小儿气道异物并发症与其留存时间的关系探讨

目的探讨小儿气道异物并发症与其留存时间的关系。方法选择笔者所在医院2007年1月～2010年12月入耳鼻喉科因气道异物进行手术的患儿60例,按异物存留时间分为3组：甲组（异物存留于气道的时间〈24h）患儿25例;乙组（异物存留于气道的时间在24h～7d之间）患儿20例;丙组（异物留存于气道的时间时间〉7d）患儿15例。记录并比较三组患儿的术前合并肺炎情况、苏醒期喉痉挛,术中及苏醒期低氧血症的发生情况。结果三组患儿的术前肺炎发生率、苏醒期喉痉挛发生率比较,差异有统计学意义（P〈0.05）。但术中、苏醒期低氧血症发生率组间比较无统计学意义（P〉0.05）。结论小儿气道异物留存于气道的时间越长,肺部并发症、苏醒期喉痉挛的发生率就越高,故应尽早明确诊断及实施手术。另外,术中和苏醒期都要警惕低氧血症的发生,这些均对患儿的预后有重要意义。     

气道异物取出术患儿Manujet Ⅲ手控喷射通气的效果

目的 评价气道异物取出术患儿Manujet Ⅲ手控喷射通气的效果.方法 拟行气道异物取出术患儿120例,年龄10月～12岁,体重8～35 kg,ASA Ⅰ或Ⅱ级,随机分为3组(n=40):S组保留自主呼吸;P组通过硬支气管镜侧孔行手控间歇正压通气;J组喷气导管经鼻置入气管,采用ManujetⅢ装置行手控喷射通气.记录术者置镜满意情况、术中缺氧发生情况、异物移除情况、手术时间、麻醉恢复时间和不良反应的发生情况.结果 与S组比较,P组和J组手术时间、麻醉恢复时间缩短,置镜满意率升高,术中缺氧发生率、屏气和躁动发生率降低(P<0.05);与P组比较,J组术中缺氧发生率降低(P<0.05).结论 气道异物取出术患儿术中使用Manujet Ⅲ装置行手控喷射通气可降低术中缺氧的发生机率,且不影响术者操作.     

老年患者喉罩拔除后通气障碍的危险因素

目的 筛选老年全麻患者喉罩拔除后通气障碍的危险冈素.方法 选择2009年1月至2010年2月在喉罩全麻下经尿道腔内手术的老年患者366例,记录患者性别、年龄、体重指数(BMI)、ASA分级、术前肺部疾病史、打鼾史、喉罩置人时间、麻醉时间、麻醉维持药物、肌松药使用剂量、术中呼吸音、术后新斯的明使用情况、喉罩拔除前苏醒程度,口腔分泌物多少、术后腹胀发生情况以及喉罩拔除后通气障碍发生情况.采用logistic回归分析筛选发生通气障碍的危险因素.结果 喉罩拔除后通气障碍的发生率为8.7%.logistic回归分析结果显示肥胖(BMI≥25 kg/m2)、合并肺部疾病、术中吸入七氟醚以及术后未给予新斯的明是喉罩拔除后通气障碍的危险因素.结论 老年患者喉罩拔除后有发生通气障碍的风险,而BMI≥25 kg/m2、合并肺部疾病、吸入七氟醚以及术后未给予肌松拮抗可能导致通气障碍的发生.     

胸科手术术后认知功能障碍的危险因素分析

目的 分析行单肺通气的胸科手术患者发生术后认知功能障碍(POCD)的危险因素.方法 46例需单肺通气的胸科手术患者于术前1 d和术后7 d分别行神经心理测验,以此评价手术前后认知功能的改变,并分析围术期因素和患者发生POCD的关系.结果 共有12例患者发生POCD.单肺通气后乳酸升高和脑氧饱和度下降与患者POCD的发生呈正相关.结论 单肺通气后乳酸升高和脑氧饱和度下降是行单肺通气的胸科手术患者发生POCD的危险因素.     

