肺炎专题

专家答疑

“新冠肺炎疫情防控专家答疑平台”目前收集到的问题主要涵盖了医护防护、医疗流程、院感管理、科室工作、人文呵护等方面。中华医学会麻醉学分会和中国医师协会麻醉学医师分会邀请常务委员、委员、青年委员等专家对问题进行实名制答疑解惑。请各位同道根据所在医疗机构的客观条件和相关规定具体执行,专家的答疑意见仅供参考。
专家答疑平台系列(双语版)作者如下:
卞金俊,陈向东,程宝莉,曹学照,戴茹萍,董海龙,邓小明,方向明,郭向阳,黄文起,李茜,李师阳,李天佐,林云,刘艳红,路志红,罗爱林,梅伟,米卫东,马虹,彭宇明,宋丹丹,苏殿三,谢克亮,徐懋,王东信,王国林,王天龙,王云,王钟兴,吴安石,夏中元,杨丽芳,俞卫锋,朱涛,赵磊,张林忠,张宗泽,左明章

中华医学会麻醉学分会 中国医师协会麻醉学医师分会 主办 (策划:米卫东 黄宇光)
中华医学会麻醉学分会青委会 协办 (编辑及英文翻译协调人:王晟,龚亚红)
  • 乙醚可以杀灭病毒,其他吸入麻醉药物(七氟烷和地氟烷等)可以杀灭病毒吗?哪些麻醉药物对重要脏器有保护作用?
    提问来自:.
    2020/03/15

    很有趣的问题,但恐怕这并不会成为麻醉药物应用的新领域。

    乙醚可以杀灭冠状病毒的原因是,作为一种脂溶剂,可以将包含脂质成分的冠状病毒包膜破坏,从而杀灭病毒。但值得注意的是,这些都是体外完成的,将乙醚用作体内抗病毒药物尚无先例。杀灭病毒所需的乙醚浓度远高于临床安全的乙醚浓度(麻醉浓度仅需3.6%)。我们可以看到目前体外杀灭病毒多为短时间使用50%以上浓度的乙醚,对最低浓度的报道是20%乙醚,但需持续使用16h以上,且效果不确切(Crandell RA. J Clin Microbiol. 1975)。这些剂量是我们无法加用在患者身上的。尽管尚无其他新型吸入麻醉剂与冠状病毒的研究,但根据其结构和脂溶特性,它们有可能干扰病毒的包膜,但效应要弱于乙醚,可以推测杀灭病毒所需的浓度也将更高。通过给患者吸入麻醉的方式想要达到能杀灭病毒的肺泡浓度从理论上来讲是不可能的。此外,目前的研究尽管提示新型的吸入麻醉剂如七氟烷和地氟烷有着潜在的肺保护作用,但总体来说麻醉药物对呼吸系统的效应是不良影响和有益效应并存的。对于已经发生了肺部损伤、炎性反应机制已经被激活的新冠状病毒肺炎患者,麻醉药物的有益效应恐怕微乎其微。对麻醉药物的使用应当局限于有镇静、镇痛、肌松等需求的患者。

    The idea is interesting, but I’m afraid anti-virus therapy would not be a novel area for the application of anesthetics.

    The antiviral mechanism of ether is based on its lipo-solubility. It can destroy the lipid in the envelope of the coronavirus. However, the evidences were all based on in vitro study. There has been no report of in vivo antiviral effect of ether. Moreover, the concentration needed for killing virus is much higher than that needed for anesthesia (about 3.6%). In the in vitro studies on antiviral effect of ether, the protocols were short-term use of high concentration ether (higher than 50%), or long-term (longer than 16 hour) use of lower concentration ether (the lowest concentration reported was 20%). And the effect of the latter was questioned (Crandell RA, J Clin Microbiol,1975). Ether with such high concentration could be lethal for patients. Though there has been no study on the antiviral effect of the novel inhaled anesthetics, theoretically their lower lipo-solubility compared with ether means higher concentration needed for killing virus. It’s impossible for the anesthetists to achieve an alveolar concentration high enough to reach the antiviral level. Furthermore, though there had been evidences supporting the potential organ protective effect of novel inhaled anesthetics including sevoflurane and desflurane, the effect of these agents on respiratory system have pros and cons. Patients with COVID-19 could have severe injury of the respiratory system, the use of inhaled anesthetics may not show protective effect and we should weigh the benefit.  

