非预计困难气管插管的处理流程与安全管理:2015版“成人非预计困难气管插管管理指南”解读

正气道管理与麻醉安全和质量息息相关,气道问题是引起麻醉不良事件和死亡的重要因素。2015年11月,英国困难气道学会(difficult airway society,DAS)发布2015版"成人非预计困难气管插管管理指南"(以下简称2015版指南)~([1])。该指南是在2004年首版"非预计困难气管插管管理指南"~([2])基础上,于2012年4月成立指南工作组,系统总结近10年来气道管理领域涌现的新方法和技术,于2013、2014 DAS年会期间专门讨论,最终于2015年     

困难气道管理的策略与流程

<正>气道管理是麻醉科、急诊科、ICU和院前急救医师的必备技能,确保患者气道通畅,充分的气体交换和氧合是危重病抢救的必备条件。但临床工作中困难气道常有发生,2011年英国皇家麻醉学院和困难气道协会报道在麻醉诉讼死亡患者中,约25%与困难气道处理失败相关~([1])。因此,处理好困难气道管理有重要意义。2013年美国麻醉医师协会将困难气道定义为完成正规培训的麻醉医师在面罩通气时遇到了困难(上呼吸道梗阻)或气管插管时遇到了困难,或两者兼有的一种临床情况~([2])。2017年中华麻醉医师协会《困难气道管理指南》指出,困难气道是经过专业训练的有5年以上临床经验的麻醉医师发生面罩通气困难或插管困     

《中国老年2型糖尿病防治临床指南(2022)》——护理实践部分要点解读

2022年中国老年医学学会老年内分泌代谢分会等在2018年《中国老年2型糖尿病诊疗措施专家共识》的基础之上,汇总了国内外老年糖尿病相关指南和研究成果,发布了具有重要实践意义的《中国老年2型糖尿病防治临床指南(2022年版)》,从老年糖尿病的现状、诊断、治疗、预防、管理等多个视角给出了最新的推荐意见,,为临床规范化实践提供有效帮助。本文主要从2022年新版指南的护理实践部分进行要点解读,为专科护理实践提供指导,提升老年糖尿病总体护理质量,改善中国老年2型糖尿病患者的临床结局。     

颈内静脉穿刺相关急诊困难气道处理

<正>急诊气管插管的成功率在90.5%~95%[1-2],困难气道特别是紧急气道的解救是麻醉医师的终极目标,也是最容易出现重大事故的危险因素,是必须要克服的困难。通过2例颈内静脉穿刺相关的急诊困难气道处理的分析,解读美国麻醉医师学会(ASA)2013版困难气道管理指南;提出紧急气道处理方案。一、临床资料例1,女,72岁。因右侧输尿管上段结石和右肾结石拟行经皮肾镜钬激光碎石术。患者张口度>     

急诊气道管理共识

气道管理是急诊医师的基本技能,是维持急危重症患者生命体征的重要手段.虽然中华医学会麻醉学分会在2013年推出了我国的《困难气道管理指南》[1],但对于急诊患者,存在病种、病情、治疗环境等多方面的差别,无法有效指导急诊临床实践.中国急诊气道管理协作组结合急诊气道管理的特点,提出“优先维持通气与氧合,快速评估再干预,强化降阶梯预案,简便、有效、最小创伤”为原则的急诊气道管理专家共识.协助急诊医师及相关从业人员掌握规范、高效的气道管理流程,提高急诊气道管理的质量.     

2012北京医学会麻醉学分会学术年会召开

2012年7月14日北京医学会麻醉学分会学术年会在北京国际会议中心顺利召开。此次年会作为北京医学会成立90周年系列活动之一,吸引了与会人员逾1500名,内容分为16个学术版块、1个困难气道管理Workshop及6个卫星会。     

气道管理的循证方法:临床实践指南的问题和对策

正由气道管理引起的并发症是麻醉相关罹患率和病死率的重要原因~([1])。为减少气道管理并发症,许多国家已制定气道管理实践指南,帮助临床医师进行气道管理~([2-7]),且近年新型气道管理工具和技术的临床应用明显增加~([8])。虽然目前在气道管理方案、技术和工具等方面均取得明显进展,但麻醉中气道管理相关并发     

