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神经内镜下经单鼻蝶垂体瘤切除手术的护理配合

作者 / Author:靳玉红 金保哲 常廷民

摘要 / Abstract:

目的 总结神经内镜下经单鼻蝶垂体瘤切除术围手术期的护理要点。方法 回顾分析经新乡医学院第一附属医院神经外科诊断为鞍区垂体瘤并在神经内镜下进行单鼻蝶垂体瘤切除术的80例患者的临床资料,并总结术前准备、术中配合、术后护理及手术情况。结果 80例患者均顺利完成手术,其中14例出现术后尿崩症,4例脑脊液漏,经对症治疗后,尿崩症患者临床症状均显著缓解,1例脑脊液漏患者出现颅内感染,经全身抗生素治疗并持续引流2周后治愈。术后随访1例出现残瘤增大,2例复发。结论 熟练快速的手术护理配合措施是神经内镜下经鼻蝶垂体瘤切除手术成功的基本保障,尤其是术前心理护理及术后并发症护理,可提高护理质量,促进患者康复。

关键词 / KeyWords:

垂体瘤,垂体腺瘤,神经内镜,单鼻蝶,经鼻蝶窦入路
神经内镜下经单鼻蝶垂体瘤切除手术的护理配合
靳玉红 金保哲 常廷民
新乡医学院第一附属医院,河南卫辉 453000
作者简介:靳玉红,Email:maLabaLei@aLiyun.com
通信作者:常廷民,Email:huangjili1979@163.com
 
摘要 目的 总结神经内镜下经单鼻蝶垂体瘤切除术围手术期的护理要点。方法 回顾分析经新乡医学院第一附属医院神经外科诊断为鞍区垂体瘤并在神经内镜下进行单鼻蝶垂体瘤切除术的80例患者的临床资料,并总结术前准备、术中配合、术后护理及手术情况。结果 80例患者均顺利完成手术,其中14例出现术后尿崩症,4例脑脊液漏,经对症治疗后,尿崩症患者临床症状均显著缓解,1例脑脊液漏患者出现颅内感染,经全身抗生素治疗并持续引流2周后治愈。术后随访1例出现残瘤增大,2例复发。结论 熟练快速的手术护理配合措施是神经内镜下经鼻蝶垂体瘤切除手术成功的基本保障,尤其是术前心理护理及术后并发症护理,可提高护理质量,促进患者康复。
关键词】 垂体瘤;垂体腺瘤;神经内镜;单鼻蝶;经鼻蝶窦入路
中图分类号】  R473.74    【文献标识码】  A    【文章编号】  1673-5110(2019)03-0316-07  DOI:10.12083/SYSJ.2019.03.058
 
Nursing cooperation for the resection of pituitary pituitary tumor under nerve endoscope
JIN YuhongJIN BaozheCHANG Tingmin
The First Affiliated Hospital of Xinxiang Medical CollegeXinxiang 453000,China
Abstract  Objective  To summarize the main points of perioperative nursing in neuroendoscopic hypophysis resection.Methods  To review the clinical data of 80 patients with pituitary pituitary tumor in the saddle area diagnosed by neurosurgery in our hospital and perform a single nasal pituitary tumor resection under the endoscope,and summarize the nursing contents of the patients 'preoperative preparation,intraoperative coordination and postoperative nursing.And statistics on patient surgery.Results  80 patients successfully completed the operation,including 14 cases of postoperative urethral collapse and 4 cases of cerebrospinal fluid leakage.After the patient's treatment,the clinical symptoms of urethral collapse were significantly relieved.In 1 case of cerebrospinal fluid leakage,intracranial infection occurred.,After treatment with systemic antibiotics and continuous drainage for 2 weeks after the cure.Postoperative follow-up showed an increase in residual tumor in 1 case and a recurrence in 2 cases.Conclusion  Skilled and rapid surgical nursing measures are the basic guarantee for the success of endoscopic transnasal pituitary tumor resection,especially preoperative psychological nursing and postoperative complication nursing,which can improve the quality of nursing care and promote the recovery of patients.
Key words】  Pituitary tumors;Pituitary adenoma;Neuroendoscope;Single nose butterfly;Transsphenoidal approach
 