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    答疑来自:董海龙,路志红 Dong Hailong,Lu Zhihong
    2020/03/15
  • 右美托咪啶在新冠肺炎患者有创及无创加强通气供氧中镇静镇痛之外对改善支气管周围血管收缩引起减轻肺炎改变是否有作用?
    提问来自:.
    2020/03/15

    (1)、右美具有拮抗儿茶酚胺释放、抑制交感神经、加强迷走神经活性等作用,细胞和动物研究提示右美能够抑制巨噬细胞NLRP3炎性体通路减轻炎症反应、经由α2AR/PI3K/Akt信号途径抑制肺上皮细胞的凋亡以及减轻ROS氧化应激等机理缓解急性肺损伤;

    (2)、临床研究文章证明无创或者有创通气患者使用右美,能够改善肺通气血流比,还有研究显示其对心脏有保护作用,而这次新冠肺炎显示对心脏的攻击比较明显,这是它的优势;

    (3)、新冠肺炎一个重要、特异性的病理生理机制就是通过结合ACE2受体、进而干扰其相关的整个肾素血管紧张素系统,右美能够抑制交感系统活性继而抑制肾素生成,可能通过这个机制而发挥保护作用(有待临床及基础研究证实)。

    (1) 、Dexmedetomidine is a specific and selective alpha-2 adrenoceptor agonist.It inhibits the release if norepinephrine, therefore, causes the decrease of sympathetic tone by binding to the pre-synaptic alpha-2 adrenoceptors. The cell level and animal experiments showed that Dexmedetomidine could decrease the lung injury by reliving the NLRP3 inflammasome dependent inflammation in macrophage, reducing the apoptosis of lung epithelial cells through α2AR/PI3K/Akt pathway, and alleviating ROS involved oxidative stress response.

    (2) 、Clinical trials have observed that the use of dexmedetomidine is associated with improved outcomes for both invasive and non-invasive mechanically ventilated patients. And evidences also supported it had cardiovascular protective effect, therefore, dexmedetomidine may benefit COVID-19 patients whose cardiovascular system had been attacked by the virus.

    (3) 、Studies showed that ACE2 receptors binds to the novel coronavirus with affinity about 10- or 20-fold higher than its binding to the SARS virus. And the high binding affinity may disturb the function of the whole renin-angiotensin-aldosterone system. As mentioned above, the dexmedetomidine decrease the sympathetic tone, so it may rescue the disorder of the RAS.(clinical and experimental evidence are needed)

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    答疑来自:方向明、程宝莉 Fang Xiangming,Cheng Baoli
    2020/03/15
  • 肺表面活性物质是否有用?
    提问来自:.
    2020/03/15

    (1)、从病理生理机制上,SARS、MERS及目前的新冠肺炎,肺部病理生理机制均涉及肺表面活性物质减少,适当补充应该能够纠正ARDS;

    (2)、文献上,未见直接使用肺表面活性物质治疗成人冠状病毒肺炎的证据;

    (3)、氨溴索是国内团队通过计算机模拟筛选出的ACE2受体阻滞剂,同时也能够促进肺表面活性物质产生,可能能够提供间接的证据。

    (1)、The autopsy pathologic examinations revealed that, the novel coronavirus triggers inflammatory symptoms in the respiratory tracts and air sacs of the lungs, and the lungs exhibited edema, proteinaceous exudate, focal reactive hyperplasia of pneumocytes with patchy inflammatory cellular infiltration which were always reported in the condition of ARDS. So from mechanism-based hypothesis, the pulmonary surfactant should work in COVID-19.

    (2)、However, till now, there are no clinical or experimental evidences directly supported the application of pulmonary surfactant in adult COVID-19 patients.

    (3)、Ambroxol, which was reported as a candidate drug to treat COVID-19, is a mucolytic agent, could enhance pulmonary surfactant production.This may be an indirect evidence. 

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    答疑来自:方向明、程宝莉Fang Xiangming,Cheng Baoli
    2020/03/15
  • 尽早给患者采用CRRT,会不会有更好的治疗效果?
    提问来自:.
    2020/03/15

    (1)、临床表现提示,新冠肺炎患者转为重症危重症,可能与肺外器官严重损伤有关(如肾、心等),ACE2受体在心、肾中高表达也支持这个现象[1-2];

    (2)、CRRT是重症医学一项成熟的器官支持技术,不仅替代肾脏功能,还能够减轻肺水、加吸附柱还能够清除炎症介质、细菌毒素,减少脏器损伤,有观点认为CRRT可以清除新冠肺炎的炎症风暴,尤其是合并AKI时,早点上应该会更好(不仅是清除炎症介质,也利于液体管理,减少肺部渗出,改善肺氧合);比较积极的是:一旦发现尿量减少小于0.5ml/kg/h持续6小时或以上,或肌酐有升高(即存在AKI),就可以上。抗凝的使用,现在一般选择低分子肝素,有明显出血风险的,则选择枸橼酸局部抗凝,即在引血端使用枸橼酸钠,回血端使用钙剂中和;

