GlideScope(R)视频喉镜经口和经鼻气管插管的心血管反应比较

目的 对比观察GlideScope(R)视频喉镜(GSVL)经口气管插管和经鼻气管插管的心血管反应.方法 选取美国麻醉医师协会(ASA)身体状况分级为Ⅰ级、拟在经口或经鼻气管插管全麻下施择期整形外科手术的成年患者60例,随机均分为GSVL经口气管插管组(经口组)和GSVL经鼻气管插管组(经鼻组).常规麻醉诱导后采用GSVL实施经口或经鼻气管插管.观察记录两组患者麻醉诱导前(基础值)、麻醉诱导后、气管插管时及气管插管后1、2、3、4和5 min的血压、心率(HR)以及观察期血压和HR的最大值,计算各时间点的收缩压-心率乘积(RPP),并记录气管插管时间.结果 两组患者的基本情况差异无统计学意义.经鼻组的气管插管时间显著长于经口组[(52.2±13.5)s比(40.5±15.2)s,P＜0.05].麻醉诱导后两组的血压和RPP均显著降低(P均＜0.05),但HR无显著变化.与麻醉诱导后比较,气管插管时两组的血压、RPP以及经口组的HR均显著升高,且经口组观察期的HR、舒张压(DBP)、平均动脉压(MAP)和RPP最大值超过了基础值,但经鼻组仅HR的最大值超过了基础值.虽然两组各时间点血压差异均无统计学意义,但经口组观察期HR和RPP的最大值较经鼻组显著升高(P均＜0.05).结论 在麻醉的成年人,GSVL经口和经鼻气管插管可导致相似的血压升高反应,但GSVL经口气管插管所致的HR增快反应却强于GSVL经鼻气管插管.     

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway

Objective

To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management.

Methods

Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO₂ reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared.

Results

A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic = 1; range = 1-7). The overall placement success rate was virtually equal across the two groups (ETI = 80.2%, King LTS-D = 80.5%; p = 0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI = 19.5 s vs. King LTS-D = 20.0 s; z = −0.25; p = 0.80).

Conclusion

In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.     

End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review

End tidal carbon dioxide (ETCO2) monitoring is the non-invasive measurement of exhaled CO2. The Intensive Care Society guidelines include (ETCO2) monitoring as one of the objective standards required for monitoring patients in transport, and the American Heart Association recommends that all intubations must be confirmed by some form of ETCO2 measurement. The physiological principles and technology underlying ETCO2 measurement and the clinical indication for its use in the prehospital environment are reviewed. ETCO2 monitoring has been widely established in the prehospital environment and is of particular use for verification of endotracheal tube placement. It is non-invasive and easy to apply to breathing circuits. The units now available are compact and rugged, with extended battery operating times, which are ideally suited for prehospital use and should be considered as an essential item for advanced airway management.     

Role of anesthesiology curriculum in improving bag-mask ventilation and intubation success rates of emergency medicine residents: a prospective descriptive study

Background

Persistent musculoskeletal pain and psychological sequelae following minor motor vehicle collision (MVC) are common problems with a large economic cost. Prospective studies of pain following MVC have demonstrated that demographic characteristics, including female gender and low education level, and psychological characteristics, including high pre-collision anxiety, are independent predictors of persistent pain. These results have contributed to the psychological and social components of a biopsychosocial model of post-MVC pain pathogenesis, but the biological contributors to the model remain poorly defined. Recent experimental studies indicate that genetic variations in adrenergic system function influence the vulnerability to post-traumatic pain, but no studies have examined the contribution of genetic factors to existing predictive models of vulnerability to persistent pain.

Methods/Design

The Project CRASH study is a federally supported, multicenter, prospective study designed to determine whether variations in genes affecting synaptic catecholamine levels and alpha and beta adrenergic receptor function augment social and psychological factors in a predictive model of persistent musculoskeletal pain and posttraumatic stress disorder (PTSD) following minor MVC. The Project CRASH study will assess pain, pain interference and PTSD symptoms at 6 weeks, 6 months, and 1 year in approximately 1,000 patients enrolled from 8 Emergency Departments in four states with no-fault accident laws.

