Ｌｉｇｈｔｗａｎｄ光棒插管在整形外科手术中的应用_光棒插管视频

　　[摘要]目的：观察lightwand光棒用于整形外科手术患者常规气管插管的安全性，和有效性以及在预测困难气管插管的可行性。方法：选择152例ASA I或II级全麻下行择期整形外科手术的患者，其中124例为正常气道，根据光棒前端弯曲角度不同随机分为A组(60°)和B组(90°)，28例预测有困难气管插管为C组(90°)。记录各组插管时间、插管次数、插管的成功率、插管期间血流动力学变化以及术后并发症情况。结果：A、B和C组的一次插管成功率分别为100%、95.2%和85.7%，三组的插管总成功率均为100%；A、B和C组完成插管时间分别为(11.8±4.9)s、(14.0±5.4)s和(17.4±8.1)s，A组的光点寻找时间、光棒退出时间和气管插管时间均较B、C组缩短；光棒插管对循环功能的干扰小，术后并发症少。 结论：lightwand光棒用于整形外科手术的常规气管插管及预测困难气管插管，插管成功率高、耗时短，对血流动力学影响较小，插管并发症少。
　　[关键词]lightwand 光棒；气管插管；困难气道
　　[中图分类号]R622 [文献标识码]A [文章编号]1008-6455（2009）01-0021-04
　　
　　The application of lightwandintubation in plastic surgery
　　WANG Lei,DENG Xiao-ming,LIU Ju-hui,SUI Jing-hu,TONG Shi-yi,ZHAGN Yan-ming,
　　WEI Ling-xin,YANG Dong,XU Kun-lin
　　(Department of Anesthesiology，Plastic Surgery Hospital，Chinese Academy of Medical Sciences and Peking Union Medical college，Beijing 100041,China)
　　
　　Abstract:ObjectiveTo observe the safety and effectiveness of lightwand in routine endotracheal intubation for plastic operations and its feasibility to predict the difficult endotracheal intubation.Methods152 ASA I－II patients scheduled for elective plastic surgery under general anesthesia were enrolled in this study. 124 amidst with normal airway were randomly divided into group A (60°) and group B(90°) according to the bent angle of the lightwand tip, and the other 28 predicted with difficult tracheal intubation were allocated into group C. The time and times of the tracheal intubation, and its succesuss ratio, together with the hemodynamic fluctuation and the complications arised during this period were recorded.ResultsThe first-time intubation success rate of group A , B , and C was 100%,95.2%,85.7%respectively, while the total intubation success rate of all the three groups was 100%. The time used for a complete intubation in A, B, C was (11.8±4.9)s,(14.0±5.4)s,(17.4±8.1)s accordingly, from which, we can find that the time spent by group A is less than group B or C on light spot searching, lightwand withdrawing and trancheal intubating, and the interference of lightwand intubation against hemodynamic circulatory was slight and complications afterwards were low.ConclusionFeatured with high success rate but short time consumption, lightwand can be used for routine tracheal intubation and prediction of difficult tracheal intubation in plastic operations for its slight influence to hemodynamics and few complications arised.
　　Key words: lightwand;tracheal intubation;difficult airway
　　
　　Lightwand光棒是通过观察颈前亮点来帮助定位实施气管插管的新方法，临床应用时不需要使用直接喉镜、方便快捷、损伤小、气管插管成功率高。还是解决小口、颌面畸形等困难气管插管患者的有效工具之一。本文观察和评估Lightwand光棒用于整形外科手术患者常规气管插管和预测困难气管插管的可行性和安全性，并比较Lightwand光棒不同弯曲角度的临床效果。
　　
　　1资料和方法
　　
　　1.1 临床资料：共152例，年龄12～54岁，ASAⅠ或Ⅱ级行整形外科手术全麻患者，其中正常气道患者124例，预测困难气管插管患者28例。符合以下一项及一项以上者为预测困难气管插管：甲颏间距＜6cm、张口度＜3cm、Mallampati分级Ⅲ级或Ⅲ级以上、有困难插管史、肥胖（体重指数>30）。近期有上呼吸道感染史（2周）、上呼吸道异物、肿瘤、息肉、脓肿的患者及使用导管内径小于6.5mm者排除在外。根据lightwand光棒前端弯曲角度的不同将正常气道患者随机分为A组(60°)和B组(90°)，预测困难气管插管患者为C组(90°)。
　　1.2设备和准备：lightwand由前端带灯泡的光棒和电池手柄组成，光棒上带导管固定器，两者连接后通电亮灯。Lightwand光棒只能使用内径6.5mm以上的气管导管。
