喉罩通气全身麻醉在纤维支气管镜氩气刀 治疗中心气道疾病中的临床应用

目的 评价喉罩通气（LMA）全身麻醉在纤维支气管镜（纤支镜）氩气刀治疗中心气道疾病中的应用效果和可行性。 方法 回顾分析2009年1月~2013年7月,LMA下纤支镜氩气刀治疗的21例中心气道疾病患者的临床和手术资料,从入室起持续监测收缩压（SP）、舒张压（DP）、心率（HR）和脉搏氧饱和度（SPO2）,记录麻醉前（T1）、手术中（T2）和术毕（T3）时的SP、DP、HR和SPO2,记录置入喉罩后（P1）、经喉罩置入纤支镜即刻（P2）、拔出纤支镜即刻（P3）的气道压力峰值,统计手术时间、通气时间、呼吸恢复时间、清醒时间、拔管时间和并发症情况。 结果 21例患者共实施了32例次LMA下纤支镜氩气刀手术。一次性成功置入喉罩30例次,另外2例次更换型号后成功置入。该组麻醉效果满意,术程顺利,手术时间为15～50（23.5±10.6） min,通气时间25～60（32.5±12.8）min,术中血压、心率等生命指征平稳,吸气气道压力峰值波动小,未发生气道并发症。 结论 喉罩通气全身麻醉下行纤维支气管镜氩气刀治疗中心气道疾病安全可行,血流动力学平稳,吸气气道压力峰值波动小,苏醒时间快,气道并发症少。     

经纤维支气管镜射频治疗气道疾病

目的 探讨经纤维支气管镜（简称纤支镜）射频治疗气道疾病的疗效。方法 20例气道疾病患者，其中恶性肿瘤12例，支气管肉芽肿4例，良性肿瘤4例，给予经纤支镜射频治疗。结果 恶性肿瘤中10例经2、3次治疗，基本将腔内肿瘤切除干净，另2例经4次治疗，管腔明显扩大，气促缓解；4例支气管肉芽肿均经1次治疗将肉芽切除；4例气道良性肿瘤经2-4次射频治疗肿瘤完全切除。结论 经纤支镜射频治疗气道内疾病有良好的效果，副反应小。     

应用纤支镜和呼吸机抢救慢性阻塞性肺病呼吸衰竭患者的护理

目的探讨应用纤维支气管镜(纤支镜)和呼吸机抢救慢性阻塞性肺疾病(COPD)合并严重呼吸衰竭患者的护理.方法利用纤支镜引导经鼻气管插管建立人工气道,进行机械通气.并采取有效的护理措施管理好人工气道.结果 25例患者共利用纤支镜引导经鼻气管插管建立人工气道并进行机械通气共36例次,均获成功.结论对晚期COPD合并严重呼吸衰竭患者严格掌握适应证,利用纤支镜建立和管理人工气道进行机械通气,能显著改善预后,取得良好的治疗效果.     

局部麻醉支气管软镜下氩气刀治疗中心气道阻塞性病变的困难

目的观察评价局部麻醉支气管软镜下氩等离子体凝固（argon plasma coagulation，APC简称氩气刀）治疗中心气道阻塞性病变的困难。方法局部麻醉支气管软镜下应用ERBE的APC300型氩气刀治疗中心气道阻塞性病变，观察治疗中的困难。结果2003年11月～2006年1月，28例中心气道阻塞的患者，共接受APC治疗71例次。术中遇到的主要困难如下。3例气管严重堵塞的患者，1例在APC治疗中少量出血，患者不愿承担手术风险而放弃继续手术，另2例术中窒息，其中1例改用全身麻醉完成手术，另外1例双侧主支气管严重堵塞未完成手术；肿物完全堵塞气道超过4cm以上的7例患者，每例患者短期内都进行了多次长时间APC治疗。患者难以耐受，其中3例被迫改用全身麻醉；8例患者在15例次的治疗中，靶组织结构不清，通过优先凝切、剥离管腔中心病变和分次治疗完成治疗；12例病变广泛的患者，在24例次的治疗中，清创费时，使用冷冻探头清创缩短了时间。3例因伴有软骨环损害气道塌陷和管壁外压，联合使用气道支架方才缓解了气道阻塞。结论局部麻醉软镜下氩气刀治疗气道阻塞性病变有一些困难，应该选择风险小、短时间能完成的手术。靶组织结构不清需要采取分次治疗。清创费时，冷冻探头能缩短清创时间。其局限性决定了软骨环损害致管壁塌陷和管壁外压者需联用支架。     

纤维支气管镜在综合ICU中的应用

目的 探讨纤维支气管镜（纤支镜）对综合ICU重症患者的应用价值.方法 回顾总结该院ICU对79例危重患者进行123例次纤支镜操作的经验.结果 23例重症肺炎患者经纤支镜吸痰、支气管肺泡灌洗,症状均有不同程度改善;7例吸入性肺炎经纤支镜治疗6例痊愈;28例肺不张治疗后全部复张;行纤支镜引导下经鼻气管插管20例,除1例失败外均一次成功;另外,对若干例人工气道梗阻、气管插管或套管易位、咯血患者的诊治也取得了明显效果.结论 纤支镜诊治在综合ICU重症病人抢救及气道管理中有重要价值,安全、有效.     

