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Data of patients underwent bronchoscopic treatment of tracheal stenosis from May 2011 to April 2016 were collected.Patients were questioned about the medical history before operation, and the airway was fully evaluated.The laryngeal mask was used for the patients with upper 1/3 tracheal stenosis and subglottic stenosis, and endotracheal intubation was applied for the other patients.Patients with severe tracheal stenosis received extracorporeal membrane oxygenation (ECMO)-assisted ventilation.The tracheal tube or laryngeal mask was removed immediately when patients were awake and spontaneous breathing and swallowing reflex recovered after operation, and oxygen was inhaled by mask.A total of 189 patients were included in this study, 93 patients received endotracheal intubation, and 91 patients were ventilated via the laryngeal mask, and 5 patients underwent ECMO-assisted ventilation.Forty-four patients adopted the method of preserving spontaneous breathing, and the other 145 patients did not.There were 165 patients in whom the endotracheal tube or laryngeal mask was removed immediately after they were awake, and the remaining 24 cases were sent to the intensive care unit with the endotracheal tube.For the patients with tracheal stenosis, preoperative interview and airway assessment are especially important, and appropriate airway management strategies should be developed; vital signs should be closely observed during operation, and the proper ventilation mode is selected, and ECMO-assisted ventilation could be considered for the patients with severe tracheal stenosis; the timing of removal of the endotracheal tube or laryngeal mask should be seized after operation.
ABSTRACT
Data of patients underwent bronchoscopic treatment of tracheal stenosis from May 2011 to April 2016 were collected.Patients were questioned about the medical history before operation,and the airway was fully evaluated.The laryngeal mask was used for the patients with upper 1/3 tracheal stenosis and subglottic stenosis,and endotracheal intubation was applied for the other patients.Patients with severe tracheal stenosis received extracorporeal membrane oxygenation (ECMO)-assisted ventilation.The tracheal tube or laryngeal mask was removed immediately when patients were awake and spontaneous breathing and swallowing reflex recovered after operation,and oxygen was inhaled by mask.A total of 189 patients were included in this study,93 patients received endotracheal intubation,and 91 patients were ventilated via the laryngeal mask,and 5 patients underwent ECMO-assisted ventilation.Forty-four patients adopted the method of preserving spontaneous breathing,and the other 145 patients did not.There were 165 patients in whom the endotracheal tube or laryngeal mask was removed immediately after they were awake,and the remaining 24 cases were sent to the intensive care unit with the endotracheal tube.For the patients with tracheal stenosis,preoperative interview and airway assessment are especially important,and appropriate airway management strategies should be developed;vital signs should be closely observed during operation,and the proper ventilation mode is selected,and ECMO-assisted ventilation could be considered for the patients with severe tracheal stenosis;the timing of removal of the endotracheal tube or laryngeal mask should be seized after operation.
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Thirty-six spontaneous intracranial hypotension patients with multiple-level leakages of cerebrospinal fluid were enrolled in the study.After 30 patients received targeted epidural blood intervention for 2 times and 6 patients received targeted epidural blood intervention for 3 times,the clinical symptoms were completely relieved.During injection of autologous blood,pain at the puncture site occurred in 24 cases,radiating pain in upper extremities in 5 cases,numbness in the upper extremity in 9 cases,radiating pain in lower extremities in 6 cases,numbness in lower extremities in 7 cases,headache in 4 cases,dizziness in 3 cases and transient bradycardia in 3 cases.Most of these symptoms were self-relieved after the end of injection or after slowing the injection rate,and some were self-relieved hours later.Neck stiffness was found in 2 cases and self-relived within a few hours or days after operation,and no severe nervous systemrelated complications were found.Recurrence happened in 2 cases at 3 months after the end of treatment,and the symptoms were self-relieved after receiving targeted epidural blood intervention for a second time.The patients were followed up for 15-36 months,and no serious nervous system-related complications were observed.Therefore,targeted epidural blood intervention is safe and effective when used to treat spontaneous intracranial hypotension caused by multiple-level leakages of cerebrospinal fluid in patients.
