纤维喉镜用于口腔颌面部肿瘤手术麻醉插管

 本文对27例ASAI～Ⅲ级口腔、颌面部肿瘤引起麻醉气管插管困难的手术病人，应用纤维光束鼻咽喉镜引导经鼻腔明视气管插管。结果：26倒插管成功；1例因肿瘤出血严重行气管造口插管；插管时监测SPO297±2%；循环呼吸影响较轻；插管后严重呛咳者２例。作者认为口腔、颌面部等头颈部肿瘤手术病人应用纤维喉镜明视引导插管可简化麻醉操作，克服麻醉插管许多困难，组织损伤小、并发症少等优点，是一种具有较好的临床应用价值的插管方法。     

右美托咪啶复合硝酸甘油在口腔颌面部肿瘤术中控制性降压的应用

目的观察口腔颌面部肿瘤患者术中应用右美托咪啶复合硝酸甘油行控制性降压的效果及安全性。方法选择ASA I~Ⅱ级口腔颌面部肿瘤需行手术治疗的患者45例,随机分为3组:右美托咪啶组(D组)、硝酸甘油组(N组)、右美托咪啶复合硝酸甘油组(DN组),每组15例。D组于麻醉诱导前10 min静脉泵注右美托咪啶1.0μg·kg-1,随后以0.4~0.8μg·kg-1·h-1速度持续泵注;DN组于麻醉诱导前10 min静脉泵注右美托咪啶0.5μg·kg-1,并以0.5μg·kg-1·h-1速度持续泵注,手术开始时泵注硝酸甘油行控制性降压;N组则于手术开始时泵注硝酸甘油行控制性降压。观察各组患者麻醉诱导前(T0)、气管插管前即刻(T1)、插管后1 min(T2)、降压后15 min(T3)、拔管时(T4)MAP、HR、CO、CI、ACI的变化,记录硝酸甘油最大泵注速度及维持速度,以及达目标血压所需时间、患者清醒时间及拔管时间。结果与T0比较,T1、T2、T3时间点D组、DN组MAP显著降低、HR明显减慢,差异有统计学意义(P0.05),T1、T2、T4时间点D组、DN组MAP、HR明显低于N组,差异有统计学意义(P0.05);3组各时间点CO、CI、ACI均无显著变化(P0.05);DN组患者硝酸甘油最大泵注速度及维持泵注速度均明显小于N组(P0.05);DN组患者达目标血压所需时间也明显小于D组、N组(均P0.05),但患者清醒时间及拔管时间D组、DN组均长于N组(均P0.05)。结论口腔颌面部肿瘤外科手术中采用右美托咪啶复合硝酸甘油较单独应用右美托咪啶或硝酸甘油行控制性降压更安全、有效,对血液动力学影响轻微,但可能延长患者清醒与拔管时间。     

2种麻醉方案对脑幕上肿瘤手术麻醉苏醒期血流动力学影响对比

目的探讨两种不同的麻醉方案对脑幕上肿瘤手术患者麻醉苏醒期血流动力学的影响。方法选择84例行手术治疗的颅脑肿瘤患者,按照随机原则平均分为对照组(术中给予右美托咪啶麻醉)与观察组(术中给予丙泊酚麻醉),分别记麻醉前(t_0)、气管插管前(t_1)、气管插管后(t_2)、切开硬脑膜时(t_3)、肿瘤取出时(t_4)、术毕时(t_5)以及气管拔除时(t_6),两组患者的心率、血压情况,并统计手术时间、输液量、术中出血量、神经阻滞效果、苏醒时间、拔管后的警觉/镇静(OAA/S)评分。观察术后30 min、60 min以及120 min患者的疼痛情况,采用VAS评分评估疼痛情况。结果与麻醉前相比,观察组患者的t_1、t_3、t_4时的血压出现了明显下降(P<0.05),HR同样明显地减慢(P<0.05)。对照组患者t_1时期血压明显下降,HR显著减慢(P<0.05),而在t_2、t_5和t_6时血压则又较麻醉前明显升高,同时HR显著加快(P<0.05)。观察组患者在除t_1外的各个时间点的血压、心率稳定性均优于对照组(P<0.05)。相较于对照组,观察组患者神经阻滞起效时间、达最高平面时间明显较短(P<0.05),且持续时间明显较长(P<0.05)。相较于对照组,观察组患者苏醒时间、拔管时间显著缩短(P<0.05),且在拔管后的OAA/S评分也显著要高(P<0.05)。相较于对照组,观察组术后30 min、术后60 min及术后120 min的VAS评分均低于对照组(P<0.05)。结论对于行脑幕上肿瘤手术的患者,应用右美托咪啶或丙泊酚复合七氟烷、芬太尼麻醉,麻醉效果均较为满意,右美托咪啶能抑制血流动力学反应,神经阻滞起效快,持续时间长,术后苏醒快,镇痛效果好,值得临床推广借鉴。     

GlideScope视频喉镜在口腔颌面肿瘤患者全麻经鼻气管插管的应用

目的:比较GlideScope视频喉镜与Macintosh喉镜应用于颌面部肿瘤手术患者全麻经鼻插管的过程.方法:48例口腔颌面肿瘤择期行全麻下手术患者随机分组,给予表面麻醉及清醒镇静后分别使用两种喉镜窥视声门,引导行经鼻腔气管插管,记录声门暴露时间,插管时间、声门暴露程度、手法辅助及气管钳使用情况、咽部损伤分级、插管困难模拟评分.结果:使用GlideScope缩短了插管时间[22(15～33)s]比[28(16～45)s],P=0.032.声门暴露分级更佳,咽喉部损伤分级降低,插管难度评分降低.结论:GlideScope视频喉镜更适用于颌面部肿瘤患者经鼻腔气管插管.     

右美托咪定对老年腹腔镜卵巢癌根治术患者术后苏醒与认知功能的影响研究

目的 探讨右美托咪定对老年腹腔镜卵巢癌根治术患者术后苏醒与认知功能的影响.方法 选取全身麻醉气管插管下行腹腔镜卵巢癌根治术的100例老年患者,按照随机数字表法分为观察组和对照组,每组50例.对照组患者使用咪达唑仑麻醉镇静,观察组患者使用右美托咪定麻醉镇静,比较麻醉拔管时两组患者的血浆S-100B蛋白、NSE水平,术后6 h ESS、MMSE评分,麻醉苏醒时间、麻醉拔管时间、复苏室停留时间及围麻醉期术中知晓、术后认知功能障碍的发生情况.结果 麻醉拔管时,观察组患者的血浆S-100B蛋白、NSE水平均明显低于对照组;术后6 h,观察组患者的ESS、MMSE评分均明显高于对照组;观察组麻醉苏醒时间、麻醉拔管时间、复苏室停留时间均明显短于对照组,差异均有统计学意义(P﹤0.01).观察组患者术中知晓、术后认知功能障碍的发生率均低于对照组,差异均有统计学意义(P﹤0.05).结论 围麻醉期使用右美托咪定,可以有效地促进老年腹腔镜卵巢癌根治术患者的麻醉苏醒,减少认知功能障碍的发生率.     

长托宁用于胃肠恶性肿瘤根治术麻醉前准备的临床观察

目的 探讨选择性M-受体拮抗剂长托宁(盐酸戊乙奎醚)用于胃肠恶性肿瘤根治术麻醉前准备的临床效果.方法 选取2009年4月～2009年6月胃肠恶性肿瘤根治术63例,其中胃癌21例,结肠癌42例;随机分为3组(每组21例,胃癌7例,结肠癌14例,胃癌:结肠癌=1:2):对照组(I组),不应用术前药;阿托品组(Ⅱ组)和长托宁组(Ⅲ组).Ⅱ组和Ⅲ组患者分别于麻醉诱导前30分钟肌肉注射阿托品0.01 mg/kg或长托宁0.01 mg/k,记录用药气管捅管后5分钟、1小时、2小时至术毕拔管时气道分泌物量、心率和血压.结果 各监测时段,Ⅱ组患者的心率明显高于Ⅲ组和I组,差异有统计学意义(P<0.05).诱导前至气管捅管后2小时,Ⅱ组和Ⅲ组患者的气道分泌物明显少于I组(P<0.05).术毕拔管时,Ⅱ组患者的气道分泌物则多于Ⅲ组(P<0.05).结论 选择性新型M-受体拮抗剂长托宁能有效控制麻醉患者的气道分泌物,且不引起心率增快,作为胃肠恶性肿瘤根治术麻醉前用药临床效果优于阿托品.     