　　麻醉诱导前，用利多卡因凝胶充分润滑lightwand光棒和气管导管，将光棒的前端固定在距导管尖端约0.5cm处，在气管导管套囊后缘将导管前端分别弯曲成60°或90°备用。
　　1.3麻醉方法：常规禁食、禁水。所有患者均未使用术前药物。入室后开放静脉通路，监测ECG、BP、HR和SpO2，静脉依次给予东莨菪碱0.3mg、咪唑安定0.05mg/kg、舒芬太尼0.2μg/kg，5min后静脉推注维库溴铵0.1mg/kg，异丙酚2 mg/kg，面罩纯氧通气2min开始气管插管。插管完成后连接麻醉机予间歇正压通气，潮气量10ml/kg，频率10～12次/min，吸入1％异氟醚，流量2.5L/min，O2∶N2O为1∶1.5。
　　1.4插管方法：患者取正中仰卧位，操作者左手调整患者头部使其后仰，右手（执笔式）将lightwand光棒缓慢置入患者口腔，当光棒前端达到咽部时注意观察颈前是否有光点及光点位置，并通过旋转及上下移动光棒直到颈前正中环甲膜附近看到一明亮光点，表明气管导管前端到达声门。右手固定光棒，左手向下缓慢推送导管到气管内的合适深度，顺气管导管弯曲方向退出光棒，如果在气管导管接头处退出受阻，可减小光棒的弯曲角度。连接麻醉机手控呼吸，看到胸廓起伏，确认气管导管在气管内后，连接呼吸机行间歇正压通气。一次插管时间不超过60s，脉搏血氧饱和度大于95%，否则中止操作。插管三次，仍不成功，改用其他插管方法。
　　1.5测量指标：麻醉诱导前测量患者的甲颏间距、张口度，评估Mallampati分级，并记录性别、年龄、体重、身高。记录患者麻醉诱导前基础值、诱导后、气管插管后即刻及气管插管后1min、2min、3min、4min和5min的收缩压（SBP）、舒张压（DBP）、心率（HR）和脉搏氧饱和度（SPO2）。插管时间为光棒进入口腔到退出口腔的时间（单次成功插管时间），每次插管时间不超过60s，三次未成功视为插管失败，改其他插管方法。
　　1.6数据处理：采用SPSS16.0统计软件进行分析，计量资料采用均数±标准差来描述，用方差分析法和单因素方差分析法处理；计数资料用χ2检验来述或采用精确率法比较，P 　　[1]Rayburn RL. "Light wand" intubation[J].Anesthesia,1979,34:677-678.
　　[2]The American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway[J]. Anesthesiology,1993,78:597-602.
　　[3]NishiyamaT, Matsukawa T, Hanaoka K. Optimal length and angle of a new lightwand device (TrachlightTM) [J]. J Clin Anesth,1999,11:332-335.
　　[4]Agrò F, Totonelli A, Gherardi S.Planned lightwand intubation in a patient with a known difficult airway[J]. Canad J Anesth,2004,51:1051-1052.
　　[5]Igarashi A, Yokoo N, Sato M, el at. Awake intubation using lightwand technique under conscious sedation with remifentanil [J]. Masui，2008,57(10):1233-1236.
　　[6] Xue FS, Yang QY, Liao X, et al. Lightwand guided intubation in paediatric patients with a known difficult airway: a report of four cases [J]. Anesthesia,2008,63(5):520-525.
　　[7]Friedman PG, Rosenberg MK, Lebenbom-Mansour M. A comparison of light wand and suspension laryngoscopic intubation techniques in outpatients[J]. Anesth Analg,1997,85:578-582.
　　[8]Nishikawa K, Omote K, Kawana S, Namiki A. A comparison of hemodynamic changes after endotracheal intubation by using the lightwand device and the laryngoscope in normotensive and hypertensive patients[J]. Anesth Analg,2000,90:1023-1027.
　　[9]Friedman PG, Rosenberg MK, Lebenbom-Mansour M. A comparison of lightwand and suspension laryngoscopic intubation techniques in outpatients[J]. Anesth Analg,1997,85:578-582.
　　[10]王冬青,陈文杰,周永连,等.光索引导气管插管1100例观察[J]. 临床麻醉学杂志,2005,21(9):613-615.
　　[11]Kazuyoshi A, Ichiro T, Etsuko N, et al. Potential damage to the larynx associated with Light-guided intubation: A case and series of fiberoptic examinations[J]. Anesthesiology,2001,94(1):165-167.
　　[12]Szigeti CL, Baeuerle JJ, Mongan PD. Arytenoid dislocation with lighted stylet intubation: Case report and retrospective review[J]. Anesth Analg,1994,78:185-186.
　　[13]Debo RF, Colonna D, Dewerd G, Gonzalez C,elt.arytenoid subluxation: Complication of blind intubation with a lighted stylet[J]. Ear Nose Throat J,1989,68:517-520.
　　[收稿日期]2008-09-20[修回日期]2008-12-05
　　编辑/张惠娟