推动麻醉学向围手术期医学转变:《加速康复外科中国专家共识及路径管理指南(2018版)》麻醉部分解读

《加速康复外科中国专家共识及路径管理指南(2018版)》的发布, 标志着中国在推进加速康复外科方面向前迈出了重要一步。对其麻醉部分进行解读对于麻醉医生更好地了解围手术期管理过程中的临床实践方法和管理路径具有重要指导价值。本文结合指南的麻醉部分, 对其关键内容进行了循证医学证据的深度挖掘, 从围手术期医学角度进一步明示麻醉学临床实践的未来发展方向。     

“美敦力——临床麻醉安全与质量”征文通知

正为能更好地提高围术期的安全与质量,《麻醉安全与质控》杂志现征集更高质量临床研究的文章,本刊与美敦力公司合作进行主题征文,围绕麻醉监测与调控及气道管理两大内容。征文活动即日起正式启动,欢迎广大医师参与、踊跃投稿。征文内容:麻醉中的监测与调控:围绕麻醉深度监测、脑氧饱和度监测、血氧饱和度监测等旨在提高围术期麻醉安全与质量的临床应用及研究气道管理:围绕分肺通气、困难气道处理或围术期气道管理的临床应用及研究     

“美敦力——临床麻醉安全与质量”征文通知

正为能更好地提高围术期的安全与质量,《麻醉安全与质控》杂志现征集更高质量临床研究的文章,本刊与美敦力公司合作进行主题征文,围绕麻醉监测与调控及气道管理两大内容。征文活动即日起正式启动,欢迎广大医师参与、踊跃投稿。征文内容:麻醉中的监测与调控:围绕麻醉深度监测、脑氧饱和度监测、血氧饱和度监测等旨在提高围术期麻醉安全与质量的临床应用及研究气道管理:围绕分肺通气、困难气道处理或围术期气道管理的临床应用及研究     

Common unsolved anesthetic problems of reconstructive maxillofacial surgery

Anesthesia for facial skeleton surgery has been studied. Mane concerns for maxillofacial surgery were difficult airways management, poorly controlled bleeding, difficult monitoring of several components of anesthesia, duration of surgery.     

插管型喉罩用于困难气道的临床研究

目的:观察插管型喉罩(intubating laryngeal mask airway,ILMA)在困难气道中应用的可行性。方法:25例Cormack与lehaneⅢ-Ⅳ级预测为困难气道的择期手术患者(Difficut组,简称D组),另匹配25例Cormack与lehaneⅠ-Ⅱ级的择期手术患者(Control组,简称C组),在静脉诱导后行ILMA插管。观察喉罩置入时间和次数、气管插管时间和次数、插管并发症以及成功率。结果:D组24例(96％)成功经ILMA插入气管导管,其中1次插管成功16例,成功率64％;2次插管成功6例;1例操作失败。C组25例(100％)全部经ILMA成功插入气管导管,其中1次插管成功23例,成功率92％。2次插管成功1例。D组和C组喉罩置入加插管总时间分别为(90．24±8．50)s和(81．26±7．20)s,插管时间分别为(41．73±7．86)s和(40．80±6．93)s。两组在气管导管插入时间、总的ILMA置入时间,成功率、术后并发症等方面无显著差异。结论:插管型喉罩是处理困难气道的有效应用工具之一。     

Airway ultrasound for patients anticipated to have a difficult airway: Perspective for personalized medicine

Airway ultrasound allows for precise airway evaluation, particularly for assessing the difficult airway and the potential for front of neck access. Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation. However, no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy. This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making. The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed. The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.     

品管圈在改善PACU全麻术后低体温发生率中的应用

摘要：目的 分析品管圈管理模式在改善PACU全麻患者苏醒期低体温发生率中的应用 方法 选取2022年1月—2022年6月本院未参加品管圈活动的120例PACU内全麻术后患者作为对照组,选取2022年7月—2022年12月在本院实施品管圈活动的120例PACU中全麻术后患者作为观察组,对照组采取常规护理措施,而观察组开展品管圈活动,并进行数据分析。结果 PACU全麻患者术后低体温发生率由品管圈活动开展前63.33%下降至开展后26.67%,品管圈活动开展后低体温发生率明显下降,差异显著（P＜0.05）有统计学意义。 结论 品管圈活动在改善PACU患者低体温的应用中效果显著,有效降低了患者术后低体温发生率,是一种值得临床推广的管理模式。     

