七氟醚在婴儿唇裂全麻诱导气管插管中的应用

近年来婴儿唇裂修复手术日益增多,通常以全凭静脉诱导再行气管插管。麻醉前静脉穿刺对患儿和医护人员均是一个考验。选择合适的诱导方法,值得探讨。本组选用七氟醚吸入诱导行气管插管取得较好效果,现报告如下。     

复合七氟醚吸入用于小儿无肌松气管插管时瑞芬太尼的半数有效血浆靶浓度

目的探讨复合七氟醚吸入用于小儿无肌松气管插管时瑞芬太尼的半数有效血浆靶浓度（cpSO）。方法择期全麻手术患儿26例,年龄3—6岁,ASAⅠ-Ⅱ级。初始七氟醚吸入浓度为8％,氧流量3L／min,患儿意识消失后调整七氟醚吸入浓度,维持七氟醚呼气末浓度为2．7％。3rain后采用Minto药代动力学参数模型靶控输注瑞芬太尼,待效应室靶浓度与血浆靶浓度相同时行气管插管。采用序贯法进行试验,瑞芬太尼血浆靶浓度由4．0ng／ml开始,相邻浓度梯度为0．5ng／ml。应用Probit检验计算瑞芬太尼的CpSO及95％可信区间。结果复合2．7％七氟醚吸入用于小儿无肌松气管插管时瑞芬太尼的cpSO为4．10ng／ml,其95％CI为3．60～4．59ng／ml。结论复合2．7％七氟醚吸入用于小儿无肌松气管插管时瑞芬太尼的Cp50为4．10ng／ml。     

成人不同浓度七氟醚诱导无肌松气管插管时瑞芬太尼的半数有效量

目的确定在不同浓度七氟醚复合瑞芬太尼诱导无肌松气管插管时瑞芬太尼的半数有效量（ED50）。方法 2009年7月-2009年11月择期手术患者60例,ASAI～II,年龄20～59岁,按照入室的顺序随机分为Ⅰ组（2%七氟醚组）和Ⅱ组（3%七氟醚组）,预冲8%七氟醚诱导,眼睑反射消失后,调节七氟醚呼气末浓度分别维持在2%或3%,同时按照序贯法注入瑞芬太尼,瑞芬太尼注射90s后气管插管。记录麻醉诱导前、患者意识消失时、插管前1min、插管后1min及插管后3min心率、平均动脉压的变化。结果 2%、3%的七氟醚复合瑞芬太尼诱导气管插管时瑞芬太尼的半数有效量（ED50）及其相对应的95%可信区间分别为0.585μg/kg及0.533～0.626μg/kg和0.492μg/kg及0.451～0.572μg/kg。结论 2%、3%的七氟醚复合瑞芬太尼诱导气管插管时瑞芬太尼的半数有效量及其相对应的95%可信区间分别为0.585μg/kg及0.533～0.626μg/kg和0.492μg/kg及0.451～0.572μg/kg。     

不同剂量瑞芬太尼复合七氟醚诱导用于小儿无肌松药气管插管的研究

目的探求瑞芬太尼复合七氟醚诱导用于小儿无肌松药气管插管的剂量-效应关系。方法45例行择期手术的全麻患儿,按不同剂量瑞芬太尼随机均分4组：R1组2．0ug／kg,R2组2．5ug／kg,R3组3．0ug／kg。诱导使用8％七氟醚半紧闭吸入,待患儿入睡后开放静脉,维持2．5％七氟醚吸入15min后分别静脉注射3个不同剂量的瑞芬太尼辅助气管插管。分别于麻醉诱导前（T0）、气管插管前即刻（T1）、插管后1min（T2）、3min（T3）记录平均动脉压（MAP）、心率（HR）,并对插管条件进行评估。结果R1组气管插管条件满意率低于R2、R3组（X^2=6．71,P〈0．05）,但R2、R3组差异无统计学意义（X^2=0．24,P〉0．05）;与T0时比较,各组患儿在T1时HR、MAP均明显下降伊分别=7．56、6．35,P均〈0．05）,R1组在T2、T3时HR、MAP较T1明显升高限分别=13．34、11．75,P均〈0．05）,且与R2、R3组比较,差异均有统计学意义伊分别=8．59、7．81,P均〈0．05）,但R2、R3组在R、B时HR、MAP与．r1比较,差异均无统计学意义（F分别=3．65、4．12,P均〉0.05）。结论瑞芬太尼2．5～3．0ug／kg复合2．5％七氟醚用于小儿无肌松药气管插管时,可提供满意的气管插管条件和稳定的血流动力学。     

