Editor's Note】 【2008 American Society of Anesthesiologists (ASA 2008) on October 18-22 meeting in Orlando. We invite Beijing Xuanwu Hospital, Capital Medical University, Professor Wang Tianlong, Beijing Chaoyang Hospital, Capital Medical University, Professor Yue Yun , Foshan First People's Hospital, Professor Deng Shuoceng as guest editor for a summary of some of the content and p. E1 ~ E4 version.
ASA 2008 an impressive new knowledge and visit hot topic of the Chinese Medical Association anesthesia mm credits will be Chairman Professor Wu Xinmin
attended by representatives of the world 17000 ASA 2008, which includes more than 150 mainland Chinese anesthesiologists. on the ASA 2008's hot topics and new knowledge, to participate in this interview with our reporter Meeting of the Chinese Medical Association on Narcotic credits Professor Wu Xinmin, director members.
introduce new knowledge emerging
Ng, ASA Annual Meeting each year will introduce some of the latest knowledge and progress, this year, causing concern of anesthesiologists new knowledge and progress are the following aspects.
dexmedetomidine given to expand the indications given
dexmedetomidine is an a2-adrenergic receptor agonists, but also has sedative and analgesic effects, particularly is that it can maintain the patient's natural non-rapid eye movement sleep (NREM) state, and has analgesic, anxiolytic effects, no significant respiratory depression, sedation sleep wake up when the system is not inhibited.
dextromethorphan asked Amy to be given approval in 1999 after intubation, mechanical ventilation for patients with ICU sedation, and use no more than 24 hours. ASA 2008, reported the U.S. FDA approval in October this year, dexmedetomidine given a new indication: for inspected and non-intubated patients with preoperative, intraoperative sedation. This significantly expanded the scope of its indications.
non-invasive real-time measurement of hemoglobin in the long and complex surgical procedures, anesthesiologists require special attention hemoglobin levels in patients to determine whether blood transfusion, to ensure the normal amount of oxygen transport, tissue, organ oxygenation is normal. current hemoglobin level of blood samples to be taken first, and then sent to the laboratory to wait for test results, can not reflect the real state of hemoglobin. < br> ASA 2008 can be displayed on a non-invasive determination of hemoglobin in the instrument, the instrument through the patient's hemoglobin level, tissue perfusion index with pulse oximetry can be displayed together, which is to improve surgical safety and effectiveness of treatment is important.
come
platelet function analyzer coagulation platelet count is an important indicator reflecting, but there were clinically normal platelet count, but abnormal platelet function abnormal bleeding caused widespread phenomenon, so platelet function testing is important.
in this conference, some scholars have described the platelet function analyzer. The instrument makes a reality of platelet function tests, can determine the status of platelet function in patients with surgery and stent placement in particular setting into the stent can disable the anti-platelet drugs in patients, can provide an objective basis for such an operation has important clinical significance.
non-invasive determination of cardiac output is possible
Some scholars report, the use of four common electrodes, According to the rate of blood flow changes in patients to determine cardiac output. Although the reliability of the technology needs further validation, but this makes the real-time, non-invasively measuring cardiac output is possible.
controllability of the new muscle relaxant Some scholars have reported strong
2 new controllable benzyl isoquinoline muscle relaxants: gantacurium and CW002, both rapid onset of muscle relaxants (<60 seconds), gantacurium clinical role time of 15 minutes, CW002 35 points, but intravenous injection of cysteine 20 ~ 50 mg / kg at any time following suspension gantacurium and CW002 muscle relaxant effect, this new muscle relaxant is expected to become a good muscle relaxant properties clinical widely used muscle relaxants.
hot topic of brilliant
Ng introduced, ASA 2008, University of California announced the grant (UCSF) Miller (Miller), Professor (his book, become a controversial issue the focus of attention. ASA 2008 causing a hot topic experts, participants include the following.
anesthetic depth control and monitoring of anesthetic depth on the topic of the conference is to discuss and learn one of the hot. for control of depth of anesthesia, most scholars do not think too deep anesthesia, as this can increase mortality and morbidity, but not too light anesthesia awareness during surgery occurs. on the depth of anesthesia monitoring, using bispectral index (BIS) monitoring or monitoring by EEG parameters, or use other technologies? present we do not form a consensus, but BIS monitoring may be more recognized experts.
