多参数结合对困难气道预测的临床研究

目的:研究头后仰角度差与改良Mallampati分级,上下切牙间距三参数结合对困难气道预测的准确性.方法:选择200例拟行气管插管全麻的患者,术前测量头后仰角度差值、上下切牙间距、改良Mallampati分级,以Cormack-Lehane 3～4级定为困难气管插管.结果:以头后仰角度差＜15°能较准确的预测困难气道(P＜0.05).结合头后仰角度差与改良Mallampati分级,上下切牙间距三参数以总分≥5认为存在困难气道的综合评估指标,与传统的单项改良Mallampati分级试验比较实际插管困难发生率,得出三参数结合评估法敏感度(81.3%)、阳性预测值高(75%)(P＜0.05),漏诊率低(18.8%)(P＜0.05).结论:在拟行气管插管全麻的患者中头后仰角度差能较准确的预测困难气道;若结合头后仰角度差、改良Mallampati分级、上下切牙间距三项评估指标,可提高困难气道预测的准确性.     

综合评估法用于困难插管的预测

我院自1998年以来对2304例全麻病人术前试用3种综合评估方法 :即联合应用Mallampati分级、甲颏间距和寰枕关节伸展度预测 ,使96 %的困难插管病例得到识别 ,作好困难插管的准备 ,有效地避免了插管意外的发生 ,降低了麻醉风险 ,现总结如下。1临床资料1.1一般资料全麻病人2304例 ,男1283例 ,女1021例。年龄18～82岁。体重38～105Kg。均为检查合作患者。1.2困难插管的综合评估方法(1)Mallampati分级 [1]:I级 :看到腭弓、软腭、悬雍垂 ;II级 :看到腭弓、软腭 ,悬雍垂被舌根遮住 ;III级 :仅见软腭 ;IV级 :未见软腭 ,III、IV级列为困难插管…     

ELISA法在诊断梅毒螺旋体感染中的临床价值及应用

目的探讨酶联免疫吸附试验（ELISA）方法在诊断梅毒螺旋体（TP）感染中的临床应用价值。方法选择2010年1月至2012年2月接收的梅毒患者68例,采用甲基胺红不加热血清试验（TRUST）和ELISA试剂分别检测68例梅毒患者和30例自身免疫性疾病患者的血清样本,将检测结果与梅毒螺旋体明胶颗粒凝集试验（TPPA）检测结果进行对比,比较TRUST和ELISA试剂的假阳性率和假阴性率。结果 TRUST假阳性率、假阴性率分别为16.67%（5/30）、26.47%（18/68）。ELISA的假阳性率、假阴性率均为0。ELISA与TPPA检测结果完全一致,无假阳性和假阴性结果。ELISA方法检测的假阳性率和假阴性率分别显著性低于TRUST（P〈0.05）。结论 ELISA方法检测T梅毒螺旋体结果可靠,可以作为筛选和确诊梅毒的首选方法。     

梅毒螺旋体3种检测方法结果分析

目的通过对梅毒螺旋体3种实验室检测方法的结果分析,为相关临床和实验室工作者合理应用实验室的检测方法、合理解释其检测结果提供依据。方法 7826例患者标本同时用酶联免疫法吸附试验(ELISA)、梅毒螺旋体抗体明胶凝集试验(TP-PA)及梅毒甲苯胺红不加热血清试验(TRUST)方法进行检测,并对检测结果进行统计分析。结果 7826例标本,结合临床诊断确诊为梅毒患者的阳性标本为256例,阴性标本7570例。采用ELISA方法检测,252例阳性,假阳性6例,假阴性10例,其中真阳性率96.1%,假阳性率0.08%,假阴性率3.9%;采用TPPA方法检测,250例阳性,假阳性0例,假阴性6例,其中真阳性率97.7%,假阳性率0.0%,假阴性率2.3%;采用TRUST方法检测,116例阳性,假阳性5例,假阴性145例,其中真阳性率43.4%,假阳性率0.07%,假阴性率56.6%。TRUST方法真阳性率较低,假阴性较多,但对一期梅毒的检出率却相对较高,与ELISA方法的检测结果有互补性。结论 ELISA和TRUST这两种方法有互补性,同时用其检测梅毒,可提高阳性率;为排除假阳性结果,再用TPPA方法进行确证。     