异氟醚全凭吸入诱导下经口气管插管法在大鼠模型制作中的应用

目的：评价异氟醚全凭诱导麻醉下大鼠经口气管插管方法的可行性。方法：SD雌性大鼠20只随机分成两组各10只,A组采用气管切开法插管。B组采用经口气管插管法,比较两种方法的优缺点。结果：A组大鼠均能一次性插管成功,在缝合大鼠气管切口时,有1只大鼠因麻醉深度控制不当（过浅）,缝合过程中诱发喉痉挛而窒。皂、死亡。有2只大鼠在拔除导管后,麻醉较深而出现呼吸抑制,紫绀状。A组大鼠清醒后均出现嘶叫,对外界声响异常警觉、敏感,8h后仍不能正常进食、饮水。B组大鼠中,有8只大鼠为一次性插管成功,2只需要重新插管,停止吸入异氟醚后在2～3min内清醒,无1例出现紫绀或死亡。B组大鼠拔除导管后,均未出现嘶叫,1h后精神状态佳,2h后活动自如,自由饮水。结论：采用异氟醚全凭诱导麻醉下经口气管插管的方法是一种简便、无创性的气管插管方法,麻醉的深度、稳定性及持续时间易于掌握;不作气管切开,对动物损伤小,非实验因素的干扰小。     

艾司洛尔复合芬太尼对七氟醚诱导气管插管BIS和NI值的影响

【目的】探讨艾司洛尔复合芬太尼是否能抑制七氟醚麻醉诱导气管插管反应,保持满意的麻醉深度以及艾司洛尔是否能减少芬太尼的用量。【方法】ASAⅠ～Ⅱ级择期行下腹部手术患者75例,随机均分为五组。Ⅰ组：生理盐水对照组;Ⅱ组：艾司洛尔组;Ⅲ组：艾司洛尔＋芬太尼3gg／kg组;Ⅳ组：芬太尼6beg／kg组;Ⅴ组：芬太尼3μg／kg组。全部采取七氟醚面罩吸入12min复合罗库溴铵1mg／kg麻醉诱导气管插管,行经口明视气管插管。监测并记录诱导开始时（T1）、插管前（T2）、插管后1、2、3、5、8min（T3、T4、T5、T6、T7）的脑电双频谱指数（BIS）、Narcotrend指数（NI）、心率（HR）、收缩压（SBP）、舒张压（DBP）值,并观察插管前与插管后各时点的各项指标变化。【结果】：与基础值（T1）相比,五组病人诱导后HR、MAP、BIS、NI均下降（P〈0．05）。Ⅱ组与Ⅰ组相比,插管前HR、MAP、BIS、NI无明显差异（P〉0．05）。而Ⅰ组在插管后1、2、3、5min（T3、T4、T5、T6）各时点的HR、MAP、BIS、NI均高于Ⅱ组（P〈0．05）。Ⅲ组与其它4组相比,插管前HR、MAP、BIS、NI无明显差异（P〉0．05）。除Ⅳ组外,其余各组在插管后1、2、3、5min（T2、T4、T5、T6）各时点的HR、MAP、BIS、NI均高于Ⅲ组（P〈0．05）。Ⅳ组与Ⅲ组插管前后HR、MAP、BIS、NI均无明显差异（P〉0．05）。     