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Objective To evaluate the efficacy of pleth variability index (PVI) in guiding volume therapy in the patients undergoing thoracoscopic surgery.Methods Forty patients of both sexes, aged 18-64 yr, with body mass index＜35 kg/m2 , of American Society of Anesthesiologists physical status I or Ⅱ ,scheduled for elective thoracoscopic lobectomy, were randomized into 2 groups (n =20 each) : control group (group C) and PVI group.During induction of anesthesia, multiple electrolyte solution was infused rapidly as a bolus of 250 ml, followed by a 2-8 ml · kg-1 · h-1 infusion.In group C, 6％ hydroxyethyl starch 130/0.4 and sodium chloride injection 50 ml and metaraminol 0.5 mg were administered to maintain mean arterial pressure ≥ 65 mmHg.In group PVI, 6％ hydroxyethyl starch 130/0.4 and sodium chloride injection 50 ml and metaraminol 0.5 mg were administered to maintain PVI ≤ 13％ and mean arterial pressure ≥ 65 mmHg.Immediately after the beginning of one-lung ventilation (T1) , immediately after the termination of one-lung ventilation (T2) and at 1 h after surgery (T3) , arterial oxygen saturation were recorded, and arterial blood samples were collected for blood gas analysis, and for determination of lactic acid concentrations.The blood creatinine concentrations were measured at 24 h before and after surgery.The fulid balance was recorded.Results The amount of colloid solution infused, total volume of fluid infused and lactic acid concentrations at T3were significantly lower in group C than in group PVI.There were no significant differences in the amount of crystralloid solution infused, urine volume, blood loss, arterial oxygen saturation at each time point, and blood creatinine concentrations at 24 h before and after surgery between the two groups.Conclusion PVI-guided volume therapy can not only maintain adequate blood volume and tissue perfusion, but also reduce the amount of fluid infused, and is helpful in mitigating lung water overload when used for the patients undergoing thoracoscopic surgery.
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Objective To identify the risk factors for postoperative reintubation in patients undergoing general anesthesia.Methods Forty-six thousand five hundred and seven patients,aged 18-83 yr,requiring reintubation after planned extubation in the postanesthesia care unit (PACU) of our hospital from January 2010 to December 2012,served as reintubation group.Patients in a 1∶5 ratio,aged 18-83 yr,admitted to the PACU of our hospital from January 2010 to December 2012,with successful extubation,served as control group.The general data of patients and operation-related factors including type of operation (emergency operation/elective operation),operative sites (head and neck,airway,within the chest,upper abdomen,lower abdomen,other sites) and operation time and anesthesia-related factors including requirement for opioids and muscle relaxants within 30 min before operation,and for neostigmine at the end of operation were recorded.The risk factors of which P values were less than 0.05 would enter the logistic regression analysis to stratify reintubation-related risk factors.Results Thirty-two patients were reintubated after operation and the incidence was 0.069％.There was significant difference in age,gender,body mass index,ASA physical status,preoperative SpO2,complication with upper respiratory infections within 2 weeks before operation,chronic obstructive pulmonary disease (COPD),or systemic inflammatory response syndrome (SIRS) and hypoproteinemia,operative sites and operation time between the two groups (P ＜ 0.05 or 0.01).The logistic regression analysis showed that ASA physical status ≥ Ⅲ,complication with COPD or SIRS,and thoracic surgery were closely correlated with postoperative reintubation in patients undergoing general anesthesia.Conclusion ASA physical status ≥ Ⅲ,complication with COPD or SIRS,and thoracic surgery are risk factors for postoperative reintubation in patients undergoing general anesthesia.
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Objective To investigate the effect of head-up tilt on cerebral blood flow velocity during general anesthesia in patients with diabetic neuropathy.Methods Sixty ASA Ⅰ - Ⅱ patients of both sexes aged 40-60 yr weighing 52-70 kg undergoing general anesthesia were divided into 3 groups according to diseases complicated with diabetes situation ( n =20 each):group Ⅰ normal control the patients did not have diabetes mellitus; group Ⅱ type Ⅱ diabetics without neuropathy and group Ⅲ Ⅱ diabetics with neuropathy.Anesthesia was induced with propofol 2 mg/kg,fentanyl 3 μg/kg and vecuronium 0.1 mg/kg and maintained with 1％ sevoflurane.The patients were intubated and mechanically ventilated.PErCO2 was maintained at 35-45 mm Hg.Transcranial doppler (TCD)was used to measure middle cerebral artery blood flow velocity (MBFV).MAP and MBFV were measured and recorded in supine position (baseline) and at 1.5,3.5 and 5.5 min of 45° head-up tilt.Results The 3 groups were comparable with respect to age,body weight,height and M/F sex ratio.MAP and MBFV significantly decreased at 45° head-up tilt as compared with the baseline in all the 3 groups.There was no significant difference in MAP and MBFV among the 3 groups.Conclusion Cerebral blood flow velocity decreases when the patients are tilted 45° head-up during general anesthesia in both diabetics with and without neuropathy,but there is no significant difference between the 2 groups.
