复杂型主动脉夹层的腔内治疗

目的探讨复杂型主动脉夹层腔内血管外科治疗方法。方法对25例复杂型主动脉夹层行腔内血管外科治疗患者的临床资料进行回顾性研究。结果25例患者年龄31—76岁，平均52．6岁。25例中6例术前合并肠管缺血，5例合并肾动脉缺血，3例既有肠管缺血又有肾动脉缺血，5例腹主动脉真腔完全被假腔压闭，4例合并下肢缺血，2例合并腹主动脉瘤。所有患者进行了腔内血管外科治疗，并取得了技术上的成功。2例合并腹主动脉瘤的夹层患者予以支架型人工血管封闭夹层破口后行开腹腹主动脉瘤切除人工血管置换术。术后内漏3例（2例漏血7d后停止，1例漏血持续存在）；其余22例患者术后即时造影示瘘口已被完整覆盖，假腔无血漏人，内脏动脉等恢复真腔供血。前述的合并症术后均逐渐恢复，无脏器及肢体缺血坏死发生，患者均痊愈出院。结论对复杂的主动脉夹层的治疗，腔内治疗与传统的手术相比，操作简单、损伤小、安全度大、并发症少，且可大大缩短患者的住院时间。腔内血管外科技术上的改进，使复杂的主动脉病变得以成功的治疗。     

DebakeyⅢ型夹层动脉瘤远侧破口的腔内封堵

目的 初步总结使用腔内技术处理夹层动脉瘤远侧破口的经验.方法 总结15例DebakeyⅢ型夹层动脉瘤近端破口腔内修复术后腹主动脉以远破口的二期介入处理经验.所有病例远侧破口持续存在,出现腰腹部症状或局部腹主动脉外径增加.本组病例中内脏动脉处破口7个(1个腹腔动脉内破口,6个肾动脉处破口),肾下腹主动脉破口4个,髂动脉破口7个;其中3例为内脏动脉破口合并髂动脉破口.肾下腹主动脉破口均采用一体式覆膜支架封堵;1例近右肾动脉破口使用先心封堵伞;其余内脏动脉和髂动脉破口均采用小覆膜支架封堵.结果 所有病例均顺利完成操作,腹主动脉和髂动脉破口封堵良好,无内漏.使用封堵伞的病例,夹层破口封堵良好,但由假腔供血的右肾动脉同时闭塞;肾动脉破口使用覆膜支架封堵病例中,1例显著内漏,2例微量内漏,其余病例封堵良好,无内漏.病例随访2 ～10个月,平均(5.0±2.0)个月,内漏病例CTA示假腔内部分血栓形成,但破口附近假腔仍有血流,其余病例夹层内均血栓形成.结论 针对适当患者,个体化方案封堵夹层动脉瘤的远侧破口是可行和安全的.     

支架型人工血管腔内治疗复杂主动脉瘤

目的：总结15例应用支架治疗复杂动脉瘤的初步经验。方法：Ⅲ型夹层动脉瘤者主动脉极度扭曲1例；破口在弓部的Ⅲ型夹层动脉瘤1例，需先行左右颈-颈和左右腋．腋动脉人工血管搭桥后再封闭左侧颈总动脉和锁骨下动脉：Ⅲ型夹层动脉瘤近侧破口来自于变异发出的右锁骨下动脉1例；Ⅲ型夹层动脉瘤合并肠系膜上动脉几乎完全闭塞和肠缺血1例；Ⅲ型夹层动脉瘤真假腔难判断者4例；腹主动脉瘤瘤颈长度〈1cm需开窗型支架治疗1例；破裂腹主动脉瘤1例：5枚支架治疗胸腹主动脉瘤1例；腹主动脉瘤瘤颈夹角为90。2例；主动脉溃疡紧邻腹腔动脉，需开窗型支架开窗型人工血管治疗1；肝动脉瘤腹腔动脉瘤合并动静脉瘘1例。结果：15例病人经支架治疗均获得成功。结论：支架型人工血管治疗复杂动脉瘤为微创方法，但需严密设计。     

