McGrath-5型视频喉镜与McCoy喉镜引导困难气道双腔支气管插管的效果比较*

目的探讨Mc Grath-5型视频喉镜与Mc Coy喉镜在困难气道双腔支气管插管的临床应用效果。方法选择预计双腔支气管插管困难的择期手术患者60例,采用随机数字表法,将其随机分为两组:Mc Grath-5型视频喉镜组(A组,n=30)和Mc Coy喉镜组(B组,n=30)。常规诱导后分别用两种喉镜引导经口插管,对两组患者一次插管成功率、插管时间、定位成功率、插管时间内脉搏血氧饱和度(Sp O2)90%次数、环状软骨按压例数、插管并发症发生情况和血流动力学指标:诱导前(T0)、置入喉镜暴露声门时(T1)、导管进入声门即刻(T2)、插管后3 min(T3)各时间点记录患者收缩压(SBP)、心率(HR)和脑电双频指数(BIS)值的变化进行分析。结果 A组患者环状软骨按压例数明显低于B组(P0.05),插管时间明显高于B组(P0.05);两组患者T3时点的SBP和HR较T0时点均明显降低(P0.05),A组患者T1、T2时点SBP和HR均明显低于B组(P0.05)。结论与Mc Coy喉镜相比,Mc Grath-5型视频喉镜引导经口双腔导管插管对血流动力学的影响较小,插管并发症较少,插管时间虽延长但不至于影响患者氧供,为临床解决困难气道双腔插管提供一种良好选择。     

视可尼视频喉镜与Macintosh喉镜用于模拟颈椎损伤病人气管插管的对比观察

目的对比观察视可尼(Shikani)视频喉镜和Macintosh喉镜用于Ambu颈托固定模拟颈椎损伤病人气管插管的临床效果。方法随机选取拟行择期手术需全身麻醉气管插管的80例患者,随机分为Shikani(S组,n=40)和Macintosh组(M组,n=40),麻醉诱导后,使用Ambu颈托固定颈椎,由熟练掌握该两种工具的同一麻醉医师完成气管插管,记录各组成功插管持续的时间、声门暴露时间、一次插管成功率、总插管成功率。记录并比较插管过程中心血管不良事件的发生次数。结果两组成功插管时间分别为30.65±8.22 s(S组)和42.48±8.32 s(M组),S组明显短于M组(P0.05);S组插管期间的心血管不良事件发生次数(11次)明显低于M组(31次)(P0.05);S组声门暴露时间(21.20±4.73 s)和一次插管成功率(97.5%)与M组(20.53±5.47 s,97.5%)比较,差异无统计学意义(P0.05)。结论与Macintosh喉镜相比,Shikani视频喉镜用于Ambu颈托固定模拟颈椎损伤病人气管插管成功插管所需时间短,插管期间心血管事件发生率低,是安全有效的。     

GlideScope视频喉镜在困难气道患者气管插管术中的临床应用价值和安全性评估

目的评价GlideScope视频喉镜对困难气道患者进行气管插管术的临床应用价值。方法选择2014年7月至2015年7月在该院就诊的困难气道患者40例,随机分为GlideScope视频喉镜组(研究组)和Macintosh直接喉镜组(对照组),每组各20例。比较两组患者喉部Cormack-Lehane分级、气管首次插管成功率、插管操作时间、插管后损伤,记录麻醉诱导前(T_0)、诱导后(T_1)和插管即刻(T_2)各时间点的心率(HR)、平均动脉压(MAP)和脉搏血氧饱和度(SPO_2)。结果研究组喉部Cormack-Lehane分级高分级者显著低于对照组(P0.05);研究组首次插管成功率明显高于对照组(P0.05);研究组插管时间明显短于对照组(P0.05);研究组无插管后损伤的情况,优于对照组;研究组患者T_2时与T_0时比较,血流动力学指标差异无统计学意义(P0.05)。结论 GlideScope视频喉镜可安全用于困难气道的气管插管,显著降低喉部Cormack-Lehane分级,提高首次插管成功率且缩短插管时间,插管后损伤小,并对循环系统影响轻微,有较高的临床应用价值。     

