腰椎间盘切除术中血管损伤:危险因素、诊断、手术矫正方法、麻醉管理特点和重症监护

Oleksii S. Nekhlopochyn, Maksym M. Pylypenko, Sergii O. Dubrov
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引用次数: 1

摘要

神经外科的首要任务之一是降低术后并发症的发生率和死亡率。腰椎间盘切除术是脊柱神经外科中最常见的介入手术,也是一种相当安全的手术。术中血管损伤是危及患者生命的并发症之一。第一例椎间盘切除术中大血管损伤的临床病例是在1945年。据信,这种并发症的发生率为1-5例/ 10000例手术干预,但文献指出,这些数字可能被严重低估。一些作者指出,尽管手术技术在过去50年里得到了发展,但这种并发症的发生频率并没有显著下降,因此外科医生对这种问题的可能性有所了解和警惕是很重要的。在显著增加血管损伤风险的因素中,先天性、后天和技术性是确定的。大血管损伤临床症状的差异是由于损伤部位、类型(动脉、静脉或联合)和血管损伤程度的不同。对于每个级别的手术干预,“最典型”的血管损伤被确定。椎间盘切除术中血管损伤可根据三种临床和病理形态学情况发生:血管破裂症状、动静脉瘘或假性动脉瘤形成。根据不同的作者,这些发现的频率差异很大。这篇综述检查了椎间盘切除术中血管损伤发展的可能变异的症状,并描述了手术矫正方法的特点。除了明确血管损伤的位置和类型外,最关键的是评估失血量和持续出血的速度。在疑似大出血的情况下,最重要的是增派医务人员进行手术止血,并为输血提供足够的血液。在血管意外的情况下,适当麻醉管理的关键要求是维持允许的动脉低血压,直到手术止血的时刻。大血管受损失血性休克的针对性治疗包括快速止血复苏,包括1:1:1比例平衡的血液成分和产物,如血浆、红细胞、新鲜冷冻血浆、血小板、凝血因子等。在乌克兰,在发生意外失血时获得足够数量的血液成分和制品(根据大量输血方案)是一项艰巨的任务,因此,在缺乏某些成分或血液制品的情况下,可以使用全血作为替代。并发症的数量和严重程度以及结果主要取决于输血的效率和及时性,以及手术止血的速度。本出版物根据现代国际标准和乌克兰法规文件详细介绍了大出血患者管理的要点。
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Vascular injury during lumbar discectomy: risk factors, diagnosis, methods of surgical correction, features of anaesthetic management and intensive care
One of the priority tasks in neurosurgery is to reduce the frequency of postoperative complications and mortality. Lumbar discectomy is the most frequently performed intervention in spinal neurosurgery and it is a fairly safe procedure. One of the possible intraoperative surgical complications, that threatens the patient’s life is vascular injury. The first clinical case of damage to the large vessels during discectomy was described in 1945. It is believed that the frequency of this complication is 1‒5 cases per 10,000 surgical interventions, but the literature notes that these figures may be significantly underestimated. Some authors indicate that the frequency of this complication, despite the development of surgical techniques over the past 50 years, has not significantly decreased, so it is important for surgeons to be informed and alert about the possibility of such a problem. Among the factors that significantly increase the risk of vascular damage congenital, acquired and technical are determined. Variability of clinical symptoms of damage to lagre vessels is due to different localization of injury, type (arterial, venous or combined) and scale of vascular disaster. For each level of surgical intervention, the "most typical" vessel damage is identified. Vascular injury during discectomy can occur according to three clinical and pathomorphological scenarios: manifestation of vessel rupture symptoms, arteriovenous fistula or a pseudoaneurysm formation. According to different authors, the frequency of these findings varies significantly. This review examines the symptoms of possible variants of vascular damage development during discectomy and describes the characteristics of surgical correction methods. Along with clarifying the location and variant of vascular damage, the critical thing is assessing the amount of blood loss and the rate of ongoing bleeding. In the case of suspected massive bleeding, the paramount importance is the involvement of additional medical personnel for the surgical haemostasis and providing sufficient blood for haemotransfusions. In case of a vascular accident, the key requirement for adequate anaesthetic management is the maintenance of permissive arterial hypotension until the moment of surgical haemostasis. Targeted treatment of haemorrhagic shock in case of damage to large vessels consists of rapid haemostatic resuscitation including blood components and products in a balanced 1:1:1 ratio, such as plasma, red blood cells, fresh frozen plasma, platelets, and coagulation factors. In Ukraine, obtaining a sufficient amount of blood components and products (according to the protocol of massive haemotransfusion) in case of unpredicted blood loss is a difficult task, therefore, in the absence of certain components or blood products, whole blood can be used as an alternative. The number and severity of complications and outcomes primarily depend on the efficiency and timeliness of blood transfusions, along with the speed of surgical arrest of bleeding. This publication describes in detail the main points of management of patients with massive bleeding according to modern international standards and Ukraine regulatory documents.
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