儿童上呼吸道软组织手术全身麻醉术后拔管期呼吸道不良事件的临床观察

目的:探讨儿童上呼吸道软组织手术全身麻醉术后拔管期呼吸道不良事件的发生情况。方法:选取收治的手术患儿180例,观察组和对照组各90例,两组患儿分别采用不同的全身麻醉手术方法,比较两组患儿呼吸道不良事件发生率及血气分析。结果:观察组患儿呼吸道不良事件发生率显著高于对照组,差异有统计学意义(P<0.05)。结论:儿童上呼吸道软组织手术全身麻醉术后拔管期不良事件的发生率较高,应采取积极有效的应对方法,使患儿平稳渡过拔管期。     

影响持续植物状态合并气管切开患者拔管的相关因素分析

目的 探讨影响持续植物状态（PVS）合并气管切开患者拔管的相关因素,为PVS患者尽早拔除气切管提供参考资料。 方法 收集2020年1月至2022年1月期间在郑州大学第一附属医院康复医学科治疗的PVS合并气管切开患者的临床资料,根据在院期间是否成功拔除气切管将其分为拔管组和拔管困难组。采用SPSS 22.0版统计学软件包对拔管影响因素进行单因素及多因素Logistic回归分析。 结果 经单因素分析发现,拔管组与拔管困难组在年龄、专业护理、营养方式、吞咽功能、是否低蛋白血症及带管时间方面组间差异均有统计学意义(P＜0.05）,两组患者在性别、颅脑损伤、脑卒中、缺血缺氧性脑病、是否气管结构异常、是否肺部感染方面组间差异均无统计学意义（P＞0.05）。经多因素Logistic回归分析发现,营养方式、吞咽功能、带管时间、肺部感染情况、专职陪护、年龄均为PVS合并气管切开患者拔管的独立影响因素(P＜0.05）。 结论 采用间歇经口至食管管饲法（IOE）作为营养方式、有专职陪护为PVS合并气管切开患者拔管的保护因素;吞咽障碍、带管时间＞30 d、肺部感染、年龄较大为PVS合并气管切开患者拔管的危险因素。对于PVS合并气管切开患者,待其病情稳定后,尽早给予IOE营养支持、吞咽功能训练及加强护理可有效提高患者拔管成功率。     

机械通气患儿气管插管非计划性拔管预防策略的最佳证据总结

目的 提炼并总结儿科重症监护病房（pediatric intensive care unit,PICU）机械通气患儿气管插管非计划性拔管预防策略的最佳证据,为临床实践提供参考依据。 方法 系统检索国内外计算机决策支持系统、指南网、数据库及相关学会网站中与机械通气患儿气管插管非计划性拔管预防策略有关的文献,检索时限为2010年1月—2022年1月,文献类型包括临床决策、指南、证据总结、系统评价、专家共识。由4名研究者对纳入文献进行评价和证据提取。 结果 共纳入14篇文献,其中指南6篇、专家共识2篇、系统评价6篇。从气管插管非计划性拔管的危险因素、气管插管及气道管理、镇静评估与管理、镇痛评估与管理、谵妄监测与预防、组织管理6个方面总结了25条最佳证据。 结论 该研究总结的最佳证据为PICU机械通气患儿气管插管非计划性拔管的预防提供循证依据。应用证据前,医护人员应评估临床情景及障碍因素,促使证据有效、安全地向临床转化。     

儿科胃管非计划性拔管的现况调查与分析

目的描述儿科发生胃管非计划拔管的现状,分析其原因并探索其对策。方法选择2011年4—9月上海市某3级甲等儿科医院留置胃管的患儿,采用自制的非计划拨管登记表进行登记。结果共收集249例有效记录,其中发生非计划性拔管19例,占7.6%;按置管日计算的拔管率为1.03次/100个置管日;重新置管率为63.2%。Logistic回归分析发现,插管类型和患儿有无肢体约束是非计划拨管的影响因素。结论加强对患儿的巡视,增加对高危管道的预见管理和恰当的肢体约束可以减少非计划拔管的发生。     

Continuous multiorgan variability analysis to track severity of organ failure in critically ill patients

Purpose

The purpose of this study is to evaluate the utility of using continuous heart rate variability (HRV) and respiratory rate variability (RRV) monitoring for (a) tracking daily organ dysfunction in critically ill patients and (b) identifying patterns of variability changes during onset of shock and resolution of respiratory failure.

