目的 研究符合建立院前高级气道管理(PHAAM)指征的患者暂缓建立PHAAM的比例、原因、替代方案和不良事件.方法 选取2018年7月1日-12月31日上海市急救中心西区4个急救车辆小组救治的院前患者,记录由院前急救医师评估具备建立PHAAM指征的患者比例、暂缓建立PHAAM的患者比例,分析暂缓建立PHAAM的原因、替代方案和不良事件发生情况.结果 纳入患者总数为2 980例,其中符合建立PHAAM指征的患者188例(6.3％).在符合建立PHAAM指征的患者中,剔除数据记录不完整的患者3例(1.6％),暂缓建立PHAAM的患者168例(89.4％),在院前建立PHAAM的患者共17例(9.0％).制约建立PHAAM的主要原因为患者因素(患者发生心跳、呼吸骤停需行心肺复苏术,或由于患者存在严重疾病、损伤,生命体征不稳定等,急救医师评估认为建立PHAAM的风险大于所带来的益处)129例(76.8％)、短距离护送(＜2 km)79例(47.0％)和患者伴随疾病[包括终末期慢性阻塞性肺疾病和(或)终末期肿瘤等更适合姑息性处理的疾病,以及创伤、蛛网膜下腔出血和(或)卒中、哮喘、心脏疾病等伴随疾病]47例(28.0％).替代气道管理方式主要为单纯自主呼吸(69例,41.1％)和球囊面罩通气(34例,20.2％),前者多用于非心脏骤停患者,后者主要用于心脏骤停患者.暂缓建立PHAAM的患者发生的不良事件主要为反流误吸和低氧血症(脉搏血氧饱和度＜90％)各3例(1.8％).结论 目前上海市在院前急救过程中暂缓建立PHAAM的比例较高,制约院前建立PHAAM的因素较为复杂,其中患者因素、短距离护送和患者伴随疾病是主要原因.

Objective:To observe the influence of different extubation on the postoperative cognitive function in elderly patients with general anaesthesia. Methods:Eighty elderly patients scheduled by operation under general anaesthesia were randomly divided into the remifentanil-dexmedetomidine group(group R) and control group(40 cases each group). Two groups were induced using fentanyl-propofol-rocurunium bromide scheme, and maintained anaesthesia using propofol-remifentanil-cisatracuriumbesylate scheme. After operation,the group R patients were injected with 0. 03 μg · kg-1 · min-1 of remifentainil and 0. 01 μg · kg-1 · min-1 of dexmedetomidine until postextubation 5 minutes. The control group were injected with the same dose of 0. 9% sodium chloride until postextubation 5 minutes. The congnitive functions of all patients at preoperation,and postoperative 1 and 3 days were assessed using the Mini-Mental State Examination, and the levels of blood glucose and blood lactic acid in two groups were detected at preoperation, intubation and extubation. Results:The difference of the congnitive function between two groups before operation was not statistically significant(P>0. 05),and the scores of congnitive function in group R at postoperative 1 and 3 days were significantly higher than that in control group(P<0. 01). The differences of the congnitive function scores in group R between preoperation,postoperative 1 and 3 days were not statistically significant(P>0. 05),and the scores of congnitive function at postoperative 1 and 3 days were significantly lower than that before operation in control group(P <0. 01). The differences of the blood glucose level between preoperation and intubation,and blood lactic acid level between intubation and extubation in two groups were not statistically significant(P>0. 05). The differences of the levels of blood glucose and blood lactic acid between preoperation, intubation and extubation in group R were not statistically significant(P>0. 05). The level of blood glucose in control group at extubation was significantly higher than that in control group at preoperation and intubation,and group R(P<0. 01). The differences of the blood lactic acid levels at preoperation,intubation and extubation in control group were not statistically significant(P > 0. 05). Conclusions:The application of remifentainil and dexmedetomidine during extubation can decrease the influence of the postoperative cognitive function in elderly patients.

In recent years the main idea has been that reactive oxygen species (ROS) play an essential,though double-edged, role in cardioprotection: they may participate in reperfusion injury or may play a role as signaling elements during myocardial adaptation to ischemia. It has been demonstrated that pre-or postconditioning triggering is redox-sensitive, via a mitochondrial KATP-ROS-dependent mechanism.In these cardioprotective phenomenon a redox signal and inhibition of mPTP are required during myocardial reperfusion following the index ischemic period. Therefore, the role of ROS in reperfusion may be reconsidered as they are not only deleterious.