病态肥胖患者胃减容术后延迟拔管的危险因素分析

目的 分析病态肥胖患者胃减容术后延迟拔管的危险因素。方法 检索医院病案系统,回顾性收集2012年9月至2018年12月在全麻下行腹腔镜下胃减容术的369例病态肥胖患者的手术麻醉相关资料,男139例,女230例,年龄18～60岁,BMI>35 kg/m²。根据拔管地点的不同将患者分为两组：非延迟拔管组(手术室拔管,ND组)和延迟拔管组(非手术室拔管,D组)。比较两组人口学资料、吸烟史、术前合并症、术中麻醉药物用量、出入量、手术时间、麻醉时间、总住院时间和术后住院时间等,采用多因素Logistic回归分析术后延迟拔管的危险因素。结果 延迟拔管的患者有109例(29.5%)。D组男性比例、体重、理想体重、BMI、吸烟史比例、合并高血压、糖尿病、冠状动脉粥样硬化、阻塞性睡眠呼吸暂停综合征(OSA)比例、睡眠呼吸紊乱指数(AHI)明显高于ND组,年龄明显大于ND组,呼吸暂停时间明显长于ND组(P<0.05)。多因素Logistic回归分析结果显示,体重增加(OR=1.045,95%CI 1.004～1.087,P<0.05),BMI增大(OR=2.020,...     

Remifentanil for INSURE in preterm infants: a pilot study for evaluation of efficacy and safety aspects

Aim:  To evaluate intubating conditions, extubation times and outcome in preterm infants receiving remifentanil as induction agent for the INSURE procedure.
Methods:  In twenty-one preterm infants of 29 to 32 weeks gestation and signs of respiratory distress, we utilized remifentanil as induction agent for the INSURE procedure. Following intubation and surfactant application, the infants were mechanically ventilated until respiratory drive was judged to be satisfactory for continuing CPAP therapy. Intubating conditions were classified by our own scoring system by rating limb movements, coughing and breathing. Heart rate, blood pressure and oxygen saturation were recorded during the entire INSURE procedure.
Results:  Remifentanil provided excellent or good intubating conditions in all patients. We observed no serious side effects after remifentanil infusion, in particular, no thorax rigidity, clinically significant bradycardia or arterial hypotension. Average extubation time after surfactant administration was 16.9 min (1–45 min); none of the infants had to be reintubated. Following extubation, the infants required only 3.3 days (1–8 days) of CPAP therapy. None exhibited serious complications of prematurity like periventricular leucomalacia, intraventricular haemorrhage >I°, necrotizing enterocolitis or retinopathy.
Conclusion:  In this pilot study, INSURE with remifentanil was associated with good intubating conditions and early extubation resulting in an excellent neonatal outcome.     

非计划性拔除引流管的相关因素分析及对策

目的探讨非计划性拔除引流管的原因和护理对策。方法回顾分析24例引流管非计划性拔除的情况及原因。结果非计划性拔除引流管最多发生在0?01～8?00时段,占41.67%;其次为17:01～24:00和12:01～14:00时段,分别占25.00%和16.67%。多发生于工作1年内护士当班时,占50.00%。非计划性拔除引流管原因:医护人员因素(62.50%)明显多于患者因素(37.50%),以固定不牢固、巡视观察不及时、健康教育不细致、工作经验不足为主。结论科学安排护理人力资源,加强护士专科知识、技能培训,落实交接班制度,加强病房巡视和病情观察,保证健康教育效果,提升护理品质是防范非计划性拔除引流管的有效措施。     

优质护理对COPD气管插管患者预防呼吸机相关性肺炎的效果分析

目的探究优质护理对COPD气管插管患者预防呼吸机相关性肺炎的应用效果。方法选取120例COPD气管插管患者,采用随机数字表法随机均分为研究组与对照组各60例,对照组采用常规护理方法,研究组在常规护理方法的基础上采用优质护理,主要包括合理应用抗生素、有效排痰、消化系统交叉感染预防、降低医源性感染概率等措施。分析2组患者治疗前后的血气指数变化情况,以及2组患者的机械通气时间、住院时间、呼吸机相关肺炎发生例数。结果 2组患者治疗后血气分析指数均有较大改善;研究组患者的平均总通气时间为(8±3.5)d,对照组患者的平均总通气时间为(14±4.0)d;研究组发生呼吸机相关肺炎的患者例数为3例(5.0%),对照组发生呼吸机相关肺炎的患者例数为10例(16.67%),差异有统计学意义(P0.05)。结论优质护理与常规护理均能有效改善患者呼吸状况,但是在对呼吸机相关性肺炎的预防以及缩短患者治疗时间的改善上,优质护理具有更好的应用效果。     

