麻醉医生主导的超声影像和麻醉实践与教学

随着临床多学科协作模式的深入发展,医学超声应用领域的扩展,超声医学逐渐活跃在临床科室的日常诊疗中。近年,随着可视喉镜,BIS监测,目标导向液体治疗等可视化技术在临床麻醉中的发展和进步,超声影像学也成为了其中的一项重要组成部分。将床旁超声影像学与基础麻醉学知识、临床实践进行有机的结合,依靠真实的临床病例,使学生在临床实践活动中激发他们的主观能动性,积极地进行思考,大大提高他们分析问题、处理问题的能力。     

异丙酚对内脏痛大鼠脊髓背角使君子酸受体GluR1亚基磷酸化水平的影响

目的 探讨异丙酚对内脏痛大鼠脊髓背角使君子酸(AMPA)受体谷氨酸受体1(GluRl)亚基831和845位点丝氨酸磷酸化水平的影响.方法 成年雄性SD大鼠,体重200～300 g,6～8周龄,行鞘内置管术,5d后选取鞘内置管成功的大鼠30只,采用随机数字表法,将其随机分为3组(n=1 0):假手术组(Ⅰ组)、内脏痛组(Ⅱ组)和异丙酚组(Ⅲ组).Ⅱ组和Ⅲ组采用经直肠注射50μl10％辣椒素的方法制备内脏痛模型,Ⅰ组给予等容量生理盐水,Ⅲ组于给予辣椒素前10 min鞘内注射异丙酚20μg,Ⅰ组和Ⅱ组给予等容量二甲基亚砜.记录给予辣椒素后30 min内大鼠累计痛评分,然后处死大鼠,取L3-6腰骶段脊髓背角组织,采用免疫印迹法检测AMPA受体GluR1亚基及其831和845位点丝氨酸磷酸化水平.结果与Ⅰ组比较,Ⅱ组和Ⅲ组累计痛评分和脊髓背角GluR1亚基831和845位点丝氨酸磷酸化水平升高(P ＜0.05或0.01),而GluR1亚基表差异无统计学意义(P＞0.05);与Ⅱ组比较,Ⅲ组累计痛评分和脊髓背角GluR1亚基831和845位点丝氨酸磷酸化水平降低(P＜0.05或0.01).结论 异丙酚可减轻大鼠内脏痛,其机制与抑制脊髓背角AMPA受体GluR1亚基831和845位点丝氨酸磷酸化有关.     

超声引导不同注药方式肌间沟臂丛阻滞的效果比较

目的 比较超声引导肌间沟臂丛阻滞方式对麻醉效果的影响.方法 选择拟行肩部或上肢手术的患者90例,ASA Ⅰ～Ⅱ级,用随机数字表法随机分成3组(每组30例),用0.5％的罗哌卡因进行肌间沟臂丛阻滞.S组:超声引导单点注射组;M组:超声引导多点注射组;R组:超声引导减药注射组.S组和M组各给予0.5％的罗哌卡因30 ml,R组臂丛各干均被局麻药包裹呈“甜圈征”即停止局麻药注射.结果 S组前臂内侧皮神经、臂内皮神经平均起效时间(92±3.1) min和(10.6±2.8)min明显长于M组(7.6±2.3) min和(6.0±2.2) min和R组(8.2±2.6) min和(7.6±2.7) min;S组臂内皮神经阻滞完善率(60％)明显低于M 组(100％)和R组(94.3％);M组并发症发生率(60％)明显高于S组(20％).结论 超声引导多点肌间沟臂丛神经阻滞可以加快前臂内侧皮神经和臂内侧皮神经起效时间,提高臂丛阻滞完善率,但与单点和减药注射组相比并发症发生率增加.     