阴道镜诊断宫颈HPV感染的价值

目的:评价阴道镜诊断宫颈HPV感染的价值.方法:对568例外生殖器湿疣患者进行阴道镜检查和活组织病理检查.结果:阴道镜检查诊断宫颈湿疣的准确度是100%,假阳性率是0,假阴性率是0,敏感度是100%,特异度是100%.阴道镜检查诊断SPI的准确度是99.30%,假阳性率是0,假阴性率是3.88%,敏感度是96.12%,特异度是100%.阴道镜检查诊断宫颈HPV感染合并CIN的准确度是99.65%,假阳性率是0,假阴性率是28.57%,敏感度是71.43%,特异度是100%.结论:阴道镜诊断宫颈HPV感染较高的准确度、敏感度和特异度,假阳性率、假阴性率低.其价值在于能检出宫颈HPV感染的早期阶段或亚临床型及有无合并癌前病变,以便早期治疗.     

大便潜血试验免疫法测定血红蛋白和转铁蛋白的临床应用

目的探讨大便潜血试验免疫法测定血红蛋白和转铁蛋白的临床应用价值。方法对60例黑色便分别使用邻联甲苯胺法、血红蛋白法和转铁蛋白法进行潜血试验检测,并对结果进行比较;另对2003-2008年先后使用上述3种方法检测的10473例随机大便标本的潜血试验结果并进行分析。结果60例黑色便潜血试验阳性率邻联甲苯胺法假阳性率16．7％,血红蛋白假阴性率10．0％,转铁蛋白法假阴性率2．0％;随机大便潜血试验阳性率邻联甲苯胺法为38．7％,血红蛋白法为11．4％,血红蛋白法与转铁蛋白法联合检测时为16．2％,3种方法差异有统计学意义（P〈0．05）。结论血红蛋白法和转铁蛋白法的灵敏度和特异性均高于邻联甲苯胺法,二者联合使用可提高检测的准确性。     

联合试验在真菌性角膜炎诊断中的应用

目的:探讨Gram染色法与墨汁-KOH湿片法联合试验在真菌性角膜炎诊断中的应用价值.方法:2008年1月至2009年12月期间临床诊断为真菌性角膜炎患者120例,角膜刮片标本分别行Gram染色法、墨汁-KOH湿片法和真菌培养及菌种鉴定.结果:120份真菌性角膜炎标本中113份培养出真菌,阳性率94.1%.Gram染色法与墨汁-KOH湿片法串联试验提高诊断试验的特异度、假阴性率、阳性预测值和阴性预测值,但降低了诊断试验的检出率、灵敏度、假阳性率和正确指数.Gram染色法与墨汁-KOH湿片法并联试验提高诊断试验栓出率、灵敏度、假阳性率和正确指数,但降低了诊断试验的特异度、假阴性率、阳性预测值和阴性预测值.结论:Gram染色法与墨汁-KOH湿片法联合试验是真菌性角膜炎早期诊断简单、快速、有效的方法.     

围术期困难气道的危险因素及预测模型研究

目的:探索一种更全面、有效的困难气道预测评估新体系.方法:选择450例口腔颌面及整形外科手术患者.根据临床需要选择在快速诱导下使用直接喉镜插管或清醒状态下使用盲探气管插管装置插管.对清醒插管者,在插管完成后再给予进行麻醉诱导.以直接喉镜下所观察的Cormack-Lehane喉头分级结果作为设定"插管困难"标准的依据.对快速诱导插管者,可在诱导用药后、插管前观察;对清醒插管者,需在插管和诱导用药后观察.插管困难的标准为Cormack-Lehane喉头Ⅲ级、Ⅳ级或无法置入直接喉镜.应用Logistic回归分析插管困难的各种可能影响因素,包括病史、年龄、体重指数、上下切牙间距离、下颌骨水平长度、下颌骨宽度、颏至甲状软骨间距离、深覆盖、颈长、颈围、颈部后仰度、Mallampati试验.采用X2检验进行敏感性、特异性、误诊率和漏诊率的比较.结果:①与困难插管可能相关的12项指标中,应用多因素回归分析得出8项阳性相关因素,按估计相对危险度(OR)由大到小依次为:体重指数[5.64(3.51-8.12)]、上下切牙间距离[4.57(2.79-11.55)]、颏至甲状软骨间距离[4.35(2.33-6.97)]、病史[4.09(1.26-7.62)]、Mallampati试验[3.79(1.95-9.20)]、下颌骨水平长度[3.52(2.48-6.90)]、颈部后仰度[3.05(1.16-8.51)]、颈围[2.79(1.35-4.96)](P<0.05).②根据阳性相关因素,设定相应评分,建立所需的困难气道预测评估体系.将已得出的8项相关因素作为预测指标,每项分别设为1～3分,总分23分,分数越大,发生插管困难的危险性越大.③新预测评估体系具有敏感性高(93.3%)、漏诊率低(6.7%)的特点,明显优于Mallampati试验、Wilson评分(P<0.05).结论:新的困难气道预测评估体系应用于术前气道评估更为全面、有效,可大大提高对困难气道预测的准确性.     

