DSpace community: 附設醫院創傷醫學部

Delayed Diagnosis of Esophageal Perforation Following Intraoperative Transesophageal Echocardiography during Valvular Replacement-a Case Report

Tue, 22 Sep 2009 07:40:58 GMT

title: Delayed Diagnosis of Esophageal Perforation Following Intraoperative Transesophageal Echocardiography during Valvular Replacement-a Case Report abstract: 案例報告的是一位62歲男性病患，在主動脈瓣膜及二尖瓣膜置換手術中會接受過經食道心臟超音波掃瞄監測，術後發生食道破裂。敗血性休克出現在術後第十二天，經胸部電腦斷層掃描确定診斷，病患在緊急手術及後續的重症照護後存活下來。由整個病程與事件間的關系來推論，我們認為發生食道延遲性破裂的原因應非超音波探頭直接的機械性損傷，而是來自食道長時間的缺血傷害，這與術中超音波探頭的壓迫，病患極度擴大的心房及體外循環時非脈衝式的血流供應有關。所以，基於進行開心手術患者的某些特殊危險因素考量，如心房擴張、手術時間過長、體外循環時易發生腸胃道缺血等，我們強烈建議，在開心手術中，有上述情況疑慮，食道超音波探頭於體外循環時，不用時應取出，另外，若在放置超音波探頭時會遇到阻力，病患術後又有發燒及胸部X光不正常表現，應考慮食道破裂發生的可能性。 A 62 year-old man sustained esophageal perforation following intra-operative transesophageal echocardiography (TEE) in a valvular replacement surgery. Septic shock developed on the 12th postoperative day (POD) and the esophageal perforation was diagnosed with chest CT. Emergent operation together with intensive care saved the patient’s life. We speculate that the mechanism of perforation was not due to manipulation of the probe, but rather due to ischemia of the esophagus resulting from the combination of probe compression, non-pulsatile flow and the distension of the atria during a lengthy procedure. It is advisable that in patients with operative risk factors, such as distension of atria, long cardiac procedure and likely ischemia of organs due to cardiopulmonary bypass, the monitoring probe of TEE should not constantly rest in the esophagus and be withdrawn when it is idle or not in actual use. In addition, if resistance has been met during the intraoperative manipulation of the probe in a patient without previous history of esophageal disease, perforation might suspected if he or she sustains postoperative fever with positive chest X-ray findings.

An Evidence-Based Review on the Use of Corticosteroids in Pen-Operative and Critical Care

Tue, 22 Sep 2009 07:40:40 GMT

title: An Evidence-Based Review on the Use of Corticosteroids in Pen-Operative and Critical Care abstract: 皮質類固醇的藥理作用複雜且廣泛，在臨床上的使用情形很多。我們針對麻醉科醫師在外科手術前後及重症醫學領域上，可能會遇到的皮質類固醇適應症作一完整的文獻回顧，並依所收集到的證據支持度，將其適應症整理如下列建議。有強烈證據支持的絕對適應症包括：腎上腺功能不足、哮喘、過敏反應、急性脊髓受傷、腦瘤併腦壓昇高。一般來說效果不錯，而建議使用的情況包括：手術後止吐、某些特定的呼吸衰竭（如急性呼吸窘迫症候群、脂肪栓塞、慢性阻塞性肺病）、腦膿瘍併腦壓昇高、甲狀腺晚暴和難控制的低體溫症。大劑量的皮質類固醇，在敗血性休克的治療上可能有助益，但仍需進一步的驗證。而在心臓停止、腦部外傷和梗塞所伴隨的腦壓昇高、拔除氣管內管後的呼吸道水腫及吸入性肺炎，則不建議給予，因爲效果不彰，甚至會進一步惡化病情。使用皮質類固醇的絕對禁忌有：全身性的黴菌感染、病患對皮質類固醇過敏、原因不明的血小板缺乏性紫斑患者施行肌肉注射給藥，以及近期接受活病毒疫苗的患者。With complex and extensive pharmacological effects, corticosteroids are widely used in many clinical situations. A survey conducted to define the role of corticosteroids in various settings of pen -operative and critical care gave strong evidence to support that the use of corticosteroid is absolutely indicated in patients with adrenal insufficiency , asthma, anaphylaxis, acute spinal cord injury, and increased ICP resulting from brain tumors. As the benefits of corticosteroids are much in evidence, their uses are recommended to extend to postoperative antiemesis, acute respiratory failure (such as ARDS, COPD, and fat embolism), increased ICP associated with brain abscess, thyroid storm, and refractory hypothermia. Beneficial effect could be expected in septic shock with high-dose corticosteroids. Despite extensive reports on their versatile usefulness, evidence-based review did not recommend the use of corticosteroids in increased ICP associated with traumatic head injury and cerebral infarct, cardiac arrest, post- extubation airway edema, and aspiration pneumonia due to poor effectiveness let alone further worsening of the conditions. Great caution must be taken in clinical situations where administration of corticosteroids is considered contraindicated such as systemic fungalinfection, hypersensitivity to the drug, intramuscular injection in idiopathic thrombocytopenia purpura, vaccination with live virus.

