强直性脊柱炎病人超声引导下腰硬联合麻醉一例

2020-05-20 李慧莉 吕建波 马丹旭 临床外科杂志

强直性脊柱炎是以骶髂关节和脊柱附着点炎症为主要症状的疾病。由于某些微生物(如克雷白杆菌)与易感者自身组织具有共同抗原,常引发异常免疫应答,导致四肢大关节、椎间盘纤维环及其附近结缔组织纤维化和骨化,以脊

强直性脊柱炎是以骶髂关节和脊柱附着点炎症为主要症状的疾病。由于某些微生物(如克雷白杆菌)与易感者自身组织具有共同抗原,常引发异常免疫应答,导致四肢大关节、椎间盘纤维环及其附近结缔组织纤维化和骨化,以脊柱为主要病变部位,常累及骶髂关节,并造成不同程度眼、肺、肌肉、骨骼病变。

腰椎受累时,多数表现为下背部和腰部活动受限。腰部前屈、背伸、侧弯和转动均可受限。体检可发现腰椎脊突压痛,腰椎旁肌肉痉挛;后期可有腰肌萎缩。胸椎受累时,表现为背痛、前胸和侧胸痛,最常见为驼背畸形。如肋椎关节、胸骨柄体关节、胸锁关节及肋软骨间关节受累时,则呈束带状胸痛,胸廓扩张受限,吸气咳嗽或打喷嚏时胸痛加重。严重者胸廓保持在呼气状态,胸廓扩张度较正常人降低50%以上,因此只能靠腹式呼吸辅助。由于胸腹腔容量缩小,造成心肺功能和消化功能障碍。

少数病人首先表现为颈椎炎,先有颈椎部疼痛,沿颈部向头部臂部放射。颈部肌肉开始时痉挛,以后萎缩,病变进展可发展至颈胸椎后凸畸形。头部活动明显受限,常固定于前屈位,不能上仰、侧弯或转动,不能抬头平视。对于麻醉方式的选择,病人常因腰椎增生增加椎管内穿刺的难度,同时由于颈椎强直固定,插管困难造成困难气道。我们曾对1例强直性脊柱炎病人采用超声引导下腰硬联合麻醉,取得较好的临床疗效。现报道如下。

1.病例资料

病人男,51岁,体重68kg,身高168 cm,因左侧胫腓骨骨折入院,拟行开放复位胫骨内固定术。有高血压、糖尿病、冠心病病史。目前服用抗高血压药物控制血压,口服降糖药控制血糖;2年前安装冠脉支架2枚,目前心脏功能尚可,偶有胸闷,服用丹参滴丸可缓解。阿司匹林停药1周,改用预防剂量低分子肝素皮下注射。低分子肝素于术前12小时停药。强直性脊柱炎病史,腰背部前屈后伸困难,胸椎成驼背畸形;颈椎强直,成前屈位,后仰困难,头部转动困难,张口度2横指。辅助检查:(1)超声心动图示主动脉瓣轻度返流,EF65%,左室肥厚。(2)心电图:窦性心律,偶发室早。(3)胸部X线片示双肺纹理增粗。(4)骨盆X线平片示骶髂关节关节面模糊,关节边缘硬化、界线模糊,关节间隙变窄,右侧髋关节狭窄(图1)。


图1 病人骨盆X线片。该病人骶髂关节增生硬化严重,腰椎骨质增生,右侧髋关节狭窄。

2.麻醉管理

1)麻醉方式选择:

麻醉方式的选择对于此病人具有重要意义。一般麻醉方式的选择取决于病情特点、手术性质和要求、麻醉方法本身的优缺点、麻醉医生的经验、设备条件等多方面因素,同时还要尽可能考虑手术医生对麻醉选择的意见和病人自己的意愿。全身麻醉几乎可以用于任何手术,是最常使用的麻醉方式。全身麻醉优点很多,是绝大多数麻醉医生最为熟悉的麻醉方式,效果确切,肌肉松弛效果好,术中易于控制气道和调整呼吸状态,病人自身感觉舒适,对体位没有限制等等。但其带来的不良反应也是不可忽视的,如返流误吸,全麻药物对循环的抑制,气道分泌物增多,术后肺部感染的发生率增加,高龄肺部有疾患的病人术后往往需长时间的机械通气,术后镇痛效果差,术后谵妄和认知功能障碍。