老年脊柱手术术后谵妄发生率及高危因素分析

目的研究老年脊柱手术术后谵妄发生率及高危因素,为老年脊柱手术术后谵妄的预防提供理论依据。方法本研究观察对象为2015-06-2017-06于我院行脊柱手术的280例老年胸椎、颈椎、腰椎手术患者。将发生谵妄的患者设为观察组,未发生的患者设为对照组,通过单因素以及Logstic多因素回归分析判断老年脊柱手术术后谵妄的独立危险因素。结果 280例患者术后发生谵妄30例,发生率10.71%,谵妄出现平均时间(1.24±0.15)d;单因素分析显示两组年龄、手术时间、术中低氧血症、苏醒时间、术前焦虑、手术部位、术中低血压、术前睡眠障碍差异具有统计学意义(P0.05);Logstic多因素回归分析显示年龄70岁(OR=3.214,%95CI:1.121～7.675)、手术时间150 min(OR=2.612,%95CI:1.721～9.623)、术前焦虑(OR=2.334,%95CI:1.021～10.421、术中低氧血症(OR=2.113,%95CI:1.733～7.316)、苏醒时间60 min(OR=3.043,%95CI:1.421～11.232)是老年脊柱手术术后谵妄发生的独立危险因素。结论老年脊柱手术术后谵妄发生率较高,年龄70岁、手术时间150 min、术前有焦虑、术中出现低氧血症、苏醒时间60 min均会增加术后谵妄的发生风险。     

全麻术后苏醒期患者去氧饱和发生现况的调查分析

目的了解全麻术后苏醒期患者脉搏氧饱和度下降(去氧饱和)发生情况,以期为全麻术后苏醒期患者的预见性氧合管理提供依据。方法由2名麻醉科护士同时通过电子病历系统和自行设计的"麻醉后监护治疗室(PACU)全麻术后苏醒期患者观察与护理记录表"提取患者信息,并记录患者在PACU内出现去氧饱和的情况。结果入住PACU苏醒至转出的3 181例患者中,289例(9.09%)发生去氧饱和,26.99%患者出现2次及以上去氧饱和;27.68%患者出现重度去氧饱和(SpO20.85),去氧饱和持续时间在30min以上的患者占20.76%;患者发生去氧饱和的时刻主要集中在入住PACU 1min内(25.61%)和拔除气管导管5min内(57.09%);带管无自主呼吸、带管有自主呼吸和拔除气管导管后再入住PACU的患者去氧饱和发生率无统计学差异(P0.05)。结论 PACU全麻术后苏醒期患者发生去氧饱和的比例较高,应重视PACU内已拔管患者的管理,在患者容易发生去氧饱和的时刻给予预见性护理,从而降低去氧饱和的发生率,确保患者麻醉苏醒期维持良好的氧合。     

术后呼吸系统并发症的危险因素及术前评估系统的建立

目的 筛选术后呼吸系统并发症的危险因素并建立术前评估系统.方法 选择2011年6月至2012年2月接受择期手术或急诊手术病人,采用全凭静脉麻醉或区域阻滞麻醉.记录病人一般资料及术前SpO2、术前1个月内是否有呼吸系统感染情况、贫血、咳嗽试验情况;记录手术部位(胸部、上腹部、其他部位)、手术时间、手术方式(急诊手术/择期手术)和麻醉方法(全身麻醉/区域阻滞).根据术后1～7d是否发生术后呼吸系统并发症,将病人分为术后呼吸系统并发症组和未发生术后呼吸系统并发症组.将组间差异有统计学意义的因素进行多因素logistic回归分析,筛选术后呼吸系统并发症的危险因素,建立术前风险评分系统.结果 最终2037例完成本研究.共计493例发生术后呼吸系统并发症,发生率为24.20％.logistic回归分析结果显示,年龄＞50岁、术前SpO2≤90％、高ASA分级、吸烟时间＞1年、咳嗽试验阳性、术前1个月呼吸系统感染、术前贫血、上腹部和胸内手术、手术时间＞2h是术后呼吸系统并发症的危险因素.选择术前SpO2、贫血、呼吸系统感染、年龄、手术时间、手术部位6个风险因素建立呼吸系统并发症术前风险评分系统.术后呼吸系统并发症发生率分别为高风险组61.9％、中风险组52.8％、低风险组17.2％,3组间比较差异有统计学意义(P＜0.01);子样本ROC曲线下区域面积为90％,验证子样本ROC曲线下区域面积为87％.结论 年龄＞ 50岁、高ASA分级、吸烟时间＞1年、咳嗽试验阳性、术前SpO2≤90％、贫血、术前1个月呼吸系统感染、手术时间＞2h、上腹部和胸内手术是术后呼吸系统并发症的危险因素;以术前SpO2、贫血、呼吸系统感染情况、年龄、手术时间、手术部位6项成功建立了术前风险评估系统.     

