小儿放射学中镇静和镇痛的应用

随着小儿放射学的迅速发展 ,特别是介入放射学及外科电视下复位等治疗性操作在小儿诊治中的应用 ,建立完善高效的镇静、镇痛程序才能保证诊治的准确、安全、有效。本文就笔者在实际工作中对小儿镇静和镇痛程序的建立和应用进行探讨。1　材料和方法选取 1995 -0 1～ 1999-12小儿放射学检查病案 2 2 4例 ,其中 ,男 12 9例 ,女 95例 ,年龄 1ｄ～ 12岁。放射学诊治包括ＣＴ扫描、静脉肾盂造影、食管狭窄球囊扩张、介入诊治、外科电视下复位等。镇静前详细采集病史和全身检查 ,按照ＡＳＡ标准评分[1] (以此选择合适的镇静方法 )。了解用药及药物…     

常用的介入诊疗技术

我们通常所说的“介入诊疗”是介入放射学的通俗叫法，这种技术将诊断和治疗有机地结合在一起，在医学影像设备的引导下，经皮肤穿刺小切口（２～３毫米）或经人体的自然腔道（如口腔、肠腔），将细小的导管直接插至病变部位，将造影剂或治疗药物、器械直接送至病变部位，操作１次，可同时完成检查和治疗两项任务。其特点是：（１）损伤小（皮肤切口仅２～３毫米），切口无需手术缝合；（２）定位准确，疗效高，高浓度药物可直达病变部位；（３）恢复快，术后仅需卧床２４小时，部分患者可门诊治疗；（４）安全、简便，并发症少。随着介入器…     

CT定位介入治疗高血压脑出血的价值

本文选取111例介入治疗高血压脑出血患者（介入组）及同等数量单纯药物治疗患者（保疗组），进行疗效观察及回顾性对比分析，旨在探讨CT定位介入治疗高血压脑出血的诊断价值。     

晚期肝癌介入栓塞化疗加射频热疗的疗效评价

目的：研究晚期肝癌介入栓塞化疗（TACE）加射频热疗的疗效和毒副作用。方法：原发性或转移性肝癌33例，分为两组，TACE加热疗组14例，单纯TACE组19例。所有患者均介入肝动脉灌注化疗药物并栓塞，TACE加热疗组于介入栓塞后行上腹部射频热疗，治疗3周期后，以WHO疗效评价标准评价疗效。治疗前后进行肝功能分级，骨髓毒副作用参照WHO化疗毒副作用标准评价，以χ^2检验法比较组间差异。结果：TACE加热疗组，3例部分缓解（PR）（21．4％），5例病灶稳定（SD）（35．7％）；单纯介入栓塞组有2例PR（10．5％），3例SD（15．8G）；疾病控制率（PR＋CR＋SD）分别为51．7％及26．3％（P〈0．05）；两组间肝功能，血常规变化未见明显差异（P〉0．05）。结论：本研究提示TACE加射频热疗较单纯介入栓塞治疗临床有效率高，副作用未见明显差异。     

喜炎平与利巴韦林治疗小儿上呼吸道感染的临床效果观察

目的：探讨喜炎平治疗小儿上呼吸道感染的疗效和安全性。方法将60例患有上呼吸道感染的小儿患者随机分为研究组（常规治疗＋喜炎平治疗）30例，对照组（常规治疗＋利巴韦林治疗）30例，治疗1周后观察两组疗效及安全性。结果1周后研究组治疗有效率93％，而对照组治疗有效率仅为83％，两组比较，数据有统计学意义（χ2＝0.145， P＜0.01）。两组治疗过程中均未见明显药物副作用。结论喜炎平治疗小儿上呼吸道感染的疗效优于对照组，且无明显药物副作用。     

小儿肠套叠空气灌肠规范化诊疗的探讨

目的：探讨小儿肠套叠空气灌肠诊断与治疗的规范化操作模式。方法：总结2031例肠套叠空气灌肠诊断与治疗的规范化操作经验,规范化模式主要围绕空气灌肠的适应证,灌肠术中、术后可能出现的相关并发症,以及从循证医学角度建立影像学诊疗依据等环节,将小儿肠套叠空气灌肠诊断与治疗过程分为诊断性灌肠和治疗性灌肠两部分,相应做出规范化操作标准,有利于规范严谨地开展此项诊疗业务。结果：通过建立规范化操作标准本组病例治疗成功率96%,诊断符合率100%,并且实现零纠纷和零投诉。结论：肠套叠空气灌肠的操作流程规范化模式的建立,有利于该项诊疗技术安全有效开展。     