全麻和颈丛阻滞复合全麻对喉癌患者术后清醒的影响

[目的]探讨单纯全麻和颈丛阻滞复合全麻对喉癌患者术后清醒的影响.[方法]40例择期喉癌手术病人,随机分为单纯全麻组(Ⅰ组)和颈丛阻滞复合全麻组(Ⅱ组)各20例,Ⅰ组在局麻下行气管造口插管全麻;术中麻醉维持用微泵恒速输注异丙酚3～4mg/(kg·h),吸入异氟醚(呼气末浓度0.5～0.8MAC),并间断追加芬太尼和维库溴铵;Ⅱ组在颈丛阻滞下行气管造口插管,术中用异丙酚1.5～2mg/(kg·h),吸入异氟醚(呼气末浓度0.3～0.5MAC),并按需追加芬太尼和维库溴铵.[结果]Ⅰ组术中异丙酚、芬太尼及维库溴铵用药量均明显大于Ⅱ组(P＜0.05或P＜0.01);术毕自主呼吸恢复用氟吗西尼后3min达4级清醒、拔管更换气管造口插管时间,Ⅱ组各项指标较Ⅰ组明显缩短(P＜0.01),且围拔管期血流动力学稳定.[结论]全麻复合颈丛阻滞可显著减少全麻用药量,有利于喉癌术后早期清醒与拔管;由于颈丛阻滞具有术后镇痛作用,因而可明显减轻围拔管期心血管应激反应.     

非气管插管在胸外科VATS中的应用

气管插管全麻技术可提高手术安全性,因此在电视胸腔镜手术（video-assisted thoracic surgery, VATS）中得到广泛应用,但气管插管的并发症却无法避免。如何发展一种“整体微创”手术（包括麻醉微损伤）,已经成为微创胸外科领域的一个研究热点。随着麻醉管理技术与对手术风险管理的进步,非气管插管技术成功应用于VATS,即采用局部麻醉以维持患者的术中自主通气,术中仅需轻微镇静或者完全清醒的状态下实施VATS,因而又称清醒状态下VATS。此麻醉方式不但减少气管插管的麻醉损伤,而且符合快速康复外科的理念。本文对非气管插管应用在胸外科VATS中的发展简史、麻醉选择、手术优势、手术风险及管理、面临的问题等方面作一综述。     

两种麻醉方法在支气管肿瘤冷冻术中的麻醉效果及不良反应

目的对比分析两种麻醉方式在支气管肿瘤冷冻术中的麻醉效果及不良反应。方法选取2014年2月至2015年1月间收治的54例支气管肿瘤患者,所有患者均行支气管肿瘤冷冻术,采用随机数字表法将患者分为研究组和对照组,每组27例。研究组患者行气管内插管全身麻醉法,对照组患者行静脉镇静加气管内表面麻醉法。观察患者手术前后的心率、血氧饱和度、平均动脉压以及术后出现的不良反应。结果研究组和对照组患者术前心率、血氧饱和度和平均动脉压差异无统计学意义(P>0.05)。对照组患者在冷冻后3、30 min和冷冻完毕时的心率显著快于研究组(P<0.05),对照组在冷冻后3、30 min时的平均动脉压明显高于研究组(P<0.05)。研究组和对照组患者的血氧饱和度差异无统计学意义(P>0.05)。对照组患者不良反应发生率也显著高于研究组(P<0.05)。结论气管内插管全身麻醉相对静脉镇静加气管内表面麻醉法更好,患者发生不良反应更少,值得推广。     

