切换至 "中华医学电子期刊资源库"

第五届中国出版政府奖音像电子网络出版物奖提名奖

中国科技核心期刊

中国科学引文数据库(CSCD)来源期刊

中华重症医学电子杂志 ›› 2021, Vol. 07 ›› Issue (03): 219 -227. doi: 10.3877/cma.j.issn.2096-1537.2021.03.005

临床研究 上一篇    下一篇

经皮扩张气管切开术标准操作流程在神经重症患者中的应用
李宏亮 1, 田野 1, 马燕娟 1, 朱宁 1, 苏芮 1, 石广志 1, 周建新 1 , ( )   
  1. 1. 100070 北京,首都医科大学附属北京天坛医院重症医学科
  • 收稿日期:2021-04-03 出版日期:2021-08-28
  • 通信作者: 周建新
  • 基金资助:
    天坛医院引进人才启动基金(RCYJ20202022-2020)

Application of standard operating procedure of percutaneous dilatation tracheotomy in patients with severe neuropathy

Hongliang Li 1, Ye Tian 1, Yanjuan Ma 1, Ning Zhu 1, Rui Su 1, Guangzhi Shi 1, Jianxin Zhou 1 , ( )   

  1. 1. Department of Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
  • Received:2021-04-03 Published:2021-08-28
  • Corresponding author: Jianxin Zhou
目的

探讨经皮扩张气管切开术(PDT)的标准操作流程(SOP)在神经重症患者中的应用效果。

方法

回顾性收集2019年9月至2021年3月在首都医科大学附属北京天坛医院ICU一病区行超声定位联合纤维支气管镜引导下PDT的56例患者的病例资料,并以SOP实施时间为节点将其分为SOP实施前组(19例,2019年9月至2020年2月)和SOP实施后组(37例,2020年3月至2021年3月),比较2组患者的基线资料[年龄、性别、体质量指数(BMI)、主要诊断、脑肿瘤比例、脑血管病比例、人工气道类型、人工气道留置时间、格拉斯哥昏迷评分(GCS)、总住院时间]、镇静镇痛药物使用时间、手术操作时间、机械通气时间、生命体征参数。

结果

2组患者的基线资料及手术难度无明显差异,但SOP的实施显著缩短了镇静镇痛药物使用时间[25(24,28)min vs 32(28,33)min,P<0.001],手术操作时间[7(6,8)min vs 10(8,14)min,P<0.001]和机械通气时间[40(40,50)min vs 70(60,80)min,P<0.001],不良事件的发生率,如心动过速(0 vs 21.1%,P=0.004)、低血压(0 vs 26.3%,P=0.001)、高血压(0 vs 21.1%,P=0.004)、低氧血症(0 vs 15.8%,P=0.013)也显著降低,差异有统计学意义。

结论

针对神经重症患者进行超声定位联合纤维支气管镜引导下PDT,应用SOP有助于缩短麻醉及手术操作时间,降低心率、血压大幅波动及低氧血症的发生率,进而有可能避免加重继发性脑缺血缺氧风险。

Objective

To explore the application of standard operating procedure of percutaneous dilatation tracheotomy in patients with severe neuropathy.

Methods

Medical records of 56 patients who underwent ultrasound localization combined with fiberoptic bronchoscope-guided PDT in ICU 1 of Beijing Tiantan Hospital, Capital Medical University from September 2019 to March 2021 were retrospectively collected, and they were divided into the pre-SOP implementation group (19 cases, September 2019 to February 2020) and the post-SOP implementation group (37 cases, March 2020 to March 2021). Two groups patients with baseline data (age, sex, body mass index), the proportions of the main diagnosis, brain tumors, cerebrovascular disease, the types of artificial airway, artificial airway indwelling time, Glasgow coma scale (GCS), total length of hospital stay, calm analgesic drug use time, operation time, mechanical ventilation, vital signs parameters were compared.

