异丙酚靶控输注辅助臂丛阻滞麻醉清醒镇静临床观察

目的观察异丙酚靶控输注（TCI）辅助臂丛阻滞麻醉清醒镇静的临床效果。方法单侧上肢手术的病人120例，随机分成观察组和对照组，每组印例，观察组在麻醉确定后即采用Diprfusor/TCI技术按目标血药浓度1．70μg／ml泵入异丙酚，对照组不行预处理。记录并比较两组病人从术前到术后不同时点心率（HR）、血压（BP）及脉搏氧饱和度（SpO2），记录观察组镇静程度，评价麻醉效果以及回访病人的满意度。结果观察组病人泵人异丙酚后5min BP有下降趋势，HR相对平稳；对照组在手术开始后BP、HR有明显上升趋势（P〈0.05）；观察组术中OAA／S镇静评分为2～3分；麻醉效果评价及病人的满意度观察组明显优于对照组（P〈0．01）。结论异丙酚靶控输注辅助臂丛阻滞麻醉，采用目标血药浓度1．70μg／ml清醒镇静效果确切，可提高臂丛阻滞麻醉的麻醉质量。     

靶控输注丙泊酚/雷米芬太尼镇静在肾移植麻醉中的应用

目的：观察丙泊酚／雷米芬太尼靶控输注在肾移植麻醉中的镇静作用。评估靶控输注丙泊酚／雷米芬太尼镇静的安全性。方法：20例肾移植患者，分为两组，每组10例，均行腰硬联合麻醉，P组靶控输注丙泊酚，R组靶控输注丙泊酚／雷米芬太尼，消毒铺单后开始靶控输注，两组丙泊酚初始血药浓度（Cp）0．5μg／mL，当效应室浓度（Ce）与之平衡后，P组调整丙泊酚浓度（每次增加0．2μg／mL）至OAA／S评分2～3分，R组则按初始1ng／mL开始靶控输注雷米芬太尼，5min后调整为2ng／mL，当Ce与Cp平衡后调整丙泊酚浓度（每次增加0．2μg／mL）至OAA／S评分2～3分。术中出现躁动，则增加丙泊酚浓度至OAA／S评分1分，连续监测EEG、MAP、RR和SpO2。结果：两组患者在手术期间均表现出良好的镇静状态，但P组丙泊酚所需浓度明显高于R组（P〈0．05），R组与P组相比HR、RR下降明显（P〈0．05），两组MAP与给药前相比均有所下降，但两组间无明显差异（P〉0．05），苏醒时间R组（8．8±3．2）min，P组（14．6±3．6）min，P组术中出现两例躁动，术后出现1例，两组术中术后均未发生恶心、呕吐，且对术中无记忆。结论：肾移植麻醉时靶控输注丙泊酚／雷米芬太尼可以提供良好的镇静，对呼吸、循环影响小，苏醒迅速、完全，可控性好。[著者文摘]     

舒芬太尼靶控输注对全麻诱导大脑状态指数的影响

【目的】使用大脑状态指数（CSI）和改良警觉镇静评分（MOAA／s）观察靶控输注（TCI）异丙酚麻醉时舒芬太尼的对大脑状态指数影响。【方法】40例ASAⅠ～Ⅱ级全麻患者随机分为对照组和舒芬太尼组（各20例）。舒芬太尼组靶控输注舒芬太尼0．2ng／ml,效应室浓度稳定10rain后给予靶控输注异丙酚（维持靶控舒芬太尼）,对照组则只靶控输注异丙酚,靶浓度从0．5μg／mL开始,每5min递增0．5gg／mL,试验开始后每20S行改良警觉镇静评分（MOAA／S）评分并由电脑相应软件同步记录靶控泵每2S自动计算生成的效应室靶浓度及每1S产生的CSI值,全程记录血流动力学各参数值,至MOAA／s为0分后调整以原靶浓度继续5min停止研究。【结果】与对照组比较,舒芬太尼组丧失语言反应（LVC）和意识消失（LOC）出现在更高的CSI值和更低的异丙酚的效应室靶浓度（EC）值（P〈0．05）。研究计算得出了两组5％、50％及95％的患者出现LVC、LOC时CSI和异丙酚的EC（μg／ml）及其他们的95％可信区间。【结论】舒芬太尼明显增强异丙酚的临床镇静效果。研究得出的相应的CSI05、CSI50、CSI95和异丙酚的EC05、EC50、EC95及其他们的95％可信区间可以为CSI提供临床麻醉深度监测参考以及为靶控异丙酚提供类似于吸入麻醉药物肺泡最小有效浓度（MAC）的临床应用参考。     