低出生体重患儿开胸心脏术后机械通气时间延长的危险因素分析

目的分析低出生体重患儿开胸心脏术后机械通气时间延长的危险因素。方法选择2003年6月至2018年3月在本院行开胸心脏手术的低出生体重(≤2.5 kg)患儿121例,男80例,女41例,手术日龄3～84 d,出生体重1.05～2.50 kg,手术日体重1.13～2.70 kg,ASAⅢ或Ⅳ级。根据术后机械通气时间分为两组:机械通气7 d的延长组(PMV组,n=40)和≤7 d的非延长组(N-PMV组,n=81)。收集两组患儿一般情况和术前、术中和术后资料,采用单因素相关分析和二元逐步Logistic回归分析观察影响机械通气时间延长的危险因素。结果与N-PMV组比较,PMV组深低温停循环时间明显延长(P0.05),术前机械通气、术后延迟关胸、再次气管插管、非计划再次手术明显增多(P0.05),术后24 h乳酸浓度最大值明显升高(P0.05),术后贫血、术后败血症明显增多(P0.05)。二元逐步Logistic回归分析显示,术后败血症(OR=26.511,95%CI 1.326～530.217,P=0.032)和术后延迟关胸(OR=6.573,95%CI 1.293～33.401,P=0.023)是低出生体重患儿开胸心脏术后机械通气时间延长的独立危险因素。结论低出生体重患儿开胸心脏术后造成机械通气时间延长的原因较多,术后败血症和延迟关胸是机械通气时间延长的独立危险因素。     

骨科手术病人术后下肢深静脉血栓形成的危险因素

目的 筛选骨科手术病人术后下肢深静脉血栓形成(DVT)的危险因素.方法 择期骨科手术病人5133例,性别不限,年龄18～89岁.术前1d访视病人,记录性别、年龄、体重、疾病诊断、吸烟史、合并症、既往病史、实验室检查结果.术中采用全身麻醉、椎管内麻醉或区域神经阻滞.术后第7天采用超声法诊断是否发生DVT,将患者分为非DVT组和DVT组.记录麻醉方法、手术种类、手术时间、是否使用低分子肝素抗凝、术后开始下地时间.将组间差异有统计学意义的因素进行多因素logistic回归分析,筛选该类病人DVT的危险因素.结果 212例患者术后发生DVT,发生率为4.13%.logistic回归分析结果显示:年龄＞64岁、体重指数≥25 kg/m2、合并糖尿病和高血压、既往静脉曲张病史,甘油三酯≥1.7 mmol/L、D-二聚体≥500 ug/L、手术时间＞4h、全身麻醉、术后开始下地时间≥5d是骨科手术病人术后DVT的独立危险因素(P＜0.05).结论 老龄、肥胖、静脉曲张病史、合并糖尿病和高血压、高甘油三酯和D-二聚体水平、长时间手术、全身麻醉、术后卧床时间长是骨科手术病人术后下肢DVT的独立危险因素.     

