改良直置式套管针替代导入鞘法在新生儿PICC置入中的应用

目的评价改良直置式套管针替代安全型撕裂式导入鞘法置入新生儿PICC的可行性和安全性。方法对135例新生儿应用20G直置式套管针置入PICC(观察组),与应用导入鞘置入PICC的128例新生儿(对照组)进行对比,比较两组穿刺时间、第1次换药时间、穿刺成功率及留置时间。结果两组穿刺时间、穿剌成功率及导管留置时间比较,差异无统计学意义(均P>0.05);观察组较对照组第1次换药时间延长(P<0.01)。结论在新生儿PICC置管中,经济简便的直置式套管针可以替代安全型撕裂式导入鞘使用。     

Risk factors for transfer from Respiratory Intermediate Care Unit to Intensive Care Unit in COVID-19

BackgroundPatients hospitalized for COVID-19-related pneumonia often need several degrees of ventilatory support, which are performed between Respiratory Intermediate Care Units (RICUs) and Intensive Care Units (ICUs), and which depend on the severity of acute respiratory distress syndrome. There is no firm consensus on transfer predictors from the RICU to the ICU.MethodsIn this retrospective observational single center study, we evaluated 96 COVID-19 patients referred to the RICU for acute respiratory failure (ARF) according to their transferal to the ICU or their stay at the RICU. We compared demographic data, baseline laboratory profile, and final clinical outcomes to identify early risk factors for transfer.ResultsThe best predictors for transfer to the ICU were elevated C-reactive protein and lymphopenia. The mortality rate was lower in the RICU than in the ICU, where transferred patients who died were mostly younger men and with less comorbidities than those in the RICU.ConclusionsFew inflammatory markers can predict the need for transfer from the RICU to the ICU. Due to the ongoing COVID-19 pandemic, we urge better clinical stratification by early and meaningful profiles in patients admitted to the RICU who are at risk of transferal to the ICU.     

双腔管冲洗引流并尿激酶溶解术治疗高血压脑出血

目的:探讨双腔管冲洗引流并尿激酶溶解术治疗高血压脑出血的方法及效果.方法:回顾性分析38例在CT定位钻孔抽吸部分血肿后行双腔管冲洗引流并尿激酶注入治疗的高血压脑出血病人的临床特点及疗效.结果: 血肿清除率高,病人恢复良好,死亡率低,并发症少.结论:双腔管冲洗引流并尿激酶溶解术是高血压脑出血的一种简单、有效的治疗方法.     

氢化可的松与丙帕他莫对全麻气管插管术后咽喉痛的影响

目的 探讨氢化可的松与丙帕他莫合用对全麻气管插管术后咽喉痛（POST）的影响.方法 纳入气管插管全麻手术患者200例,年龄18 ～ 65岁,ASA Ⅰ或Ⅱ级.依手术时间先后随机分成A、B、C、D四组,每组各50例,A组为对照组,B、C、D为实验组,分别实施：A组气管插管后生理盐水20ml静注;B组氢化可的松50mg＋生理盐水20ml静推;C组丙帕他莫2.0加入生理盐水100ml中静滴（15min内滴完）;D组同时合用B组和C组药.四组均记录拔管后的1、6、12、24小时POST的发生率和严重程度.结果 四组拔管后12小时POST发生率达高峰.B组达40％、C组36％与D组22％发生率均低于A组66％ （P＜0.05）,且D组明显低于B组和C组（P＜0.05）,各组未见与注射药物相关的不良反应.结论 氢化可的松与丙帕他莫合用能有效降低POST的发生率及严重程度,且安全性高.     