消化道大出血的介入应用

目的：探讨消化道大出血的介入诊断及治疗价值。资料与方法：对14例消化道出血病例进行血管造影，术中根据不同的出血原因和部位，分别采用动脉栓塞或缩血管药物、止血药物的灌注治疗。结果：动脉栓塞治疗4倒，即时止血率为100％；缩血管药物加止血药物灌注8例，即时止血率100％。1例24小时内再出血；2例进行血管造影明确诊断，行外科手术。治疗术后病人均无严重并发症。结论：消化道出血介入治疗，可明确诊断确定出血点，术中同时行动脉栓塞或缩血管药物、止血药物灌注治疗是安全有效的，为临床诊断及治疗提供了帮助；若复发出血，亦可为急诊病人争取时间。     

综合医院心血管病介入诊疗操作4472例临床分析

目的：分析综合医院心血管病介入性诊疗操作资料，探讨减少并发症和提高成功率的经验。　方法：总结１９７９～１９９９ 年陆续开展的 ６ 项介入诊断项目和９ 项介入治疗项目，分析成功率、失败率、严重并发症率和病死率。　结果：２０ 年间共完成介入诊疗操作４ ４７２ 例，成功４ ４６９ 例（９９．９％ ），失败３ 例（０．１％ ），并发症７ 例（０．２％ ），无死亡病例。同一位术者独立完成１００ 例介入操作前后的手术失败率和并发症率差别显著（Ｐ＜ ０．０５）。　结论：①在大型综合医院谨慎开展心血管病介入诊疗操作是可行和安全的；②严格适应证选择、完善术前准备、相对固定手术班子和密切术后观察是提高成功率、减少并发症和病死率的重要措施；③齐全的设备和器械是保证安全有效地完成介入操作的重要因素；④术者积累较为熟练的介入经验需独立完成单项操作１００ 例以上。     

X线导向经皮胸部穿刺针吸活检(附401例报告)

目的：评价Ｘ线导向经皮穿刺针吸活检术对胸部病变的诊断价值。方法：对４０１例胸部肿块或结节进行了４５１人次Ｘ线导向经皮穿刺针吸活检术。结果：穿刺针吸标本细胞学或细菌学检查阳性３５６例（８８．８％），阴性４５例（１１．２％）。经手术病理、随访或治疗等证实，真正阳性３５６例，真正阴性４例，诊断正确率为８９．８％，假阴性４１例，误诊率为１０．２％。穿刺活检术后发生气胸４１例（１０．２％），少量咯血３３例（８．２％），无大出血或大量咯血者，亦无死亡病例。结论：Ｘ线导向经皮穿刺针吸活检对胸部肿块或结节是一种简单实用且比较安全的获取诊断资料的检查方法。     

以突眼为表现的眼部血管病——颈动脉海绵窦瘘的介入治疗

目的探讨颈动脉海绵窦瘘眼部表现特点、影像学检查及介入治疗方法。 方法回顾分析5年中18例首诊于我院眼科的颈动脉海绵窦瘘者的眼部症状及体征、影像学检查、治疗方法等。18例患者均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例,应用弹簧圈+Onyx胶封堵瘘口3例,覆膜支架隔绝瘘口3例。 结果所有病例中最常见的眼部表现为搏动性眼球突出、球结膜充血水肿、眼球运动障碍等。头颅或眼部CT平扫检查所有病例均显示患侧眼球突出,眼上静脉增粗;全部患者均行数字减影血管造影检查明确诊断。本组18例（20眼）均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例（14眼）,结果10例（12眼）瘘口完全闭塞,发生并发症2例,无严重并发症或死亡病例。应用弹簧圈+Onyx胶封堵瘘口3例（3眼）、覆膜支架隔绝瘘口3例（3眼）,瘘口均完全闭塞,无并发症或死亡病例。全部手术患者眼部症状和体征均得到明显改善。随访时间（12±3.4）个月,无复发病例,颈动脉覆膜支架内未发生狭窄及闭塞。 结论对于以突眼及其他相关症状就诊于眼科的患者,应考虑颈动脉海绵窦瘘的可能,血管造影是该病诊断的金标准,介入手术治疗对颈动脉海绵窦瘘是安全有效的。     

Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients

PURPOSE: To establish a protocol for credentialed pediatric radiology nurses, with radiologist supervision, to administer ketamine to induce sedation and analgesia during interventional radiologic procedures. MATERIALS AND METHODS: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed. RESULTS: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department. CONCLUSION: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors' knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision.     

