右美托咪定复合小剂量氯胺酮在困难气道纤维支气管镜插管中镇静遗忘的效果

目的观察右美托咪定复合小剂量氯胺酮在择期手术困难气道患者纤维支气管镜经鼻气管插管中的镇静遗忘的效果。方法择期困难气道纤维支气管镜经鼻插管患者90例,ASAⅠ或Ⅱ级,按照随机数字表法均分为三组:右美托咪定1.0μg/kg+氯胺酮0.5 mg·kg-1·h-1(DK组)、右美托咪定1.0μg/kg+丙泊酚2.0mg·kg-1·h-1(DP组)和右美托咪定1.0μg/kg+瑞芬太尼5.0μg·kg-1·h-1(DR组)。比较三组患者入室后安静10min(T0)、纤维支气管镜置入前(T1)、气管导管进入声门即刻(T2)及插管后5min(T3)时HR、MAP、SpO2及Ramsay镇静评分和不良反应,及术后24h随访患者对气管插管过程的知晓情况。结果与T0时比较,T1时DP和DR组HR明显减慢,MAP明显下降,T1时DP组SpO2明显降低(P0.05);T3时DP和DR组HR明显加快,DR组MAP明显增高(P0.05);T2时DR组MAP明显高于DP组。T2时DP组和DR组Ramsay镇静评分明显低于DK组,T3时DR组Ramsay镇静评分明显低于DK和DP组(P0.05);DP组心动过缓、呼吸抑制发生率明显高于DK组,DR组呛咳、躁动、心动过速、插管知晓发生率明显高于DK组(P0.05)。结论右美托咪定复合小剂量氯胺酮用于困难气道患者经鼻纤支镜插管可保证良好的镇静遗忘效果,维持稳定的血流动力学,并且不良反应发生率低。     

右美托咪定持续静脉注射对甲状腺手术患者全麻恢复期的影响

目的观察不同剂量右美托咪定持续静注对甲状腺手术全麻恢复期患者的影响。方法全麻下行择期甲状腺手术患者120例,ASAⅠ或Ⅱ级,随机均分为四组:在手术开始前10min至术毕前20min,分别泵注生理盐水(C组)、右美托咪定0.2μg·kg-1·h-1(D2组)、0.5μg·kg-1·h-1(D1组)和0.7μg·kg-1·h-1(D3组)。记录四组患者拔管前和拔管后呛咳评分和镇静-躁动评分(SAS评分),拔管后5、10、30、60、120min时VAS、Ramsay镇静评分和围术期MAP、HR;记录自主呼吸恢复时间、睁眼时间、拔管时间、定向力恢复时间,并记录不良反应等情况及用药情况。结果与C、D1、D2组比较,拔管前和拔管后D3组呛咳评分明显降低(P0.05)。与C、D1组比较,拔管前和拔管后D2、D3组SAS评分明显降低(P0.05)。在全麻恢复过程中,D2、D3组MAP和HR基本平稳,不同程度低于其他组,以D3组效果更明显(P0.05)。与C、D1组比较,D2、D3组躁动、心动过速,D3组高血压发生率明显降低(P0.05),D3组心动过缓发生率、阿托品用量明显升高(P0.05)。与C组比较,D3组PONV、D2组高血压发生率明显降低(P0.05)。D3组七氟醚用量最低(P0.05),术后追加芬太尼量最少(P0.05)。结论持续静脉泵注右美托咪定0.5、0.7μg·kg-1·h-1能有效减少甲状腺手术全麻恢复期呛咳、躁动的发生,维持血流动力学稳定,且不影响苏醒。0.7μg·kg-1·h-1速率给药优于0.5μg·kg-1·h-1。     

右美托咪定对扁桃体摘除术麻醉苏醒期躁动的影响

目的 评价右美托咪定对扁桃体摘除术患者麻醉苏醒期躁动的影响.方法 择期扁桃体摘除术患者60例,年龄12～20岁,体重35～65 kg,ASA Ⅰ或Ⅱ级,随机均分为两组.麻醉诱导后,右美托咪定组(D组)在10 min内静脉泵注右美托咪定1.0μg/kg(用生理盐水稀释至50 ml),然后以0.5μg,kg-1·h-1持续泵入至手术结束前20 min.对照组(C组)以同样方式泵注生理盐水.术中吸入异氟醚和静注丙泊酚维持麻醉.记录吸痰拔管时镇静躁动(SAS)评分及拔管后10 min的Ramsay镇静评分及VAS评分.结果 D组阿托品使用次数明显多于C组(P＜0.05).拔管时D组SAS评分明显低于C组,而Ramsay评分明显高于C组(P＜0.05).结论 右美托咪定可明显减少扁桃体摘除术患者麻醉苏醒期闻躁动的发生.     

不同速率输注右美托咪定对老年白内障手术患者的镇静效应

目的 观察不同速率输注右美托咪定对老年白内障手术患者球后神经阻滞麻醉下的镇静效应.方法 选择90例60～80岁白内障手术患者,根据应用右美托咪定维持剂量随机均分为右美托咪定Ⅰ组(0.2μg·kg-1·h-1)、Ⅱ组(0.4μg·kg-1·h-1)、Ⅲ组(0.6 μg·kg-1 ·h-1).观察并记录三组患者麻醉前(T0)、神经阻滞完毕即刻(T1)、用药后10 min(T2)、20 min(T3)、30 min(T4)、60 min(T5)的Ramsay评分和MAP、HR、RR、SpO2.结果 T2～T5时各组Ramsay评分高于T0时(P＜0.05),T3～T5时Ⅲ组高于Ⅰ组(P＜0.05).T3～T5时三组HR显著慢于T0时(P＜0.05),以Ⅲ组减慢最明显;T3～T5时三组RR均慢于T0时,但差异无统计学意义;三组间MAP、SpO2差异无统计学意义.结论 静注右美托咪定0.5 μg/kg后以0.2～0.4 μg·kg- 1·h-1维持适合老年白内障手术患者的清醒镇静.     

右美托咪定复合氯胺酮与单纯氯胺酮在患儿烧伤换药镇静中的比较

目的 观察右美托咪定复合氯胺酮用于小儿烧伤换药的临床镇静效果及安全性.方法 分别对20例烧伤住院患儿的两次换药采用不同镇静方式.A镇静方式为右美托咪定6μg·kg-1 ·h-1静脉泵注10 min后静注氯胺酮1 mg/kg,随后右美托咪定0.6 μg·kg-1·h-1维持,根据换药中的体动情况按0.5 mg/kg追加氯胺酮.B镇静方式用等容量生理盐水代替右美托咪定,其余方法与A相同.监测静脉泵注前(T1)、静脉泵注10 min后(T2)、换药开始后1 min(T3)、5 min(T4)、10 min(T5)、换药结束时(T6)患儿的MAP、HR、RR、PETCO2、SpO2等指标,并对小儿作Ramsay镇静评分,记录换药完成时间、氯胺酮使用量、苏醒期睁眼或体动时间,观察小儿苏醒期躁动(PAED)评分及恶心呕吐情况,记录小儿父母及换药医师满意度评分.结果 T2～T6时A镇静方式的MAP明显低于,HR明显慢于B镇静方式(P＜0.05);T2时Ramsay镇静评分A镇静方式明显低于B镇静方式(P＜0.05).两种镇静方式的氯胺酮使用量差异无统计学意义,A方式苏醒时间长于B方式,但PAED评分、恶心呕吐评分及父母满意度明显高于B方式(P＜0.05).结论 右美托咪定复合氯胺酮应用于小儿烧伤换药的镇静,患儿血流动力学指标较为平稳,且对呼吸无明显影响.本研究中虽然右美托咪定不能减少氯胺酮使用量,且可稍延长患儿苏醒时间,但可以提高患儿苏醒质量,可以安全用于小儿烧伤换药的镇静.     