King Airway Use by Air Medical Providers

Background. In cases of difficult or failed endotracheal intubation (ETI), alternate airways are designed to provide adequate oxygenation andventilation until a definitive airway can be established. The King Laryngeal Tube Disposable (LTD) is a new superglottic alternate airway. Objective. To describe the use, rates of success, andoutcomes of the King airway by highly skilled prehospital providers. Method. In this retrospective analysis, we examined prehospital King airway use by a large regional air medical service for the period from March 2006 to December 2006. Rescuers used alternate airways after three unsuccessful ETI attempts or in situations of anticipated ETI difficulty. We identified clinical characteristics, described airway difficulties, anddetermined the success of airway placement. Where available, we evaluated the hospital course andoutcomes. Results. Of 575 ETI, alternate airways were used in 27 cases, including 26 King airway placements (4.5%, 95% CI: 3.0–6.6%). All were successfully placed; 24 required one attempt, andtwo required more than one attempt. No immediate complications were observed. No prehospital surgical airways were performed. Follow-up data were available for 15 of 26 patients. Five patients were in cardiac arrest anddid not survive to hospital admission. Many of the patients required specialized efforts from anesthesia or surgery for definitive airway management with 40% (4/10) requiring emergent tracheostomy. Conclusion. In this series of critically ill patients, air medical providers successfully used the King airway as an alternate airway device. Definitive airway management was complicated andrequired specialized efforts from surgery andanesthesia.     

The difficult airway in the emergency department

Background

The patient with difficult airways is a common challenge for emergency physicians.

Aims

Our goal was to study the reasons for difficult airways in the emergency department.

Methods

We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.

Results

There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.

Conclusions

Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.     

Clinical review: Management of difficult airways

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway.     

Some methodological aspects of modern anesthesia

The paper provides evidence for that it is necessity to introduce anesthesia standards (protocols). The anesthesia protocols (standards) are meant as a combination of the principles, rules, and provisions to be binding. The constituents of these protocols are all stages of anesthesia: preoperative examination of patients, choice of a method of anesthesia, a mode of provision of upper airways patency, the scope of monitoring, recording of the use of drugs. The minimum requirements below which an anesthesiologist cannot do his/her work are worked out for each constituent of the protocol. The wide introduction of anesthesia protocols in foreign countries could largely level differences in the quality of anesthesiological support and resulted in the emergence of a middle-leveled anesthesiologist. The paper considers the advantages and disadvantages of setting up of protocols above and their establishment in some clinical and clinical amalgamations. The author considers that there are so far two known ways to avoid the "parochiality", incompetence in determining local standards: (1) the use of the points of evidence-based medicine, i.e. the whole experience accumulated by the international anesthesiological community. To have such recommendations is not a problem if internet is available; (2) medical audit is a relatively new method for assessing the quality of anesthesia, which makes it possible through clinical analysis of the collected data to identify the areas that require developments and their introduction. It is local audit on whose basis the administration, the head of units, senior physicians generally develop and make amendments into different protocols and instructions that regulate the principles of clinical activities.     

医护协同管理模式在麻醉专科护理管理中的应用

目的：探讨医护协同管理模式在麻醉专科护理管理中的应用。方法：建立麻醉科医护协同管理模式并实施。结果：医护协同管理模式提高了护理人员麻醉护理专业知识及技能,明确了麻醉护理的全程概念,改善了护理人员的沟通能力。结论：医护协同管理模式的运用是现代麻醉科护士发展的需要,对培养护理人员的专业能力起着积极的作用,同时促进了麻醉护理工作的良性发展。     

Migraine development, treatments, research advances, and anesthesia implications

The purpose of this course is to update anesthesia providers on the phenomenology and biological mechanisms underlying migraines. As experts in pain management who encounter this common ailment, anesthesia providers frequently are consulted to assist in patient care. Effective assessment and treatment of migraine will lead to better anesthesia management. Knowledge of preventive measures of surgical patients with migraine history can avoid events that can elicit a headache attack. The clinical implications of migraine disorder--and each patient's preventive medication profile--is relevant to safe, accommodative anesthesia nursing care. Research advances in migraine treatment may profoundly improve our current pain relief measures. Adequate knowledge of the development, treatments, and research advances concerning migraine will improve patient care.