氯诺昔康、右美沙芬与吗啡协同镇痛作用的临床观察

目的:观察小剂量氯诺昔康、右美沙芬复合小剂量吗啡用于上腹部手术后镇痛的效果.方法:择期上腹部手术患者45例,术后使用100mL一次性镇痛泵.所用药物为分别为吗啡50mg(吗啡组,n=14)、吗啡30mg 右美沙芬15mg(右美沙芬组,n=14)、吗啡30mg 氯诺昔康16mg(氯诺昔康组,n=14)和吗啡30mg(对照组,n=6).记录术后3,6,24,48h疼痛视觉模拟评分(VAS)、Ramsay镇静评分、活动后VAS评分和48h内使用吗啡总量并记录可能出现的不良反应.结果:术后6和24h吗啡组、氯诺昔康组VAS明显低于对照组,右美沙芬组6h明显低于对照组.术后6和24h吗啡与氯诺昔康组活动后VAS明显低于对照组,而右美沙芬组与对照组差异无显著性,且在6h显著高于吗啡组.各组术后镇静评分无差异.术后48h吗啡总量吗啡组明显高于其他3组,氯诺昔康与右美沙芬组低于对照组.术后恶心呕吐病例吗啡组明显高于其他3组.右美沙芬组1例眩晕,吗啡组1例皮肤瘙痒,未发现其他不良反应.结论:小剂量非阿片类药物氯诺昔康与右美沙芬与吗啡联合应用可增加吗啡的镇痛效果.     

应激状态下前列腺素E2的合成与代谢

前列腺素E2 (PGE2 )具有广泛的生理和病理功能 ,在心血管、胃肠、呼吸和生殖系统均具有重要作用 ,是炎症、疼痛、发热反应中的重要介质[1] ,研究认为肺脏是PGE2 重要的作用器官和代谢场所 ,可主动摄取并降解循环中的PGE2 [2 ] 。肺脏是感染、创伤等应激反应中炎性因子损伤的首要靶器官 ,肺感染又是这些严重应激后常见的并发症 ,肺脏的损伤不仅降低呼吸功能 ,而且可能通过影响PGE2 的正常代谢 ,增加PGE2 水平产生一系列病理作用[3 ] 。笔者从代谢的角度探讨严重应激状态下PGE2 的变化及其意义。1　应激状态下PGE2 的合成PGE2 由环…     

丁丙诺啡与罗哌卡因混合液改善臂丛神经阻滞效果的临床观察

自从阿片受体在外周神经元表面发现以来，许多研究表明阿片类药物可通过其外周受体发挥镇痛作用。临床观察显示阿片类药物与局麻药合用，可明显改善椎管内麻醉的效果并延长镇痛时间，但使用阿片类药物与局麻药混合液用于外周神经阻滞的效果尚有争论。本研究采用随机双盲观察方法，评价丁丙诺啡与0．5％罗哌卡因混合液用于腋路臂丛神经阻滞效果和术后镇痛的影响。     

Change of Th1/Th2 Cytokine Equilibrium in Rats with Severe Sepsis and Therapeutic Effect of Recombinant Interleukin-12 and Shenmai Injection(参麦注射液)

Objective: To evaluate the dynamic change of Th1/Th2 cytokines in serum, peritoneal lavage fluid (PLF) and splenic macrophages (SM) in rats with severe peritonitis, and to observe the therapeutic preparation. Methods: Severe peritonitis (SP) model was induced by intraperitoneal injection of E. coli and B. frag, and mild peritonitis (MP) model was induced by cecal ligation and punching. Then the following experiments were done: (1) Survival rates of animals after every 6 hrs in the 72 hrs after modeling were recorded, serum and PLF levels of cytokines, including tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ),and interleukin-10 (IL-10), 6 hrs, 12 hrs, 24 hrs and 48 hrs after modeling were measured. (2) Model rats were treated with rlL-12 or SMI, the survival rate was recorded and serum levels of TNF-α, INF-γ, and IL-10before and after treatment were measured, and (3) amount of these cytokines produced by SM were determined 6 hrs, 12 hrs and 24 hrs after treatment. The survival rates and levels of cytokines were then compared between the groups (model group treated with rlL-12 or SMI, untreated model group, and blank group). Results: Serum and PLF levels of IFN-γ, TNF-α at all the time points in SP rats were significantly lower than those in MP rats while those of IL-10 6 hrs and 12 hrs after modeling were significantly higher in the former than that in the latter ( P＜0.05). IFN-γ secretion of SM in SP rats was significantly higher than that in MP rats 6 hrs after modeling (P＜0.05). Administration of rlL-12 or SMI given before modeling could improve the survival rate of the model rats (P＜0.05) and cause significant increase of the serum level and SM secretion of IFN-γ. Conclusion: Imbalance in promoting/antagonizing inflammatory cytokines and Th2 response dominance appear in SP rats early at the initiating stage, and SM secretion of inflammation promoting factor also reduces. Administration in time of rlL-12 and SMI, may increase the survival rate, and its mechanism may be related with their immuno-stimulating action.     

