このスライドは、以下の論文の解説です。
Ramped versus sniffing position for tracheal intubation: A systematic review and meta-analysis. Am J Emerg Med. 2020
この論文では、気管挿管の姿勢としてRamp positionとSniffing positionを比較したランダム化比較試験のシステマティックレビューとメタ解析を行っています。
This case series analyzes 25 patients with tracheal stenosis treated between 2011-2021. Most patients were younger than 25 years old and the stenosis was caused by intubation in 23 cases. Surgical techniques included tracheal resection and anastomosis. Outcomes were successful in 23 cases, with only 2 cases experiencing restenosis. The conclusion emphasizes that tracheal resection and reconstruction can successfully treat stenosis when performed by experienced surgeons, with careful attention to anatomy and tension-relieving sutures for wound healing.
Airway stenosis resection and ltp d_chhetri_11-19-08vinhvd12
This document discusses tracheal stenosis, including its causes, evaluation, and treatment options. It covers endoscopic and open surgical approaches. Staged laryngotracheoplasty is described as the multi-step process of resecting scar tissue, lining the area with mucosa grafts, and placing stents to prevent restenosis. Different types of stents are compared. Surgical techniques like suprahyoid and infrahyoid releases can provide additional tracheal length for resection and anastomosis. Treatment is tailored based on the location and severity of stenosis, and whether a tracheostomy is already present.
Tracheostomy is an ancient surgical procedure where an opening is created in the trachea to allow for breathing. It has been performed since 3600 BC in Egypt. Modern indications include prolonged intubation, airway obstruction, difficulty managing secretions, and as an adjunct to head and neck or chest surgery where ventilation may be problematic. Potential complications range from minor bleeding or infection to serious issues like tracheal stenosis, tracheoesophageal fistula, or erosion into major blood vessels. Careful surgical technique and postoperative management can help reduce risks.
This case series analyzes 25 patients with tracheal stenosis treated between 2011-2021. Most patients were younger than 25 years old and the stenosis was caused by intubation in 23 cases. Surgical techniques included tracheal resection and anastomosis. Outcomes were successful in 23 cases, with only 2 cases experiencing restenosis. The conclusion emphasizes that tracheal resection and reconstruction can successfully treat stenosis when performed by experienced surgeons, with careful attention to anatomy and tension-relieving sutures for wound healing.
Airway stenosis resection and ltp d_chhetri_11-19-08vinhvd12
This document discusses tracheal stenosis, including its causes, evaluation, and treatment options. It covers endoscopic and open surgical approaches. Staged laryngotracheoplasty is described as the multi-step process of resecting scar tissue, lining the area with mucosa grafts, and placing stents to prevent restenosis. Different types of stents are compared. Surgical techniques like suprahyoid and infrahyoid releases can provide additional tracheal length for resection and anastomosis. Treatment is tailored based on the location and severity of stenosis, and whether a tracheostomy is already present.
Tracheostomy is an ancient surgical procedure where an opening is created in the trachea to allow for breathing. It has been performed since 3600 BC in Egypt. Modern indications include prolonged intubation, airway obstruction, difficulty managing secretions, and as an adjunct to head and neck or chest surgery where ventilation may be problematic. Potential complications range from minor bleeding or infection to serious issues like tracheal stenosis, tracheoesophageal fistula, or erosion into major blood vessels. Careful surgical technique and postoperative management can help reduce risks.
The document provides an overview of airway anatomy and management techniques. It describes the anatomy starting from the nose down to the trachea. It then discusses factors that can make the airway difficult and techniques for assessing the airway. It explains various airway management techniques including mask ventilation, use of airways, laryngoscopy, intubation, and alternative techniques like LMA and needle cricothyrotomy.
CXR and abdominal film interpretation for medical studentPatinya Yutchawit
1. The document provides guidance on interpreting chest x-rays and abdominal films through a systematic approach.
2. Key steps include evaluating technique and quality, checking for abnormalities in the airways, lungs, heart, diaphragm and other delicate areas. Common lung diseases and findings are described.
3. Interpreting abdominal films involves checking for bowel gas patterns, soft tissue masses, fluids, calcifications and bone abnormalities. Relating densities seen to different tissues helps with interpretation.
