پديد آورندگان :
بيگي، علي اكبر دانشگاه علوم پزشكي اصفهان - بيمارستان الزهراء - بخش جراحي عمومي و عروق - گروه جراحي عمومي و عروق , قريشي، مهرداد دانشگاه علوم پزشكي اصفهان - بيمارستان الزهراء - بخش جراحي عمومي - گروه جراحي عمومي , گلپرور، محمد دانشگاه علوم پزشكي اصفهان - بيمارستان الزهراء - گروه بيهوشي , محموديه، محسن دانشگاه علوم پزشكي اصفهان - بيمارستان الزهراء - بخش جراحي عمومي و عروق - گروه جراحي عمومي و عروق , طهماسبي راد، مروا , صحت، سياوش دانشكدة پزشكي اصفهان
كليدواژه :
ترﻭﻣﺎ , ﺟﺮﺍﺣﻲ ﺗﺮﻣﻴﻢ ﻋﺮﻭﻕ , ﺁﻣﭙﻮﺗﺎﺳﻴﻮﻥ , MESS
چكيده فارسي :
ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺩﺭﻣﺎﻥ ﺑﻪ ﻣـﻮﻗﻊ ﺁﺳﻴﺐ ﺍﻧﺪﺍﻡ ﺩﺭ ﺑﻴﻤـﺎﺭﺍﻥ ﺗﺮﻭﻣﺎﻳﻲ، ﻣﻮﺟﺐ ﺣﻔﻆ ﺍﻧﺪﺍﻡ ﻣﻲ ﺷﻮﺩ، ﻭﻟﻲ ﺍﺻﺮﺍﺭ ﺑﻲ ﻣﻮﺭﺩ ﺩﺭ ﺣﻔﻆ ﺍﻧﺪﺍﻡ ﺩﺭ ﻣـﻮﺍﺭﺩ ﺁﺳﻴﺐ ﺷﺪﻳﺪ ﺑﺪﻭﻥ ﺩﺭ ﻧﻈﺮ ﮔﺮﻓﺘﻦ ﻣﺮﺍﻗﺒﺖ ﻫﺎﻱ ﻭﻳﮋﻩ ،ﻋـﻮﺍﺭﺽ ﻣﺘﻌﺪﺩﻱ ﺑﻪ ﻫﻤـﺮﺍﻩ ﺧﻮﺍﻫﺪ ﺩﺍﺷﺖ. ﺍﻳﻦ ﻋﻮﺍﺭﺽ ﻛﻪ ﻋﻤـﺪﺗﺎﹰ ﺑﻪ ﻋﻠﺖ ﺑﺮﻗﺮﺍﺭﻱ ﻣﺠـﺪﺩ ﭘﺮﻓﻴـﻮﮊﻥ ﺑﺎﻓﺘﻲ ﺩﺭ ﺍﻧﺪﺍﻡ ﺩﭼﺎﺭ ﺍﻳﺴﻜﻤﻲ ﺍﻳﺠﺎﺩ ﻣﻲ ﺷﻮﻧﺪ، ﺍﺩﺍﺭﻩ ﺑﻴﻬـﻮﺷﻲ ﺑﻴﻤﺎﺭ ﻭ ﻭﺿﻌﻴﺖ ﻭﻱ ﺣﻴﻦ ﻭ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﺭﺍ ﺗﺤﺖ ﺗﺄﺛﻴـﺮ ﻗﺮﺍﺭ ﻣﻲ ﺩﻫﻨﺪ ﻭ ﮔﺎﻩ ﺳﺒﺐ ﻣﺮﮒ ﻭ ﻣﻴﺮ ﺑﻴﻤﺎﺭﺍﻥ ﻣﻲ ﮔﺮﺩﺩ. ﺍﺯ ﺍﻳﻦ ﺭﻭ ﺍﮔﺮ ﺑﺘﻮﺍﻥ ﺑﻪ ﻛﻤﻚ ﻣﻌﻴـﺎﺭﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ، ﻣﻴـﺰﺍﻥ ﻭ ﺷﺪﺕ ﺑﺮﻭﺯ ﺍﻳﻦ ﻋﻮﺍﺭﺽ ﺭﺍ ﭘﻴﺶ ﺑﻴﻨﻲ ﻛﺮﺩ، ﺍﻣﻜﺎﻥ ﺍﺩﺍﺭﻩ ﺑﻬﺘـﺮ ﺑﻴﻤﺎﺭ ﻭ ﻛﺎﻫﺶ ﺍﻳﻦ ﻋـﻮﺍﺭﺽ ﻓـﺮﺍﻫﻢ ﻣﻲ ﮔﺮﺩﺩ. ﻫﺪﻑ ﻣﺎ ﺍﺯ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ
ﺗﻌﻴﻴﻦ ﭘﻲ ﺁﻳﻨﺪ ﻭ ﻋـﻮﺍﺭﺽ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺗﺮﻣﻴﻢ ﻋـﺮﻭﻕ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺑﻌﻀﻲ ﻣﺸﺨﺼﻪ ﻫﺎﻱ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﻣﻲ ﺑﺎﺷﺪ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻪ ﺻﻮﺭﺕ ﺗﻮﺻﻴﻔﻲ ـ ﺗﺤﻠﻴﻠﻲ ﮔﺬﺷﺘﻪ ﻧﮕﺮ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﻃﻲ ﺳﺎﻝ ﻫﺎﻱ 1374 ـ 1384 ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﺍﻟﺰﻫﺮﺍ ﺑﻪ ﺳﺒﺐ ﺁﺳﻴﺐ ﻫﺎﻱ ﻋﺮﻭﻗﻲ ﺗﺤﺖ ﺗﺮﻣﻴﻢ ﺷﺮﻳﺎﻥ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺑﻮﺩﻧﺪ ﺻﻮﺭﺕ ﮔﺮﻓﺖ ﻭ ﺑﺮ ﭘﺎﻳﻪ ﺗﻌﺪﺍﺩﻱ ﺍﺯ ﻣﻌﻴﺎﺭﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﺷﺎﻣﻞ ﺷﺪﺕ ﺁﺳﻴﺐ ﺑﺎﻓﺖ ﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻧﻲ ﻭ ﻧﺮﻡ ، ﺩﺭﺟﻪ ﺷﻮﻙ، ﻣﺪﺕ ﺯﻣﺎﻥ ﺍﻳﺴﻜﻤﻲ ﺍﻧﺪﺍﻡ ﻭ ﺳﻦ، ﻧﻤﺮﻩ ﺍﻱ ﺗﺤﺖ ﻋﻨﻮﺍﻥ MESS= Mangled Extremity Severity Score ﺑﺮﺍﻱ ﺗﻌﻴﻴﻦ ﺩﺭﺟﻪ ﺁﺳﻴﺐ ﺍﻧﺪﺍﻡ ﻣﺤﺎﺳﺒﻪ ﮔﺮﺩﻳﺪ. ﺳﭙﺲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻪ ﺩﻭ ﮔﺮﻭﻩ، ﻳﻜﻲ ﺑﺎ ﻧﻤﺮﻩ ﻛﻤﺘﺮ ﺍﺯ 7 ﻭ ﺩﻳﮕـﺮﻱ ﺑﺎ ﻧﻤﺮﺓ ﻣﺴﺎﻭﻱ ﻳﺎ ﺑﻴﺸﺘﺮ ﺍﺯ 7 ﺗﻘﺴﻴﻢ ﺷﺪﻩ، ﻓﺮﺍﻭﺍﻧﻲ ﻧﺴﺒﻲ ﺑﺮﺧﻲ ﻋـﻮﺍﺭﺽ ﺣﻴﻦ ﻭ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﺩﺭ ﻫﺮ ﮔﺮﻭﻩ ﻣﺤﺎﺳﺒﻪ ﮔﺮﺩﻳﺪ ﻭ
ﺿﻤﻦ ﻣﻘﺎﻳﺴﻪ ﺩﻭ ﮔﺮﻭﻩ، ﺑﺎ ﺁﺯﻣﻮﻥ ﺁﻣﺎﺭﻱ Fisher’s Exact Test ﺗﺤﻠﻴﻞ ﺁﻣﺎﺭﻱ ﺍﻧﺠﺎﻡ ﮔﺮﻓﺖ ﻭ P value <0.05 ﻣﻌﻨﻲ ﺩﺍﺭ ﺗﻠﻘﻲ ﺷﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﺩﺭ ﻣﺠﻤـﻮﻉ 68 ﺑﻴﻤﺎﺭ ﺩﺭ ﻫﺮ ﮔﺮﻭﻩ، ﺷﺎﻣﻞ ﻳﻚ ﮔﺮﻭﻩ 54 ﻧﻔﺮﻱ ﺑﺎ MESS ﻛﻤﺘـﺮ ﺍﺯ 7 ﻭ ﻳﻚ ﮔﺮﻭﻩ 14 ﻧﻔﺮﻱ ﺑﺎ MESS ﺑﻴﺸﺘﺮ ﻳﺎ ﻣﺴﺎﻭﻱ 7 ﺑﺮﺭﺳﻲ ﻭ ﻣﻘﺎﻳﺴﻪ ﺷﺪﻧﺪ. ﻓـﺮﺍﻭﺍﻧﻲ ﻧﺴﺒﻲ ﻋـﻮﺍﺭﺽ ﺣﻴﻦ ﻋﻤﻞ ﺷﺎﻣﻞ: ﻫﻴﭙﻮﺗﺎﻧﺴﻴﻮﻥ، ﻧﻴﺎﺯ ﺑﻪ ﺩﺍﺭﻭﻫﺎﻱ ﻭﺍﺯﻭﭘﺮﺳﻮﺭ، ﺍﺧﺘﻼﻝ ﺍﺳﻴﺪ ﻭ ﺑﺎﺯ ﻭ ﻓـﺮﺍﻭﺍﻧﻲ ﻧﺴﺒﻲ ﻋـﻮﺍﺭﺽ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺷﺎﻣﻞ: ﻧﻴﺎﺯ ﺑﻪ ﺗﻬﻮﻳﻪ ﻣﻜﺎﻧﻴﻜﻲ، ﺗﺄﺧﻴﺮ ﺩﺭ ﺧﺎﺭﺝ ﺳﺎﺯﻱ ﻟﻮﻟﻪ ﺗﺮﺍﺷﻪ، ﻋﻤﻞ ﻣﺠـﺪﺩ ﺍﻧﺪﺍﻡ، ﺁﻣﭙﻮﺗﺎﺳﻴـﻮﻥ ﺍﻧﺪﺍﻡ، ﻣـﺮﮒ )ﻓـﻮﺕ ﺑﻴﻤﺎﺭ( ﻭ ﺍﻳﺴﺖ ﻗﻠﺒﻲ ﺩﺭ ﻃﻮﻝ ﺩﺭﻣﺎﻥ، ﻫﻤﭽﻨﻴﻦ ﻣﻴﺎﻧﮕﻴﻦ ﺑﻲ ﻛﺮﺑﻨﺎﺕ ﻭ ﺧﻮﻥ ﻣﺼﺮﻓﻲ ﺣﻴﻦ ﻋﻤﻞ ﻭ ﻣﻴﺎﻧﮕﻴﻦ BUN ﻭ ﻛـﺮﺍﺗﻴﻨﻴﻦ ﺑﻴﻤﺎﺭﺍﻥ 24 ﺳﺎﻋﺖ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﻭ ﻃﻮﻝ ﻣـﺪﺕ ﺑﺴﺘﺮﻱ ﺑﻴﻤـﺎﺭﺍﻥ ﺩﺭ ﮔﺮﻭﻩ ﺑﺎ 7 ≥MESS ﻧﺴﺒﺖ ﺑﻪ ﮔﺮﻭﻩ ﺑﺎ
MESS<7 ﺑﻴﺸﺘـﺮ ﺑﻮﺩ. ﻣﻴﺎﻧﮕﻴـﻦ ﺍﻳﺴﺖ ﻗﻠﺒﻲ ﺣﻴﻦ ﻋﻤﻞ ﺩﺭ ﺩﻭ ﮔﺮﻭﻩ ﺍﺧﺘﻼﻑ ﻣﻌﻨﻲ ﺩﺍﺭﻱ ﻧﺪﺍﺷﺖ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺷﻴـﻮﻉ 14 ﻣﻮﺭﺩ ﺍﺯ 17 ﻣﻮﺭﺩ ﻋﺎﺭﺿﻪ ﺑﺮﺭﺳﻲ ﺷﺪﻩ، ﺑﻪ ﻃﻮﺭ ﻗﺎﺑﻞ ﻣﻼﺣﻈﻪ ﺍﻱ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ 7 ≥MESS ﺑﻴﺸﺘـﺮ ﺍﺯ ﮔﺮﻭﻩ ﺑﺎ MESS<7 ﻣﻲ ﺑﺎﺷﺪ ﻭ ﺍﺻﺮﺍﺭ ﺑﺮ ﺣﻔـﻆ ﺍﻧﺪﺍﻡ ﺩﺭ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ، ﺑﺮ ﺷﺪﺕ ﻋـﻮﺍﺭﺽ ﻭ ﻭﺧﻴـﻢ ﺷﺪﻥ ﭘﻴﺶ ﺁﮔﻬﻲ ﻣﻲ ﺍﻓـﺰﺍﻳﺪ. ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺍﻳﻨﻜﻪ ﺑﺎ ﺍﻓـﺰﺍﻳﺶ ﺩﺭﺟﻪ ﻣﻌﻴﺎﺭ MESS ﺑﺮ ﻣﻴﺰﺍﻥ ﻋـﻮﺍﺭﺽ ﺍﻳﺠﺎﺩ ﺷﺪﻩ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﻭ ﺍﺣﺘﻤﺎﻝ ﻣﺮﮒ ﺍﻓـﺰﻭﺩﻩ ﻣﻲ ﺷﻮﺩ ﻟـﺬﺍ، ﻗﺎﺑﻞ ﺗﻮﺟﻪ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺑﻴﻤـﺎﺭﺍﻧﻲ ﻛﻪ ﺍﻗـﺪﺍﻡ ﺑﻪ ﺗﺮﻣﻴﻢ ﻋـﺮﻭﻕ ﺩﺭ ﺁﻧﻬﺎ ﺍﻧﺠـﺎﻡ ﻣﻲ ﺷﻮﺩ ﻫﺮ ﭼﻘﺪﺭ ﻣﻌﻴﺎﺭ ﻓـﻮﻕ ﺑﺎﻻﺗﺮ ﺑﺎﺷﺪ ﺑﺎﻳﺪ ﺍﻗﺪﺍﻣﺎﺕ ﺍﺣﻴﺎﺀ ﻭ ﻣﺮﺍﻗﺒﺖ ﻫﺎﻱ ﻭﻳﮋﻩ ﺧﺎﺻﻲ ﺣﻮﻝ ﻭ ﺣﻮﺵ ﻋﻤﻞ ﺑﺮﺍﻱ ﺍﻳﻦ ﺩﺳﺘﻪ ﺍﻓـﺮﺍﺩ ﺻﻮﺭﺕ ﮔﻴﺮﺩ. ﺍﻧﺠﺎﻡ ﺗﺤﻘﻴﻘـﺎﺕ ﻣﺸﺎﺑﻪ ﺩﺭ ﺳﺎﻳﺮ ﻣـﺮﺍﻛﺰ ﻛﺸﻮﺭ ﺟﻬﺖ ﮔﺴﺘﺮﺵ ﺩﺍﻧﺶ ﻣﺎ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ ﻭ ﻓـﺮﺍﻫﻢ ﺁﻭﺭﺩﻥ ﺑﺴﺘﺮ ﻣﻨﺎﺳﺐ ﺑﺮﺍﻱ ﺍﺳﺘﻔـﺎﺩﻩ ﻋﻤﻠﻲ ﺍﺯ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ ﭘﻴﺸﻨﻬـﺎﺩ ﻣﻲ ﮔﺮﺩﺩ.
چكيده لاتين :
ntroduction & Objective: Appropriate management of extremity injuries results in limb salvage but such attempts in severe injuries may cause several complications. These complications are due to restoration of perfusion to ischemic tissues and include: respiratory failure, renal failure, decreased level of consciousness and decreased cardiac output. These can disturb managing patient, both intraoperatively and postoperatively. Thus predicting such events preoperatively, can help in better management .
We are aiming at assessing outcome and complications of limb vascular repair operations, regarding MESS preoperatively.
Materials & Methods: As a descriptive - analytic study, we evaluated all patients operated due to extremity vascular injuries during years 1995-2005.
An score named Mangled Extremity Severity Score (MESS) was calculated for each patient, using certain clinical criteria including: skeletal/soft tissue injuries, limb ischemia, shock and age. Then patients divided into two groups: one with scores less than 7 and the other with scores ≥ 7.
