电视胸腔镜手术的麻醉处理

目的 :探讨胸腔镜手术的麻醉处理要点、并发症的防治。方法 :分析 172例胸腔镜手术的麻醉过程 ,全组均采用快诱导双腔支气管插管静吸复合全麻。结果 :全组麻醉效果满意 ,发生 5例与麻醉有关的并发症 ,无手术及围麻醉期死亡病例。结论 :胸腔镜手术的麻醉处理关键是双腔管插管位置准确 ,加强呼吸管理 ,避免低氧血症     

纤支镜吸痰＋支气管肺泡灌洗在机械通气患者治疗中的应用

目的：探讨纤维支气管镜（简称：纤支镜）吸痰＋支气管肺泡灌洗对机械通气患者的临床疗效。方法：回顾性分析接受机械通气治疗的34例呼吸衰竭患者的临床资料,均给予镇静镇痛、营养支持、抗感染等治疗;治疗组（n=17）行纤支镜吸痰＋支气管肺泡灌洗,对照组（n=17）行常规吸痰。比较两组治疗前后动脉血气分析、机械通气时问、肺部阴影消散时间、ICU住院时间、28d病死率等指标变化。结果：治疗前两组PaO2、PaCO2、SaO2、PaO2／FiO2相比较,差异均无统计学意义（P〉0．05）;治疗后,治疗组PaO2、SaO2、PaO：／FiO2升高和PaCO2下降与对照组比较,差异均有统计学意义（P〈0．05）;治疗组机械通气时间和肺部阴影消散时间短于对照组,差异有统计学意义（P〈0．05）,但ICU住院时间和28d病死率差异无统计学意义（P〉0．05）。结论：应用纤支镜吸痰＋支气管肺泡灌洗治疗机械通气患者,可以有效改善氧合和肺内通气,利于肺部炎症控制,但不改变病死率。     

纤维支气管镜下肺灌洗在严重肺部感染治疗中的临床意义

目的:评价纤维支气管镜(纤支镜)吸痰及支气管肺泡灌洗对严重肺部感染的治疗价值。方法:对26例重症肺部感染患者床边应用纤维支气管镜行吸痰和灌洗术,同时取痰培养根据药敏结果选择抗生素治疗。结果:痰培养26例,21例阳性,阳性率80.77%,无明显并发症发生。治疗2 w后,治愈13例,好转11例,有效率达84.62%。结论:对重症肺部感染患者尽早经纤支镜灌洗吸痰,明确病原菌及指导抗生素选用,提高治愈率,临床效果确切,安全性高,值得临床推广应用。     

纤维支气管镜在危重急诊病人中的应用

目的探讨急诊床旁纤维支气管镜（简称纤支镜）技术在危重病急救中作用观察纤支镜对急性肺不张的诊疗价值。方法对住院期间发生肺不张的76例患者，在心电监护、血氧饱和度监测下行纤支镜检查，并进行支气管灌洗治疗。结果对73例肺部感染或合并叶段肺不张患者进行纤支镜下吸痰，其中对格林巴利综合征、严重脑外伤、严重肺挫伤伴多发肋骨骨折等并发肺不张患者行支气管肺泡灌洗，术后患者血氧饱和度明显升高，肺均基本复张；纤支镜及时诊断外伤性支气管断裂3例。结论急诊床旁纤支镜技术在危重病并急性呼吸衰竭的急救中极为重要，是必备的急救技术，操作简单、便捷、疗效确切、是抢救危重患者的较好手段，值得在临床推广应用。     

支气管内膜结核的特殊治疗——附77例报告（摘要）

我所用纤支镜检查(活检及刷检)经病理组织学及细菌学检查,证实支气管内膜结核者共77例,其中男性29例,女性48例,年龄最小为16岁,最大为53岁,全部病人除进行传统的全身抗痨治疗外,局部病灶进行药物(异烟肼)注射,部分病人进行经纤支镜电烧灼治疗,(支气管管腔狭窄明显或接近阻塞者采用电烧灼治疗加局部病灶注射药物治疗,管腔狭窄不严重者,仅采用局部注射药物方法。)部分病人     