右美托咪定预防神经外科全麻术后躁动的临床观察

目的观察右美托咪定预防神经外科手术患者术后躁动的临床效果。方法选择神经外科全麻手术患者60例,随机均分为右美托咪定组(D组)和生理盐水组(C组)。患者手术结束前10min停用麻醉药,D组静脉泵注右美托咪定0.4μg/kg10min,C组静注等剂量的生理盐水。记录麻醉前、拔管即刻、拔管后5min血流动力学变化,并对拔管后5、30、60、120min躁动程度、镇静状态、躁动发生率进行评估。观察呼吸恢复时间、唤醒时间和拔管时间。结果与C组比较,D组拔管即刻及拔管后5min的MAP明显降低,HR明显减慢(P<0.05);与麻醉前比较,D组拔管后5min的MAP明显降低,HR明显减慢,C组拔管即刻及拔管后5min的MAP明显升高,HR明显增快(P<0.05)。D组麻醉苏醒期躁动发生率、躁动程度明显低于C组,D组VAS评分在拔管后5、30、60、120min均明显低于C组(P<0.05),Ramsay镇静评分拔管后5、30min明显高于C组(P<0.05)。结论静脉泵注0.4μg/kg右美托咪定能减轻拔管期应激反应,减少躁动,不延迟呼吸恢复时间、唤醒时间和拔管时间,可预防神经外科全麻术后躁动。     

右美托咪定联合地佐辛对老年高血压患者全麻苏醒期躁动及血流动力学的影响

目的探讨右美托咪定联合地佐辛对老年高血压患者全麻苏醒期躁动及血流动力学的影响。方法择期行肺癌根治术的老年高血压患者80例,年龄65~80岁,ASAⅡ或Ⅲ级,根据随机数字表法均分为四组:右美托咪定组(DEX组)、右美托咪定+地佐辛组(DD组)、对照组(C组)、地佐辛组(DEZ组)。所有患者于手术结束前60min时,DEX组静脉泵注右美托咪定0.2μg·kg-1·h-1至关胸完毕;DD组泵注右美托咪定后静脉注射地佐辛0.1 mg/kg;C组给予等容量生理盐水;DEZ组关胸完毕时静脉注射地佐辛0.1mg/kg。分别于麻醉诱导前(T0)、关胸完毕缝皮时(T1)、拔除气管导管即刻(T2)、拔除气管导管后5min(T3)、30min(T4)时抽取肘静脉血3ml,测定血糖(Glu)和皮质醇(Cor)的浓度,并记录各时点的MAP和HR,观察苏醒期间躁动、高血压及心动过缓的发生情况,T3、T4、拔除气管导管后60min(T5)时评估患者的VAS评分、Ramsay镇静评分。结果与C组比较,T1~T4时DEX组和DD组MAP明显降低,HR明显减慢(P0.05),与T0时比较,T2~T4时C组和DEZ组MAP明显升高、HR明显增快(P0.05);与C组比较,T2~T4时DEX和DD组Glu、Cor浓度明显降低;与C组比较,T3~T5时DEX组、DD组、DEZ组的VAS评分明显降低,Ramsay镇静评分明显升高,术后躁动程度和高血压发生率明显降低(P0.05)。结论右美托咪定可降低老年高血压患者苏醒期躁动程度及高血压发生率,能有效抑制应激反应,右美托咪定联合地佐辛可提供更稳定的血流动力学和改善患者的苏醒质量,苏醒时间和拔管时间略延迟。     

