Influence of epidural blockade on postoperative plasma fibronectin concentrations

To investigate the influence of neurogenic and hormonal stimuli during and after surgery on plasma fibronectin levels, 16 females undergoing cholecystectomy were studied. Eight patients received general anaesthesia, and eight also received a thoracic epidural block with local anaesthetic, which was maintained for 24 h postoperatively. The epidural group had significantly lower plasma levels of adrenaline and Cortisol than the general anaesthesia group in the postoperative period. The previously well-documented early decrease in plasma fibronectin concentration following surgery was observed, and was essentially parallel with that of albumin, pre-albumin and thyroid hormones, with no differences between the groups. However, the restoration of the fibronectin level was slower in the epidural group, with significantly lower values as compared with controls at 48 and 72 h after surgery (p<0.01–0.001). It was concluded that the post-traumatic plasma fibronectin decrease is not mediated by neurogenic or adrenal stimuli. Such stimuli may, however, influence the subsequent restoration of the plasma fibronectin concentration.     

The maternal and neonatal effects of the volatile anaesthetic agents desflurane and sevoflurane in caesarean section: a prospective, randomized clinical study

This study compared maternal and neonatal outcomes in women undergoing elective caesarean section under general anaesthesia with desflurane or sevoflurane; the neonatal effects were also compared with those in women undergoing epidural anaesthesia. Fifty women requesting general anaesthesia were randomly assigned to receive either 3% desflurane or 1% sevoflurane. Twenty-five women requesting regional anaesthesia received epidural anaesthesia with ropivacaine. Comparing desflurane sevoflurane with respect to their maternal haemodynamic effects, maternal blood pressure levels were higher and tachycardia was more frequent in the desflurane group. Comparing general and epidural anaesthesia, no significant differences were detected in terms of neonatal Apgar scores or neurological adaptive capacity scores. In conclusion, 3% desflurane or 1% sevoflurane for general anaesthesia and ropivacaine for epidural anaesthesia for elective caesarean section had similar effects on neonatal outcomes. In women who received desflurane, blood pressure and heart rate elevation were significantly higher than in the sevoflurane group, though this difference did not have any clinical importance.     

硬膜外阻滞复合全身麻醉对血浆儿茶酚胺的影响

目的：探讨硬膜外阻滞复合全身麻醉对机体应激反应的影响。方法：随机选择ASAI-Ⅱ级的肝癌和食管癌病人88例,分成两组：W组（44例）在诱导前硬膜外导管不加药,Y组（44例）则加入0.5%的布比卡因4ml,测定诱导前后的血压、心率、肾上腺素和去甲肾上腺素的值。结果：两组的心率和血压在诱导后（插管前）显著降低,Y组尤为显著（P＜0.05)。插管后Y组血压略有升高,而W组插管后血压明显上升,与Y组比较有统计学意义（P＜0.05);在插管前W组的儿茶酚胺显著高于Y组（P＜0.05）。插管后5min两组的儿茶胺都升高,W组尤为明显。插管后1h,Y组的肾上腺素和去甲肾上腺素的含量略增加（P＞0.05),而W组比插管后低（P＜0.05)。结论：硬膜外阻滞复合全麻能减少血浆CA的释放,在保持机体适度的应激反应能力的同时,控制亢进的反应。     

超低浓度罗哌卡因硬膜外阻滞复合全麻在老年患者上腹部手术中的应用

<正>老年人腹部大手术(肝癌手术、结肠癌手术、直肠癌手术等)占所有老年人大手术比例的50%以上,如何降低麻醉风险、减少并发症、实现老年患者的快速康复值得深入研究[1-2]。近年来,麻醉界较多采用全身麻醉+硬膜外阻滞的方式进行麻醉,罗哌     

Plasma fibronectin and complement following infusion of colloidal solutions after spinal anaesthesia

A randomized study of 30 patients undergoing uncomplicated surgery under spinal anaesthesia was conducted to assess the influence of colloids on the kinetics of plasma fibronectin and complement. Both are opsonins of the reticuloendothelial system; moreover fibronectin is concerned with host resistance against septic complications following trauma and surgery. The patients were assigned to receive either Ringer's lactate (Group 1), gelatin (Group 2) or dextran 40 (Group 3). Blood samples were withdrawn before colloids or Ringer's infusion and during the 4 postoperative days. There was a reduction in plasma fibronectin throughout the study in groups 1 and 3, but an increase in group 2 by 24h. The adhesion of plasma fibronectin to gelatin was maximal 1h after infusion (44%) and remained significant up to day 2 in group 2. There was no relationship in groups 1 and 3. C3 and C4 components of complement exhibited a low value in the early post-operative period, due to hemodilution. This study shows an in vivo fibronectin-gelatin interaction, and suggests that gelatin infusion inhibits the increased shift of plasma fibronectin at the site of tissue injury after surgery.The study was supported by a grant from the Cernep Synthelabo laboratory     

