全身麻醉后复苏室患者术后肌松残余发生率的调查研究

目的 肌松残余（RNMB）是并发症发生的重要因素之一,确定全身麻醉后复苏室患者术后神经肌肉不完全恢复的发生率.方法 全身麻醉后转运至复苏室患者,由一位独立的麻醉医生通过肌松加速度仪测量神经肌肉传递速度,4个成串刺激比值≥0.9和＜0.9作为判定神经肌肉阻滞完全和不完全恢复的标准.记录相关患者手术信息、麻醉医生信息和药物处理等.结果 180例男性患者和240例女性患者,平均年龄54.3±15.9岁.在麻醉恢复室肌松残余发生率为31％.使用丙泊酚麻醉的患者较七氟醚RNMB发生率高分别为27.3％和15.2％.肝胆外科和胃肠外科手术发生RNMB比率较高,分别为32％和28％.RNMB主要发生在上午11点～下午2点（54％）,上午8点～上午11点和下午2点～下午5点分别为22％和24％.RNMB住院医师处理发生率较高为42％,而主治医师、副主任医师和主任医师职称间无统计学差异.结论 笔者医院麻醉恢复室不完全性神经肌肉恢复的发生率为31％,需要重视肌肉松弛剂合理应用和加强围手术期肌松监测.     

围手术期膈肌超声评估术后肌松残余的可行性

目的 通过膈肌超声观察膈肌的变化情况评,估术后肌松残余的可行性。方法 随机纳入2019年8至10月拟行非胸腹部手术的全麻插管患者75例,美国麻醉医师协会分级:Ⅰ~Ⅱ,年龄:18~65岁,性别不限。分别于术前和拔管后即刻用超声检查评估膈肌运动情况,采用高频探头(4~15 MHz)于右侧腋前线第8、9肋间观察并记录平静呼吸和深呼吸(DB)在吸气末及呼气末的膈肌厚度,计算膈肌厚度变化率(DTF)。再采用低频探头(1~5 MHz)于右侧肋骨缘肝区分别测量平静呼吸和深呼吸时膈肌移动度(DE)的变化。围手术期进行肌松监测并记录拔管时四个成串刺激比值和 镇静评分。在恢复室记录改良Aldrete 恢复评分及术后呼吸系统并发症发生率等。结果 术后肌松残余发生率为54.7%。肌松残余组拔管时DTF-DB [31.3(21.1,45.0)比38.5(26.6,53.9),P=0.045]和DE-DB(2.9±1.4比4.1±1.0,P<0.001)显著低于无肌松残余组,相关分析显示DTF-DB(r=0.351,P=0.002)和DE-DB(r=0.580,P<0.001)均与拔管时四个成串刺激比值显著相关。结论 围手术期应用超声评估膈肌运动度和膈肌厚度变化率对于判断肌松恢复情况具有一定的临床参考价值。     

