妇科腹腔镜手术患者双管喉管和双管喉罩通气效果的比较

目的 比较双管喉管和双管喉罩用于妇科腹腔镜手术的通气效果.方法 拟行妇科腹腔镜手术患者50例,ASA Ⅰ或Ⅱ级,体重指数＜30 kg/m2,随机分为2组(n=25),双管喉管组(L组)和双管喉罩组(P组).两组均靶控输注异丙酚(血浆靶浓度3～5 μg/ml)和瑞芬太尼(血浆靶浓度4～6 ng/ml),静脉注射维库溴铵0.1 mg/kg,待BIS40～60时置人适宜型号的双管喉管或双管喉罩,置入成功后应用纤维支气管镜观察口咽部解剖结构显露分级情况.记录双管喉管或双管喉罩置入时间、一次置人情况和气道密封压.术中持续监测HR、SP、DP、MAP、SpO2、气道峰压(Ppeak)和呼气末二氧化碳分压(PETCO2),记录手术时间、气腹时间、清醒时间、拔除时间及术后24 h内咽部不良反应发生情况.结果 两组置入时间、一次置入成功率、气道密封压、手术时间、气腹时间、清醒时间、拔除时间及术后24 h内咽部不良反应发生率比较差异均无统计学意义(P＞0.05).两组术中血液动力学平稳,SpO2、Ppeak和PETCO2均在正常范围,且差异无统计学意义(P＞0.05).与L组比较,P组纤维支气管镜下口咽部解剖结构更清晰(P＜0.01).结论 双管喉管可有效地用于妇科腹腔镜手术,安全性良好,其通气效果与双管喉罩无差异.     

聚丙烯酰胺水凝胶隆乳取出后同期假体置入

目的 探讨聚丙烯酰胺水凝胶（polyacrylamide hydrogel,PAHG）注射隆乳取出术后,同期行假体置入的临床适应证与疗效.方法 对PAHG注射隆乳后发生并发症者,术前做乳腺超声、磁共振成像（MRI）检查,明确注射物分布层次和组织浸润情况,经乳晕切口行注射物及病变组织彻底清除后,根据组织浸润程度、包膜完整性、胸肌和乳腺变性情况,分别选择乳腺后、胸大肌后、双平面3种方式,同期行硅凝胶假体置入术.结果 56例切口均愈合良好,乳房对称、挺拔.术后随访6个月至3年,乳房外形良好,无瘢痕和假体疝出,无纤维包膜挛缩等并发症发生.结论 依据PAHG取出后乳房畸形特点,同期假体置入重塑乳房形态,既可改善乳房外观,又可缓解心理障碍,效果满意.     

可回收下腔静脉滤器的临床应用

下腔静脉滤器置入是预防肺栓塞发生的主要措施之一.可回收下腔静脉滤器兼具永久和临时滤器的特性,将其置入人体是静脉血栓性疾病重要的处理方法.本文从适应证、置入结果、置入术后的处理、滤器取出时间以及滤器血栓形成的处理等方面探讨可回收下腔静脉滤器的临床应用现况及其意义.     

可弯曲喉罩的临床应用进展

背景 可弯曲喉罩(flexible laryngeal mask airway,FLMA)是专为头颈、上躯干手术设计的一种声门上人工气道装置,由与经典喉罩(classic laryngeal mask airway,CLMA)相同的通气罩及充气阀和带螺旋形钢丝的通气管组成,兼具普通喉罩操作简便、呼吸道刺激小、血流动力学稳定、术后并发症少等优点,及加强型气管导管的可弯曲性、抗折抗扭曲性、不干扰术野等优点,在临床中被逐渐推广. 目的 了解FLMA的分类,掌握FLMA使用方法及适用范围. 内容 对FLMA的发展历史及特点、应用前选择及检查、置入及拔除操作、术中管理及应用现状进行总结. 趋向 对FLMA目前存在的问题及改良方向进行探讨.     

