瑞芬太尼复合异丙酚靶控静脉输注用于老年桡神经损伤修复手术效果分析

目的探讨桡神经损伤修复手术的病人采用瑞芬太尼、丙泊酚靶控静脉输注进行诱导和维持麻醉,观察此种麻醉方案的临床效果。方法 50例桡神经损伤老年病人分2组,I组瑞芬太尼靶效应室浓度3.5ng/mL,II组瑞芬太尼靶效应室浓度2.0ng/mL。根据患者体征每次以0.5～1ng/mL递增瑞芬太尼血浆靶浓度。2组均使用丙泊酚静脉输注,血浆靶浓度从2.0μg/mL开始根据临床征象逐渐调整,记录患者意识消失时间丙泊酚血药浓度、瑞芬太尼靶浓度。结果 II组病人手术维持期间丙泊酚靶血药浓度、瑞芬太尼靶血药浓度均低于I组。结论术中认真监测各项生命指标,并随即调整丙泊酚和瑞芬太尼血浆靶浓度,可以使行桡神经损伤修复手术病人的麻醉深度维持在与中青年相似的水平,是比较理想的麻醉方式。     

丙泊酚闭环靶控输注全凭静脉麻醉在颅脑手术的应用

目的以脑电双频指数（BIS）为反馈控制变量，探讨丙泊酚闭环靶控输注复合舒芬太尼全凭静脉麻醉应用于颅脑手术的可行性。方法44例择期行大脑半球肿瘤切除患者，随机分为闭环靶控输注组和靶控输注组．各22例。闭环组设定反馈值为BIS=50，两组丙泊酚血浆靶控浓度设定为2．0μg／mL．舒芬太尼恒速持续静脉输注。记录两组在麻醉前、插管即时、插管后3min、切皮、锯颅骨、切开脑皮质、切肿瘤1h、缝皮等时间点的MAP、CVP、HR、HRV、BIS变化及丙泊酚的用量。结果靶控组在插管后3min、切开脑皮质、切肿瘤1h等时间点MAP下降较闭环组明显（P〈0．05），HRV变化幅度也大于闭环组（P〈0．05）。闭环组丙泊酚用量少于靶控组（P〈0．01）。结论以BIS为反馈值，丙泊酚闭环靶控输注复合舒芬太尼全凭静脉麻醉用于颅脑手术，术中患者麻醉深度易于维持．血流动力学稳定，并明显减少丙泊酚用量。     

丙泊酚靶控输注复合舒芬太尼在脑胶质瘤切除术中的应用

目的探讨不同剂量舒芬太尼复合丙泊酚靶控输注麻醉对脑胶质瘤切除术患者镇痛及神经损伤的影响。方法将75例择期脑胶质瘤切除术患者,随机数字表简单随机分组为A组(n=37)和B组(n=38);2组均采用相同的麻醉诱导(丙泊酚+舒芬太尼+罗库溴铵),麻醉诱导后,舒芬太尼靶浓度A组为0.1 ng/mL,B组为0.25 ng/mL,麻醉维持采用舒芬太尼复合丙泊酚靶控输注。记录患者围术期麻醉药物用量、术后补救镇痛及不良反应情况,分别于麻醉诱导前(T_0)、手术结束时刻(T_1)、术后1 h(T_2)、术后12 h(T_3)、术后24 h(T_4)采用酶联免疫吸附法测定患者血清S-100β蛋白(S100β)、神经元特异性烯醇化酶(NSE)水平。结果丙泊酚及舒芬太尼用量比较差异无统计学意义(P0.05);而B组术后补救镇痛率明显低于A组(15.79%vs 48.65%,P0.05)。T_0时刻,2组血清S100β、NSE水平比较差异无统计学意义(P0.05);而在T_1、T_2、T_3、T_4时刻,B组S100β、NSE水平均明显低于A组(P0.05)。2组术后不良反应发生率比较差异无统计学意义(P0.05)。结论与0.1 ng/mL靶浓度相比,舒芬太尼靶浓度0.25ng/mL复合丙泊酚靶控输注麻醉能够提高镇痛效果,并减轻患者神经损伤,且不增加不良反应。     

丙泊酚和咪达唑仑靶控镇静在颅内动脉瘤介入治疗中的对比研究

目的研究丙泊酚和咪达唑仑靶控输注清醒镇静用于颅内动脉瘤介入治疗的可行性。方法40例Hunt-Hess 0-Ⅱ级的颅内动脉瘤患者,随机分为丙泊酚组（P组）和咪达唑仑组（M组）,每组20例。术中分别采用丙泊酚和咪达唑仑实施靶控输注观察清醒镇静。记录清醒镇静评价（OAA／S）评分不同时相应的MAP、HR、SpO2和脑电双频谱指数（BIS）,以及两种药物的靶浓度（Ct）和效应室浓度（Ce）。结果随着OAA／S评分下降,MAP、HR和SpO2均明显下降（P〈0．05）;随着Ct、Ce的增加,镇静逐渐加深,OAA／S评分降低,BIS明显下降（P〈0．05）;P组镇静诱导时间和苏醒时间均短于M组（P〈0．05）。结论丙泊酚和咪达唑仑TCI清醒镇静均可用于颅内动脉瘤介入治疗,但丙泊酚安全性更高,患者合作程度更高。     