本例病人既往冠心病史,2年前安装冠脉支架2枚,目前活动可,偶有胸闷,服用丹参滴丸可缓解,超声心动图示左室射血分数65%,提示病人心脏功能可耐受椎管内或全身麻醉,心功能方面应不至于影响全身麻醉或椎管内麻醉的选择。但本例病人,由于颈段脊柱强直,颈椎成前屈状态,且不能后仰和转动,虽张口度2横指,但困难气道的风险很大;胸椎成驼背畸形,肺功能可能受影响,全麻术后拔管可能困难,且可能出现术后肺部感染,因此,如选择全麻,势必要全面评估气道风险,做万全准备,术后注意并发症的预防和处理。

椎管内麻醉也是老年病人下肢手术的重要麻醉方式之一。老年病人穿刺难度较大,如平面过高,对循环和呼吸的影响较大。麻醉医生在选择椎管内麻醉时需要注意其适应症和禁忌症,如凝血功能障碍、腰椎骨折、穿刺部位感染或全身感染、循环不稳定、骨盆或脊柱骨折导致潜在休克状态。

本例病人平素口服阿司匹林,停药1周,已改用低分子肝素抗凝治疗。术晨低分子肝素已经停药12小时,病人凝血情况不影响椎管内麻醉的选择。但是病人腰段脊柱强直,骨质增生,椎板间隙骨质增生,导致了椎板间隙的狭窄或闭合,给腰椎穿刺带来困难。传统的X线、CT技术对骨性结构显像较好,广泛应用于对脊柱结构的检查,如脊柱骨折、先天畸形和脊柱侧弯等。而MRI对软组织显像较好,广泛应用于脊柱相关结构如脊髓、椎间盘等的检查。

相比之下,超声可以实时动态地得到所观察组织部位的图像,对操作者和病人无辐射危害,清楚地显示肌肉、韧带、血管、关节和实体器官等结构,但对骨性结构分辨差。脊柱结构不规则,同时存在椎间孔、椎板间隙、椎间关节等软组织覆盖的“窗口”。脊柱结构的这一特点,为超声用于显示脊柱相关的结构提供了绝佳的“条件”。

一方面,超声波不能穿透骨性组织,故不能分辨骨性组织内部结构,但能清楚显示骨面,通过超声对脊柱骨面不规则结构的显示,能判断相应的脊柱结构如椎间关节、椎板、棘突、横突、颈椎横突的前后结节。另一方面,超声波束可以穿透脊柱结构存在的“窗口”,通过这些“窗口”超声波可以显示椎管内部结构,如硬膜囊、脊髓、脑脊液等。临床上可以通过超声对脊柱骨性标志及椎管内部结构的辨识,确认相关组织结构的位置、距皮肤距离和角度等,方便进行椎管内穿刺,提高了穿刺的准确性和安全性。

本例病人虽然由于强直性脊柱炎,腰段脊柱会有明显增生,椎板间隙可能存在狭窄,但在超声实时扫描技术下,有可能显示尚未完全闭合的椎板间隙(即穿刺路径),因此采用超声引导下椎管内穿刺技术,可以完成椎管内麻醉,避免行全麻所带来的困难气道风险。

2)超声引导椎管内麻醉:

根据以上分析,我们决定在超声引导下行椎管内麻醉(腰硬联合麻醉)。我们拟采用旁正中长轴斜扫描技术,平面内进针将Tuohy硬膜外针穿刺入腰3-4水平椎板间隙的黄韧带,然后再使用无阻力注射器,通过阻力消失法确认针尖进入硬膜外间隙。然后再置入腰麻针,给予重比重0.5%(1%罗哌卡因1.5ml+10%葡萄糖1.5ml)罗哌卡因15mg(3ml),拔出腰麻针后,通过Tuohy针置入硬膜外导管。

3)麻醉实施和术中管理:

病人入手术室后,检查麻醉药物和抢救药物及插管物质设备准备到位。升高手术室温度,使用暖风机保温。同时注意与病人交流,减少病人的焦虑情绪。待一切准备妥当后开始实施麻醉。先开放外周静脉输液,测袖带血压为148/87mm-Hg、心率68次/分钟、末梢血氧饱和度为97%。给予麻醉面罩吸氧,连续监测袖带血压。

调整手术床头高15°左右,将病人摆左侧卧位(患肢在下),使用便携式超声仪,将耦合剂涂于病人腰背部,超声探头长轴置于右侧腰骶段旁正中2 cm左右,在超声图像上呈曲面光滑的高回声线即为骶骨,进一步向头侧分辨波浪线一样的L5S1小关节、L4/5小关节和L3/4小关节。确认L3/4小关节后,将超声探头扫描角度调整为向脊柱中线方向扫描,适当头尾侧移动探头,注意在超声图像上分辨椎板间隙,此时超声图像的椎板显示为高回声“马头”征,上下两椎板不相连。