全麻患者麻醉恢复期躁动与术后认知功能障碍的关系

目的 评价全麻患者麻醉恢复期躁动与术后认知功能障碍(POCD)的关系.方法 择期全麻手术患者280例,性别不限,年龄18～70岁,体重52 ～ 80 kg,ASA分级Ⅰ或Ⅱ级.于拔除气管导管后15～40 min时采用术后恢复质量评估量表评估麻醉恢复期躁动的发生情况,于术前1d、术后1～7d评估认知功能.根据是否出现POCD将患者分为POCD组和非POCD组.记录患者一般情况、术前合并症及手术类型,将组间差异有统计学意义的因素进行多因素logistic回归分析.结果 术后POCD发生率40.7％.logistic回归分析结果显示:与POCD发生明显相关因素的危险程度从高至低:麻醉恢复期躁动、麻醉时间、年龄.结论 全麻患者麻醉恢复期躁动是POCD发生的独立危险因素之一.     

General anaesthetic management for laser resection of central airway lesions in 85 procedures

The perioperative course of 41 patients undergoing 85 endoscopic laser resections of central airway lesions under general anaesthesia was reviewed. The CO2 laser was used in 60 procedures and the Nd:YAG in 25. Intravenous anaesthesia and Venturi ventilation were utilized for 65 resections; 20 procedures involved predominantly inhalation anaesthesia via the ventilating bronchoscope. Significant intraoperative complications included arterial desaturation (SaO2 less than 90 per cent) in 26 per cent of procedures, and refractory hypertension requiring vasodilator therapy in 19 per cent. Intravenous anaesthesia was associated with a longer duration of recovery room care and a higher incidence of postoperative respiratory complications (delayed extubation, recovery room re-intubation and ventilation, and post-extubation stridor). Inhalation anaesthesia appeared to simplify the intraoperative management and decrease the incidence, duration and severity of immediate postoperative respiratory complications.     

Propofol–remifentanil intravenous anesthesia and spontaneous ventilation for airway foreign body removal in children with preoperative respiratory impairment

Purpose: To investigate the efficacy and safety of propofol–remifentanil total intravenous anesthesia (TIVA) and spontaneous ventilation for foreign body (FB) removal in pediatric patients with preoperative respiratory impairment. Methods: We carried out a prospective observational clinical study of FB removal using a rigid bronchoscope under propofol–remifentanil TIVA and spontaneous ventilation in 65 pediatric patients who presented with preoperative respiratory impairment. Heart rate, blood pressure, pulse oxygen saturation (SpO₂), respiratory rate, endtidal CO₂ (ETCO₂)_, induction time, and remifentanil rate were recorded. Adverse events, the intervention for these events, and the duration of postoperative care were also of interest. Results: Sixty children completed the study. The mean induction time was 12.3 min. During the procedure, the maximum remifentanil rate was 0.14 μg·kg^?1·min^?1. Light breath holding occurred in 16 (26.7%) patients. No severe breath holding or body movements were observed. An SpO₂ below 90% occurred in 10 (16.7%) cases. No progressive desaturation was observed. The mean ETCO₂ at the end of the procedures was 7.91 KPa and returned to normal 5 min after the procedure. In the postanesthesia care unit (PACU), no hypoxemia was observed and the mean recovery time was 23.4 min. No laryngospasm, pneumothorax, or arrhythmias were observed. Conclusion: Propofol–remifentanil TIVA and spontaneous ventilation are effective and safe techniques to manage anesthesia during airway FB removal in children with preoperative respiratory impairment.     

Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy

BACKGROUND: Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory failure. METHODS: Patients undergoing elective pneumonectomy at the authors' institution from January 1999 to January 2003 were studied. The authors collected data on demographics, relevant comorbidities, neoadjuvant therapy, pulmonary function tests, site and type of operation, duration of surgery, intraoperative ventilator settings, and intraoperative fluid administration. The primary outcome measure was postoperative respiratory failure, defined as the need for continuation of mechanical ventilation for greater than 48 h postoperatively or the need for reinstitution of mechanical ventilation after extubation. RESULTS: Of 170 pneumonectomy patients who met inclusion criteria, 30 (18%) developed postoperative respiratory failure. Causes of postoperative respiratory failure were acute lung injury in 50% (n = 15), cardiogenic pulmonary edema in 17% (n = 5), pneumonia in 23% (n = 7), bronchopleural fistula in 7% (n = 2), and pulmonary thromboembolism in 3% (n = 1). Patients who developed respiratory failure were ventilated with larger intraoperative VT than those who did not (median, 8.3 vs. 6.7 ml/kg predicted body weight; P < 0.001). In a multivariate regression analysis, larger intraoperative VT (odds ratio, 1.56 for each ml/kg increase; 95% confidence interval, 1.12-2.23) was associated with development of postoperative respiratory failure. The interaction between larger VT and fluid administration was also statistically significant (odds ratio, 1.36; 95% confidence interval, 1.05-1.97). CONCLUSION: Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure.     