右美托咪定复合氟比洛芬酯预防全麻苏醒期躁动的临床研究

目的观察右美托咪定复合氟比洛芬酯对全麻患者苏醒期躁动及拔管期心血管反应的影响。方法择期行全身麻醉的口腔颌面部肿瘤手术患者80例,ASAⅠ或Ⅱ级,随机分为氟比洛芬酯组(F组)、右美托咪定组(D组)、右美托咪定复合氟比洛芬酯组(DF组)和对照组(C组),每组20例。F组于手术结束前30min经静脉注射氟比洛芬酯50mg;D组于手术结束前30min经静脉注射右美托咪定0.5μg/kg;DF组手术结束前30min经静脉注射氟比洛芬酯50mg,同时经静脉注射右美托咪定0.25μg/kg;C组静脉注射与D组等容量的生理盐水。记录四组患者拔管前(T0)、拔管时(T1)、拔管后5min(T2)MAP、HR的变化;记录苏醒时间、拔管时间以及拔管前Riker镇静躁动评分、拔管后5min的Ramsay镇静评分。结果 T1、T2时F组、C组MAP明显高于,HR明显快于T0时(P0.05或P0.01);D组、DF组MAP明显低于,HR明显慢于C组(P0.01)。D组苏醒时间、拔管时间明显长于,Ramsay镇静评分明显高于其他三组(P0.05);D组、DF组Riker镇静躁动评分明显低于C组(P0.05);D组、DF组患者躁动发生率明显低于C组(P0.05或P0.01)。结论右美托咪定0.25μg/kg复合氟比洛芬酯50mg可有效降低全麻患者苏醒期躁动并能降低患者拔管期心血管反应,不会延长患者的苏醒时间和拔管时间。     

右美托咪定用于患者清醒经鼻盲探气管插管的效果

目的 评价右美托咪定用于患者清醒经鼻盲探气管插管的效果.方法 选择择期行困难气道需清醒经鼻插管口腔颌面手术患者60例,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将患者均分为:表面麻醉组(S组)、表面麻醉+咪达唑仑组(SM组)、表面麻醉+右美托咪定组(SD组).S组1％丁卡因喉头、舌根喷雾；SM组静脉输注咪达唑仑0.1 mg/kg;SD组静脉输注右美托咪定0.1μg·kg-1 ·min-1,10 min后改为0.5 μg·kg- 1·h-1维持.分别于入室时(T0)、环甲膜穿刺前即刻(T1)、环甲膜穿刺后即刻(T2)、插管前即刻(T3)和插管后即刻(T4)记录MAP、HR、SpO2、BIS、Ramsay镇静评分、一次插管成功及体动、咳嗽、流泪、术后不良记忆等不良反应.结果 与S组比较,T3、T4时SM组和SD组MAP、BIS值降低,HR减慢,Ramsay镇静评分升高,术后患者不良记忆发生率降低,SD组一次插管成功率明显升高,插管时不良反应发生率明显降低(P＜0.05)；与SM组比较,T3、T4时SD组MAP降低,HR减慢,一次插管成功率升高,插管时不良反应及术后不良记忆发生率明显降低(P＜0.05).结论 右美托咪定用于清醒患者经鼻盲探气管插管时效果良好,一次插管成功率高,不良反应发生率低.     

不同剂量右美托咪定对视频喉镜清醒镇静插管时心血管反应的影响

目的观察不同剂量右美托咪定对视频喉镜清醒镇静插管时心血管反应的影响。方法择期气管插管全麻手术患者90例,ASAⅠ或Ⅱ级,MallampatiⅠ或Ⅱ级,随机均分为三组,D1组:右美托咪定0.8μg/kg+瑞芬太尼0.5μg/kg;D2组:右美托咪定1.0μg/kg+瑞芬太尼0.5μg/kg和D3组:右美托咪定1.2μg/kg+瑞芬太尼0.5μg/kg。插管前15min三组患者分别按上述剂量缓慢静脉泵注右美托咪定(10min泵注完毕),插管前90s快速静注瑞芬太尼,并在气管完善表面麻醉的基础上,行视频喉镜插管。记录入室后安静10min(基础值,T0)、喉镜置入前(T1)、气管插管后即刻(T2)时HR、MAP及Ramsay镇静评分;并记录插管时间、气管插管过程中躁动、呛咳、呼吸抑制、心血管不良反应的发生情况;术后随访患者对气管插管过程的知晓情况。结果 T1时三组HR明显慢于、MAP明显低于T0时(P0.05);T2时D1组HR明显快于、MAP明显高于D2、D3组(P0.05)。T1、T2时D1组Ramsay镇静评分明显低于D2、D3组(P0.05)。D1组高血压、心动过速、躁动、呛咳等不良反应的发生率明显高于D2、D3组(P0.05)。D3组心动过缓、呼吸抑制发生率明显高于D1、D2组(P0.05)。结论在完善的气道表面麻醉基础上,右美托咪定1μg/kg复合瑞芬太尼0.5μg/kg可以明显抑制视频喉镜清醒镇静插管时的心血管反应,并且不良反应少,是较为合理的临床用药剂量。     