真腔远端完全闭塞De Bakey Ⅲb主动脉夹层的治疗方法

主动脉夹层是一类病情十分凶险的血管疾病,起病急骤,进展快,病死率高。我们对1例复杂的主动脉夹层病人联合采用覆膜支架腔内隔绝术和远端腹主动脉切开 人工血管置换术治疗,疗效较好。报告如下。1资料和方法1.1一般资料真腔远端完全闭塞的De BakeyⅢb型主动脉夹层,经磁共振血管造影(MRA)及数字减影血管造影(DSA)确诊。病人为男性,63岁。病史1年。术前MRA(如图1a、b)示:De BakeyⅢb型主动脉夹层假腔明显扩张,真腔受压明显,近端破口位于降主动脉,距离左锁骨下动脉开口约3cm,破口长径约1.8cm,腹腔干动脉、肠系膜上动脉、双肾动脉均起源于…     

血管内覆膜支架系统在主动脉夹层二期手术重建肾动脉中的应用

目的探讨血管内覆膜支架系统在主动脉夹层二期手术重建肾动脉中的应用效果。方法分析2010年5月至2018年5月宜昌市第一人民医院收治的10例累及腹腔内脏动脉的主动脉夹层进行二期手术中接受开放手术的患者临床资料。结果手术均获得成功,无围术期死亡病例。术后腹主动脉CT血管造影示患者人工血管及支架内血流均通畅,缝扎的腹主动脉不显影。二期手术后随访0.5～3.0年,患者人工血管及支架内血流均通畅,未见狭窄,缝扎的胸腹主动脉不显影。6例患者因髂动脉有破口致髂动脉仍有夹层表现,未做处理,随访假腔未见增大。结论血管内覆膜支架系统可代替缝合线连接两根血管,尤其适用于解剖位置较深、不方便暴露和吻合的肾动脉重建,具有缩短肾热缺血时间、节省手术时间、创伤小、操作方便等优点,值得在临床中推广。     

主动脉夹层TEVAR术后远端破口的临床分型及手术时机的选择

目的 探讨主动脉夹层TEVAR术后远端破口的治疗方法.方法 对新疆维吾尔自治区人民医院血管外科2006年1月-2012年4月168例行TEVAR的Stamford B型主动脉夹层患者的病例资料进行同顾性分析,根据远端破口位置的不同将其分为4型:Ⅰ型:破口位于支架尾部;Ⅱ型:破口位于胸腹主动脉,距离内脏动脉较近或累及内脏动脉;Ⅲ型:破口位于肾下腹主动脉,破口未累及内脏动脉;Ⅳ型:破口位于髂动脉.据此分型标准,对主动脉夹层TEVAR术后发生远端破口的82例患者制定相应的治疗策略并决定手术时机.结果 有82例患者支架远端仍有破口,临床分型为Ⅰ型:12例出现支架尾部破口,均行支架远端破口腔内隔绝术;Ⅱ型:47例破口位于腹主动脉并累计内脏动脉,经随访,其中4例在随访中发现假腔持续扩大或伴有症状,行“杂交”手术,即先行内脏动脉重建(髂动脉-双肾动脉,髂动脉-肠系膜上动脉,髂动脉-腹腔干人工血管搭桥术),二期行胸腹主动脉腔内隔绝术.43例患者随访发现假腔无扩大,目前继续随访.Ⅲ型:13例破口位于肾下腹主动脉,均行腔内隔绝术.Ⅳ型:10例破口位于髂动脉,均行腔内隔绝术.术后围手术期无死亡.82例患者获得随访,随访时间10 ～36个月,平均随访时间(25.6±8.4)个月,在随访过程中未发现并发症.结论 对于TEVAR术后远端破口,应根据个体情况,结合临床分型选择适宜的手术时机和手术方式,从而达到满意的治疗效果.     