anesthetics
organ protection and neurotoxicity of anesthetics, especially anesthetics in organ protection and neurotoxicity not form a consensus, but this topic was of particular concern to experts, some scholars reported on their experimental results . Some scholars reported that sevoflurane on myocardial protection with a clear, isoflurane, and sevoflurane on cerebral ischemia-reperfusion has a protective effect. There is also a study showed that isoflurane increases the amount of amyloid protein in brain, and promote Alzheimer's disease (AD) occur. isoflurane role in development of the brain, the brain can promote a large number of neuronal apoptosis. The clinical significance of these findings remains to be further clarified.
difficult airway management difficult airway management is the eternal theme of clinical anesthesia. ASA 2008 in terms of timing, or to discuss arrangements for a variety of related topics, or everyone's enthusiasm, reflects the importance of airway management difficulties. one from Japanese scholars report on the Japanese youth in the head and neck for many years anatomical studies were followed up and found that, over time, human tracheal intubation becomes more and more difficult. Therefore, to continuously improve difficult airway management is a long term project.
ultrasound guided peripheral nerve block routine
ASA last year and the year before the annual meeting of special attention under the guidance of ultrasound peripheral nerve block, the attention the topic of this year degree of decline, which may be in the United States under the guidance of ultrasound peripheral nerve block has become the resident must master technology-related clinical practice.
case discussion of lessons learned to become an important way to
ASA 2008 to discuss high priority cases access to clinical anesthesia knowledge and skills to improve the level of the role of clinical anesthesia, a change in previous years, arrangements only 2 hours a day practice of case discussion, the General Assembly scheduled throughout the day, multi-venue of the case discussion presentations, problem-based learning discussion (problem based learning discussion) has become an anesthesiology education and experience summary of important ways. Professor Wu pointed out that, in addition to the basic knowledge and basic skills teaching and the introduction of new knowledge and new technologies, but because of the complexity and particularity of people, from a variety of cases, summed up the experience is worth learning is particularly important.
anesthesia awareness of Beijing Chaoyang Hospital, Capital Medical University, Department of Anesthesiology, Xu Liang Yue Yun
general anesthesia (GA) under anesthesia awareness occurs is very painful for patients experience, can cause severe emotional and mental problems. It is reported that up to 30% to 50% anesthesia awareness in patients with post-traumatic stress disorder (PTSD), characterized as follows: anxiety, irritability, insomnia, recurring bad dreams, depression and sense of impending doom, fear of patients physicians, hospitals, in particular, fear of future surgery, severe cases can last for months or years.
awareness during anesthesia caused by serious mental problems in recent years has developed into a social problem. American Society of Anesthesiologists (ASA) 2006 years have closed medical malpractice claims in anesthesia awareness of complaints 1.9% (129/6811 patients). Although the incidence of anesthesia awareness is not high (the United States is 0.13%) However, the United States each year over 20 million cases of general anesthesia, meaning that each year 26,000 cases of anesthesia awareness during anesthesia in patients. Our recently completed a multicenter, large sample survey found that the incidence of domestic anesthesia awareness is much higher than abroad.
on the ASA 2008, Atlanta, Emory (Emory) University School of Medicine Se Bier (Sebel) Professor anesthesia awareness for a special report, which attracted great interest from the participants.
Se Bier professor pointed out that anesthesia does not mean loss of consciousness or awareness, it could happen under general anesthesia awareness during anesthesia is not entirely clear. physicians only after the end of general anesthesia via surveys or whether there were complaints that awareness during anesthesia , which gives control and awareness in anesthesia research difficult.
He pointed out that many patients will describe the known operating room heard the sound, feeling paralyzed, pain, anxiety and fear, and helplessness and weakness. in PTSD after awareness in patients, 96% of the above situation. A double-blind study reviewed the patients awareness and control of anesthesia records, failed to find clear indications occurred awareness can be judged.
known to monitor anesthesia it? Se Bier, Professor, from the ethical considerations, not on the conditions of anesthesia awareness occurs in direct study. so most researchers hope through the brain of intraoperative electrophysiological monitoring of changes in brain function. Some researchers believe that middle latency auditory evoked potentials to monitor the occurrence of awareness, but there are researchers that the large individual differences between patients may limit its usefulness. Another scholar of the bispectral index (BIS) and the known relationship, research shows that low BIS values No patients at 60, knows. it must be stressed that these studies were stimulated in the absence of surgery carried out under the circumstances, can not ensure that the result remains true when surgical stimulation.
Se Bier, Professor, is currently asking the city brain function monitoring instruments, BIS monitoring is the only substantive clinical data to support one: There is no reliable information to prove that BIS values below 60 are still known to occur. In addition, some scholars and by reviewing the control study conducted on high-risk groups The small sample prospective randomized double-blind study found that awareness using BIS monitoring can decrease 77% to 82%. However, it still lacks large-scale prospective randomized study supported by the evidence.