带储气囊无重复呼吸面罩在COPD患者脱机后的应用

目的探讨带储气囊无重复呼吸面罩、普通面罩及经鼻吸氧在慢性阻塞性肺病(COPD)脱机后的优缺点。方法选取2010年6月至2013年1月郧县人民医院收治的须行气管插管机械通气的COPD急性发作并发重度呼吸衰竭患者66例,依据随机数字表法分为三组:第1组(22例)脱机后应用带储气囊无重复呼吸面罩吸氧,第2组(22例)应用普通面罩进行吸氧,第3组(22例)应用鼻导管进行吸氧。比较三组3 d内再次应用呼吸机人次、脱机后24、48、72 h血气分析中pH、二氧化碳分压、氧合指数。结果再次应用呼吸机患者会在第1、2、3组分别为2、6、8人次,再次上呼吸机率分别为9%、27%、36%。脱机后24、48、72 h,三组患者的二氧化碳分压、氧分压、pH比较差异均有统计学意义(P<0.05)。结论带储气囊无重复呼吸面罩应用于COPD可有效提高氧分压,无明显加重二氧化碳蓄积的不良反应。     

合用盐酸右美托咪定对异丙酚最低诱导剂量和气管插管心血管反应的影响

目的 探讨妇科腹腔镜患者使用右美托咪定对异丙酚最低诱导剂量的影响和对气管插管心血管反应的影响.方法 本研究采用双盲、随机、对照法,选择60例妇产科择期腹腔镜手术患者为研究对象,随机平分为右美托咪定组（治疗组）和对照组.诱导前治疗组按照右美托咪定0.1 μg/（kg·min）速度泵入并持续10 min;10 min后改为0.4μg/（kg·h）的速度输注,至麻醉插管后1h,观察结束;对照组以同样方法输注等量的0.9％氯化钠注射液.10 min后,两组均以0.4mg/（kg·min）的速度泵注丙泊酚诱导.待患者睫毛反射消失,且脑电双频谱指数（BIS）值在40～60时,记录丙泊酚的使用量.恒速输注丙泊酚基础上,给予芬太尼、罗库溴后2 min行气管内插管.记录镇静警觉评分（OAA/S评分）值、平均动脉压、心率、血氧饱和度（SpO2）、BIS值.记录时间点为给药前（基础值）及给药后5、10 min和睫毛反射消失时、插管前、置入喉镜时及插管后1、3、5 min时.结果 OAA/S评分和BIS值在用药后5、10min,治疗组均明显低于对照组（P均＜0.05）.治疗组睫毛反射消失时、插管前、置入喉镜时及插管后1、3、5 min时,平均动脉压均高于对照组,两组间比较差异均有统计学意义（P均＜0.05）.在用右美托咪定后5、10 min时以及在插管前,治疗组的心率均低于对照组,两组间比较差异均有统计学意义（P均＜0.05）.两组患者SpO2比较差异无统计学意义（P＞0.05）.患者意识消失且BIS值在40～60时异丙酚的最低诱导剂量在治疗组为（88.00±25.91） mg,对照组为（117.33±25.45） mg,治疗组异丙酚的用量明显少于对照组（t=4.423,P＜0.05）.结论 右美托咪定可减低异丙酚的最低诱导剂量,维持诱导期的血流动力学平稳,但对气管插管引起的心血管反应无明显的抑制作用.     

Real-life study of the role of high-flow nasal cannula for bronchiolitis in children younger than 3 months hospitalised in general pediatric departments

We aimed to describe the real-life role of high-flow nasal cannula (HFNC) for bronchiolitis in infants under 3 months of age admitted to three general pediatric departments during the 2017–2018 epidemic period. We retrospectively assessed the clinical severity (Wang score) for every 24-h period of treatment (H0–H24 and H24–H48) according to the initiated medical care (HFNC, oxygen via nasal cannula, or supportive treatments only), the child's discomfort (EDIN score), and transfer to the pediatric intensive care unit (PICU). A total of 138 infants were included: 47 ± 53 days old, 4661 ± 851.9 g, 70 boys (50.7%), 58 with hypoxemia (42%), Wang score of 6.67 ± 2.58, 110 (79.7%) staying for 48 consecutive hours in the same ward. During the H0–H24 period, only patients treated with HFNC had a statistically significant decrease in the severity score (n = 21/110; ?2 points, P = 0.002) and an improvement in the discomfort score (n = 15/63; ?3.8 points, P < 0.0001). There was no difference between groups during the H24–H48 period. The rate of admission to the PICU was 2.9% for patients treated for at least 24 h with HFNC (n = 34/138, 44% with oxygen) versus 16.3% for the others (P = 0.033). Early use of HFNC improves both clinical status and discomfort in infants younger than 3 months admitted for moderately severe bronchiolitis, whatever their oxygen status.     

