吸引型喉导管与食管引流型喉罩在腹腔镜手术麻醉中的应用

目的：探讨吸引型喉导管与食管引流型喉罩用于腹腔镜手术麻醉通气的效果。方法：择期腹腔镜胆囊切除术患者32例,随机分为吸引型喉导管组（LTS组）与食管引流型喉罩组（PLMA组）,进行麻醉中通气。结果：LTS组与PLMA组气腹前后,放气腹前后pH、PaCO2各组内与本组间比较无明显差异（P〉0.05）。PETCO2、SpO2于气腹前后无明显差异（P〉0.05）。Ppeak、VT于气腹前后差异明显（P〈0.05）,Ppeak于放气腹前后也有明显差异（P〈0.05）。结论：LTS与PLMA用于全麻腹腔镜手术通气,气腹建立时VT由8mL/kg调整为10mL/kg,可避免CO2气腹引起的PaCO2升高,通气效果可维持稳定。     

Prospective, randomized comparison of laryngeal tube and laryngeal mask airway in pediatric patients

BACKGROUND: While reports of the use of laryngeal mask airway (LMA)-Classic in great patient numbers are available, data on the use of the laryngeal tube (LT) in this age group is limited. The two devices are compared in a prospective randomized trial to evaluate success rates and quality of airway seal. METHODS: Sixty children, aged 2-8 years, scheduled for elective surgical interventions were randomized to be ventilated with LMA or LT. Standardized anesthesia was induced with fentanyl and propofol. Number of insertion attempts, time until first tidal volume and intraoperative tidal volumes, and peak pressures were recorded. Airway leak pressure was measured with cuff pressure adjusted to 60 cmH(2)O. RESULTS: Demographic data were comparable, average age in the LMA/LT group was 5.2 +/- 1.9/5.3 +/- 1.9 years. Insertion was successful in 29 of 30 patients in the LMA group (second attempt 8) and in all patients in the LT group (second attempt 3). Time until first tidal volume for LMA/LT was 23.1 +/- 7.3/19.2 +/- 8.6 s (P < 0.05). Peak airway pressures for LMA and LT were 15.3 +/- 3.4 and 17.1 +/- 4.0 cmH(2)O (P < 0.05) with tidal volumes of 10.2 +/- 2.2 and 10.2 +/- 1.9 ml.kg(-1), airway leak pressure was 19.2 +/- 8.6 cmH(2)O for LMA and 26.3 +/- 7.3 cmH(2)O for LT (P < 0.001). CONCLUSION: Insertion success rate is high with both LMA and LT in the age group studied. The airway leak pressure, serving as an estimate to judge quality of airway seal, is higher with the LT.     

Use of the ProSeal laryngeal mask airway for pressure-controlled ventilation with and without positive end-expiratory pressure in paediatric patients: a randomized, controlled study

Background. Tracheal intubation and positive end-expiratorypressure (PEEP) are frequently used in children to avoid airwayclosure and atelectasis during general anaesthesia. Also, thelaryngeal mask airway (LMA     

Laryngeal mask airway for management of a difficult airway and extracorporeal shock wave lithotripsy

We report successful use of the laryngeal mask airway (LMA) in an eight-year-old child with failure to thrive and a known difficult tracheal intubation for ESWL in a mobile lithotripter van.     

Laryngeal mask versus endotracheal tube for airway management in tracheal surgery: a case–control matching analysis and review of the current literature

 Open in a separate windowOBJECTIVESThe endotracheal tube (ETT) and the laryngeal mask airway (LMA) are possible strategies for airway management during tracheal resection and reconstruction for tracheal and laryngotracheal stenosis. The goal of the study was to analyse and compare outcomes in the LMA and ETT groups.METHODSBetween 2003 and 2020, a total of 184 patients affected by postintubation, post-tracheostomy and idiopathic stenosis who had tracheal or laryngotracheal resections and reconstructions via a cervicotomy were retrospectively enrolled in this single-centre study. In 29 patients, airway management was achieved through LMA during tracheal surgery, whereas in 155 patients, it was achieved through ETT. A case–control matching analysis was performed with a 1:1 ratio, according to age, gender, body mass index, aetiology and length of stenosis (1–4 cm), resulting in 22 patients managed through LMA (LMA group) matched with 22 patients managed through ETT (ETT group).RESULTSNo significant differences were found in the reintubation rate, 30-day mortality and postoperative length of stay. Operative time was shorter in patients with LMA (96.23 ± 34.72 min in the ETT group vs 76.14 ± 26.94 min in the LMA group; P = 0.043). Intensive care unit (ICU) admission rate and stay were lower in the LMA group [18 in the ETT group vs 8 in the LMA group, odds ratio = 10.17, confidence interval (CI) 95% 1.79–57.79; P = 0. 009; 22.77 ± 16.68 h in ETT group vs 9.23 ± 13.51 h in LMA group; P = 0.005]. Dysphonia was more frequent in the ETT group than in the LMA group (20 in the ETT group vs 11 in the LMA group, odds ratio = 13.79, CI 95% 1.86–102; P = 0.010).CONCLUSIONSLMA is a feasible option for airway management in tracheal surgery, with lower operative time, ICU admission rate, ICU length of stay and postoperative dysphonia occurrence.     