Sugammadex: revolutionary muscle relaxant
antagonist drugs in this ASA annual meeting, the selective antagonist of sugammadex muscle relaxants because of its unique mechanism of action, rapid and safe reversal of neuromuscular blockade effect and the number of advantages, the focus of attention as one of the participating experts. Some experts believe that the drug may be of clinical use of muscle relaxants to bring revolutionary changes.
rapid reversal of neuromuscular blockade and safe
Canadian research reports, more comfort agent and neostigmine, Sugammadex fast (3 min) with any degree reversal of rocuronium-induced neuromuscular blockade, and no adverse reaction. Sugammadex reversal of shallow neuromuscular blockade of the best dose of 2 to 4 mg / kg, the depth of neuromuscular blockade reversal of the optimal dose is 8 ~ 12 mg / kg.
the current depth of neuromuscular blockers neuromuscular blockade can not be reversed, and there are many side effects. sugammadex reversed the evaluation researchers rocuronium induced neuromuscular block safety and efficacy of randomized controlled trials (RCT) conducted a systematic review and meta-analysis.
showed shallow neuromuscular blockade to give sugammadexg2 ~ 4 mg / kg, the depth of neuromuscular block grant sugammadexg8 ~ 12 mg / kg, can shorten the recovery time of patients (mean l3 min).
have two RCT compared sugammadex and neostigmine in the antagonistic effect, the results show that given sugammadex 2 mg / kg reversal of shallow neuromuscular blockade than the new Si's crisp 16 min (P <0.0001), given sugammadex 4 mg / kg reversal of neuromuscular blockade than the depth of the bright new Sri Lanka 47 min (P <0.0001).
all studies not observed adverse events related to sugammadex.
role of American scholars from the report of obesity, obesity does not affect the sugammadex reversal of vecuronium or rocuronium induced neuromuscular blockade effect. This in obese disease and related comorbidities (including cardiovascular, respiratory and metabolic diseases, etc.) increasing the incidence of today, seems interesting.
researchers Sugammadex related Ⅱ and Ⅲ clinical trial data collection, more obese Patients with non-obese patients receiving sugammadex reversal of vecuronium or rocuronium induced neuromuscular blockade effect. The results showed that the obese group and non-obese group, the average similar to the rapid recovery time, recovery time, or there are no significant differences.
more to look forward to
addition to the above advantages of advantages, the researchers also reported sugammadex few research reports, sugammadex reversed not only the depth of neuromuscular blockade, but also rapid recovery of spontaneous breathing functions. In the function. On the contrary, sugammadex through the selective inclusion of vecuronium and rocuronium to failure, once the recovery of muscle function is sugammadex, respiratory function is also recovered. This shows that, sugammadex perhaps ventilation can not be significantly reduce the large muscles of the upper airway opening muscle activity and tidal volume, and given sugammadex does not affect genioglossus muscle activity and normal breathing. Therefore, after the disappearance of neuromuscular blockade using neostigmine can cause part of the airway obstruction, the use of sugammadex no such danger.
Experts
Sugammadex parcel of vecuronium by rocuronium and reverse the muscle relaxant effects of molecules, it has other muscle relaxant antagonists are not available characteristics: that can be given muscle relaxants in the play quickly, antagonism. Sugammadex especially for minor surgery a short time, but also as Specialty is recognized as the high-risk profession. The World Health Organization (WHO) statistics for anesthesia-related mortality in developed countries in recent years, an average of ~ 1:300000 1:100000, 1:5000 ~ 1:10000 developing countries, some backward countries is even higher. a narcotic by the French Ministry of Health, the National Survey of major complications (anesthesia cases included 198,103 cases) found that postoperative respiratory depression (accounting for 61% of deaths) is a narcotic-related deaths in the survey the most important reasons, not all of the difficult intubation guess. Thus, the role of postoperative residual neuromuscular blockade, should pay close attention to risk factors.
new neuromuscular antagonism to the narcotic drugs listed Sugammadex physicians a new choice. a number of studies have shown, Sugammadex can improve the postoperative recovery of muscle relaxation, in improving the safety of general anesthesia has a positive meaning.