ICU中纤维支气管镜的临床应用

目的 :探讨纤维支气管镜对ICU危重病患者的诊治价值及应用范围。方法 :对于 32 1例危重病人共进行10 17例操作。其中对应检患者行纤支镜检查、吸痰 885例 ,进行诊断及救治 34例 ,引导经鼻气管插管 6 8例 ,直视下调整插管深度 12例 ,引导更换气管切开套管 2例 ,对气道出血患者进行诊治 2 0例 ,经纤支镜取痰培养10例。结果 :应检患者经纤支镜治疗 (885例 )后呼吸道症状明显好转 ;34例急性呼衰、急性呼吸道梗阻患者经检查明确原因后对症处理 ,预后良好 ;引导经鼻气管插管 6 8例、直视下调整插管深度 12例、引导更换气管切开套管 2例 ,全部一次成功 ;2 0例气道出血患者经诊治后有不同程度的效果 ;10例经纤支镜取痰培养者敏感性均优于直接取痰培养者。结论 :在ICU危重病人中开展纤支镜诊治是一种安全、有价值和有效的诊断、治疗方法。     

经纤维支气管镜氩气刀治疗气道狭窄

目的观察纤维气管镜下氩气刀（APC）治疗各种原因所致气道狭窄的近期疗效。方法应用ERBE300型氩离子凝固器对18例气道狭窄患者进行治疗,包括支气管鳞癌4例、腺癌4例、食管癌气管内转移4例、腺样囊性癌2例、支气管结核2例、透明细胞癌1例和放疗后气管狭窄1例,其中5例为气管或支气管支架置入后再狭窄。氩气刀功率20～40W,时间1～3s,1周后重复治疗,共1～3次。结果18例患者进行了30次APC治疗（10例1次,4例2次,4例3次）。完全有效10例（55.6%）,部分有效5例（27.8%）,轻度有效2例（11%）,无效1例（5.6%）。5例气管或支气管支架置入后再狭窄患者治疗均为完全有效,对镍钛记忆合金支架无损伤。结论纤维支气管镜下氩气刀治疗气道狭窄疗效明显,使用安全,操作方便。     

气管镜下气道内肿物开通术的临床研究

目的探讨氩等离子体凝固与二氧化碳(CO2)冷冻联合治疗气道内良、恶性肿物及中心气道阻塞性病变的疗效及安全性。方法在有创机械通气支持和复合麻醉下,经电子纤维支气管镜,采用氩气刀、冷冻治疗仪,对52例气管、支气管内肿物通过烧灼、切割等方法,将肿物粘出或吸出,使气道开通,对其近期效果进行评估。结果 52例气道内肿物经上述治疗,绝大部分患者临床症状明显缓解,气道打通,瘤体变小,肺功能改善,提高了患者的生活质量。结论在有创机械通气支持和复合麻醉下通过纤支镜下烧灼和冷冻治疗气道内肿物的疗效理想、操作安全,值得临床推广。     

经纤维支气管镜射频治疗在气道内疾病中的应用

目的：研究经纤支镜射频治疗在气道内疾病中的应用。方法：气道内疾病22例，其中恶性肿瘤17例，支气管结核4例。支气管内芽肿1例。结果：恶性肿瘤中显效者11例(64．7％)，有效4例(23．5％)，无效2例(11．8％)。4例支气管结核患者，经射频治疗后狭窄管腔明显增大，去除了l例戈气管内芽肿腔内病灶。有不同程度咯血的12例。经射频热凝止血，10例(83．3％)获得成功。结论：经纤支镜射频治疗在气道内疾病中有良好的效果。     

经纤维支气管镜引导放置气管内吸氧管1例

1 临床资料。患者，男，63岁，因“确诊右肺中心型肺鳞癌1a，胸闷气短2个月，加重10d”入院。患者曾于1a前经纤维支气管镜（纤支镜）取活检病理明确诊断为右肺中心型肺鳞癌，但一直未正规治疗，此次因呼吸困难明显而入院。查体：呼吸急促约28次／min，口唇紫绀明显，右侧呼吸运动明显减弱，右肺叩诊实音，呼吸音消失，左肺叩诊呈过清音，呼吸音粗糙。心率110次／min，律齐。胸部CT检查发现右主支气管内新生物已将气管完全堵塞并右肺实变。气管下端及气管隆突部明显狭窄，左肺未见异常。纤支镜检查见气管远端近气管隆突处管腔已为癌性肉芽肿堵塞约2／3，右主支气管已完全被癌肿堵塞，癌肿侵犯隆突并已生长人左主支气管近端，导致左主支气管管腔明显狭窄，此狭窄处几乎无法通过纤支镜。为解除患者气道狭窄导致的呼吸困难，拟进行局部氩气刀治疗或放置左主支气管支架治疗。再次在纤支镜准备进行治疗时，患者出现呼吸极度困难，意识渐模糊，监护仪显示氧饱和度逐渐下降至70％，心率上升至140次／min，退出纤支镜后氧饱和度仍呈下降趋势。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.