双联试剂法检测粪便潜血的临床应用

探讨双联试剂法检测粪便潜血的临床应用价值。90例经内窥镜确诊为消化道出血患者,采用胶体金法对进行粪便潜血测定,采用化学法(愈创木酯)对粪便进行测定,采用免疫法和化学法进行联合检测,比较三种检测方法的特异度、敏感度、阴性预测值和阳性预测值。和免疫法对比,双联试剂法检测的特异度、敏感度、阳性预测值和阴性预测值更高,其中敏感度(χ2=10.150,P=0.001)、阴性预测值(χ2=7.120,P=0.008),差异显著,有统计学意义(P0.05)。和化学法对比,双联试剂法检测的特异度、敏感度、阳性预测值和阴性预测值更高,其中敏感度(χ2=38.984,P=0.000)、阴性预测值(χ2=31.457,P=0.000),差异显著,有统计学意义(P0.05)。和单纯免疫法、化学法对比,联合检测法能综合免疫法和化学法二者的优点,克服化学法的假阳性,避免免疫法由于抗原过量所致的前带反应而引起的假阴性,能大大地提高消化道出血的诊断阳性率,为临床诊断消化道出血提供可靠的依据,值得临床广泛应用。     

Wilson评分预测困难气道准确性的Meta分析

目的系统评价Wilson评分预测困难气道的准确性。方法计算机检索PubMed、EMbase、CNKI、WanFangData和VIP数据库,纳入Wilson评分预测困难气道准确性的文献,检索时间截至2013年1月。由两位研究者独立进行文献筛选、资料提取,并采用QUADAS条目评价纳入研究的方法学质量后,使用Meta—Disc1．4软件通过随机效应模型计算合并敏感度、特异度、阳性似然比、阴性似然比、诊断比值比及其95％CI,绘制综合受试者工作特征曲线（SROC）,以综合探讨Wilson评分预测困难气道的总体诊断准确性。结果共纳入9个研究,包括6506例研究对象。Meta分析结果显示：Wilson评分预测困难气道的合并敏感度为O．57[95％CI（O．53,0．62）],特异度为0．89[95％CI（O．88,0．90）,阳性似然比为6．11[95％CI（4．63,8．07）】,阴性似然比为0．52[95％CI（0．41,0．66）],诊断比值比为12．76[95％CI（8．60,18．93）],SROC曲线下面积为0．84。结论Wilson评分对于困难气道具有一定的预测价值,但应用中还需要参考其他临床指标。     

Comparison of Sitting Face-to-Face Intubation (Two-Person Technique) with Standard Oral-tracheal Intubation in Novices: A Mannequin Study

Background

Few studies have evaluated the impact of the upright position on the success of oral-tracheal intubation. Yet, for patients with airway difficulties (i.e, active intraoral bleeding or morbidly obese), the upright position may both benefit the patient and facilitate intubation.

Objectives

We compared the success rates of subjects performing standard intubation to a modified version of the sitting face-to-face oral-tracheal intubation technique on a simulation model. We also reviewed the possible advantages and limitations of the sitting face-to-face intubation technique.

Methods

Volunteer medical and paramedical students were given instruction, then tested, performing in random order both standard oral-tracheal and two-person sitting face-to-face oral-tracheal intubation on full-bodied mannequins. Observers reviewed video recordings, noting the number of successful intubations and the time to completion of each procedure at 15, 20, and 30 s.

