162例气管插管患者的气道管理

笔者通过报道162例气管插管患者的气道管理，阐述痰痂形成的原因：(1)气道干燥，湿化不够。(2)吸痰管插入深度不够，吸痰不彻底。管理措施：(1)用金霉素眼膏润滑吸痰管，使之易于插入，保证吸痰管插入深度超过插管远端3-5cm。(2)预防气道干燥，注重湿化效果，重视吸痰环节。认为气囊不需定时放气，只需不定时调整气囊压力。     

老年卧床病人鼻饲并发症的护理干预

目的　通过护理干预 (增加置入胃管深度、抬高床头、适宜鼻饲量及鼻饲速度 )预防鼻饲时出现的呛咳、食物反流、胃潴留以及吸入性肺炎。方法　将 16例老年卧床鼻饲患者随机分成四组 ,对照组给予教科书上常规的置管深度及鼻饲方法 ;实验一组 (A)给予常规置管深度 ,鼻饲时抬高床头 30～ 80cm ;实验二组 (B)置管深度延长 8～ 10cm ,实验三组 (C)置管深度延长8～ 10cm ,鼻饲时抬高床头 30～ 80cm(坐位或半坐位 ) ,保持该体位 30min。结果　四组病人比较呛咳 ,对照组与实验组 (A、B、C)P <0 .0 1,差异有统计学意义 ;食物返流率P <0 .0 5 ;胃潴留对照组与实验组P >0 .0 5 ,差异无统计学意义 ;吸入性肺炎对照组 2例 ,A、B组各 1例 ,C组无发生。结论　护理干预可以减少与预防鼻饲并发症的发生。     

老年病人鼻饲方法的改进

目的探讨增加置管深度并抬高床头对预防老年鼻饲病人食物反流的效果。方法将 5 75例需鼻饲的卧床老年病人按鼻饲医嘱时间顺序及不平衡指数最小原则分成三组 ,分别给予教科书中的常规置管深度置管 (对照组 )、置管深度延长 10cm(观察 1组 )、置管深度延长 10cm并抬高床头 30～ 45°(观察 2组 )进行鼻饲。结果三组病人食物反流率比较 ,P <0 .0 1;观察 1、2组分别与对照组比较 ,P <0 .0 5、P <0 .0 1;观察 1组与观察 2组比较 ,P <0 .0 1。增加置管深度并抬高床头其食物反流率最低 ,仅增加置管深度次之 ,常规置管最高。结论增加置管深度并抬高床头可显著降低老年鼻饲病人食物反流发生率。     

院前紧急气管插管与机械通气24例临床分析

目的总结紧急气管插管与机械通气在院前急救中应用的经验,以期提高院前急救水平。方法回顾性分析24例院前气管插管与机械通气抢救心搏呼吸骤停病人的临床资料。结果24例病人气管内插管均获成功,成功率100%。完成气管内插管的时间是15s～60s,平均时间(25±15)s。心搏、自主呼吸恢复4例(16.7%),心搏恢复8例(33.3%);心搏及自主呼吸均未恢复12例(50.0%)。结论气管插管与机械通气是急诊抢救危重病人的基础,对保证进一步心肺复苏、挽留手术机会以及提高危重患者抢救成功率有重要意义。要加强对抢救人员进行紧急气管插管和机械通气的培训。     

Accidental bronchial intubation An analysis of AIMS incident reports from 1988 to 1994 inclusive

Accidental bronchial intubation was examined in the first 3947 cases reported to the Australian Incident Monitoring Study and was found to have accounted for 154 (3.7%) of the total incidents reported. Most incidents were detected in the operating theatre (93.5%) and during maintenance of anaesthesia (77.9%), by unexplained oxygen desaturation alone (63.6%). Capnography remained normal or unremarkable during 88.5% of the episodes. One-third of cases were associated with head or neck surgery and possible flexion of the patient's head. A RAE tube was used in 20% of incidents, a greater frequency than occurred in the study overall. A third party was implicated in 36 (23.4%) of cases. Ninety per cent of cases were considered preventable. Major morbidity occurred in three cases and unplanned intensive care admission was required in a further five. Almost two-thirds (61.1%) of the incidents might have been avoided by the proposed markings on the tracheal tube. We conclude that when arterial desaturation occurs at any stage during anaesthesia the possibility of bronchial intubation must be considered. Asymmetrical ventilation may be difficult to detect clinically and in most cases there is no change in capnography.     

