七氟醚吸入与丙泊酚复合瑞芬太尼麻醉在全胃切除手术中的应用比较

目的：比较七氟醚吸入与丙泊酚复合瑞芬太尼麻醉在全胃切除手术中的应用效果。 方法：146例择期全胃切除术患者随机均分为对照组和观察组,对照组患者使用丙泊酚复合瑞芬太尼麻醉,观察组使用吸入性七氟醚。记录观察两组患者术后不良反应、术后恢复情况、术后的疼痛情况。 结果：术后观察组患者不良反应发生率明显低于对照组患者,差异有统计学意义（P<0.01）;两组术后恢复情况基本一致（P>0.05）;观察组在5 min至3 h的术后疼痛评分低于对照组（P<0.01）,24 h后,两组患者疼痛情况基本一致,患者疼痛均得到较好的控制（P>0.05）。 结论：七氟醚吸入麻醉或丙泊酚复合瑞芬太尼静脉麻醉均可安全应用于全胃切除手术,七氟醚吸入麻醉效果更好。

     

丙泊酚与瑞芬太尼静吸复合麻醉对腹腔镜胆囊切除术后认知功能的影响

目的 探讨丙泊酚与瑞芬太尼静吸复合麻醉与靶控静脉麻醉对老年腹腔镜下胆囊切除术患者术后认知功能的影响.方法选取择期行腹腔镜下胆囊切除术老年患者79例,以随机数字表法将患者分为A组34例和B组35例.B组予以丙泊酚与瑞芬太尼静脉麻醉复合吸入七氟烷麻醉,A组予以丙泊酚与瑞芬太尼靶控静脉麻醉.比较两组患者的手术时间、自主呼吸恢复时间、苏醒时间、拔管时间与定向力恢复时间;采用意识状态评分法（OAAS）评价患者拔管后即刻,拔管后1小时、3小时和24小时的意识状态;采用简易精神状态量表（MMSE） 评价患者术前24小时,拔管后1小时、3小时和24 小时的认知功能.结果两组患者手术时间、苏醒时间、拔管时间比较,差异均无统计学意义（t＝0.11～0.21,P＞0.05）;B组患者自主呼吸恢复时间、定向力恢复时间均短于A组,差异均具有统计学意义（t＝4.77和4.07,P＜0.05）.B组拔管后即刻OAAS评分高于A组（t＝3.67,P＜0.05）,拔管后1小时 MMSE评分高于A组（t＝4.61,P＜0.05）;其余各时点两组OAAS、MMSE评分比较,差异均无统计学意义（t＝0.07～1.07,P＞0.05）.结论丙泊酚与瑞芬太尼静吸复合麻醉用于老年腹腔镜下胆囊切除术患者具有满意的麻醉效果,较好的稳定了患者的术后意识状态及认知功能,对术后认知功能的影响较小,其效果优于丙泊酚与瑞芬太尼靶控静脉麻醉,对老年腹腔镜下胆囊切除术患者的手术麻醉具有一定的指导借鉴意义.     

全凭静脉麻醉与吸入麻醉用于老年腹部手术患者的临床观察

目的观察全凭静脉麻醉与全程吸入麻醉对老年腹部手术患者血流动力学及术后认知功能的影响。方法以90例择期进行腹部手术的老年患者为研究对象,按随机数字表法分为对照组(45例)和研究组(45例)。对照组予以七氟醚全程吸入麻醉,研究组予以丙泊酚联合瑞芬太尼全凭静脉麻醉。监测患者不同麻醉时刻HR、MAP和SPO2等血流动力学参数,记录术中血管活性药物使用情况,统计患者术后苏醒时间和拔管时间,评估患者术后认知功能水平。结果两组患者之间不同麻醉时点心率(HR)、平均动脉压(MAP)和血氧饱和度(SPO2)差异均无统计学意义(均P0.05);两组术中血管活性药物使用率(8.89%vs 13.33%)差异无统计学意义(χ~2=0.450,P=0.5020.05);研究组术后苏醒时间(6.33±1.57)分钟和拔管时间(8.91±2.06)分钟均显著短于对照组(9.05±1.94)分钟和(11.62±2.49)分钟(P0.05);研究组患者术后1小时、术后6小时和术后12小时MMSE评分均显著高于对照组(均P0.05)。结论全凭静脉麻醉与全程吸入麻醉均可有效维持老年腹部手术患者术中血流动力学稳定,且全凭静脉麻醉更有利于促进术后苏醒及认知功能恢复。     