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Objective To investigate the effect of intravenous lidocaine on the efficacy of sevoflurane combined with remifentanil for tracheal intubation without neuromuscular relaxants. Methods Seventy-five ASA Ⅰor Ⅱ patients, aged 18-64 yr, scheduled for elective surgery, needing tracheal intubation under general anesthesia, were randomly divided into 3 groups ( n = 25 each) : sevoflurane + remifentanil 1 μg/kg group (group A) ;sevoflurane + remifentanil 1 μg/kg + lidocaine 1 mg/kg group (group B); sevoflurane + remifentanil 2 μg/kg group (group C) . Two minutes after inhalation of 8% sevoflurane for anesthesia induction, remifentanil 1 μg/kg, remifentanil 1 μg/kg + lidocaine 1 mg/kg, and remifentanil 2 μg/kg were injected intravenously in groups A, B and C respectively. Tracheal intubation was performed after completion of remifentanil injection. Intubating conditions were assessed based on ease of laryngoscopy, position of vocal cords, activity of vocal cords, degree of coughing and limb movement. MAP and HR were also recorded before induction and immediately before and after intubation. Results Tracheal intubations were successful in all patients. The satisfactory rates of coughing were significantly higher in groups B and C, and MAP and HR were significantly lower immediately before and after intubation in group C than in group A ( P ＜ 0.05) . The satisfactory rate of coughing was significantly higher in group B than in group C ( P ＜ 0.05) . During intubation, 3 cases developed hypotension and 1 case bradycardia in group C. Conclusion When sevoflurane combined with remifentanil is used for tracheal intubation without neuromuscular relaxants, intravenous lidocaine 1 mg/kg can not only improve intubating conditions, but also decrease the consumption of remifentanil.
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Objective To investigate the effect of stroke volume variability (SVV)-guided intraoperative fluid restriction on liver and renal function in patients undergoing hepatic lobectomy. Methods Forty ASA Ⅰ - Ⅲpatients of both sexes aged 33-60 yr weighing 52-80 kg undergoing elective hepatic lobectomy were randomly divided into 2 groups ( n = 20 each): group A routine fluid administration and group B restricted fluid administration.Anesthesia was induced with iv lidocaine, fentanyl and TCI of propofol (target plasma concentration 3-4 μg/ml).Tracheal intubation was facilitated with cisatracurium 0.2 mg/kg. The patients were mechanically ventilated.PETCO2 was maintained at 32-38 mm Hg. Anesthesia was maintained with 1%-2% sevoflurane inhalation and intermittent iv boluses of fentanyl and cisatracurium. BIS value was maintained at 40-60. Radial artery was cannulated and connected to continuous cardiac output monitor (Edwards Lifeaciences, USA). ECG, MAP, CVP and SVVtained at 5-7 in group A and 11-13 in group B. Blood loss, urine output and the amount of RBC and plasma infused during operation were recorded. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total protein (TP), albumin (ALB), total bilirubin ( TBIL), direct bilirubin ( DBIL), blood urea nitrogen (BUN), creatinine (Cr) and lactate and Hb, Hct were measured the day before surgery (baseline) and at day 1,3 and 5 after operation. Results The hemodynamic parameters were maintained within normal limits during operation in both groups. The blood loss, the amount of RBC and plasma infused and urine output during operation were significantly less, while the serum TP and ALB concentrations were higher on the 1st postoperative day in group B than in group A. The serum levels of ALT, AST, TBIL and DBIL were significantly increased and serum concentrations of TP and ALB and Hb,Hct decreased, but there was no significant change in serum BUN and Cr concentrations and lactate after operation as compared with the baseline values before operation in both groups. There were no significant differences in serum levels of ALT, AST, TBIL, DBIL, BUN, Cr, lactate,Hb and Hct after operation between the 2 groups. Conclusion SVV can guide effectively intraoperative fluid restriction in patients undergoing hepatic lobectomy.
