患儿共享气道类手术气道管理研究进展

共享气道类手术需要外科医师与麻醉科医师在同一气道解剖空间内实施操作及气道管理,围术期需要麻醉、外科和护理团队间保持密切沟通与合作。患儿上气道尤其狭窄,因病变种类多、对正常通气换气功能影响大,其共享气道手术的麻醉管理实施难度更大、风险更高,是临床麻醉的难点问题。在保障氧合与通气安全的基础上,尽可能为外科提供更好的视野暴露是共享气道工具开发及通气策略优化的目标。本文归纳总结了儿科共享气道类手术的种类与特点,重点分析非插管气道管理技术的应用范围和优缺点,以期为安全个性化地实施患儿共享气道的麻醉管理提供参考。     

气道狭窄支架置入术的麻醉管理

气管 支气管内支架置入技术为治疗气道狭窄提供了有效的治疗手段。该治疗技术的麻醉管理是麻醉医师面临的具有挑战性的临床工作之一。现就气道狭窄病人的支架置入术及麻醉管理等进展作一综述。     

气道狭窄支架置入术的麻醉管理

气管-支气管内支架置入技术为治疗气道狭窄提供了有效的治疗手段。该治疗技术的麻醉管理是麻醉医师面临的具有挑战性的临床工作之一。现就气道狭窄病人的支架置入术及麻醉管理等进展作一综述。     

Shikani在临床气道管理中的应用

背景 作为一种新型可视光导芯,Shikani Optical Stylet(SOS)既具有纤支镜的可视优点,又具有硬性管芯的特点,已成为常规气管插管和困难气道处理的重要工具.目的 介绍SOS气管插管的操作技术要点,对该工具目前在临床气道管理中的应用情况进行了总结.内容 系统阐述了SOS的结构特性、操作技术、临床应用和临床评价,并简短介绍了其在临床应用的局限性.趋向 SOS在临床气道管理中发挥越来越重要的作用,但其并不是解决困难气道的“万能钥匙”,在临床中应根据具体情况选择不同的气管插管设备.     

广西126家公立医院气道管理资源配置现状调查

目的调查分析广西公立医院麻醉科的气道管理现状, 并探讨其改进方法。方法以微信的方式发放腾讯问卷给广西公立医院麻醉医师填写。问卷内容包括:麻醉医师一般信息;麻醉科人员、设备配置, 气道工具配置, 气道管理培训及掌握情况, 气道管理需要改进的方面等。结果收到广西126家公立医院(三级医院57家, 二级医院69家)的有效问卷共637份, 其中三级医院508份(79.7%), 二级医院129份(20.3%)。每个手术间可配置麻醉医师1.4名, 麻醉机1.1台, 呼气末二氧化碳分压监护仪0.8台。喉罩配置率为80.2%, 参加过困难气道培训班的麻醉医师为48.0%, 22.8%～55.7%麻醉医师对不同版本的困难气道处理流程有了解, 35.5%的麻醉医师掌握使用纤维支气管镜/电子软镜。结论广西公立医院麻醉医师短缺情况仍然存在, 气道管理资源配置仍需进一步提高。     

2022版美国麻醉医师协会指南：困难气道管理实践解读

<正>为了更好地帮助临床医生应对困难气道，麻醉学权威杂志《Anesthesiology》发表2022年美国麻醉医师协会(American Society of Anesthesiologists, ASA)更新版困难气道管理指南，对困难气道如何做出决策给出指导建议。指南建议的困难气道管理流程见图1、图2。与8年前旧的指南相比，新的指南更符合临床实践的实际情况。新的指南从困难气道的评估、准备、管理、拔管、随访等5个方面对困难气道管理进行了阐述。     

上呼吸道出血气道管理的研究进展

上呼吸道出血是一种临床急症，其发生突然、进展迅速，是导致气道相关性死亡的重要原因。与其他部位的出血不同，上呼吸道出血可能迅速淹没气道，导致窒息，甚至危及生命。上呼吸道出血时，因血液阻碍了气道视野，很多传统的气道管理设备的使用受到限制，为麻醉管理增加了难度。本文通过总结上呼吸道出血的常见原因、气道管理的挑战、气道管理方法，为麻醉科医师应对此类情况提供参考，从而更好地保障患者生命安全。     

中国医疗机构困难气道的调查与分析

目的通过网络问卷对全国31个省、市、自治区的医疗机构气道管理情况进行调查。方法拟定一份有关气道管理情况的网络调查问卷,包含9大类63个问题,通过微信发放和回收。结果回收问卷1 935份,有49.7%的被调查者来自三级医院,主治医师及以上占75.7%。63.2%的参与者曾因困难气道而取消或延迟手术。13.8%调查者所在医院发生过因困难气道导致严重不良事件(患者死亡或脑损伤等)。肥胖(26.2%)是困难气道最常见原因。对已预见的困难气道,选择全麻快速诱导比例达16.9%。未阅读ASA和CSA困难气道管理流程比例为34.3%和6.8%。对于未预料困难气道,盲探3次及以上的比例为2.5%。手术室外插管时,69.8%的参与者认为最担心困难气道。36.1%的参与者曾使用过颈前急救技术抢救患者。最常采用的技术是环甲膜穿刺技术,达74.4%。73.0%配备可视喉镜,可视插管软镜(含纤维支气管镜和电子镜)比例达到52%,气道急救箱或急救车比例34.1%。79.8%的医师经历过拔管后再插管。仅50.9%参加过气道管理培训。结论气道工具配备虽有明显改善,但因困难气道导致的严重并发症依然存在;紧急气道急救工具普遍缺乏,困难气道管理培训有待普及,困难气道管理仍然需不断改善。     