不同氧流量对异氟醚吸入和呼出浓度的影响

目的：研究半紧闭低流量麻醉时等量异氟醚不同氧流量对异氟醚吸入和呼出浓度的影响。方法：30例美国麻醉医师协会（ASA）评分Ⅰ~Ⅱ级静吸复合麻醉腹部手术患者随机分为A组和B组,每组15例,分别在新鲜气流量O20.6L/min时设定异氟醚挥发罐浓度（Fd）为5%和新鲜气流量O21L/min时设定异氟醚挥发罐浓度为3%,即每分钟向回路内输入30mL异氟醚气体。用Datex-Ohmeda S/5气体监测仪连续监测麻醉气体吸入浓度（Fi）、呼气末浓度（Fa）、呼气末二氧化碳分压（PETCO2）、吸入氧浓度,观察30min。结果：（1）2组异氟醚Fi和Fa上升缓慢,相同时间点Fi和FaA组显著高于B组（P〈0.05）。（2）A组异氟醚的Fa/Fi上升速率在12min内显著高于B组（P〈0.05）,随后逐渐接近。（3）A组异氟醚的Fi/Fd显著低于B组（P〈0.05）。结论：半紧闭低流量麻醉时向回路内输入等量的异氟醚,降低流量的同时提高挥发罐设定浓度,能达到较高的麻醉深度,该方法有一定的临床实用价值。     

不同靶浓度瑞芬太尼对小儿全麻诱导时七氟醚呼气末浓度和插管反应的影响

目的:比较靶控输注不同血浆靶浓度的瑞芬太尼复合七氟醚诱导对小儿全麻诱导期间及气管插管时血流动力学的影响并观察瑞芬太尼对达到一定镇静程度时七氟醚呼气末浓度的影响.方法:60例择期全麻手术患儿按瑞芬太尼输注速度随机分为4组(R0、R1、R2、R3组,n=15),接受瑞芬太尼靶控输注效应室浓度分别为0、1、2、3 ng/mL.七氟醚吸入浓度为3%,与瑞芬太尼同时开始诱导,脑电双频指数(BIS)达60后10 min静注琥珀胆碱辅助气管插管.记录各组麻醉诱导前、BIS达60时、插管前、插管即刻和插管后2 min的SBP和HR;BIS达60后在1 min内每隔10 s记录相应的BIS值,计算平均值.采用传统的上下波动法测定七氟醚呼气末浓度(ET%).结果:R0和R1组插管即刻SBP和HR高于诱导前及插管前(P＜0.05),R2组的SBP和HR插管后与插管前差别不显著,而R3组在诱导期间出现较严重的循环抑制.4组患儿七氟醚ETBIS60%值分别为2.33%、2.18%、1.38%、0.97%,R1、R2、R3组七氟醚ETBIS60%与R0组比较均明显降低(P＜0.05).结论:瑞芬太尼与七氟醚在小儿全麻诱导时具有协同作用,使达到一定镇静程度时七氟醚呼气末浓度随瑞芬太尼靶控输注浓度的增加而降低;在适合的靶浓度下,瑞芬太尼能有效抑制小儿七氟醚吸入诱导时气管插管的应激反应,维持血流动力学的稳定.     

七氟醚吸入复合利宁凝胶涂布气管镜表面在小儿气管异物取出术的麻醉观察

目的探讨七氟醚吸入复合利宁凝胶涂布气管镜表面在小儿气管异物取出术麻醉的效果。方法选择136例气管异物患儿,年龄10个月-5岁。随机分为3组：A组（56例）患儿用γ-羟丁酸钠、氯胺酮复合麻醉;B组（40例）用七氟醚吸入麻醉;C组（40例）麻醉方法与B组相同,只是在气管镜表面涂抹利宁凝胶。三组患儿分别在麻醉诱导前（T0）、诱导后（T）、置镜1min（T1）、2min（T2）、5min（T3）观察HP、SpO2变化,以及声门开放、术中呛咳、屏气程度、苏醒时间、术者对麻醉满意度。结果A、B两组患儿T2、T3时刻心率上升,SpO2下降,与T时刻比较P〈0．05,C组T2,T3时刻心率、SpO2无明显变化,与T时刻比较P〉0．05;C组术中并发症低于A、B两组（P〈0．05）;手术医生对麻醉满意度以C组最高。结论七氟醚吸入复合利宁凝胶涂布气管镜表面用于小儿气管异物取出术的麻醉具有HP、SpO2平稳,术中并发症少、苏醒快、术者满意度高等优点。     

Drug-Assisted Effects on Protective Airway Reflexes During Out-of-Hospital Endotracheal Intubation (Preliminary Report)

