冠心病患者腹部手术全麻诱导气管插管过程中自主神经功能的变化

目的 探讨冠心病非心脏手术患者在全麻诱导气管插管过程中自主神经系统功能的变化。方法 应用心率变异性(HRV)分析法对30例择期冠心病患者腹部手术(Ⅰ组)和30例择期无冠心病腹部手术患者(Ⅱ组)麻醉前、麻醉诱导后、气管插管后的心率变异性改变进行分析。结果 麻醉诱导后Ⅰ组LF、HF、LF／HF、TP显著降低，Ⅱ组LF、LF／HF及TP亦显著降低而HF未见明显改变。气管插管后两组HRV值均显著升高；组间比较显示，麻醉诱导后及气管插管后Ⅰ组HF和TP显著低于Ⅱ组，而LF组间无明显差异。结论麻醉诱导气管插管过程中，冠心病患者述走神经活性及总自主神经张力显著低于非冠心病患者，表明冠心病患者迷走神经对心脏窦房结的调控作用严重受损。     

静脉注射利多卡因对老年冠心病非心脏手术围插管期心率变异性的影响

目的：研究静脉注射利多卡因在全麻诱导气管插管期间对老年冠心病自主神经系统功能的影响。方法：选择90例择期腹部手术老年冠心病患者．随机分成利多卡因组（L组n=45）和安慰剂组（P组n=45）．分别于麻醉前（T0）,麻醉诱导后（T1）及气管插管后（T2）用心率变异功率谱分析（HRPSA）技术观察患者的心率变异性（HRV）改变。结果：麻醉诱导后．两组HRV总功率频段（TP）和其中低频段（LF）,高频段（HF）．LF／HF（低频／高频比）均显著降低（P〈0．05）．组间比较L组LF低于C组（P〈0．05）;气管插管后,两组LF、HF、LF／HF及TP均显著升高（P〈0．05）．组间比较L组LF与LF／HF升高程度显著低于P组（P〈0．05）,HF组间差异无统计意义。结论：静注利多卡因能明显抑制插管操作引起植物神经功能的干扰．有利于维护老年冠心病患围插管期心脏自主神经调节功能。     

七氟醚和丙泊酚对老年冠心病患者麻醉诱导期心率变异性的影响

目的 观察七氟醚和丙泊酚对老年冠心病患者全麻诱导期心率变异性(HRV)的影响.方法 40例择期行上腹部手术老年冠心病患者,年龄60～80岁,ASAⅡ或Ⅲ级,随机均分为七氟醚(S组)和丙泊酚(P组):分别予4%七氟醚或靶控输注丙泊酚3μg/ml行麻醉诱导.分别记录麻醉前(基础值)、诱导后5、10、15、20 min SBP、DBP、HR及HRV的变化.结果 与麻醉前比较,诱导后5、10 min两组SBP、DBP下降,HR减慢(P＜0.05).诱导后5、15 min P组SBP、DBP显著低于S组,P组HR快于S组(P＜0.05).在麻醉诱导中,S组主要是低频(LF)逐渐降低,P组则是高频(HF)逐渐降低.结论 与靶控输注丙泊酚麻醉比较,七氟醚吸入麻醉对血流动力学影响较轻,诱导相对平稳,更适合老年冠心病患者的麻醉诱导.     

利多卡因对老年冠心病非心脏手术围插管期心率变异性的影响

目的研究静脉注射利多卡因在全麻诱导气管插管期间对老年冠心病患者自主神经系统功能的影响。方法 90例择期腹部手术老年冠心病患者,随机分为静注利多卡因1.5 mg/kg组(L组)和对照组(P组),每组45例。分别于麻醉前(T0)、麻醉诱导后(T1)及气管插管后(T2)用心率变异功率谱分析(HRPSA)技术观察患者的心率变异性(HRV)变化。结果 T1时两组HRV低频段(LF)、高频段(HF)、低频/高频(LF/HF)和总功率频段(TP)均显著降低(P0.05),L组LF低于P组(P0.05);T2时两组LF、HF、LF/HF及TP较T0、T1时均显著升高(P0.05),T2时L组LF与LF/HF升高程度显著低于P组(P0.05)。结论静注利多卡因能明显抑制插管操作引起植物神经功能的干扰,有利于维护老年冠心病患者围插管期心脏自主神经功能。     

