视频喉镜引导困难气管插管的护理配合

对69例气管插管困难患者在视频喉镜引导下气管插管成功,无一例因护理配合不当出现并发症。提出术前做好用物准备,对患者气管插管困难进行预测及判断患者有无寰椎关节运动受限或张口异常,针对性做好应对措施;术中熟练操作步骤,密切配合,加强生命体征观察,可提高气管插管成功率、减少损伤、增加安全性。     

Submental intubation in complex craniomaxillofacial trauma

The submental route for endotracheal intubation is an alternative to nasal intubation or tracheostomy in the surgical management of patients with complex craniomaxillofacial injuries. The critical indication for submental intubation is the requirement for intraoperative maxillomandibular fixation (MMF) in the presence of injuries that preclude nasal intubation and in a situation where a tracheostomy is not otherwise required. MMF to re-establish dental occlusion is essential for a normal functional result in dentate patients with fractures involving alveolar segments of the jaws. However, MMF precludes orotracheal intubation. Nasotracheal intubation is often used but is contraindicated in the presence of skull base fractures and will interfere with the access to certain fracture types. A tracheostomy has a high potential complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. A submental intubation has been used in 11 selected cases amongst 190 consecutively treated patients with craniomaxillofacial trauma over a 3-year period. These cases have been retrospectively reviewed and there have been no significant complications. The indications and technique used are described. Submental intubation is a simple and useful technique with low morbidity in selected cases of craniomaxillofacial trauma and the author's clinical experience with this technique is described.     

Use of the bispectral index to predict a positive awareness reaction to laryngeal mask airway-Fastrach insertion and intubation

Aim:  To determine whether the bispectral index (BIS) can be monitored to predict and indicate an awareness reaction to laryngeal mask airway–Fastrach (LMA–Fastrach) insertion and intubation at BIS values between 40 and 60.
Methods:  Fifty-one American Society of Anesthesiologists' (ASA) class I or II status patients aged over 20 years were included in this study. Midazolam 0.1 mg/kg was given for pre-medication, 30 min before induction. For induction, a 0.1-μg/kg bolus injection of remifentanil was followed by infusion, and propofol was administered until the eyelash reflex disappeared; the infusion rate was adjusted to maintain BIS values between 40 and 60. Loss of the eyelash reflex, loss of response to verbal commands, yawning and total propofol consumption were recorded. Patients were tested for awareness twice at 1-min intervals using the isolated forearm technique. The test was considered to be positive if the patient squeezed a hand when asked; after muscle relaxation, the patient was intubated and the test was repeated. In the recovery room and ward, patients were asked whether they could recall this event.
Results:  Seven patients tested positive: two following LMA–Fastrach insertion and the remaining five following intubation. None of the patients had recall.
Conclusion:  Awareness during anaesthesia may occur at BIS levels that indicate adequate anaesthesia, but this is not associated with recall of the events later.     

Use of the laryngeal mask for fibrescope–aided tracheal intubation in an awake patient with a deviated larynx

I report a case in which fibrescope–aided awake tracheal intubation was achieved using a laryngeal mask, in a patient with a mediastinal goitre in whom tracheal intubation with both a laryngoscope and a fibreoptic bronchoscope had failed. The tumour extended to the upper part of the mediastinum. The larynx and the upper segment of the trachea were displaced by the tumour. Awake tracheal intubation with both a laryngoscope and a fibreoptic bronchoscope failed. The laryngeal mask was then inserted without difficulty. After a fibreoptic bronchoscope had been covered by a plastic tube, the combination was passed through the laryngeal mask into the trachea. The fibreoptic bronchoscope and the laryngeal mask were removed, and a reinforced endotracheal tube was then inserted over the plastic tube into the trachea. The time for tracheal intubation was about 70 s. The laryngeal mask may allow easier location of the laryngeal inlet with a fibreoptic bronchoscope, and this technique is a useful alternative to the conventional technique of tracheal intubation in the patient with a deviated larynx.     