国产舒芬太尼用于术后静脉自控镇痛的疗效和安全性——多中心、随机、双盲、平行对照临床研究

Objective To evaluate efficacy and safety of sulfentanyl (China) for PICA in surgical patients with general anes-thesia in a multiple-center, randomized, double-blind, parallel study. Methods 200 ASA grade Ⅰ -Ⅱ patients aged 18-55 undergo-ing surgery with general aneathesia enrolled from 3 hospitals were randomly and double-blindly divided into 2 groups: sulfentanyl (China, n=100) versus sulfentanyl(German, n=100). Sulfentanyl(China 0.1 μg/kg or German)was given before the end of surgery. VAS scores less than 3 after patient awake and PCA started after extubation(200 μg sulfentanyl was diluted with 50 ml saline solution, background dose 0.5 ml/h,bolus of 0.5 ml with lockout interval 15 min, continuous infusion 48 h). Vital signs including BP, HR, PR, SpO2 and side effects such as nausea, vomiting, urine retention, pruritus, breath depression, etc. And VAS scores with patients in quiet and cough were recorded at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. The total number of PCA, the total effective number of PCA, and the ratio of both and other analgesics as well as the satisfactory degree of patients and the cumulative suffen-tanyl consumption were recorded at 24 h. Results There were no significant difference of BP, HR, PR, SpO2 and the adverse effect and VAS scores in quiet and cough between two groups at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. There were no signifi-cant difference of the total number of PCA, the total effective number of PCA and other analgesics as well as the satisfactory degree of patients and the total dosage of sulfentanyl at 24 h. Conclusion The sulfentanyl (China) had satisfactory effects of postoperative analgesia and had no significant side effects compared with sulfentanyl (German). The efficacy and the side effects of both drugs had no significant difference.     

氯胺酮咪达唑仑联合用药在小鼠快速实验的麻醉效果评价

目的 探讨氯胺酮及咪达唑仑单药及联合用药对于小鼠快速实验的麻醉效果.方法 6周龄雌性小鼠30只,随机分为氯胺酮单药组120.0 mg/kg(K组)、咪达唑仑单药组75.0 mg/kg(M组)、联合药物组氯胺酮50.0 mg/kg+咪达唑仑2.5 mg/kg(KM1组)、氯胺酮70.0 mg/kg+咪达唑仑3.5 mg/kg(KM2组)、氯胺酮100.0 mg/kg+咪达唑仑5.0 mg/kg(KM3组),每组6只.所有小鼠在腹腔注射药物后记录翻正反射消失时间及恢复时间.在翻正反射消失后3、5、10 min进行刺激评分,包括夹尾反射、前脚回缩反射、后脚回缩反射和角膜反射.反射存在记0分、反射消失记1分,比较3个时点每只小鼠的4项相加评分.结果 与K组和M组相比,KM1组、KM2组、KM3组的翻正反射消失时间均显著缩短(P＜0.01),翻正反射恢复时间在KM2组、KM3组均显著延长(P＜0.01).与K组相比,KM2、KM3组翻正反射消失后5 min和10 min的评分显著增高(P＜0.05);与M组相比,KM2组翻正反射消失后5 min和10 rain的评分显著增高(P＜0.05),KM3组翻正反射消失后3、5、10 rain的评分均显著增高(P＜0.05).结论 氯胺酮联合咪达唑仑麻醉小鼠可达到满意的麻醉效果.其中,氯胺酮100.0 mg/kg联合咪达唑仑5.0 mg/kg剂量组的麻醉起效快,动物耐受疼痛刺激效果好,适用于小鼠快速实验.     

局部应用不同剂量氨甲环酸对胸科手术后止血效果的研究

目的 探讨胸膜腔内局部应用不同剂量氨甲环酸(tranexamic acid,TXA)对胸科手术患者术后总失血量、术后引流量、凝血功能和术后疼痛的影响.方法 选取2015年9月至2016年1月首都医科大学附属北京朝阳医院择期行胸腔镜肺叶切除术的患者60例,随机分为2 gTXA组(A组)、3 gTXA组(B组)和对照组(C组).于淋巴结清扫充分止血后,关胸放置胸腔闭式引流管前,A、B、C3组分别将2 gTXA溶液、3g TXA溶液、等体积(40 ml)的生理盐水均匀喷洒于胸腔内,随即夹闭胸腔闭式引流管并记录夹闭时间.观察术后l、3、6、12、24 h引流量,计算总失血量,监测患者术前及术后血常规、凝血功能,随访术后第1天疼痛视觉模拟评分(visual analogue score,VAS)及引流管拔除时间和出院时间.结果 A组和B组术后各时点的引流量均低于C组,且在术后3h[A组与C组:(109.75±60.12)ml比(155.25±77.57) ml;B组与C组:(109.50±44.83) ml比(155.25±77.57) ml]和术后24h [A组与C组:(449.50±98.76) ml比(479.50±142.03) ml;B组与C组:(384.50±81.75) ml比(479.50±142.03) ml]的差异均有统计学意义(P＜ 0.05).A组和B组的总失血量较C组降低7.9％和15.9％,但差异无统计学意义(P＞0.05).3组术后PLT及凝血功能比较,差异均无统计学意义(P＞0.05).B组的住院时间较A组和C组缩短[(5.05±1.27)d比(5.23±1.42)d,(5.05±1.27)d比(6.10±1.56)d],差异有统计学意义(P＜0.05).所有患者未出现心肌梗死、脑梗死等并发症.结论 胸膜腔内局部应用2 g和3 gTXA溶液均可减少胸腔镜肺叶切除术患者术后总失血量及胸腔引流量,缩短住院时间,不增加血栓形成的风险.胸膜腔内局部应用3 gTXA较2 gTXA在减少术后24 h引流量方面有优势,但对于总失血量无明显影响,尚不能证实局部应用TXA存在剂量-反应关系.     