        垂体瘤是指垂体前叶、后叶及颅咽管上皮残余细胞的肿瘤,又称垂体腺瘤,临床较为常见的是垂体前叶,因垂体瘤可导致机体激素分泌异常,同时还可压迫周围组织,出现持续性头痛、视力减退等压迫症候群,极大干扰患者生活质量[1-7]。临床多采用手术切除予以治疗,随着微创学技术及器械飞越发展,现临床多采用神经内镜下经鼻蝶窦入路式,与传统开颅手术比较,具有创伤小、术后恢复快,且适合年老体弱者,在显微镜下操作,术中可清晰分辨正常垂体组织与肿瘤,可有效保留正常垂体,具有良好的治疗效果[5-13]。这一技术普及与临床护理密不可分,优质的围手术期护理是保证手术顺利进行的关键[14-18]。本研究总结80例患者的临床资料及围手术期护理重点。
 
1  资料与方法
1.1  一般资料  回顾性分析2015-07—2016-04新乡医学院第一附属医院神经外科收治的80例垂体瘤患者的临床资料,术前根据临床表现、内分泌检查及影像学检查等确诊,采用神经内镜下经单鼻蝶入路进行垂体瘤切除。本组患者男34例,女46例,年龄18~63(35.8±6.7)岁,病程3个月~5 a;临床表现:头晕头痛62例,视力模糊57例,内分泌功能紊乱58例,溢乳闭经50例,肢端肥大10例。
1.2  影像学资料 影像学检查显示患者均为鞍区垂体瘤占位性病变,且以鞍内为主,共52例,同时向鞍旁、蝶窦方向生长者28例,肿瘤直径<10 mm者12例,10~30 mm者68例。
1.3  手术资料  36例患者采用左侧单鼻蝶入路,44例采用右侧单鼻蝶入路。全身麻醉,平卧头后仰,并偏向手术鼻侧,略高于心脏,先予以抗生素、地塞米松,常规消毒鼻腔、铺巾,随后采用纯肾上腺素棉布置入鼻腔,保证鼻黏膜收缩扩张手术通道;充分显露蝶窦前壁后,43例使用高速磨钻扩大蝶窦开口,37例使用蝶窦咬骨钳磨除蝶窦内间隔进入蝶鞍区后,明确解剖标志,切除肿瘤,明胶海绵填塞止血,回复鼻中隔黏膜瓣,检查有无出血,清点物品。术后半卧位,给予常规抗生素及维持水电解质平衡治疗。
 