血管、淋巴管

支架型人工血管腔内治疗复杂主动脉瘤；Stanford B型主动脉夹层腔内修复后转为StanfordA型10例分析；胸主动脉夹层合并腹主夹层动脉瘤的一期腔内治疗；血管损伤的腔内治疗体会；四肢骨骼肌血管畸形的分类与治疗方法的研究     

急性Stanford B型主动脉夹层并灌注不良的腔内治疗

目的 总结急性Stanford B型主动脉夹层并内脏或下肢动脉灌注不良的腔内治疗经验.方法 回顾性分析2001年7月至2012年12月收治的23例急性Stanford B型主动脉夹层并内脏或下肢动脉灌注不良患者的临床资料,其中男20例,女3例,年龄42～ 75岁,平均(52±9)岁.5例(21.7％)肾动脉缺血,9例(39.1％)肠系膜上动脉缺血,3例(13％)腹腔干缺血,6例(20.1％)下肢缺血(左下肢坏死1例).其中2例同时有肾动脉及下肢动脉缺血.分别采用不同的腔内技术治疗.结果 23例支架人工血管成功覆盖近端第一破口.11例(47.8％)其他分支动脉植入了支架.23例患者灌注不良得到改善,手术技术成功率100％.1例合并右髂动脉闭塞致下肢缺血者,支架人工血管覆盖第一破口并右髂动脉内植入支架后治愈.1例合并下肢动脉缺血坏死者支架人工血管植入术后一期行大腿中上段截肢术.23例患者均获随访,随访6 ～72个月,平均(21±11)个月,无移植物移位及器官缺血.本组无截瘫病例.结论 腔内支架人工血管植入覆盖主动脉夹层第1破口是首选的治疗手段.部分患者尚需结合分支动脉支架植入等方法来进一步治疗.     

主动脉腔内支架隔绝术治疗降主动脉瘤

目的探讨主动脉腔内支架隔绝术治疗降主动脉瘤的适应证和疗效。方法2005年3月-2008年10月,对21例典型B型（Stanford分型）主动脉夹层、5例假性动脉瘤、2例主动脉壁内血肿合并主动脉壁溃疡,在局麻（26例）或全麻（2例）下行主动脉腔内支架隔绝术。采用Medtronic Talent支架10例,Medtronic Valiant支架12例,微创直管型支架6例。结果28例手术均获成功,术后即刻造影示破口封闭,无内漏。术后无胸痛,无神经系统并发症,无内漏,术后住院时间（4.5±1.1）d,3-7 d。5例术后发热,吲哚美辛治疗1个月,体温正常。21例主动脉夹层术后1周CT扫描显示真腔扩大,血供明显改善,胸主动脉假腔内血栓形成,腹主动脉假腔存在,开口于假腔的分支靠远端破口供血;5例假性动脉瘤CT扫描显示破口封闭,假腔内血栓形成;2例壁内血肿CT扫描显示溃疡被支架覆盖。23例随访（21.3±10.2）月（1-40个月）,无并发症发生。结论主动脉腔内支架隔绝术疗效可靠,操作简单,创伤小,患者恢复快,并发症少,住院时间短。B型主动脉夹层、降主动脉假性动脉瘤和降主动脉壁内血肿均可采用腔内支架隔绝术治疗。     

腔内修复术治疗主动脉疾病：附64例报告

目的总结主动脉疾病腔内修复治疗的初步经验。方法回顾性分析7年余64例主动脉疾病腔内修复术患者的临床资料。包括主动脉夹层42例(其中Stanford B型38例,Stanford A型4例),主动脉瘤22例。局麻或全麻下经股动脉入路植入支架型人工血管修复病变的动脉内膜。4例分别同期行血管搭桥手术(股-股动脉搭桥,锁骨下-颈总动脉搭桥,左-右颈总动脉搭桥,腹主动脉-肾动脉搭桥1例)。6例支架型人工血管一期覆盖了左锁骨下动脉而未行血管搭桥手术。结果即刻内漏18例,发生率28.12%(18/64)。无移植物错放、移位、瘤体破裂、中转手术和截瘫等并发症发生。所有受破坏的分支血管修复后真腔供血明显改善。围手术期病死率6.25%(4/64)。随访1～84(平均23.4)个月。动脉瘤组和动脉夹层组各有2例行再次手术。结论腔内修复治疗主动脉病变近期效果满意,中远期疗效有待进一步观察。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

