#16
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Óâàæàåìûé Zubarew, ìîæíî íåñêîëüêî ãëóïûõ âîïðîñîâ äèëåòàíòà ïî LMA:
-êàêîå ìàêñèìàëüíîå peep óäåðæèâàåò LMA, åñëè, íàïðèìåð, ïðèõîäèòñÿ ïðîâîäèòü ÈÂË ó áîëüíûõ ñ îòåêîì ëåãêèõ? -êàêàÿ ãëóáèíà àíåñòåçèè îáû÷íî òðåáóåòñÿ äëÿ ââåäåíèÿ LMA -íàñêîëüêî îïðàâäàíî ïðîâåäåíèå ÈÂË ñ ïîìîùüþ LMA ó áîëüíûõ "ñ ïîëíûì æåëóäêîì"? Öèòàòà:
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#17
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Öèòàòà:
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#18
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Äëÿ äîëãîñðî÷íîãî äîñòóïà (*áîëåå 5 ÷àñîâ) ËÌÀ íå ïîäõîäèò - ýòî âðåìåííûé äîñòóï ê äûõàòåëüíûì ïóòÿì íà íåêîòîðûå îïåðàöèè è â ñëó÷àå òðóäíîé èíòóáàöèè. Ïîñòàâèòü ËÌÀ çíà÷èòåëüíî ïðîùå, ÷åì èíòóáèðîâàòü, ïîýòîñó (âåðîÿòíî) è îæèäàåòñÿ ïîÿâëåíèå ðåêîìåíäàöèé ïî èñïîëüçîâàíèþ íà äîãîñïèòàëüíîì ýòàïå.  ðåêîìåíäàöèÿõ ERC - òîæå óïîìèíàåòñÿ íà ïåðâîì ìåñòå (ñðåäè àëüòåðíàòèâíûõ bag-mask âåíòèëÿöèè óñòðîéñòâ äëÿ íåìåäëåííîãî äîñòóïà ê äûõàòåëüíûì ïóòÿì âî âðåìÿ CPR íà äîãîñïèòàëüíîì ýòàïå). Åñëè ëàðèíãåàëüíàÿ ìàñêà áûëà óñòàíîâëåíà íåçàïëàíèðîâàííî (ïðè òðóäíîé èíòóáàöèè, íàïðèìåð), êàê ïðàâèëî ïðåäïîëàãàåòñÿ, ÷òî â áëèæàéøåå âðåìÿ îíà âñå ðàâíî áóäåò çàìåíåíà íà èíòóáàöèîííóþ òðóáêó òåì èëè èíûì ñïîñîáîì.
Àíåñòåçèÿ äëÿ ïàöèåíòîâ â ïëàíîâîé îïåðàöèîííîé îáû÷íî òðåáóåòñÿ äîñòàòî÷íî ãëóáîêàÿ, òàê êàê áîëüøèíñòâî ïðîáëåì, ñâÿçàííûõ ñ óñòàíîâêîé è ïðîâåäåíèåì âåíòèëÿöèè ÷åðåç ËÌÀ ñâÿçàíû èìåííî ñ íåäîñòàòî÷íî ãëóáîêîé àíåñòåçèåé. Ó áîëüíûõ ñ îñòàíîâêîé ñåðäöà, âåðîÿòíî ñåäàöèè ïîòðåáóåòñÿ ìåíüøå. Ïèêîâîå äàâëåíèå è ÏÄÊ êîòîðîå âûäåðæèâàåò ËÌÀ - çàâèñèò îò êîíêðåòíîé ìîäåëè ìàñêè è îò òîãî, êàê ïëîòíî îíà ñåëà. Îò àñïèðàöèè îíà çàùèùàåò çíà÷èòåëüíî õóæå, ÷åì èíòóáàöèîííàÿ òðóáêà.  ìîäåëÿõ supreme è proseal åñòü êàíàë äëÿ óñòàíîâêè íàçîãàñòðàëüíîãî çîíäà è ñ÷èòàåòñÿ, ÷òî â ñëó÷àå ïîòåíöèàëüíî ïîëíîãî æåëóäêà - ýòî áîëåå ïîäõîäÿùèé âàðèàíò. |
#19
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Ñïàñèáî. Òî åñòü, äëÿ áîëüíûõ ñ îòåêîì ëåãêèõ è ïîëíûì æåëóäêîì ýòî íå âàðèàíò?