Relative frequency was calculted for certain complications in each group and then the results were compared and analyzed statistically by Fisher's Exact Test.
Results: Of 68 patients, 54 had MESS<7 and 14 had MESS ≥ 7. Relative frequency of intraoperative complications, including hypotension, need to vasopressors, and acid - base disturbance were 50%, 14.3% and 92.9% in group with MESS ≥ 7 and 13%, zero and 29.6% in group with MESS<7, respectively.
Relative frequency of postoperative complications, including mechanical ventilation, delay in extubation, limb reoperation, limb amputation, mortality and cardiac arrest were 25%, 35.7%, 72.7%, 72.7%, 28.6% and 28.6% in group with MESS ≥ 7 and 2%, 1.9%, 13.2%, 7.5%, 1.9% and 3.8% in group with MESS<7, respectively.
Mean of bicarbonate and blood infused intraoperatively were 0.4 ± 0.9 vial and 3.3 ± 2.7 unit in group with MESS<7 and 2.4 ± 3.3 vial and 7.3 ± 5.4 unit in group with MESS ≥ 7, respectively.
Mean of BUN and creatinine 24 hour after operation and duration of hospitalization were 18 ± 6mg/dl, 0.9 ± 0.3mg/dl and 8.8 ± 8.2 days in group with MESS<7 and 31 ± 14mg/dl, 1.6 ± 1.2mg/dl and 17.7+11 days in group with MESS ≥ 7, respectively. There were no statistically significant difference in mean of fluids infused intraoperatively, relative frequency of acid - base disturbance and mean of GCS, both 24 hours after operation, comparing two groups.
Conclusions: Relative frequency of complications in patients with MESS ≥ 7 was significantly more than those with MESS<7 and limb salvage efforts, when not indicated, caused more severe complications and poorer prognosis.