Pediatric imaging: sedation with an injection formulation modified for rectal administration.

PURPOSE: To determine if rectal sedation with thiopental sodium produced for intravenous administration provides safe and effective sedation for children undergoing diagnostic imaging. MATERIALS AND METHODS: Five hundred twenty-five consecutive children (mean age, 2.7 years +/- 2.2 [SD]) underwent magnetic resonance imaging (n = 425), computed tomography (n = 89), and nuclear medicine (n = 11) examinations after rectal administration of thiopental sodium injection solution. The solution was prepared from thiopental sodium powder mixed with sterile water to create a concentration of 100 mg/mL. The dose ranged from 25 to 40 mg per kilogram of body weight, with a total dose limit of 1.5 g. The percentages of successful sedations and adverse reactions were evaluated on the basis of data collected at the time of the sedation. RESULTS: Sedation was successful in 504 (96%) children. Ten (2%) children experienced desaturation, but only three of the 10 experienced sedation failure. All cases of desaturation were treated successfully with head repositioning, administration of supplemental oxygen, or both. No children experienced vomiting, acute rectal irritation, paradoxical hyperactivity, or prolonged sedation. CONCLUSION: Thiopental sodium sedation for pediatric imaging, with use of a rectal solution prepared from thiopental sodium preparation for intravenous injection, is safe and effective.     

Anesthesia Practice and Clinical Trends in Interventional Radiology: A European Survey

Purpose: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends. Methods: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived from a similar survey of interventional practice in the United States. Results: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds. Conclusion: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.     

Pediatric interventional radiology

In the last several years, we have witnessed a steady growth in both the number and the complexity of interventional procedures in the pediatric population. This article presents our approach to interventional techniques in children of different ages, specifying our methods of sedation, patient monitoring, and selection or modification of equipment. We present our experience with nonvascular and vascular intervention. In the nonvascular group, we have focused on genitourinary and gastrointestinal procedures, outlining the techniques we have found to be safe and effective. Percutaneous aspiration, drainage, and biopsy can be successfully accomplished in the majority of cases, even in the smallest child. Over this same period, the indications for vascular intervention have dramatically increased. Embolization has become an important asset for treatment of vascular malformations, management of hemorrhage, and medical renal ablation. In our institution, embolization is now the preferred method in many cases previously considered only amenable to surgery. Percutaneous transluminal angioplasty and the use of fibrinolytic therapy are considered effective in all age groups, but continue to have limited indications in the pediatric population. It is our hope that this experience will stimulate others to continue development of pediatric interventional techniques, thereby making them more widely available to children of all ages.     

Interventional radiology in infants and children: clinical and technical aspects

The authors performed 53 extravascular interventional procedures in 47 pediatric patients between July 1981 and September 1983. Except for transhepatic cholangiography in patients without intrahepatic biliary dilatation, the success rate was high. There were few complications, and none that were life-threatening or required surgery. More than 90% of procedures were performed without general anesthesia. Factors essential to safe and successful intervention in infants, children, and adolescents, in the authors' opinion, include (a) active involvement by the radiologist, (b) guidance by real-time imaging, (c) careful matching of needles, catheters, and guide wires to patient size, and (d) adequate sedation and analgesia.     

Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology

PURPOSE: To evaluate the safety and effectiveness of a systematic protocol for sedation and analgesia in interventional radiology. MATERIALS AND METHODS: Ninety-one adult patients underwent 113 abdominal interventional procedures. Fentanyl citrate and midazolam hydrochloride were administered in one to five steps (A, B, C, D, E) until the patient was drowsy and tranquil at the effective loading dose (ELD). Doses per step were as follows: A, fentanyl 1 microg per kilogram of body weight; B, midazolam 0.010-0.035 mg/kg; C, repeat dose in A; D, repeat half the dose in B; and E, midazolam 1-2-mg boluses (maximum, 0.15 mg/kg). RESULTS: The ELD was reached in no procedure after step A, in 70 after B, in 23 after C, and in 18 after D. Step E was needed in two procedures. The mean maximum pain score (scale of 0 to 10) was 3.4; pain scores in 85 (75%) procedures were 4 or less (discomforting). Severe pain occurred in seven (6%) procedures. Hypoxia (oxygen saturation < 90%) occurred in 11 (22%) procedures performed in patients breathing room air and four (6%) performed in those breathing supplemental oxygen (P: =.04). All patients responded to supplemental oxygen. CONCLUSION: This stepwise "ABCDE protocol" allows safe and effective sedation of patients. It is easy to use and may be useful in training radiology residents, staff, and nurses in the techniques of sedation and analgesia. Supplemental oxygen should be used routinely.     

Sedation,anesthesia, and physiologic monitoring during MR imaging: Evaluation of procedures and equipment

The authors developed safe standard sedation and general anesthesia procedures for adults and children, including adequate physiologic monitoring, during magnetic resonance (MR) imaging. Six-year results are reported from one institution; 75% of the 600 patients per year who require sedation or anesthesia are children who require sedation only. Testing was done to determine MR compatibility of various types of equipment essential for monitoring and supporting sedated or anesthetized patients in 1.0-and 1.5-T MR imagers. Use of sedation procedures that include oral chloral hydrate after sleep deprivation resulted in a failure rate of 3.8% in sedating outpatient children. Every physiologic parameter that can be monitored under normal circumstances in the critical care unit or operating room can be monitored during MR imaging. Our experience indicates that with careful consideration of the unique MR environment and with rigorous testing of monitoring equipment, MR imaging can be performed safely in sedated or anesthetized patients.     

Conscious sedation for interventional procedures: a practical guide

Sedation is often used in interventional procedures to minimize discomfort, improve the patient's experience, and reduce the risk of procedural complications by assuring nonmobility and compliance of the patient. Sedation, however, adds a new dimension to the procedure by compromising the patients' normal protective mechanisms and carries the potential of cardiac, respiratory, and cognitive complications. Interventional procedures could be performed under local anesthesia with or without sedation, or under general anesthesia. Sedation itself could be categorized into minimal, moderate, or deep sedation. The choice generally depends on patient factors such as age, cardiovascular stability, pain tolerance, and procedural factors such as complexity, extent, and degree of induced pain. In longer and more extensive procedures on more fragile patients, the assistance of an anesthesiologist will be required. The purpose of this article is to provide a basic understanding and a practical guideline for minimal and moderate sedation for the interventionalist contemplating to administer sedation for less involved procedures.     

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

Introduction We evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures. Methods A total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture. Results The procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%. Conclusion Our experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.     

Establishing diagnostic reference levels for interventional procedures in Kenya

PurposeTo quantify ionizing radiation exposure to patients during interventional procedures and establish national diagnostic reference levels (NDRLs) for clinical radiation exposure management.MethodsThe cumulative reference point air kerma, kerma area product, fluoroscopy time and other operational parameters were monitored for 50 children and 261 adult patient procedures in five catheterization medical laboratories in Kenya. To estimate the risk associated with the exposure, effective doses were derived from the kerma area product using conversion factors from Monte Carlo models.ResultsAbout 3% of the measured cumulative reference point air kerma for the interventional procedures approached the threshold dose limit with the potential to cause deterministic effects such as skin injuries. In interventional cardiology, the results obtained for both children and adults indicated 33% were below the diagnostic reference levels (DRLs). In adult interventional radiology, 29% for cumulative reference point air kerma, and 43% for kerma area product and fluoroscopy time respectively were below the diagnostic reference levels. NDRLs were proposed for routine use in the procedures considered and for the non-existent DRLs situations in paediatric interventional cardiology.ConclusionThe measured patient doses were above the DRLs available in the literature indicating a need for radiation optimization through, continuous monitoring and recording of patient dose. To promote radiation safety, facilities performing interventional procedures need to establish a radiation monitoring notification threshold for possible deterministic effects, in addition to the use of the newly established national diagnostic reference levels, as a quality assurance measure.