雷米芬太尼对患者心率变异性的影响

目的 探讨麻醉诱导期雷米芬太尼对患者心率变异性(HRV)的影响.方法 择期行气管插管全麻患者60例,年龄19～55岁,随机分为三组,每组20例.麻醉诱导时R1组、R2组和R3组分别用雷米芬太尼1、1.5和2μg/kg.记录诱导前(T0)、气管插管前即刻(T1)、气管插管后即刻(T2)及插管后1 min(T3)、3 min(T4)、5 min(T5)患者HRV中的低频功率(LF)、高频功率(HF)、标化的低频功率(LFnu)、标化的高频功率(HFnu)、LF/HF比值及SBP、DBP、HR的变化.结果 与T0时比较,T1时三组BP均明显降低(P＜0.01),而R3组T2～T4时仍明显偏低(P＜0.05);R1组T2～T5时HR增快(P＜0.05或P＜0.01);R1组T1～T5时LF、HF、T5时HFnu明显降低,LF/HF值明显升高(P＜0.05或P＜0.01).结论 以1.5μg/kg雷米芬太尼麻醉诱导可预防气管插管时血流动力学反应,维持自主神经调节的均衡性.     

盐酸右美托咪定对老年冠心患者全麻气管插管期心率变异性的影响

目的：研究盐酸右美托咪定（dexmedetomidine．Dex）在全麻诱导气管插管期间对老年冠心病患者自主神经系统功能的影响。方法：98例择期腹部手术老年冠心病患者．随机分成盐酸右美托咪定（D组n=49,诱导前给予负荷剂量右美托咪定0．7ug,／0g．注射泵缓慢静脉注射．输注时间超过10rain．维持剂量以0．4ug/（kg·h）持续静脉注射）和安慰剂组（P组n=49．诱导前静脉注射等容量氯化钠溶液）．分别于麻醉前（To）．麻醉诱导后（T1）及气管插管后（T2）用心率变异功率谱分析（heart rate Power spectrum analysis．HRPSA）技术观察患者的心率变异性（heart rate variability．HRV）改变。结果：麻醉诱导后．两组HRV总功率频段（TP）和其中低频段（LF）、高频段（HF）．LF／HF（低频／高频比）均显著降低（P〈O．05）．组问比较D组LF低于P组（P〈O．05）;气管插管后,两组LF、HF及TP均显著升高（P〈O．05）,而D组的LF／HF较麻醉前（T0）差异无统计意义,P组的LF／HF较麻醉前（T0）显著升高（P〈O．05）：组间比较D组LF、TP升高程度显著低于P组（P〈0．05）．HF组间差异无统计学意义。结论：盐酸右美托咪定能明显抑制插管操作引起的对植物神经功能的干扰,有利于维护老年冠心病患者围插管期心脏的自主神经调节功能。     

雷米芬太尼对上腹部手术患者心率变异性的影响

目的观察雷米芬太尼对上腹部手术患者心率变异性(HRV)的影响。方法择期胃癌手术患者40例,年龄35~60岁,随机均分为雷米芬太尼全麻组(R组)和硬膜外阻滞复合全麻组(E组)。观察麻醉前(T0)、麻醉诱导后插管前(T1)、腹腔探查时(T2)、手术1h(T3)、2h(T4)和拔管后10min(T5)的平均动脉压(MAP)、心率(HR)和HRV各参数:低频功率(LF)、高频功率(HF)、低频功率/高频功率比(LF/HF)、总功率(TP)。结果与T0时相比,E组T3和T4时TP下降(P<0.05),低频百分率(LFR)、高频百分率(HFR)、LF/HF变化不明显;R组TP、LFR均明显下降(P<0.01),LFR、LF/HF低于E组(P<0.05或P<0.01)。E组T2时HFR明显下降(P<0.01),TP、LF/HF升高不明显;R组TP、HFR明显升高(P<0.01),而LFR、LF/HF明显下降(P<0.01)。E组HR在T2时与术中比有明显升高(P<0.01),R组HR在T2~T4时明显下降(P<0.01)。结论硬膜外复合全麻可维持植物神经的均衡性。雷米芬太尼显著兴奋迷走神经,易致交感-迷走神经失平衡。     