Clinical Practice Guidelines for Traumatic Brain Injury 2556Utai Sukviwatsirikul
Clinical Practice Guidelines for Traumatic Brain Injury 2556
แนวทางเวชปฏิบัติกรณีสมองบาดเจ็บ (Clinical Practice Guidelines for Traumatic Brain Injury) พิมพ์ครั้งที่ 1 2556
http://pni.go.th/pnigoth/wp-content/uploads//2013/10/Clinical-Practice-Guidelines-for-Traumatic-Brain-Injury.pdf
This document discusses parasagittal meningiomas, which are tumors that arise near the superior sagittal sinus. It describes the typical presentation, imaging characteristics, surgical approaches, and factors to consider during resection, such as venous anatomy and arterial feeders. The goal of surgery is to remove as much tumor as possible while preserving the superior sagittal sinus and draining veins when feasible.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
Decompressive craniectomy in Traumatic Brain Injuryjoemdas
Decompressive craniectomy is a surgical technique used to relieve increased intracranial pressure by removing a portion of the skull bone and opening the dura mater. It allows swollen brain tissue room to expand and reduces pressure. The document discusses the history of the procedure, indications such as severe traumatic brain injury and malignant stroke, types including decompressive hemicraniectomy and bifrontal craniectomy, potential complications like subdural fluid collections, and the role of later cranioplasty. While controversies remain, decompressive craniectomy can be life-saving for carefully selected patients with medically refractory elevated intracranial pressure.
Flaps are units of tissue transferred from one site to another while maintaining their own blood supply. There are several types of flaps classified by blood supply, proximity to defect, transfer method, and tissue contained. Key advantages include replacing tissue with like tissue and obtaining bulk. Careful patient evaluation and flap design are needed to choose the best option. Monitoring after surgery is also important to detect any vascular issues promptly.
The document discusses skull base surgery and tumors of the nasal cavity and paranasal sinuses. It provides details on the types of tumors that can occur in these areas, including images from CT and MRI scans. It also discusses the techniques, advantages, and complications of external skull base surgery. International studies on skull base surgery for malignant tumors are summarized, showing improvements in local control and survival rates over time based on factors like histology, extent of disease, and surgical margins.
This document discusses various strategies for managing acute respiratory distress syndrome (ARDS). It begins by describing the pathophysiology of ARDS including pulmonary capillary leak, surfactant inactivation, and diffuse lung injury. It then discusses early management strategies like mechanical ventilation using low tidal volumes and recruitment maneuvers. Alternative ventilation strategies are covered such as high frequency oscillatory ventilation, liquid ventilation using perfluorocarbons, and nitric oxide administration. Adjuvant therapies like secretion clearance techniques, incentive spirometry, and surfactant administration are also summarized. The document aims to provide an overview of ARDS management approaches.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
The document provides an overview of airway anatomy and management techniques. It describes the anatomy starting from the nose down to the trachea. It then discusses factors that can make the airway difficult and techniques for assessing the airway. It explains various airway management techniques including mask ventilation, use of airways, laryngoscopy, intubation, and alternative techniques like LMA and needle cricothyrotomy.
CXR and abdominal film interpretation for medical studentPatinya Yutchawit
1. The document provides guidance on interpreting chest x-rays and abdominal films through a systematic approach.
2. Key steps include evaluating technique and quality, checking for abnormalities in the airways, lungs, heart, diaphragm and other delicate areas. Common lung diseases and findings are described.
3. Interpreting abdominal films involves checking for bowel gas patterns, soft tissue masses, fluids, calcifications and bone abnormalities. Relating densities seen to different tissues helps with interpretation.
Clinical Practice Guidelines for Traumatic Brain Injury 2556Utai Sukviwatsirikul
Clinical Practice Guidelines for Traumatic Brain Injury 2556
แนวทางเวชปฏิบัติกรณีสมองบาดเจ็บ (Clinical Practice Guidelines for Traumatic Brain Injury) พิมพ์ครั้งที่ 1 2556
http://pni.go.th/pnigoth/wp-content/uploads//2013/10/Clinical-Practice-Guidelines-for-Traumatic-Brain-Injury.pdf
This document discusses parasagittal meningiomas, which are tumors that arise near the superior sagittal sinus. It describes the typical presentation, imaging characteristics, surgical approaches, and factors to consider during resection, such as venous anatomy and arterial feeders. The goal of surgery is to remove as much tumor as possible while preserving the superior sagittal sinus and draining veins when feasible.
This document summarizes several clinical trials related to critical care medicine. It discusses trials on topics such as decompressive craniectomy for traumatic brain injury, hypothermia for traumatic brain injury, erythropoietin for brain injury, blood pressure management for intracerebral hemorrhage, vasopressin versus norepinephrine for septic shock, dexmedetomidine for delirium, timing of renal replacement therapy for acute kidney injury, acetazolamide for chronic obstructive pulmonary disease, paracetamol for fever, balanced fluids versus saline, and transfusion thresholds.
Decompressive craniectomy in Traumatic Brain Injuryjoemdas
Decompressive craniectomy is a surgical technique used to relieve increased intracranial pressure by removing a portion of the skull bone and opening the dura mater. It allows swollen brain tissue room to expand and reduces pressure. The document discusses the history of the procedure, indications such as severe traumatic brain injury and malignant stroke, types including decompressive hemicraniectomy and bifrontal craniectomy, potential complications like subdural fluid collections, and the role of later cranioplasty. While controversies remain, decompressive craniectomy can be life-saving for carefully selected patients with medically refractory elevated intracranial pressure.