缺氧对肾小管上皮细胞分泌外泌体的影响

目的    观察缺氧对肾小管上皮细胞分泌外泌体的影响,探讨外泌体在缺氧致肾脏损伤中的作用及机制。 方法    （1）常氧（21% O₂）及缺氧（1% O₂）分别处理大鼠肾小管上皮细胞（NRK-52E）48 h,收集细胞上清液并使用高速梯度离心法分离外泌体。采用透射电镜、纳米示踪分析、Western印迹、蛋白浓度定量鉴定并比较两组外泌体的基本特性。（2）在共培养实验中,以不同浓度（1、10、50、100、300 mg/L）的常氧外泌体、缺氧外泌体分别干预脂多糖（LPS）诱导的大鼠原代腹腔巨噬细胞,使用实时荧光定量PCR与酶联免疫吸附试验（ELISA）法分别检测巨噬细胞白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、诱导型氮氧化物合酶（iNOS）水平;使用Western印迹法检测巨噬细胞磷酸化（p）STAT/STAT及细胞因子信号传导抑制蛋白1（SOCS1）的蛋白表达;最后,使用实时荧光定量PCR法检测常氧外泌体与缺氧外泌体中炎性反应相关微RNA（microRNA,miR）的表达差异。 结果    （1）离心得到的囊泡具有外泌体典型的结构,粒径小于150 nm,表达外泌体标志蛋白CD63,说明分离得到外泌体。缺氧对肾小管上皮细胞分泌的外泌体形态、粒径分布比例无明显影响,但提高了外泌体的分泌量。（2）缺氧外泌体相比于常氧外泌体促进了LPS诱导的M1型巨噬细胞IL-6、TNF-α、iNOS 的表达和分泌（均P＜0.01）,同时提高STAT的磷酸化水平并减少SOCS1的蛋白表达（均P＜0.01）;对炎性反应相关microRNA检测发现缺氧外泌体中miR-155、miR-27a表达量较常氧外泌体明显升高（P＜0.05）。 结论    缺氧可改变外泌体的生物学功能,表现为协同促进LPS诱导的M1型巨噬细胞的表型转化,这可能是慢性肾脏病微炎性反应状态持续的原因之一。     

In Vitro Function and Durability Assessment of a Novel Polyurethane Heart Valve Prosthesis

Abstract While flexible-leaflet, central-flow prosthetic heart valves promise relief from anticoagulation therapy, they continue to be restricted by inadequate durability. In consequence, a novel trileaflet valve, made entirely from polyurethane, has been developed. A batch of 6 consecutively manufactured polyurethane valves was subjected to hydrodynamic function and accelerated fatigue testing. Computerized data acquisition and control systems have been introduced to improve valve testing methodologies. In terms of hydrodynamic function, the polyurethane valve demonstrates transvalvular pressure gradients similar to those for a bioprosthetic valve (Carpentier-Edwards) and levels of retrograde flow significantly less than those for either the bioprosthetic valve or a bileaflet mechanical valve (St Jude Medical). The equivalent of 10 years of cycling without failure has been exceeded by all 6 polyurethane valves in accelerated fatigue tests with 2 valves remaining intact after 674 million cycles (equivalent to approximately 17 years) in continuing tests. Highspeed photography revealed considerable differences in leaflet motion between valves cycled at accelerated and physiological rates.     

Negative pressure ventilation vs. spontaneous assisted ventilation during rigid bronchoscopy: A controlled randomised trial

Background: Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). Methods: Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre-and intra-operative arterial blood gases and O₂ flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. Results: Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 ± 1.8 (μg · kg^?1· h^?1 vs. 6.6 ± 4.8 μg · kg^?1· h^?1), a lower O₂ supply (3.3 ± 2.8 1/min vs. 11.6 ± 3.4 1/min), a shorter recovery time (5.4 ± 2.9 min vs. 9.8 ± 7.1 min) and no manually assisted ventilation (0 ± 0 vs. 1 ± 1.1 nd?/procedure). Intraoperative PaCO₂ was higher in the SAV (8.1 ± 1.3 kPa) than in the INPV group (5.0 ± 1.6 kPa) and intraoperative pH differed in the two groups (7.26 ± 0.05, SAV vs. 7.47 ± 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). Conclusions: As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces 02 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.