七氟醚吸入麻醉与丙泊酚静脉麻醉对骨科大手术老年患者血液动力学及免疫功能的影响

目的探讨七氟醚吸入麻醉与丙泊酚静脉麻醉对骨科大手术老年患者血液动力学和免疫功能的影响。方法选择在本院进行骨科大手术的134例老年患者为研究对象,随机分为七氟醚吸入麻醉组(A组)与丙泊酚静脉麻醉组(B组),比较两组患者麻醉诱导前(t1)、插管即刻(t2)、插管后即刻(t3)及手术结束时(t4)的血氧饱和度(Sp O2)、脑电双频指数(BIS)、平均动脉压(MAP)、心率(HR)等指标,并检测t1、t4和术后1天(t5)CD4+细胞、CD8+细胞含量、CD4+/CD8+的比值、IL-2和IL-10水平。结果 A组和B组患者t2和t3时间点BIS、MAP、HR较t1时间点均明显下降,但A组下降的幅度明显低于B组,差异均具有统计学意义(P0.05)。与t1时间点比较,t4和t5时间点A组和B组患者CD4+细胞、CD4+/CD8+和IL-2水平均明显降低,且A组IL-2水平降低的幅度低于B组(P0.05)。B组t4和t5时间点IL-10水平明显升高,且高于同一时间点A组的水平(P0.05)。结论七氟醚吸入麻醉与丙泊酚静脉麻醉对骨科大手术老年患者T淋巴细胞亚群的影响无明显差异,但七氟醚吸入麻醉维持血流动力学的稳定状态优于丙泊酚静脉麻醉,且七氟醚吸入麻醉可减少对患者免疫功能的损伤。     

区域阻滞麻醉与老年患者术后神经系统功能、病死率关系的研究进展

背景 区域阻滞麻醉应用于老年患者手术日益增多,其对老年患者术后神经系统功能、病死率的影响有待总结. 目的 通过文献综述,分析区域阻滞麻醉对老年患者术后神经系统、病死率的影响. 内容 讨论区域阻滞麻醉与老年患者术后神经系统功能,包括术后谵妄、认知功能障碍、脑卒中以及与病死率之间的关系. 趋向 区域阻滞麻醉可以减少老年患者术后肺部并发症,减少术后早期认知功能障碍,与全身麻醉相比,具有一定优势.区域阻滞麻醉是否能降低老年患者术后病死率、心血管并发症发生率、谵妄发生率、围手术期脑卒中发生率尚有待于进一步研究.     

麻醉方式对鼻内镜手术鼻黏膜血流及术野的影响

目的 研究相同麻醉深度下雷米芬太尼-丙泊酚静脉麻醉及异氟醚吸入麻醉对血流动力学、鼻黏膜血流及术野清晰度的影响.方法 择期鼻内镜手术(ESS)患者30例,随机均分为雷米芬太尼-丙泊酚静脉麻醉组(T组)及氧化亚氮-氧-异氟醚吸入麻醉组(Ⅰ组).观察两组麻醉前、麻醉后10 min BP、HR、鼻黏膜血流灌注量(PU)、运动的血细胞浓度(CMBC)、血细胞平均运动速率(Ⅴ)及术野清晰度.结果 T组麻醉后10 min BP低于、HR慢于、PU、Ⅴ低于麻醉前(P<0.05);Ⅰ组麻醉后10 min BP低于麻醉前(P<0.05),但HR快于麻醉前(P<0.05),PU及Ⅴ麻醉前后差异无统计学意义.T组术野清晰度优于Ⅰ组(P<0.05).结论 与异氟醚吸入麻醉相比,雷米芬太尼-丙泊酚静脉麻醉可降低鼻黏膜血流,提高术野清晰度,适于ESS.     

