ATP阻抑正常血压病人气管插管反应的探讨

作者研究小剂量ＡＴＰ阻抑插管反应的有效性。３０例ＡＳＡＩ级择期手术病人发为对照组、ＡＴＰ０．０５ｍｇ／ｋｇ组和ＡＴＰ０．１ｍｇ／ｋｇ组（每组１０例）进行比较观察，硫喷妥钠、芬太尼、琥珀胆碱诱导并肌肉完全松驰后，在２－３ｓ内注毕预定预定剂量ＡＴＰ或生理盐水，同时在３０ｓ内完成插管操作，于诱导前即刻、诱导后１ｍｉｎ，２ｍｉｎ（肌肉完全松驰、２．７５ｍｉｎ（插管完成０．２５ｍｉｎ）、３，３．５，４，５，     

带管芯导管经鼻气管插管术

目的探讨带管芯的经鼻气管插管术的可行性。方法ASAⅠ~Ⅱ级患者60例,择期行上颌或下颌手术,随机分为实验组、对照组,每组30例。实验组以带管芯的气管导管行盲探经鼻气管插管术,对照组则不带管芯。结果实验组盲探经鼻气管插管成功率为86.7%,较对照组63.3%高(P<0.01),实验组鼻腔出血1例,远低于对照组6例(P<0.01)。结论带管芯的经鼻气管插管术较不带管芯的传统方法插管成功率高,发生鼻腔损伤率低,可推广用于临床。     

Lightwand Tracheal Intubation with and without Muscle Relaxation

Background: Lightwand tracheal intubation is a suitable technique for patients who are difficult to intubate but who are receiving effective ventilation. The effect of muscle relaxants on the efficacy of lightwand intubation has not yet been evaluated. The authors conducted a prospective, double-blind, placebo-controlled study to assess the effectiveness and incidence of complications of lightwand tracheal intubation performed during general anesthesia with and without the use of a muscle relaxant in patients with apparently normal airway anatomy.

Methods: One hundred seventy-six patients who required orotracheal intubation were prospectively included. Anesthesia was administered using propofol (2 mg/kg, then 3 mg [middle dot] kg-1 [middle dot] h-1) and remifentanil (1 [mu]g/kg, then 0.3 [mu]g [middle dot] kg-1 [middle dot] min-1). Patients were randomly assigned to one of two groups (n = 88 for each) to receive rocuronium 0.6 mg/kg or saline intravenously. Lightwand orotracheal intubation (Trachlight(R); Laerdal Medical Inc., Armonk, NY) was attempted after 3 min. The authors recorded the number of successful intubations, the number of attempts and their duration, and events during the procedure.

Results: The failure rate of lightwand intubation was 12% in the placebo group and 2% in the rocuronium group (P = 0.021). Patients in the placebo group received more multiple intubation attempts (P < 0.001), required a greater intubation time (77 +/- 65 vs. 52 +/- 31 s; P = 0.002) and experienced a greater incidence of events during intubation (61 vs. 0%; P < 0.001) than patients in the rocuronium group.     

尼卡地平预防气管插管时心血管反应的研究

目的和方法：为了解尼卡地平预防气管插管心血管反应，将３８例病人随机分为治疗组和对照绷，诱导前５分钟治疗组静注尼卡地平１５μｇ／ｋｇ，对照组静注生理盐水５ｍｌ。诱导药为依托咪酯０．３ｍｇ／ｋｇ、芬太尼５μｇ／ｋｇ和琥珀胆碱１．５ｍｇ／ｋｇ。结果：治疗组插管后血压无明显增高，但心率仍有一过性增快，静注尼卡地平后ＣＯ增加，但两组病估诱导和插管过程ＣＯ、ＳＶ和ＥＶＩ均有较明显下降，提示对心肌有一过性轻度的     

Submandible Angle in Nonobese Patients with Difficult Tracheal Intubation

Background: Although functional immobility of craniofacial structures during direct laryngoscopy may cause difficult tracheal intubation (DTI), there may be an unfavorable specific craniofacial feature for successful tracheal intubation. The aim of this study was to identify the specific craniofacial features associated with DTI.

Methods: Digital photographs of nonobese patients with DTI (23 males and 18 females) and age- and body mass index-matched patients with easy tracheal intubation (ETI) (16 males and 16 females) were taken and used for measurements of various craniofacial dimensions. Composite facial pictures of each patient group were constructed for visualization of differences of the craniofacial features.