超声技术应用于气道管理的研究进展

背景 目前气道评估及管理仍然是一门不断更新的临床科学.近些年超声可视化技术的应用为围手术期、急诊及重症医学科患者的气道管理提供了一个动态的监测工具. 目的 针对超声技术在气道管理中的应用情况进行综述. 内容 描述呼吸道超声解剖结构,并概括超声在围手术期气道管理中的应用. 趋向 超声的应用使围手术期气道管理发生里程碑式的发展,未来将有更广阔的应用前景.     

无症状型会厌囊肿围手术期气道管理

背景 术前对困难气道的准确评估,使麻醉医师对患者气道的管理愈加合理及安全.无症状型会厌囊肿会引起难以预测的紧急困难气道,在全身麻醉快速诱导中易导致通气不畅或插管困难,威胁患者生命安全. 目的 讨论这种突发情况的围手术期气道处理,提高对该病的认识,并为临床提供借鉴. 内容 参考国内外无症状型会厌囊肿病例,收集整理近期困难气道的管理方法,完善无症状型会厌囊肿气道处理流程. 趋向 麻醉医师应迅速对患者的紧急情况进行判断,并选择最佳气道管理方案.     

Point-of-care ultrasound (POCUS) of the upper airway

Airway management is a critical skill in the practice of several medical specialities including anesthesia, emergency medicine, and critical care. Over the years mounting evidence has showed an increasing role of ultrasound (US) in airway management. The objective of this narrative review is to provide an overview of the indications for point-of-care ultrasound (POCUS) of the upper airway. The use of US to guide and assist clinical airway management has potential benefits for both provider and patient. Ultrasound can be utilized to determine airway size and predict the appropriate diameter of single-lumen endotracheal tubes (ETTs), double-lumen ETTs, and tracheostomy tubes. Ultrasonography can differentiate tracheal, esophageal, and endobronchial intubation. Ultrasonography of the neck can accurately localize the cricothyroid membrane for emergency airway access and similarly identify tracheal rings for US-guided tracheostomy. In addition, US can identify vocal cord dysfunction and pathology before induction of anesthesia. A rapidly growing body of evidence showing ultrasonography used in conjunction with hands-on management of the airway may benefit patient care. Increasing awareness and use of POCUS for many indications have resulted in technologic advancements and increased accessibility and portability. Upper airway POCUS has the potential to become the first-line non-invasive adjunct assessment tool in airway management.     

Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds.     

Acquiring and maintaining point-of-care ultrasound (POCUS) competence for anesthesiologists

Purpose

Point-of-care ultrasound (POCUS) involves the bedside use of ultrasound to answer specific diagnostic questions and to assess real-time physiologic responses to treatment. Although POCUS has become a well-established resource for emergency and critical care physicians, anesthesiologists are still working to obtain POCUS skills and to incorporate them into routine practice. This review defines the benefits of POCUS to anesthesia practice, identifies challenges to establishing POCUS in routine anesthesia care, and offers solutions to help guide its incorporation going forward.

Principal findings

Benefits to POCUS include improving the sensitivity and specificity of the physical examination and helping to guide patient treatment. The challenges to establishing POCUS as a standard in anesthesia practice include developing and maintaining competence. There is a need to develop standards of practice and a common language between specialties to facilitate training and create guidelines regarding patient management.

Conclusions

Presently, our specialty requires consensus by expert stakeholders to address issues of competence, certification, development of standards and terminology, and the management of unexpected diagnoses. To promote POCUS competency in our discipline, we support its incorporation into anesthesiology curricula and training programs and the continuing professional development of POCUS-related activities at a national level.

     

Cardiac and lung point‐of‐care ultrasound in pediatric anesthesia and critical care medicine: Uses,pitfalls, and future directions to optimize pediatric care

Point‐of‐care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.     

Point-of-care gastric ultrasound and aspiration risk assessment: a narrative review

This narrative review summarizes the current knowledge on point-of-care ultrasound (POCUS) of gastric contents in order to inform an assessment of aspiration risk and guide anesthetic management at the bedside. An I-AIM framework (Indication, Acquisition, Interpretation, and Medical decision-making) is used to summarize and organize the content areas. This narrative review spans the breadth of the literature on pediatric and adult subjects as well as on special patient populations such as obstetric and severely obese individuals. Areas that need further investigation include the diagnostic accuracy of gastric POCUS from a Bayesian perspective and the impact of POCUS on patient outcomes, healthcare economics, and educational curricula.     