喉罩通气非气管插管麻醉对肺癌行胸腔镜手术患者临床疗效的影响

目的探讨喉罩通气非气管插管麻醉对肺癌行胸腔镜手术患者疗效的影响。方法将90例接受胸腔镜手术的肺癌患者分为插管组与喉罩组,每组45例。两组患者均采取胸腔镜下肺部手术,其中插管组采取气管插管全身麻醉,喉罩组采取喉罩通气静脉麻醉。比较两组诱导前、插管时、开始手术时、苏醒拔管时的收缩压(SBP)、舒张压(DBP)、心率(HR),以及麻醉苏醒时间、定向力恢复时间、排气时间、住院时间、住院花费、并发症发生情况。结果插管组患者插管时与苏醒拔管时的SBP、DBP、HR水平均高于诱导前(P﹤0.05),而喉罩组无明显变化(P﹥0.05)。喉罩组患者插管时与苏醒拔管时的SBP、DBP、HR水平均明显低于插管组,差异均有统计学意义(P﹤0.01)。喉罩组患者麻醉苏醒时间、定向力恢复时间、排气时间、住院时间均短于插管组,住院花费少于插管组,并发症总发生率低于插管组,差异均有统计学意义(P﹤0.05)。结论喉罩通气麻醉在胸腔镜手术中的应用对血流动力学指标的影响小,且操作简单,肺部损伤轻,有利于患者恢复,住院花费少,并发症少,效果优于气管插管全身麻醉,可作为胸腔镜手术首选麻醉方案。     

Radiotherapy of extra-medullary plasma cell tumor--report of 13 patients

13 patients with extra-medullary plasma cell tumor treated by radiotherapy in a Cancer Hospital from March 1958 to December 1983 are reported. The tumor occurred more frequently in the head and neck, particularly in the upper respiratory tract and oral cavity. Grossly, the majority of the tumor showed dark reddish polypoid masses with the surface bled easily. A misdiagnosis of polyp or hemangioma was usually made. The tumor is sensitive to radiotherapy. In the patients with recurrence or metastasis, retreatment is still effective, at least, palliative. The 5 year survival rate was 70%. A dose of 4,000-6,000 rad in 4-6 weeks is advised for the primary tumor.     

AAI监测下不同麻醉镇静深度对肿瘤患者围术期炎性因子的影响

目的:探讨不同镇静麻醉深度对肿瘤患者围术期炎性细胞因子的影响,为肿瘤患者选择适宜的麻醉深度,减少围术期炎症反应维护术后免疫力,保护患者免疫功能,提供依据。方法:选择2017年08月-2019年01月我院普外科择期行消化道肿瘤根治性切除患者66例,年龄34~88岁,体重40~95 kg,采用随机数字表法,将患者随机分为3组。应用听觉诱发电位指数（AAI）监测镇静麻醉深度,分为浅镇静麻醉组(AAI值在40-30范围内)、深镇静麻醉组(AAI值在29-20范围内)、传统麻醉组,根据血压、心率波动及制动、流泪、呛咳等指标及麻醉医师的经验调控镇静麻醉深度。分别于手术开始前即刻（T1）、手术开始后2 h（T2）、手术后24 h（T3）、手术后48 h（T4）及72 h（T5）时点检测患者血清白介素-2(IL-2 )、白介素-4(IL-4)和肿瘤坏死因子(TNF-α)浓度。结果:组间比较,IL-2血浆浓度T1时点浅麻醉组与传统组比较,浅麻醉组明显降低（P＜0.05）;T4和T5时点深麻醉组与传统组比较,深麻醉组明显降低（P＜0.05）,其余时点比较无统计学差异。IL-4血浆浓度比较,T2和T4时点浅麻醉组与传统组比较,浅麻醉组明显降低（P＜0.05）;T4时点浅麻醉组与深麻醉组比较,深麻醉组明显升高（P＜0.05）。TNF-α血浆浓度比较,T1、T2和T4时点浅麻醉组与传统组比较,浅麻醉组明显降低（P＜0.05）,T1时点浅麻醉组与深麻醉组比较,深麻醉组明显升高（P＜0.05）。结论:浅镇静麻醉即AAI值在40-30范围比深镇静麻醉即AAI值在29-20时可以更好的保护肿瘤患者围术期Th1细胞介导的细胞免疫功能,降低IL-4对细胞免疫的抑制作用,控制过度的炎症反应,保护患者免疫状态,帮助患者更好的康复。     