经食管超声心动图在肺移植术中的作用

目的 探讨术中经食管超声心动图(TEE)在肺移植术中的应用价值.方法 2005年8月至2009年8月,19例平均年龄(48.35±13.04)岁的肺疾病晚期病人行肺移植手术.于肺移植术前麻醉后送入TEE探头,检测左、右肺静脉开口和肺动脉血流速度,右室壁运动,左、右心室容积,右室射血分数.观察房间隔有无交通.肺移植术中分别于断肺后和供肺支气管、肺静脉、肺动脉全部吻合开放后连续观察上述指标.结果 19例中6例为序贯式双肺移植,13例单肺移植,其中左叶肺移植2例、右叶肺移植11例.术中阻断一侧被移植肺的动、静脉后,该侧肺动、静脉血流消失,右室容积轻度增大.供体肺与受体肺全部气管、肺静脉、肺动脉吻合完毕开放后,右室容积恢复.TEE依次检测肺静脉、肺动脉吻合口,吻合口流速均轻度增快.开放后发现1例右肺动脉血流速度显著增快,经重新吻合后血流速度降低,血氧分压恢复.术中发现3例卵圆孔未闭.结论 TEE在肺移植术中监测肺动脉和肺静脉血管吻合口直径和血流速度,检测右心功能,对并发症的预测等起重要作用.

Abstract：

Objective To investigate the clinical value of transesophageal echocardiography during the lung transplanta tion. Methods From August 2005 to August 2009, 19 patients with advanced lung diseases received lung transplantation.The average age was(48.35±13.04) years. The echocardiographic probe was placed in patient's esophagus before surgery.The left and right pulmonary venous openings, artery blood flow velocity, right ventricular wall motion, left and right ventricular volume, right ventricular ejection fraction were recorded at different time intervals during lung transplantation, especially at the break and after completion of bronchus, pulmonary veins, and pulmonary artery anastomosis. Results The procedure included sequential-type lung transplantation in 6 cases and single lung transplantation in 13. The blood flow disappeared when blocking pulmonary artery and vein and right ventricular volume increased slightly. The right ventricular volume restored after completion of trachea, pulmonary veins, pulmonary artery anastomosis. TEE detected that the blood flow velocity of pulmonary veins, pulmonay artery anastomosis increased slightly. In 1 case the opening of the right pulmonsry artery blood flow velocity increased significantly and blood flow velocity decresed and blood oxygen partial pressure resumed after re-anastomosis of pulmonary artery. Conclusion TEE play an important role in monitoring pulmonary artery and vein anastomosis diameter and blood flow velocity and right ventricular function and predicting complications during lung transplantation.     

麻醉科研究生创新意识和科研能力培养的探讨

培养具有较强创新意识的麻醉科研究生关系到我国麻醉学科的发展。以培养麻醉科研究生浓厚的科研兴趣和正确的科研态度为基础,通过英语语言能力和数据库检索能力的培养,逐步提高研究生获取国内外科技信息的能力;在掌握最新的科技信息的基础上,进一步引导他们提出自己创新性的思想和开展创新性的科研临床实践工作。这些措施不仅可以提高麻醉科研究生的学术水平,更重要的是使他们养成创新性思维习惯,有利于他们未来的职业生涯。     

术中血液保护的药物措施及进展

术中用于血液保护的药物有纤溶酶抑制剂,如氨基己酸(EACA)、氨甲环酸(TXA),巴曲亭,乌司他丁,去氨加压素(desmopressin,DDAVP),重组活化凝血因子等。给药方式包括静脉给药(单独或联合用药)和局部给药。现重点介绍抗纤溶药TXA和蛇毒血凝酶制剂巴曲亭对术中血液保护的作用及应用进展。