用标记笔在病人皮肤上标记好超声探头的位置。消毒铺巾,将凸阵超声探头套上无菌塑料套,在上述方法下进行超声扫描,采用硬膜外Tuohy针平面内穿刺,针尖指向L3/4椎板间隙,当针尖抵达黄韧带时,接上无阻力注射器继续推进,直至有落空感,置入腰麻针,有脑脊液回流,给予给予重比重0.5%罗哌卡因15mg,拔出腰麻针后,通过Tuohy针置入硬膜外导管(图2)。


图2脊柱旁正中长轴扫描。图①示超声旁正中长轴扫描下探头和穿刺针的位置。图②示超声旁正中长轴扫描下脊柱结构的超声图像。H,头侧;T,尾侧;A,椎板;B,黄韧带;C,背侧硬膜;D,腹侧硬膜

给药后使病人保持右侧卧位5分钟,然后平卧位。测麻醉平面已达T9水平。麻醉后病人无明显不适。连续监测病人的呼吸、血压、心率,术中呼吸频率16~18次/分钟。手术持续约65分钟,血压波动于115~138/58~82mmHg间,末梢血氧饱和度维持在99%。手术中出血量约为50ml,术中尿量约200ml。术毕拔出硬膜外导管。送回病房,继续吸氧、心电监护。

4)术后管理:

术后病人使用预防剂量低分子肝素预防血栓。该病人使用静脉病人自控镇痛,100μg舒芬太尼稀释至100ml,每小时2ml。术后出现轻度恶心呕吐,给予欣贝5mg对症治疗后好转。病人1周后出院,无麻醉相关并发症。

原始出处:

李慧莉,吕建波,马丹旭,徐紫清,王云.强直性脊柱炎病人超声引导下腰硬联合麻醉一例[J].临床外科杂志,2019,27(06):470-473.