Prospective randomized comparison of the EasyTube and the esophageal-tracheal Combitube airway devices during general anesthesia with mechanical ventilation

Study Objective

To evaluate the ease of use of two airway devices, the EasyTube (EzT) versus the esophageal-tracheal Combitube (ETC).

Design

Prospective, randomized controlled trial.

Setting

University hospital.

Subjects

80 adult, ASA physical status 1 and 2 patients scheduled for elective surgery.

Interventions

Patients’ tracheas were intubated with the EzT or the ETC in randomized fashion.

Measurements

Difficulty of insertion, time to achieve an effective airway, insertion success rate, maneuvers to achieve an effective airway, oropharyngeal leak pressure, intracuff pressure, ventilatory parameters, success rate of gastric tube insertion, and frequency of adverse effects were compared.

Main Results

Insertion was easier in the EzT than in ETC; insertion of the EzT was rated easy in 36 7cases and moderately difficult in 4 cases versus 26 and 14 cases, respectively, for the ETC (P = 0.014). Less time was required to achieve an effective airway with the EzT than the ETC: 19.4 ± 5.3 sec versus 30.6 ± 4.1 seconds, respectively (P < 0.001). Oropharyngeal leak pressure was higher with the EzT than the ETC (34.3 ± 5.95 vs 31.6 ± 2.42 cm H₂O; P = 0.011). Peak airway pressures for the EZT and the ETC were 22.2 ± 0.99 cm H₂0 and 33.7 ± 1.82 cm H₂O, respectively (P < 0.001). Gastric tube insertion was successful with both devices; however, the EzT allowed insertion of gastric tubes of wider diameter. No severe perioperative adverse events were recorded for either device.

Conclusion

The EzT has distinct advantages over the ETC in airway management, including shorter time to achieve an effective airway and easier insertion.     

Sevoflurane versus propofol for induction and maintenance of anaesthesia with the laryngeal mask airway in children

We compared patient outcomes for propofol vs sevoflurane with the laryngeal mask airway (LMA) using either spontaneous breathing (SB) or pressure controlled ventilation (PCV). One hundred and twenty children undergoing minor surgery below the umbilicus were randomly assigned to receive either (1) propofol 3 mg.kg-1 followed by a maintenance infusion of 5 mg.kg-1.h-1, or (2) induction with sevoflurane 7% followed by maintenance with 1.7%. Following LMA insertion, patients were given atracurium and underwent PCV if surgery was expected to last > or = 30 min. The following assessments were made: time to LMA insertion/removal, airway problems, cardiorespiratory effects and recovery characteristics. The first time insertion success rates were similar, but insertion time was shorter with sevoflurane (115 +/- 67 s vs 252 +/- 107 s, P < 0.0001). One patient coughed during placement, but there were no other problems during any phase of anaesthesia in any group. Heart rate was higher in the sevoflurane group following insertion, during maintenance and emergence (all P < 0.03). There were no differences in blood pressure and oxygen saturation among groups PECO2 in the SB group was unaffected by the agent used. Emergence was more rapid (232 +/- 104 s vs 348 +/- 127 s, P < 0.0001) and postoperative agitation more common (15% vs 0%, P = 0.02) with sevoflurane. There were no differences in the Aldrete scores among groups. Patient outcome was similar for the SB and PCV groups. We concluded that the techniques described here using propofol and sevoflurane are equally suitable for induction and maintenance of anaesthesia with the LMA in children undergoing minor surgery below the umbilicus. Emergence is more rapid, but postoperative agitation more common with sevoflurane.     

Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching

Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8–1.15]; p = 0.764 and 0.93 [0.82–1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75–0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61–0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07–1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07–4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16–4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.     

