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醫(yī)學(xué)論文范文:急性化膿性膽管炎合并心血管疾病的循證麻醉
【摘要】 目的：借助循證醫(yī)學(xué)的方法為一例急性化膿性膽管炎合并心血管疾病的老年患者確定麻醉方案。方法：充分評(píng)估患者情況后，提出臨床問題，從Cochrane 圖書館(2009年第1期 )、Pubmed(1999年1月-2009年4月)檢索。檢索主題詞為：hypertension， cardiovascular disease，acute suppurative cholangitis，elderly patient，epidural anesthesia，general anesthesia， RCT,human，meta-analysis，systmatic review。結(jié)果：共檢索出與麻醉處理相關(guān)問題的隨機(jī)對(duì)照試驗(yàn)24篇，系統(tǒng)評(píng)價(jià)12篇。分析文獻(xiàn)后為患者制定合理的麻醉方案。結(jié)論：在臨床工作中采用循證方法，結(jié)合最佳文獻(xiàn)證據(jù)及醫(yī)務(wù)人員的臨床經(jīng)驗(yàn)和患者的期望值，為急性化膿性膽管炎合并心血管疾病的患者制定理想的治療方案，有效提高麻醉安全性。
【關(guān)鍵詞】 心血管疾病;急性化膿性膽管炎;老年患者;麻醉
Evidence-Based Anesthesia for an Acute Suppurative Cholangitis Patient Complicated Cardiovascular DiseaseZENG Wen-jing,LIU Ju-ying (Renmin Hospital of Wuhan University,Wuhan,Hubei 430060;Department of Anesthesiology,Taihe Hospital,Yunyang Medical College,Shiyan,Hubei 442000,China)Abstract:Objective A clinical scheme of anesthesia for an an acute suppurative cholangitis elderly patient complicated cardiovascular disease was made with the evidence-based medicine approach.Methods The situation of patient was fully assessed,the clinical problems were proposea and the information about how to slove the problems was searched in the database of Cochrane library(the first period,2009),PubMed(from January 1999 to April 2009).The searched Medical Subject Headings(MeSH) were:hypertension,cardiovascular disease,acute suppurative cholangitis,elderly patient,epidural anesthesia,general anaesthesia,RCT,human,meta-analysis,systmatic review.Results There were total 24 randomized controlled trials(RCTs) and 12 systmatic reviews correlating with the anesthetic treatment,the clinical scheme was worked out through the analysis of those literatures.Conclusion The evidence-based medicine method,the effective information from literatures,the clinical practise of medical staff combined with the expected value of patients could provide an ideal scheme for acute suppurative cholangitis patients complicated cardiovascular disease,and effectively improve the safety of anesthesia醫(yī).學(xué).全.在.線f1411.cn.
Key words: Cardiovascular disease;Acute suppurative cholangitis;Elderly patient;Anesthesia
1 一般資料
1.1 臨床資料患者，女，84歲，因反復(fù)右上腹疼痛一周入院。既往有膽囊結(jié)石，腦血栓，高血壓病史。入院前行頭孢噻肟和替硝唑抗炎治療一周，緩解后再發(fā)。查體：T 40 ℃，HR 125 bpm，R 20 bpm，BP 125/75 mmHg。神志清楚，精神差，皮膚鞏膜黃染，右上腹壓痛，劍突下和右上腹有明顯壓痛和肌緊張，墨菲征陽(yáng)性。輔助檢查：白細(xì)胞：14.5×109/L，血生化：GPT 539 mmol/L，GOT 1 013 mmol/L，總血膽紅素明顯升高;B超提示：膽囊腫大、膽囊多發(fā)性結(jié)石、膽總管擴(kuò)張。
1.2 評(píng)估患者并提出問題
根據(jù)患者臨床表現(xiàn)，結(jié)合實(shí)驗(yàn)室檢查和體格檢查，參照1983年全國(guó)肝膽管結(jié)石專題研討會(huì)制定的診斷標(biāo)準(zhǔn)，患者急性化膿性膽管炎的診斷成立。術(shù)前訪視患者，ASA為3級(jí);根據(jù)Goldman非心臟手術(shù)病人心血管疾病危險(xiǎn)因素評(píng)分方法，對(duì)此例病人進(jìn)行分析，得分12分，術(shù)前請(qǐng)相關(guān)科室會(huì)診;根據(jù)非心臟手術(shù)心血管危險(xiǎn)度分層，心血管危險(xiǎn)1%～5%(心血管危險(xiǎn)度包括心源性死亡及非致命性心肌梗死總發(fā)病率)，屬中危，施行麻醉有一定風(fēng)險(xiǎn)�；颊吆粑鼉�(chǔ)備功能明顯下降，無(wú)困難氣道體征。既往有高血壓、腦血栓病史，規(guī)律服用降壓藥及抗凝藥，發(fā)病前血壓維持在150/90 mmHg水平。據(jù)此，提出問題：⑴此病人手術(shù)時(shí)機(jī)如何選擇?⑵采取哪種麻醉方式相對(duì)安全?⑶用麻醉藥時(shí)注意哪些方面?
