经皮扩张气管切开术与常规手术气管切开术的比较

目的 比较经皮扩张气管切开术(percutaneous dilational tracheostomy，PDT)和常规手术气管切开术(surgical tracheostomy，ST)的效果和并发症。方法 6例病人实施PDT，10例病人实施ST。应用特制的扩张钳进行经皮扩张气管切开术(Griggs技术)。结果 PDT操作时间较ST显缩短，并发症少见。结论 PDT是一种简单、安全、有前途的气管切开术。     

State of the art: percutaneous tracheostomy in the intensive care unit

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.     

老年内科危重症患者急性肾衰竭的临床分析

目的 了解老年内科危重症患者发生急性肾衰竭(ARF)的致病因素及转归.方法 对我院内科近10年老年(≥60岁)ARF患者的临床资料进行回顾分析,将老年患者分为院外获得性ARF(院外ARF)组和院内获得性ARF(院内ARF)组,并与同期内科非老年ARF患者进行比较.结果 (1)老年内科ARF患者381例,院外获得性ARF为218例(57.2%),医院获得性ARF为163例(42.8%),其中来自内科重症监护室153例(93.9%);(2)与院外ARF组比较,院内ARF组患者年龄较高.慢性基础疾病较多,伴发感染和/或心力衰竭的比率和病死率较高,ARF的程度较重;(3)院内ARF组的致病因素以感染及心力衰竭或心肌缺血为主;(4)院内ARF组死亡147例,死亡组伴慢性基础疾病、合并严重感染及心力衰竭、伴发老年多器官功能障碍综合征(MODS)者均多于存活组,危霞症程度(APACHEⅡ评分)更高,肾衰竭程度更重;(5)与非老年组比较,老年组院内ARF构成比、伴发MODS、APACHEⅡ评分及病死率均显著增高. 结论 老年危重症患者更易发生ARF,医院获得性ARF的主要诱因为感染,心力衰竭或严重心肌缺血,病死率较高.     

Percutaneous dilatational tracheotomy

Summary Percutaneous dilatational tracheotomy is a procedure for inserting a tracheal cannula without a large incision, without extensive dissection of pretracheal tissue, and without exposure of the trachea. The early complications of the technique are usually minor and late complications are rare. Although it is a simple procedure, it is not a minor operation. Users must be familiar with the technique, the indications and contra-indications for the procedure, as well as the complications. These are described. Proper training of the operation and knowledge of the procedure will avoid unnecessary complications. Percutaneous dilatational tracheotomy is a relatively new technique for inserting a cannula in the tracheal lumen. It can be done at the patients bedside with only minimal complications. A short history, the indications and contraindications, the early and late complications of the technique, and comparisons with other techniques as well as with conventional open tracheotomy are reviewed. Received: 30 July 1997 Accepted: 10 November 1997     

Percutaneous tracheostomy in patients on anticoagulants

Aims:

To determine if percutaneous tracheostomy is safe in critically ill patients treated with anticoagulant therapies.

Settings and Design:

Single-center retrospective study including all the patients who underwent percutaneous dilatational tracheostomy (PDT) placement over a 1-year period in a 14-bed, cardiothoracic and vascular Intensive Care Unit (ICU).

Materials and Methods:

Patients demographics and characteristics, anticoagulant and antiplatelet therapies, coagulation profile, performed technique and use of bronchoscopic guidance were retrieved.

Results:

Thirty-six patients (2.7% of the overall ICU population) underwent PDT over the study period. Twenty-six (72%) patients were on anticoagulation therapy, 1 patient was on antiplatelet therapy and 2 further patients received prophylactic doses of low molecular weight heparin. Only 4 patients had normal coagulation profile and were not receiving anticoagulant or antiplatelet therapies. Overall, bleeding of any severity complicated 19% of PDT. No procedure-related deaths occurred.

Conclusions:

PDT was proved to be safe even in critically ill-patients treated with anticoagulant therapies. Larger prospective studies are needed to confirm our findings.     