90例肺结核患者的纤支镜检查资料分析

近年来肺结发病率有上升的趋势,现将我院90例肺结核患者的纤支镜检查结果报道如下.1 资料与结果本组90例患者,均经临床表现、胸部X线、痰菌检查及治疗结果的确诊,男性64例,女性26例,年龄17～73岁,平均55岁.检前痰阳12例、痰阴72例.其中Ⅲ型肺结核进展期8例,Ⅳ型肺结核9例.纤支镜检采用日本产Olympus BF—P20纤维支气管镜及自配套附件,操作步骤及标本处理接常规.对10例刷检阳性患者配合全身抗结核治疗下进行经纤支镜局部注药治疗.在纤支镜下确认病变肺段或亚段支气管,尽可能负压吸除支气管腔内的分泌物,然后注入INH0.1～0.3或SMO.5～1.0,每次镜下治疗间隔3～4天.90例患者均行经纤支镜支气管粘膜刷检,18例检出抗酸杆菌,其中检前痰阳9例、痰阴9例,刷检总阳性率为20%.经纤支镜局部注药治疗的10例患者.全部在2个月内痰菌阴转.最早者3周.平均50天;另8例刷检阳性病人平均痰菌阴转时间超过60天,最长者3个月.     

我国首次发现3例喉兽比翼线虫病

目的：了解3例因吃未熟龟血及龟内脏而患呼吸道疾病的病原病因。方法：采用支纤镜查气管、支气管，用涂片和沉淀法检查24h痰，用涂片和饱和盐水浮聚法检查晨粪；支纤镜钳取的和药物驱出及疫中咳出的虫体经活体和染色制片后测量和鉴定；虫卵加盖片后观察及测量。结果：3例粪涂片及浮聚法均阴性；3例24h痰中，查到交配虫体及虫卵；3例支纤镜检查和鼠药后，均获交配的虫体。结论：3例患者均患比翼线虫病。     

预观察右上叶支气管开口解剖对右双腔支气管导管对位的临床意义

目的探讨以纤维支气管镜预观察右上叶支气管开口解剖方位,对插右双腔支气管导管(R-DLT)对位的临床意义。方法选择插R-DLT成年患者160例,随机分为实验组和对照组,每组80例。实验组病例麻醉诱导后预先行支气管镜检查,主要测量右主支气管长度及右上叶支气管开口在右主支气管横切面的方位(以患者正前方12点钟位置为0度起点,按顺时针增大)。两组按常规方法将R-DLT插入右侧支气管,之后以纤维支气管镜检查调整导管位置。实验组按之前测定的支气管解剖调整导管深度并作适当的旋转,对照组只调整导管深度使蓝色的支气管套囊上缘在隆突之下见到。然后纤维支气管镜改从右管腔插入通过导管的侧孔查看右上叶支气管开口的对位情况,没有进一步调整就能够看到右上叶支气管开口即为初步对位成功。最后适当微调导管,直至能看清右上肺尖段、后段及前段3个开口。比较两组初步对位成功率以及插管失败率。结果实验组右主支气管长度(2.29±0.58)cm,其中短于1cm的有2例,占2.5%;右上叶支气管开口在右主支气管横切面方位(94.5±8.3)°,其中有4例(5.0%)明显偏前或偏后。实验组右上叶支气管开口初步对位成功实验组有77例(96.3%),而对照组为62例(77.5%),组间差异显著(P0.05)。两组各有1例插管失败,占1.25%,均为右上叶支气管开口与隆突距离较近(1cm)。结论预先以纤维支气管镜查看右支气管解剖有助于提高插R-DLT初步对位的准确性,并利于插管前发现右上叶支气管开口变异而选择合适的导管具有重要意义。     

经纤维支气管镜介入治疗支气管结核合并肺不张

目的 探讨经纤维支气管镜介入治疗支气管结核合并肺不张的有效性和安全性。方法 62例支气管结核合并肺不张患者随机分为治疗组和对照组。对照组应用常规抗结核治疗，治疗组在常规抗结核治疗的基础上给予清醒镇静麻醉下经纤支镜多点针刺注射或经纤支镜球囊扩张术为主的介入治疗。结果 治疗组强化期末及疗程结束时痰菌阴转率分别为64．86％和100．00％，高于对照组的34．78％和65．22％，经比较差异均有统计学意义；疗程结束时治疗组胸片不张病灶吸收效率为91．89％，高于对照组的69．57％，经比较差异均有统计学意义。病人对治疗的耐受性好，未发现与介入治疗有关的严重副反应。结论 清醒镇静下经纤支镜介入治疗方法是治疗支气管结核合并肺不张的有效方法，可弥补全身化疗的不足，提高治愈率，清醒镇静麻醉方式提高了患者的依从性，此疗法无明显毒性反应，并发症少，安全性好，值得临床推广应用。     