The Analgesic Effect of Oral Morphine or Pentazocine for Extracorporeal Shock Wave Lithotripsy

Tue, 22 Sep 2009 07:40:05 GMT

title: The Analgesic Effect of Oral Morphine or Pentazocine for Extracorporeal Shock Wave Lithotripsy abstract: 背景：由于震波碎石術所使用之機型改良後，震波對人體造成之疼痛大為減輕，麻醉止痛之方式也因而不再侷限於傳統之全身麻醉，硬膜外腔麻醉或靜脈麻醉等，因此使得適當的口服止痛且并發較少的副作用成為必要考量。方法：我們選擇100位因泌尿道結石須接受體外震波碎石術(ESWL)之病人，任意區分為二組，每組各50人，分別給予不同之口服止痛劑加上鎮靜劑(lorazepam 1mg)，觀察這二種口服止痛劑之效果及其副作用，并記錄血流動力及血氣之變化。本實驗病人所使用碎石機之機型為 Dornier HM3改良型。口服止痛劑分別為morphine 30mg，及pentazocine 100mg，均與lorazepam 1mg溶於15 ml之開水中，於手術前30分鐘分別給各組病人服下，并于各選區定時段觀察并記錄相關指標，若病人不堪疼痛，則追加靜注fentany1使手術繼續進行。結果：結果顯示，二組病人中，接受pentazocine 100 mg為口服止痛劑的病人，有94%能順利完成手術，不須追加任何靜注止痛劑，且其止痛程度-pain, sedation 及efficacy scale之指數均令人滿意，在碎石過程中，病人之嗜睡反應也較理想，但眩暈之副作用，此組病人則呈現較高之比率。而接受morphine 30mg的病人則68%之病人可以不需追加靜注止痛劑而完成手術，但惡心嘔吐副作用比例較高。血壓變化組內與組間均無差异，但給予pentazocine此組有較高心跳和較低血氧飽和度之變化，但臨床上對病人均未產生明顯之症狀或需要加以處理。結論：我們認為對震波碎石術之止痛麻醉方式，若考慮成本效益及避免靜注麻醉劑過量之風險，單一口服止痛劑 pentazocine 100mg加上鎮靜劑lorazepam 1mg，可以提供新型高科技碎石機進行震波碎石術病人滿意之止痛效果。 Background: Extracorporeal shock wave lithotripsy (ESWL) in these days is usually carried out on ambulatory or outpatient basis. With the application of a lithotriptor of modern version an appropriate yet cost-effective analgesia with minimal side effects for ESWL is mandatory. Methods: The analgesic effect of oral morphine (30mg) was compared with that of pentazocine (100mg) in a prospective study comprising 100 patients undergoing ESWL with a lithotripter of improved version for urinary tract stones. All patients received orally lorazepam 1 mg as sedative together with the appointed tested drug 30mim before the procedure. The analgesic effects of both drugs were assessed having recourse to the pain scale and efficacy scale. Results: There were 94% of patients in the pentazocine (mixed agonist-antagonist) group who felt satisfied with the regimen and stood the procedure well without resort to supplemental drug, as compared with the morphine (potent μ-agonist) group in which only 70% of patients did so. Although the adverse effect such as dizziness was found in the pentazocine group, the degree of sleepiness produced by its deeper sedation effect was to the advantage of patients during the lithotripsy procedure. There were no significant changes in intergroup mean blood pressure (MBP), but heart rate (HR) was higher and O 2 saturation (SpO2) was lower in the pentazocine group after treatment. Both narcotics did not induce renal colic in our study. Also, pentazocine 100mg plus lorazepam 1mg given orally did not induce psychotomimetic reaction intraoperatively or postoperatively. Conclusions: We concluded that oral pentazocine at 100mg plus lorazepam 1mg, could offer satisfactory analgesia in patients undergoing ESWL for urinary tract stones with a lithotripter of improved version.

Pressure Criterion for Placement of Distal Perfusion Catheter to Prevent Limb Ischemia during Adult Extracorporeal Life Support

Tue, 22 Sep 2009 07:39:18 GMT

title: Pressure Criterion for Placement of Distal Perfusion Catheter to Prevent Limb Ischemia during Adult Extracorporeal Life Support