2  护理
2.1  术前护理准备 主要包括患者准备、环境准备、物品准备及护士准备。(1)患者准备:为收缩鼻部血管、消炎,术前3 d使用氯霉素滴鼻剂及氧氟沙星液或麻黄碱呋喃西林滴鼻前庭。因手术入路方式为经单鼻孔入路,故术前1 d应修剪鼻毛,清洗鼻腔,做好鼻腔清洁,严格消毒;如术前出现感冒、流鼻涕等,需控制病情稳定才可进行手术,以免发生术后感染。(2)环境准备:患者推送至手术室应保证室内温度26 ℃左右,手术开始后温度保持在22~25 ℃,湿度50%左右,因手术对无菌要求高,应选择百级净化手术间,且手术较为精细,实行手术时应保持环境安静,尽量减少走动。(3)物品准备:手术器械包括经蝶手术器械包、神经手术显微镜器械、小金刚高速气钻、油纱条、消毒棉签、肾上腺素等手术器械、绝缘双极电凝器等,注意仪器使用前检查其录像系统、冷光源线及仪器附件等功能是否完好,并在术前注意硬质内镜及其冷光源线采用STERIS低温灭菌柜进行灭菌,保证使用器械均为无菌状态。(4)护士准备:术前护士应做好上述事项,整理好仪表,还应进行恰当的心理护理。垂体瘤虽可手术切除,对患者预后无较大影响,但患者仍将其视为危及生命安全的疾病,易出现悲观、恐惧心理,进而出现术前焦虑,质疑术中安全,从而影响睡眠适量,干扰术前状态[19-25],因此术前护士应针对患者不同的心理状态进行疏导,充分讲解手术方式及垂体瘤危害,有条件科室还可组织手术成功治疗的患者进行演讲,并邀请主刀医师就手术过程进行讲解,消除其恐惧心理,督促患者保持良好的术前心态,调整好机体状态,从而配合手术。
2.2  术中护理 手术进行时除了器械护士,还应有巡回护士。术前准备事项应由巡回护士进行检查,在患者推入手术室后,巡回护士应主动协助麻醉师行全麻气管插管、动脉置管监测血压及血氧饱和度等。护士还应合理安置体位,保证头部后仰15°~20°,上半身抬高20°~25°;麻醉后巡回护士注意给患者眼角涂抹金霉素眼膏,保护其眼膜,并留置合适导尿管。尿崩症是垂体瘤手术患者较为常见的一种并发症,护士应术中严格观察尿量,并做好记录,为后期医生治疗提供参考。洗手护士是手术护理中的关键,术前需熟悉手术步骤及主刀医师喜好,积极掌握显微镜、双极电凝等相关仪器使用方法,以主动配合医师手术。其次,在鼻腔消毒过程中,使用肾上腺素棉片进行鼻道扩张时,如鼻甲肥厚,通道扩张不足,护士应及时行电凝收缩鼻甲;分离鼻中隔、暴露蝶窦区时,洗手护士需仔细观察主刀医师步骤,提前递给手术器械,并观察手术进展,提醒主刀医师在使用咬骨钳或高速磨钻扩大蝶窦时,注意不要偏向下外侧进入蝶腭动脉区等细节问题;术毕止血填塞纱条中,护士注意油纱条与鼻黏膜剥离面紧贴一致,预防鼻黏膜皮下血肿,可使用吸收止血纱布贴附止血,为防止术后尿崩,可使用明胶海绵填塞鞍底骨窗,如患者出现脑脊液漏,取自体脂肪进行鞍内填塞,再用明胶海绵修复鞍底,术后48~72 h取出,并观察鼻腔内切口处渗血情况。
2.3  术后护理 全麻未清醒前患者应头偏向一侧,以免呕吐导致呕吐物阻塞呼吸道引起误吸。全麻清醒4~6 h后,取半卧位,抬高头部15°~30°,有助于颅内静脉回流,预防脑水肿。
2.4  并发症护理  (1)尿崩症护理:垂体瘤患者因垂体后叶及垂体柄影响,抗利尿激素缺乏易导致尿崩症,如患者出现术后连续2 h尿量>300 mL/h或24 h尿量>5 000 mL,则可判断为尿崩症[10]。护士应及时上报医师采取相应措施,可以垂体后叶素6 U皮下注射或口服药物弥散,治疗时注意观察水、电解质,防止出现水、电解质紊乱。因尿液多导致机体含钾相对较少,护士应嘱咐患者多进食含钾食物,如香蕉、橙、蘑菇等。(2)脑脊液漏护理:患者出现脑脊液漏多因手术操作不当引起,或填塞不严实、鞍底蝶窦壁重建所致,一般发生在术后3~7 d,表现为患者坐起时鼻腔流出清水样液体,与鼻涕相似,但鼻涕中不含葡萄糖,需临床工作者及时采取样本送检,观察糖定性结果,如为阳性,表示合并脑脊液漏[26-33],护士立即报告医师,并嘱咐患者绝对卧床休息,去枕平卧2~3周,并告知患者及家属,禁用棉球、卫生纸私自填塞鼻腔,防止血液逆行感染;同时还需强调饮食重要性,多进食易消化食物,避免用力排便引起颅内压升高,加重脑脊液漏[34-40]
2.5  出院指导 嘱咐患者加强营养,多进食高热量、高蛋白、低盐低脂易消化食物,提高机体免疫力,避免感冒咳嗽、打喷嚏。如发现鼻腔内仍有量多、质清透液体,应及时入院就诊,并每隔3个月检查性激素,术后3个月定期MRI复查,随后半年1次,以便了解肿瘤变化情况。
 