综合护理干预对女性甲状腺手术患者效果的研究

目的 探讨综合护理干预措施对颈丛麻醉下行甲状腺手术的女性患者的效果.方法 选取拟行甲状腺手术的女性患者71例,随机分为对照组(35例)和干预组(36例).对照组给予常规护理,干预组给予综合护理干预措施.比较两组患者术中及术后相关指标的变化.结果 颈丛麻醉下行甲状腺手术的女性患者术中心率、血压升高明显;干预组心率、血压低于对照组(P＜0.05);干预组术中疼痛程度显著低于对照组(P＜0.001);术后2 h和6 h于预组疼痛评分均显著低于对照组(P＜0.001).结论 颈丛麻醉下行甲状腺手术的女性患者处于应激状态;综合护理干预能够降低应激反应.     

Combined general and thoracic epidural anaesthesia: When is it indicated?

There has been a large volume of recent literature which supports the use of combined general/thoracic epidural anaesthesia and postoperative epidural analgesia in high risk patients. Much of this literature has focused on patients undergoing surgery to treat cancer, patients undergoing vascular surgery, and patients at high risk for cardiovascular disease. In these groups of patients, combined thoracic epidural and general anaesthesia, with continuation of epidural analgesia into the postoperative period, has been shown to have certain advantages over general endotracheal anaesthesia followed by postoperative intravenous opioid analgesia. However, how the anaesthetic is conducted may be more important than merely placing an epidural catheter prior to induction of general anaesthesia. In this review, the authors will examine the physiological and clinical data underlying the advantages of combined thoracic epidural/general anaesthesia, examine how the conduct of the anaesthetic may be an important influence on clinical outcome, and discuss the indications for this technique of anaesthesia and postoperative analgesia.     

不同麻醉方法对老年患者术后认知功能的影响

目的探讨不同麻醉方法对老年患者术后认知功能的影响。方法将110例拟行手术的老年患者按麻醉方法的不同分为2组:观察组和对照组,每组55例。观察组行硬脊膜外阻滞麻醉,对照组行全身麻醉。观察2组异丙酚、芬太尼使用量、术后疾病恢复时间及术后认知功能障碍发生的情况,并对2组麻醉前及术后6、24和72 h采用简易精神状态量表(MMSE)进行认知功能评分。结果与对照组比较,观察组术后6、24和72 h MMSE得分、异丙酚使用量均明显升高(均P<0.05),芬太尼使用量、术后认知功能障碍发生率均明显降低和术后疾病恢复时间明显缩短(均P<0.05)。结论硬脊膜外阻滞麻醉较全身麻醉对老年患者术后认知功能影响轻,术后认知功能障碍发生率低,且不增加麻醉药量,对老年患者实行硬脊膜外阻滞麻醉是最佳的选择。     

Proseal喉罩全麻复合硬膜外阻滞在老年病人上腹部手术中的应用

目的探讨Proseal喉罩全麻复合硬膜外阻滞在老年病人上腹部手术中应用的安全性、可行性。方法40例择期上腹部手术老年患者，美国麻醉师协会（ASA）分级Ⅰ-Ⅱ级，随机分为实验组（LE）、对照组（GE），每组20例。观察比较两组的血流动力学变化和术后并发症的发生情况。结果LE组较GE组患者血流动力学稳定，术后并发症少。结论Proseal喉罩全麻复合硬膜外阻滞可用于老年病人上腹部手术，插喉罩（拔喉罩）对血压、心率的影响不如气管导管剧烈，且全麻药用量更少，拔管反应和术后咽痛少。     