Objective. Out-of-hospital rescuers often use drug-assisted intubation (DAI) to facilitate endotracheal intubation (ETI) of nonarrest patients. However, the relationship between the ablation of individual protective airway reflexes andresulting DAI success has not been defined. We sought to describe the relationship between the depression or ablation of protective airway reflexes andDAI success. Methods. We analyzed data from a prospective multicenter trial. Rescuers from 42 emergency medical services systems reported clinical ETI data using standardized reporting forms. We analyzed the subset receiving sedative and/or neuromuscular blocking agents to facilitate ETI. We defined successful ETI as intratracheal placement of the endotracheal tube on the last ETI attempt. Rescuers reported the presence andablation of six protective airway reflexes, including the presence of a gag, trismus, inadequate relaxation, combativeness, laryngospasm, andseizure/myoclonus. We examined the relationship between protective reflex ablation andDAI success. Results. Of 1,953 ETIs, 208 (10.7%) used DAI (128 sedation only, 80 neuromuscular blocking agents/rapid sequence intubation). Successful DAI was associated with ablation of gag reflex (odds ratio [OR], 12.7; 95% confidence interval [CI] 3.7 to 46.2), clenched jaw/trismus (OR, 54.4; 95% CI, 11.1 to 292.4), inadequate relaxation (OR, 16.3; 95% CI, 3.7 to 96.4), andcombativeness (OR, 10.2; 95% CI, 1.5 to 76.8). Successful DAI was associated with the total number of ablated protective reflexes (p < 0.001). Conclusions. The ablation of selected andthe total number of protective airway reflexes was associated with DAI success. Successful ablation of protective airway reflexes should be considered when attempting to characterize DAI performance or the effectiveness of specific drug facilitation regimens.     

早期雾化吸入不同药物对全身麻醉气管插管下行妇科腹腔镜手术患者术后咽喉部不适的影响

目的 比较妇科腹腔镜手术气管插管患者入麻醉恢复室后即刻雾化吸入不同药物对术后咽喉部不适的改善情况。方法 便利抽样选取200例妇科腹腔镜手术患者作为研究对象,按随机单盲对照实验设计要求分为四组:A组(呋塞米),B组(布地奈德),C组(氨溴索)及D组(生理盐水,对照组),每组各50例。各组患者于术后进入麻醉恢复室即刻雾化吸入相应药物,并于入室即刻(雾化前)、雾化吸入结束后即刻、雾化后6h、12h、24h、36h、48h、72h、96h对四组患者进行咽喉部不适(咽喉疼痛、声音嘶哑、咽部异物感)评估并记录分值。结果 A、B、C组患者的咽喉疼痛评分在雾化吸入后36h低于D组,在雾化吸入后即刻到吸入后24h各时点的声音嘶哑评分低于D组,差异均有统计学意义(均P0.05);咽部异物感的评分结果显示,A组与C组在雾化后即刻、雾化后12h、36h和48h记录点的评分低于D组,而B组在雾化后36h和48h记录点的评分低于D组,差异均有统计学意义(均P0.05)。结论 气管插管术后即刻雾化吸入布地奈德、呋塞米、氨溴索均可在缓解患者术后咽喉疼痛、声音嘶哑、咽部异物感等咽喉部不适方面取得确切的疗效,但在缓解咽喉异物感方面,呋塞米、氨溴索的作用优于布地奈德,其机制尚待进一步研究。     

改良蝶形胶布固定法对经口气管插管固定的效果评价

目的探讨经口气管插管安全、舒适、有效的固定方法。方法方便性抽样选取2010年5月至2011年11月在长海医院急诊科行经口气管插管患者64例,随机分成两组,分别采用传统蝶形胶布固定法(传统组)和改良蝶形胶布固定法(改良组)。观察两组患者在插管后气管插管移位情况、患者舒适度以及皮肤黏膜并发症发生率的差别。结果改良组在气管插管移位、皮肤黏膜并发症发生率等方面低于传统组,舒适度优于传统组,差异均有统计学意义(均P<0.05)。结论经口气管插管非口角处交叉蝶形胶布固定法明显优于传统蝶形胶布交叉固定法,可在临床护理中推广应用。     

Assessment of a New Method to Distinguish Esophageal from Tracheal Intubation by Measuring the Endotracheal Cuff Pressure in a Porcine Model

