手术室外抢救性气管插管的常见问题分析

目的分析手术室外抢救性气管插管存在的问题,总结相应的预防和处理经验。方法回顾分析我院2年来853例手术室外抢救性气管插管的经过,总结相应的成功经验或有关教训。结果能经口明视插入气管导管者791例,48例经口插管失败后改经鼻盲探成功,9例需用镇静、肌松剂后才成功插入,5例借助纤维支气管镜引导插入。插管时常见问题依次为患者牙关紧闭开口困难、吸引设备未到位或无功能,开口后直接喉镜难于显露声门、插管器械准备不足、患者家属干涉、求救电话表述不清或讹传。结论手术室外抢救性气管插管经口明视困难时应改经鼻盲探法,有条件时可辅用肌松剂或纤支镜。插管器具及吸引设施应随时处于备用状态。     

10例气管癌外科治疗体会

【目的】探讨气管肿瘤的麻醉和手术治疗方式【方法】本组10例中采用气管节段性切除术4例，支气管纤维镜下电切及烧灼2例，气管楔形切除2例。隆突半切除重建2例。上段气管肿瘤麻醉先行气管切开插管，中下段气管肿瘤及隆突手术病人先经口（鼻）气管插管麻醉，开胸后切开气管或右（左）主支气管再插管。【结果]10例均治疗成功，9例随访4个月至8年，3例分别于5、11、18个月后死亡，余6例存活。【结论】怀疑气管肿瘤病人需早期行CT及支纤镜检查，气管癌手术的麻醉及手术方式因人而异。气管节段性切除长度最好控制在5cm以内。行左（右）主支气管插管是有效、安全的麻醉方法。对于低度恶性的气管小肿瘤支纤镜下电切及烧灼加术后放疗是一种打击小，效果较好的方法。     

ICU内气管插管发生心搏骤停27例

目的：分析ICU内气管插管时心搏骤停的危险因素并加以防范。方法：回顾性分析ICU内行紧急气管插管的916例患者的资料，比较心搏骤停与未停组病人的基本情况、插管方式、有无应用肌松剂、操作时间、尝试次数等因素，采用Logistic回归分析心搏骤停的危险因素。结果：本组发生心搏骤停27例。心搏骤停组与未停组在动脉血氧分压、动脉血氧饱和度、指脉血氧饱和度等方面差异有显著性（P〈0.01）。单因素Logistic回归分析显示气管插管时发生心搏骤停可能与操作时间、尝试次数、肌松剂应用有关（P〈0.05）；多因素Logistic回归分析显示心搏骤停主要与肌松剂应用、尝试次数有关（P〈0.001）。结论：把握插管时机，插管前适当应用镇静剂而非肌松剂，加强操作者的自身建设，可能减少气管插管时心搏骤停的发生。     

腹腔镜胆囊切除术的麻醉与手术问题探讨

目的探讨腹腔镜胆囊切除术的麻醉与手术问题。方法回顾总结749例分别采取硬膜外麻醉666例（88．9％）、硬膜外＋气管插管麻醉45例（6．0％）及气管插管静脉复合麻醉26例（3．5％）；用三孔法或四孔法行腹腔镜胆囊切除术的临床资料。结果三种麻醉方法均良好的满足了腹腔镜胆囊切除术的要求，全麻苏醒快，硬膜外麻醉成本低。749例手术中．中转开腹2例（0．3％），发生并发症11例（1．5％），均痊愈出院。结论三种麻醉方法的恰当选用，更能发挥各自优势及处理好病情与安危问题。而ASA1—2级患者选择硬膜外麻醉安全可行且经济。只要提高术前诊断水平，充分估计病情，严把手术适应证及手术关，即会预防和减少并发症发生，提高手术质量。     

爱可松用于全麻气管插管的临床体会

爱可松是一种新型非去极化氨基甾类肌松药，其显著特点是起效快速，给予正常气管插管剂量时便可迅速产生优良的气管插管条件。2007年我院对30例患者采用麻醉快速诱导，使用爱可松气管插管体会报告如下：     