两种控制性降压方法对老年患者心率变异性的影响

目的 观察雷米芬太尼或硝酸甘油复合七氟醚控制性降压对老年患者心率变异性(HRV)的影响.方法 40例行鼻内窥镜手术患者,年龄60～74岁,静吸复合全麻,分为A、B两组,A组(n=22)以0.2 μg·kg-1·min-1持续输注雷米芬太尼,B组(n=18)以0.5 ng·kg-1·min-1持续输注硝酸甘油.根据血压变化调整速度及七氟醚呼末浓度,将SBP降低至基础值的70%左右.记录降压过程中HRV及SBP、HR,术毕记录苏醒时间及呼吸恢复情况.结果 降压过程中A组HR较降压前明显减慢,B组明显增快;复压后A组HR无明显变化,B组明显减慢(P<0.01);降压过程中A组LF、HF、LF/HF均较降压前显著下降,B组LF、HF较降压前显著下降,但LF/HF显著升高(P<0.01);复压后两组LF、HF较复压前明显升高,但A组LF/HF无明显变化,B组LF/HF显著下降;A组有2例拔管后出现呼吸抑制.结论 雷米芬太尼复合七氟醚降压更适用于老年患者,但术后应加强呼吸管理.     

三种喉镜对老年患者气管插管应激反应的影响

目的探讨直接喉镜、视频喉镜、SOS喉镜对老年患者麻醉诱导心率变异性(HRV)及血流动力学的影响。方法拟行全麻手术气管插管的老年患者90例,ASAⅠ或Ⅱ级、BMI 18~24kg/m2,年龄65~80岁,随机均分为直接喉镜组(M组)、视频喉镜组(G组)和SOS喉镜组(S组)。三组患者采用相同的全身麻醉诱导方法,分别记录麻醉诱导前(T0)、麻醉诱导后(T1)、插管即刻(T2)、插管后1min(T3)、3min(T4)、5min(T5)的SBP、DBP、HR及各时点的HRV频域分析指标:低频(LF)、高频(HF)、标化的LF(LFnu)、标化的HF(HFnu)、LF/HF,并记录三组插管时间和插管引起的并发症。结果与T0时比较,T1、T4、T5时三组患者SBP、DBP明显降低(P0.05或P0.01);T2、T3时M组,T2时G组HR明显增快(P0.01)。与M组比较,T2时S组HR明显减慢(P0.01)。三组患者不同时点HRV、LF、LFnu、HF、HFnu差异无统计学意义;与T0时比较,T2~T4时M组和G组LF/HF明显升高(P0.05);与M组比较,T2、T3时S组LF/HF明显降低(P0.05)。S组的插管时间明显短于M组(P0.01);术后随访M组1例牙齿脱落、2例咽痛、1例声嘶,G组3例咽痛、1例声嘶,S组1例咽痛。结论直接喉镜、视频喉镜、SOS喉镜均可用于老年患者气管插管,但SOS喉镜更适用于老年患者。     

