大学精品课件：15例外伤术后顽固性硬脑膜下积液...-王莺.ppt

1、The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 外伤术后脑脊液鼻漏的治疗及护理外伤术后脑脊液鼻漏的治疗及护理 神 外 一 王 莺 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 核心价值观与愿景核心价值观与愿景 具有鲜明学科特色的国际品牌医院 精湛演绎技术 关

2、爱体现服务 患者与服务对象至上 科技创新 服务大众 培育新人 引领未来 核心价值观核心价值观 使使 命命 服务理念服务理念 愿愿 景景 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 定定 义义 脑脊液鼻漏是一种由于脑膜破裂，脑脊液自颅骨 生理或病理的缝隙进入鼻窦或鼻腔，由前鼻孔或 鼻咽部溢出的疾病，易发生颅内感染而危及生命 ，手术修补是有效的治疗方法 The Needs of The Patients and The Cus

3、tomers Come FirstThe Needs of The Patients and The Customers Come First 脑脊液鼻漏病因脑脊液鼻漏病因 创伤性 1外伤性 最主要病因（80%）； 多见于前颅窝骨折 2医源性 非创伤性 1自发性 2肿瘤及化脓性炎症 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 外伤性脑脊液漏在颅脑外伤中最常见 其中最常见是脑脊液鼻漏，耳漏 The Needs of The

4、Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 外伤性脑脊液鼻漏诊断外伤性脑脊液鼻漏诊断 定性诊断 漏口定位：常用的方法有：x线断层；CT扫描及 颅底薄层CT冠扫 水溶性造影剂CT脑池造影：文献报道水溶性造影 剂CT脑池造影有很高的诊断价值 核素脑池动态显像 头颅MRI The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customer

5、s Come First 治疗方法治疗方法 保守治疗：绝对卧床 预防性使用抗菌药物防治颅内感染 脱水降颅压 对鼻漏液较多、1周以上未自愈或合并 有颅内感染的患者行持续性腰大池穿刺放液 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 手术治疗 前颅底硬膜外人路 鼻内镜的颅外入路（首选术） The Needs of The Patients and The Customers Come FirstThe Needs of The

6、Patients and The Customers Come First 15例外伤后脑脊液鼻漏行修补术及腰大池置管引流例外伤后脑脊液鼻漏行修补术及腰大池置管引流 术后并发症观察护理术后并发症观察护理 摘要：15例外伤后脑脊液鼻漏修补术+腰大池置管引流术 后观察护理。术后出现尿崩，引流不畅，颅内感染，颅内 出血等并发症。 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 病病 例例 分分 享享 患者，男，外伤后左侧鼻腔流 液2

7、月 现病史（现病史（History of Present Illness）:患者于2月前因外伤 头部着地，当地医院急诊头颅 CT示：1、左侧颞叶脑挫伤颅内 血肿 2、左额叶创伤性硬膜下 出血 3、眶骨骨折 4、颅底骨折 ，住院期间出现侧卧及坐起时 左侧鼻孔无色液体流出，无体 温升高，无鼻腔流血 2014-06-29行全麻下左眼鼻内 窥镜下视神经减压术 2014-07-28行局麻下腰大池置 管，患者脑脊液漏仍存在 2014-08-04拔除腰大池置管 拟“脑脊液漏”收住入院（8月 11号）。 The Needs of The Patients and The Customers Come Firs

8、tThe Needs of The Patients and The Customers Come First 2014年 08月 20 日 15 时 内镜下经鼻蝶脑脊液 鼻漏修补术+腰大池置管引流术 术后诊断：脑外伤 左侧视神经减压术后 颅底骨折 脑脊液鼻漏 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 术前术前CT The Needs of The Patients and The Customers Come Firs

9、tThe Needs of The Patients and The Customers Come First 术前术前MRI The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 术后术后MRI The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs

10、of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 填塞材料 自体脂肪和筋膜 明胶海绵、生物 胶止血 膨胀海绵填塞左侧鼻腔 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 术后并发症：尿崩术后并发症：尿崩 0 0 500500 10001000 15001500 20002000 2

11、5002500 30003000 35003500 40004000 45004500 8.218.218.238.238.258.25至9.10至9.10 24小时尿量24小时尿量 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 并发症并发症:颅内感染颅内感染 患者术后高热，（39.6） 脑脊液涂片找到革兰阴性菌 血常规示白细胞高，中性粒百分比91.4% 脑脊液常规、生化均提示存在颅内感染 感染科会诊， The Needs

12、of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 颅内感染治疗颅内感染治疗 稳可信1g q12h静滴治疗， 美罗培南加量至2g q8h静滴治疗 西力欣1.5g静滴q8h 复查脑脊液常规、生化、涂片及培养 监测血常规、CRP、PCT等指

13、标 患者诉有少许咳痰，可行痰涂片及痰培养，必要 时行胸部CT检查。 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 术后并发症：引流管堵塞术后并发症：引流管堵塞 8月30腰大池置管引流管堵塞 ： 引流液浑浊、粘稠 颅内压力较高 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Com

14、e First 预防措施预防措施 (1)对于严重颅脑损伤仍有颅高压征象，仍需使用激素、脱水 利尿降颅压控制好引流的速度 (2)通过调节引流袋水平来调节引流速度及引流量。 (3)对于引流液浑浊，或较浓的患者，医生于引流管内定期注 入少量生理盐水冲洗确保引流管通畅。 (4)更换引流袋过程中，应严格无菌操作。发现颅内感染。可 经引流管内注入敏感抗生素。 (5)穿刺点渗液应及时拔除引流管，用凡士林纱条压迫穿刺 点，待穿刺点愈合后再更换新穿刺点引流。 The Needs of The Patients and The Customers Come FirstThe Needs of The Patien

15、ts and The Customers Come First 2014-09-11 10:27脑脊液 培养+药敏(脑脊液)：细菌 、真菌培养未生长 主治医师查房，患者目前 术后恢复可，感染控制可 ，予转当地医院进一步治 疗 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 讨论：腰大池置管持续引流？讨论：腰大池置管持续引流？ 1腰大池置管持续引流必要性 2反复腰穿？ The Needs of The Patients and

16、The Customers Come FirstThe Needs of The Patients and The Customers Come First 腰大池置管持续引流具有创伤小、置管时间长、 感染率相对较低等优点，治疗外伤脑脊液漏有效 ，切实可行。 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 大多数外伤性脑脊液鼻漏患者可经保守治疗而自愈 病程超过l周未愈而行腰大池持续穿刺放液时，应注意控 制引流时间及引流量且应使用抗菌药预防感染 经保守治疗持续34周不愈者或自愈后多次复发者，需 行脑脊液鼻漏修补术，必要时行腰大池置管引流 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 感谢！感谢！