细光导纤维支气管镜在双腔气管插管中的应用体会(附90例报告)

目的 应用细光纤维支气管镜观察双腔管在气管内位置状况。方法 观察90例双腔气管插管，分为插管成功和需调整两个标准。插管成功51例，需调整39例，对发生原因进行了解。结果 需调整病例占插管总数的43．0％，最常见为导管过深或过浅，占需调整总数69．2％，其次为套囊充气不足占17．9％，方向错位7、7％，导管过细5．1％。以上发现的状况均在纤支镜明视下调整成功。结论 细光学纤维支气管镜对双腔气管插管准确定位有很大的帮助。     

Comparison of train-of-four and posttetanic response as guides for endotracheal intubation in children

Study Objective: To evaluate and compare the predictive values of the absence of train-of-four (TOF) or Posttetanic response as guides for endotracheal intubation in children.

Design: Prospective controlled study in children.

Setting: Induction of anesthesia and endotracheal intubation at a university-affiliated hospital.

Patients: Thirty pediatric patients age 1 to 10 years, ASA physical status I, who were undergoing elective surgery were divided into two equal groups.

Interventions: Anesthesia was induced with halothane and maintained at 1% inspired concentration. Fifteen children were stimulated with the TOF (2 Hz for 2 seconds) technique and 15 with the twitch-tetanus-twitch sequence. All the patients received atracurium 0.4 mg/kg. Upon abolishment of the TOF or tetanus-twitch sequence, endotracheal intubation was performed and the conditions for intubation were evaluated.

Measurements and Main Results: In the group of Patients stimulated by the TOF technique, the neuromuscular response was ablated in 1.7 ± 0.1 minutes, a significantly shorter time than in those stimulated by the tetanus-twitch sequence (4.0 ± 0.4 minutes; p < 0.0001). Conditions for intubation did not differ between the two groups.

Conclusions: Good intubating conditions can generally be counted on when the TOF has disappeared; additional waiting for the disappearance of posttetanic response is unnecessary. The observation that the disappearance of the tetanus-twitch sequence is a good indicator of deep neuromuscular blockade during recovery from atracurium in children cannot be extrapolated to the induction period.     

异丙酚不同诱导方法对气管插管时心血管反应的影响

为了探讨更合适的异丙酚诱导给药方案，本文观察了异丙酚不同给药方法对气管插管时心血管反应的影响。２２例成年患者，ＡＳＡ１～２级，常规术前用药后随机分为２组。Ａ组（ｎ＝１２）预先静注２μｇ／ｋｇ芬太尼（Ｆｅｎｔａｎｙｌ）后先以４ｍｌ（４０ｍｇ）／１０ｓ的速度静注异丙酚（Ｐｒｏｐｏｆｏｌ），当异丙酚用量达到１５ｍｇ／ｋｇ体重时停止给药１０ｓ，观察患者反应，若患者入睡则静注肌肉松驰剂，否则继续以２ｍｌ（２０ｍｇ）／１０ｓ的速度静注异丙酚直至患者入睡及眼睫毛反射消失后静注琥珀胆碱（２ｍｇ／ｋｇ）。Ｂ组（ｎ＝１０）仅以异丙酚及琥珀胆碱完成气管插管，两组患者均于静注完异丙酚后２ｍｉｎ实施气管插管。分别于诱导前（Ｔ０），注完异丙酚后１ｍｉｎ（Ｔ１），２ｍｉｎ（Ｔ２），气管插管即刻（Ｔ３）及气管插管后的３ｍｉｎ（Ｔ４）观察并记录ＨＲ，ＳＢＰ（收缩压），ＤＢＰ（舒张压），ＭＡＰ（平均压），并计算心率收缩压乘积（ＲＰＰ）以之间接反映心肌耗氧量。结果：Ａ组诱导后各时期ＨＲ，ＳＢＰ，ＭＡＰ，ＤＢＰ及ＲＰＰ无显著改变。Ｂ组诱导后ＨＲ呈逐渐上升趋势，Ｔ３时显著高于Ｔ０（Ｐ＜００５）；Ｔ３及Ｔ４时ＲＰＰ显著高于Ｔ０（Ｐ＜００１），Ｓ?     

Endotracheal Intubation with the King Laryngeal Tube™ In Situ Using Video Laryngoscopy and a Bougie: A Retrospective Case Series and Cadaveric Crossover Study

Background

Removal of a functioning King laryngeal tube (LT) prior to establishing a definitive airway increases the risk of a “can't intubate, can't oxygenate” scenario. We previously described a technique utilizing video laryngoscopy (VL) and a bougie to intubate around a well-seated King LT with the balloons deflated; if necessary, the balloons can be rapidly re-inflated and ventilation resumed.

非气管插管胸腔镜下肺癌手术的临床应用

目的评估非气管插管麻醉下胸腔镜肺癌手术的可行性和安全性。方法实验组与对照组各20例周围型肺癌患者。实验组采用喉罩通气麻醉、对照组采用气管插管麻醉行胸腔镜下肺部手术,监测并记录各组诱导前(T0)、诱导插管时(T1)、手术实施时(T2)和苏醒拔管时(T3)患者的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、心率(HR)、心电图(ECG)、脉搏血氧饱和度(Sp O2)、呼末二氧化碳分压(PETCO2)、中心静脉压、有创动脉血压及血糖指标,并记录患者术后的相关并发症,如有无咽痛、声音嘶哑和恶心等。结果喉罩组患者麻醉过程中对心血管系统刺激小,术后进食、排气、下床活动时间、平均住院日缩短,住院费用降低,咽部、呼吸及心血管系统并发症少于插管组。结论喉罩通气静脉麻醉配合胸内迷走神经阻滞在胸腔镜肺叶切除术中操作简易、安全性好、无插管相关并发症及单肺通气肺部损伤,符合手术-麻醉整体微创发展的理念,值得临床推广。     

不同吸痰方式对急性呼吸窘迫综合征血流动力学影响的实验研究

目的研究更适宜急性呼吸窘迫综合征(ARDS)机械通气气管内吸痰的方式。方法采用静脉注射油酸制备动物ARDS模型;每只犬随机选择使用开放式气管内吸痰(OS)和密闭式气管内吸痰(CS)2种吸痰方式。于吸痰前后记录血流动力学等监测指标的数据。结果OS和CS后,犬平均肺动脉压(MPAP)与吸痰前比较均明显升高(P<0.05);OS后平均动脉压(MAP)显著升高(P<0.05)。结论OS、CS均可影响血流动力学的稳定。本研究提示,在护理工作中,对ARDS机械通气者应重视吸痰引起的继发性损害,加强吸痰前后血流动力学等监测。     

An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

Objectives: To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. Methods: This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. Results: A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. Conclusions: Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.