舒芬太尼与瑞芬太尼用于颅内肿瘤患者全麻诱导的比较

目的比较舒芬太尼与瑞芬太尼靶控输注（TCI）在全麻诱导期对神经外科患者血流动力学影响的差异，为临床合理用药提供支持。方法60例拟行开颅肿瘤切除术的患者，分为舒芬太尼与瑞芬太尼组（n=30）。分别接受舒芬太尼TCI（血浆靶浓度0．53ng／ml）和瑞芬太尼TCI（血浆靶浓度5．3ng／ml）诱导，均复合丙泊酚TCI和维库溴铵。比较两组患者血流动力学各参数和脑电双频指数（BIS）值的变化。结果舒芬太尼或瑞芬太尼TCI在复合异丙酚与维库溴铵行全麻诱导时，具有相似的血流动力学效应，瑞芬太尼所致血流动力学抑制较强，而舒芬太尼（血浆靶浓度0．53ng／ml）抑制气管插管所致的血压升高效果更好。两组患者BIS值无显著差异。结论就神经外科患者全麻诱导插管期的血流动力学稳定性而言，舒芬太尼优于瑞芬太尼。     

靶控输注瑞芬太尼、丙泊酚置入喉罩静脉全麻在手腕部神经损伤修复术中的应用

目的比较靶控输注瑞芬太尼、丙泊酚置入喉罩静脉全麻与丙泊酚、芬太尼全凭静脉麻醉的效果及不良反应。方法80例手腕部神经损伤修复术病人,随机分为2组,每组40例:A组(靶控输注瑞芬太尼、丙泊酚全凭静脉麻醉组)、B组(芬太尼、丙泊酚全凭静脉麻醉组)。诱导:A组瑞芬太尼2.5μg/ml 丙泊酚3.0μg/ml,B组芬太尼3μg/kg,丙泊酚2mg/kg,诱导后均置入喉罩。术中维持:A、B组均靶控输注丙泊酚(效应部位浓度3μg/ml),分别采用复合靶控瑞芬太尼和间断静注芬太尼维持麻醉。记录各组麻醉前(T0)、诱导后(T1)、置入喉罩后(T2)、拔除喉罩(T3)各时点血压、心率变化,记录手术时间、睁眼时间、定向力恢复时间。结果2组诱导时间(A>B)、术毕睁眼时间(A>B)、定向力恢复时间(A>B)均有显著性差异(P<0.05),B组患者诱导后心率明显低于A组;A组T1、T2、T3时收缩压明显低于B组,均有显著性差异。结论靶控输注瑞芬太尼、丙泊酚置入喉罩静脉全麻可以安全有效地用于手腕部神经损伤修复术,术中患者生命体征稳定,术后苏醒迅速,是较理想的麻醉方式。     

不同异丙酚诱导麻醉对颅内假性动脉瘤介入治疗气管插管 期心血管反应的影响

目的 观察异丙酚不同输注法行麻醉诱导对颅内假性动脉瘤介入治疗气管插管期心血管反应的影响。方法 选择2010年6月至2018年5月血管内介入治疗的颅内假性动脉瘤60例,根据麻醉诱导方 法分为三组:单次静脉推注组（A组）、血浆靶控组（B组）和效应室靶控组（C组）,每组20例。麻醉诱导方法:A组采用异丙酚2 mg/kg单次静脉推注;B组设定异丙酚血浆靶浓度为4 μg/ml;C组设定异 丙酚效应室靶浓度4 μg/ml。三组均同时采用瑞芬太尼4 ng/ml血浆靶浓度靶控输注诱导,待意识消失后静注罗库溴铵0.6 mg/kg,脑电双频谱指数在40~60并维持5s时行气管插管。记录进入手术室（T0） 、喉镜暴露声门（T1）、气管导管过声门（T2）、气管导管进入气管后1 min（T3）、2 min（T4）、3 min（T5）平均动脉压（MAP）、心率（HR）;并记录气管插管期不良反应及纠正次数。结果 与T0比 较,三组T1~T3 MAP均明显降低（P<0.05）,三组T1~T5 HR均明显减慢（P<0.05）;与B组比较,A组与C组T1 MAP明显降低（P<0.05）、HR明显减慢（P<0.05）。B组低血压、心动过缓等发生率和纠正次数 明显少于A组（P<0.05）,而且B组心动过缓发生率和纠正次数少于C组（P<0.05）。C组纠正次数明显少于A组（P<0.05）。结论 4 μg/ml异丙酚血浆药物浓度作为目标靶控输注浓度更适合颅内假性动脉 瘤介入治疗的麻醉诱导,低血压和心动过缓不良反应等发生率更低。     