喉管与喉罩用于腹腔镜胆囊切除术患者气道管理效果的比较

喉罩是麻醉过程中常用的气道管理工具,具有操作简单、对气道刺激小、术后并发症少等优点,已成功用于腹腔镜手术患者[1-2].喉管是新近发明的气道管理工具,带有食道封闭套囊的咽部封闭器,提供有通向食道的径路,可以最大限度降低误吸风险,但其用于腹腔镜胆囊切除术患者气道管理的效果尚不清楚.本研究拟通过比较喉管与喉罩用于腹腔镜胆囊切除术患者气道管理的效果,为临床提供参考.     

血管内支架临床应用状况

血管腔内成形术创伤小、费用低、短期疗效好，但是术后血管再狭窄和闭塞发生率高。据统计经皮穿刺冠状动脉菜术后半年内再狭窄发生率３０－４０％，使其临床应用受到限制。而术后置入血管内支架，是预防这些并发症的有效方法。本文就临床上应用的各种血管内支架的特点及其研究现状作一综述。     

经腹腹腔镜与后腹腔腹腔镜手术切除肾上腺肿瘤的比较

从适应证、禁忌证、手术方法、并发症及术后康复等方面对腹腔镜肾上腺肿瘤切除术的两种不同方法即经腹途径和后腹腔途径进行比较,以供临床医师根据患者和自身情况选择合适的方法.     

结直肠息肉内镜下治疗方法及选用

随着结直肠息肉内镜治疗应用日益广泛，其治疗效果和并发症的发生在临床逐渐成为关注焦点。内镜下切除结直肠息肉经济、安全、痛苦小，通过息肉的形状、局部浸润情况选择合适的治疗方法，不仅能保证其治疗效果，更能减少术后并发症，应予以提倡。本文总结了近期文献中关于内镜切除结直肠息肉常见方法，并对其选用适应证进行分析汇总，以便在临床中选用。     

腹腔镜胆囊切除术患者ALMA喉罩和Supreme喉罩气道管理效果的比较:多中心、随机、对照研究

目的 比较ALMA喉罩和Supreme喉罩用于腹腔镜胆囊切除术患者气道管理的效果.方法 本研究为多中心、随机、对照研究.择期行腹腔镜胆囊切除术患者240例,ASA分级Ⅰ级或Ⅱ级,年龄18～64岁,体重50～70 kg,采用随机数字表法,将患者随机分为2组(n=120):Supreme喉罩组(S组)和ALMA喉罩组(A组).两组麻醉诱导后分别置入4号Supreme喉罩或ALMA喉罩,罩囊内注气后通过引流管漏气试验、胸骨上窝按压试验和胃管置入试验检查喉罩是否对位良好,对位良好后行机械通气.喉罩置入成功后行纤维支气管镜检查分级.记录喉罩置入成功情况、置入时间、气道密封压、口咽部漏气、拔除时间、苏醒时间、拔除喉罩时罩体带血和返流及术后咽喉部不良反应的发生情况.对气道管理效果和喉罩放置难易程度进行评分.结果 与S组比较,A组喉罩置入时间延长,气道密封压、纤维支气管镜检查分级、气道管理效果评分升高,口咽部漏气发生率降低(P＜0.05),喉罩置入成功率、引流管漏气率、胸骨上窝波动率、胃管置入成功率、喉罩置入难易程度评分、罩体带血、返流发生率、术后咽喉部不良反应发生率、喉罩拔除时间、苏醒时间比较差异无统计学意义(P＞0.05).结论 ALMA喉罩和Sureme喉罩用于腹腔镜胆囊切除术患者均可有效通气,ALMA喉罩气道管理的效果更好.     