纤支镜介导注药并插管铱192腔内放射治疗气道肿瘤的疗效和安全性观察

目的为了探讨经纤支镜介导局部注射药物并插后装管进行腔内放射治疗气道肿瘤的临床应用价值。方法22例气道肿瘤患者均为中心型晚期肺癌，经纤支镜用专用注射针向腔内肿瘤局部注射5-Fu MMC和／或乙醇，并经纤支镜插后装管进行铱192腔内近距离放射治疗，比较治疗前后腔内肿瘤的消退，气道梗阻和肺不张的缓解及患者生存质量的改善情况及不良反应。结果治疗后15例肺不张，2例完全或部分张开，17例咯血均停止，病员自觉症状缓解率91％，全部病员生存质量提高，气管内肿瘤完全消退（CR）8例；消退在50％以上（PR）11例；有效率（CR＋PR）86．4％，无一例恶化。3例治疗后短期发热（38．5℃以下），1例胸痛不适，无严重并发症。结论经纤支镜注射药物加插管腔内放疗能有效地缓解气道梗阻，对不能手术的气道肿瘤引起的呼吸困难，肺不张，阻塞性肺炎及手术后残喘病，均有明显疗效，可改善患者生存质量，是综合治愈肺癌和姑息治疗的良好手段，其并发症少。     

High vacuum drainage of the chest using a miniature double lumen chest tube

The purpose of this study was to test the safety and efficacy of a high vacuum pressure drainage system with a 7F double lumen chest tube. Methods included animal experiments, where seven rabbits were subjected to bilateral tube thoracostomies, using a 7F double lumen chest tube at 340 torr on one side and more than 500 torr on the other for 30 minutes. Then, a preliminary clinical study was done. Three patients were treated with a 7F double lumen chest tube and a vacuum box at 340 torr after a thoracoscopic sympathectomy for approximately 60 minutes. An additional 460 patients were treated with a conventional system, using a 20F single lumen chest tube and chest drainage system at 14.7 torr following the same operation. All animals tolerated the test well. Suction injury of the lung was noted on the control side. In the clinical study, the air leaks stopped within 15 minutes, and no patients showed a radiologic sign of lung suction injury. Six patients in the control group developed subcutaneous emphysema. In conclusion, high vacuum pressure drainage of the chest using the 7F double lumen chest tube is safe and effective.     

Optimal positioning of right-sided internal jugular venous catheters: Comparison of intra-atrial electrocardiography versus Peres' formula

Central venous catheters are routinely placed in patients undergoing major surgeries where expected volume and hemodynamic disturbances are likely consequences. The incorrect positioning may give false central venous pressure (CVP) readings leading to incorrect volume replacement and other serious complications. 50 American Society of Anaesthesiologists grade II-IV patients aged 18-60 years were selected for right-sided internal jugular vein (IJV) catheterization using Seldinger''s technique. In group A, central venous catheterization was done under electrocardiography (ECG) guidance. In group B, the catheter was inserted blindly using Peres'' formula of “height (in cm)/10”. The position of the tip of central venous catheter was confirmed radiologically by postoperative chest X-ray. 92% of patients in group A had radiologically correct positioning of catheter tip i.e. above the carina, while in group B 48% patients had over-insertion of the catheter in to the right atrium. Intra-atrial ECG technique to judge correct tip positioning is simple and economical. It can determine the exact position intraoperatively and can justify a delayed postoperative chest X-ray to confirm CVC line tip placement.     

Characterisation and evaluation of a new double lumen central venous catheter.

The performance of a new double lumen central venous haemodialysis catheter was tested in two laboratory models. In a bench model the patient's venous system was simulated by a reservoir from which water or glycerol was drawn through a fixed tube. A double lumen silastic catheter was then inserted into the tube, as it would in a major vein, with the tip directed away from the direction of flow. The catheter was linked to a dialysis circuit incorporating pressure sensors and dye was infused at constant rate so that recirculation at the tip could be measured and found to be less than 5%. The same catheters were inserted operatively into the superior vena cava via the external jugular vein of three pigs (weight 27-31 kg). The catheters remained patent for four weeks and when connected to an extracorporeal circuit had recirculation and pressure flow characteristics comparable to the bench model in the range 50-400 ml/min. The new double lumen catheter is worthy of clinical evaluation.     