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1769827, encodeId=52751e698279a, content=<a href='/topic/show?id=b3fc92e7516' target=_blank style='color:#2F92EE;'>#超声引导#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Wed Apr 07 22:33:58 CST 2021, time=2021-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813478, encodeId=2b5618134e848, content=<a href='/topic/show?id=0ba692e7473' target=_blank style='color:#2F92EE;'>#超声引#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92774, encryptionId=0ba692e7473, topicName=超声引)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Thu Jun 11 20:33:58 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1946902, encodeId=ac421946902e6, content=<a href='/topic/show?id=9a3950183e9' target=_blank style='color:#2F92EE;'>#强直性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50183, encryptionId=9a3950183e9, topicName=强直性)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Sun Nov 01 21:33:58 CST 2020, time=2020-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1440408, encodeId=7ed4144040886, content=<a href='/topic/show?id=6f0e845427f' target=_blank style='color:#2F92EE;'>#脊柱炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84542, encryptionId=6f0e845427f, topicName=脊柱炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=50834728424, createdName=1249898am16暂无昵称, createdTime=Fri May 22 01:33:58 CST 2020, time=2020-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469062, encodeId=6a5746906249, content=已转, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 17:54:55 CST 2020, time=2020-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469045, encodeId=3c6f4690453d, content=写的很棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 10:36:07 CST 2020, time=2020-05-20, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=1769827, encodeId=52751e698279a, content=<a href='/topic/show?id=b3fc92e7516' target=_blank style='color:#2F92EE;'>#超声引导#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Wed Apr 07 22:33:58 CST 2021, time=2021-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813478, encodeId=2b5618134e848, content=<a href='/topic/show?id=0ba692e7473' target=_blank style='color:#2F92EE;'>#超声引#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92774, encryptionId=0ba692e7473, topicName=超声引)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Thu Jun 11 20:33:58 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1946902, encodeId=ac421946902e6, content=<a href='/topic/show?id=9a3950183e9' target=_blank style='color:#2F92EE;'>#强直性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50183, encryptionId=9a3950183e9, topicName=强直性)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Sun Nov 01 21:33:58 CST 2020, time=2020-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1440408, encodeId=7ed4144040886, content=<a href='/topic/show?id=6f0e845427f' target=_blank style='color:#2F92EE;'>#脊柱炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84542, encryptionId=6f0e845427f, topicName=脊柱炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=50834728424, createdName=1249898am16暂无昵称, createdTime=Fri May 22 01:33:58 CST 2020, time=2020-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469062, encodeId=6a5746906249, content=已转, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 17:54:55 CST 2020, time=2020-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469045, encodeId=3c6f4690453d, content=写的很棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 10:36:07 CST 2020, time=2020-05-20, status=1, ipAttribution=)]
    2020-11-01 zywlvao
  4. [GetPortalCommentsPageByObjectIdResponse(id=1769827, encodeId=52751e698279a, content=<a href='/topic/show?id=b3fc92e7516' target=_blank style='color:#2F92EE;'>#超声引导#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Wed Apr 07 22:33:58 CST 2021, time=2021-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813478, encodeId=2b5618134e848, content=<a href='/topic/show?id=0ba692e7473' target=_blank style='color:#2F92EE;'>#超声引#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92774, encryptionId=0ba692e7473, topicName=超声引)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Thu Jun 11 20:33:58 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1946902, encodeId=ac421946902e6, content=<a href='/topic/show?id=9a3950183e9' target=_blank style='color:#2F92EE;'>#强直性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50183, encryptionId=9a3950183e9, topicName=强直性)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Sun Nov 01 21:33:58 CST 2020, time=2020-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1440408, encodeId=7ed4144040886, content=<a href='/topic/show?id=6f0e845427f' target=_blank style='color:#2F92EE;'>#脊柱炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84542, encryptionId=6f0e845427f, topicName=脊柱炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=50834728424, createdName=1249898am16暂无昵称, createdTime=Fri May 22 01:33:58 CST 2020, time=2020-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469062, encodeId=6a5746906249, content=已转, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 17:54:55 CST 2020, time=2020-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469045, encodeId=3c6f4690453d, content=写的很棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 10:36:07 CST 2020, time=2020-05-20, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1769827, encodeId=52751e698279a, content=<a href='/topic/show?id=b3fc92e7516' target=_blank style='color:#2F92EE;'>#超声引导#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Wed Apr 07 22:33:58 CST 2021, time=2021-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813478, encodeId=2b5618134e848, content=<a href='/topic/show?id=0ba692e7473' target=_blank style='color:#2F92EE;'>#超声引#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92774, encryptionId=0ba692e7473, topicName=超声引)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Thu Jun 11 20:33:58 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1946902, encodeId=ac421946902e6, content=<a href='/topic/show?id=9a3950183e9' target=_blank style='color:#2F92EE;'>#强直性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50183, encryptionId=9a3950183e9, topicName=强直性)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Sun Nov 01 21:33:58 CST 2020, time=2020-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1440408, encodeId=7ed4144040886, content=<a href='/topic/show?id=6f0e845427f' target=_blank style='color:#2F92EE;'>#脊柱炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84542, encryptionId=6f0e845427f, topicName=脊柱炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=50834728424, createdName=1249898am16暂无昵称, createdTime=Fri May 22 01:33:58 CST 2020, time=2020-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469062, encodeId=6a5746906249, content=已转, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 17:54:55 CST 2020, time=2020-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469045, encodeId=3c6f4690453d, content=写的很棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 10:36:07 CST 2020, time=2020-05-20, status=1, ipAttribution=)]
    2020-05-20 Ahui

    已转

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1769827, encodeId=52751e698279a, content=<a href='/topic/show?id=b3fc92e7516' target=_blank style='color:#2F92EE;'>#超声引导#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Wed Apr 07 22:33:58 CST 2021, time=2021-04-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1813478, encodeId=2b5618134e848, content=<a href='/topic/show?id=0ba692e7473' target=_blank style='color:#2F92EE;'>#超声引#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92774, encryptionId=0ba692e7473, topicName=超声引)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Thu Jun 11 20:33:58 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1946902, encodeId=ac421946902e6, content=<a href='/topic/show?id=9a3950183e9' target=_blank style='color:#2F92EE;'>#强直性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50183, encryptionId=9a3950183e9, topicName=强直性)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKeia4TJeMGvEH3wKKIBNjuHuIic1HDNOB10j4tCd3nbylxkxm6HSMfEaKkSu6OZOak4uZv7UVicsWEg/132, createdBy=bc9a2500116, createdName=zywlvao, createdTime=Sun Nov 01 21:33:58 CST 2020, time=2020-11-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1440408, encodeId=7ed4144040886, content=<a href='/topic/show?id=6f0e845427f' target=_blank style='color:#2F92EE;'>#脊柱炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84542, encryptionId=6f0e845427f, topicName=脊柱炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=50834728424, createdName=1249898am16暂无昵称, createdTime=Fri May 22 01:33:58 CST 2020, time=2020-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469062, encodeId=6a5746906249, content=已转, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 17:54:55 CST 2020, time=2020-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=469045, encodeId=3c6f4690453d, content=写的很棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200315/6c52e73f687745e5b92987fb63ac6545/路径.png, createdBy=fb822254669, createdName=Ahui, createdTime=Wed May 20 10:36:07 CST 2020, time=2020-05-20, status=1, ipAttribution=)]
    2020-05-20 Ahui