Results of transverse tracheal resection in post-intubation tracheal stenoses

Tracheal problems in form of stenosis and malacia are a calculated risk of long-term tracheal intubation. Results with conservative treatment of such problems by bougienage, laser therapy, biopsy, cryotherapy, local steroids, tracheal stenting, and tracheostomy are not satisfactory in a higher percentage of cases. Resectional therapy of benign tracheal lesions has become an established technique, which combines excellent functional results with a low complication incidence. We have treated 40 patients of 17 to 76 years of age with postintubation tracheal lesions by cross resection of the affected segment. Of these patients 40% had received conservative therapeutical steps preoperatively. The mean resection length was 3.0 cm (1.5 to 6.5 cm). The perioperative morbidity was 7.8%, mortality was 2.5%. 85% of the patients operated between 1970 and 1989 were reached for a follow-up examination with x-ray, pulmonary function test and endoscopy. The patients subjective satisfaction with the operative result was good in 85%, minor in 12% and less in 3%. The objective investigations proved very good results in 90%. Our experience confirm the good results of other authors and recommend the resection treatment for cases of postintubation tracheal lesions.     

Experience with tracheal resection for traumatic tracheal stenosis

Ten patients with traumatic tracheal stenosis--unresponsive to conservative therapy--underwent tracheal resection. Two of the stenoses resulted from gunshot injuries, three were due to prolonged intubation, and five developed after tracheotomy. Eight of the operations were completely successful. There was one death, and one patient has had recurrent granulation tissue at the anastomotic site. The pathogenesis of tracheal stenosis, as well as its treatment--including the technical details of tracheal resection--are discussed.     

Total tracheal resection for long-segment benign tracheal stenosis

Tracheal resection for long benign tracheal stenosis is challenging because of the lack of a suitable replacement to facilitate tension-free anastomosis. We describe a patient with a 6-cm post-tuberculous tracheal stricture, severely debilitated post-recurrent bronchoscopic intervention. Staged resection facilitated near-total tracheal resection with primary anastomosis and complete symptom resolution.     

Self-made tracheal stomal stent using a tracheal T-tube

Adapting a silicone tracheal safe T-tube is a simple method to guarantee upper airway permeability. Its making and availability ease offers a cheap and valid option to avoid the complications of the tracheostomy tube.     

Post-intubation tracheal rupture: poor healing of the tracheal wall

Purpose

To describe tracheal rupture after orotracheal intubation assisted by a tracheal tube introducer.

Clinical features

A 73-yr-old morbidly obese female patient with a history of hypertension underwent a total knee replacement. There were no anticipated signs of difficult intubation. Orotracheal intubation was attempted twice by direct laryngoscopy, and a Boussignac bougie was used as a tube exchanger for the second attempt. Seven hours after tracheal extubation, the patient became dyspneic and showed a large subcutaneous emphysema. A chest x-ray and computerized tomography scan revealed rupture of the posterior tracheal wall. The distal part of the injury was 26.5 cm from the patient’s teeth and 0.5 cm from the carina (i.e., beyond the normal location of the tracheal tube tip) and extended to the origin of the right main bronchus, where the tip of the Boussignac bougie was probably pushed. Formation of an endotracheal sac occurred during the first two weeks after intubation, accompanied by dyspnea and alveolar hypoventilation, but symptoms resolved favourably with conservative management.

Conclusion

The tracheal rupture was attributed to airway manipulations, and the distal location of the lesion suggests that the cause was the Boussignac bougie rather than the tracheal tube. Long-term healing of the injury was satisfactory, although the patient continued to complain of dyspnea one year after the rupture.