不同剂量顺式阿曲库铵的残余肌松作用

目的观察不同剂量顺式阿曲库铵的残余肌松作用。方法择期行腰椎管狭窄或胸腰椎体骨折手术患者80例,美国麻醉医师协会（ASA）分级Ⅰ～Ⅱ级,年龄18～70岁,随机分为顺式阿曲库铵静脉持续输注组（A）,静脉间断给药组（B）。麻醉诱导后,A1组持续输注顺式阿曲库铵0.75μg·（kg·min）^-1,A2组1.5μg·（kg·min）^-1,B1组间断给药0.05 mg·（kg·h）^-1,B2组0.1 mg·（kg·h）^-1,每组各20例。手术结束前20min停用所有药物。使用闭环肌松注射系统（CLMRIS-I）进行肌松效应监测,记录肌松药使用总量、第一次睁眼时间、四个成串刺激比值（Train-of-Four ratio,TOFr）达25%、50%、75%、90%的时间、拔管时间、患者抬头5s的时间及患者麻醉前后潮气量、呼吸频率等。结果拔管时四组患者收缩压、舒张压、呼吸频率及氧饱和度与术前比较差异均无统计学意义（P〉0.05）,而拔管时心率较术前明显增快（P〈0.05）,A2、B1、B2组患者潮气量高于术前（P〈0.05）;同种给药方式下,顺式阿曲库铵高剂量组患者TOFr恢复至25%、50%、75%、90%时间、肌力达Ⅳ～Ⅴ级和能够持续抬头5s时间长于低剂量组（P〈0.05）,而拔管时间及第一次睁眼时间两组间差异无统计学意义（P〉0.05）。相同剂量下,持续输注给药较间断单次给药TOFr恢复至25%、50%、75%时间延长（P〈0.05）,而TOFr恢复至90%、拔管时间、第一次睁眼时间、肌力达Ⅳ-Ⅴ级和能够持续抬头5s时间两组间差异无统计学意义（P〉0.05）。结论不同剂量顺式阿曲库铵的术后残余肌松作用不同,高剂量可延长患者术后肌肉功能恢复时间。顺式阿曲库铵持续输注与间断给药两种方式对残余肌松作用均无明显影响。     

顺式阿曲库铵用于老年患者肌松效应的临床观察

目的 观察不同年龄组患者使用顺式阿曲库铵的肌松效应.方法 将40例患者分为I组(20～60岁)与II组(65～85岁),均接受丙泊酚-舒芬太尼静脉复合麻醉.采用闭环肌松药效监测和注射装置,监测方法为四个成串刺激(TOF),肌松药插管剂量为顺式阿曲库铵0.15mg/kg,T1为0时气管插管,T1恢复到10时自动追加肌松药.记录肌松药起效时间、维持时间、恢复指数和肌松药使用量.结果 两组患者体温与血pH值均无显著差异,II组起效时间、维持时间与药物平均使用量显著长于I组(P<0.05),恢复指数无统计学差异.结论 老年患者使用顺式阿曲库铵起效时间与维持时间比青年组要延长,老年组的平均使用量比青年组小,但恢复指数不受年龄影响.     

TOF监测T1低于20％的肌松效应在腹腔镜手术中的应用

目的探讨全麻联合硬膜外麻醉下,腹腔镜手术4个成串刺激(train of four,TOF)监测T1低于20%肌松程度的可行性。方法选择行腹腔镜肠道肿瘤手术患者20例,麻醉方法采用全麻联合硬膜外麻醉,全麻前将麻醉平面控制于T6以下水平。全身麻醉采用丙泊酚、瑞芬太尼靶控输注。肌松监测采用TOFW ATCH SX肌松监测仪监测TOF,肌松药物采用非去极化肌松剂罗库溴铵,诱导剂量0.6mg/kg,追加时机为T1恢复至20%,追加剂量0.15mg/kg。记录首次给予肌松剂至T1恢复至20%的时间,每次追加药物时间至T1恢复20%时间,最后一次追加至4个成串刺激比值(train of four ratio,TOFR)恢复至0.9的时间,术中肌松剂使用剂量。记录术中肌松效果评价,包括术者抱怨肌紧张和患者体动反应。记录拔管后残余肌松并随访24h术后呼吸系统并发症。结果本组中男13例,女7例;平均年龄65岁;体质指数(23.2±3.9)kg/m2;手术时间(202.6±73.0)min,罗库溴铵用量(116.7±27.1)mg。所有患者无体动反应,术者抱怨腹肌紧张患者4例。术毕拔管时间(10.8±6.7)min,拔管后TOF中位数为107%,无残余肌松,随访24h无呼吸系统并发症。结论全麻复合硬膜外麻醉下,颤搐高度T1控制目标在20%以下可以满足大部分腹腔镜手术肌松要求。     

