery before the installation of temporary pacemaker in patients with slow arrhythmia in 274 cases, according to the work of pacemaker, divided into pacing group and alternate pacing group, including 90 cases of pacing group, alternate pacing group 184 cases, using SPSS18.0 software for statistical analysis, comparing the indicators of the level differences in the group whether there is statistical significance (with P0.05 as the difference was statistically significant).
Result
Pacemaker arrhythmia under different situation is different, complicated with sinus bradycardia and third degree AVB, atrial fibrillation with long interval, patients with temporary pacemaker working state speed syndrome (P0.05), and more patients with degree AVB, bifascicular block, complete left bundle branch block, complete left bundle branch block with temporary pacemaker less states (P0.05). Different age stages of pacemaker is different, older than 70 years of temporary pacemaker arrhythmia in patients with multiple working conditions (P0.05), younger than 70 years of temporary pacemaker arrhythmia in patients with less working state (P0.05) with different cardiac pacemaker working status; when the disease is different, in patients with DCM cases of viral myocarditis and pacemaker working status was significantly higher (P0.05), and in patients with coronary heart disease (stable angina), high heart disease pacemaker work. A few states (P0.05). No effect of anesthesia on temporary pacemaker state (P0.05). Primary and secondary surgery temporary pacemaker working status, and operation of high (P0.05).
conclusion
1. for patients with severe sinus bradycardia (50 BPM) and third degree AVB, bifascicular block, atrial fibrillation with long interval, the speed of syndrome patients, preoperative pacemaker placement can reduce the incidence of life-threatening arrhythmia surgery, make the operation smoothly.
2. of older than 70 years with heart disease arrhythmia patients before implantation of pacemaker can reduce intraoperative arrhythmia events associated with dilated cardiomyopathy and viral myocarditis patients before implantation of pacemaker can effectively prevent malignant arrhythmia events for patients with coronary heart disease, hypertension; heart disease patients before implantation of pacemaker protection has little significance.
3. although the temporary pacemaker working state of general anesthesia is the proportion of local anesthesia and spinal anesthesia, but no significant difference between the effects of anesthesia on temporary pacemaker working status.
4. small surgery temporary pacemaker working status and less operation.
Elderly patients undergoing non cardiac surgery, if the following conditions exist, regardless of the size of operation, anesthesia, the best first temporary pacemaker implantation: (1) severe sinus bradycardia and atrioventricular delay; (2) atrial fibrillation with long interval (2S); (3) the speed of syndrome. When the patients have the following situation and combined with DCM, viral myocarditis, in major surgery, general anesthesia can advance temporary pacemaker implantation in order to ensure the safety of operation: second degree atrioventricular block, bifascicular block, completely left posterior fascicular block.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R654.2

【引证文献】