Discussion

The results from this study will provide insights into the pathophysiology of persistent pain and PTSD following MVC and may serve to improve the ability of clinicians and researchers to identify individuals at high risk for adverse outcomes following minor MVC.     

Sperm retrieval in infertile males: Comparison between testicular sperm extraction and testicular sperm aspiration techniques

Improvements in using retrieved testicular spermatozoa in infertile males to achieve fertilization and pregnancy has enabled patients with clinical azoospermia and non-obstructive testicular failure to father children. In this review article, we compare the relative yields of the two major techniques for sperm retrieval in males with non-obstructive azoospermia; TESE (Testicular Sperm Extraction) and TESA (Testicular Sperm Aspiration). We also discuss the role of follicle-stimulating hormone (FSH), testicular volume, serum levels of inhibin B, testicular doppler flow pattern, chromosome Yq deletions, and presence of spermatids in azoospermic ejaculates as predictors of presence or absence of spermatozoa in biopsied testicular tissues. In conclusion, although most studies favor the more invasive TESE in terms of sperm retrieval success rate, the degree of certainty in this regard remains unsatisfactory, and future studies need to address the issues of standard error and differential misclassification attributable to needle gauge size in patients undergoing TESA.     

两种经气管插管推注PS方法对NRDS患儿的影响

目的:探讨两种推注肺表面活性物质(PS)方法对新生儿呼吸窘迫综合征(NRDS)的影响。方法:将65例NRDS需经气管插管给PS患儿,随机分为观察组35例和对照组30例,观察组使用注射器针头斜刺插入气管导管给药,对照组按照传统方法给药。观察两组患儿给药过程中心率、血氧饱和度、药物反流、呼吸困难改善等情况。结果:观察组给药过程中血氧饱和度及心率下降例数少于对照组,药物反流率明显减少(P<0.01),给药后呼吸困难改善优于对照组(P<0.01)。结论:使用注射器针头直接插入气管导管给药方便易行,可有效减少缺氧发生及药物反流,有利于药物弥散。     

Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study

Objective

Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations.

Methods

Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling.

Results

A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS.

Conclusion

Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.     

神经内科 ICU 气管插管与气管切开发生呼吸机相关性肺炎的比较

目的：探讨神经内科 ICU 患者气管插管与气管切开后使用呼吸机,发生呼吸机相关性肺炎（VAP）的比较。方法对2013年1～12月使用有创呼吸机的166例患者进行统计,分析人工气道建立方式、VAP 发生率、VAP 发生时间、病原菌特征。结果经气管插管后切开 VAP 的发生率最高,高达55．00％;其次是单纯气管切开患者,VAP 的发生率为22．22％,单纯气管插管患者,VAP 的发生率为20．44％。VAP 发生时间是使用呼吸机＜5 d,占26．83％、使用呼吸机5～30 d,占58．54％、使用呼吸机＞30 d,占14．63％;VAP 感染的人数共27例,其中有10例为混合感染,共发生 VAP 感染41例,以革兰阴性菌为主,占85．36％,其次为革兰阳性菌（9．76％）,真菌（4．88％）。结论神经内科 ICU 是 VAP 的高发科室,经气管切开 VAP 发生率大于经气管插管,并且气管插管/切开的次数和天数成为 VAP 发生的重要因素。     

Comparison of circuit patency and exchange rates between 2 different continuous renal replacement therapy machines

Background

Continuous renal replacement therapy (CRRT) is an important tool in the care of critically ill patients. However, the impact of a specific CRRT machine type on the successful delivery of CRRT is unclear. The purpose of this study was to evaluate the effectiveness of CRRT delivery with an intensive care unit (ICU) bedside nurse delivery model for CRRT while comparing circuit patency and circuit exchange rates in 2 Food and Drug Administration–approved CRRT devices. This article presents the data comparing circuit exchange rates for 2 different CRRT machines.

Materials and Methods

A group of ICU nurses were selected to undergo expanded training in CRRT operation and empowered to deliver all aspects of CRRT. The ICU nurses then provided all aspects of CRRT on 2 Food and Drug Administration–approved CRRT devices for 6 months. Each device was used exclusively in the designated ICU for a 2-week run-in period followed by 3-month data collection period. The primary end point for the study was the differences in average number of filter exchanges per day during each CRRT event.