经皮微创气管切开术在ICU中的临床应用

目的 评价经皮微创气管切开术(PDT)在ICU危重病人救治中的临床应用价值.方法 我院ICU符合气管切开指征无禁忌证的患者70例,随机分为经皮微创气管切开术组(PDT组)29例和传统开放式气管切开术组(OT组)41例,比较两组间在手术时间、切口大小、出血量、并发症等方面的差异.结果 PDT组手术时间较OT组明显缩短(11.28±3.48 min VS 22.95±4.67 min,P=0.00);切口明显减小(1.60±0.21 cm VS 4.09±0.74 cm,P=0.00),出血量(6.46±3.74 ml VS 26.68±11.07 ml,P=0.00)及切口感染机率较OT组明显减少(0% VS 14.6%,P=0.031),差异均有统计学意义(P＜0.05).结论 PDT具有省时、创伤小、并发症低等优势,对救治重危病人具有较大的应用价值.     

Tracheostomy placement in infants with bronchopulmonary dysplasia: Safety and outcomes

Optimizing the timing and safety for the placement of a tracheostomy in infants with bronchopulmonary dysplasia (BPD) has not been determined. The purpose of the present study was to describe the data from a single institution about the efficacy and safety of tracheostomy placement in infants with BPD needing long‐term respiratory support. We established a service line for the comprehensive care of infants with BPD and we collected retrospective clinical data from this service line. We identified patients that had a trachostomy placed using the local Vermont‐Oxford database, and obtained clinical data from chart reviews. We identified infants who had a tracheostomy placed for the indication of severe BPD only. Safety and respiratory efficacy was assessed by overall survival to discharge and the change in respiratory supportive care from just before placement to 1‐month post‐placement. Twenty‐two patients (750 ± 236 g, 25.4 ± 2.1 weeks gestation) had a tracheostomy placed on day of life 177 ± 74 which coincided with a post‐conceptual age of 51 ± 10 weeks. At placement these infants were on high settings to support their lung disease. The mean airway pressure (MAP) was 14.3 ± 3.3 cmH₂O, the peak inspiratory pressure was 43.7 ± 8.0 cmH₂O, and the FiO₂ was 0.51 ± 0.13. The mean respiratory severity score (MAP × FiO₂) 1 month after tracheostomy was significantly (P = 0.03) lower than prior to tracheostomy. Survival to hospital discharge was 77%. All patients with tracheostomies that survived were discharged home on mist collar supplemental oxygen. In conclusion, the high survival rate in these patients with severe BPD and the decreased respiratory support after placement of a tracheostomy suggests that high ventilatory pressures should not be a deterrent for placement of a tracheostomy. Future research should be aimed at determining optimal patient selection and timing for tracheostomy placement in infants with severe BPD. Pediatr Pulmonol. 2013; 48:245–249. © 2012 Wiley Periodicals, Inc.     

Percutaneous transluminal angioplasty of the popliteal artery without the use of stents: A review of 116 consecutive procedures

PURPOSE

To evaluate the safety and efficacy of percutaneous transluminal angioplasty (PTA), without the use of stents, for the treatment of popliteal artery stenosis.

METHODS

From March 1997 to December 2003, 116 consecutive PTAs of the popliteal artery were performed in 98 patients. All patients underwent preoperative and postoperative colour duplex scans and preoperative angiography. In all cases, the superficial femoral artery was patent and without significant stenosis. Follow-up patency was assessed by clinical examination and colour duplex scanning in all patients.

RESULTS

There was no perioperative mortality. Primary patency after two years was 86% for intermittent claudication (IC) patients and 54% for critical limb ischemia (CLI) patients. Secondary patency rates were 98% for IC patients versus 92% for CLI patients after one year, 94% for IC patients versus 83% for CLI patients after two years and 69% for IC patients versus 7% for CLI patients after five years (P<0.001).

CONCLUSION

Popliteal artery PTA is safe and efficient, especially in IC patients with single lesions.     