Materials and Methods

Thirty-three critically ill patients experiencing respiratory and/or cardiac failure underwent continuous recording of their electrocardiogram and capnogram (CO₂) waveforms from admission or intubation until discharge (maximum 14 days). HRV and RRV were computed in 5-minute overlapping windows, using Continuous Individualized Multi-organ Variability Analysis software. Multiple organ dysfunction scores were recorded daily. HRV and RRV trajectories were characterized during onset of shock and resolution of respiratory failure.

Results

Both HRV and RRV decreased with increasing severity of multiple organ dysfunction scores for a variety of variability metrics. A decline in several measures of HRV and no decline in RRV were observed before onset of shock (n = 6). In contrast, during resolution of respiratory failure, an increase in RRV was observed in patients who successfully passed extubation (n = 12), with no change in RRV in those who subsequently failed extubation (n = 2).

Conclusions

There is an association between reduced HRV and RRV and increasing organ dysfunction in critically ill patients. The significance of observing trends of decreasing HRV (with onset of shock) and increasing RRV (with resolution of respiratory failure) merits further investigation.     

A comparison of the rapid shallow breathing index and complexity measures during spontaneous breathing trials after cardiac surgery

Purpose

Extubation failure is associated with worse outcomes. Physicians use respiratory parameters to help them to decide to extubate or not. The purpose of this study is to determine if novel measures of respiratory physiology such as complexity and variability can identify patients who will tolerate extubation.

Methods

Eighty-three patients who required reinstitution of mechanical ventilation after extubation (Extub-Fail) were matched to 83 patients who successfully tolerated extubation (Extub-Success) and to 83 who failed a spontaneous breathing trial (SBT-Fail). Patients were compared using interbreath intervals and tidal volumes using means, SDs, measures of complexity, spikiness, and rapid shallow breathing index (RSBI).

Results

From SBT-Fail to Extub-Fail to Extub-Success, the interbreath intervals progressively lengthened (mean ± SD, 2.2 seconds ± 0.6 vs 2.5 ± 0.6 vs 2.7 ± 0.8; P < .001), became more variable (mean ± SD, 0.57 ± 0.13 vs 0.62 ± 0.21 vs 0.66 ± 0.23; P = .012), and became more complex. Complexity as measured by approximate and sample entropy was greater in the Extub-Success group than in the SBT-Fail group. Patients who were in the SBT-Fail group had a higher RSBI than did either of the extubated groups, but there was no difference in RSBI between Extub-Success and Extub-Fail.

Conclusions

Patients who successfully tolerate extubation have longer interbreath interval with greater complexity and variability of that series. Although the V_T was similar between the Extub-Success and the SBT-Fail groups, the Extub-Success group had greater long-term complexity with no difference in short-term complexity. This implies that the respiratory controllers are differently impacted in patients tolerating or not tolerating extubation.     