Hemodialysis Catheter Insertion Without Chest X-Ray: Review of a 24-Month Study

Acute care hemodialysis catheters have traditionally been validated for use through chest X-ray interpretation. This study was implemented to evaluate if hemodialysis catheters can be placed safely and accurately, utilizing an electrocardiogram plus doppler or dual vector positioning system to validate for use. Over a 24-month period hemodialysis catheters were inserted and validated by utilizing a dual vector positioning system instead of chest X-ray. During the study period, 260 hemodialysis catheters were inserted without chest X-ray and validated for use via the dual vector positioning system. An additional 74 inserted catheters required follow-up chest X-rays because of failure to obtain technological validation. During the study period, no patients had a pneumothorax or hemothorax complication subsequent to catheter placement. The use of a dual vector positioning system in this study demonstrated optimal hemodialysis catheter insertion can be done with no X-ray and no increase in mechanical complications.     

双腔气囊尿管闭式引流治疗COPD并自发性气胸

目的观察双腔气囊尿管治疗慢性阻塞性肺疾病（COPD）并自发性气胸的疗效。方法将106例COPD合并自发性气胸患者随机分为A、B两组,A组53例行双腔气囊尿管闭式引流,B组53例行传统粗硅胶管闭式引流。观察两组置管手术时间、置管引流持续时间、术后疼痛指数、引流管脱落、阻塞、皮下气肿发生率等情况,并进行比较。结果双腔气囊尿管组在治愈率、置管引流持续时间、引流管脱落等方面与传统硅胶管组无明显差异。而在置管手术时间、术后疼痛指数及皮下气肿发生等方面却明显优于传统硅胶管组。结论双腔气囊尿管治疗COPD合并自发性气胸具有手术置管快捷,病人耐受性好,术后并发症少等优点,可常规作为COPD合并气胸治疗的首选方法。     

How correct is the correct length for central venous catheter insertion

Background and Aim:

Central venous catheters (CVC) are important in the management of critically ill patients. Incorrect positioning may lead to many serious complications. Chest radiograph is a convenient means of determining the correct position of the catheter tip. The present study was designed to evaluate the depth of CVC placed through the right and left internal jugular vein (IJV) in order to achieve optimum placement of the catheter tip.

Materials and Methods:

A total of 107 patients in whom CVCs were put through either the right or left IJV through a central approach were included in this prospective study. Catheter tip position was observed in the post procedure chest radiograph. It was considered correct if the tip was just below the carina in the left-sided catheters and just above carina in the right-sided catheters. The catheters were repositioned based on the chest radiographs. The catheter depth leading to optimum tip placement was noted.

Results:

In males, catheter repositioning was required in 13 of 58 patients (22.41%) in the right IJV catheters, whereas in 2 of 13 patients (15.38%) in the left IJV catheters. In females, repositioning was required in 12 of 25 patients (48%) in the right IJV catheters and 2 of 11 patients (18.18%) in the left IJV catheters. Repositioning rate was higher in females (14/36) compared with males (15/71), which was statistically significant (P = 0.05, 95% CI). Repositioning rates were significantly higher in females (12/25) as compared with males (13/58) in the right IJV catheters (P = 0.019, 95% CI).

Conclusion:

By cannulating the IJV through a central approach, the catheters can be fixed at a length of 12-13 cm in males and 11-12 cm in females in the right IJV and at a length of 13-14 cm in males and 12-13 cm in females in the left IJV in order to achieve correct positioning.     

A randomized controlled trial of a soft double lumen embryo transfer catheter versus a firm single lumen catheter: significant improvements in pregnancy rates

