重症监护室内急救插管预氧合的研究现状

背景 预氧合是进行气管插管的必要程序之一,但由于临床证据不足,预氧合并未在重症监护室(ICU)内得到普及和重视.关于手术室内麻醉预氧合的研究较多,ICU内急救插管预氧合的研究才刚刚起步.目的 对ICU内预氧合的相关技术、实施,以及存在的问题、今后的发展进行探讨.内容 对ICU急救插管的患者进行预氧合能够有效地增加患者的...     

呼吸机面罩通气在紧急气管插管中的应用

目的：比较呼吸机面罩通气和简易球囊面罩通气在重症医学科紧急气管插管中脉搏氧饱和度（SPO2）改善的效果。方法入住重症医学科需紧急气管插管的患者260例,在气道开放后,给氧去氮期间,随机分为观察组与对照组,每组130例,观察组使用呼吸机面罩通气,对照组使用简易球囊面罩通气,全麻快速诱导后给予经口气管插管,监测给氧去氮期间,SPO2开始上升所需时间、上升速度及达到目标SPO2值所需时间。结果两组患者APACHEII评分无明显差异,抢救成功率有待进一步研究。观察组SPO2开始上升时间早,上升速度快,达目标值所需时间短,明显优于对照组,同时由于氧浓度及潮气量准确、分钟通气量保证、吸呼比更符合患者病理生理状态,明显提高抢救效率。结论呼吸机面罩通气和简易球囊面罩通气用于紧急气管插管前给氧去氮期间,前者具有明显的优越性。     

气管插管新器械和困难气管插管处理

目前临床上广泛使用的气管导管的前端为一个斜面，即使我们是给Cormack-lehaneI和II级的病人插管，有时候尽管我们能够看得见声门却插不进。     

Cookgas气管插管型喉罩在困难气道处理中的应用

Cookgas气管插管型喉罩(CILA)是Daniel Cook医师研制的一种新型气管插管型喉罩,该喉罩不仅具有操作简单、引导插管成功率高等优点,还能直接使用普通气管导管进行插管[1]。本文报道我院在30例困难气道患者使用的临床体会。资料与方法一般资料择期在全麻下行整形手术的困难气道患     

小儿困难气管插管的临床处理

本文评价目前推荐用于小儿困难气管插管处理的相关技术和设备。主要阐述的内容包括手术前准备、首选的麻醉方法,硬质喉镜和光导纤维喉镜气管插管技术等。另外,本文亦讨论小儿未预知性困难气道的处理问题。     

纤维支气管镜引导下气管插管技术在困难气管插管的应用

目的 为困难气管插管病人提供一种安全、有效的建立人工气道方法。方法 采用纤维支气管镜(纤支镜)引导下气管内插管技术。结果 36例困难气管插管病人均一次插管成功。插管时间30s～3min，平均1．6min。结论 纤支镜引导下气管插管技术是一种安全、准确、迅速建立人工气道的新技术，为临床解决困难气管插管提供一种可靠的选择。     

气管插管状态下纤维支气管镜导引经皮扩张气管造口术的临床研究

目的探讨气管插管病人用纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术（PDT）的优点。方法ICU60例气管插管患者随机分为两组,即纤支镜导引组（A组,n=32）,常规组（B组,n=28）。记录两组的手术时间,并发症例数,作统计分析。结果A组有更大的成功率,更少的并发症,手术时间并没有延长。结论气管插管病人以纤支镜导引行经皮扩张气管造口术相对于常规经皮扩张气管造口术有更高的安全性与实用性。     

新型气管插管器具发展的新特点

背景自上世纪40年代Macintosh和Miller喉镜片问世以来，各种新的气管插管器具被商业性推广。目的综述与目前临床实践相关的新型气管插管器具。内容重点阐述新型气管插管器具与传统直接喉镜性能的比较、新型气管插管器具的并发症、新型气管插管器具在清醒气管插管方法中的应用以及新型气管插管器具气管插管失败的预测等。趋向在预知的和未预知的困难气管插管或者气管插管失败的情况下，应用新型气管插管器具可获得极高的气管插管成功率。然而更重要的是，操作者应用各种新型气管插管器具的经验和技能是保证其在不同临床情况下成功应用的关键。     

紧急气管插管机械通气用于急性呼吸衰竭抢救的临床效果分析

目的分析紧急气管插管机械通气用于急性呼吸衰竭抢救的临床效果。方法选择笔者所在医院32例急性呼吸衰竭患者,采用紧急气管插管机械通气,并监测通气前后的患者血气分析及生命体征的变化。结果全部患者在常规治疗的基础上,给予紧急气管插管机械通气及其他积极抢救措施后,20例患者痊愈后出院,痊愈率为62.5%,其他患者的症状都有不同程度的改善。结论通过临床效果可以看出,急性呼吸衰竭在紧急气管插管机械通气下能快速改善症状,提高抢救成功率。     

Institutional preparedness to prevent and manage anaesthesia-related ‘can't intubate,can't oxygenate’ events in Australian and New Zealand teaching hospitals