老年人肺切除手术的围手术期处理

目的：探讨老年人肺切除围手术期的特点，提高治疗水平。方法：本组67例患者均采用气管插管静脉复合麻醉。肺叶切除59例，楔形切除6例，全肺切除2例。结果：64例好转，死亡3例。术后病死率为5．3％。结论：只要围手术期认真处理并存疾病，尤其注意防治最易造成老年人死亡的肺部并发症，老年人是可以耐受肺切除术的。     

心脏手术婴幼儿气管插管的护理

笔总结366例婴幼儿体外循环心脏手术气管插管的护理。提出做好以下几点：胶布固定气管插管、对躁动明显加用约束带固定,遵医嘱应用地西泮、阿端等镇静剂、肌松剂;适宜的气道湿化与温化;吸痰前后予简易呼吸囊膨肺给氧;密切监测呼吸功能,病情稳定给予翻身拍背;严格遵守各项操作规程：有效防止了意外情况发生,减少了术后并发症。     

全麻快速诱导期肌松药选择再认识

全麻诱导期使用肌松药物可以使患者咽喉部肌肉很快松弛。短时间内即可进行气管插管，有利于缩短诱导时间，减少诱导期并发症的发生机会。传统上一般选择琥珀胆碱，但近年来随着一些新的肌松药和麻醉技术在临床上的使用。全麻诱导期肌松药的选择也趋于多样。     

肌松药给药途径对气管插管的影响

目的：通过不同径路的肌松药给药法，观察其对气管插管的影响，从而选择出最佳的给药途径，以提高气管插管的成功率。方法：选择择期手术患者198例，随机分为两组，一组经静脉直接推入，另一组由静脉滴入，观察插管时的情况。结果：静脉推注肌松药，肌松抑制80％左右,临床肌松良好，可以顺利完成插管。而由静脉滴入肌松药法，对正常生理解剖患者，可较顺利地完成插管，但对有插管困难指征的患者，不能很好地把握最佳插管时机和掌握插管技巧，增加了插管的难度。结论：选择正确的给药途径，即将肌松通过三通接头直接推入，才能保证用药集中，作用完全，提高插管的成功率。     

瑞芬太尼与芬太尼用于气管插管及麻醉苏醒期血流动力学与拔管条件的比较

目的：研究瑞芬太尼与芬太尼对患者气管插管及苏醒期血流动力学变化与拔管条件的比较。方法：40例择期颅脑手术的患者麻醉诱导和麻醉维持分别用瑞芬太尼（R组）或芬太尼（F组）。观察气管插管及苏醒期血流动力学变化与拔管条件等情况。结果：麻醉诱导后气管插管1～5min内血流动力学变化幅度R组明显小于F组（P〈0．05）；术后苏醒恢复状况及拔管条件R组优于F组（P〈0．05）。结论：瑞芬太尼在气管插管和麻醉苏醒期的血流动力学更稳定，拔管条件优，并发症少。     

Management of acute epiglottitis in pediatric patients

Of 41 pediatric cases of acute epiglottitis treated at the same institution during an 8-yr period, 33 patients were managed by nasotracheal intubation, one by tracheostomy performed at a referring hospital, and seven by intensive care observation and iv antibiotics. Twenty of the 33 nasotracheally intubated patients underwent intubation in the pediatric ICU by the pediatric anesthesiologist-intensivist, who used iv anesthetic agents and muscle relaxants. The remainder were intubated at referring hospitals. All of the intubated patients were paralyzed, sedated, and mechanically ventilated. The intubation technique caused no apparent complications; however, it required the skill and expertise of an experienced pediatric anesthesiologist-intensivist.     