Results

All of the sitting face-to-face intubations were successful, 53/53 (100%, 95% confidence interval [CI] 93–100%); whereas of the 53 subjects who performed standard intubation, 48 were successful (91%, 95% CI 80–96%). The difference between successful intubations using the standard vs. sitting face-to-face technique was 9% (95% CI 1.3–9.4%, p = 0.025). At times 15 and 20 s, medical student subjects who successfully performed both techniques were less successful at completing the procedure when performing the standard technique as compared to the sitting face-to-face technique (p = 0.016). A post-procedural survey found that the majority of subjects preferred the sitting technique.

Conclusion

Subjects were significantly more successful at performing and preferred the sitting face-to-face intubation when compared to standard intubation.     

Endotracheal intubation and esophageal tracheal combitube insertion by regular ambulance attendants: : A comparative trial

Objective

Recent cardiac arrest resuscitation guidelines have recommended the esophageal tracheal Combitube (ETC) as an advanced airway management alternative for individuals who infrequently perform endotracheal intubation (ETI). This study attempted to analyze basic (nonparamedic) ambulance attendant success rates at ETI and ETC insertion as well as their continuing skill competency over time and whether ongoing practice on mannequins improved skill performance.

Methods

Three hundred fifty-seven adult patients in cardiorespiratory arrest were treated by 81 basic ambulance attendants. Original study design called for the analysis of two treatment options in three patient groups: ETC insertion, ETI insertion with mannequin practice (ETI-MP), and ETI insertion without mannequin practice (ETI-NMP). The main outcome measures were:

(1)

successful insertion and ventilation with ETC or ETI, assessed by receiving physicians; and

(2)

differences in successful insertion/ventilation between the MP and NMP groups.

Results

Successful insertion (intent-to-treat) for the ETI-NMP group was 70 of 111 (63%; 95% confidence interval [CI], 54-73%); ETI-MP success was 105 of 139 (76%; 95% CI, 67-84%); ETC-NMP success was 26 of 42 (62%; 95% CI, 49-75%); and ETC-MP success was 36 of 53 (68%; 95% CI, 54-82%). Continuing mannequin practice appeared to improve ETI success (as-treated): MP 75% versus NMP 61% (odds ratio, 2.1; 95% CI, 1.11-3.94).

Conclusions

There were similar rates of successful insertion/ventilation with the ETC and ETI. ETI insertion success was lower without mannequin practice. ETI skill erosion was partially mitigated by additional field experience.     

气管插管昏迷患者鼻胃管置管法探讨

目的探讨气管插管昏迷患者鼻胃管置管方法,提高一次置管成功率。方法将90例气管插管昏迷患者随机分为对照组和实验组1、实验组2,每组30例。对照组按照传统方法置管。实验组1采用螺旋式胃管置管法。实验组2采用舌钳向外牵拉舌体配合旋转式胃管置入法。比较三组一次置管成功率。结果对照组一次置管成功率为46.67%,实验组1一次置管成功率为76.67%,实验组2一次置管成功率为96.67%。结论舌钳向外牵拉舌体配合旋转式胃管置管法,可提高一次置管成功率,减轻患者痛苦,减少气管黏膜的损伤和肺部感染。     

ICU患者经口气管插管与经鼻气管插管后行气管切开的比较

目的探讨经口气管插管与经鼻气管插管在ICU留置时间,比较两组气管插管后行气管切开的比例。方法将42例气管插管患者随机分为经口气管插管组24例和纤维支气管镜引导下经鼻气管插管组18例,比较两组患者插管留置时间及插管后再行气管切开率。结果经鼻气管插管留置时间明显长于经口气管插管,经鼻气管插管后行气管切开的比例明显低于经口气管插管。结论纤维支气管镜引导经鼻气管插管在ICU是有效的,插管留置时间更长,部分经鼻气管插管患者避免行气管切开。     

不同辅助手法对Bonfils纤维光导硬镜引导气管插管的影响

  目的  比较不同辅助手法下Bonfils纤维光导硬镜气管插管的效果。  方法  选择本院经口气管插管全身麻醉下实施择期整形外科手术成年患者90例, 美国麻醉医师协会(American Society of Anesthesiologists, ASA)分级Ⅰ~Ⅱ级, 按不同辅助手法随机分为A组(常规操作, 即头颈伸展位)、B组(单人提下颌)和C组(助手托下颌)。常规麻醉诱导后, 采用Bonfils纤维光导硬镜实施气管插管, 记录气管插管的操作次数、操作时间、血流动力学变化、插管所致气道损伤和术后咽痛等不良反应。  结果  90例患者均一次气管插管成功, A、B和C组的操作时间分别平均为(44.6±38.9)、(33.7±29.4)和(18.9±10.3)s, C组与A、B组比较差异均有统计学意义(P < 0.05);三组患者血流动力学变化相近。A、B和C组术后咽痛或不适分别为12、11和7例; A组上唇损伤1例, 其余2组未发生口咽部组织损伤。  结论  Bonfils纤维光导硬镜在不同辅助手法下行气管插管时, 采用助手托下颌的操作时间最短, 插管损伤最小。     