芬太尼增强左旋布比卡因硬膜外阻滞效果的临床研究

目的观察和比较不同剂量芬太尼和左旋布比卡因硬膜外麻醉用于骨科下肢手术。方法60例骨科下肢手术患者,ASAI或Ⅱ级,年龄22～60岁。随机分为三组,每组20例。Ⅰ组：为0．75左旋布比卡因10ml＋生理盐水2ml（对照）,Ⅱ组：为0．75左旋布比卡因10ml＋芬太尼50μg＋生理盐水至12ml和Ⅲ组：为0．75左旋布比卡因10ml＋芬太尼75μg＋生理盐水至12ml（观察）。结果芬太尼两组分别能够增强硬膜外左旋布比卡因的镇痛效果,同时明显改善患者术中不适反应和提高麻醉质量。50μg和75μg芬太尼组镇痛效果无统计学差异。结论50μg芬太尼可明显增强左旋布比卡因硬膜外麻醉效果,改善术中患者不适和提高麻醉质量,75μg芬太尼未见明显优势。     

Outcome of surgery for obstructive jaundice is not associated with reduced levels of plasma fibronectin

Reduced levels of plasma fibronectin have been implicated in the septicaemia and/or endotoxaemia that can accompany trauma or burns. Patients undergoing surgery for the relief of obstructive jaundice are also at risk of developing endotoxaemia or septicaemia. In this study, levels of plasma fibronectin were measured by immunoassay and bioassay in 16 such patients. No patient had a significantly reduced level of plasma fibronectin. Even in the case of patients developing a fatal septicaemia and general system failure there was no significant decrease in circulating fibronectin. It is concluded that measurement of plasma fibronectin is of no prognostic value and similarly infusion of fibronectin-rich cryoprecipitate would be of no therapeutic benefit.     

罗哌卡因丁丙诺啡硬膜外阻滞复合全身麻醉对上腹部手术应激反应的影响

目的:探讨罗哌卡因丁丙诺啡硬膜外阻滞复合全身麻醉对上腹部手术应激反应的影响。方法:60例择期行上腹部手术的患者,随机分成2组:观察组为罗哌卡因丁丙诺啡硬膜外阻滞复合全身麻醉,对照组为单纯气管插管全身麻醉。分别于麻醉前、切皮时、手术开始60 min、术后3 min采集静脉血检测血糖、血清去甲肾上腺素、肾上腺素、血清皮质醇含量;记录患者平均动脉压、心率、全身麻醉用药量及术毕清醒时间。结果:对照组患者血糖、血清去甲肾上腺素、肾上腺素、皮质醇浓度在切皮时、手术开始60 min、术后3 min明显高于麻醉前(P<0.01),且明显高于观察组(P<0.05,P<0.01),观察组患者平均动脉压、心率在切皮时、手术开始60 min、术后3 min均无异常波动,而对照组显著高于麻醉前(P<0.01)。全身麻醉药用量和术毕清醒时间观察组均明显少于对照组(P<0.05,P<0.01)。结论:罗哌卡因丁丙诺啡硬膜外阻滞复合全身麻醉用于上腹部手术可减轻术中的应激反应,对生理干扰小,术毕清醒快,是一种较好的麻醉方法。     

右美托咪定与咪达唑仑对老年患者呼吸抑制时异丙酚EC_(50)的影响

目的研究右美托咪定与咪达唑仑对老年患者呼吸抑制时异丙酚的半数有效浓度(EC50)的影响。方法选择硬膜外麻醉下行下肢手术的老年患者,年龄65⁸0岁,性别不限,ASAⅠ80岁,性别不限,ASAⅠ^Ⅱ级,随机分为三组,D组、M组和C组分别静脉泵注右美托咪定0.4μg/kg、咪达唑仑0.03 mg/kg和生理盐水。之后开启靶控输注(TCI)异丙酚,D组、M组和C组第1例患者的血浆靶浓度分别设定为1.4μg/ml、1.2μg/ml和2.2μg/ml。根据呼吸抑制的发生情况确定下1例血浆靶浓度,相邻靶浓度的比值为1.1。计算出三组异丙酚TCI时患者呼吸抑制的EC50。结果 D组、M组和C组呼吸抑制时异丙酚EC50分别为1.64μg/ml(95%可信区间为1.52Ⅱ级,随机分为三组,D组、M组和C组分别静脉泵注右美托咪定0.4μg/kg、咪达唑仑0.03 mg/kg和生理盐水。之后开启靶控输注(TCI)异丙酚,D组、M组和C组第1例患者的血浆靶浓度分别设定为1.4μg/ml、1.2μg/ml和2.2μg/ml。根据呼吸抑制的发生情况确定下1例血浆靶浓度,相邻靶浓度的比值为1.1。计算出三组异丙酚TCI时患者呼吸抑制的EC50。结果 D组、M组和C组呼吸抑制时异丙酚EC50分别为1.64μg/ml(95%可信区间为1.52¹.78μg/ml)、1.18μg/ml(95%可信区间为1.151.78μg/ml)、1.18μg/ml(95%可信区间为1.15¹.21μg/ml)和2.35μg/ml(95%可信区间为2.191.21μg/ml)和2.35μg/ml(95%可信区间为2.19².51μg/ml)。D组、M组的EC50明显低于C组,M组低于D组。结论右美托咪定和咪达唑仑均能降低老年患者呼吸抑制时异丙酚的EC50,右美托咪定降低异丙酚的EC50的幅度显著小于咪达唑仑。     

