机械通气患者留置胃管技术进展

机械通气是治疗各种呼吸衰竭的重要方法之一,此类患者经常需要留置胃管进行负压引流或鼻饲,有效地插入胃管对帮助患者恢复作用关键。但对于机械通气患者会出现不能一次成功置管的情况,其主要原因是机械通气患者常伴有不同程度的意识障碍和各种棘手问题,如不能做吞咽动作配合、

呼吸机呼气末插胃管技术的临床应用

机械通气患者由于不能经口进食，为保证患者能摄入足够的营养，满足机体的代谢需要，促进身体的康复，往往需要置胃管进行鼻饲。但机械通气患者按常规方法留置胃管操作难度大，患者耐受性差，一次性插管成功率低，有报道称，对于昏迷、镇静状态下或清醒不合作的患者可采用“探针法”、“气管导管导引下胃管插管法”、“喉镜直视下插胃管方法”等。由于以上方法在置入胃管时对患者的体位要求较高，对操作者的技术要求也较高，还需要多人合作才能完成，不适用于临床推广。我科通过改善置管方法，采用在呼吸机呼气末、送气开始时插胃管，取得了较好效果，现报道如下。

冻硬法插胃管解除全麻诱导期所致急性胃扩张

目的:介绍一种为解除全麻诱导期急性胃扩张而采用的冻硬法插胃管技术。方法:遇有全麻诱导期急性胃扩张的病人,将普通胃管放入冰箱(-20℃)中冰冻3min以变硬。插入该冻硬的胃管以解除急性胃扩张。观察1次试插成功率、3次试插失败率及插入所需平均时间。结果:6736例全麻病人,诱导期发生急性胃扩张356例。冻硬法插胃管的1次试插成功率可达72.27%,3次试插失败率仅1.25%,平均操作时间为3min。结论:冰箱冻硬胃管后插入法可迅速便捷地解除全麻诱导期所致的急性胃扩张。

难置鼻胃管的护理对策

鼻胃管置入法是基础护理中常用的护理技术操作之一．大多数护士都能熟练掌握，但临床置管困难，置管异常的现象仍时有发生。随着人们要求的日益增高，常规的鼻胃管置入法已不能满足清醒患者、特殊患者的置管需要。为此，对鼻胃管置入的研究更加注重个体化与操作方法的多样化^[1]。在实践中我们进行了大量的尝试，针对不同患者采取各异的置管方法、自制带芯胃管应用于临床并对常规插胃管技术做了改良，取得较好的效果，提高了置胃管一次成功率，现报道如下。

介绍一种婴儿经口留置胃管的方法

经口留置胃管技术一般应用于乳牙尚未萌出,同时存在经鼻留置胃管禁忌的患儿。但经口插入胃管时患儿恶心强烈,容易导致胃管插入不畅,盘曲在口腔中。因此,如何使改善插入胃管时患儿的舒适状况,并使胃管置入更加顺畅,成为护士关注的重点。我们经过不断探索和改良,采用一种新的方法经口留置胃管。现将此方法介绍如下：

急诊置胃管失败原因及对策

置胃管是临床上常用的基础护理操作技术，是每一个急诊护士必须掌握的基本技能。如何正确、及时地置入胃管关系到洗胃的效果，甚至关系到患者的安危。临床工作中我们常遇到胃管置入困难、置管失败的情况。如果一次置管不成功，不但延误抢救时机使病情加重，而且还会损伤患者食道黏膜，增加患者对置胃管的恐惧和痛苦，以至造成插管失败的恶性循环。在连续快速置胃管技术应用之前，我院急诊科曾用一年的时间（2005年2月～2006年1月）对急诊置胃管失败现象做了专题研究，现将研究结果报告如下。

用胃管哺喂初生仔猪

强壮的仔猪吃过初乳后便自动回到哺育箱里去,而弱小的仔猪却嘬住母猪乳头不放,以期得到维持生命的初乳。仔猪初生重低并不是问题,而仔猪互相竞争才是一个关键。我们用哺乳前后称取仔猪体重的办法,摸清了每头新生仔猪在出生后一小时内大约吸入80～100毫升初乳。一定要设法让体重轻及羸弱的仔猪吃到这一数量的初乳,以提高成活率。我们用简便的胃管技术给弱小仔猪喂初乳,取得了满意效果。胃管技术具有特殊的功效。

两种改良法固定鼻饲管385例

神经内科患者由于意识障碍,球麻痹,咽反射迟钝或消失,常采用留置胃管技术给患者进行胃肠营养。笔者所在科自2007～2009年共有留置胃管患者385例。均采用复尔凯（FR14）鼻胃管,插管深度为55～65cm。笔者发现传统固定法弊端较多,不适合临床应用,改良了两种鼻饲管固定法,现介绍如下。

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue.Treatment of heterotopic pancreas may include expectant observation,endoscopic resection or surgery.The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection(EMR) for resection of heterotopic pancreas of the stomach.Two patients(both female,mean age 32 years) were referred for management of gastric subepithelial tumors.Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa.Band ligation-assisted EMR was performed in both cases without complications.Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa.Margins were free of pancreatic tissue.Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Ductal adenocarcinoma of the pancreatic head:A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

口含维生素C片插胃管效果观察

目的对需要留置胃管的病人,给其口腔含化一片维生素C,诱发唾液分泌,诱发吞咽反射,从而提高插管成功率。方法对需要留置鼻胃管的101例病人,随机分为观察组48例和对照组53例,对照组采用传统方法插胃管,观察组在插胃管之前1min,口腔含化1片维生素C,其他操作方法同对照组。结果观察组病人唾液分泌增多,吞咽活动自然,并且能连续数次吞咽,一次插胃管成功率为91.7%,对照组病人一次插胃管成功率为58.5%(P<0.01);观察组病人呛咳发生率为4.2%,对照组为22.6%(P<0.01);观察组呕吐发生率为4.2%,对照组为24.5%(P<0.01);观察组病人主诉舒适率为85.4%,对照组为47.2%(P<0.01);观察组插管时间较对照组短(P<0.01)。结论对需要留置胃管的病人,如果无特殊禁忌症,可在插管前1min口腔含化1片维生素C,以诱发和刺激唾液分泌,能提高一次插胃管成功率。