1. 1 General data There were 10 cases in this group, including 4 males and 6 females, with an average age of (54.8 9.8) years. Among them, there were 8 cases of posthepatitic cirrhosis, portal hypertension complicated with splenomegaly and hypersplenism, 65,438+0 cases of drug-induced cirrhosis and 0 cases of schistosomiasis cirrhosis. The size of spleen (oblique diameter under ribs) was (65,438+07.2 4.0) cm by B-ultrasound before operation.
1.2 treatment methods all patients in this group underwent in situ splenectomy under tracheal intubation anesthesia. The key point of the operation is to keep the spleen in its original position, cut off the short gastric vessels and portal vein vessels, then separate the surrounding tissues, and finally completely remove the spleen. Among them, 1 case of gallstones underwent cholecystectomy at the same time, and 2 cases of severe esophageal varices underwent combined portal azygos devascularization (Hassb 1 case, sugi ura 1 case).
Results 1.3 There were 10 cases in this group, and there was no death during and after operation. The average intraoperative blood loss was (581.2 683.4) ml, and 2 cases received blood transfusion, with an average blood transfusion volume of (100 213.8) ml, and the average postoperative hospital stay. There were no serious complications such as bleeding, venous thrombosis, pancreatic fistula and gastric fistula.
2 Preoperative nursing
2. 1 Psychological nursing All patients in this group have repeated course of disease, and patients often have the experience of seeing a doctor for many times. Among them, 1 patient with drug-induced liver cirrhosis suffered from gastrointestinal bleeding for 6 times, and needed surgical treatment, resulting in depression, doubt that his disease was incurable, loss of confidence in life, anxiety, resentment and self-abandonment. Introduce the knowledge about the disease, the advantages and nursing experience of orthotopic splenectomy to patients, eliminate their fear and nervousness about surgery, and enhance their confidence in overcoming the disease.
2.2 Nutritional support to assess the nutritional status of patients, hypoproteinemia is an important indicator of poor prognosis in perioperative period [2], and it has been reported that the infection of patients with hypoproteinemia has increased significantly. All patients in this group have different degrees of hypoproteinemia. The goal of perioperative nutritional support is to supplement calories, protein and vitamins to the maximum extent, so as to maintain protein, immune function and tissue repair. According to the patient's condition, we use medium and long chain fat emulsion, various amino acids and albumin to supplement nutrition.
2.3 Prevention and treatment of bleeding and infection The white blood cells of patients in this group are all lower than the normal value [(1.20 ~ 3.72) ×109/L]. Thrombocytopenia [(40~90)× 109/L], so patients are prone to bleeding and infection. Good observation and health education are also important links in nursing. Regularly measure the changes of body temperature, blood routine and blood coagulation function, instruct patients not to eat food with thorns and bones to prevent collision and trauma, brush their teeth gently, and press the injection site with sterile cotton balls for more than 5 minutes. 2.0g of rosfosine was given by intravenous injection 30 minutes before operation, so that the antibiotics can reach sufficient concentration in blood circulation and tissue wounds before bacteria enter the body, effectively resisting invading bacteria and preventing infection.
2.4 preoperative preparation preoperative indwelling gastric tube and catheter. When inserting the gastric tube, apply proper amount of lubricant and move it gently to avoid bleeding from varicose veins. Prepare 600 ~ 800 ml of blood before operation.