Effect of HFNC flow rate,cannula size,and nares diameter on generated airway pressures: An in vitro study

Increased use of non‐invasive forms of respiratory support such as CPAP and HFNC in premature infants has generated a need for further investigation of the pulmonary effects of such therapies. In a series of in vitro tests, we measured delivered proximal airway pressures from a HFNC system while varying both the cannula flow and the ratio of nasal prong to simulated nares diameters. Neonatal and infant sized nasal prongs (3.0 and 3.7 mm O.D.) were inserted into seven sizes of simulated nares (range: 3–7 mm I.D. from anatomical measurements in 1–3 kg infants) for nasal prong‐to‐nares ratios ranging from 0.43 to 1.06. The nares were connected to an active test lung set at: TV 10 ml, 60 breaths/min, Ti 0.35 sec, compliance 1.6 ml/cm H₂O and airway resistance 70 cm H₂O/(L/sec), simulating a 1–3 kg infant with moderately affected lungs. A Fisher & Paykel Healthcare HFNC system with integrated pressure relief valve was set to flow rates of 1–6 L/min while cannula and airway pressures and cannula and mouth leak flows were measured during simulated mouth open, partially closed and fully closed conditions. Airway pressure progressively increased with both increasing HFNC flow rate and nasal prong‐to‐nares ratio. At 6 L/min HFNC flow with mouth open, airway pressures remained <1.7 cm H₂O for all ratios; and <10 cm H₂O with mouth closed for ratios <0.9. For ratios >0.9 and 50% mouth leak, airway pressures rapidly increased to 18 cm H₂O at 2 L/min HFNC flow followed by a pressure relief valve limited increase to 24 cm H₂O at 6 L/min. Safe and effective use of HFNC requires careful selection of an appropriate nasal prong‐to‐nares ratio even with an integrated pressure relief valve. Pediatr Pulmonol. 2013; 48:506–514. © 2012 Wiley Periodicals, Inc.     

Patients with New York Heart Association class III heart failure may benefit with high flow nasal cannula supportive therapy : High flow nasal cannula in heart failure

Purpose

High flow nasal cannula (HFNC) may decrease preload being associated with beneficial hemodynamic and respiratory effects in adults with heart failure.

Methods

This is a sequential intervention prospective study including 10 adults with New York Heart Association (NYHA) class III and left ventricle ejection fraction 45% or less. High flow gas was administered (fraction of inspired oxygen, 0.21) through nasal cannula (Optiflow^TM; Fisher & Paykel, Auckland, New Zealand). Sequential echocardiographies were performed at baseline, using HFNC with 20 lpm and 40 lpm and post-HFNC. A reduction greater than 20% in the estimated inspiratory collapse of the inferior vena cava (IVC) from baseline was considered clinically significant.

Results

Ten patients were included, with median age of 57 (44-65) years; 6 (60%) were female, and 8 (80%) had dilated cardiomyopathy. Median IVC inspiratory significantly (P < .05) decreased from baseline (37%) to HFNC with 20 lpm (28%) and HFNC with 40 lpm (21%), representing mean attributable reductions of 20% (95% confidence interval, 6-55) and 53% (95% confidence interval, 36-67) from baseline. Changes in the IVC inspiratory collapse were reversible after HFNC withdrawal. Respiratory rate was significantly reduced from 23 breaths per minute at baseline to 17 breaths per minute at HFNC with 20 lpm and 13 breaths per minute at HFNC with 40 lpm. In contrast, no significant changes in other echocardiographic or clinical variables were documented.

Conclusion

These findings suggest that patients with NYHA class III heart failure may benefit with HFNC supportive therapy.     

A simple method of nucleus removal during extracapsular surgery

A simple method of removing the nucleus during extracapsular cataract extraction uses an irrigating cannula with an inferior distal lip for retracting the iris and capsule. The nucleus is irrigated out of the eye by directing the irrigating stream toward the equator of the nucleus. Slight counterpressure at the 6-o'clock position is helpful but not always necessary. This technique is easy to perform and does not require expensive equipment.