    (3)、然而,目前CRRT的应用也存在有争议,一是穿刺操作带来的风险,二是CRRT设备、超滤液/吸附柱和专业操作人员的要求较高,在一线使用增加医疗工作负荷及资源消耗(防护服等),有一定局限性,三是如对循环影响可能进一步激活肾素血管紧张素系统(一线大规模早期应用还是需要临床证据支持)

    (1)、Clinical presentation among reported critically ill cases of COVID-19 showed complications including cardiac injury, acute kidney injury, septic shock, and multi-organ failure;

    (2)、Continuous renal replacement therapy (CRRT) is commonly used to provide renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. It could reduce the pulmonary edema, help clearing the proinflammatory factors and relive the organ injury. So some experts supported that we should apply the CRRT to severe and critical ill cases ASAP to shut down the inflammatory storm; Timing of Initiation:urine output≤0.5ml/kg/h for more than 6hrs,or serum Cr inscreases sharply; anticoagulating agents: we generally select Low-molecular-weight Heparin and sometimes use sodium citrate/calcium agent to avoid haemorrhage;

    (3)、However, there remained some debates about CRRT in COVID-19: Firstly, the risk of the invasive manipulation; sencondly, the facilities and physicians/nurses who could run the CRRT were limited; thirdly, the potensial effect on RAS through disturbing the hemodynamics stability.(clinical and experimental evidence are needed)

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    答疑来自:方向明、程宝莉Fang Xiangming,Cheng Baoli
    2020/03/15
  • 胸片可以代替CT吗?
    提问来自:.
    2020/03/15

    不能。早期胸部平片多无异常发现。核酸检测阳性的普通型患者,多表现为两肺中外带和胸膜下的局限性斑片状,或多发节段性片状阴影为主。胸片对新冠肺炎患者早期渗出性病变不能及时发现,病变初期多无异常发现,漏诊率高,不推荐使用。

    No, X-ray could not replace chest CT scan. In early stage, no abnormal in chest radiograph was founded in most cases. The common findings of chest X-ray manifests as peripheral and subpleural localized opacification, or multiple patchy consolidation in patients with positive results of nucleic acid testing. Early exudative lesions cannot be detected by X-ray in COVID-19 patients. Thus X-ray is not recommended to be used at early stage because of no abnormalities and the high rate of false negative.


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    答疑来自:王东信,彭宇明Wang Dongxin,Peng Yuming
    2020/03/15
  • 新冠感染患者,急诊手术全身麻醉期保护性肺通气策略?
    提问来自:.
    2020/03/15

    新冠肺炎患者由于全身及肺部严重的炎症反应,肺顺应性受到明显损害,气道由于炎症状态其反应性也会急剧增加,因此全身麻醉期间肺保护性通气策略需要采用通气保护策略联合全身给药。具体方法为:

    (1)、提供有效抗应激措施,防止由于抗应激不足导致机体内环境紊乱,加重全身炎性反应,且由于严密防护的时限性不主张采用全麻联合外周神经阻滞,可以给与充分剂量瑞芬太尼,辅助给与右美托咪定;

    (2)、采用目标导向液体管理联合预防性缩血管药物,实施限制性输液管理方案;

    (3)、给与抗炎药物乌司它丁10000单位/kg,抑制过重炎性反应;

    (4)、维持患者心率在基线心率80%至120%范围内,特别是老年患者;

    (5)、如果术中气道分泌物过多,建议静脉给与戊乙奎醚0.5~1.0mg;

    (6)、实施肺保护性通气策略,包括低潮气量6~8ml/kg,PEEP(5-10cmH2O), 每小时肺复张性通气手法,在确保动脉血氧饱和度100%前提下,使用最低吸入氧浓度;

    (7)、根据需要对气道进行吸引清理。

    For COVID-19 patients, the lung compliance and airway reactivity are heavily affected by severe systematic and pulmonary inflammatory response, so it is necessary to combine protective pulmonary ventilation strategies with systematic medication. The details are as follows:

    (1)、To prevent the internal environmental disorders and the aggravation of systemic inflammatory response which are caused by insufficient anti-stress, effective anti-stress measures such as sufficient remifentanil infusion assisted with dexmedetomidine should be taken. General anesthesia combined with peripheral nerve block is not recommended because of the time limitation in OR.

    (2)、Infused fluid volume should be restricted through goal-directed fluid therapy combined with preventive vasoconstrictive medication.