学龄儿童丙泊酚全凭静脉麻醉和七氟醚吸入麻醉与静吸复合麻醉的比较

观察学龄儿童丙泊酚全凭静脉麻醉、七氟醚吸入麻醉与静吸复合麻醉围麻醉期血流动力学、脑电参数的变化,比较术中情况及术后苏醒过程,为学龄儿童临床全麻的应用提供参考.     

手术对肿瘤转移的影响以及麻醉对策

背景 手术会增加肿瘤的转移,影响肿瘤患者的长期预后. 目的 通过探讨手术影响肿瘤转移的机制来指导麻醉方法和药物的选择,从而减少肿瘤术后转移的机会. 内容 介绍了肿瘤转移的过程,以自然杀伤细胞(natural killer cell,NK)和T辅助(T helper,Th)细胞为例阐述了肿瘤与免疫的关系,分析了手术增加肿瘤转移的原因,着重讨论了围术期免疫功能抑制的影响因素,包括神经内分泌,炎症,垂体-下丘脑-肾上腺轴,低体温和输血等5个主要方面.麻醉可以通过β受体阻滞药,环氧酶(cyclo-oxyge-nase,COX)抑制剂,良好的镇痛,区域麻醉,谨慎选择吸入和静脉麻醉药以及保温和节约用血来减少手术对肿瘤转移的影响. 趋向 麻醉方法与药物的选择能减少肿瘤术后的转移复发,但仍需大量的前瞻性研究证实.     

七氟醚复合丙泊酚静吸复合麻醉对老年食管癌患者术后早期认知功能的影响

目的 观察七氟醚复合丙泊酚静吸复合麻醉对老年食管癌患者术后早期认知功能的影响.方法 择期食管癌根治术老年患者30例,ASA Ⅰ～Ⅲ级,年龄60～75周岁,随机均分为七氟醚复合丙泊酚麻醉组(S组)和丙泊酚全凭静脉组(P组).分别于手术前1天、术后第3天和第7天测定简易精神状态量表(MMSE)评分,并分别于麻醉前、术毕和术后第3天检测血清S1000β和血清神经元特异性烯醇化酶( NSE)的含量.结果 与手术前1d比较,两组患者术后第3天MMSE评分均降低(P<0.05),但组间差异无统计学意义,术后第7天恢复正常.S组术后出现轻度认知功能障碍的患者为4例(27%),P组为2例(13%).与麻醉前相比,两组患者术毕及术后第3天NSE的含量显著增高(P<0.05),但组间差异无统计学意义.结论 与丙泊酚全凭静脉麻醉相比,七氟醚复合丙泊酚静吸复合麻醉并不增加术后早期认知功能障碍的发生率.     

吸入七氟醚与丙泊酚复合雷米芬太尼麻醉在全胃切除手术中的比较

目的 比较七氟醚吸入与丙泊酚复合雷米芬太尼麻醉在全胃切除手术中的应用效果.方法 40例ASA Ⅰ或Ⅱ级择期全胃切除术患者随机均分为七氟醚组(S组)和丙泊酚复合雷米芬太尼组(P组).记录围麻醉期各时点的血流动力学、脑电双频指数(BIS)、麻醉药浓度及用量、麻醉恢复期时间和苏醒期不良反应.结果 麻醉期两组DBP、MAP、HR均较麻醉前显著下降(P<0.05).两组患者术中均能维持足够的麻醉深度(BIS 45～60),术中血流动力学平稳.麻醉恢复期P组躁动、呛咳发生率明显低于S组(P<0.05).结论 七氟醚吸入麻醉或丙泊酚复合雷米芬太尼静脉麻醉均可安全应用于全胃切除手术.     