Âàì áû íå áûëî çàòðóäíèòåëüíî âûëîæèòü òóò êàêîå-íèáóäü âìåíÿåìîå ðóêîâîäñòâî ïî òåìå? ß ïîèñêàë, íî ìàëî êîíêðåòèêè. |
#20
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Îòâåò íà âîïðîñ ÊÌÍ îá îïàñíîñòè àñïèðàöèè:
Åñëè ëàðèíãåàëüíàÿ ìàñêà óñòàíîâëåíà äëÿ îáåñïå÷åíèÿ àäåêâàòíîé âåíòèëÿöèè íà êîðîòêèé ïðîìåæóòîê âðåìåíè (ïîêà íå ïîäîéäóò ýíäîñêîïèñòû èëè íà âðåìÿ íàëîæåíèÿ òðàõåîñòîìû) - âåðîÿòíîñòü àñïèðàöèè ìèíèìàëüíà. Õîòÿ ñëåäóåò ïðèçíàòü, ÷òî îïàñíîñòü àñïèðàöèè ñóùåñòâóåò âñåãäà, ïîêà ïðîñâåò òðàõåè ïîëíîñòüþ íå ãåðìåòèçèðîâàí. |
#21
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#22
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Öèòàòà:
http://www.youtube.com/watch?v=UA1wWmehuuI http://www.youtube.com/watch?v=RCyQf...eature=related Ñ ïîìîùüþ áðîíõîñêîïà - ïðèìåðíî òîæå ñàìîå, òîëüêî áîëåå íàäåæíî. Èíòóáèðîâàòü ÷åðåç êëàññè÷åñêóþ LMA ïî áðîíõîñêîïó òîæå ìîæíî, íî íóæíî ïðåäâàðèòåëüíî ñðåçàòü ðåøåòêó ("ãðèëü") íà ëàðèíãåàëüíîì êîíöå òðóáêè, èíà÷å èíòóáàöèîííàÿ òðóáêà íå ïðîéäåò. Ïîñëå ýòîãî ëàðèíãåàëüíóþ ìàñêó ìîæíî óäàëèòü, îíîâðåìåííî óäåðæèâàÿ ýíäîòàõåàëüíóþ òóáêó â ôèêñèðîâàííîì ïîëîæåíèè ñ ïîìîùüþ äðóãîé ýíäîòàõåàëüíîé òðóáêè ìåíüøåãî ðàçìåðà, âñòàâëåííîé â íàðóæíûé êîíåö òîé, êîòîðàÿ ó ïàöèåíòà â òðàõåå (ëèáî èñïîëüçóÿ ñïåöèàëüíûé ïðîâîäíèê, êàê â ñëó÷àå ñ fasttrach LMA). Âîò çäåñü, êñòàòè èíòåðåñíûé òîïèê íà ðóñàíåñòå, êàê ðàç ïîñâÿùåííûé ðàçíûì íþàíñàì, ñâÿçàííûì ñ èñïîëüçîâàíèåì ëàðèíãåàëüíûõ ìàñîê: http://rusanesth.com/forum/index.php?showtopic=173 |
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#23
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Èíòóáèðîâàòü (ñ ïîìîùüþ áðîíõîñêîïà) ìîæíî è ÷åðåç "êëàññè÷åñêóþ" ËÌ è ÷åðåç Supreme (ýòî ïîìèìî èíòóáàöèîííîé ËÌ). Ïðàâäà, ÷åðåç Supreme (ëè÷íî íå ïðîáîâàëà, íî ìîæåò áûòü òðóäíåå, ÷åì ÷åðåç "êëàññè÷åñêóþ" èç-çà äèçàéíà) ëó÷øå ñ èñïîëüçîâàíèåì ñïåöèàëüíîãî êàòåòåðà (Aintree intubation catheter), õîòÿ â ëèòåðàòóðå åñòü è ðåïîðòû ñ èñïîëüçîâàíèåì îáû÷íûõ òðóáîê (åñòåñòâåííî, íå áîëüøå 6.5-6.0, êàê è ïðè èíòóáàöèè ÷åðåç "êëàññè÷åñêóþ" ËÌ). Åñëè èíòóáèðîâàòü ÷åðåç "êëàññè÷åñêóþ" ËÌ, òî íà ñàìîì äåëå ïðè ïðàâèëüíî óñòàíîâëåííîé ìàñêå - ýòî íàìíîãî ïðîùå, ÷åì îáû÷íàÿ áðîíõîñêîïèÿ: ëàðèíãåàëüíûå ñòðóêòóðû "ïðÿìî ïåðåä òîáîé", êàê òîëüêî áðîíõîñêîï ïîêèäàåò äûõàòåëüíóþ òðóáó. Ìû ÷àùå âñåãî èñïîëüçóåì Aintree: îí êîðî÷å áðîíõîñêîïà (ïåäèàòðè÷åñêîãî) íà ïàðó ñàíòèìåòðîâ, îñòàâëÿåòñÿ â òðàõåå ïîñëå óäàëåíèÿ áðîíõîñêîïà è ËÌ, è èñïîëüçóåòñÿ â êà÷åñòâå ïðîâîäíèêà äëÿ ïîñëåäóþùåé èíòóáàöèè.