丙泊酚长期镇静对重型脓毒症患者免疫平衡的影响

目的观察丙泊酚长期镇静对腹内感染所致重型脓毒症患者促炎/抗炎性细胞因子平衡的影响。方法15例符合重型脓毒症诊断的外科腹腔感染患者术后随机分为丙泊酚镇静组和对照组,另设健康组3例。丙泊酚组为连续使用丙泊酚镇静超过48h,对照组未常规应用镇静药物。比较两组患者入SICU即刻和48h后血清TNF-α、IL-10、TNF-α/IL-10(T/I)比值。结果两组患者入SICU后即刻细胞因子明显高于健康组,组间无差别。丙泊酚平均负荷量0．063 mg/kg,维持剂量0．054 mg/(kg·h)。48 h后丙泊酚组TNF-α、IL-10较入院明显下降,T/I比值较基础值有增高趋势(P=0．057)。对照组TNF-α、IL-10均较入院时差异无显著性,丙泊酚组IL-10低于对照组,而T/I比值高于对照。结论重型脓毒症患者使用丙泊酚长期镇静可抑制促炎因子TNF-α、抗炎因子IL-10的分泌,但使免疫平衡向Th1方向漂移,外科高危患者术后应用镇静药物应考虑其对免疫平衡的影响。     

左西孟旦临床应用的循证医学

左西孟旦是一种新型的钙增敏剂和KATP通道开放剂。与其他正性肌力药相比,它在不增加氧耗的情况下提高心肌收缩力,使外周血管和冠状动脉血管扩张,可以减轻心肌缺血。目前左西孟旦在临床上应用于治疗急性心力衰竭、慢性心力衰竭、缺血性心脏病、心源性和感染中毒性休克以及成人心脏手术围术期的过渡性治疗。该文总结了近期的文献中关于左西孟旦在多种临床情况下的应用。     

外科脓毒症诊治进展

脓毒症(sepsis)是严重创伤、烧伤、重症腹内感染、大手术后常见的并发症,也是外科危重病人主要死亡原因之一.尽管新型抗生素不断涌现和ICU的不断进展,脓毒症的病死率仍然高达30%～50%.据报道,美国每年有75万脓毒症患者发病,其中22.5万人死亡,并呈逐年上升趋势[1].     

硬膜外用药对胃肠动力的影响

本文从腹部手术后胃肠功能障碍的病理生理机制、硬膜外麻醉和术后硬膜外镇痛对胃肠动力的影响、胸段和腰段硬膜外用药对胃肠功能的作用差异以及硬膜外应用局麻药或阿片类药物镇痛的不同作用等方面将近年来的有关研究内容作一综述。     

脊髓蛋白酶体在大鼠慢性吗啡耐受形成中的作用

目的 评价脊髓蛋白酶体在大鼠慢性吗啡耐受形成中的作用.方法 取鞘内置管成功的健康雄性大鼠24只,采用随机数字表法,将大鼠随机分为4组(n=6),生理盐水组(NS组)、慢性吗啡耐受组(M组)、吗啡+蛋白酶体抑制剂MG-132组(M+ MG组)和MG-132组(MG组)于每天8:00和20:00分别鞘内注射生理盐水10 μl、吗啡10μg、吗啡10 μg+ MG-132 2.5μg、MG,-132 2.5 μg,连续7d.于鞘内注射前1 d(基础值)、鞘内注射第1、3、5和7天时测定大鼠甩尾潜伏期,以计算最大抗伤害效应百分比(MPAE).于最后一次鞘内注射结束后取5只大鼠,处死后取L3-5脊髓,采用Western blot法测定谷氨酸-天冬氨酸转运体(GLAST)和兴奋性氨基酸转运体1(EAAC1)的表达水平.结果 M组和M+MG组鞘内注射期间MPAE逐渐降低(P＜0.05);与NS组比较,M组和M+ MG组鞘内注射期间MPAE升高,M组脊髓GLAST和EAAC1表达下调(P＜0.05),M+ MG组脊髓GLAST和EAAC1表达差异无统计学意义,MG组上述指标差异均无统计学意义(P＞0.05);与M组比较,M+ MG组MPAE升高,脊髓GLAST和EAACI表达上调(P＜0.05或0.01).结论 脊髓蛋白酶体参与了大鼠慢性吗啡耐受的形成.