Myocardial damage prevented by volatile anesthetics: a multicenter randomized controlled study

OBJECTIVE: The purpose of this study was to evaluate the effects of volatile anesthesia versus total intravenous anesthesia on cardiac troponin release in off-pump coronary artery bypass grafting (OPCAB). DESIGN: The authors performed a multicenter randomized controlled study to compare cardiac troponin release in patients receiving either volatile anesthetics or total intravenous anesthesia for cardiac surgery on the beating heart, which is an excellent model of human myocardial ischemia. SETTING: Three university hospitals. PARTICIPANTS: The authors randomly assigned 57 patients to desflurane (volatile anesthetic) and 55 patients to propofol (intravenous anesthetic) in addition to an opiate-based anesthesia for OPCAB. INTERVENTIONS: The 2 groups of patients received either desflurane (volatile anesthetic) or propofol in addition to an opiate-based anesthesia for OPCAB. Peak postoperative troponin I release was measured as a marker of myocardial necrosis. Prolonged hospitalization was considered as a secondary outcome. MEASUREMENTS AND MAIN RESULTS: Patient mean age was 69 years, and 82% were men. There was a significant (p < 0.001) reduction in postoperative median (25th-75th percentiles) peak of troponin I in patients receiving volatile anesthetics, 1.2 (0.9-1.9) ng/dL, compared with patients receiving total intravenous anesthesia, 2.7 (2.1-4.0) ng/dL. This myocardial protection resulted in a reduced (p = 0.04) number (percentage) of patients requiring postoperative inotropes, 20 (35%) versus 31 (56%), and a reduced number (percentage) of patients submitted to prolonged hospitalization (> or =7 days), 7 (12%) versus 20 (36%) in the 2 groups (p = 0.005). One patient receiving total intravenous anesthesia died within 30 days of surgery. CONCLUSIONS: Myocardial damage measured by cardiac troponin release could be reduced by volatile anesthetics during OPCAB. Because patients underwent cardiac surgery on the beating heart, these results could have implications for cardiac patients undergoing noncardiac surgery.     

Do inhalational anesthetics cause cognitive dysfunction?

Increasing evidence indicates that inhalational anesthetics may cause or increase the risk of developing postoperative cognitive dysfunction (POCD), especially in the elderly population. POCD may exist as a transient or long-term complication of surgery and anesthesia and is associated with reduced quality of life. There remains great discrepancy between clinical studies investigating the prevalence of POCD and inhalational anesthetics as many fail to show an association. However, numerous animal studies have suggested that inhalational anesthetics may alter cognitive function via amyloid β accumulation, modified neurotransmission, synaptic changes and dysregulated calcium homeostasis. Other factors such as neuroinflammation and pro-inflammatory cytokines may also play a role. This paper reviews the role of inhalational anesthetics in the etiology and underlying mechanisms that result in POCD.     

Randomized Controlled Trial of Total Intravenous Anesthesia with Propofol versus Inhalation Anesthesia with Isoflurane-Nitrous Oxide: Postoperative Nausea and Vomiting and Economic Analysis

Background: To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed.

Methods: Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed.

Results: Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms.     

Inhaled anesthetic enhancement of amyloid-beta oligomerization and cytotoxicity

BACKGROUND: The majority of surgical patients receive inhaled anesthetics, principally small haloalkanes and haloethers. Long-term cognitive problems occur in the elderly subsequent to anesthesia and surgery, and previous surgery might also be a risk factor for neurodegenerative disorders like Alzheimer and Parkinson disease. The authors hypothesize that inhaled anesthetics contribute to these effects through a durable enhancement of peptide oligomerization. METHODS: Light scattering, filtration assays, electron microscopy, fluorescence spectroscopy and size-exclusion chromatography was used to characterize the concentration-dependent effects of halothane, isoflurane, propofol, and ethanol on amyloid beta peptide oligomerization. Pheochromocytoma cells were used to characterize cytotoxicity of amyloid oligomers with and without the above anesthetics. RESULTS: Halothane and isoflurane enhanced amyloid beta oligomerization rates and pheochromocytoma cytotoxicity in vitro through a preference for binding small oligomeric species. Ethanol and propofol inhibited oligomerization at low concentration but enhanced modestly at very high concentration. Neither ethanol nor propofol enhanced amyloid beta toxicity in pheochromocytoma cells. CONCLUSIONS: Inhaled anesthetics enhance oligomerization and cytotoxicity of Alzheimer disease-associated peptides. In addition to the possibility of a general mechanism for anesthetic neurotoxicity, these results call for further evaluation of the interaction between neurodegenerative disorders, dementia, and inhalational anesthesia.     

Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: postoperative nausea with vomiting and economic analysis

BACKGROUND: To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed. METHODS: Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed. RESULTS: Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms. CONCLUSION: Propofol TIVA results in a clinically relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia (number needed to treat = 6). Both anesthetic techniques were otherwise similar. Anesthesia costs were more than three times greater for propofol TIVA, without economic gains from shorter stay in the postanesthesia care unit     

Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach

Study objectiveEarly post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium.DesignSingle Center Observational Study.SettingPost Anesthesia Care Units at a German tertiary medical center.Patients30,075 patients receiving general anesthesia for surgery.MeasurementsDelirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models.Main resultsOut of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model.ConclusionsOur exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.     

Perioperative cerebral ischemia and the possibility of neuroprotection by inhalational anesthetics

Deteriorated neurological outcome is not rare after major surgeries. With aging of the surgical population in Japan, an increasing frequency of perioperative cerebral ischemia is expected. To avoid neurological deterioration after surgery and general anesthesia, especially in high-risk patients, it is important to provide appropriate CNS-oriented anesthesia management. Controlling factors such as cerebral perfusion pressure, arterial blood gases, blood glucose concentration and body temperature may influence brain metabolism and neurological outcome. Inhalational anesthetics may also play an important role in perioperative neurological management, because numerous studies have demonstrated some degree of neuroprotective effect with halothane, sevoflurane, desflurane and isoflurane. Among these inhalational anesthetics, isoflurane has been most extensively studied regarding neuroprotection against cerebral ischemic insult. Although no clinical outcome trials have been performed, both in vivo and in vitro studies have consistently shown that the isoflurane provides neuroprotection. However, it is also suggested that factors such as sympathetic reactivity, brain temperature, anesthetic dosage, timing of anesthetic administration, and co-administration of nitrous oxide might affect the neuroprotective effect of isoflurane.     

脑电双频谱指数监测提高麻醉管理及全麻苏醒质量Meta分析研究

目的 评价脑电双频谱指数（BIS）监测是否改善麻醉管理和麻醉苏醒质量。方法按照制定的检索策略检索Pubmed和Medline—CDRom数据库（1990年1月至2004年1月），随后按照一定的入选原则找出符合要求的文献。按已制定的研究评价标准进行筛选，共10篇文献纳入最终的Meta分析。结果 BIS监测在镇痛药用量一致的情况下可减少催眠药物的用量。吸入麻醉中BIS监测可减少吸入麻醉药用量，但肌松药用量增加。BIS组病人睁眼时间、言语指令反应恢复时间、拔管时间、定向力恢复时间均缩短。BIS监测对术后恶心呕吐及术后疼痛的发生率没有影响。BIS监测减少术中知晓与术后记忆发生的证据尚不足。结论 BIS监测能减少全身麻醉中药物用量并提高麻醉苏醒质量。     

Perioperative pain control and mortality

Surgical stress response affects the neuroendocrine system and depresses the immune function. Anesthetic induction drugs (except propofol), volatile anesthetics and opioids also have an immunosupressive effect. Therefore, it is possible that the anesthetic drugs and methods may contribute to the recurrence of cancer after surgery. COX inhibitors prevent the opioid-induced tumor growth and metastasis, and regional anesthesia is expected to reduce the cancer recurrence via attenuating the surgical stress and reducing the amount of general anesthetics and opioids. Although some experimental studies and some clinical retrospective data show advantage of regional anesthesia over general anesthesia and opioid for postoperative analgesia, evidence level is still low and insufficient to prove its efficacy on postoperative mortality. Much more research and controlled clinical trials are needed to elucidate the advantage of the regional anesthesia in cancer operation.