右美托咪定复合七氟醚和瑞芬太尼在甲状腺肿瘤患者无肌松药气管插管中的应用

目的评价右美托咪定复合七氟醚及瑞芬太尼麻醉诱导在甲状腺肿瘤患者无肌松药气管插管中的应用价值。方法甲状腺肿瘤患者40例,麻醉诱导前15min静脉注射右美托咪定0．5μg／kg,10min注射完毕,以七氟醚和瑞芬太尼进行麻醉诱导。记录诱导前（T0）、插管即刻（T1）、插管后1min（T2）及插管后3min（T3）时平均动脉压、心率及Narcotrend指数,记录睫毛反射消失时间,采用VibyMogensen评分法评价气管插管条件。结果睫毛反射消失时间（76±6）s,一次气管插管成功率为97％,气管插管条件优良率100％;与T0时比较,T1、T2时平均动脉压、心率及Narcotrend值明显降低（P〈0．05）,T3时平均动脉压及Narcotrend值明显降低（P〈0．05）;T1、T2、T3时平均动脉压、心率及Narcotrend值比较差异无统计学意义（P〉0．05）。结论右美托咪定复合七氟醚及瑞芬太尼麻醉诱导迅速而平稳,可提供良好的气管插管条件,用于甲状腺肿瘤患者无肌松药气管插管安全可行。     

McCoy 喉镜在气管插管中的应用

目的:观察McCoy 喉镜在气管插管全麻中的作用。方法:120例全麻手术患者随机分为两组,普通喉镜(A),McCoy 喉镜(B)(n=60)。A组:常规监测,全麻诱导后用普通喉镜显露声门,进行气管插管;B组:全麻诱导后,用McCoy喉镜显露声门后行气管插管。分别观察两组喉镜显露程度,记录一次插管成功次数,插管时间,及喉部的损伤,对各项指标进行相关性分析。结果:McCoy 喉镜插管,喉显露情况优于普通喉镜,一次插管成功率高,插管时间短(P<0.05);对喉部的损伤两组无差异性。结论:McCoy 喉镜降低困难插管难度,提高插管成功率, 插管效果优于普通喉镜.     

孕期微创手术中胎儿的麻醉方法:附6例次报告

目的:探讨孕期微创手术中安全有效的胎儿麻醉方法。方法:回顾分析6例次接受宫内输血术的胎儿及母体的一般资料、麻醉用药、给药途径、术中监测情况等相关资料。结果:6例次孕期微创手术、胎儿麻醉操作均成功,其中1例次孕期微创手术采用母体静脉麻醉,术中胎儿胎动频繁、胎心率较快,影响操作;4例次采用胎儿静脉注射麻醉以及1例次采用胎儿肌内注射麻醉的胎儿胎动控制良好。应用肌松药可抑制胎动,加用镇痛药可维持胎心率平稳。结论:对于接受孕期微创手术的胎儿,建议应用肌松药;对于孕中期的胎儿,则推荐加用阿片类镇痛药。     

光棒引导气管插管的临床应用

目的对光棒引导气管插管的操作方法及其有效性、安全性等进行探讨和评价。方法随机选择需气管插管全身麻醉的患者60例,其中男21例,女39例;年龄15～79岁,体重35～110kg,术前预测存在困难气道者3例。采用Tubestat光棒引导气管插管,观察并记录插管时间、插管次数、血流动力学变化及不良反应。结果60例患者中有57例使用光棒插管成功（95％）其中1次插管成功者38例（63％）,试插2次成功者12例,试插3次成功者7例,插管失败3例（5％l插管时间（29．9l±24．21）s。插管后1min与麻醉前比较血流动力学变化无差异;术后诉有轻度咽喉痛者3例,未见其他与插管有关的并发症。结论光棒插管技术简单实用,容易掌握,成功率高,并发症少,可作为麻醉科常规气管插管方法。     

Postoperative management of children after single-stage laryngotracheal reconstruction

