小儿阻塞性睡眠呼吸暂停低通气综合征的诊断及治疗

目的探讨基层医院小儿阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的诊断和治疗。方法对临床疑似患儿,用多功能监测仪行夜间持续脉搏氧饱和度和呼吸监测、头颈侧位摄片、纤维鼻咽镜检查,确诊后行手术治疗。结果患儿多有睡眠粗响鼾声、扁桃体和(或)腺样体肥大,呼吸道感染、中耳炎、发育不良及中枢系统并发症的发生率较高。最低氧饱和度(85±7)%,睡眠呼吸暂停指数(apneaindex,AI)≥1者22例,睡眠呼吸暂停低通气指数(apneahypopneaindex,AHI)≥5者30例。在全麻下行扁桃体和腺样体切除术,同时行改良悬雍垂腭咽成形3例,双侧鼓膜切开引流术15例。术后症状及相关指标改善明显。结论便携式多功能监测仪可精确诊断OSAHS,扁桃体和腺样体切除是有效的治疗方法。     

Transcranial cerebral oximetry and carotid cavernous fistula occlusion

Summary Different methods have been used in the evaluation and monitoring of the cerebral oxygen supply during neuro-interventional therapies. Attenuation of near-infrared light by the chromophores oxyhemoglobin and deoxyhemoglobin have shown to be useful in the study of the cellular oxygen metabolism and oxygen delivery to the brain. Transcranial cerebral oximetry (TCCO) has the advantage of providing real-time information regarding regional brain oxygen saturation (rSO₂) by using wavelengths in the near-infrared range.We present a patient with a carotid cavernous fistula who underwent balloon occulusion and concurrent continuous TCCO monitoring. TCCO was found to be a useful tool providing immediate rSO₂ values during the angiographic and interventional procedures. Initial balloon occlusion of a carotid cavernous fistula resulted in partial occlusion of the internal carotid artery lumen causing an immediate decrease in rSO₂ which correlated with angiographic findings. Subsequent reocclusion of the fistula produced a slower and smaller degree of decrease in rSO₂ with clinical improvement in the patient. Changes in rSO₂ were detected before any adverse clinical event was observed. TCCO was reliable, safe, sensitive, and provided a real-time assessment tool for the monitoring of brain oxygen supply in a patient undergoing a neuroendovascular procedure.     

Pulse Oximetry Screening in Wisconsin

Introduction. Pulse oximetry can be used as a screening tool to detect critical congenital heart disease (CCHD) in neonates prior to hospital discharge and the development of symptoms. Newborns suspected of having CCHD based on pulse oximetry screening should have the diagnosis excluded or confirmed with echocardiography. However, echocardiography is not immediately available in all settings in which newborns are delivered and the best course of action in these settings remains to be determined. The purpose of this study was to evaluate the resources available to diagnose and treat newborns with CCHD born in the state of Wisconsin. Methods. We surveyed the nurse managers or administrators of the 99 Wisconsin hospitals in which babies are routinely delivered in the state of Wisconsin. A telephone survey was performed in February and March 2011. The number of births per facility was estimated from the most recent available data (2010). Results. There were 66 179 total births occurring in 106 hospitals in the state of Wisconsin in 2010, with 99 hospitals routinely delivering newborns. Surveys were completed in 88/99 (88.9%), representing 95% of the state's in‐hospital births. All responding hospitals had pulse oximetry available in the nursery. Twenty‐five of 88 (28.4%) of responding hospitals routinely use pulse oximetry to screen for CCHD, representing 35.2% of surveyed hospital births. Same‐day neonatal echocardiography was available at 33/88 (37.5%) of the responding hospitals, representing 74.4% of surveyed hospital births. The average distance to the higher‐level care facility of choice from the hospitals without neonatal echocardiography is 53.1 miles. Conclusion. Pulse oximetry is universally available in Wisconsin newborn nurseries, and pulse oximetry screening for CCHD is currently being performed for many of Wisconsin's newborns. The majority of births in Wisconsin occur in hospitals where same‐day neonatal echocardiography is available for confirmatory diagnosis of CCHD when necessary.     

老年男性阻塞性睡眠呼吸暂停低通气综合征患者低氧血症与嗜睡的相关性

目的 分析老年男性阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者低氧血症(氧减)与白天嗜睡的关系. 方法 2008年3月至2011年2月来我院就诊的1 47例老年男性OSAHS患者,使用Epworth嗜睡量表(ESS)自我评价嗜睡程度,并与多导睡眠呼吸监测结果结合进行分析.结果 147例OSAHS患者根据ESS评分分为嗜睡组和无嗜睡组,两组氧减饱和度指数(ODI)、平均血氧、最低血氧、90％氧减时间百分比(CT90)差异有统计学意义(P＜0.01).ESS评分与ODI、平均血氧、最低血氧、CT50有相关性(r分别为0.683、-0.450、-0.583、0.507.均P＜0.01);Logistic回归分析显示,仅ODI为ESS评分的危险因素(OR=1 11,95％CI:1.07～1.15).而ODI与平均血氧、最低血氧、CT90呈显著相关(r值分别为-0.628、-0.763、0.689,均P＜0.01).ODI≥23次/h时预测白天嗜睡的敏感度、特异度分别为79.2％、88.2％. 结论 在老年男性OSAHS患者中,氧减与白大嗜睡相关,ODI有预测白大嗜睡的价值,而平均血氧、最低血氧及CT90可能通过ODI与白天嗜睡相关.     