Flaps are units of tissue transferred from one site to another while maintaining their own blood supply. There are several types of flaps classified by blood supply, proximity to defect, transfer method, and tissue contained. Key advantages include replacing tissue with like tissue and obtaining bulk. Careful patient evaluation and flap design are needed to choose the best option. Monitoring after surgery is also important to detect any vascular issues promptly.
The document discusses skull base surgery and tumors of the nasal cavity and paranasal sinuses. It provides details on the types of tumors that can occur in these areas, including images from CT and MRI scans. It also discusses the techniques, advantages, and complications of external skull base surgery. International studies on skull base surgery for malignant tumors are summarized, showing improvements in local control and survival rates over time based on factors like histology, extent of disease, and surgical margins.
This document discusses various strategies for managing acute respiratory distress syndrome (ARDS). It begins by describing the pathophysiology of ARDS including pulmonary capillary leak, surfactant inactivation, and diffuse lung injury. It then discusses early management strategies like mechanical ventilation using low tidal volumes and recruitment maneuvers. Alternative ventilation strategies are covered such as high frequency oscillatory ventilation, liquid ventilation using perfluorocarbons, and nitric oxide administration. Adjuvant therapies like secretion clearance techniques, incentive spirometry, and surfactant administration are also summarized. The document aims to provide an overview of ARDS management approaches.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
骨盤骨折の身体所見の診断性能のシステマチックレビューとメタ解析の下記の論文の解説です。
外傷患者に対して骨盤骨折の有無の身体所見を診察しますが、その診断性能(診断精度)についてシステマチックレビューを行いました。*医療関係者向け
Diagnostic accuracy of physical examination for detecting pelvic fractures among blunt trauma patients: a systematic review and meta-analysis. World J Emerg Surg. 2020
Okada Y, Nishioka N, Ohtsuru S, Tsujimoto Y.
Oct 2;15(1):56. doi: 10.1186/s13017-020-00334-z.
PMID: 33008428
9. 方法
対象文献: 16歳以上成人の気管挿管適応
Ramp vs Sniffing のRCT
検索媒体: MEDLINE, CENTRL, Embase
Clinical trial.gov, WHO register
1次検索: Title, Abstractで評価
2次検索: Full textで評価
2人の独立した評価者
シミュレーション研究は除く
*Conflictは3rd reviewersとの協議で解決する
10. 検索式の一例
MEDLINE via Ovid
#1. exp Laryngoscopy/ or exp Laryngoscopes/
#2. exp Intubation, Intratracheal/ or intubat$.ti,ab.
#3. (sniff$ or ramp$ or head$ or body$ or position$).ti,ab.
#4. ((randomized controlled trial or controlled clinical
trial).pt. or randomized.ab. or placebo.ab. or clinical trials
as topic.sh. or randomly.ab. or trial.ti.) not (animals not
(humans and animals)).sh.
#5. (1 or 2) and 3 and 4
17. Study Collins, 2004 Lee, 2015 Semler, 2017
Design / Allocation unit Parallel /Individual patient Parallel /Individual patient Parallel /Individual patient
Country USA Korea USA
COI/ Funding source Unknown Unknown Declared
Setting OR in university hospital
OR in university and branch
hospital
ICU in four tertiary care centers
Inclusion criteria
BMI ≥40kg/m2 Expected difficult intubation Patients ≥ 18 years of age
Undergoing elective bariatric
surgery
Undergoing general anesthesia
Undergoing tracheal intubation
in ICU
Exclusion criteria None
Unstable cervical spine
Too emergent to perform
randomization
Rapid sequence intubation
Clinicians' judge for the safe
procedure
Total No of cases 60 193 260
Ramp/Sniffing Sniffing Ramp Sniffing Ramp Sniffing Ramp
The number of allocated 27 33 97 96 130 130
Age, median [IQR]/ mean
+-SD
43.3+-10.0 41.9+-8.9 50.7+-9.8 51.8+-8.1 56 [45-64] 56 [47-65]
Male, n, (%) 2 (7.4%) 6 (18.2%) 48 (49.5%) 49 (51.0%) 79 (60.8%) 79 (60.8%)
BMI median [IQR]/
mean +-SD
46.9+-7.1 49.9+-6.9 28.7+-5.9 29.6+-5.0
27.3
[24.0-32.6]
26.7
[23.9-33.3]
Indication for intubation
General anesthesia for Bariatric
surgery
General anesthesia Various
Performer The same one anesthesiologist
Residents or attending
anesthesiologists
Pulmonary and critical care
medicine fellow
Video-Laryngoscopy for
first attempt
None None 33 32
Second operator required None Unknown 1 4
Characteristics