3  结果
        本次研究中80例患者手术一次性成功,14例出现术后尿崩症,4例脑脊液漏。尿崩症患者采取补液、用药、口服弥散对症治疗,脑脊液漏患者采用腰大池引流,3例1周~10 d停止,1例出现颅内感染,经全身抗生素治疗并持续引流2周后治愈。所有患者3~7 d内显著缓解,1例脑脊液漏患者再次行神经内镜下经蝶手术,手术成功。术后所有患者顺利获得随访,1例残瘤增大,2例复发,激素检查正常。
 
4  小结
        目前垂体瘤切除术运用最为广泛的是经鼻蝶入路式[41-48],尤其对于鞍区肿瘤,只需磨除蝶窦前壁、部分犁状骨即可进进入蝶窦腔内,无需剥离鼻腔底部和鼻中隔上部黏膜,术后患者不会出现鼻中隔穿孔、鼻部变性,符合现代人们对的审美观点[49-56]。但如何充分发挥神经内镜在经蝶入路的优势,不仅需要主刀医师精湛的技术,还对护士熟练的围手术期高度配合。通过本次研究,总结出以下四大护理要点:(1)术前护理中最重要的是心理护理,通常患者认为肿瘤是会剥夺生命,且垂体瘤生长在垂体部分,而垂体又是机体重要的内分泌腺源泉,称为“内分泌腺之首”[57-63],可分泌生长激素、促甲状腺激素、催产素、性激素等,不同部位的垂体分工不同,本研究纳入的患者均为鞍区垂体瘤,此区间腺体主要是产生抗利尿激素、催乳素,患者易表现为激素异常症群,如肢端肥大症(激素分泌过多)、女性闭经不孕、男性不育阳痿(激素分泌过少),患者自觉身体异样,肿瘤压迫还可引起压迫综合征,出现头晕、头痛等现象[64],严重影响患者生活质量,且患者对神经内镜的陌生感,不如显微镜治疗普及范围广泛,其多少会产生恐惧感,因此适当的术前心理护理是很有必要的[65-66]。(2)常见术后并发症护理配合要点:尿崩症的发生还可因术中下丘脑及垂体柄损伤所致,护士应掌握损伤的诱因,如在电凝过程中,如肿瘤与下丘脑粘连紧密可导致过度电凝引起热损伤,减压性损伤是瘤体突然收缩牵动丘脑下部引起,还有缺血性损伤,切除肿瘤时破坏丘脑下部供血动脉造成出血,护士应警惕上述原因,与主刀医师高度配合,仔细观察手术过程,避免损伤[67-68]。视力下降主要诱因是鞍内填塞物过多或鞍内血肿,护士应在术中严格清点纱条,并配合医师冲洗、止血等。
        神经内镜下经鼻蝶入路垂体瘤切除术具有创伤小、术后恢复快、并发症少等优势,但垂体瘤周围均为重要神经、血管,手术需谨慎,对主刀医师的专业能力是个较大的挑战,对相应护理工作的护士专业素养也是个挑战,临床应建立围手术期护理团队,不断优化工作流程,抬高医护配合度,保证手术顺利进行。
 
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(收稿2018-04-15)
本文责编:夏保军
本文引用信息:靳玉红,金保哲,常廷民.神经内镜下经单鼻蝶垂体瘤切除手术的护理配合[J].中国实用神经疾病杂志,2019,22(3):316-322.DOI:10.12083/SYSJ.2019.03.058

Reference informationJIN YuhongJIN BaozheCHANG Tingmin.Nursing cooperation for the resection of pituitary pituitary tumor under nerve endoscope[J]Chinese Journal of Practical Nervous Diseases201922(3)316-322.DOI10.12083/SYSJ.2019.03.058

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