残余肌松药作用的评估与拮抗

临床上应用肌松药后判断神经肌肉功能是否恢复到正常是很困难的。客观监测神经肌肉功能和桔抗残余肌松药作用对临床麻醉十分重要。     

不同年龄患者全麻后在肌松监测下气管拔管的研究

目的:观察老年人与青壮年在肌松监测指导气管拔管时和在临床评估指导气管拔管时的血流动力学变化和术后肌松残余(PORC)的发生率.方法:80例择期全麻患者,根据病人年龄分为4组:老年组(年龄65～80岁:其中A1组为临床评估指导气管拔管组,B1组为肌松监测指导气管拔管组)和青壮年组(年龄18～55岁:相同方法分为A2、B2维),每组20例.全麻后A1、A2组在患者呼之睁眼、抬头5秒、握拳有力时气管拔管;B1、B2组在TOF值(网个成串刺激比率)恢复至0.9时拔气管导管.结果:A1与B1组MAP,HR无明显差异(P＞0.05),B2的MAP,HR变化比A2组显著(P＜0.05),B2组MAEHR变化比B1组显著(P＜0.05),A1组拔管后1小时的肌松残余(PORC)发生率30%,B1组5%;A2组拔管后1小时的PORC发牛率5%,B2组0%.结论:在肌松监测下气管拔管,老年人较青壮年循环稳定,术后肌松残余(TOF＜0.9)发生率明显减少,对于老年患者具有临床应用价值.     

患者在清醒或镇静状态下校准定标对术后肌松监测指标的影响

目的 观察患者在清醒或镇静状态下行单刺激肌颤搐（single twitch stimulation,T1）与4个成串刺激（train of four,TOF）（T4/T1）校准定标,对术后T1与TOF值是否有影响.方法 将40例ASAⅠ或Ⅲ级患者采用数字表法随机均分为2组（每组20例）：清醒组（A组）与镇静组（S组）.清醒组在患者未给予任何镇静剂情况下对T1与TOF校准定标,镇静组在患者给予依托咪酯使BIS处于40-60时校准定标.2组患者术中均不使用肌松药.观察2组患者术后清醒脑电双频指数（bispectral index,BIS）值恢复至术前水平时T1与TOF最大值.结果 镇静组患者术后T1最大值明显高于清醒组患者（P=0.005）,两组患者术后TOF最大值比较,差异无统计学意义（P=0.191）.结论 在肌松监测观察中,患者清醒状态下进行T1与TOF校准定标,对术后T1值影响小,更具有临床指导意义.     

残余阻滞及肌松监测进展

肌松药的残余阻滞作用是引起术后呼吸功能不全的危险因素之一,已日趋引起重视。不同的监测方法以及对不同肌群的监测近来也有深入的研究。     

肌松药物残余作用的研究进展

<正>肌松作用残余是一个与临床结局息息相关的问题,因为麻醉后残余的肌松作用(以下简称肌松残余)可导致肌肉无力、血氧饱和度下降、肺萎陷、急性呼吸衰竭,而上述麻醉并发症可能导致严重的永久性的脑损伤甚至死亡。在临床实际工作中,肌松监测的应用以及使用肌松药拮抗剂等诸多临床问题,往往是基于传统的观念或者使用者各自的方法,而并非基于循证医学的结果来指导和制定具体的使用方案。     

Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit

INTRODUCTIONThe use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU).METHODSAn online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed.RESULTSA large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB.CONCLUSIONPRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.     

Device-Associated Healthcare-Associated Infections (DA-HAI) and the caveat of multiresistance in a multidisciplinary intensive care unit