Point-of-care ultrasound in urology: Design and evaluation of a feasible introductory training program for Canadian residents

IntroductionPoint-of-care ultrasound (POCUS) is an increasingly used bedside tool. Applications in urology include the assessment of an undifferentiated acute scrotum, renal colic, and the guidance of suprapubic catheter placement. However, the user-dependent nature of this modality necessitates appropriate use and competence. The objective of this study was to develop and evaluate a low-cost, feasible, and guideline-based introductory POCUS program for Canadian urology residents.MethodsResidents from McMaster University’s urology program completed a three-hour online course, followed by a three-hour hands-on seminar. Course material was developed by ultrasound educators based on national guidelines. Low-cost testicular phantoms and suprapubic catheter insertion models were constructed. Pre- and post-course surveys focused on participant skill confidence, while multiple-choice questionnaires assessed theoretical knowledge.ResultsFourteen residents participated in the course. Theoretical knowledge in POCUS improved significantly (p<0.001, d=2.2) and mean confidence scores improved for all skills, including performing kidney, bladder, and testicular POCUS (all p<0.001; d=3.4, 1.9, 2.9, respectively). Participants indicated that the course increased their confidence and likelihood of using POCUS in clinical practice, and that POCUS training should be integrated into urology training curricula.ConclusionsThis novel study included the development of an inexpensive, feasible, guideline-based introductory training program for urological POCUS, developed in collaboration with ultrasound educators. Participants significantly improved in theoretical knowledge and skill confidence. Although this study was limited to one residency program, the basis of this course may serve as a foundation for the development of competency-based training for urological POCUS in Canada.     

Strangulated epigastric hernia in a 90-year-old man: Point-of-Care Ultrasound (POCUS) as a saving kit: Case report

IntroductionThe physiological reserve of extreme elderly patients is very limited and has major impact on clinical decisions on their management. Hereby we report a 90-year-old man who presented with a strangulated epigastric hernia and who developed postoperative intra-abdominal bleeding, and highlight the value of Point-of-Care Ultrasound (POCUS) in critical decisions made during the management of this patient.Presentation of caseA 90-year-old man presented with a tender irreducible epigastric mass. Surgeon-performed POCUS using colour Doppler showed small bowel in the hernia with no flow in the mesentery. Resection anastomosis of an ischaemic small bowel and suture repair of the hernia was performed. Twenty four hours after surgery, in a routine follow up using POCUS, significant intra-peritoneal fluid was detected although the patient was haemodynamically stable. The fluid was tapped under bedside ultrasound guidance and it was frank blood. During induction of anaesthesia for a laparotomy, the patient became hypotensive. Resuscitation under inferior vena cava sonographic measurement, followed by successful damage control surgery with packing, was performed. 36 h later, the packs were removed, no active bleeding could be seen and the abdomen was closed without tension. The patient was discharged home 50 days after surgery with good general condition.ConclusionPOCUS has a central role in the management of critically-ill elderly patients for making quick critical decisions.     

The comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures

ObjectiveIt was aimed to compare the efficacy of point-of-care ultrasonography (POCUS) with radiography in the diagnosis and management of metatarsal fracture (MTF).MethodsPatients aged 5–55 years admitted to emergency room due to low-energy, simple extremity trauma and had a suspected MTF, were included in this prospective study. Patients were evaluated by two different emergency physicians in the emergency room. The first physician performed POCUS examination. Second physician evaluated the radiography images. The obtained results were compared.ResultsSeventy-two patients were enrolled in the study. Fracture was detected in 39% by radiography and in 43% of patients by POCUS. Multiple MTFs were identified in 5% of patients. Compared with radiography, POCUS had a sensitivity of 93%, specificity of 89%, positive predictive value of 84% and a negative predictive value of 95% (95% CI, 83–98%) in the detection of fractures. While soft tissue edema was seen in 61% of patients by POCUS, soft tissue edema with hematoma was detected in 14%. Compared with radiography, the sensitivity and specificity of POCUS in the decision for surgery were 100% and 98% (95% CI, 97–100%), respectively, whereas its sensitivity and specificity were both 100% in the decision for reduction.ConclusionIn our study, we demonstrated that POCUS could be applied with success in the diagnosis and treatment of MTF in low-energy injuries. POCUS can be used as an alternative to radiography in the emergency rooms due to being easy to learn and practice and availability of soft tissue examination along with bone tissue examination.     

超声在气道管理中的应用

背景 超声技术在临床麻醉中的应用越来越广泛,近些年关于其在气道管理中的应用也有了一些报道,并认为其安全、方便.目的 分析、总结超声在气道管理各方面应用的文献资料.内容 简要介绍上呼吸道的超声解剖以及获得满意的超声图像的方法和途径,综述超声技术在插管前评估、气管导管位置的确定、双腔气管导管和经皮扩张气管造口术(percu...     

Consensus guidelines for managing the airway in patients with COVID-19

Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies.