神经外科危重患者行牛角型经皮气管切开术的围手术期护理

目的：探讨神经外科危重患者行牛角型经皮气管切开术的围手术期护理方法。 方法：回顾性分析和总结我院神经外科85例危重患者行牛角型经皮气管切开术的手术步骤、术前评估、术后观察与护理方法,总结围手术期护理经验。结果：经精心的准备及完善护理配合,85例患者手术顺利,均无严重并发症发生。结论：牛角型经皮气管切开术(GWCH)在神经外科危重患者抢救中具有明显的优势,术前安全评估,术中密切配合与观察,术后加强气道护理,是手术成功的重要保证。     

蛛网膜囊肿合并慢性硬膜下血肿患者的围手术期护理

目的:探讨蛛网膜囊肿合并慢性硬膜下血肿患者的围手术期护理要点。方法:采用回顾性病例研究方法,对2002年12月～2010年12月期间我院神经外科收治的15例蛛网膜囊肿合并慢性硬膜下血肿患者的围手术期护理措施进行分析,同时结合国内相关文献报道进行总结。结果:15例患者中,13例患者行颅骨钻孔硬膜下血肿引流术,11例术后恢复好,2例术后复发硬膜下血肿;另2例行开颅硬膜下血肿清除加蛛网膜囊肿切除术,术后痊愈。无1例护理并发症发生。结论:根据蛛网膜囊肿合并慢性硬膜下血肿患者疾病的特点,采取针对性的个体化护理,加强引流管的护理和病情观察,积极预防并发症,做好心理护理、安全护理及康复期护理,是提高手术治愈率、降低病死率的有效保证。     

1例颈总动脉破裂伴椎管异物患者的急救护理

总结1例意外创伤致右颈总动脉破裂伴椎管异物患者的急救护理经验.接诊时立即开放气道,迅速配合医生完成纤维支气管镜下经鼻气管插管,保持呼吸道通畅;紧急压迫伤口迅速止血的同时,防止脑灌注不足;积极快速补液,及时备血及时输血防止休克;无缝隙衔接,安全转运患者.通过紧密有效的抢救措施,患者在入科15 min后完成纤维支气管镜引导下经鼻气管插管,入院45 min后转入手术室成功行"全脑血管造影术+椎动脉栓塞术,颈部血肿清除术、颈部异物取出术",术后第9天患者康复出院.     

经纤支镜气管支气管支架置入的护理

目的:探讨经纤支镜气管支气管支架置入治疗气道狭窄患者的围手术期护理。方法:对50例用纤维支气管镜置入镍钛记忆合金支架治疗气道狭窄的患者进行心理护理、气道出血及窒息等围手术期护理。结果:50例患者均成功置入支架,围手术期均无并发症发生。结论:做好纤维支气管镜置入支架围手术期护理,对预防围手术期并发症的发生起到重要作用。     

原发性肝癌合并肥胖症患者围手术期护理

目的:探讨原发性肝癌合并肥胖症患者围手术期的护理。方法:回顾性分析我科2010年12月~2013年12月28例原发性肝癌合并肥胖症患者的临床资料,总结围手术期护理经验。结果:术前气管插管困难1例,术后并发切口裂开2例,肺部感染1例,经积极的治疗护理措施后,28例患者均康复出院。结论:原发性肝癌合并肥胖症患者围术期潜在并发症多、风险大,需术前全面评估,加强饮食和安全管理;术后严格气道管理、血糖管理、切口护理、心理护理以降低并发症发生率。     

颈髓损伤患者围术期医院获得性肺炎危险因素分析

目的探讨颈髓损伤患者围术期发生医院获得性肺炎(HAP)的危险因素。方法收集216例颈髓损伤患者的临床资料,评价围术期合并肺炎情况,分为HAP组与非HAP组,比较两组患者围术期观察项目的差异性,并进行logistic回归多因素分析。结果 36例(16.7%)患者发生HAP,单因素分析发现气管切开、机械通气、Frankle分级A～B、损伤节段C1～4、气管导管留置时间、抑酸药物使用时间、鼻胃管留置时间、术中输液量、手术时间、血清白蛋白<35 g/L和血清钠<135 mmol/L与围术期HAP有关;logistic多因素回归分析发现只有血清白蛋白<35 g/L(OR 15.307;95%CI:4.502～52.403;P=0.000)、气管切开(OR 22.663;95%CI:2.674～192.102;P=0.004)、Frankle分级A～B(OR 12.200;95%CI:4.134～36.003;P=0.000)、机械通气(OR 21.818;95%CI:2.174～218.929;P=0.009)为独立危险因素。结论血清白蛋白<35g/L、气管切开、Frankle分级A～B、机械通气是颈髓损伤患者围术期发生HAP的重要危险因素。     

经皮微创气管切开在重型颅脑损伤抢救中的应用研究

目的评价经皮微创气管切开术在神经外科重型颅脑损伤患者抢救中的临床价值。方法回顾性分析120例重型颅脑损伤并行经皮微创气管切开患者,其中98例为直接切开,22例为术后拔除气管插管后再行气管切开,观察其术后疗效。结果手术成功120例,111例病情稳定后拔管,5例合并重度脑干损伤及2例高位颈髓损伤呼吸肌麻痹患者长期带管,术后出现多器官功能衰竭死亡2例。手术平均时间4.5min,平均切口长1.3cm,术中及术后均未出现严重并发症及手术相关死亡的发生。结论经皮微创气管切开术具有迅速、微创的优点,可快速开放气道,且并发症较少,在重型颅脑损伤患者抢救及治疗过程中,具有较高的应用价值。     

急诊困难气道开放技术进展

正急诊气道最重要的特点是紧急和不可预见性[1],人工紧急开放气道保证患者通气与氧合良好是急诊医师需掌握的基本技能,对急诊危重症患者的抢救有相当重要的价值。一项评估困难气道及困难插管的临床研究表明其发生率高达3.2%[2]。然而,急诊患者往往病情危重,常不能配合,气道分泌物多,甚至有各种创伤合并颈部损伤患者等,这些情况均可增加插管困难,或导致插管失败。近年来,国内外许多学者对急诊常用的气道开放技术进行了研究,现就急诊困难气道常用的紧急人工气道     

重度颅脑损伤气管切开的护理体会

目的总结重度颅脑损伤患者气管切开护理的经验。方法对解放军第107医院神经外科2006年9月至2008年1月收治的56例重度脑损伤患者气管切开后的护理工作进行回顾性分析探讨。结果56例患者中，9例因颅脑损伤严重死亡，47例抢救成功恢复良好。结论对重度颅脑损伤患者尽早采取气管切开支持呼吸，做好基础护理，有效的气道湿化，及时清除气道分泌物及防治并发症等措施，可改善患者的预后。     

冠状动脉旁路移植同期行颈动脉内膜剥脱术12例

目的:探讨冠心病合并颈动脉狭窄患者同期行冠状动脉旁路移植和颈动脉内膜剥脱术的临床效果.方法:选择冠心病并颈动脉狭窄的12例,在全麻下先行颈动脉内膜剥脱,颈动脉内膜剥脱结束后同期行非体外循环下冠状动脉旁路移植术.结果:本组均行单侧颈动脉内膜剥脱及冠状动脉旁路移植术,每例平均冠状动脉移植3.3支.全组围术期无死亡,无脑梗死发生.1例术后出现颈部切口血肿,1例术后出现谵妄.术后3个月～1年复查未发现脑梗死和短暂性脑缺血发作,4例有慢性脑缺氧症状者均不同程度好转,全组无心绞痛和心肌梗死发生,颈动脉超声再血管化部位血流通畅.结论:冠状动脉旁路移植同期行颈动脉内膜剥脱术安全、有效,严格把握手术适应证和科学规范的外科操作是取得良好手术效果的关键.     

The difficult airway in the emergency department

Background

The patient with difficult airways is a common challenge for emergency physicians.

Aims

Our goal was to study the reasons for difficult airways in the emergency department.

Methods

We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.

Results

There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.

Conclusions

Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.     

Airway equipment in Scottish emergency departments.

Airway management is the cornerstone of resuscitation. Emergency endotracheal intubation is more likely to be difficult in the accident and emergency (A&E) department setting compared with the operating room. A&E departments must have an appropriate selection of equipment to deal with difficult airway problems. The aim of this study was to determine the type and range of equipment for airway management in A&E departments in Scotland, UK. A two-page postal survey was sent to consultants in charge of 24 A&E departments covering 98% of major trauma patients in Scotland. The response rate was 96% (23/24). Every department had equipment for basic airway management and all had laryngoscopes, stylets, gum elastic bougies and capnography. Ninety-six per cent (22/23) had equipment for performing a surgical airway and 74% (17/23) possessed laryngeal mask airways suitable for adults; only one department did not possess a suitable rescue device. Thirty per cent (7/23) of departments did not use capnography routinely to confirm correct placement of endotracheal tubes. It is concluded that airway equipment in Scottish A&E departments is adequate for basic airway care and endotracheal intubation. Nearly all departments have access to a suitable rescue device for the failed or difficult airway. Capnographic confirmation of tube placement should be mandatory in A&E.     

The Intubating Laryngeal Mask Airway: Suggestions for Use in the Emergency Department

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.     

颈椎前路手术后切口血肿的风险评估及对策

目的：观察行颈椎前路手术后切口血肿压迫的临床表现,评估其风险因素,以尽早采取预防措施。方法：对2012年1月—2013年6月行颈椎前路手术的226例患者,行前路颈椎体次全切除植骨融合术（ACCF）85例,行前路颈椎间盘切除植骨融合术（ACDF）119例,ACCF＋ACDF＋人工颈椎间盘置换术（ADR）22例,术后对颈部切口血肿的风险因素进行分析并采取相应对策。结果：在后两种手术方式中有10例患者在术毕关闭伤口时评估术中损伤大,创面渗血较多,在术后安置冲洗管,术后引流液性质清亮后改接负压引流管。226例中4例出现术后切口血肿,在床旁立即把伤口全层打开,畅通气道后,急诊行血肿清除术。所有患者均康复出院,无一例死亡。结论：颈部血肿是颈前路术后最严重的早期并发症之一,对患者采取的手术方式、患者的既往史、术后生命体征观察、呼吸道和切口的护理等因素的正确评估、严密观察并全过程采取积极有效对策,是减少血肿发生率的关键。     

A 12 month retrospective study of airway management practices

IntroductionAustralian emergency nurses have a primary role in advanced airway management. Consequently, they need to be competent in, and have a systematic approach to, airway preparation, management and rescue.AimThe aims of the study were to (i) identify all patients undergoing endotracheal intubations in the emergency department; (ii) describe patient characteristics, diagnosis and disposition; and, (iii) review the introduction of an advanced airway management algorithm and difficult airway equipment tray.MethodsA 12 month retrospective study was undertaken (1/1/2006 to 31/12/2006) of all patients requiring oral endotracheal intubation. A survey was conducted to determine nursing confidence and practice with intubation and the benefit of introducing an advanced airway management algorithm and a preassembled difficult airway equipment tray.ResultsTwo hundred and fifty three patients required intubation during the study. The age ranged from neonates/infants to 98 years. Emergency nurses felt confident in assisting with endotracheal intubation and regularly encountered airway rescue situations. The pre-assembled difficult airway equipment and airway management algorithm led to improved confidence and practice.ConclusionEndotracheal intubation is a regular ED intervention. Emergency nurses need to have knowledge of airway management and rescue. A developed airway management algorithm and difficult airway equipment tray improved nursing confidence, expertise and response time in advanced airway interventions.     

专职胰岛素泵护理岗位的设置在神经外科血糖管理中的作用

目的：探讨专职胰岛素泵护理岗位的设置,对神经外科围术期使用胰岛素泵治疗患者血糖管理的作用。方法将神经外科接受胰岛素泵治疗的患者78例按住院时间分组,2014年5—9月的38例患者为对照组,采用每周安排内分泌护士轮流护理神经外科胰岛素泵治疗患者为主的管理模式;2014年10月—2015年2月的40例患者为观察组,内分泌科设置专职胰岛素泵护理岗位,实施院内胰岛素泵的标准化管理。比较2组患者血糖达标时间和胰岛素泵意外事件发生率的差异。结果患者血糖达标时间由4.90 d缩短至2.10 d,观察组胰岛素泵运行中意外事件发生率低于对照组,患者满意度高于对照组,差异均有统计学意义（P＜0.05）。结论通过专职胰岛素泵护理岗位的设置,保证了神经外科胰岛素泵的安全运行,保障了患者的治疗效果,提高了患者的满意度。     

急诊内科危重病人气管插管时机与方法的探讨

目的:总结急诊内科病人气管插管的特点,分析其治疗效果,并探讨其插管时机、方法与转归。方法:根据病人在急诊科治疗情况,将病人分成三组。第Ⅰ组23例,系到医院前已临床死亡;第Ⅱ组30例,经抢救无效在急诊科死亡;第Ⅲ组30例,经抢救病人在急诊科存活,后转入病房或急诊留观。结果:第Ⅰ组病人经口气管插管,抢救平均30分钟,无一例心跳呼吸恢复;第Ⅱ组虽经急诊CPR,但呼吸功能不能恢复正常,或因其原发病未能控制,最终在急诊科死亡;第Ⅲ组病人经口插管13例,经鼻插管17例,6例病人在急诊留观治疗后出院,12例病人经ICU或病房住院治疗后基本痊愈出院,另12例最终死亡。结论:急诊科所遇垂危病人,多数需气管插管者是由内科医师首诊实施。正确的插管方法和较高的成功率是直接影响病人转归的重要因素。     

Successful Tracheal Intubation through an Intubating Laryngeal Airway in Pediatric Patients with Airway Hemorrhage

Background

This case report describes the use of the air-Q intubating laryngeal airway (air-Q ILA; Cookgas LLC, St. Louis, MO) for airway rescue and a conduit for blind tracheal intubation in two pediatric patients with failed rapid sequence intubation and difficult airways secondary to airway bleeding in the emergency department (ED).

Objectives

To describe the use of a new supraglottic rescue device in the management of the pediatric patient’s difficult airway in the emergency setting.

Case Report

Case 1 was a 5-year-old boy who presented to the ED for bleeding one day after his tonsillectomy. After a rapid sequence intubation, direct laryngoscopy was difficult, with copious bleeding in the oropharynx and inability to visualize the glottis. After two failed direct laryngoscopic attempts to intubate, a size-2 air-Q ILA was inserted. A cuffed 5.0-mm inner diameter (ID) endotracheal tube (ETT) was blindly inserted through the lumen of the air-Q ILA into the trachea successfully. Case 2 was a 13-year-old boy who presented to the ED with a large nasopharyngeal laceration from a motor vehicle accident. After a rapid sequence intubation, direct laryngoscopy showed copious blood with no glottic visualization. A size 3 Laryngeal Mask Airway Classic™ (cLMA; LMA North America Inc., San Diego, CA) was inserted with a large airway leak, and blind ETT insertion via the cLMA was unsuccessful. Subsequently, a size-2.5 air-Q ILA was inserted and adequate ventilation was restored. A cuffed 6.0-mm ID ETT was blindly inserted through the air-Q ILA into the trachea successfully.

Conclusion

Two cases of failed laryngoscopy in pediatric patients with blood in the airway are described. In each case, insertion of an air-Q ILA was followed by successful blind tracheal intubation via the lumen of the air-Q ILA.     

Difficult airway management in the emergency department.

Most airway management in the emergency department is straightforward and readily accomplished by the emergency physician. The exact incidence of difficult intubations is difficult to discern from available evidence, but these are probably more frequent in the Emergency Department than in the operating room, given the urgent nature of the procedure and the lack of preparation of the patient population. A variety of adjuncts for airway management are available to assist in both intubation and ventilation. The utility of these adjuncts is detailed in this review, with emphasis on techniques most useful to the emergency physician.     

F AILED P REHOSPITAL I NTUBATIONS : A N A NALYSIS OF E MERGENCY D EPARTMENT C OURSES AND O UTCOMES

Objective. To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). Methods. Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. Results. During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of “truly difficult” intubation in this system is approximately 0.8–1.6%. Conclusions. Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were “truly difficult” and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.