国产UE可视喉镜与普通喉镜用于小儿气管插管比较

目的评价国产UE可视喉镜在小儿气管插管中的应用价值。方法择期全身麻醉下气管插管行手术治疗患儿200例,随机分为可视喉镜组和普通喉镜组各100例,分别应用UE可视喉镜和普通喉镜行气管插管,记录2组声门暴露程度（Cormark—Lehane分级）、气管插管时间、插管成功率并进行比较。结果可视喉镜组声门暴露程度优于普通喉镜组,插管成功率高于普通喉镜组（P〈0．05）;2组气管插管时间比较差异无统计学意义（尸〉O．05）。结论国产UE可视喉镜用于小儿气管插管明显优于普通喉镜。     

Shikani可视插管镜与Macintosh喉镜引起心血管反应比较

  目的  比较Shikani可视插管镜与Macintosh喉镜用于非困难气道患者的插管反应及插管并发症, 评价Shikani可视插管镜的临床应用价值和前景。  方法  将40例拟在气管插管全身麻醉下接受妇科腹腔镜或开腹手术的女性患者随机分为两组, 分别接受Shikani可视插管镜插管或Macintosh喉镜插管, 记录插管前后的平均动脉压、心率、气管导管误入食道的次数、插管时间和咽痛、声嘶的发生率。  结果  两组患者人口统计学指标差异无统计学意义。Shikani组插管前后平均动脉压分别为(69.0±6.7)和(86.0±11.6)mm Hg, 心率分别为(70.8±8.8)和(78.3±9.9)次/min。Macintosh组插管前后平均动脉压分别为(69.3±9.0)和(93.6±8.9)mm Hg, 心率分别为(71.2±12.5)和(87.6±13.5)次/min。两组插管后平均动脉压及心率与插管前比较差异均有统计学意义(P < 0.05), 但Shikani组波动更小(P < 0.05)。两组插管时间、咽痛、声嘶发生率比较差异均无统计学意义(P > 0.05)。  结论  应用Shikani可视插管镜进行气管插管引起的心血管反应小于Macintosh喉镜。     

HC可视喉镜在非麻醉专业住院医师气管插管中的应用

目的:评估HC可视喉镜在已完成麻醉规范化培训的非麻醉专业住院医师气管插管中的应用效果。方法:32名完成麻醉规范化培训的非麻醉专业住院医师,每人使用HC可视喉镜及Macintosh喉镜分别实施3例非困难气道气管插管。记录首次气管插管成功率、首次成功插管所用时间、Cormack-Lehane评分、总体插管成功率、导管误入食道发生率以及总体并发症发生率。结果:HC可视喉镜组首次插管成功率明显高于Macintosh喉镜组(98%vs 78%,P0.05);首次成功插管用时明显短于Macintosh喉镜组[(51.2±0.8)秒vs(59.2±0.7)秒,P0.05]。在每病例最多两次插管尝试研究设定下,住院医师总体插管成功率在HC可视喉镜组明显高于Macintosh喉镜组(100%vs 85%,P0.05)。导管误入食道发生率明显低于Macintosh喉镜组(1%vs 26%,P0.05)。结论:非麻醉专业住院医师接受麻醉规范化培训后,可使用HC可视喉镜成功实施非困难气道气管插管;和传统使用Macintosh喉镜行气管插管比较,具有成功率高、耗时短等优点。     