Objectives: With the knowledge of differences in anatomic structures between the trachea and the esophagus, the authors conducted an animal study to evaluate the usefulness of endotracheal cuff pressure in distinguishing endotracheal and esophageal intubations. Methods: Six swine were anesthetized and endotracheally intubated with 7.5-mm cuffed endotracheal tubes. The intubations were confirmed by fiber-optic bronchoscopy. Each pilot balloon was connected to a 10-mL syringe and a manometer via a three-way stopcock. The cuff pressures were measured for each 1-mL incremental filling of air (1–10 mL). After removal of the endotracheal tubes, each swine was then intubated with the same endotracheal tubes into its esophagus. The cuff pressures of the esophageal intubation were measured with the same procedure. The cuff pressures and the pressure–volume relationships in both intubations were compared. Results: The cuff pressure increased significantly in the esophageal intubation in comparison with the endotracheal intubation in all the comparisons from 1 mL to 10 mL (p = 0.028 for all Wilcoxon signed-rank tests). The slope of the pressure–volume curve of the cuff pressure was also significantly higher in the esophageal intubation during the inflation of the cuff on average (0.047 vs. 0.032 cm H₂O/mL; p = 0.001), particularly in the first 5 mL of air inflation. Conclusions: The cuff pressure in the esophageal intubation was significantly higher than that in the endotracheal intubation under the same inflated volume from 1 to 10 mL. This may provide the basis for an adjunctive, simple, rapid, and reliable method to verify endotracheal intubation.     

Out-of-hospital Rapid-sequence Induction for Intubation of the Pediatric Patient

Objective: To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.
Methods: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted.
Results: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5–17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation ( n = 20), combativeness ( n = 16), apnea ( n = 5), and unknown ( n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts ( n = 9), aspiration ( n = 8), and esophageal intubation ( n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.
Conclusions: 1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.     

截瘫患者气管插管应激反应的临床研究

20例胸腰段截瘫患者，随机分为两组。Ⅰ组静注硫酸喷妥纳、潘库溴铵及小剂量芬太尼诱导，诱导前舌下含化硝苯吡啶，肌松后插管。Ⅱ组仅静注硫喷妥钠与潘库溴铵。两组分别于诱导前后定时进行血流动力学及血浆儿茶酚胺含量的测定。结果显示Ⅰ组的各项血流动力学测定指标与血浆儿芬酚胺含量接近或低于诱导前基础值，而Ⅱ组插管后均明显上升，两组对比有显著性差异，说明胸腰段脊髓损伤患者气管插管时仍存在血压上升、心率增快及血浆儿茶酚胺增多的应激反应，小剂量芬太尼与硝苯吡啶可有效地减弱插管时的应激反应。     

纤维支气管镜引导下经鼻气管插管救治慢性阻塞性肺病并Ⅱ型呼吸衰竭的临床价值

目的:探讨纤维支气管镜引导下经鼻气管插管救治慢性阻塞性肺病(COPD)Ⅱ型呼吸衰竭的临床价值。方法:对32例COPDⅡ型呼吸衰竭的患者,通过纤维支气管镜引导下经鼻气管插管连接呼吸机辅助呼吸,辅予纤支镜下吸痰及灌洗,比较治疗前后血气分析的结果,统计其抢救成功率、并发症发生率及机械通气时间来评价疗效。结果:纤维支气管镜引导下经鼻气管插管抢救COPDⅡ型呼吸衰竭成功率为84.38%,平均机械通气时间为8.35±2.15天,并发症少。结论:纤维支气管镜引导下经鼻气管插管救治COPDⅡ型呼吸衰竭疗效好,并发症少,值得推广。     

气管插管扩张术联合气管球囊扩张术治疗良性气管狭窄患者的护理

目的总结经纤维支气管镜引导下气管插管扩张术联合气管球囊扩张术治疗良性气管狭窄患者的护理方法。方法回顾性分析2010年4月至2011年9月在广西医科大学第一附属医院呼吸内科行纤维支气管镜引导下气管插管扩张术联合气管球囊扩张术的12例良性气管狭窄患者的临床资料,总结护理方法。结果12例患者术后气管平均直径由术前的（5．7±1．2）mm增加到术后的（12．2士2．1）mm,呼吸困难等症状明显改善。结论术前及术后周到的护理措施和术中默契的医护配合是保证患者安全、有效预防并发症及提高手术成功率的重要环节。