Ambu AuraGain喉罩用于无痛纤维支气管镜检查术患者气道管理的效果

目的评价Ambu AuraGain喉罩用于无痛纤维支气管镜检查术患者气道管理的效果。方法择期行无痛纤维支气管镜检查术患者60例,性别不限,ASA分级Ⅰ～Ⅲ级,年龄30～64岁,体重45～80 kg,Mallampati分级Ⅰ～Ⅲ级,采用随机数字表法将其分为2组(n=30):Ambu AuraGain喉罩组(A组)与Supreme喉罩组(S组)。麻醉诱导后置入喉罩,术中使用间歇正压模式通气维持PETCO2 30～45 mmHg、SpO2>95%。纤维支气管镜经过喉罩出口末端时记录Brimakombe评分,评价喉罩对位准确情况。分别于麻醉诱导后成功置入喉罩时和纤维支气管镜检查结束即刻,记录气道密封压。记录喉罩置入时间、置入成功情况、首次置入成功情况和喉罩拔除时间。记录术中低氧血症、高血压、心动过速和喉罩拔除后低氧血症、咽喉疼痛、喉罩粘血的发生情况。记录内镜医师对纤维支气管镜检查操作的满意度。结果 2组喉罩置入时间、置入成功率、首次置入成功率、喉罩拔除时间、术中和喉罩拔除后不良反应发生率比较差异无统计学意义(P>0.05)。与S组比较,A组喉罩对位准确率和检查结束即刻气道密封压升...     

Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures

Objective: Difficult laryngoscopy in pediatric patients undergoing anesthesia. Aim: This retrospective analysis was conducted to investigate incidence and predictors of difficult laryngoscopy in a large cohort of pediatric patients receiving general anesthesia with endotracheal intubation. Background: Young age and craniofacial dysmorphy are predictors for the difficult pediatric airway and difficult laryngoscopy. For difficult laryngoscopy, other general predictors are not yet described. Methods: Retrospectively, from a 5‐year period, data from 11.219 general anesthesia procedures in pediatric patients with endotracheal intubation using age‐adapted Macintosh blades in a single center (university hospital) were analyzed statistically. Results: The overall incidence of difficult laryngoscopy [Cormack and Lehane (CML) grade III and IV] was 1.35%. In patients younger than 1 year, the incidence of CML III or IV was significantly higher than in the older patients (4.7% vs 0.7%). ASA Physical Status III and IV, a higher Mallampati Score (III and IV) and a low BMI were all associated (P < 0.05) with difficult laryngoscopy. Patients undergoing oromaxillofacial surgery and cardiac surgery showed a significantly higher rate of CML III/IV findings. Conclusion: The general incidence of difficult laryngoscopy in pediatric anesthesia is lower than in adults. Our results show that the risk of difficult laryngoscopy is much higher in patients below 1 year of age, in underweight patients and in ASA III and IV patients. The underlying disease might also contribute to the risk. If the Mallampati score could be obtained, prediction of difficult laryngoscopy seems to be reliable. Our data support the existing recommendations for a specialized anesthesiological team to provide safe anesthesia for infants and neonates.     

Description and function of a difficult airway service

The goal of the Pediatric Difficult Airway Service (DAS) is to improve the care of children with airway abnormalities primarily through identification of children at risk for failed airway management. The airway service encourages early recognition and provides consultation, a plan for airway management, expertise in airway management, and follow‐up care for children who have a difficult airway. The service has improved the education of healthcare professionals and heightened awareness about the consequences of failed airway management.     

Anesthesia for shared airway surgery in children

Shared airway surgery in children is a complex, high‐risk undertaking that requires continuous communication and cooperation between the anesthetic and surgical teams. Airway abnormalities commonly seen in children, the surgical options, and the anesthetic techniques that can be used to care for this vulnerable population are discussed. Many of these procedures were traditionally carried out using jet ventilation, or intermittent tracheal intubation, but increasingly spontaneously breathing “tubeless” techniques are being used. This review has been written from both the surgical and anesthetic perspective, highlighting the concerns that both specialties have in relation to the maintenance of surgical access and operating conditions, and the need for the provision of anesthesia, oxygenation, and ventilation where the airway is the primary site of operation.     

The normal and the challenging pediatric airway

Management of a child’s airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists’ repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted – the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of ‘cannot ventilate, cannot intubate’ in children.     