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Objective To investigate the effect of different target plasma concentrations (Cp) of remifentanil on sedative effect of propofol. Methods Eighty adult ASA Ⅰ or Ⅱ patients aged 18-60 yr undergoing elective laparoscopic cholecystectomy were randomly assigned into 4 groups (n = 20 each). Anesthesia was induced with TCI of remifentanil (Cp = 2, 4 and 8 ng/ml in group Ⅱ-Ⅳ respectively) and propofol TCI (the initial Cp of propofol was 2 μg/ml in the 4 groups). Then the Cp of propofol increased by 0.5 μg/ml every 1 min until BIS value decreased to 50. BIS value and the Cp of propofol were recorded as the patient lost consciousness.The Cp and consumption of propofol were recorded when BIS value decreased to 50. Results BIS value was significantly increased, while the Cp of propofol was significantly decreased as the patient lost consciousness, and the Cp and consumption of propofol were significantly decreased when BIS value decreased to 50 in group Ⅲ - Ⅳ compared with group Ⅰ (P ＜ 0.05). Conclusion Remifentanil 4 ng/ml is the suitable Cp for anesthesia when combined with propofol.
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Objective To evaluate the effect of small dose ketamine on the efficacy of intravenous PCA (POA) with sufentanil after intra-abdominal surgery in aged patients.Methods Sixty ASA Ⅰ orⅡpatienm aged 65-82 yr undergoing elective intra-abdominal surgery under general anesthesia were randomized into 3 groups (n=20 each)according to the composition of PCIA solution:group I sufentanil 200 μg in 200 ml of noilnal saline (group S);group μ sufentanil 200μh+ketmine 100 mg in NS 200 ml(group K1)and group Ⅲ sufentannil 200 μg+ketmine 200 mg in NS 200 ml(group K2).A loading dose of 5 ml wag given at the end of operation.The PCIA setting was as follows:backgound infusion 1 ml/h,bolus dose 2 ml,lockout interval 5 min and 4-hour maximum dose 30 m1.If VAS score(0=no pain,10=womt pain)was≥7,pethidine 25 mg was given iv.The total amount of pethidine given within 48 h after operation and postoperative complications including nausea and vomiting and respiratory depression were recorded.Results Small dose ketamine added to the PCIA solution can significantly reduce the amount of pethidine administered after operation in a dose-dependent manner.Conclusion Small dose ketamine can improve the efficacy of PCIA with sufentanil after intra-abdominal surgery in aged patients with no significant adverse effect.
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Six patients(3 male,3 female)aged 33-66 yr, Course of disease 6-35 days, diagnosed with spontaneous intracranial hypotemion in Sir Run Run Shaw Hospital from November 2007 to May 2008,Were treated with on epidural autologus blood patch trader X-ray guidance. According to the results of CT myelography. the puncture site Was chosen in the 1-2 vertebral interspaees below the site of a single eerebrospinal fluid leak. For patients with multiple cerebrospinal fluid leaks.the procedure was performed at the spinal cord segment of the most severe leak. The mixture of augous blood and Omnipaque(300g/100 ml)at a ratio of 2:1 was injected into the epidural space to cover the spinal cord segment of the leaks under C-arm fluoroscopic guidance.Side effects were recorded during and after the injection of autologus blood.The treatment was repeated one week later if the former one failed.One patient was treated with epidural blood patch 3 times.and the rest 5 patients were treated with epidural blood patch 1 time.During the injeetion of autologus blood,5 patients complained of pain in the purtclure site,2 experienced pain radiating to the upper limb,2 felt,numbness in the right leg and all of these syndromes could be self-relieved.No side effects were observed after the injection of autologus blood.All the patients were Cured and no recurrence was observed during a 2-6 month follow-up.
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Objective To observe the effects of pretreatment in rats with prostaglandin E1 on expression of kidney caspase-3, and TNF-α mRNA and iNOS mRNA after hemorrhagic shock and resuscitation(HSR). Method Totally 32 male S-D rots were randomly divided into four groups: group A (normal group, n=8), rats didn't receive any treatment; group B(sham, n=8), rats were pretreated with normal saline and underwent all experi-mentation procedures except bleeding; group C (HSR, n=8): rats were anesthetized with intraperitoneal sodium pentobarbital(30 mg/kg) and then subjected to hemorrhagic shock followed by resuscitation; group D (lipo-PGEl +HSR, n=8): rats were pretreated with lipo-PGEl one hour before HSR. The expressions of TNF-α mRNA and iNOS mRNA was measured by Northern blotting analysis and the expression of caspase-3 at 6 hours was determined by immunohistochemistry after HSR. Data were analyzed by ANOVA (SNK-q test), and P<0.05 was considered as significantly different. Results There were no differences in TNF-α mRNA and iNOS mRNA between normal group and sham group [(0.029±0.002) vs. (0.030±0.003),(0.029±0.002) vs. (0.030±0.003), P> 0.05]. HSR led to overexpression of caspase-3. The expression of kidney TNF-α mRNA and iNOS mRNA also increased in HSR group, compared with normal group [(0.651±0.028) vs. (0.030±0.003), (0.524±0.022) vs. (0.026±0.003), P<0.05] and sham group[(0.651±0.028) vs. (0.029±0.002), (0.524±0.022) vs. (0.025±0.003), P<0.05]. Pre-treatment with lipo-PGEl markedly reduced the expression of Caspase-3, which was consitent with decrease in expressions of TNF-α mRNA and iNOS mRNA 6 hours after HSR[(0.250± 0.019) vs. (0.651±0.028), (0.203±0.020) vs. (0.524±0.022), P<0.050]. Conclusions Lipo-PGEl could reduce the expressions of kidney Caspase-3 after HSR. The mechanisms might be attributed to inhibiting the expression of TNF-α mRNA and iNOS mRNA.