Digital palpation of the pilot balloon vs. continuous manometry for controlling the intracuff pressure in laryngeal mask airways

This study compared two methods of controlling the intracuff pressure in laryngeal mask airways. One hundred and eighty patients were randomly assigned into two groups. In the first group (n = 90), after training, the intracuff pressure was controlled using digital palpation of the pilot balloon. In the second group (n = 90), continuous manometry was used to control the intracuff pressure. An upper pressure limit of 60 cmH₂O was set. The median (IQR [range]) intracuff pressure in the palpation group was 130 (125–130 [120–130]) cmH₂O compared with 29 (20–39 [5–60]) cmH₂O in the manometry group (p < 0.001). In the palpation group, 37% of patients experienced pharyngolaryngeal complications vs. 12% in the manometry group (p < 0.001). We conclude that the digital palpation technique is not a suitable alternative to manometry in controlling the intracuff pressure in laryngeal mask airways.     

Anaesthesia for surgery of the trachea and main bronchi

Major surgery on the trachea and airway is an anaesthetic challenge, which necessitates the simultaneous control of the airway, maintenance of gas exchange and good surgical exposure. Advance planning, good communication and teamwork among surgeon, anaesthetist and theatre staff are never more important. A major indication for laryngeal and tracheal surgery is laryngotracheal stenosis, a rare condition, which can cause significant morbidity and life-threatening airway obstruction. In the era of modern medicine, post-intubation injury has superseded infection and external trauma as the commonest aetiology. Definitive surgery is usually carried out in tertiary specialist centres, where segmental resection of the trachea with primary end-to-end anastomotic reconstruction is usually the technique of choice. Provision of anaesthesia for bronchial sleeve resection and removal of inhaled foreign bodies faces similar challenges.     

A comparison of the laryngeal mask airway and PA(Xpress) for short surgical procedures

Sixty adult patients undergoing minor peripheral surgery under general anaesthesia were randomly allocated to receive either the laryngeal mask airway (laryngeal mask airway; size 4 for females and size 5 for males) or the PAXpress (adult size), inserted by a single operator with experience of > 50 insertions of each device. The laryngeal mask airway was correctly placed on the first attempt in 27 patients (90%) compared with 20 patients (67%) when using the PAXpress (p < 0.01). No patient required more than two attempts at insertion and there were no failures with the laryngeal mask airway, compared with four (13%) who needed three attempts and two failures (7%) with the PAXpress (p < 0.001 and p < 0.01, respectively). Mean (SD) total placement time was shorter with the laryngeal mask airway [24.6 (3.1) s] than with the PAXpress[35.4 (2.5) s; p < 0.01]. The most common complication was sore throat, which occurred less frequently with the laryngeal mask airway (8 patients; 26%) than with the PAXpress (15 patients; 53.5%; p < 0.001).     

Percutaneous or surgical trachetomy. Prospective, randomized comparison of the incidence of early and late complications]

BACKGROUND: To compare early and late complications after either conventional surgical or percutaneous dilatational tracheostomy. DESIGN: Prospective, randomized study. SETTING: General intensive care unit and neuro-surgical intensive care unit in a university hospital. PATIENTS: 50 consecutive patients, requiring tracheostomy for prolonged mechanical ventilation. INTERVENTIONS AND MEASUREMENTS: Patients were randomly allocated to receive either surgical (surgical group, n = 25) or percutaneous dilatational tracheostomy (percutaneous group, n = 25). Occurrence of perioperative complication were carefully evaluated during ICU stay. Late complications were evaluated with both physical and endoscopic examination at 1, 3 to 6 months after tracheostomy. RESULTS: All surgical and percutaneous tracheostomies were successfully completed and no deaths directly related to the tracheostomy procedures were reported. Completion of the procedure required 41 +/- 14 min in the surgical group and 14 +/- 6 min in the percutaneous one (p < 0.0001). The incidence of early perioperative complications was higher in the surgical group (36%) than in percutaneous one (12%), (p < 0.05). The endoscopic follow-up demonstrated one segmental malacia and one stenosis of the trachea in the percutaneous group only (p = n.s.). Skin repair was better after percutaneous tracheostomy than in the surgical group (p < 0.01). CONCLUSIONS: In experienced hands, percutaneous dilatational tracheostomy is as safe and effective as the conventional surgical tracheostomy. The percutaneous technique is less time-consuming and has a lower rate of early infectious complications with better cosmetic results than the surgical technique.     

Difficult tracheal tube passage and subglottic airway injury during intubation with the GlideScope® videolaryngoscope: a randomised,controlled comparison of three tracheal tubes

Difficulty during placement of the tracheal tube is a known problem when intubating with the GlideScope^®, which may lead to subglottic airway injury. This randomised, controlled clinical trial was designed to compare the resistance to passage of PVC (polyvinyl chloride), reinforced or BlockBuster tracheal tubes during intubation with the GlideScope. Secondary outcomes included the time taken to intubate and assessment of subglottic airway injury. One‐hundred and seventy‐seven patients were included in the data analysis. There was difficult tracheal tube passage (moderate or severe resistance) in 15 (21.4%) patients using the PVC tube compared with 4 (7.4%) and 1 (1.9%) using the reinforced and BlockBuster tubes, respectively (p = 0.003 for PVC vs. BlockBuster). The median (IQR [range]) time taken to intubate was 35 (27–45 [15–115]) s, 25 (20–27 [15–110]) s and 25 (22–30 [16–90]) s, respectively, (p < 0.001 for PVC vs. reinforced as well as PVC vs. BlockBuster). Subglottic airway injury, assessed using a fibreoptic bronchoscope after extubation, was higher with the PVC tube (p < 0.001) and the reinforced tube (p = 0.012) compared with the BlockBuster tube. We conclude that the BlockBuster tracheal tube is a better choice for orotracheal intubation with the GlideScope than PVC or reinforced tubes.     

Abdominal surgical interventions: local and systemic consequences for the immune system--a prospective study on elective gastrointestinal surgery

BACKGROUND: Little is known about the local accumulation and function of immune cells in peritoneal fluid after elective surgery of the upper and lower gastrointestinal tract. Our study was designed to investigate whether systemic immune cell response mirrors the local response. We focused on the cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha and on monocytes, natural killer (NK) cells, and T cells that play an important role in eliciting the innate and adaptive immune response. METHODS: Blood samples were taken prospectively from 25 patients 24 h before surgery, as well as 24 h and 48 h afterward. Abdominal drainage fluids were collected intraoperatively 1 h after the abdomen was opened and 24 h and 48 h postoperatively. Apart from the white blood cells, intracellular T-helper-cell (TH1/TH2) cytokine production (interferon-gamma, IL-2, IL-4, IL-13) and HLA-DR on monocytes were measured by four-color flow cytometry, IL-6, and TNF-alpha with the fast immunoluminescence method. RESULTS: Cells of the innate immune system (NK cells, monocytes, NK-T cells, CD5(+) B cells) rapidly decreased in abdominal fluids (P < 0.05: +24 h; +48 h) after surgery, which was paralleled by a concomitant decline in peripheral blood. The percentage of abdominal interferon-gamma, IL-2, IL-4, and IL-13-producing TH cells increased in a way that distinctly counteracted the decrease of the natural immune cells. HLA-DR expression on monocytes in peripheral blood declined significantly (P < 0.05: +24 h; +48 h). In contrast, monocytes in abdominal fluids had high HLA-DR expression. Furthermore, abdominal fluids contained significantly higher concentrations of TNF-alpha (P < 0.05: +24 h; +48 h) and IL-6 (P < 0.05: +24 h) compared with peripheral blood. CONCLUSIONS: Specific immune cell recruitment and cytokine production play an important role in post-trauma events. Measuring distinct local immune cell repertoires and cytokines provides answers as to how the different phases of postoperative immune events proceed. The evaluation of the local response may provide additional criteria for the evaluation of operative trauma. This knowledge may be helpful in detecting postoperative pathological aberrancies.     

Management of and indications for tracheostomy in care of the critically ill patient

Tracheostomy is a procedure that has evolved over many hundreds of years. In the 21st century, the majority of tracheostomies are now inserted by intensivists in the intensive care unit (ICU). Commonly performed to assist in weaning patients from mechanical ventilation, the procedure is performed using a percutaneous dilatational technique. Percutaneous tracheostomy can generally be performed safely in the ICU, although a number of contra-indications and complications do exist. Recent publications have highlighted weaknesses in the quality of care both in the immediate and longer term. Consequently, a number of organizations, based in the UK and internationally, have turned the focus in recent years to improving the quality of care delivered to these patients. Clinicians caring for patients with tracheostomies should not only be familiar with the indications, anatomy and insertion techniques, but also current guidance on routine care and the emergency management of complications.