3 postoperative care
3. 1 Bleeding mostly occurred on the day after operation or within 48 hours. The most common causes are diaphragmatic or retroperitoneal bleeding, or the ligation of spleen pedicle falls off. (1) Vital sign monitoring. After operation, the patient's temperature, pulse, respiration, blood pressure and oxygen saturation were continuously monitored for 2 days, and oxygen inhalation was continued for 2 days to improve the oxygen supply to hepatocytes. Two patients in this group developed hypotension after operation, with systolic blood pressure of 82~96mmHg, diastolic blood pressure of 45~60mmHg and heart rate of 68~90 beats/min. However, the patient's skin color and limb color are normal, and there is no active bleeding in the abdominal drainage tube. Considering the hypotension caused by epidural analgesia pump, the blood pressure returned to the normal range 48 hours after the analgesia pump was removed. (2) Closely observe the quantity, color and nature of the liquid drained by the subphrenic drainage tube. If the amount of bleeding is more than 200 ml/h or more than > 1000ml/d/d within 3 hours after operation, it indicates active bleeding. At the same time, we should pay attention to the patient's chief complaint and observe whether there is tenderness in the abdomen. In this group, the drainage volume was 100~300ml on the first day after operation, 50~ 100ml on the second day after operation, and the drainage volume was less than 40ml or no drainage volume on the third day after operation, and the color gradually changed from bright red to light red. The drainage tube was removed when there was no bleeding, and there was no abdominal bleeding in this group. (3) In order to prevent stress ulcer bleeding, we should observe the color and nature of gastrointestinal decompression. On the day after operation, cimetidine 0.8g bid or losec 40mg bid were injected intravenously for ***5 days.
3.2 Prevention of postoperative infection Patients with portal hypertension should prevent infection because of their low immune function. Main measures: (1) Try to place patients in a single ward, keep the air in the ward unobstructed, keep the temperature and humidity appropriate, and strictly control the accompanying personnel. (2) postoperative application of large doses of antibiotics. (3) Close observation of body temperature changes, it is generally believed that postoperative fever is related to the decline of reticuloendothelial cell function, and can also be related to the absorption of residual blood in abdominal cavity. In this group, the body temperature fluctuated between 38℃ and 38.5℃ in 1 week, among which 7 cases were excluded from pleural effusion and subphrenic infection, and the white blood cell count was normal or slightly higher than normal in laboratory examination, so it was considered as spleen fever and treated with antibiotics for 7~ 10 days. (4) Do basic nursing, such as oral care and perineal care, to prevent complications.
3.3 Prevention of venous thrombosis venous thrombosis is a serious complication, which can lead to portal vein embolism and pulmonary embolism. The changes of platelets were closely monitored on the day of operation, 1, and 3, 5 and 7 days after operation, especially on 3-5 days after operation [3], so we adopted the principle of predictive nursing to prevent venous thrombosis. (1) Patients were encouraged and assisted to do lower limb exercises after operation, and patients were encouraged to get out of bed for 3 days after operation. (2) Observe the patient's body temperature and limb swelling, pain, congestion, local tenderness and other symptoms. (3) When the platelet count exceeds 60× 109/L, anticoagulants such as aspirin should be given immediately. In this group 1 patient, the platelet continuously increased to 82×109/L. After treatment with warfarin and dipyridamole, the platelet gradually decreased to normal level.
3.4 Discharge guidance is extremely important for patients with portal hypertension, telling patients to have a regular life, pay attention to the combination of work and rest, and should not do strenuous exercise; Eat less and eat more, avoid rough and irritating food, give priority to high-quality protein, quit smoking and drinking; Maintain an optimistic psychological state and avoid negative emotions such as tension and depression; Instruct patients (family members) to master bleeding precursors and basic observation methods.
4 discussion
The concept of China's in situ splenectomy was first put forward by Sun Wenbing of 302 Hospital of PLA in June 2003 [4]. In September, 2003, our department also started in-situ splenectomy for patients with portal hypertension and splenomegaly. Portal hypertension due to liver cirrhosis: (1) Spontaneous portosystemic shunt channels are formed in the spleen and stomach, and the adhesion around the spleen is very dense. (2) The number and range of short gastric vessels are enlarged. (3) Splenic blood vessels are tortuous and fragile. (4) Spleen portal is widened, and the distance between pancreatic tail and spleen is shortened. Although splenectomy in situ can effectively protect the important structures such as gastric fundus and pancreatic tail, it avoids the serious complications that may be caused by traditional methods. However, the operation risk of patients with portal hypertension and splenomegaly is still very high and the nursing requirements are high. Our department has only accumulated 10 nursing experience for the next operation, but we fully realize that perioperative care of such patients is still an important link in the whole treatment. By strengthening psychological nursing and nutritional support before operation, closely observing the changes of illness after operation and taking effective preventive measures in time, the surgical effect was improved, the workload of clinical nursing was reduced and the postoperative cycle was shortened.