癫痫细胞悬液对海马干细胞分化的影响

目的 观察癫痫大鼠海马细胞悬液对海马干细胞分化的影响.方法 实验分为对照组、谷氨酸组(包括5 μmol/mL、25 μmol/mL2个亚组)、正常大鼠海马细胞悬液组(包括20μg/mL、40μg/mL 2个亚组)及癫痫细胞悬液组(包括20 μg/mL、40 μg/mL 2个亚组),分别向接种了海马干细胞神经球的96孔培养板内加入培养基、相应浓度谷氨酸、正常大鼠海马细胞悬液及癫痫细胞悬液,应用MTT法比较4组在分化第1、7、10、14天之间海马干细胞分化活力.结果随着分化时间的延长,各组MTT值均呈增加趋势.各浓度谷氨酸组及正常海马细胞悬液组细胞活力较对照组下降,而癫痫细胞悬液组的细胞活力较对照组轻微增加.但差异没有统计学意义(p>05).相同浓度的癫痫细胞悬液组与正常海马细胞悬液组之间 MTT值差异没有统计学意义(p>0.05).结论 癫痫细胞悬液未对海马干细胞的分化产生影响.     

靶控输注依托咪酯在颅内动脉瘤介入手术中的应用

目的探讨靶控输注依托咪酯在颅内动脉瘤介入手术中的应用效果。方法选择美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级择期行颅内动脉瘤介入手术的患者70例,随机分为依托咪酯组(E组)和丙泊酚组(P组),分别采用靶控输注依托咪酯和丙泊酚行麻醉诱导和维持。记录麻醉诱导前、气管插管前、气管插管后5 min、手术开始时、停药时的SBP、DBP、HR;并记录手术时间、拔管时间;记录麻醉维持时依托咪酯的靶控输注血浆浓度。结果与麻醉诱导前比较,在气管插管前、气管插管后5 min、手术开始时、停药时P组血压均明显下降,差异有统计学意义(P0.05),E组气管插管前、气管插管后5 min、手术开始时、停药时血压与麻醉诱导前比较略下降,差异无统计学意义(P0.05);组间比较,与E组相比气管插管前、气管插管后5 min、手术开始时、停药时血压均明显下降,差异有统计学意义(P0.05);两组拔管时间无统计学差异(P0.05);麻醉维持时依托咪酯的靶控输注血浆浓度为(0.25±0.08)μg/m L。结论在动脉瘤介入术中,靶控输注依托咪酯能有效减少麻醉诱导和维持期的循环波动,可使术中血流动力学稳定且患者苏醒迅速,是一种可靠的静脉全麻药。     

脑电双频指数指导下芬太尼复合靶控输注异丙酚在老年患者纤支镜检查的应用

目的探讨脑电双频指数指导无痛纤支镜老年患者检查的临床应用。方法选择80例,年龄65～75岁行纤支镜检查的患者,随即分2组(n=40),A组间断推注异丙酚、芬太尼组,B组BIS指导下芬太尼复合异丙酚靶控输注组,观察2组六个时间点的Sp02、HR、SBP、DBP、苏醒时间、异丙酚用量及不良事件的发生。结果 B组苏醒时间、异丙酚用量均明显小于A组,异有统计学意义(P<0.05),B组不良事件发生率小于A组,差异有计学意义(P<0.05),B组各时间点SBP、DBP、HR、SP02更平稳(P<0.05)。结论在BIS指导下芬太尼复合丙泊酚靶控输注老年患者的无痛纤支镜检查更安全。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

The influence of comorbid depression on seizure severity

PURPOSE: To determine the relation between depressive symptoms and seizure severity among people with epilepsy. METHODS: A postal questionnaire was used to survey a nationwide community sample about seizures and depression. The Seizure Severity Questionnaire (SSQ) assessed the severity and bothersomeness of seizure components. The Centers for Epidemiological Studies-Depression scale categorized levels of depression. RESULTS: Respondents categorized as having current severe (SEV, n = 166), mild-moderate (MOD, n = 74), or no depression (NO, n = 443) differed significantly in SSQ scores (all p < 0.0001). People with SEV or MOD reported significantly worse problems than did those with NO depression for overall seizure recovery (mean, 5.3, 4.9, 4.5, respectively); overall severity (5.0, 4.5, 4.2); and overall seizure bother (5.3, 4.8, 4.4) (all p < 0.005). Cognitive, emotional, and physical aspects of seizure recovery also were rated worse among people with SEV than with NO depression (all p < 0.05). Symptoms of depression were significantly correlated with higher levels of all components of generalized tonic-clonic seizure severity (r = 0.33-0.48; all p < 0.0001), and partial seizures (r = 0.31-0.38; all p < 0.01). CONCLUSIONS: Clinically depressed people with epilepsy reported higher levels of perceived severity and bother from seizures, as well as greater problems with overall seizure recovery than did nondepressed people experiencing similar types of seizures. The pervasive influence of depressive symptoms on reports of seizure activity suggests that people with epilepsy should be screened for depression. These data highlight the importance of detecting and treating depression among people with epilepsy.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.