(Beijing Union Medical College Hospital professor of anesthesia Keluoailun)
advanced cardiac life support guidelines child recovery of the Commission in 2008 updated children, cardiopulmonary arrest is not a common phenomenon, in most cases, the cause is respiratory distress and failure, if not treated timely and correct way, lead to cardiac arrest. and adult cardiac arrest may be the primary event, caused by the arrhythmia, and rapid deterioration of the non-perfusion.
outside the hospital and hospital epidemiology
infants and children, common causes of cardiac arrest following table,
hospital trauma hospital with respiratory failure < br> sudden infant death syndrome, sepsis
(SIDS)
food poisoning, drowning, poisoning or excessive metabolic disorders
suffocation or aspiration status asthmaticus
arrhythmias Viral bronchitis
infants and children hospital cardiac arrest prognosis is poor, the survival rate to discharge less than 9%. The hospital cardiac arrest, more than 60% of the patients by cardiopulmonary resuscitation (CPR) can be successful restoration of spontaneous circulation, However, the survival rate to discharge about 15% or less.
respiratory failure in infants and children
CPR key to the success of early detection and timely correction of respiratory distress or shock. respiratory distress can be manifested as shortness of breath, breathing acting to increase, nose incitement, ribs, ribs or the sternum under the depression and wheeze or snore.
respiratory distress in children is not good signs of sleepiness, suggesting that respiratory failure to occur, requiring immediate treatment. Other signs of poor prognosis include improper or lower respiratory rate, reduced unilateral or bilateral breath sounds and skin pale or cyanotic. Without treatment, children with respiratory failure occurs (and possible hypoventilation apnea).
shock
shock of blood and oxygen supply can not meet the metabolic needs. decompensation in the early stages of shock, heart rate and peripheral vasoconstriction would be important to maintain blood pressure and organ perfusion in critical normal level. When the body's compensatory capacity is insufficient, decompensated shock will lead to rapid deterioration, manifested as low blood pressure and central circulation pump function of weakness.
the normal vital signs vary with age, it is easy to mistake compensated or decompensated shock signs. infant and children, bradycardia or cardiac arrest shock showed more heart rate was significantly lower than expected (usually less than 100 beats / min), accompanied by other signs of circulatory failure.
airway airway problems issues children, the main reason for respiratory distress and failure. smaller babies and more nasal breathing, when attracted by the nose would be a serious risk of infant discomfort. In anatomy, the baby is relatively large tongue and occiput, throat higher therefore prone to airway obstruction. neck or place the appropriate positioning can alleviate suffering by the tone of infants Road obvious airway obstruction, the airway should be used when other appropriate assistive devices, including the laryngeal mask and tracheal intubation.
oxygen < br> resuscitation guidelines recommend using 100% oxygen, but are uncertain of the recommended class, 100% oxygen inhalation may have side effects. These effects include increased cerebral vascular resistance, lung, heart and other tissues of the oxidative stress and atelectasis . PALS resuscitation guidelines recommend the use of lower concentrations of oxygen to avoid hyperoxia on pulmonary and systemic adverse effects. and once the recovery of patients is required to reduce the oxygen concentration to be sufficient to maintain the appropriate level of systemic oxygen delivery.
ventilation
manual ventilation during the recovery period often leads to significant over-ventilation. infant lung over-expansion will lead to barotrauma, even pneumothorax, which affects adequate venous return and cardiac output. In addition, hypocapnia will increase the brain hypoperfusion. Therefore, the need to be careful to ensure proper ventilation of lung ventilation, while avoiding hyperventilation.
cuff cuff catheter with no catheter
Pediatrics often use high volume low pressure cuff endotracheal tube should be noted Use appropriate size endotracheal tube, and note under the door of the damage to the epiglottis to minimize sound. catheters is estimated to be about the size, no cuff catheter (age / 4) +4, a cuff catheter (age / 4) +3 . even in emergency situations, should also be chest auscultation, or by end-tidal carbon dioxide monitoring catheter position confirmed.
vascular access
PALS guidelines emphasize the need for the timely establishment of vascular access, can not be established within 90 seconds if the peripheral pathway, suggested placing intramedullary infusion needle (intraosseous needle). All ambulances and operating room personnel should use the intramedullary infusion needle. experienced physicians should be able to build a more secure, central access, but this may affect the cardiac arrest When the effectiveness of the implementation of chest compressions. If no IV access or intramedullary infusion needle, the majority of rescue medication can be given through the tube means, but need more than vein or intramedullary infusion needle means higher doses.
cardiac arrest < br> pulseless cardiac arrest require ventilatory support coupled with effective chest compressions. effective recovery and return of spontaneous circulation may be that the start time and the appropriate chest compressions. cardioplegic recovery objective is to maintain adequate diastolic longer force to meet the coronary perfusion. Therefore, the recommended program of recovery of children and adults like this: when the perpetrators of only a single recovery for each chest compressions 30 times 2 times after the artificial respiration, the two perpetrators of recovery for each 15 underwent 2 manual press breathing, and the press should give full range (up to chest anteroposterior diameter of 1 / 3 to 1 / 2), to ensure adequate chest recoil.