剖宫产术后硬膜外自控镇痛对催乳素影响的观察及护理

目的 :观察剖宫产患者术后硬膜外自控镇痛对催乳素 (PRL)的影响。方法 :选择足月妊娠剖宫产产妇 4 1例 ,随机分为两组 ,观察组 2 1例剖宫产术后硬膜外采用自控镇痛 (PCEA) ,对照组 2 0例术后肌肉注射镇痛药 (MI)。术后 72h监护心电图 (ECG)、心率 (HR)、无创血压 (NIBP)、初乳时间。用放射免疫分析法测定血浆催乳素浓度 ;用视觉模拟评分法 (VAS)评定镇痛效果 ;用Ramsay评分法测定镇静程度。结果 :VASPCEA组明显低于MI组 (P <0 0 1) ,两组术后 2 4h血浆PRL浓度较术前明显增高 (P <0 0 1) ,PCEA组 2 4、 4 8h血浆PRL浓度较MI组明显升高 (P <0 0 5 ) ;PCEA组初乳时间明显早于MI组 (P<0 0 5 )。结论 :剖宫产术后采用PCEA镇痛效果好 ,能增加PRL分泌 ,促进早泌乳     

The response of plasma fibronectin to acute myocardial infarction in humans

The purpose of this study was to investigate the plasma fibronectin response to complicated and uncomplicated acute myocardial infarction. All patients admitted to a Coronary Care Unit over a six-month period were prospectively assessed by measuring admission and daily plasma fibronectin levels using an electroimmunoassay. Of 166 patients admitted to the Unit, 66 were diagnosed as having an acute myocardial infarction. Plasma fibronectin levels were significantly lower 48 h after the onset of symptoms in 15 patients with a complicated acute myocardial infarction, compared to fibronectin levels in patients with an uncomplicated course; patients who had received intracoronary streptokinase had consistently higher plasma fibronectin levels than those seen in patients who did not receive this thrombolytic agent. This hepatocyte-derived plasma protein not only has diagnostic potential, but alterations in its levels may also provide insight into the systemic response to acute myocardial injury.     

Efficacy of thoracic epidural analgesia for laparoscopic cholecystectomy

Introduction Postoperative pain is a commonly observed phenomenon after laparoscopic procedures. The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with them is not sufficiently known. Optimally, analgesic therapy should be started in sufficient time as to be effective at the point of emergence from anaesthesia. We compared the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period. Methods Thirty adult patients with American Society of Anesthesiologists (ASA) physical status I–II, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the intravenous group (n=15) received general anaesthesia with sevoflurane and intravenous infusion of 1.5 μg/ml/kg/h fentanyl analgesia followed by postoperative intravenous infusion of 1.0 μg/ml/kg/h fentanyl, supplied by a programmed continuous analgesia pump. The patients in the epidural group (n=15) had combined epidural analgesia with 0.125% bupivacaine plus 50 μg fentanyl and general anaesthesia with sevoflurane, followed by continuous epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. Visual analogue scores and the patients’ needs for analgesics and were recorded.     