Effects of Milrinone continuous intravenous infusion on global cerebral oxygenation and cerebral vasospasm after cerebral aneurysm surgical clipping

BackgroundCerebral vasospasm (CVS) is a disabling disease with high morbidity and mortality risk. Milrinone (phosphodiesterase III inhibitor) has inotropic and vasodilator effects, noninvasive transcranial cerebral oximetry (rSO2%) useful in estimating the effect of triple-H therapy preventive measures against CVS.ObjectiveThe objective of the study is to clarify the value of the use of Milrinone continuous IV infusion as a cerebral vasodilator in post-clipping spasm prevention during the period of maximum vasospasm incidence, guided by noninvasive rSO2%.MethodsPost-clipping all patients extubated in the operative room, shifted to Neurosurgical ICU, and fully monitored. Then, in the period from 4th till the 11th day post-clipping, they were divided into two groups 15 patients each: Group 1: control group, given Norepinephrine continuous IV infusion alone in a dose ranges from 0.05 to 0.2 μg/kg/min. Group 2: given Norepinephrine continuous IV infusion 0.05–0.2 μg/kg/min, Plus Milrinone starting with 50 μg/kg bolus dose, followed by IV infusion at a rate of [0.5–0.75 μg/kg/min]. IMAP, ICP and CPP, GCS, Norepinephrine dose, rSO2%, were recorded every 6 h for the next 168 h. Any attack of cerebral vascular spasm recorded as number and % in each group as an incident.ResultsMBP, rSO2%, ICP, CPP, Norepinephrine Infusion dose, and GCS were significantly increased in Group (2) in comparison with Group (1) mostly during the period of the study. CVS occurrence was significantly lower in group (2), i.e., (20%) cases compared to (46.6%) in group (1).ConclusionsMilrinone improved significantly the global cerebral oxygenation and reduced the incidence of cerebral vasospasm during the dangerous period of cerebral spasm after cerebral aneurysm clipping.     

儿童睡眠呼吸暂停低通气综合征呼吸事件时间判定的研究

目的通过分析阻塞性睡眠呼吸暂停低通气综合征(obstructivesleepapneahypopneasyndrome,OSAHS)患儿的多导睡眠监测(polysomnogram,PSG)结果,探讨OSAHS患儿的呼吸事件(呼吸暂停/低通气)时间的判定标准。方法随机抽取107例自2004年1月至2006年5月间行多导睡眠监测后被诊断为OSAHS患儿的原始多导睡眠图,在排除了伪差后,观察每次血氧饱和度的下降值(△SaO2)及其伴随的呼吸事件时间。结果①△SaO2与呼吸暂停/低通气时间高度相关(P<0.01);②学龄前儿童与学龄期儿童在身高、体重、人体质量指数(bodymassindex,BMI)之间的差异具有显著性(P<0.01);③学龄前儿童与学龄期儿童在快动眼(rapideyemovement,REM)睡眠期及慢动眼(nonrapideyemovement,NREM)睡眠期之间的氧减指数具有显著性差异(P<0.01);④不同性别的患儿在REM期NREM期之间氧减指数也有显著性差异(P<0.01);⑤血氧饱和度下降3个百分点时(△SaO2=3%)呼吸事件的持续时间为5.4秒。结论①对儿童多导睡眠监测图的分析可为探索儿童呼吸事件判定标准提供方法;②△SaO2=3%时呼吸事件的时间与年龄有一定的相关性(r呼吸暂停=0.213,r低通气=0.225,P<0.05);③5.4秒可以作为儿童呼吸事件的判定依据,统一的儿童呼吸事件的判定标准应尽早制定。     

Non-invasive measurement of hemoglobin during cesarean hysterectomy: a case series

Obstetric patients diagnosed with abnormal placentation (placenta accreta, increta or percreta) are at increased risk of major postpartum hemorrhage and cesarean hysterectomy. Obstetric anesthesiologists are primarily involved in intraoperative transfusion management in these cases. Hemoglobin assessment is invaluable for assisting transfusion decision-making during the acute period of obstetric hemorrhage. However, laboratory and point-of-care tests of hemoglobin concentration are time-dependent and intermittent, and do not provide a real-time assessment of change during the acute phase of blood loss. A new non-invasive hemoglobin monitor has been introduced recently, which provides real-time measurement of hemoglobin values (SpHb) using multi-wavelength pulse co-oximetry. We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution. We discuss the potential clinical utility of non-invasive hemoglobin monitoring for pregnant patients at high risk of obstetric hemorrhage, and the potential role of SpHb in guiding transfusion therapy.