孕期避孕指导对产后避孕行为的影响

目的　了解孕期给予避孕指导对产后避孕方法选择、使用率及其产后 1年内再次妊娠率的影响。　方法　募集 5 2 7名孕妇 ,随机分为干预组和对照组 ,干预组在孕期接受专家的避孕指导 ,对照组接受常规的孕期教育。干预组 2 5 4例和对照组 2 6 3例在产后 16周及 2 4 6例和 2 4 9例在 5 2周接受随访。　结果　产后 16周 2组各种避孕方法使用率差异无显著性 (P>0 .0 5 ) ,已恢复性生活者中干预组的避孕率 97.8(178/ 182 )高于对照组 92 .8% (192 / 2 0 7)差异有显著性 (χ2 =4 .5 7,P>0 .0 5 ) ;2组有 4 3.7% (2 2 6 / 5 17)的对象夫妇采用避孕套 ;平均性生活恢复和产后避孕开始使用之间的时距 ,干预组为 (0 .2± 0 .9)周 ,对照组为 (0 .3± 1.2 )周 ,差异无显著性 ;产后 16周表示产后未来 8个月内可能更换现用避孕方法的有 5 2 .2 % (2 70 / 5 17) ,其中约 30 %的准备放置宫内节育器。在产后5 2周时 ,干预组 5 1.6 % (12 7/ 2 4 6 )和对照组 4 0 .2 % (10 0 / 2 4 9)的使用避孕套 ,差异有显著性 (χ2 =6 .2 7,P>0 .0 5 ) ,但其他避孕方法差异无显著性 (P>0 .0 5 ) ;干预组 2 .8% (7/ 2 4 6 )和对照组 2 .0 %(5 / 2 4 9)曾经使用过紧急避孕方法 ,2组共 79.6 % (394 / 4 95 )从未听说过紧急避孕方法或仅一知半解     

全麻后具备“临床拔管指征”病人的SpO_2和分钟通气量监测

本研究监测了具备“临床拔管指征”病人拔管前后SpO_2和分钟通气量。结果表明,拔管前后分别有13/80例(16%)和21/80例(26%)SpO_2低于94%;分别有7/40例(17.5%)和8/40例(20%)分钟通气量比麻醉前降低超过1000ml。因此认为,单纯用临床拔管指征指导拔管并不安全,应用SpO_2和分钟通气量指导拔管是必要的。     

有机磷农药中毒气管插管患者非计划性拔管的原因分析

目的 总结有机磷农药中毒气管插管患者非计划性拔管(Unplanned extubation,UE)的发生率,分析UE发生的相关原因.方法 回顾性分析2009年1月至2010年12月我科收治的43例有机磷农药中毒气管插管患者年龄、性别、Ramsay评分、阿托品日平均用量、气道痰痴评分、使用气管导管型号等临床资料,评估UE发生率并筛查UE的临床危险因素.结果 本组有机磷农药中毒气管插患者UE发生率为30.23％,单因素分析显示,UE组与非UE组Ramsay评分、阿托品日平均用量及气道痰痴评分差异有统计学意义,Logistics逐步回归分析显示Ramsay评分(OR=0.079)和气道痰痴评分(OR=7.029)与UE的发生独立相关.结论 有机磷农药中毒气管插患者UE发生率较高,Ramsay评分低和气道痰痂评分高是发生UE的独立危险因素.有效镇静和强化气道管理可能有助于减少UE的发生,提高有机磷农药中毒患者的救治成功率.     

自主呼吸试验在机械通气脱机过程中的应用

目的 自主呼吸试验(SBT)作为程序化拔管步骤在机械通气脱机过程中的应用.方法 程序化拔管患者行前瞻性研究,非程序化拔管患者行回顾性分析,比较两组机械通气时间、呼吸机相关性肺炎(VAP)发生率、48 h复插管率、住ICU天数及ICU病死率.对于程序化拔管组患者,比较SBT成功与SBT失败、拔管成功与拔管失败组SBT前后监测指标的变化.结果 程序化拔管组较非程序化拔管组机械通气小时数(经Ln数据转换后)缩短(4.01±0.71 vs 4.51±0.85,P<0.05).住ICU天数(经Ln数据转换后)缩短(1.86±0.82 vs 2±48±0.92±P<0.05),VAP发生率及48 h复插管率差异无统计学意义.程序化拔管组SBT成功与SBT失败患者SBT前后心率、呼吸频率、浅快呼吸指数(f/Vt)、PaC_2的变化差异有统计学意义;而拔管成功与拔管失败患者SBT前后监测指标的变化差异无统计学意义.5例拔管失败患者中3例由于痰液引流障碍导致48 h内复插管.结论 程序化拔管可缩短机械通气时间.减少住ICU天数,不增加48 h复插管率.SBT前后心率、呼吸频率、f/Vt、PaCO_2变化对于判断SBT是否成功较其他指标更为重要.对于拔管后可能存在痰液引流障碍的患者需谨慎拔除气管插管.