Intramuscular dexmedetomidine premedication—an alternative to midazolam-fentanyl-combination in elective hysterectomy?

Sedation, anxiolysis, intubation responses and fentanyl anaesthetic requirements were investigated in a double-blind, randomized study in twenty ASA I-II elective hysterectomy patients. Ten patients received dexmedetomidine 2.5 μg kg^-1 i.m. 60 min before induction and saline placebo i.v. 2 min prior to induction (= DP group). Ten patients received midazolam 0.08 mg kg^-1 i.m. 60 min and fentanyl 1.5 μg kg^-1 i.v. (= MF group) 2 min before induction of anaesthesia with thiopentone 4 mg kg^-1. Anaesthesia was maintained with 70% nitrous oxide in oxygen and with fentanyl 2 μg kg^-1 i.v. increments according to predetermined criteria. Both premedications induced sedation ( P < 0.01 in both groups) and anxiolysis ( P < 0.01 in DP vs <0.05 in MF group) without any differences between the groups. Haemodynamic changes following tracheal intubation did not significantly differ between the groups. Intraoperatively systolic and diastolic arterial pressure were 15% and 13% lower in DP group ( P < 0.01 and P < 0.05 for drug effect), the mean heart rate was approximately 9 beats min^-1 lower in DP group (n.s.). Fentanyl was required more often in MF group: median 3.5 (QD 1.5) vs. 2.5 (QD 0.5) times in DP group ( P < 0.05), the total amount being 57% smaller in DP group: 0.03 (QD 0.01) vs. 0.07 (QD 0.02) μg kg^-1 min^-1 ( P < 0.05). Postoperative course and analgesic requirements were similar in both groups. Dexmedetomidine premedication may offer an alternative to current anaesthesia practice in elective hysterectomy.     

利多卡因对大鼠离体气管平滑肌的作用及机制

目的:研究利多卡因对气管平滑肌的作用及机制.方法:观察利多卡因对乙酰胆碱(ACh)和高钾预收缩大鼠离体气管的作用,对ACh、高钾和CaCl2诱发气管平滑肌收缩作用剂量反应曲线和ACh致两种收缩组分的影响并与维拉帕米进行比较.结果:利多卡因对ACh和高钾诱发的大鼠离体气管平滑肌标本收缩有舒张作用,并不被L-NAME和普萘洛尔阻断.利多卡因浓度依赖性地使ACh、KCl和CaCl2对大鼠离体气管条标本的量效反应曲线右移,最大反应降低.利多卡因0.69和3.45 mmol/L对ACh所致依赖细胞内钙收缩的抑制率及依赖细胞外钙收缩的抑制率差别均十分显著(P＜0.01).结论:利多卡因对离体大鼠气管平滑肌的舒张作用可能是通过非特异性地抑制细胞外钙经电压调节和受体调节钙通道向内流动及抑制细胞内钙释放来实现的.     

Difficulties with tooth protectors in endotracheal intubation

The suitability of three tooth protectors for routine use during endotracheal intubation was studied in 300 consecutive patients undergoing elective operations under general anaesthesia. The main disadvantages of the protectors were lack of space and the consequent difficulty of guiding the endotracheal tube into the larynx, and poor visibility, especially when the Camo protector was used. These difficulties could be avoided in most cases by cutting off the right angle of the Camo protector. The less experienced anaesthesiologists especially had difficulties with the protectors: 20% of patients in the Camo group were considered impossible to intubate unless the protector was removed. The silicone inlay of the Camo protector melts and becomes adhesive at body temperature, which makes its prolonged use hazardous. Two patients lost a maxillary incisor despite the proper use of a protector (Denex). Thus the use of a tooth protector alone does not guarantee avoidance of dental trauma. Better results could be obtained by improving the design of the protectors and by careful pre-anaesthetic dental examination.     

Anaesthesia for Cockayne's syndrome. Contemporary solutions to an old problem

The management of a failed intubation in a nineteen-year-old patient suffering from Cockayne's syndrome is described. Use of a laryngeal mask prevented major anaesthetic morbidity. Tracheal intubation was subsequently facilitated by a fibreoptic bronchoscope passed through the laryngeal mask. Cockayne's syndrome is reviewed including recent important developments in its aetiology and pathogenesis.;