BackgroundDevice-Associated Healthcare-Associated Infections (DA-HAI), including Ventilator-Associated Pneumonia (VAP), Central-Line-Associated Blood Stream Infection (CLABSI), and Catheter-Related Urinary Tract Infection (CAUTI), are considered as principal contributors to healthcare hazard and threat to patient safety as they can cause prolonged hospital stay, sepsis, and mortality in the ICU. The study intends to characterize DA-HAI in a tertiary care multidisciplinary ICU of a teaching hospital in eastern India.MethodsThis prospective outcome-surveillance study was conducted among 2157 ICU patients of a 760-bedded teaching hospital in Eastern India. Clinical, laboratory and environmental surveillance, and screening of HCPs were conducted using the US Centers for Disease Control and Prevention (CDC)’s National Healthcare Safety Network (NHSN) definitions and methods.ResultsWith 8824 patient/bed/ICU days and 14,676 device days, pooled average device utilization ratio was 1.66, total episodes of DA-HAI were 114, and mean monthly rates of DA-HAI, VAP, CLABSI, and CAUTI were 4.75, 2, 1.4, and 1.25/1000 device days. Most common pathogens isolated from DA-HAI patients were Klebsiella pneumoniae (24.6%), Escherichia coli (21.9%), and Pseudomonas aeruginosa (20.2%). All Acinetobacter baumanii, >80% K. pneumoniae and E. coli, and >70% P. aeruginosa were susceptible only to colistin and tigecycline. One P. aeruginosa isolate was panresistant.ConclusionMean rates of VAP, CLABSI, and CAUTI were 14.4, 8.1, and 4.5 per 1000 device days, which are comparable with Indian and global ICUs. Patients and HCPs form important reservoirs of infection. Resolute conviction and sustained momentum in Infection Control Initiatives are an essential step toward patient safety.     

肺癌患者血清血管内皮生长因子的检测及其临床意义

目的探讨肺癌患者血清血管内皮生长因子(serum vascular endothelial growth factor,sVEGF)水平与不同组织学类型和临床分期的关系,观察其化疗前后的变化,评价其临床意义.方法用酶联免疫法(ELISA)检测189例初诊肺癌病人的sVEGF水平;分别给含顺铂的联合化疗方案4个周期后,检测86例非小细胞肺癌(non-small cell lung cancer,NSCLC)、22例小细胞肺癌(small cell lung cancer,SCLC)的sVEGF .结果 NSCLC Ⅰ、Ⅱ期患者sVEGF水平显著低于Ⅲ、Ⅳ期患者(P<0.01),鳞癌sVEGF水平与腺癌及SCLC相比有显著统计学差异(P<0.05);所有缓解病例化疗后sVEGF水平均显著下降(P<0.05),其中以达到完全缓解组最明显.结论肺癌患者sVEGF水平与临床分期及治疗效果密切相关.     

High intensity focused ultrasound in combination with chemotherapy by the regime of PFC：a clinical study for advanced gastric carcinoma

Objective： To evaluate the recent curative efficacy and security of High intensity focused ultrasound （HIFU） in combination with chemotherapy（PFC） in patients with advanced gastric carcinoma. Method： Sixty patients with measurable advanced gastric carcinoma, proved pathologically, were divided into Group A and Group B. Group A： Patients were treated by HIFU（FEP-BY01） in combination with chemotherapy（PFC, paclitaxel, cisplatin and 5-fluorouracil）. Group B： Patients were treated with the single regime of PFC. Results： All cases could be evaluated, ha group A, 5 patients achieved complete response, 17 patients achieved partial response,and a response rate was 73.3%. The stable disease（SD） and the inefficiency all were 13.3% （4/30） respectively, and msurvival time（MST） was 13.9 months. In group B, 2 patients achieved complete response, 14 patients achieved partial response, and a response rate was 53.3%. The stable disease（SD） was 23.3%（7/30）. The inefficiency all were 23.3%（7/30） respectively, and median survival time was 9.6 months. There was significant difference between two groups MST（ P 〈 0.05）. Major toxicities included bone marrow depression, nausea, vomiting and alopecia, without significant differences between two groups（ P 〉 0.05）. Conclusion： This study shows that HIFU in combination with chemotherapy（PFC） was a new efficent and secure therapy for the patients with advanced gastric carcinoma. It was observed that the MST was prolonged. Prospective trials should be warranted to determine the result.