逆行钢丝顺行换管器引导困难气管插管技术的临床应用体会

目的：总结分析逆行钢丝顺行换管器引导困难气管插管技术的临床应用体会。方法：选择术前预测困难气道患者42例为研究对象,分析其临床资料,对应困难气管特点后给予经环甲膜或其下1~2、2~3气管环的间隙行穿刺,予以逆行钢丝顺行换管器引导下气管插管,分析其操作方法及结果。结果：逆行钢丝顺行换管器引导困难气管插管技术42例均成功,成功率为100%,插管过程中可维持SpO2在95%之上,术后无1例出现相关并发症。结论：逆行钢丝顺行换管器引导气管插管技术操作较为简便,且对组织的损伤小,有较高的成功率。     

Long‐term outcomes of microsurgical reconstruction for large tracheal defects

BACKGROUND:

Reconstruction of large tracheal defects has been largely unsuccessful. The purpose of this study was to review the authors' experience with microsurgical reconstruction of these defects.

METHODS:

Seven cases of microsurgical tracheal reconstruction were performed between May 2002 and April 2008. All but 1 patient had recurrent thyroid cancer; the other patient had primary adenocystic carcinoma of the trachea. The radial forearm free flap was used for lining in all cases. Rigid support was provided with a variety of prosthetic materials.

RESULTS:

All defects involved the cervical trachea, with an average length of 5.8 cm ± 1.0 cm (range, 5 cm‐7.5 cm). The width of defects ranged from half of the tracheal circumference to the entire circumference. Major complications included air leak in 4 patients, exposure and removal of prosthesis in 2 patients, and cardiopulmonary complications in 2 patients. One patient with postoperative retroperitoneal hematoma, abdominal compartment syndrome, and multiple organ failure died 2 months after surgery. Two patients died of other causes 1 year and 4 years, respectively, after surgery. The other 4 patients were alive and disease free, with follow‐up ranging from 1 to 4.5 years. Four patients are asymptomatic, with normal speech and swallowing functions. Two patients remained tracheostomy dependent, but vocal ability was intact. All patients tolerated a regular diet.

CONCLUSIONS:

Microsurgical reconstruction is a viable option in selected patients with large cervical tracheal defects that are beyond primary repair. Cancer 2011. © 2010 American Cancer Society.     

Percutaneous tracheostomy and cricothyrotomy techniques

Percutaneous tracheostomy is currently accepted as a standard technique for longer-term airway care in the critically ill patients in many intensive care units (ICUs). Early tracheostomy has not shown any survival benefit compared to late tracheostomy following prolonged tracheal intubation in ICU patients. The main indications for tracheostomy in the ICU setting include weaning from artificial ventilation or airway protection. Nevertheless, many questions about choice of techniques, post-tracheostomy care and decannulation remain unanswered. This review gives an overview of current techniques.     

国产曲马多对全麻围拔管期反应的影响

目的:观察国产曲马多对全麻围拔管期反应及术后疼痛的影响。方法:选择行静吸复合全麻患者42例,随机均分为两组。观察组在手术结束前约1小时肌肉注射国产曲马多1mg/kg,对照组不用曲马多。观察两组患者围拔管期血液动力学变化及不吸氧时SpO2值,有无躁动及躁动程度、初醒时间和拔管时间,术后疼痛程度评分及有无不良反应。结果:观察组围拔管期MAP、HR、SpO2没有明显变化(P>0.05);对照组MAP在拔管时明显升高(P<0.05);观察组重度躁动的发生率、术后8小时疼痛程度Ⅲ级者明显低于对照组(P<0.05),且不延长初醒和拔管时间。结论:国产曲马多肌肉注射可安全有效地抑制全麻围拔管期反应,且有明显的术后镇痛作用。     

气囊-面罩、食管气管导管和经口气管内插管在心肺复苏中的应用评价

【目的】探讨气囊-面罩、食管．气管导管盲插法和经口气管插管法在心肺复苏中（CPR）的应用价值。【方法】351例心脏呼吸骤停患者按照有无咽部解剖生理异常，分为正常组和异常组。每组根据CPR时对患者建立人工气道的不同措施将其随机均分为3组，A组常规CPR时即使用气囊-面罩通气；B组常规CPR时即行食管-气管导管盲插法；C组常规CPR时即行气管导管经口插管法。比较3种方法建立人工通气所需时间，复苏过程中患者的血氧饱和度以及复苏成功率。【结果】正常组气囊-面罩通气复苏成功率最差（P〈0．01），异常组食管气管导管盲插法复苏成功率最高（P〈0．01）。【结论】经口气管内插管是临床最常用和有效的建立高级气道的方法，在异常情况下，食管气管导管可作为首选。