BACKGROUND: Embryo transfer has changed little since originally described in 1978. Clinicians rate the type of catheter used as the third most important variable in embryo transfer, but there are no adequately powered randomized trials. We compared the clinical pregnancy rates with the single lumen catheter (TCC) and the double lumen catheter (CC) in a randomized single blind trial. METHODS: A total of 650 cycles of women from the Adelaide University reproductive medicine units in Australia were included in this trial. Patients were <40 years of age undertaking IVF and embryo transfer. Exclusion criteria were: known uterine abnormality, day 3 FSH >10 IU/l, previous difficult embryo transfer and pre-implantation genetic diagnosis. Cycles were randomized from numbered sealed envelopes immediately prior to embryo transfer with stratification for fresh or frozen cycles. RESULTS: There was a significantly higher pregnancy rate in the group treated with the CC compared with the TCC catheter [29.6 versus 20.5% per embryo transfer, odds ratio (OR) = 1.63 (95% confidence interval: 1.14-2.30), P = 0.0076]. The point estimate for the OR was similar for fresh and frozen cycles. CONCLUSIONS: The pregnancy rate was increased by 50% and this justifies the increased cost of the soft double lumen catheter and the training of clinical staff required.     

Bedside Peripherally Inserted Central Catheter Tip Confirmation: A Direct Savings Analysis

Peripherally inserted central catheter use has increased dramatically over the past decade, parallel to health care costs. Traditional bedside peripherally inserted central catheter placement requires anthropometric measurements of estimated catheter length and confirmation of appropriate tip positioning via chest radiograph. Newer bedside technology, using magnet and electrocardiogram capabilities, seeks to replace the traditional method with equal efficacy but less overall cost. The need for follow-up chest radiograph can been removed, a significant cost savings in direct patient care. In this retrospective case control study, we examine costs related to these 2 tip confirmation methods while assessing overall cost savings to the health care industry.     

Prolonged catheter survival in intermittent hemodialysis using a less thrombogenic micropatterned polymer modification

Adequate vascular access is a major prerequisite for hemodialysis treatment. Catheter related complications, in particular thrombus formation, are frequent, difficult to handle, and cost intensive. We investigated whether a new surface modified catheter containing a microdomain structure is beneficial for catheter survival. Surface thrombogenicity of standard double lumen catheters (STD-DC) and surface modified film-coated domain structured double lumen catheters (FCDS-DC) consisting of a novel reactive polyurethane copolymer coating was assessed by measurement of thrombinantithrombin (TAT) III complex in vitro. Furthermore, in a randomized observational study with 20 patients on hemodialysis, we analyzed catheter survival of either STD-DC (GamCath GDK 11 French, length 12.5 or 15 cm) or FCDS-DC (GamCath Dolphin GDK 11 French, length 12.5 or 15 cm). Catheter care protocol was identical, and dialysis treatment parameters were kept constant in both groups. In vitro measured surface thrombogenicity was reduced in the modified catheter compared with standard catheter. The clinical investigation revealed that both number of days before catheter removal according to clinical requirements and number of treatments per catheter were significantly higher with the modified catheter as compared with the standard catheter (14.5 vs. 10.3 days; 7 vs. 4 treatments; p < 0.03, Fisher-Yates test). Micropatterned surface coating with a polyurethane polymer significantly increased catheter survival and the number of treatments per catheter.     

The 'Ronco' catheter for continuous flow peritoneal dialysis

To perform CFPD, a two way access must be available in order to allow continuous inflow and outflow of the solution. This is most likely achieved with a double lumen peritoneal catheter. To design a double lumen catheter does not necessarily mean to increase the size of the tube or to increase the discomfort of the patient. However, the real challenge is to find a design in which minimal re-circulation is experienced. The two tips of the catheter must be positioned such that a maximal exposure of the peritoneal surface to the fluid is guaranteed during one single passage of the fluid from one lumen to another. Double lumen catheters with one short branch and another long of straight and of spiral shape were originally designed. Ash and coworkers have designed a catheter with a t-shape configuration in order to distantiate to the maximum the tips of the two lumens. Recently we have designed a novel catheter for CFPD equipped with a thin walled silicone diffuser used to gently diffuse the inflow dialysate into the peritoneum. The holes on the round tapered diffuser are positioned to allow dialysate to perpendicularly exit 360 degrees from the diffuser. The diffuser design and hole locations disperse the high-flow dialysate fluid at 360 degrees, reducing trauma to the peritoneal walls and allowing the dialysate to mix into the peritoneum. The dispersed fluid infused into the peritoneal cavity is then drained through the second lumen whose tip is placed into the lower Douglas cavity. The new catheter with diffuser is also equipped with a special removable hub that allows for easy creation of the subcutaneous tunnel without increasing the size of the skin exit site. The results so far achieved seems to offer advantages in terms of high flows, minimal pressure regimes and negligible recirculation.