infusion and drug infusion and drug dose children to be based on the child's weight. hospitalized children should be marked in the bed next to the recently measured body weight, and the dose is calculated, an emergency. If the body weight in children is unknown, tape measure the length of the budget-based doses of effective and economically feasible.
recovery should be used Zhang Jing and other body fluids, not recommended for routine use of sugary liquid. because the baby is very easy to hypoglycemia, blood sugar levels should be detected early recovery.
similar adult drug recovery. pulseless cardiac arrest in the past recommended including the use of the dose including some undesirable consequences, such as hypertension, ventricular ectopic, myocardial necrosis and cardiac dysfunction in a long time.
defibrillation of children recovering cardiac arrest as the majority of children the consequences of respiratory events, children The most common rhythm disorder is a cardiac arrest and bradycardia widened QRS wave. children may result from sudden cardiac arrest in ventricular fibrillation or electromechanical dissociation. For children with ventricular fibrillation, defibrillation is a life-saving measures, the survival probability close to 20%. hospital cardiac arrest from 5% of children 15% caused by the ventricular fibrillation, for these children, especially sudden cardiac arrest witnesses, rapid defibrillation available and functional recovery in survival. because of the automatic external defibrillators, significant benefit, many countries have developed public participation defibrillation program (PAD).
children with supraventricular tachycardia (SVT) and ventricular tachycardia (VT) can be associated with no pulse or pulse state . for pulseless patients, treatment should be based on the implementation of cardiac arrest guidelines. If there is pulse, treatment should include oxygen, airway support, and assessment of the current cardiac rhythm. QRS wave stenosis may indicate SVT, vagus nerve stimulation should be used, intravenous injection of adenovirus glycosides and progressive treatment of electrical cardioversion. If SVT unresponsive to other treatment or relapse, may need to use amiodarone or procainamide, but these drugs prolong QT interval, so be careful. QRS wave widening of the heart had differences in speed may be prompted to SVT with conduction or VT, electrical cardioversion often effective, but often need the same time give amiodarone or procainamide.
reverse ventricular tachycardia may be the children of the original VT Fat congenital, or due to some anti-arrhythmic drugs, the toxicity of antidepressant drugs, or drug toxicity caused by the interaction between, for a variety of forms. the treatment of intravenous magnesium sulfate to reverse the type of VT of any cause choice.
children cardiopulmonary arrest may be the result of ingestion of poison. relevant medical history and rapid diagnostic tests will be prompted to poison or drug-specific reasons. treatment effects due to intake of drugs or poisons differ, the three Central class of antidepressants, b-receptor antagonists, calcium channel blockers, methylamphetamine and cocaine, can bring additional difficulties.
neuroprotective
recovery protection and prevention of secondary brain function brain injury is an important goal of recovery. should avoid excessive ventilation and low carbon dioxide acidosis, because there is no exact benefits. severe low hypercapnia can cause brain ischemia and myocardial dysfunction. Pediatric Anesthesia basic measures to maintain normal body temperature. However, the brain resuscitation hyperthermia harmful. child recovers quickly after rewarming and recovery is not necessary because it may lead to hyperthermia. for continuing coma patients, infants or children head cooling the body temperature to 32 ℃ ~ 34 ℃ conducive to brain recovery.
family presence during resuscitation in children with family members
recovery will be very eager to be present. in the treatment and recovery process, families have been the presence of American College of Emergency Nurses Association and the American Pediatric Emergency Plan recognition. Although the presence of family members in the operating room is not feasible, but in the emergency department or bedside Shique recovery is possible. For children with chronic disease, family history and children can provide useful information on clinical status. to encourage the medical group during the recovery period to allow family members to consider present and a medical officer designated to provide assistance to the families.
summary
current PALS guidelines emphasize early detection and treatment of respiratory failure and shock. Once the quick placement difficult venous access is recommended intramedullary pin as an intravenous infusion pathway. For the SVT, vagus nerve stimulation is a first-line intervention, if not improve, further use of adenosine and electrical cardioversion. amiodarone is recommended for most of the arrhythmias, especially VT. adrenalin is still an important drug recovery. recommended standard dose of 0.01 mg / kg, while the high dose (0.1 mg / kg) may cause harm. external defibrillators, is recommended for> 1 year of age, for <1 year old children is unknown effectiveness. CPR During chest compressions should be
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