昨天群里老师讨论了面罩通气困难的相关问题
麻醉大夫最重要的三个难题 气道气道气道
永远是最最重要的
让我们大家一起来看一下
三个问题
1.给完其他诱导药的患者 出现面罩通气困难 这时你会继续给肌松药吗?
2.如果选择继续 给常规剂量还是给一点能通气就行?
3.如果给完了 不能插管也不能通气CICO了 您如何处理?
气道问题永远讨论不
完欢迎大家留言或后续入群继续讨论啊大家讨论的很热烈啊
我也搜了下uptodate 大家可以参考
面罩通气 — 预吸氧和麻醉诱导之后,如果不计划行快速诱导插管,则应使用100%氧气进行面罩通气。一旦患者失去意识,我们就使用胶带或透明敷贴闭合并遮盖患者的眼睛,以免在处理气道期间发生损伤。面罩通气的技术详见其他专题。(参见“成人基础气道管理”,关于'气囊-面罩通气’一节)
NMBA的应用 — 计划在麻醉诱导后进行气管插管时,应在诱导期间常规给予NMBA,以改善插管条件及降低上气道损伤风险[63]。(参见“Clinical use of neuromuscular blocking agents in anesthesia”, section on 'Endotracheal intubation’)
应用时机 — 通常应先建立面罩通气,再给予NMBA。这一顺序体现了临床医生在患者自主通气能力消除之前对患者进行通气的能力,并且如果气道控制的尝试失败,则保留了唤醒患者的机会。
在建立面罩通气后再给予NMBA的做法受到了质疑,部分原因是肌肉松弛可能会改善面罩通气[64-67]。同时给予NMBA与诱导药物还可能缩短距离气管插管的时间。一项随机试验在114例有着正常气道的患者中,比较了丙泊酚给药后立即给予罗库溴铵与确定面罩通气后再给予罗库溴铵,发现较早接受NMBA的患者距离气管插管的平均时间更短(116 vs 195秒)[67]。而且,在较早接受罗库溴铵的患者中,面罩通气期间的平均潮气量更大(每次呼吸550 vs 390mL)。
然而,肌肉松弛可使某些患者难以或无法进行面罩通气。在给予NMBA之前先评估面罩通气的能力可能有利于改变计划;例如,当面罩通气很吃力时使用琥珀胆碱而不是长效NMBA,或者尽可能唤醒患者。因此,除非正在施行快速顺序插管,否则给予NMBA的时机应根据预期的气道管理困难视个体情况而定。施行快速顺序诱导和插管时,通常同时给予NMBA和诱导药物,而不进行面罩通气。(参见“全麻快速顺序诱导插管”)
如果预见患者存在面罩通气或插管困难,可在确认面罩通气后再给予肌松药,或考虑清醒插管或吸入诱导。如果未预见气道管理困难,可先给予肌松药再确认面罩通气。(参见“成人全身麻醉时困难气道的管理”,关于'用药时机’一节)
对NMBA的选择 — 对适当NMBA的选择取决于临床应用情况和患者因素,相关内容详见其他专题。(参见“Clinical use of neuromuscular blocking agents in anesthesia”, section on 'Selection of neuromuscular blocking agents’)
如果术中需要,或在有意料之外的气道管理困难时,采用舒更葡糖可以比较快速地逆转罗库溴铵。然而,在可能或确实无法插管、无法通气的情况下,不应将快速逆转神经肌肉阻断作为一种挽救策略。舒更葡糖逆转插管剂量罗库溴铵的速度比插管剂量琥珀胆碱自行消退的速度更快,但逆转过程可能仍需耗时长达6分钟[68]。麻醉诱导后恢复自发通气的主要决定因素为麻醉深度和诱导药物的呼吸抑制作用,而不是神经肌肉阻断的逆转[69]。在无法插管、无法通气的情况下,应致力于恢复氧合和通气。I
特别强调麻醉诱导后恢复自发通气的主要决定因素为麻醉深度和诱导药物的呼吸抑制作用,而不是神经肌肉阻断的逆转
American Society of Anesthesiologists difficult airway algorithm
SGA: supraglottic airway; LMA: laryngeal mask airway; ILMA: intubating laryngeal mask airway.
* Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO2.
¶ Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.
Δ Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (eg, LMA, ILMA, laryngeal tube), local anesthesia infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.
◊ Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (eg, LMA or ILMA) as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and blind oral or nasal intubation.
§ Emergency noninvasive airway ventilation consists of a SGA.
¥ Consider re-preparation of the patient for awake intubation or canceling surgery.
Reproduced with permission from: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2. Copyright © 2013 by the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this material is prohibited.
Graphic 94447 Version 8.0
补充最新版清醒插管指南美图
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