Difficulties with tooth protectors in endotracheal intubation

The suitability of three tooth protectors for routine use during endotracheal intubation was studied in 300 consecutive patients undergoing elective operations under general anaesthesia. The main disadvantages of the protectors were lack of space and the consequent difficulty of guiding the endotracheal tube into the larynx, and poor visibility, especially when the Camo protector was used. These difficulties could be avoided in most cases by cutting off the right angle of the Camo protector. The less experienced anaesthesiologists especially had difficulties with the protectors: 20% of patients in the Camo group were considered impossible to intubate unless the protector was removed. The silicone inlay of the Camo protector melts and becomes adhesive at body temperature, which makes its prolonged use hazardous. Two patients lost a maxillary incisor despite the proper use of a protector (Denex). Thus the use of a tooth protector alone does not guarantee avoidance of dental trauma. Better results could be obtained by improving the design of the protectors and by careful pre-anaesthetic dental examination.     

Pharyngeal pouch as a cause of difficult intubation

The presence of a lateral pharyngeal pouch may cause difficulty in recognising the glottis when awake intubation is undertaken. This is mainly because the orifice may open and close during phonation and therefore be mistaken for the glottis. A case is described and some aspects of relevance to the anaesthetist are discussed.     

改良单腔气管导管引导法对Univent管放置成功率的影响

目的评价改良单腔气管导管(ETT)引导法对Univent管左主支气管放置成功率的影响。方法需左侧肺萎陷的择期胸科手术患者80例,随机均分为改良组和常规组。气管插管前,将前端呈135°弯曲的Univent管放置于ETT(ID8.5mm)内,Univent管前端弯曲方向与ETT弯曲方向一致。改良组与常规组的主要不同点在于:内含Univent管的ETT过声门后即向左旋转90°(Univent管随ETT也向左旋转90°),两者向下推进至隆突,使ETT前端开口正对左主支气管口,然后将Univent管继续插入约5cm,ETT退至22～24cm处,用纤维支气管镜(FOB)检查Univent管是否进入左主支气管,并将Univent管调至最佳位置。记录Univent管试插次数,放置到最佳位置所需时间(从暴露声门开始),以及气道黏膜有无损伤。结果改良组Univent管一次试插成功率明显高于常规组(100%vs.60%,P<0.01);放置时间改良组明显短于常规组[(4.0±1.5)minvs.(10.0±5.5)min,P<0.01];气道黏膜损伤发生率改良组明显低于常规组(6.5%vs.17.5%,P<0.05)。结论改良ETT引导法使Univent管更容易被放置到左主支气管。     

艾司洛尔对老年冠心病患者气管插管QTc间期的影响

目的 评价艾司洛尔在麻醉诱导气管插管时对老年冠心病患者QTc间期的影响.方法 50例ASA Ⅱ级,年龄60～75岁择期全麻手术患者随机分为艾司洛尔组(E组)与对照组(C组).E组麻醉诱导前单次静脉缓慢注射艾司洛尔0.3 mg/kg后100 μg·kg-1·min-1持续输注至气管插管后4 mim;C组给予等容量生理盐水.记录给予艾司洛尔前(T0)、单次给予艾司洛尔或生理盐水后2 min(T1)、芬太尼与丙泊酚诱导后1 min(T2)、维库溴铵后3 min(插管前,T3)及插管后30 s(T4)、2 min(T5)与4 min(T6)QTc、MAP及HR变化.结果 T4～T6时QTc间期C组均长于T0时(P＜0.05),且C组明显长于E组(P＜0.01),其中QTc＞440 ms者C组显著多于E组(P＜0.05).结论 麻醉诱导气管插管期间老年冠心病患者QTc间期延长,而艾司洛尔可缩短与气管插管有关的QTc间期延长.     