丙泊酚伍用瑞芬太尼消除连续硬膜外麻醉患者术中知晓的研究

目的探讨麻醉安全状态下，丙泊酚伍用瑞芬太尼消除连续硬膜外麻醉患者术中知晓的可行性及两药的最佳用量。方法选择下腹部开腹手术患者60例，行硬膜外麻醉联合靶控输注异丙酚和瑞芬太尼（丙泊酚血浆靶浓度为1．5～2．5μg／ml、瑞芬太尼血浆靶浓度为0．5～1．5ng／ml），观察患者呼吸指标、循环指标、大脑意识状态指数和警觉／镇静观察评分，并对相关指标进行相关分析。此外，对患者进行调查，统计是否出现术中知晓。结果①丙泊酚血浆靶浓度为1．9～2．5μg／ml、瑞芬太尼血浆靶浓度为1．0～1．5ng／ml），大脑意识状态指数（CSI）在40～60区间时，患者无知晓，且呼吸循环等生命体征平稳。CSI与警觉-镇静（OAA／S）评分标准呈正相关，OAA／S降低，CSI值也随之降低，而且不同OAA／S评分之间的CSI值有统计学差异。②在呼吸、循环安全范围[最低标准呼吸频率（RR）〉8次／min，脉搏氧饱和度（SpO2）〉90％，心率（HR）〉50bpm，收缩压（SBP）改变〈30％基础值]内，CSI、OAA／S值与丙泊酚、瑞芬太尼两药剂量呈负相关。③当丙泊酚血浆靶浓度低于0．8～1．0μg／ml、瑞芬太尼血浆靶浓度为0．6～0．9ng／ml，CSI〉80时患者会出现术中知晓的情况。结论TCI丙泊酚伍用瑞芬太尼能有效消除CEA患者术中知晓。     

靶控输注不同浓度瑞芬太尼对脑电双频指数的影响

目的通过靶控输注不同浓度瑞芬太尼，研究其对脑电双频指数（BIS）的影响。方法美国麻醉学会手术前分级标准原则（ASA）Ⅰ～Ⅱ级择期全麻手术患者60例，随机分为3组（n=20）。瑞芬太尼靶控输注（TCI）靶浓度2．0ng／ml（Ⅰ组），4．0ng／ml（Ⅰ组），6，0ng／ml（Ⅲ组），记录给药前和达到预设效应室浓度1min后的心率（HR），平均动脉压（MAP），氧饱和度（SpO2），BIS和镇静警醒（OAA／S）评分。结果与给药前相比，靶控输注瑞芬太尼后，Ⅱ组Ⅲ组BIS降低明显（P〈0．05或P〈0.01），Ⅲ组OAA／S评分降低明显（P〈0，05）。与Ⅰ组相比较，Ⅱ组的BIS值降低有显著性差异（P〈0，05），Ⅲ组BIS值和OAA／S评分降低均有显著性差异（P〈0.05）。结论 瑞芬太尼靶浓度与BIS值呈负相关性，与OAA／S评分相比，BIS监测瑞芬太尼镇静效果更敏感与准确。     

靶控输注依托咪酯用于老年患者硬膜外麻醉清醒镇静的疗效

目的：观察依托咪酯用于老年患者硬膜外麻醉静脉靶控输注清醒镇静的可行性。方法：60例行硬膜外麻醉老年患者,分别予以依托咪酯（E组）和丙泊酚（P组）靶控输注,记录OAA／S评分为3分时两组的MAP、SpO2、HR值及0AA／s评分为5～1分时的CSI值。结果：P组患者出现MAP、SpO2、HR下降的例数多于E组,两组的OAA／S评分与CSI值呈正相关。结论：CSI值指导靶控输注依托咪酯可用于老年患者硬膜外麻醉清醒镇静。     

瑞芬太尼靶控输注用于无痛人工流产术的可行性分析

[摘要]　目的　探讨瑞芬太尼靶控输注（TCI）用于无痛人工流产术的可行性。方法　120例接受无痛人流术的病人，随机分成瑞芬太尼靶控输注组(TCI组)和瑞芬太尼静脉恒速输注组(C组)，每组60例。TCI组：瑞芬太尼血浆靶浓度为2μg/L。C组: 瑞芬太尼的用量为1.0μg/kg/h。待病人睫毛反射消失后开始手术，扩张宫颈结束时停止给药。结果　两组清醒时间、准确定向时间、麻醉效果、异丙酚总用药量及不良反应均无统计学差异（P>0.05）。结论　瑞芬太尼靶控输注和单纯静脉恒速输注效果相当，对于基层医院，采用单纯静脉恒速输注更为合理。 [关键词]　瑞芬太尼；靶控输注；人工流产     