老年子宫肌瘤患者麻醉前不同剂量长托宁的疗效比较

目的 比较不同剂量长托宁在老年子宫肌瘤患者麻醉前用药的临床疗效.方法 选择连续硬膜外麻醉下行全子宫切除术的老年子宫肌瘤患者120例,随机分为Ⅰ、Ⅱ、Ⅲ组,每组40例,分别于麻醉诱导前静脉注射长托宁0.005、0.010、0.020mg/kg.记录静脉注射前,静脉注射后10、20、30 min的HR、SBP、DBP变化;...     

Squamous cell carcinoma with sarcomatoid stroma

Two cases of squamous cell carcinoma with sarcomatoid stroma are presented. One tumor was located in the soft palate that metastasized to a neck lymph node; the epithelial and the spindle cell component of the tumor at the primary as well as at the metastatic site showed ultrastructural features of squamous cell carcinoma. The other case, a laryngeal tumor with spindle cell stroma, was shown by ultrastructural studies to be composed of proliferating fibro-blasts. The diagnostic problems and the controversies regarding classification and behavior of these rare tumors of upper respiratory tract and upper gastrointestinal tract are discussed.     

Risk of multiple primary tumors following oral squamous-cell carcinoma

The follow-up of 727 patients with squamous-cell carcinoma (SCC) of the lip and oral cavity has been used for the risk analysis of multiple primary tumors (MPTs) following SCC of the lip and oral cavity. Age-, gender-and site-specific cancer-incidence rates from the general population have been applied to the appropriate persons-years of follow-up of patients with SCC of the lip and oral cavity. The study indicates that patients with a primary SCC of the lip and oral cavity have, compared with the general population, a significantly elevated risk of developing an additional cancer of the oral cavity and/or pharynx, the risk being 74.7-fold for males and 190.4-fold for females. Furthermore, a 24.6 and 45.3 times higher risk of an additional esophageal tumor was found in males and females respectively. The risk of cancer of the lung and pharynx was less elevated compared with the risk of cancer of the upper digestive tract. No elevated risks were established in organs outside the respiratory and upper digestive tract.     

气管隆凸主支气管肿瘤的外科治疗

目的 总结气管、隆凸主支气管肿瘤手术治疗经验,探讨合理的手术方法及治疗措施。方法 回顾性分析我院在1996年1月至2004年6月期间,手术治疗的27例气管、隆凸主支气管肿瘤患者的临床资料。27例中,鳞癌15例,腺癌3例,其余9例为良性腺瘤、腺样囊腺癌和类癌。结果 气管肿瘤切除＋端端吻合8例;全肺隆凸切除＋气管与主支气管端端吻合9例（右6例,左3例）;右上肺隆凸袖式切除重建术2例;隆凸切除重建术3例;气管肿瘤及气管壁部分切除5例,其中体外循环辅助下手术2例。术后早期死亡3例,其中2例死于多器官衰竭,1例系因胸腔感染、出血死亡。半年以上随访24例,无死亡,无外科并发症。结论 隆凸及气管手术比较复杂,难度大,应选择合理的术式及麻醉方法,必要时应用体外循环辅助,可以取得满意疗效。     

Endoscopic Occlusion of Tracheoesophageal Fistula in Ventilated Patients Using an Amplatzer Septal Occluder