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#24
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Ïî ïîâîäó èñïîëüçîâàíèÿ ËÌ ïðè ïðîâåäåíèè ïåðâè÷íûõ ðåàíèìàöèîííûõ ìåðîïðèÿòèé è ðèñêà àñïèðàöèè áûëà èíòåðåñíàÿ ïóáëèêàöèÿ â 90õ, íî, ê ñîæàëåíèþ, íè÷åãî ïîäîáíîãî áîëüøå íå ïóáëèêîâàëîñü, íàñêîëüêî ÿ çíàþ.
Resuscitation. 1998 Jul;38(1):3-6. The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway. Stone BJ, Chantler PJ, Baskett PJ. Department of Resuscitation, Conquest Hospital, Hastings, E. Sussex, UK. The risk of gastric regurgitation and subsequent pulmonary aspiration is a recognised complication of cardiac arrest--a risk which may be further increased by the resuscitative procedure itself. The purpose of this study was to compare the incidence of gastric regurgitation between the bag valve mask (BVM) and laryngeal mask airway (LMA). The resuscitation data collection forms of 996 patients who underwent in-hospital cardiopulmonary resuscitation over a 3.5 year period were reviewed. Of these, 199 patients were excluded from the study because there was no airway management involving a BVM or LMA. The incidence and timing of regurgitation was studied in the remaining 797 patients. Regurgitation was recorded to have occurred at some stage in 180 of these patients (22.6%). However, 84 regurgitated prior to CPR (46.7% of those patients who regurgitated). These patients were excluded from further analysis as regurgitation could not have been affected by any form of ventilation. Of the remaining 713 patients, BVM ventilation was used in 636 cases. In 170 of these the LMA was also used following the BVM. Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%. The LMA was used during resuscitation in 256 cases of which 170 had BVM ventilation prior to the LMA. Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%. The study confirms experience reported in earlier studies that when an LMA is used as a first line airway device, regurgitation is relatively uncommon. À ïî íàñòîÿùèì ðåêîìåíäàöèÿì (American Heart Association) èíòóáàöèÿ íà ýòàïå ïåðâè÷íûõ ðåàíèìàöèîííûõ ìåðîïðèÿòèé íå ðåêîìåíäóåòñÿ (äàáû íå îòâëåêàòüñÿ îò ïðîâåäåíèÿ íåïðÿìîãî ìàññàæà ñåðäöà), äîñòàòî÷íî àäåêâàòíîé âåíòèëÿöèè ìåøêîì ÀÌÁÓ (õîòÿ, íà ìîé âçãëÿä, àäåêâàòíàÿ âåíòèëÿöèÿ - åù¸ áîëåå ñëîæíîå óìåíèå, ÷åì èíòóáàöèÿ). ×òî êàñàåòñÿ "èäåàëüíîãî" èíòóáàöèîííîãî "ïðèáîðà", òî òóò, ê îãðîìíîìó ñîæàëåíèþ, íåò íè÷åãî, ÷òî áû ðàáîòàëî 100%(. Äàæå Glidescope íå ãàðàíòèðóåò óñïåõà â ëþáîé ñèòóàöèè (õîòÿ ÿ ëè÷íî ïîëüçóþñü èì íûí÷å âî ìíîãèõ ñèòóàöèÿõ, ãäå ïðåæäå äåëàëà áû áðîíõîñêîïè÷åñêóþ èíòóáàöèþ äî ââîäíîãî íàðêîçà). |