妇科手术患者Guardian喉罩与Supreme喉罩气道管理效果的比较

目的 比较Guardian喉罩与Supreme喉罩用于妇科手术患者气道管理的效果.方法 择期全麻下行妇科手术患者120例,年龄19～80岁,体重50～70kg,ASA分级Ⅰ或Ⅱ级,随机分为2组:Supreme喉罩组(S组,n=59)和Guardian喉罩组(G组,n=61).麻醉诱导后置入4号喉罩,行机械通气.术中监测BP、HR、SpO2、PETCO2和Ppeak.记录喉罩置人情况、置入时间、纤维支气管镜检查分级、气道密封压、正常通气时(VT 8 ml/kg)的气道压、大潮气量(VT20 ml/kg)通气试验时的气道压和漏气的发生情况、术中口咽部漏气的发生情况、拔除喉罩时不良反应和术后咽喉部不良反应的发生情况、麻醉时间、手术时间、喉罩拔除时间和苏醒时间.结果 两组喉罩置入成功率、置入时间、正常通气时的气道压、大潮气量通气试验时的气道压、拔除喉罩时罩体带血和术后咽喉疼痛、声音嘶哑和吞咽困难的发生率、麻醉时间、手术时间、喉罩拔除时间和苏醒时间差异无统计学意义(P＜0.05).两组患者BP、HR、SpO2、Ppeak和PETCO2均在正常范围内.与S组比较,G组纤维支气管镜检查分级和气道密封压升高,大潮气量通气试验时漏气和术中口咽部漏气的发生率降低(P＜0.01).结论 Guardian喉罩和Supreme喉罩置入简单易行,气道密封效果好,可有效保证通气,对咽喉部的刺激小.Guardian喉罩用于妇科手术患者气道管理的效果更好.     

肝门部胆管癌术后医院感染的预测因素:一项回顾性分析

目的 探讨肝门部胆管癌术后医院感染的预测因素.方法 回顾性分析2013年1月至2019年12月于福建医科大学附属第一医院手术治疗的243例肝门部胆管癌病人的临床资料,根据术后是否出现感染分为感染组和非感染组,对比两组病人的一般临床资料、治疗、手术及术后并发症等情况.观察术后感染病人病原学特点,采用单因素分析及多因素Lo...     

Delirium Development After Lung Transplantation: An Intraoperative Assessment

BackgroundThis study aimed to evaluate the relationship between intraoperative hemodynamic and laboratory parameters with postoperative delirium development after lung transplantation.MethodsA total of 77 patients who underwent lung transplantation in a single center were included in the study. Demographic and clinical data recorded at critical intraoperative stages (after induction [T1], after bilateral lungs are dissected [T2], while the patient is ventilated for 1 lung [T3], while the unilateral transplanted lung is ventilated [T4], while bilateral transplanted lungs are ventilated [T5], and after the thorax is closed [T6]), postoperative complications, mechanical ventilation duration, intensive care, and hospitalization durations and mortality rates were recorded.ResultsA total of 83.1% of the 77 patients were male, and the mean (SD) age was 47.56 (12.95) years. The mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 23.30 (3.99), and the median Charles Comorbidity Index (CCI) was 1. The diagnosis of 36.4% of the patients was chronic obstructive pulmonary disease. Delirium was seen in 51.9% of the patients. Age, CCI, intraoperative mean arterial pressure changes, lactate levels, mechanical ventilation duration, and hospital stay were all associated with delirium development.ConclusionAge, CCI, duration of mechanical ventilation, and hospital stay were independent predictors of postoperative delirium development. We believe that our study will be a guide for future prospective randomized controlled studies.     

Mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery

BACKGROUND: Early postoperative mobilization induces a marked reduction in mixed venous oxygen saturation (S(v)O(2)) after aortic valve replacement. We investigated whether a similar desaturation occurs among coronary artery bypass grafting (CABG) patients, and if the desaturation was related to the preoperative ejection fraction (EF). METHODS: Thirty-one CABG patients with a wide range in EF were included in an open observational study. We recorded hemodynamic and oxygenation variables during mobilization on postoperative day 1 and day 2 using a pulmonary artery catheter. RESULTS: Patients with an EF ranging from 24 to 87% were mobilized without clinical problems. S(v)O(2) at rest was 65.4 +/- 4.9% (mean +/- SD) on day 1 and 64.3 +/- 5.8% on day 2 (NS). During mobilization, cardiac index and oxygen delivery were reduced while oxygen consumption was increased (P-values: 0.000, 0.007 and 0.000, respectively). Consequently, oxygen extraction increased, resulting in a marked reduction in S(v)O(2)-42.9 +/- 8.3% on day 1 and 47.4 +/- 8.5% on day 2 (P = 0.025 between days). Several pre-, intra- and postoperative factors were tested as possible predictors for S(v)O(2) during mobilization. No factor contributed substantially. CONCLUSION: Patients with CABG exhibit a marked desaturation during early postoperative mobilization. Preoperative ejection fraction did not affect S(v)O(2) during exercise. The clinical consequences and underlying mechanism require further investigation.     

由嵌顿性声门异物演变为气管异物的抢救一例并文献复习

目的 探讨声门异物的临床表现、诊断及治疗方法。方法 结合文献复习,回顾性分析2018年6月12收治的一例由嵌顿性声门异物演变为气管异物患者资料。患者女,1岁3个月。因“误食鱼骨后咳嗽、拒食10天”入院。入院前予抗炎、雾化治疗未见好转,后经纤维喉镜检查提示声门异物。予全麻下行气管镜探查术,术中患者出现喉痉挛,血氧饱和度下降,行紧急气管插管后演变为气管异物,并再次在全麻下行气管镜探查取出术,手术过程顺利,取出异物。结果 术后第一天拔除气管插管,第13天患者无发热,无咳嗽咳痰,无声嘶气促,面色红润,听诊双肺呼吸音清,复查胸片提示肺炎基本痊愈及未见异物残留,予顺利出院。结论 喉异物、气管异物较常见,但由嵌顿性声门异物演变成气管异物罕见。有异物误吞史的患儿应考虑喉异物的可能,需完善相关检查及进一步明确诊断,并且选择适宜的麻醉方法及掌握手术技巧。     

由嵌顿性声门异物演变为气管异物的抢救一例并文献复习

目的 探讨声门异物的临床表现、诊断及治疗方法。方法 结合文献复习，回顾性分析2018年6月12收治的一例由嵌顿性声门异物演变为气管异物患者资料。患者女，1岁3个月。因“误食鱼骨后咳嗽、拒食10天”入院。入院前予抗炎、雾化治疗未见好转，后经纤维喉镜检查提示声门异物。予全麻下行气管镜探查术，术中患者出现喉痉挛，血氧饱和度下降，行紧急气管插管后演变为气管异物，并再次在全麻下行气管镜探查取出术，手术过程顺利，取出异物。结果 术后第一天拔除气管插管，第13天患者无发热，无咳嗽咳痰，无声嘶气促，面色红润，听诊双肺呼吸音清，复查胸片提示肺炎基本痊愈及未见异物残留，予顺利出院。结论 喉异物、气管异物较常见，但由嵌顿性声门异物演变成气管异物罕见。有异物误吞史的患儿应考虑喉异物的可能，需完善相关检查及进一步明确诊断，并且选择适宜的麻醉方法及掌握手术技巧。