It is unclear how the recent local and international focus on systems issues and human factors in ‘can't intubate, can't oxygenate’ events has impacted institutional preparedness in Australia and New Zealand. This study attempts to capture a snapshot of current practices in Australian and New Zealand teaching hospitals with regard to preparedness to prevent and manage ‘can't intubate, can't oxygenate’ events. All Australian and New Zealand College of Anaesthetists’ teaching hospitals were invited to complete an online survey consisting of 33 questions on terminology, equipment, cognitive aids, training and quality assurance. Follow-up was by both email and telephone. Responses were received from 129 (91%) of the 142 sites. The survey revealed both countries have largely moved to point-of-care ‘can't intubate, can't oxygenate’ equipment. There were regional differences reported, with Australia favouring equipment, cognitive aids and teaching that supports a combined cannula and scalpel approach to ‘can't intubate, can't oxygenate’, whilst New Zealand favours those promoting a scalpel-only approach. A lack of consistency with the terminology used around ‘can't intubate, can't oxygenate’ both within and between the two countries was also identified. This survey has revealed a generally reassuringly high degree of institutional preparedness to prevent and manage ‘can't intubate, can't oxygenate’ events across both countries but with strong regional differences in approaches. Little is known of the institutional practices outside these countries, making international comparison difficult.     

急诊有创呼吸支持方法的选择

目的：观察在急诊抢救危重患者的呼吸阶梯化管理中应用有创呼吸支持方法的效果。方法：对1994～2004年期间292例急诊抢救患者的呼吸阶梯管理进行统计分析和实施有创呼吸支持方法调查,并比较四种有创呼吸支持方法差异。结果：本组病例有创呼吸支持方法采用气管切开术203例(69．5%)、气管穿刺导入气管套管术58例(19．8%)、环甲膜穿刺术25例(8．6%)、气管穿刺旋切术6例(2．1%)。使用呼吸机占95例(32．5%)。神经系统卒中、严重创伤、呼吸道烧伤患者应及时使用有创呼吸支持方法。在可以预见插管困难、失败的可能性增大或患者病情逐渐加重、恶化等情况下应及时使用有创呼吸支持方法。气管切开术常需两个人以上操作,15～30min完成。气管穿刺导入气管套管术只需单人操作,一般在3～5min内完成,出血少,损伤小,对生命体征影响微小,术中术后并发症少,伤口愈合快。皮下气肿、脱管、管堵、出血是气管切开术后最常见的并发症。结论：急诊抢救中对有创呼吸支持方法的选择是急诊抢救流程中的关键环节,有助于危重患者的呼吸阶梯化管理,可以有效地帮助提高危重患者呼吸管理效果,提高抢救成功率。     

Strategies and algorithms for management of the difficult airway

We have some good evidence but no proof regarding the usefulness of algorithms and guidelines for management of the difficult airway. Therefore, it is logical that there are no mandatory standards (yet) but only voluntary recommendations. Airway management is a practical matter, and a sufficient range of proven techniques should be practiced every day to facilitate successful use in emergencies.     

An institutional approach to the management of the ‘Can't Intubate,Can't Oxygenate’ emergency in children

The ‘Can't Intubate Can't Oxygenate’ emergency is rare in children. Nevertheless, airway clinicians involved in pediatric airway management must be able to rescue the airway percutaneously through the front of the neck should this situation be encountered. Little evidence exists in children to guide rescue techniques, and extrapolation of adult evidence may be problematic due to anatomical differences. This document reviews the currently available evidence, and presents a practical approach to standardizing equipment, techniques, and training for managing the ‘Can't Intubate Can't Oxygenate’ emergency in children.     

批量重度烧伤患者急救和空运的组织管理思考

目的:总结急救和空运批量重度烧伤患者的应急保障管理经验,为各种突发灾害时组织伤病员的急救和空运提供有益的参考.方法:回顾性分析我院2006年5月组织急救和空运严重烧伤的35名患者的管理经验.结果:全部患者均安全飞抵医院,经过1月余的救治,了全部患者"零死亡"的目标.结论:重度烧伤患者的早期处理和快速转运到有条件的大型医院是救治成功的关键.有效的急救和空运组织流程有利于患者救治;建立全国性伤病员空运组织管理机构、批量伤病员紧急空运机舱内部改装预案和早期医护人员常规心理测评及干预机制十分重要.     

Proposal for the management of the unexpected difficult pediatric airway

The incidence of unanticipated difficult or failed airway in otherwise healthy children is rare, and routine airway management in pediatric patients is easy in experienced hands. However, difficulties with airway management in healthy children are not infrequent in nonpediatric anesthetists and are a main reason for pediatric anesthesia‐related morbidity and mortality. Clear concepts and strategies are, therefore, required to maintain oxygenation and ventilation in children. Several complicated algorithms for the management of the unanticipated difficult adult and pediatric airway have been proposed, but a simple structured algorithm for the pediatric patient with unanticipated difficult airway is missing. This paper proposes a simple step‐wise algorithm for the unexpected difficult pediatric airway based on an adult Difficult Airway Society (DAS) protocol, discusses the role of recently introduced airway devices, and suggests a content of a pediatric airway trolley. It is intended as an easy to memorize and a practical guide for the anesthetist only occasionally involved in pediatric anesthesia care as well as a call to stimulate discussion about the management of the unanticipated difficult pediatric airway.