Berman A T, Parmet J L, Harding S P, Israelite C L, Chandrasekaran K, Horrow J C, Singer R, Rosenberg H
Department of Orthopaedic Surgery, Allegheny University Hospitals, MCP-Hahnemann School of Medicine, Philadelphia, Pennsylvania 19102, USA.
J Bone Joint Surg Am. 1998 Mar;80(3):389-96. doi: 10.2106/00004623-199803000-00012.
The right atrium and the right ventricle of fifty-five patients were imaged with transesophageal echocardiography during fifty-nine total knee arthroplasties performed with cement and the use of general anesthesia. The patients ranged in age from thirty-two to eighty-three years (mean, 65.5 years). Cardiopulmonary parameters were measured with use of hemodynamic monitoring systems, such as pulse oximeters, pulmonary artery catheters, and radial artery catheters. In addition, a femoral vein catheter was inserted on the side of the operation in ten of the fifty-five patients. Showers of echogenic material traversing the right atrium, the right ventricle, and the pulmonary artery after the tourniquet was deflated were observed to various degrees in all patients and lasted three to fifteen minutes. The mean peak intensity occurred within thirty seconds (range, twenty-four to forty-five seconds) after the tourniquet was released. The mean mixed venous oxygen saturation (and standard error of the mean) decreased (from 83+/-0.9 to 72+/-1.5 per cent) and the mean pulmonary arterial pressure increased (from 20+/-1.0 to 27+/-1.0 millimeters of mercury [2.67+/-0.13 to 3.60+/-0.13 kilopascals]), compared with the values before the tourniquet was released, in all patients. The pulmonary vascular resistance index increased after release of the tourniquet (to a maximum of 328+/-29 dyne.s.cm(-5).m2; p = 0.00002) only in the patients who had echogenic material that was at least 0.5 centimeter in diameter. Clinical pulmonary embolism developed postoperatively in three patients; all three had had echogenic particles that were more than 0.5 centimeter in maximum diameter on imaging. Blood aspirated from one of the pulmonary artery catheters and from five of the ten femoral vein catheters demonstrated fresh venous thrombus. Histological evaluation of the aspirates failed to demonstrate fat, marrow, or particles of polymethylmethacrylate. Surgeons should consider acute pulmonary embolism as a diagnosis when evaluating a patient who has hemodynamic collapse during total knee arthroplasty performed with cement.
在59例使用骨水泥并采用全身麻醉进行的全膝关节置换术中，对55例患者的右心房和右心室进行了经食管超声心动图检查。患者年龄在32岁至83岁之间（平均65.5岁）。使用血流动力学监测系统测量心肺参数，如脉搏血氧仪、肺动脉导管和桡动脉导管。此外，55例患者中有10例在手术侧插入了股静脉导管。所有患者在止血带放气后均不同程度地观察到有回声物质穿过右心房、右心室和肺动脉，持续3至15分钟。平均峰值强度出现在止血带松开后30秒内（范围为24至45秒）。与止血带松开前的值相比，所有患者的平均混合静脉血氧饱和度（及平均标准误差）均下降（从83±0.9%降至72±1.5%），平均肺动脉压升高（从20±1.0毫米汞柱[2.67±0.13至3.60±0.13千帕斯卡]）。仅在有直径至少0.5厘米的有回声物质的患者中，止血带松开后肺血管阻力指数升高（最高达328±29达因·秒·厘米⁻⁵·米²；p = 0.00002）。术后有3例患者发生临床肺栓塞；所有3例在影像学上均有最大直径超过0.5厘米的有回声颗粒。从一根肺动脉导管和十根股静脉导管中的五根吸出的血液显示有新鲜静脉血栓。对吸出物的组织学评估未发现脂肪、骨髓或聚甲基丙烯酸甲酯颗粒。在评估使用骨水泥进行全膝关节置换术期间发生血流动力学衰竭的患者时，外科医生应考虑急性肺栓塞的诊断。