    (3)、Ulinastatin infusion of 10,000 U/kg can effectively inhibit excessive inflammatory response by surgery and anesthesia.

    (4)、Heart rate should be maintained between 80% and 120% of baseline heart rate, especially for elderly patients;

    (5)、If there are excessive airway secretion during operation,0.5~1.0mg intravenous penehyclidin is considerable;

    (6)、Protective pulmonary ventilation strategies includes low tidal volume of 6~8 ml/kg, PEEP 5~10 cmH2O, lung recruitment maneuver 3-5 times/h, and keep the inspired fraction of oxygen as low as possible provided that SaO2can be maintained at 100%;

    (7)、Keep airway clear with aspirator.

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    答疑来自:王天龙,赵磊Tianlong Wang, Lei Zhao
    2020/03/15
  • 抑制分泌物用什么药比较好?
    提问来自:.
    2020/03/15

    抑制气道分泌物的最佳药物为抗胆碱药物,此类药物包括戊乙奎醚(长托宁),东莨菪碱,阿托品和格隆溴铵,在这些药物当中,戊乙奎醚除外抑制气道分泌物外,还具有改善肺部顺应性的效应,可适用于儿童和成人,由于在上述四种药物中,戊乙奎醚最易通过血脑屏障(戊乙奎醚>东莨菪碱>阿托品>格隆溴铵),影响神经元的神经递质胆碱的合成及传递,导致术后谵妄的风险增加,因此不建议用于老年患者,如果要用于老年患者推荐剂量不超过0.008mg/kg。老年患者不通过血脑屏障的格隆溴铵可能是较好的选择,麻醉前用药的剂量为0.005-0.01mg/kg,成人最大剂量0.2-0.3mg。

    Anticholinergic agents, including penehyclidin, scopolamine, atropine and glycopyrronium bromide are considered as clinical option to inhibit airway secretion. Among these drugs, penehyclidin can not only inhibit airway secretion, but also improve lung compliance, which is suitable for both adults and children. But penehyclidin is inappropriate for the eldly patients, because it is the easiest to cross the blood-brain barrier comparing to other anticholinergic agents (penehyclidin> scopolamine> atropine> glycopyrronium bromide), which can increase the risk of postoperative delirium in elderly patients by affecting the synthesis and transmission of neurotransmitter acetyl choline. If the use of penehyclidin on the aged cannot be avoided, the recommended dosage is no more than 0.008mg/kg. For eldly patients, glycopyrronium bromide may be a better choice since it is hard to cross the blood-brain barrier. The dose is 0.005~0.01mg/kg as pre-anesthetic drug and the maximum dose for adult is 0.2~0.3mg.

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    答疑来自:王天龙,赵磊Tianlong Wang, Lei Zhao
    2020/03/15
  • 如何做好科室的院感管理?
    提问来自:.
    2020/03/15

    科室应遵循所在医院的院感管理方案或流程,结合科室手术间条件、设备及人员等因素,因地制宜,制定适用于本科室的感控管理预案或流程。原则上,应当加强所属全部人员的培训考核,对此次新型冠状病毒肺炎的流行病学和临床特征予以充分掌握,可参考中华医学期刊网“新型冠状病毒肺炎防控和诊治专栏”发表的最新文章学习。科室应加强麻醉科、手术室环境、设备及医疗废弃物的感控管理,落实并细化各项感控制度。应加强新冠肺炎疑似病例的排查工作,根据患者的不同类型,采取不同的麻醉及相应的防护措施。对确需手术或急诊插管的患者,具体流程可参照《麻醉科防控新型冠状病毒肺炎工作建议(第一版)》、《新型冠状病毒肺炎围术期感染控制的指导建议》等。

    The department should first follow the protocol or document of infection control released by the hospital, and then make applicable plan or protocol for their own. In principle, the training and assessment of all anesthesia care providers should be strengthened. All staff should fully understand the epidemiology and clinical characteristics of COVID-19, which can be learned from the latest articles published in the column of prevention, control and diagnosis of COVID-19 by Chinese Medical journal Network (http://medjournals.cn/2019NCP/index.do). At the department level, Infection control measures, safety of operating room environment, management of equipment and medical waste should be focused on and strengthened. Implementation of every infection control measure should be emphasized. Any procedure during the pandemic of COVID-19 should be fully evaluated to make sure whether the patients is with COVID-19 or not, and then choose appropriate  anesthesia method and protective measures. For patients who need emergent surgery or tracheal intubation, procedures should follow  "Anesthesia and Nursing Standard Operation Protocol in the Operating Rooms for Patients with Suspected and Confirmed NOVID-19" released by CSA and CAA, "Recommendations for tracheal intubation in critically ill COVID-19 patients (Version 1.0) " released by CSA Task Force on Airway Management.