Percutaneous coronary intervention in an anomalously arising totally occluded circumflex coronary artery

Congenital coronary anomalies are present in approximately 1% of the patients referred to cardiac catheterization. The present case describes a successful percutaneous coronary intervention in totally occluded left circumflex coronary artery (LCx) with an anomalous origin from right sinus of Valsalva. To the best of our knowledge this is the first case presented of successful recanalization of a chronic total occlusion in an anomalously arising LCx. The case highlights the feasibility of such a challenging procedure on the basis of the knowledge of coronary anatomy and the selection of appropriate guiding catheters and coronary wires.     

Tracheostomy tube manometry: evaluation of speaking valves,capping and need for downsizing

Introduction: Readiness to speak is a major problem for many tracheostomized patients. Evaluation for tracheostomy tube capping or speaking valve is often subjective. Objectives: We first wanted to assess whether there were differences among speaking valves. We developed a care pathway for tracheostomy tube evaluation and management including manometry, which we wanted to evaluate. Methods: Three different speaking valves were assessed using manometry and measuring dyspnea in 21 patients. Subsequently, 100 consecutive patients referred for tracheostomy tube evaluation in a long‐term acute‐care rehabilitation hospital were studied using our care pathway with manometry before and after tracheostomy tube changes. Results: Inspiratory pressures differed among the speaking valves. Borg scale was higher among patients with high expiratory pressures. Of the 100 patients, following our care pathway, speech (speaking valve or capping) was recommended for 78 patients with their initial tube, and for 93 patients within 2 days of their initial evaluation. Tracheostomy tube downsizing was recommended in 94 patients. Downsizing led to significant reductions in airway pressures. Capping was initially recommended for 12 patients and for 71 following downsizing. Women had higher pressures than men for the same size tubes. Conclusion: Tracheostomy tube manometry is very helpful in objectively guiding recommendations for speaking valve use, capping, and changing tracheostomy tubes. Speech is an early recommendation for most patients. Please cite this paper as: Johnson DC, Campbell SL and Rabkin JD. Tracheostomy tube manometry: evaluation of speaking valves, capping and need for downsizing. The Clinical Respiratory Journal 2009; 3: 8–14.     

老年危重症患者心力衰竭特征及其危险因素分析

目的探讨老年危重症患者心力衰竭特征并分析其相关危险因素。 方法回顾性分析2016年1月至2017年7月在徐州医科大学附属医院急诊重症医学科治疗的100例老年危重症患者的临床资料,将所有患者分为未合并心力衰竭组65例,合并心力衰竭组35例,分析心力衰竭特征及相关危险因素。 结果合并心力衰竭组患者年龄和冠心病、糖尿病、呼吸衰竭、肾功能不全、瓣膜性心脏病占比均高于未合并心力衰竭组,差异有统计学意义(P<0.05);Logistic回归分析显示,冠心病、糖尿病、呼吸衰竭、肾功能不全、瓣膜性心脏病均为导致老年危重症患者心力衰竭的危险因素。 结论冠心病、糖尿病、呼吸衰竭等为导致老年危重症患者心力衰竭的危险因素,在救治该疾病患者时应综合考虑其相关基础疾病。     

慢性肾衰竭透析患者经皮冠状动脉介入治疗的临床分析

目的:探讨慢性肾衰竭维持血液透析合并冠心病患者,行经皮冠状动脉介入治疗(PCI)的安全及有效性。方法:慢性肾衰竭维持血液透析合并冠心病的患者12例,在适当水化和强化透析的基础上应用非离子型造影剂行择期PCI。术后随访6个月,观察PCI术后患者心绞痛改善情况、住院期间及术后6个月的主要不良心脏事件(MACE,包括心源性死亡、再次急性心肌梗死、充血性心力衰竭、靶血管再次血运重建)及肾功能及尿量的变化。结果:12例患者3支冠状动脉病变比例最大,其次为双支病变,单支病变比例最小,C型病变最多。12例患者PCI手术成功率为100%,平均置入支架(2.8±1.3)个。12例患者术后72小时及随访6个月时SCr、BUN及尿量无明显变化。12例患者术后心绞痛症状消失,住院期间无MACE发生,随访6个月1例患者因PCI术后2个月时再次出现心绞痛症状而行再次PCI术,其他患者随访6个月无MACE发生。结论:对慢性肾衰竭维持血液透析的冠心病患者,行PCI是安全有效的。