硬膜外麻醉与全身麻醉对老年患者术后认知功能的影响

目的研究探讨硬膜外麻醉与全身麻醉对老年患者术后认知功能影响的临床意义。方法随机选取美国麻醉医师协会Ⅰ～Ⅱ级、无严重心脑血管疾病、无重大呼吸循环系统疾病、未服用影响神经精神系统功能的药物且行择期骨科大手术的老年(≥65岁)患者150例,按所采用的麻醉方法的不同将患者分为硬膜外麻醉组(硬膜外组)和全身麻醉组(全麻组)。记录不同时间点的平均动脉压(BP)和心率(HR),采用简易智力状态检查(MMSE)法测定两组患者不同时间点的认知功能,最大评分为30分,≤23分即可认为发生了认知功能障碍(POCD)。结果两组患者在麻醉前、麻醉后手术前、手术30min时、主要手术步骤操作时、手术结束时的BP与HR比较差异无统计学意义(P>0.05);在麻醉后的24h,硬膜外组MMSE评分明显高于全麻组(P<0.05),其余时间点差异无统计学意义(P>0.05)。POCD发生率在麻醉后6h和12h硬膜外组发生率低于全麻组,分别为13.3%与6.7%、24.0%与20.0%,差异有统计学意义(均P<0.05)。结论在硬膜外麻醉与全身麻醉中,老年患者术后早期均可发生POCD,而全身麻醉在术后24h内对老年患者认知功能的影响比硬膜外麻醉更为明显。     

Haemodynamic, endocrine and nociceptive response to gynaecological procedures under epidural local anaesthesia during continuous epidural infusion or bolus epidural fentanyl dosing

This study aimed to evaluate the analgesic effects and hormonal responses of a single epidural bolus compared to continuous epidural infusion of fentanyl as supplements to intraoperative local epidural anaesthesia for major gynaecological surgery. Forty patients undergoing total vaginal hysterectomy were randomised to receive in a double blind fashion either 1.5 μg kg⁻¹ fentanyl epidurally (group A) or saline (group B) as bolus injections followed by epidural infusion of saline or fentanyl (0.7 μg kg⁻¹h⁻¹) respectively at a rate of 10 ml h⁻¹. Postoperative pain intensity was assessed by visual analogue scale (VAS). Prolactin and cortisol plasma levels were used as stress markers. The onset of anaesthesia was significantly shorter in group A (p<0.05) but the duration of T₁₀ blockade was significantly longer in group B (p<0.01). Pain intensity was significantly higher in group A at 90, 105 and 120 minutes after skin incision (p<0.001). There was no intraoperative difference in heart rate or mean arterial pressure between the two groups nor was there any difference in the incidence of adverse effects such as nausea, vomiting or shivering. Both groups had a progressive decrease in serum cortisol and prolactin concentrations 30 and 60 min after skin incision, but cortisol and prolactin concentrations were higher in group A (p<0.05) 120 minutes after skin incision.Our observations suggest that perioperative continuous epidural infusion of fentanyl begun intraoperatively attenuates the endocrine stress response, but a bolus dose of fentanyl given along with bupivacaine lacks this protective effect. A possible explanation for these findings is that an infusion begun intraoperatively, just after administration of epidural bupivacaine, prolongs the duration of sensory blockade and provides a better quality of analgesia, and thereby attenuates the endocrine response triggered by regression of the intraoperative level of anaesthesia.     

下腹部手术后自控镇痛的疗效及对血清补体系统的影响

目的:探讨硬膜外自控镇痛(PCEA)对下腹部手术后自控镇痛的疗效及对血清补体C3和C4的影响。方法:选择择期施行下腹部手术的患者60例,其中30例于术后行PCEA(PCEA组),另30例于术后肌内注射镇痛药止痛(对照组)。比较2组病例的镇痛效果,并分别测定术前12h及术后12、24、48h时补体C3、C4含量。结果:PCEA组患者术后伤口疼痛明显减轻;术后12h2组患者补体C3、C4含量均下降,术后48hPCEA组补体C3、C4含量回升,而对照组仍处于低水平。结论:下腹部手术后施行PCEA能有效地减轻术后伤口的疼痛,并能减轻应激反应所致的免疫抑制,从而保护机体的免疫功能,有利于机体的康复。     

Plasma fibronectin in idiopathic myelofibrosis and related chronic myeloproliferative disorders

Plasma fibronectin concentrations were measured in 49 patients with chronic myeloproliferative disorders and compared to sex- and age-matched controls. A significantly lower plasma fibronectin concentration was observed in patients with idiopathic myelofibrosis as compared with the control group (p less than 0.01). In addition, plasma fibronectin concentrations in myelofibrosis patients differed significantly, when compared with patients with polycythaemia vera (p less than 0.01), whereas no significant difference was found between myelofibrosis patients and those with a transitional myeloproliferative disorder or chronic myelogenous leukaemia (p greater than 0.05). An inverse relationship was demonstrated between plasma fibronectin and spleen size, the lowest plasma fibronectin levels being found in patients with large spleens. It is supposed that low plasma fibronectin concentrations in splenomegalic patients may be due to enhanced consumption of the opsonin in the expanded splenic mononuclear-macrophage system.