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    答疑来自:邓小明,卞金俊(Deng Xiaoming, Bian Jinjun)
    2020/03/15
  • 如何避免手术室及恢复室内患者的交叉感染?
    提问来自:.
    2020/03/15

    在疫情期间,应尽可能选择神经阻滞、椎管内麻醉等非全麻方式,避免将手术室的患者送至恢复室进行苏醒、气管拔管等操作。为疑似或确诊的新型冠状病毒肺炎患者实施手术麻醉时,应严格遵循三级防护标准和转运标准。如为全身麻醉患者,应在手术室内苏醒并气管拔管;若患者无法或不需要气管拔管,则应直接经专门转运通道,送至ICU等科室进一步治疗。如为非全身麻醉患者,应按照相应标准送回原病房等。在疫情较严重的地区,可将所有患者视为潜在的疑似患者,有条件的话均宜采取二级或三级防护。

    During the epidemic of COVID-19, regional anesthesia including peripheral nerve blocks and neuroaxial  anesthesia should be preferred than general anesthesia. Patients with general anesthesia should be woken up and extubated in the operating room, not the PACU, for recovery. The Third-level protection and transport criteria should be strictly followed when performing anesthesia and procedures for patients with COVID-19 confirmed or suspected. If tracheal extubation is not required, unable or unnecessary, the patient should be directly transferred to ICU or other departments for further management through predefined transport channels. Those who underwent non-general anesthesia should be returned to their original wards according to relevant standards. In areas considered as severe pandemic, all patients may be considered as COVID-19 suspected, and the second or third protection should be taken where possible.


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    答疑来自:邓小明,卞金俊Deng Xiaoming, Bian Jinjun
    2020/03/15
  • 没有负压手术室,怎么开展新冠感染病例手术麻醉工作,是否能在正压手术室做手术?手术结束后,中央空调及层流净化如何处理?
    提问来自:.
    2020/03/15

    如没有负压手术室,不建议开展新型冠状病毒感染患者的手术麻醉,确诊患者可转至当地指定定点医院如公共卫生中心进行手术治疗。如为必须立即实施的紧急手术,且只有正压手术室条件时,必须做到增加手术室内排风,使洁净手术室保持不低于5Pa负压,人为创造一个负压环境。可以考虑手段的手段如下:1)更换该手术室的排风机,加大排风量;2)如该手术室有外墙,增加带高效过滤器的排风装置后,可直接向外排放;3)如该手术室位于内部,则在非洁净区走廊侧设置带高效过滤器的排风装置,并向该区域排放。同时,非洁净区走廊窗户或通向外部的门应打开。
        在手术结束后,应当更换回风口和排风口过滤器。擦拭并消毒排风口、回风口与送风口。但不用更换天花板送风装置内的高效过滤器。如过滤器不合格或效率交叉,则难以确保飞沫不进入管道,还应消毒管道。
        若无负压手术室,条件允许还可在空旷地临时搭建帐篷或板房临时手术间为疑似或确诊患者实施手术,或者使用远离大手术室外的小型手术室,以减少对大手术室的污染。

    If there is no negative pressure operating room, it is not recommended to perform anesthesia and surgical procedures for patients with COVID-19. Patients should be transferred to a designated hospital such as public health center for further therapy. If an emergent procedure should be performed immediately, and only with positive pressure operating room, preparation and measures are as follows. Increase the exhaust air in the operating room to keep the negative pressure of the clean operating room no less than 5Pa, artificially creating a negative pressure environment. 1) replace the exhaust blower in the operating room and increase the exhaust air volume; 2) if the operating room has an external wall, the exhaust device with a high-efficiency filter can directly discharge the air outward; 3) if the operating room is located interior, the exhaust device with an efficient filter can arranged at the side of the corridor and discharge the air to the non-clean area. Meanwile, open windows or doors outside the non-clean area.

    After the operation, the air in and  out filter should both be replaced. Please wipe and disinfect the exhaust outlet, air in and air out. There is no need to replace the high-efficiency particulate air in the ceiling air supply unit. If the filter is not qualified or working well, unable to prevent the entry of droplets into the pipeline, the pipeline should be also sterilized.

    When there is no negative pressure operating room, it is allowed to temporarily set up a tent or board room in the open area to perform operations for patients with COVID-19 suspected or confirmed if possible. Another choice is using a small and remote operating room far away from the major operation center or unit, so as to reduce the underlying pollution to a less extent

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    答疑来自:邓小明,卞金俊Deng Xiaoming, Bian Jinjun
    2020/03/15