全膝關節置換術後引發肺及全身動脈栓塞之病例報告

壓脈帶及骨泥常用於骨科下肢手術中，因手術本身或壓脈帶的因素，產生靜脈栓塞，當手術結束後壓脈帶解除，可能引發器官栓塞尤其是肺已是眾所皆知。病患如有卵圓孔閉鎖不全之先天缺損或肺臟內部分流等右向左分流時，則會造成全身性的動脈栓塞，其病程的演進快速且怪異。在這裡我們報告一位60歲患有糖尿病之女性患者，因左膝骨性關節炎進入開刀房接受全膝關節置換術，於手術後隔日清晨，病人出現過度換氣、竇性心搏過速及腹痛等症狀。當時動脈氣體分析資料為低血氧合併呼吸性鹼中毒，胸部x-光片顯示pulmonary trunk engorgement，左右下葉有infiltrating patch，兩側血管紋路減少，右橫膈膜微升。兩天後因腹部疼痛持續惡化，故接受正中切開之腹式探查術，手術中發現小腸之迴腸部份有多處壞死，膽囊也有缺血現象。由以上臨床徵狀和手術中發現，研判是患肢之栓塞流出引發肺栓塞合併異位栓塞(paradoxical embolism)。病人之心、肺、腎功能逐漸惡化，於第二次手術從第四日，因敗血症合併多器官衰竭而宣告死亡。

關鍵字

手術：全膝關節置換術；設備：壓脈帶；肺栓塞：異位

並列摘要

Pneumatic tourniquet and bone cement are often applied in orthopaedic surgery. In lower limb surgery, deep vein thrombosis may occur after release of tourniquet, causing embolism of lungs and vital organs. Paradoxical embolism may develop if the patients present extracardiac or intracardiac right to left shunt, such as atrial septum defect, etc. A 60-year-old female patient suffered from osteoarthritis of both knees was admitted for total knee replacement (TKR). Pneumatic tourniquet was inflated on the operated leg for the orthopaedic surgery which lasted for 2h. Dyspnea, sinus tachycardia and abdominal pain were noted after TKR. Blood gases analysis showed arterial hypoxemia and respiratory alkalosis. Chest X-ray revealed diffused bilateral pulmonary infiltration, pulmonary trunk engorgement, and decreased lung markings. Two days after TKR under the impression of peritonitis, she received exploratory laparotomy in which ischemic bowel and gall bladder were found. Pulmonary and paradoxical embolism were diagnosed, both of which were the well-known complications of TKR with tourniquet and bone cement application. The patient finally succmubed because of multiple organ failures.

並列關鍵字

Surgery: total knee replacement ； Equipment: tourniquet ； Pulmonary embolism: paradoxical

國際替代計量

全膝關節置換術後引發肺及全身動脈栓塞之病例報告

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