Results: Mandible position angle was significantly smaller in DTI males than in male patients with ETI. Submandible angle was significantly larger in both male and female DTI patients than in patients with ETI. Logistic regression analysis revealed that the submandible angle was a significant and independent variable associated with DTI among the craniofacial dimensions for both sexes. The specific craniofacial features were visually more evident in the profile in than frontal composites.     

Laryngeal Morbidity and Quality of Tracheal Intubation: A Randomized Controlled Trial

Background: Vocal cord sequelae and postoperative hoarseness during general anesthesia are a significant source of morbidity for patients and a source of liability for anesthesiologists. Several risk factors leading to laryngeal injury have been identified in the past. However, whether the quality of tracheal intubation affects their incidence or severity is still unclear.

Methods: Eighty patients were randomized in two groups (n = 40 for each) to receive a propofol-fentanyl induction regimen with or without atracurium. Intubation conditions were evaluated with the Copenhagen Score; postoperative hoarseness was assessed at 24, 48, and 72 h by a standardized interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness or vocal cord sequelae persisted, follow-up examination was performed until complete restitution.

Results: Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients;P = 0.02). The number of days with postoperative hoarseness was higher when atracurium was omitted (25 vs. 6 patients;P < 0.001). Similar findings were observed for vocal cord sequelae (incidence of vocal cord sequelae: 15 vs. 3 patients, respectively, P = 0.002; days with vocal cord sequelae: 50 vs. 5 patients, respectively, P < 0.001). Excellent intubating conditions were less frequently associated with postoperative hoarseness compared to good or poor conditions (11, 29, and 57% of patients, respectively; excellent vs. poor:P = 0.008). Similar findings were observed for vocal cord sequelae (11, 22, and 50% of patients, respectively; excellent vs. poor:P = 0.02).     

A Comparison of the Intubation Conditions between Mivacurium and Rocuronium during Balanced Anesthesia

Background: Comparisons of the intubation conditions with mivacurium and rocuronium from previous reports are confounded by the use of varied induction regimens. The authors compared intubation conditions of mivacurium, rocuronium, and a placebo at 90 s and their recovery profiles during anesthesia with nitrous oxide, oxygen, and propofol.

Methods: After induction with midazolam, fentanyl, and propofol in a randomized blinded study, 100 patients received one of the following treatments: 0.25 mg/kg mivacurium in divided doses (0.15 mg/kg followed by 0.1 mg/kg 30 s later); 0.45, 0.6, 0.9, or 1.2 mg/kg rocuronium; or placebo. Evoked thumb adduction was measured throughout. Intubation was attempted 90 s after the initial dose of mivacurium and other treatment doses by a "blinded" physician. Intubating conditions were graded as excellent, good, poor, or not possible. Spontaneous recovery was studied until a 25% initial twitch height was reached. Mean arterial blood pressure and heart rate changes between groups were determined before induction through 6 min after administration of the study drugs.

Results: There were no important changes or intergroup differences in mean arterial blood pressure and heart rate. Intubation conditions were good or excellent for both mivacurium and rocuronium at the 0.9 mg/kg dose (93%) and at the 1.2 mg/kg dose (100%). Rocuronium at the 0.6 mg/kg dose was excellent in 27% of patients, whereas rocuronium at the 0.45 mg/kg dose had the least number of excellent conditions and the most poor or not possible assessments. Patients given placebo could not be intubated. Times to maximum blockade for 0.9 and 1.2 mg/kg rocuronium were the shortest. The times to 25% recovery for 0.6 mg/kg rocuronium (mean +/- SD = 27 +/- 8.6 min), 0.9 mg/kg (43.1 +/- 10.8), and 1.2 mg/kg (62.3 +/- 17.4 min) were significantly longer than were those for mivacurium (17.4 +/- 6.2 min).     

Intramuscular Rocuronium in Infants and Children: Dose-ranging and Tracheal Intubating Conditions

Background: Rocuronium's rapid onset and intermediate duration of action with intravenous administration suggests that intramuscular administration might facilitate tracheal intubation without producing prolonged paralysis. Accordingly, in infants and children, the authors measured onset at the adductor pollicis and respiratory muscles to determine the optimal dose (phase I), then gave this optimal dose to determine the optimal time for tracheal intubation (phase II).

Methods: The authors studied 45 unpremedicated patients aged 3 months to 5 yr. In phase I, 25 patients were anesthetized with nitrous oxide and halothane and breathed spontaneously; twitch tension and minute ventilation were measured. Rocuronium (800-2,400 micro gram/kg) was injected into the quadriceps or deltoid muscle; doses varied, using an "up-down" technique, the goal being to bracket the dose depressing twitch 75-90% within 5 min. In phase II, deltoid injections of the optimal dose from phase I (infants: 1,000 micro gram/kg; children: 1,800 micro gram/kg) were given to 20 patients anesthetized with 0.82-1.0% halothane. Tracheal intubation was attempted 1.5-3.0 min later; time to tracheal intubation was varied, using an "up-down" technique.