Results

There were no significant differences in baseline data and surgical difficulty between the two groups, but the implementation of SOP significantly shortened the time of sedative and analgesic drugs [25 (24, 28) min vs 32 (28, 33) min, P<0.001], and the operation time [7 (6, 8) min vs 10 (8, 14) min, P<0.001] and duration of mechanical ventilation [40 (40, 50) min vs 70 (60, 80) min, P<0.001], the incidence of adverse events, such as tachycardia (0 vs 21.1%, P=0.004), hypotension (0 vs 26.3%, P=0.001), hypertension (0 vs 21.1%, P=0.004) and hypoxemia (0 vs 15.8%, P=0.013) were also significantly decreased, with statistically significant differences.

Conclusion

For PDT guided by ultrasound and fiberoptic bronchoscope in neurocritical patients, SOP can help shorten the length of anesthesia and operation, reduce the adverse events and avoid aggravating of secondary cerebral ischemia and hypoxia.

图1 患者筛选入组流程图
图2 超声定位联合纤维支气管镜引导下PDT的SOP
表1 体质量与镇静镇痛药物微量泵泵入速度(ml/h)对照情况
图3 经皮扩张气管切开术的神经重症患者第1、2气管软骨环间隙的超声定位图。图a为纵切面;图b为横切面
表2 2组PDT患者临床资料比较
表3 2组患者的手术相关指标比较
1
Freeman BD, Stwalley D, Lambert D, et al. High resource utilization does not affect mortality in acute respiratory failure patients managed with tracheostomy [J]. Respir Care, 2013, 58(11): 1863-1872.
2
Mehta AB, Syeda SN, Bajpayee L, et al. Trends in Tracheostomy for Mechanically Ventilated Patients in the United States, 1993-2012 [J]. Am J Respir Crit Care Med, 2015, 192(4): 446-454.
3
Trouillet JL, Collange O, Belafia F, et al. Tracheotomy in the intensive care unit: guidelines from a French expert panel [J]. Ann Intensive Care, 2018, 8(1): 37.
4
Bosel J. Use and timing of tracheostomy after severe stroke [J]. Stroke, 2017, 48(9): 2638-2643.
5
Kurtz P, Fitts V, Sumer Z, et al. How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? [J]. Neurocrit Care, 2011, 15(3): 477-480.
6
Kuechler JN, Abusamha A, Ziemann S, et al. Impact of percutaneous dilatational tracheostomy in brain injured patients [J]. Clin Neurol Neurosurg, 2015, 137: 137-141.
7
Sherren PB, Tricklebank S, Glover G. Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill [J]. Scand J Trauma Resusc Emerg Med, 2014, 22: 41.
8
Wurmb TE, Fruhwald P, Knuepffer J, et al. Application of standard operating procedures accelerates the process of trauma care in patients with multiple injuries [J]. Eur J Emerg Med, 2008, 15(6): 311-317.
9
Alansari M, Alotair H, Al Aseri Z, et al. Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review [J]. Crit Care (London, England) 2015, 19: 229.
10
Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report [J]. Intensive Care Med, 2002, 28(3): 299-303.
11
Mussa CC, Gomaa D, Rowley DD, et al. AARC Clinical Practice Guideline: management of adult patients with tracheostomy in the acute care setting [J]. Respir Care, 2021, 66(1): 156-169.
12
Costa R, Navalesi P, Cammarota G, et al. Remifentanil effects on respiratory drive and timing during pressure support ventilation and neurally adjusted ventilatory assist [J]. Respir Physiol Neurobiol, 2017, 244: 10-16.
13
Morel DR, Forster A, Bachmann M, et al. Effect of intravenous midazolam on breathing pattern and chest wall mechanics in human [J]. J Appl Physiol Respir Environ Exerc Physiol, 1984, 57(4): 1104-1110.
[1] 徐桂兴, 刘华, 于萍, 郑东华. 急性神经重症患者7天内进展为脑死亡的预测评分[J]. 中华神经创伤外科电子杂志, 2020, 06(02): 81-85.
[2] 张丽娜, 艾宇航. 重症神经:脑与脑外器官[J]. 中华重症医学电子杂志, 2018, 04(03): 226-230.
[3] 于强, 黄好峰, 李习珍, 胡海成, 李春, 张成, 韩超, 王如海, 曹祥记. 深静脉穿刺包行经皮气管切开术在神经重症患者中的应用效果[J]. 中华脑科疾病与康复杂志(电子版), 2019, 09(05): 281-284.
阅读次数
全文


摘要