Acquired tracheoesophageal fistula (TEF) is a challenging, life threatening condition. It most commonly appears in critically ill patients requiring prolonged mechanical ventilation, who cannot withstand open neck or chest surgery. An endoscopic technique could be better tolerated by these patients. We present our experience using a cardiac Amplatzer ASD septal occluder for an endoscopic TEF repair in ventilation-dependent patients. Two high risk patients underwent the procedure under general anesthesia and close respiratory monitoring. In one patient the device was inserted through the trachea and in the other through the esophagus. In both cases fistula closure was achieved for different periods of time allowing the patients a temporary relief of symptoms. The procedure was well tolerated by the patients, and no significant adverse effect documented. The technique was successful as a temporary solution for unstable patients with TEFs and should be considered as a treatment modality for similar patients.     

Microsatellite instability in squamous cell carcinomas of the head and neck related to field cancerization phenomena.

Patients affected by squamous cell carcinoma of the head and neck (HNSCC) show frequent occurrence of multiple cancers and widespread precancerous lesions in the mucosa of the upper respiratory tract, a phenomenon known as field cancerization. In this study, we investigated the role of genetic instability in the development of HNSCC and in particular in tumour multiplicity phenomena of the upper respiratory tract. For this purpose, we analysed microsatellite instability (MI) and loss of heterozygosity (LOH) at 20 loci mapping on five chromosomal arms in 67 HNSCC patients, 45 of whom had a single cancer and 22 had multiple primary tumours. The possible involvement of the hMLH1 gene in genetic instability and as a potential target of 3p21 deletion phenomena in head and neck cancers was also investigated. Our data indicate that mismatch repair-related genetic instability plays a minor role in the carcinogenesis of HNSCC and in tumour multiplicity of the head and neck region. Moreover, our results exclude a role for the hMLH1 gene as a determinant of MI and as a specific gene target of deletion at 3p21 in HNSCC. We conclude that presumably other genetic mechanisms, such as those hypothesized for MI-negative hereditary non-polyposis colorectal cancer patients, may play a major role in the carcinogenesis of the mucosa of the upper respiratory tract.     

Nonepithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. A clinicopathologic study. XIII: Meningiomas

Twelve cases of meningiomas involving the nasal cavity and paranasal sinuses are reported. Meningiomas only rarely involve the upper respiratory tract; these 12 cases were found among the 566,000 surgical pathology cases that have been studied in this laboratory. In this series, five meningiomas probably arose in the cranial cavity and secondarily extended into the nasal cavity and paranasal sinuses. Because radiographs demonstrated hyperostosis or bone destruction, three other tumors could have involved the cranial cavity, but this was never proven. In two other cases, the meningiomas appeared to involve only extracranial tissues and thus probably were primary extracranial lesions. (The data available in two other cases were insufficient to assess the possibility of intracranial involvement). These patients clinically had nonspecific signs and symptoms similar to those produced by other types of neoplasms growing in the upper respiratory tract. The tumor involved the sphenoid area in seven cases, the nasal cavity in six, the maxilla in five, the ethmoid sinus in four, and the frontal sinus in one. The diagnosis was first established when biopsy material was examined, although in several cases the presence of meningioma was first suggested on radiographic examination. Treatment depended upon the size and location of the tumor. In some cases, surgical resection appeared to control the lesion. These tumors did not appear to respond well to radiotherapy. The histologic differential diagnosis is discussed.     

Current status and perspectives of brachytherapy for head and neck cancer

Brachytherapy delivers a high radiation dose to a limited volume while sparing surrounding normal tissues. In head and neck cancer, severe soft-tissue damage and bone damage to the mandible has decreased markedly since the introduction of computer dosimetry and the use of spacers during treatment. For the curative treatment of head and neck cancer, the selection of brachytherapy sources from among the several linear and small permanent implant sources available, not only according to the tumor site but also according to the patient’s physical and mental condition is important. Following the successful treatment of early head and neck cancer by brachytherapy, two major problems and one minor problem may confront the physician. The major problems are neck node metastasis and a second primary cancer of the respiratory tract or upper digestive tract, and the minor problem is radiation-induced cancer.