Results: In phase I, 5 of 7 patients given quadriceps injections (1,200-2,200 micro gram/kg) had slow onset of twitch and ventilatory depression. With deltoid injections (800-2,400 micro gram/kg), all patients developed complete twitch depression; median time to 50% depression of minute ventilation was 3.2 min in infants and 2.8 min in children. In phase II, intubating conditions were consistently adequate or good-excellent at 2.5 min in infants and 3.0 min in children. Initial twitch recovery was at 57+/-13 min (mean+/-SD) in infants and 70+/-23 min in children.     

Induction of Anesthesia and Tracheal Intubation with Sevoflurane in Adults

Background: The speed, quality, and cost of mask induction of anesthesia and laryngeal mask airway insertion or tracheal intubation were studied in young non-premedicated volunteers given high inspired concentrations of sevoflurane (6 to 7%).

Methods: Twenty healthy persons who were 19 to 32 years old participated three times, received 6 l/min fresh gas flow, and were randomized to receive 6 to 7% sevoflurane in 66% nitrous oxide/28% oxygen by face mask until tracheal intubation (treatment 1) or until laryngeal mask airway insertion (treatment 3), or 6 to 7% sevoflurane without nitrous oxide to tracheal intubation (treatment 2). Participants exhaled to residual volume and took three vital capacity breaths of the gas mixture; thereafter ventilation was manually assisted. The time of exposure to the inhaled gas was varied for consecutive participants. It was either increased or decreased by 30-sec increments based on the failure or success of the preceding volunteer's response to laryngoscopy and intubation after a preselected exposure time. Failure was defined as poor jaw relaxation, coughing or bucking, or inadequate vocal cord relaxation.

Results: Loss of the lid-lash reflex in unpremedicated young volunteers was achieved in 1 min and did not differ among groups. Average time (and 95% confidence interval) for acceptable conditions for LMA insertion was achieved in 1.7 (0.7 to 2.7) min, and all participants had an immediate return of spontaneous ventilation. The time for acceptable tracheal intubating conditions after manual hyperventilation by mask was 4.7 (3.7 to 5.7) min and 6.4 (5.1 to 7.7) min in treatments 1 and 2, respectively. There were no cases of increased secretions or laryngospasm. The incidence of breath holding and expiratory stridor ("crowing") was 7.5% and 25%, respectively, during treatment 1 and 15% and 40%, respectively, during treatment 2.     

用带光源可塑形气管导管管芯行经口腔气管插管的效果及对循环的影响

报告用带光源可塑形的气管导管管芯行经口腔气管插管的效果和循环改变及与Macintosh喉镜暴露法气管插管进行比较的结果。用管芯组插管时间虽短于喉镜暴露组(21.1±9.1s,26.3±9.1s),但无统计学意义。在气管插管即刻HR较诱导前显著增快(P<0.01),但两组间无明显差异;而SBP、DBP升高在管芯组较喉镜暴露组有明显差异(P<0.05);MAP则有非常显著的升高(P<0.01)。室性早搏发生例数管芯组(4例)也高于喉镜组(1例),但无统计学差异。根据以上结果认为,带光源可塑性形气管导管管芯是经口腔气管插管时的有效辅助用具,但用此管芯对喉头和气管粘膜刺激性较强,心血管副反应较明显,使用时应注意加强循环监测,并适当加深麻醉。     

Attenuation of Circulatory Response to Laryngoscopy and Tracheal Intubation: A Comparison of Two Methods of Topical Anaesthesia

Circulatory responses to laryngoscopy and endotracheal intubation were compared between throe groups of patients, two of which were subjected to a procedure of topical anaesthesia before induction of general anaesthesia. Topical anaesthesia, achieved with either a lidocaine dose aerosol or by gargling with viscous lidocaine, attenuated the magnitude of the pressor response to laryngoscopy and intubation but had no effect on the heart rate response. Lidocaine aerosol had some advantages over viscous lidocaine; these were the significantly smaller haemodynamic response to the local anaesthetic procedure itself and probably shorter duration of the circulatory changes produced by intubation. It is concluded that both of these simple methods are relatively ineffective in preventing haemodynamic changes associated with laryngoscopy and intubation and should probably be combined with another preventive method.