Airway management research: a systematic review

Recent controversy regarding the ethics of conducting airway research in patients led to disagreements concerning the value and frequency of manikin-based investigation. However, no formal examination of the methodology of airway research has been undertaken. We, therefore, performed a systematic bibliometric review of airway management research to describe the conduct, quantify the subjects (patient vs. manikin vs. other), assess the reported outcomes and map global trends. We retrieved 1505 relevant studies published between 2006 and 2017, together recruiting 359,648 subjects, of which 341,233 were patients, the remaining being volunteers or subjects managing manikins, human cadavers, animals or bench models. There were 701 randomised controlled clinical trials (46.6%), 83 non-randomised experimental clinical trials (5.5%), 298 observational studies (19.8%) and 423 non-patient studies (28.1%). A total of 1082 studies (71.9%) were patient studies and 322 were manikin studies (21.4%). The total annual number of airway management studies increased over time, as did the annual number of patient studies, but there was no significant increase in the annual number of manikin studies over time. Of the patient studies, subject baseline characteristics were most likely to be ASA status 1–2 (n = 531, 49.1%), populations were most often elective surgical patients (n = 918, 84.8%) and the most common interventions studied were tracheal intubation (n = 820, 54.4%) or supraglottic airway device insertion (n = 257, 17.1%). There was a total of 77 different primary outcomes used in the included studies, the most commonly reported being success rate and procedure time. By understanding how and what has been previously studied these data can be used to form the basis for future priority setting exercises, core outcome set development, and could inform strategy on the future directions of airway management research.     

Evaluation of the airway of the SimMan full-scale patient simulator

BACKGROUND: SimMan is a full-scale patient simulator, capable of simulating normal and pathological airways. The performance of SimMan has never been critically evaluated. METHODS: Sixty subjects (anesthesiologists, nurse anesthetists, and anesthesia residents) performed mask ventilation, laryngeal mask insertion and endotracheal intubation on SimMan. The simulator's airway was evaluated using visual analog scales (VAS) and by measuring the subject's performances. RESULTS: The SimMan full-scale patient simulator's airway is generally acceptably realistic but it significantly differs from the human airway in important aspects. Mask seal was more difficult than in humans whereas Laryngeal mask (LMA) insertion and function was acceptable. The distance from the teeth to the vallecula was too short. Cervical spine mobility was significantly reduced in the 'reduced neck movement' mode but the intubation was only slightly more difficult than in the 'normal' mode. CONCLUSION: The SimMan full-scale patient simulator's airway is generally acceptably realistic but it significantly differs from the human airway in important aspects. The user must be aware of these aspects in order to obtain maximum benefit from training and evaluation scenarios and when using the simulator for testing new equipment and techniques.     

A review of traumatic airway injuries: potential implications for airway assessment and management

BACKGROUND: Obtaining a patent airway can be difficult in patients with traumatic airway injuries (TAI). There is a paucity of data available about the incidence of airway compromise and techniques used in these patients. METHODS: Charts review of all patients with TAI treated in a Regional Trauma Center from July 1989 to June 2005. RESULTS: One hundred and four patients were identified as TAI in the study period (incidence of 0.4% for blunt and 4.5% for penetrating trauma). Sixty-eighty patients were victims of penetrating trauma (ISS: 24+/-10; mortality: 16%). Thirty-six patients were blunt trauma victims (ISS: 33+/-16; mortality: 36%). Overall, 65% of the patients received a definitive airway (DA) in the pre-hospital setting or at the initial hospital assessment. Alternative techniques for obtaining DA including wound tracheal tube, surgical airway and intubation under fiberoptic bronchoscopy were used in 30% of the patients. Among 24 deaths, 10 were considered primarily due to the airway injury. Twelve patients presented with thoracic TAI with nine deaths in this subgroup. CONCLUSIONS: Overall, the incidence of TAI is low. Blunt trauma TAI is less common, and these patients have a different clinical presentation, higher ISS and mortality than the penetrating TAI group. Early assessment of airways is crucial and DA was required in 2/3 of the patients with TAI. Lower airway injuries have higher mortality than upper airway injuries. Even though most patients died as a result of other injuries, causative factors of death included difficulty in obtaining DA and ventilation/oxygenation problems.     

A technique for maintenance of airway access in infants with a difficult airway following tracheal extubation

Tracheal extubation of patients with a difficult airway represents a challenge to anaesthesiologists and intensive care physicians. While a variety of techniques designed to maintain access to the airway in case of the need for tracheal reintubation have been described in adults, no reports have been published in infants and young children. We describe an approach to this issue in a young child with severe micrognathia.