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Objective To investigate pharmacodynamics of propofol for smooth exchange of tracheal tube for u laryngeal mask airway after surgery in elderly patients. Methods Twenty elderly patients, ASA Ⅰ or Ⅱ, aged 65-70 yr, scheduled for elective laparoscopic cholecystectomy were enrolled in this study. Anesthesia was induced with propofol, atracurium and remifentanil. The patients were mechanically ventilated after the trachea was intubated. Anesthesia was maintained with propofol combined with remifentanil. After surgery, a predetermined propofol concentration was achieved and a steady state maintained for at least 5 min. The target plasma concentration of propofol at which the laryngeal mask airway following tracheal extubation was attempted was determined by Dixon's up-and-down method with 0.5 μg/ml as the step size, The probit model was used to calculate the EC_(50) and EC_(95) and 95% confidence interval (95% CI) of propofol for inhibiting patient's response induced by smooth excharge of tracheal tube. Results The EC50 of propofol to achieve laryngeal mask airway following tracheal extubation was 2.79 μg/ml (95% CI 2.44-3.04 μg/ml) and EC_(50) 3.61 μg/ml (95% CI 3.27-4.78 μg/ml). Conclusion The target plasma concentration of propofol for laryngeal mask airway following tracheal extubation in elderly patients is 3.61 μg/ml.
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ObjectiveTo evaluate the effects of ketamine on the minimum alveolar concentration of scvoflurane for blunting adrenergic responses to skin incision (MAC_(BAR)) in patients undergoing abdominal surgery. Methods Forty-four ASA Ⅰ or Ⅱ patients aged 30-60 yr undergoing elective abdominal surgery were randomly divided into 2 groups (n=22 each) : control group (group K_0) and ketamine group (group K_1). Anesthesia was induced with propofol 2 mg/kg and fentanyl 3 μg/kg. Tracheal intubation was facilitated with cisatracurium 0.15 mg/kg. The patients were mechanically ventilated. Anesthesia was maintained with sevoflurane inhalation (the initial end-tidal concentration 3% ). Ketamine at 14 μg·kg~(-1)·min~(-1) was infused at the same time in group K,. The patients' response to skin incision was described as positive if MAP or HR increased by≥15%. If the response was positive, the end-tidal concentration of sevoflurane for the next patient was increased by 0.5%, while if negative, decreased by 0.5% . ResultsThe MAC_(BAR) of scvoflurane was 3.25 % (95 % confidence interval 3.05%-3.45%) in group K_0, and 2.20% (95% confidence interval 1.96%-2.44%) in group K~1. The MAC_(BAR) of sevoflurane was significantly lower in group K~1 than in group K_0 (P<0.05). Conclusion Ketamine infusion at 14 μg·kg~(-1)·min~(-1) can reduce MAC_(BAR) of sevoflurane and enhance the inhibitory effect of sevoflurane on the stress response.
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Objective: To assess the value of transesophageal echocardiography (TEE) during cardiac surgery. Method: Intraoperative TEE was performed to record left atrial gas during and for 15 minutes after bypass in 131 pa tients and to evaluate mitral regurgitation after mitral replacement in 38 patients. The degrees of the gas and mitral re gurgitation by TEE was visually quantified on a 4-point scale(0 to 3) and a 5-point scale(0 to 4), respectively. Result: The left atrial gas was detected in 115(88%)patients, two of which with positive echograms(gas grade=3). There was significant improvement in the mean mitral regurgitation grade after mitral replacement (3.4?0.6 to 0.5?0.2, P