Complications of a Retrograde Intubation in a Trauma Patient

The authors report the case of an elder woman involved in a motor vehicle collision (MVC) requiring emergent intubation using the technique of retrograde intubation (RI). Since RI is a blind technique, potential complications arising from its use are numerous and may result in increased morbidity and mortality. Such was the case of this RI that involved incorrect placement of the endotracheal tube (ETT), resulting in suboptimal ventilation and increased morbidity. Additionally, this case illustrates how the failure to detect this error in multiple settings (ambulance, helicopter, emergency department) led to unnecessary and potentially deleterious procedures and significant delay in providing the basics of trauma care, oxygenation and ventilation. Although theoretical complications of RI have been addressed in the past, there have been very few published reports of actual complications. The emergency physician must be aware of difficult airways, options available to establish alternative airways, and methods to confirm appropriate placement of the ETT. The authors also discuss the indications, procedures, and complications involved in performing an RI.     

气管插管患者胃管置入法的研究进展

胃管置入法是临床最常用的护理操作技术,成功的置入对实施肠内营养、保持和改善患者的营养状况及促进康复起着重要的作用,特别是对已行气管插管且需长期留置胃管的危重患者,胃管的置入就显得更为重要。虽然大部分护士能熟练掌握其操作方法,但临床上置管困难、     

Delayed Sequence Intubation by Intensive Care Flight Paramedics in Victoria,Australia

Objective: Delayed sequence intubation (DSI) involves the administration of ketamine to facilitate adequate preoxygenation in the agitated patient. DSI was introduced into the Clinical Practice Guideline for Intensive Care Flight Paramedics in Victoria in late 2013. We aimed to describe the clinical characteristics of patients receiving DSI. Methods: A retrospective analysis was undertaken of patients who received DSI between January 1, 2014, and December 31, 2016, during both primary response and retrieval missions. Patients' clinical characteristics, DSI success rates, and complications were determined from electronic patient care records. Results: Forty patients received DSI during the study period. Of these, 32 were intubated to manage traumatic injury and the remaining 8 were intubated for medical reasons. On arrival of the first road ambulance, median oxygen saturation was 96.5%, and immediately prior to DSI the median was 98.0%. One patient had a period of self-limiting apnea (< 15 seconds) following ketamine administration. Oxygen saturation was either maintained or increased prior to laryngoscopy in all patients. Post-intubation, one patient experienced bradycardia (heart rate < 60 beats per minute), two patients had a systolic blood pressure drop of > 20 mm Hg, one patient experienced an increase in heart rate of > 20 beats per minute, and two patients had transient oxygen desaturation (< 85%). No patients experienced cardiac arrest or required surgical airway intervention. All patients were successfully intubated. After DSI, the median oxygen saturation was 100%. Conclusions: DSI provides a reasonably safe and effective approach for intensive care flight paramedics in the preoxygenation of agitated, hypoxic patients in order to decrease the risk of peri-intubation desaturation and related hypoxic injury     

纤维支气管镜在口腔颌面外科困难插管中的应用

目的 探讨纤维支气管镜（简称纤支镜）在口腔外科全麻过程中插管困难患者中的应用.方法 使用Olympus P30型纤维支气管镜引导,经鼻将气管导管插入气管.结果 15例盲插失败或插管困难的病例均在纤维支气管镜引导下快速顺利成功插入气管导管,且无任何并发症.结论 纤维支气管镜引导下气管插管几乎无创伤,操作时间短;避免了气管切开插管对患者产生的恐怖感和由此可能产生的各种并发症以及术后各种繁杂的护理工作,同时为颈清扫或颈部手术创造无污染、无障碍的手术环境,也避免了盲插过程中可能造成的损伤出血.