    写的很棒

    0

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慢性肾衰竭为各种慢性肾病持续进展的共同结局,各种原因造成的慢性进行性肾实质损害,进而不能维持肾脏的基本功能。慢性肾脏病尿毒症期,大多患者需要进行肾脏替代治疗,必然造成患者内环境发生改变。此类患者若因疾病需要手术治疗,手术和麻醉的风险都将大大增加。我院于2017年收治的一名孕期合并慢性肾衰竭的产妇,麻醉处理情况如下。

LANCET:麻醉深度与术后并发症的关系研究

研究报道麻醉深度增加和术后生存率降低之间存在一定的关系;但尚缺乏来自随机对照试验的证据。本研究的目的是比较接受大手术的浅麻醉或深麻醉的老年患者术后一年的全因死亡率。

Alzheimer’s & Dementia:局部麻醉或全身麻醉后的认知功能:一项基于人群的研究

我们的目的是研究与先前报道的全麻术后(GA)相比,接受区域麻醉/局部麻醉(RA)手术后是否与认知功能快速下降有关。

合并房间隔缺损的小儿癫痫病灶切除术麻醉管理一例报告

患者女,2岁,体质量11kg,身高80 cm。因“发作性抽搐1年10个月余”于2016年1月7日就诊,诊断为症状性癫痫,拟行癫痫病灶切除术。既往有先天性心脏病史,为中央型房间隔

Eur J Anaesthesiol:麻醉诱导时呼气末正压对面罩通气过程中胃进气的影响

麻醉诱导期间面罩通气(FMV)与胃内气体进入相关,可能导致返流及误吸。研究表明治疗阻塞性睡眠呼吸暂停综合征(OSAS)和胃食管反流病时,持续正压通气(CPAP)可增加下段食管括约肌 (LES) 压力来减少胃反流。本研究假设麻醉诱导过程中,在CPAP预充氧后应用呼气末正压(PEEP)行面罩通气可以减少胃内气体注入的风险。本研究主要目:(1)比较麻醉诱导后固定PEEP水平或零PEEP(ZEEP)时FM

手术1小时,苏醒3小时,遇到苏醒延迟该怎么办?

患者的麻醉苏醒情况不仅是手术后气管插管的主要评估指标,也是早期诊断术后神经系统损伤的最便捷、最重要观察指标之一。

拓展阅读

强直性脊柱炎的预防和康复锻炼

强直性脊柱炎(AS)是一种慢性炎性疾病,主要侵犯中轴骨骼,以骶骼关节炎为标志,而髋、肩以外的四肢关节受累少见。

BMC Surg:强直性脊柱炎患者两节段椎弓根复位截骨术后腹中矢状面表面变化的新数学模型

本研究的目的是建立一个数学模型来预计算强直性脊柱炎(AS)患者腹部正中矢状面(ac-AMSP)面积的变化,该患者计划进行两段椎弓根减截骨术(PSO)。

Int J Spine Surg:强直性脊柱炎或弥漫性特发性骨骼肥大患者椎体骨折固定后住院死亡率预测

本研究是利用全国住院患者样本医疗成本和利用项目(HCUP- NIS)数据库进行机器学习(ML)分析,以预测强直性脊柱炎(AS)或弥漫性特发性骨骼肥厚症(DISH)患者的术后死亡率。

髋关节经常疼痛?强直患者一定要警惕!

在外周关节病变中 ,髋关节病变是强直性脊柱炎致残的主要原因之一。髋关节一旦受累,很有可能急速发展并导致残疾,需要特别警惕。

除了腰背疼痛,强直患者的足跟痛也不容忽视!

强直性脊柱炎是一种病因、症状都较为复杂的疾病,除了常见的骶髂关节、脊柱关节疼痛,看似没什么关联的足跟痛,也是强直性脊柱炎的表现之一,而且不少强直性脊柱炎患者还以足跟痛为首发症状。

关于强直性脊柱炎的这些事,你一定要知道

强直性脊柱炎的患者如果能够及早发现,及时治疗,并在生活中多加注意,是可以达到一个很好的预后效果,不影响生活的。