硬膜外复合丙泊酚静脉麻醉对老年人脑电双频谱指数和心率变异的影响

目的　探讨老年人硬膜外复合丙泊酚静脉麻醉中脑电双频谱指数 (BIS)和心率变异性(HRV)的改变。方法　择期腹部手术病人 4 0例 ,按年龄分成年轻组和老年组。诱导前T8～ 1 1 穿刺置管 ,咪唑安定 0 1mg/kg、丙泊酚 1mg/kg、维库溴铵 0 1mg/kg、芬太尼 3μg/kg诱导后插管 ,丙泊酚4mg·kg 1 ·h 1 恒速泵入维持麻醉 ,术中每 4 5～ 6 0min硬膜外追加局麻药 3～ 5ml,静注芬太尼 1～2 μg/kg、维库溴铵 0 0 5mg/kg。记录入室后、诱导后、插管后、术中及清醒睁眼时的BIS、低频与高频比值 (LF/HF) ;记录手术时间、术中用药情况、术中发生低血压和心动过缓次数。结果　两组平均年龄分别为 (31 4 4± 6 6 9)岁和 (71 0 0± 5 1 5 )岁 ,P <0 0 1。手术时间分别为 (1 96 1 1± 36 94 )和(2 0 8 34± 2 4 0 0 )min ,P >0 0 5。用药情况及各时点BIS值未见显著性差异 ;组间诱导和插管后的LF/HF有显著性差异 (P <0 0 1 ) ;两组低血压发生率分别是 2 0 %和 5 5 % ,P <0 0 5 ;心动过缓发生率分别是 1 0 %和 2 0 % ,P >0 0 5。结论　BIS可较好地反映硬膜外复合丙泊酚静脉全麻的镇静深度 ,且不受年龄影响 ,心率变异的LF/HF可较好地反映老年人围麻醉期间自主神经功能的均衡性 ,为老年人围术期的管理提供有益的指     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Development of Selective Low-Density Lipoprotein (LDL) Apheresis System: Immobilized Polyanion as LDL-Specific Adsorption for LDL Apheresis System

Abstract: Low-density lipoprotein (LDL) is widely recognized as one of the major risk factors for developing coronary heart diseases. Despite intensive development of LDL-lowering drugs, there still exist those patients with refractory hyperlipidemia whose plasma LDL levels are not sufficiently lowered by drugs. LDL apheresis, direct removal of plasma LDL from circulating blood, is thought to be the most promising treatment for such refractory patients. Various techniques, such as the use of an im-munoadsorbent utilizing an anti-LDL antibody, have been used in an attempt to achieve the selective removal of LDL. However, none were widely used because of complications, poor selectivity, and so forth. To establish a safe and effective LDL apheresis system, we chose a synthetic affinity adsorbent as the LDL-removing device. Synthetic polyanion compounds were used as the affinity ligands for LDL adsorbent to simulate the anion-rich sequence of LDL binding sites in the human LDL receptor. Among various polyanion compounds, those polyanions with sulfate or sulfonate groups and hydrophilic backbone were found to have strong affinity for LDL. In contrast, polyanions with carboxyl groups showed poor affinity. Dextran sulfate (DS) was selected as the affinity ligand of LDL adsorbent for its high affinity and low toxicity. The influence of its charge density and molecular weight on its affinity for LDL was suitable. The affinity rapidly increased as the charge density increased, then, reached a constant value. Little affinity was found for either the DS monomer (glucose sulfate) or DS with a molecular weight higher than 10⁴ daltons whereas DS with molecular weights in the midrange showed strong affinity. DS with a midrange molecular weight was immobilized on cellulose hard gel to give LDL adsorbent clinical application. The adsorbent demonstrated an excellent selectivity for LDL and very low density lipoprotein (VLDL) in vitro. Adsorption of high-density lipoprotein and major plasma proteins was almost negligible. Additional study of the LDL-binding mechanism revealed that DS directly interacts with positively charged sites on LDL, which demonstrates that the nature of the interaction is the same as that of LDL receptor. An LDL adsorption column (Liposorber) packed with an LDL adsorbent and polysulfone hollow-fiber plasma separator (Sulflux) was developed as an efficient LDL apheresis system. Clinical investigation proved that this system is capable of intensively lowering the plasma LDL level without affecting major plasma components.     

Artificial organs 2010: a year in review

In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.