异丙酚靶控输注用于小儿心导管治疗术

目的：观察异丙酚靶控输注用于小儿心导管治疗术对呼吸和循环功能的影响、术后恢复情况以探讨其可行性。方法：30例患儿随机分两组：P组，行异丙酚靶控输注，效应室浓度先从2μg／ml开始，2min后增至5～6μg／ml，待心导管进入股静脉或股动脉后，浓度减至2～3μg／ml。K组，行氯胺酮微泵持续输注，开始为50～60μg．kg^-1．min^-1，待心导管进入股动脉或股静脉后，浓度减至30μg．kg^-1．min^-1。测定术前、注药后2min、5min、术始、术中刺激最强时、术毕时的心率、平均动脉压、血氧饱和度、呼吸频率和每分钟通气量。停麻药后观察耳垂反应；术后观察唤名反应和完全清醒的时间。结果：异丙酚靶控输注组组内心率、血压、呼吸频率、每分钟通气量数值，麻醉后各时段与麻醉前相比较，差异无显著性。术后观察耳垂反应、唤名反应和完全清醒的时间均明显少于氯胺酮持续输注组。结论：异丙酚靶控输注用于小儿心导管治疗术的麻醉术中稳定，术后恢复平稳，可以安全地应用小儿心导管治疗术。     

两种椎管内麻醉方式对BIS引导异丙酚镇静效果影响

目的比较两种椎管内麻醉方式对BIS引导异丙酚镇静效果的影响。方法妇科择期开腹手术病人60例,随机分为腰椎硬膜外联合麻醉镇静组（A组）与硬膜外麻醉镇静组（B组）。两组病人均控制无痛阻滞平面T6～T8水平,阻滞平面固定后,异丙酚靶控输注镇静,血浆靶控起始浓度为1.2mg/L,达到预期血浆靶浓度后,每30s上调血浆靶浓度0.2mg/L,使BIS值达到70,术中维持BIS值在65～75范围内。比较两组切皮（T0）、腹腔探查牵拉子宫（T1）、冲洗腹腔（T2）及术毕（T3）异丙酚效应室浓度;比较两组异丙酚镇静初始用量、异丙酚总用量、手术时间、镇静时间;比较两组麻黄碱、阿托品使用率与输液量、出血量。结果与B组比较,A组各时间点异丙酚效应室浓度均明显降低（t=2.201～2.920,P〈0.05）;异丙酚镇静初始用量、异丙酚总用量减少（t=2.473、2.639,P〈0.05）;麻黄碱使用率增高（χ2=9.130,P〈0.05）;两组手术时间、镇静时间、输液量、出血量及阿托品使用率比较差异无显著性（P〉0.05）。结论腰椎硬膜外联合麻醉与硬膜外麻醉相比,可降低BIS引导异丙酚镇静的效应室浓度及用量,具有更明显的镇静作用。     

靶控输注异丙酚在无痛肠镜检查中的应用

目的:观察异丙酚靶控输注(TCI)技术应用于门诊无痛肠镜检查中的临床效果.方法:60例患者分为靶控输注组(T组)和手控输注组(M组),两组均先静脉注射芬太尼0.8～1 μg/kg,T组用TCI泵输注异丙酚,效应室浓度从2.5μg/mL开始,以0.5μg/mL递增,镜检过程中浓度维持在2.5～4.0μg/mL,M组用输液泵输注异丙酚60mg/(kg·h)的速率诱导,然后以6mg/(kg·h)的速率维持,两组术中根据体动反应、MAP及SpO<,2>变化情况调整异丙酚输注速率.观察记录异丙酚诱导量和总量、诱导时间、镜检持续时间、苏醒时间、术中呼吸循环的变化及不良反应.结果:与M组相比T组的麻醉诱导时间、苏醒时间、诱导所需的异丙酚用量均明显少于M组(P<0.05),术中不良反应率低于M组(P<0.5),术中血压下降幅度及低血压发生率比较差异有显著性(P<0.05),异丙酚总量及镜检时间两组差异无显著性.结论:靶控输注异丙酚应用于门诊无痛肠镜检查能达到满意的麻醉效果,稳定的血流动力学,较少的不良反应发生率,但在体弱或老年患者异丙酚TCI应从较低靶控浓度开始诱导.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.