Results

A total of 45 unique patients who underwent 64 separate CRRT treatment periods were included. Four CRRT events were excluded (see text for details). Twenty-eight CRRT events occurred in the NxStage System One arm (NxStage Medical, Lawrence, Mass) and 32 events in the Gambro Prismaflex arm (Gambro Renal Products, Boulder, Colo). Average (SD) filter exchanges per day was 0.443 (0.60) for the NxStage System One machine and 0.553 (0.65) for Gambro Prismaflex machine (P = .09).

Conclusions

There was no demonstrable difference in circuit patency as defined by the rate of filter exchanges per day of CRRT therapy.     

两种不同弛豫率钆对比剂在脑转移瘤中的磁共振对比研究

目的 对比研究钆贝葡胺(Gd-BOPTA)与钆喷酸葡胺(Gd-DTPA)在磁共振增强榆查中对脑转移瘤的诊断价值.方法 第一部分同顾性分析40例无颅内疾患成人MR增强图像资料,其中20例应用钆贝葡胺,另20例应用钆喷酸葡胺,均使用标准剂量(0.1 mmol/kg体重),两组年龄、体重相匹配,比较两组下鼻甲与正常脑白质的对比噪声比.第二部分10例临床诊断为脑转移瘤患者间隔24～48小时分别用标准剂量(0.1 mmol/kg体重)钆贝葡胺与钆喷酸葡胺行磁共振增强检查,比较二者对转移瘤的显示情况及病灶与对侧正常脑白质的对比噪声比.结果 第一部分钆贝葡胺组下鼻甲与正常脑白质的对比噪声比(36/6±11.9)高于钆喷酸葡胺组(25.6士8.1),P=0.002.第二部分10例脑转移瘤中有3例钆贝葡胺增强检查比钆喷酸葡胺增强榆查多榆出一小病灶;5例钆贝葡胺比钆喷酸葡胺对病灶强化更明显;另2例两者无明显差别.钆贝葡胺与钆喷酸葡胺增强后病灶与对侧正常脑白质的平均对比噪声比前者(22.5±10.5)明显高于后者(12.0±6.4),P＜0.009.结论 同等剂量条件下,使用钆贝葡胺行MR增强检查不仅使脑转移瘤显示更清晰,对比更明显,而且能提高隐匿性病灶的检出率,改善临床治疗方案.     

辅助生殖技术取卵前医患认知差异调查分析及对策

目的了解辅助生殖技术取卵前医护人员与患者心理状况、健康知识需求的认知差异,调整健康教育方式和内容。方法利用自行设计的调查表,对2012年7～8月在我院生殖中心取卵的92例患者与生殖中心49例医护人员进行调查,内容包括一般情况、患者术前、术后、对辅助生殖技术的认知情况等七个方面共37个条目。结果患者与医护人员对取卵失败增加经济负担、取卵较多发生卵巢过度刺激综合征、取卵术后什么时候可以洗澡、胚胎质量、取卵后影响卵巢加速变老、取卵后影响性生活、取卵失败引起家庭的矛盾7项内容认知,差异有统计学意义（均P〈0．05）。结论患者在取卵前的心理状况与医护人员的认知存在差异,医护人员应在术前调整健康教育的内容,针对患者担心的问题进行宣教,消除其焦虑心理,保证手术顺利进行和康复。     

两种不同重量及大小的胶囊内镜之间胃肠通过时间及全小肠检查完成率的对比*

目的探究两种不同重量及大小的胶囊内镜之间胃通过时间(GTT)、小肠通过时间(SBTT)及全小肠检查完成率(CR)是否不同。方法回顾性纳入因各种原因而接受了OMOM胶囊内镜检查或Miro Cam胶囊内镜检查(比OMOM胶囊更小且更轻)的患者,对比分析了这两种不同重量及大小的胶囊内镜的GTT、SBTT以及CR。结果共纳入1 448名符合条件的患者,其中OMOM组628例,Miro Cam组820例。总体上,在工作时间校正后SBTT和CR方面,两组之间差异无统计学意义(P0.05)。在克罗恩病或可疑克罗恩病患者中,OMOM组的GTT明显长于Miro Cam组[(53.4±52.6)min比(41.1±47.9)min,P=0.022)];在消化道出血患者中,OMOM组的GTT明显短于Miro Cam组[(42.1±44.8)min比(62.0±78.6)min,P=0.016]。结论总体来说,两种不同重量及大小的胶囊内镜之间的GTT、SBTT及CR没有明显差别,但在克罗恩病或可疑克罗恩病患者中,更轻且更小的胶囊内镜的GTT较短;而在消化道出血患者中,更轻且更小的胶囊内镜的GTT较慢。     