Isoflurane in nitrous oxide and oxygen increases plasma concentrations of noradrenaline but attenuates the pressor response to intubation

The haemodynamic response to laryngoscopy and intubation was evaluated in 52 ASA I patients anaesthetized with thiopentone 4-6 mg.kg-1. Vecuronium 0.1 mg.kg-1, followed by 3 min mask ventilation with nitrous oxide in oxygen with (isoflurane group) or without (control group) 3% inspired isoflurane preceded tracheal intubation. In 21 of 52 patients, concentrations of noradrenaline (NA), adrenaline and 3,4-dihydroxyphenylethyleneglycol (DHPG) were measured from central venous plasma. During the 3-min ventilation, in the isoflurane group, heart rate increased by 22% but remained stable in the control group. A marked pressor response to laryngoscopy and intubation was seen in the control but not in the isoflurane group. During the 3-min ventilation, the plasma concentration of NA was doubled in the isoflurane group and increased by 49% in the control group (P less than 0.05). The concentration of DHPG also increased in the isoflurane group. Peripheral skin temperature increased similarly after 3 min ventilation in both groups. After intubation, it was significantly higher in the isoflurane than in the control group (P less than 0.05). In conclusion, compared to nitrous oxide in oxygen, ventilation with isoflurane in nitrous oxide in oxygen causes a sympathetic activation combined with an increase in heart rate and peripheral temperature while the pressor response to laryngoscopy and intubation is attenuated.     

利多卡因雾化吸入用于纤维支气镜引导清醒气管插管患者的效果观察

目的 观察超声雾化吸入2%利多卡因气道表面麻醉用于经鼻纤维支气管镜(FOB)辅助清醒气管插管的临床效果.方法 择期颈椎手术患者42例,随机均分为两组,分别采用超声雾化吸人2%利多卡因行呼吸道表面麻醉(Ⅰ组)和1%丁卡因鼻拭子鼻腔表面麻醉,环甲膜穿刺及喉上神经阻滞的联合局部麻醉(Ⅱ组).记录插管的时间(FNIT),入室后5 min(基础值,T1)、气管导管过鼻腔(T2)、FOB过咽喉(T3)、FOB过声门进气管确认气管隆突位置(T4)、气管导管进入气管(T5)时患者的反应及血流动力学的变化;记录Ⅰ组患者局部麻醉药物的用量及两组患者局部麻醉药的不良反应;术后第1天随访患者对两种方法的评价.结果 与T1时比较,T2～T5时两组患者HR增快;T2～T5时Ⅰ组及T2、T3时Ⅱ组患者MAP均增高;T2～T4时Ⅱ组SPO2明显降低(P<0.05).Ⅰ组患者利多卡因的平均用量为4.86 mg/kg,最大用量为7.64 mg/kg.Ⅰ组患者对所接受的局部麻醉方法评价为((6.71±1.23)分,明显高于Ⅱ组(4.90±1.41)分(P<0.05).结论 超声雾化吸入2%利多卡因可为经鼻FOB清醒插管提供充分的表面麻醉,易于被患者所接受,值得在临床工作中推广.     

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target‐controlled infusions of remifentanil and propofol. Oxygenation was achieved with high‐flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over‐sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.     

环甲膜穿刺在急诊饱胃清醒气管插管中的应用

目的探讨环甲膜穿刺在急诊饱胃病人清醒气管插管中应用的可行性及安全性。方法急诊饱胃病人37例,气管插管采用慢诱导,静注氟芬合剂,丁卡因喷喉,环甲膜穿刺注入利多卡因,后行气管插管。结果在整个插管过程中,3例病人不适反应稍大,其余均能很好地耐受气管插管,无气道痉挛和呛咳等动作。37例病人整个插管监护过程中,心电图及血压变化在预料范围内,SpO2无下降,无一例出现反流及误吸。结论环甲膜穿刺后行气道表面麻醉应用于清醒气管插管具有较高的安全性和可行性。     

Use of selective decontamination of the digestive tract in United Kingdom intensive care units*

The use of selective decontamination of the digestive tract (SDD) remains controversial despite several large randomised‐controlled trials and meta‐analyses. A postal survey of intensive care units in the United Kingdom was conducted to document current use of SDD, and to identify factors influencing this practice. The response rate was 71%. The vast majority (182 units, 95%) do not use SDD mainly because practising clinicians do not believe it works or that there is not enough evidence (51%), and because of concerns about antibiotic resistance (47%). Of the 10 units using SDD, three apply it to all intubated patients and five do not use intravenous antibiotics in their protocol.