OBJECTIVE: To report the safety and efficacy of a postoperative approach that avoids pharmacologic and physical restraints and allows liberal physical activity after single-stage laryngotracheal reconstruction in children. DESIGN: Retrospective study. SETTING: Tertiary care pediatric intensive care unit. PATIENTS: One hundred thirty-three children who underwent single-stage laryngotracheal reconstruction, including laryngotracheoplasty, tracheal resection, and cricotracheal resection. INTERVENTIONS: Five-year period of data collection regarding postoperative care and complications. MEASUREMENTS AND MAIN RESULTS: The medical records of all patients (age range, 2-336 months; mean age +/- SEM, 66 +/- 5 months) who underwent single-stage laryngotracheoplasty, tracheal resection, or cricotracheal resection between 1993 and 1998 were reviewed. Tracheally intubated, awake, and unrestrained patients (group 1, n = 54; mean age, 113 +/- 8 months) were compared with tracheally intubated, sedated, and restrained patients (group 2, n = 79; mean age, 33 +/- 3 months). Pediatric intensive care unit length of stay was less in group 1 in comparison with group 2 patients (11.2 +/- 0.5 days vs. 13.7 +/- 0.6 days; p = .007). Hospital length of stay was less in group 1 than group 2 patients (16.7 +/- 1.0 days vs. 21.1 +/- 1.1 days; p = .01). Adverse events were fewer in group 1 compared with group 2 patients: atelectasis, 44% vs. 73% (p < .001); postextubation stridor, 22% vs. 53% (p < .001); and withdrawal syndromes, 0% vs. 43% (p < .001). The occurrence of pneumonia, airleak syndromes, unplanned extubation, and aspiration events was not different between groups. CONCLUSIONS: For developmentally appropriate children, postoperative management after single-stage laryngotracheal reconstruction does not require the use of physical and pharmacologic restraints. Older children who are not sedated or restrained and who are allowed liberal physical activity have shorter pediatric intensive care unit and hospital lengths of stay, and a decreased incidence of postoperative adverse events. Centers performing single-stage laryngotracheal reconstruction should consider a postoperative management strategy that avoids sedatives, muscle relaxants, and physical restraints, and allows liberal bedside physical activity in developmentally appropriate children.     

Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report

BackgroundEndotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.Case ReportWe report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful.Why Should an Emergency Physician Be Aware of This?This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.     

"恩纳"用于气管表面麻醉的动物实验研究

目的：研究“恩纳”用于气管插管表面麻醉的可行性。方法：20只成年白兔随机分为两组，经耳缘静脉推注安定0．5mg/kg，氯胺酮1mg/kg全身麻醉后，用直喉镜暴露声门，实验组插入直径3．5mm，前端5cm均匀涂有“恩纳”乳剂的气管导管；对照组插入同型导管，但不使用“恩纳”。观察气管插管后的耐受情况及麻醉苏醒后的呼吸道反应；插管4小时后，取气管导管接触段行光镜检查。结果：两组白兔经全身麻醉气管插管后，生命体征平稳，嘴唇红润，呼吸通畅，没有分泌物增加现象：麻醉作用消失后，实验组白兔一般能耐受气管导管，没有呛咳，打喷嚏的现象（0／10），而对照组白兔一般均有呛咳，打喷嚏的现象（10／10），两组白兔气管标本均未见形态学改变，双肺观察也无水肿，充血，分泌物增加的现象。结论：“恩纳”乳剂用于气管插管，能减轻导管在麻醉维持期及拔管后的应激反应，减少术后喉部并发症，对实验动物呼吸道未见过敏及炎性病理学改变。     

胸主动脉瘤介入治疗中双管型喉罩结合无肌松静脉全麻效果评价

目的探讨双管型喉罩结合无肌松静脉全麻在胸主动脉瘤介入治疗中的临床应用效果。方法择期行覆膜支架介入治疗胸主动脉瘤患者60例,ASAⅡ～Ⅲ级。采用随机区组法分为气管插管+静脉全麻+肌松组(Ⅰ组)与双管型喉罩+静脉全麻组(Ⅱ组)各30例。观察两组各检查时点血流动力学、脉搏血氧饱和度(SpO2)、术毕清醒与拔管时间,术后24小时随访有无麻醉相关并发症。结果双管型喉罩+静脉全麻在覆膜支架介入治疗胸主动脉瘤中麻醉效果满意,血流动力学较传统方法更加平稳,术中及术后未发生麻醉相关并发症。结论双管型喉罩+无肌松静脉全麻用于覆膜支架介入治疗胸主动脉瘤效果良好,简便易行,是一种值得临床推广应用的方法 。     

低出生体重新生儿及早产儿体外循环心脏手术的麻醉处理

目的:总结低出生体重儿(LBWI)行体外循环心脏手术的麻醉处理体会,对围术期管理进行探讨.方法:回顾分析17例低出生体重先心病手术患儿,出生体重1 225～2 500 g,平均(2 109.1±399.29)g;孕30.3～42.2周,平均(36.5±2.81)周.手术时日龄为8～79 d,平均(28.4±18.39)...