宫腔镜下不同方式治疗子宫内膜息肉不孕患者的临床疗效分析

目的比较宫腔镜下刮匙刮除术与宫腔镜下息肉电切除术治疗子宫内膜息肉不孕症患者的疗效。方法对有检查指征的不孕不育患者473例行宫腔镜检查,镜下诊断子宫内膜息肉患者67例,用随机表法分为两组,A组31例行宫腔镜下刮匙定点刮除术,B组36例行宫腔镜下子宫内膜息肉电切除术,比较两组患者术后1年月经量、子宫内膜厚度及形态、随访1年妊娠例数和复发例数。结果不孕不育患者子宫内膜息肉发生率为14.16%,原发不孕中发生率20.18%,继发不孕中发生率12.07%,反复流产中发生率13.89%,原发不孕与继发不孕发生率比较(P<0.05)。治疗前后比较:A组月经量治疗后半年内明显减少(P<0.05)、一年时无明显减少(P>0.05),子宫内膜厚度治疗后3个月明显减少(P<0.05)、半年后无明显减少(P>0.05),子宫内膜“三线征”例数3个月显著增加(P<0.05)、半年后与治疗前差异无显著性(P>0.05);B组月经量和子宫内膜厚度减少、子宫内膜“三线征”例数增加治疗后1年异差均有显著性(P<0.05)。两组比较:月经量和子宫内膜厚度治疗后一年内均B组优于A组(P<0.05),子宫内膜“三线征”例数治疗后3个月A组优于B组(P<0.05),半年和一年B组优于A组(P<0.05)。妊娠例数半年内A组多于B组(P<0.05),一年时两组差异无显著性(P>0.05)。复发例数半年时两组差异无显著性(P>0.05),1年时B组复发少于A组(P<0.05)。结论宫腔镜下刮匙定点刮除术组疗效主要见于治疗后半年内,而宫腔镜下子宫内膜息肉电切除术组在术后一年仍保持良好疗效。对于不孕不育患者治疗后1a的妊娠率两种术式比较差异无显著性。     

血尿素氮、肌酐及尿酸在两种生化分析系统的比对和偏倚评估

目的 探讨不同的生化检测系统间血尿素氮(BUN)、肌酐(Cr)、尿酸(UA)三项指标测定结果的可比性,为本实验室不同检测系统检验结果的一致性提供依据.方法 取中值和高值质控品分别在Beckman LX-20和日立7600两种生化分析系统进行批内以及日间精密度检测,并以厂商声明和本实验室规定的精密度要求为评价标准.然后依据美国临床实验室标准化协会(CLSI)的EP9-A2文件,以Beckman LX-20型生化分析仪为比较方法,以日立7600为实验方法,分别测定40例患者血清BUN、Cr、UA的含量,计算实验方法与比较方法之间的相对偏倚(SE％),并以各专业室间质量评价检验项目及可接受性能准则的规定为判断标准,判断不同生化分析系统的一致性.结果 两种生化分析系统肾功能项目的批内CV和日间CV均低于厂商声明和本实验室规定的精密度要求,符合临床要求,比对实验数据可靠.日立7600的BUN在低中高三个医学决定水平的SE％分别为9.4％、2.0％、0.8％,Cr的SE％则为7.3％、3.8％、2.8％,UA的SE％为7.9％、1.7％、1.2％.而除BUN在低医学决定水平处的SE％超过了规定范围9％,两种生化分析系统不具可比性外,其余项目均低于可接受限,两种生化分析系统均一致.结论 在一个实验室当同一检测项目存在两种或两种以上的检测系统时,应进行比对及偏倚评估,判断其一致性,以保证检验结果的可比性.