膝关节表面置换术中用经食道超声心动图监测心腔内栓子的研究

发布时间：2018-05-31 00:22

本文选题：关节成型术 + 置换　；参考：《重庆医科大学》2014年硕士论文

【摘要】：目的：探索骨水泥型膝关节表面置换术术中心腔内超声栓子的发生率、发生时段和程度、及其对呼吸循环系统的影响。方法：对13例择期在全麻下行单侧膝关节表面置换术的患者进行研究。手术假体全部为后交叉韧带替代型骨水泥固定人工膝关节假体(美国DePuy公司RP或RPF假体)。手术时气囊止血带压力均调整为350mmHg（不使用驱血带），全采取内侧髌旁入路，先行胫骨截骨，再行股骨远端截骨，在股骨钻孔后立即予负压吸引管抽吸骨髓组织，并予50ml生理盐水冲洗、抽吸干净后再插入带凹槽的髓内定位杆，在胫骨钻孔、打入龙骨冲后予负压吸引管抽吸干净。所有病例未行髌骨面置换。所有手术在75分钟内完成。用多维TEE成人探头（VividS6TEE）插入食管，调整探头于合适的位置，分别于止血带充气前1min至止血带开始充气、止血带开始充气后3分钟内、股骨开始钻孔后3分钟内、开始植入假体后5分钟内、止血带开始放气后15分钟内，约在食道中段获取心脏四腔室图像。分别于止血带充气前5分钟、止血带开始充气后5分钟、股骨开始钻孔时、开始植入假体后5分钟、止血带准备放气时、止血带开始放气后5分钟、术毕，记录心率（HR）、桡动脉收缩压（SBP）和舒张压（DBP）、脉氧饱和度（SpO2）、呼气末二氧化碳（ETCO2）。分别于止血带充气前、股骨开始钻孔后5分钟、止血带开始放气后5分钟、术毕，从桡动脉采集血液进行动脉血气分析以了解氧合指数（PaO2/FiO2）、二氧化碳分压（PCO2）的变化。不同时段右心TEE栓子的等级程度采用Friedman秩和检验，两两间的比较采用两相关样本的非参数检验（Wilcoxon符号秩和检验），不同时间点血流动力学指标采用单因素重复测量方差分析（repeatedmeasures ANOVA),多重比较采用LSD法（Least Significant Difference)。相关性分析采用Spearman秩相关分析。结果：所有的入选病例都顺利完成了麻醉、手术、以及术中监测，所有患者于术中TEE监测均未发现卵圆孔未闭等先天性心脏结构异常。在止血带充气前、止血带充气后3min内均未发现栓子影像；有2例在股骨髓内定位时开始监测到栓子，在植入假体时有4例监测到栓子。所有患者释放止血带后均监测到栓子，成一个先上升后逐渐下降的高峰。栓子在止血带开始放气后1分钟内最明显，约40s时达到高峰，所有病例5分钟内栓子基本消失，若再次活动膝关节，部分病例会再次出现细小栓子。有3例患者在止血带释放后监测到3级强回声栓子，大小约2.0×2.0cm2，如棉花团样漂过右心房和右心室，所有观察到的栓子在右侧心房及心室短暂存留后随血流进入肺动脉。全程所有观察时间点上HR、SpO2、ETCO2、DBP、PCO2无显著变化（P0.05）；止血带开始放气后5分钟SBP和PaO2/FiO2与止血带开始充气前相比显著下降（P0.05）；各时间段栓子的等级程度与SBP、PaO2/FiO2呈负相关；大部分病人能耐受SBP及PaO2/FiO2的变化，，但有2例患者需给予升压药物及调高给氧浓度干预处理，这2例均为出现3级超声栓子的患者。结论：1.骨水泥型膝关节表面置换术（使用止血带）中，心腔内可出现微栓子现象，个别患者在止血带放气后会出现大栓子；2.栓子在止血带开始放气后1分钟内十分明显；3.止血带放气后往往伴有收缩压及氧合指数的下降，可能大多数病人能够耐受这种变化；4.TEE可作为监测TKR术中心腔内栓子的一个手段。
[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.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.4

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