Shikani喉镜用于老年人全麻气管插管

目的:探讨Shikani喉镜用于老年人全麻气管插管,是否可减轻气管插管的应激反应,维持老年人血流动力学稳定方法:30例ASA Ⅰ～Ⅲ级65岁以上择期全麻手术患者随机均分为两组,在全麻诱导后分别用Shikani喉镜(S组)和Macintosh直接喉镜(M组)行气管插管.记录诱导前(Tn),插管时(T1),插管后1 min(T2),插管后5 min(T3)的血压(BP)、心率(HR),并计算各时点RPP(rate pressure product)指数.同时采血测定T0、T3的皮质醇浓度.记录两组插管时间,计算一次插管成功率,并记录插管时的并发症.结果:插管后1 min,插管后5 min M组SBP及RPP指数均显著高于S组(P＜0.01).插管时SBP两组均显著低于诱导前,S组插管后5 min SBP仍显著低于诱导前(P＜0.001),而M组插管后5 min SBP与诱导前差异无显著性(P＞0.05),但插管后5 min HR显著高于诱导前(P＜0.01),插管后5 min RPP指数也显著高于诱导前(P＜0.001).M组插管后皮质醇浓度较诱导前高95(33～156)nmol/L(P＜0.01),也高于S组插管后皮质醇浓度(P＜0.01).两组插管时间、插管成功率、并发症差异均无显著性(P＞0.05).结论:Shikani喉镜用于老年人全麻气管插管,可减轻气管插管的应激反应,稳定血流动力学,增加老年人围术期的安全性.     

“一种操作便利的新型喉镜系统”与Ⅰ代Shikani喉镜在单人快诱导插管中的应用比较

目的:比较"一种操作便利的新型喉镜系统"(以下简称"新型喉镜")与I代Shikani喉镜在单人快诱导插管中的效率和安全性。方法:择期行插管全麻的成年患者108例,随机分为Shikani喉镜组(S组)和新型喉镜组(X组)。常规诱导后,由专一麻醉医师负责插管;记录两组插管时间(即开始插管到确认导管位于气管内的时间)、插管次数、首次插管成功率及并发症的发生率,同时观察两组围插管期的HR和MAP值。结果:两组患者一般情况无统计学差异(P0.05);与S组相比,X组插管时间较短,首次插管成功率较高且不良反应较少(P0.05);同时刻相比,两组间血流动力学改变无统计学差异(P0.05)。结论:"新型喉镜"有助于缩短单人快诱导的插管时间、提高首次插管成功率,减少插管并发症并维持血流动力学平稳,值得临床推广。     

Airtraq可视喉镜在急诊手术清醒气管插管术中的临床应用

目的探讨Airtraq可视喉镜在急诊手术患者处于清醒状态下进行气管插管的临床效果和安全性。方法选取2011年7月至2013年12月因急诊手术需要接受气管插管的患者62例作为研究对象。按随机数表将患者随机分为普通喉镜插管组和Airtraq可视喉镜插管组,对两组患者的插管所需时间、一次性插管成功率以及插管时的血流动力学变化进行对比与分析。结果 Airtraq可视喉镜插管组的平均插管时间为(19.5±6.2)s,与普通喉镜插管组(28.7±7.3)s相比明显缩短,前者的一次性插管成功率(100%)明显高于后者(64.52%),差异具有统计学意义(P0.05);且前者的血流动力学变化幅度小于后者,差异具有统计学意义(P0.05)。结论 Airtraq可视喉镜在急诊患者处于清醒状态下的气管插管技术操作简单,图像清晰,成功率高,并发症少,值得临床推广应用。     

Airtraq视频喉镜联合纤维支气管镜在困难气道插管中的效果评价

目的分析评价Airtraq视频喉镜联合纤维支气管镜(FOB)在处理困难气道中的临床效果。方法选择全身麻醉手术患者,术前经麻醉医师行Mallampati评估分级为Ⅲ或Ⅳ级,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,常规麻醉诱导后,先用普通喉镜行Cormack-Lehane评级,Ⅰ或Ⅱ级患者直接插管,将Ⅲ或Ⅳ级患者随机分为Airtraq视频喉镜联合FOB(A组)30例与Airtraq视频喉镜(B组)30例,然后实施经口气管插管,观察并记录两组患者插管次数、插管总时间、血流动力学变化及咽喉部损伤、咽喉痛情况。结果 A组患者插管时间和插管次数明显小于B组患者,差异均有统计学意义(P 0.05);插管前后,两组收缩压(SBP)、心率(HR)和血氧饱和度(SpO_2)比较,差异均无统计学意义(P0.05)。结论全身麻醉时应用Airtraq视频喉镜联合FOB,Cormack-Lehane评级Ⅲ级以上患者经口气管插管,具有全程可视、成功率高、插管时间短和减少气道及咽部损伤的优势。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.