Normothermic cardiopulmonary bypass: effect on the incidence of persistent postoperative neurological dysfunction following coronary artery bypass graft surgery

We retrospectively reviewed the records of 250 consecutive patients undergoing coronary artery bypass graft surgery (CABG) from January 1994 through January 1996 to determine the incidence of persistent postoperative neurological dysfunction after CABG and to compare normothermic and moderate hypothermic cardiopulmonary bypass (CPB). Normothermic CPB was used in 128 patients (36°–37°C) and hypothermic CPB (27°–28°C) in 122 patients. Postoperative neurological dysfunction included focal motor deficits, delayed recovery of consciousness (>24h) after surgery, and seizures within 1 week postoperatively. Persistent neurological dysfunction was diagnosed if complete resolution had not occurred within 10 days of surgery. The incidence of persistent postoperative neurological dysfunction was 4.1% in the hypothermic CPB group and 2.3% in the normothermic CPB group. There were no statistically significant differences between the two groups (P=NS). These results suggest that normothermic CPB did not increase the incidence of persistent postoperative neurological dysfunction compared to hypothermic CPB.     

颈动脉切除术的临床研究

目的 探讨颈部恶性肿瘤侵犯颈总动脉和I或颈内动脉以及颌面部难控制大出血时对颈总动脉和颈内动脉的外科处理方法及其并发症、后遗症的预防。方法 回顾性分析1990年－2000年行颈总或I和颈内动脉结扎、切除术的6例临床资料。结果 本组均为男性，年龄17－66岁。其中颈部复发性转移癌浸润颈总动脉、颈内动脉3例，鼻咽癌放疗后颈部溃疡侵犯颈总动脉1例，上颌骨中央性血管瘤大出血1例，鼻咽纤维轿管瘤术中、术后大出血1例。单纯结扎、切除颈总动脉4例，颈总及颈内动脉同时结扎、切除2例。经随访，术后短暂性肢体偏瘫2例，脑梗塞、永久性偏瘫1例，无任何并发症3例。无手术死亡病例。结论 颈动脉切除术对已累及颈动脉的颈部恶性肿瘤是一种有效的治疗手段，对于颌面颈难以控制的致命性大出血是一种有效的急救措施。单纯切除颈总动脉所产生的术后并发症的发生率比颈总动脉和颈内动脉同时切除低；而已先期或同时切除颈外动脉，出现并发症的机会更大。术后酌用抗凝或溶栓药物对于脑血栓、脑梗塞的防治作用有待进一步研究。     

An audit of the safety of an acute pain service

We audited and analysed the adverse effects and safety of postoperative pain management on 2509 consecutive patients under care of the Acute Pain Service at a tertiary referral teaching hospital over a 32-month period. Our standard respiratory monitoring consisted of continuous pulse oximetry, hourly respiratory rate counting, sedation scoring and intermittent arterial blood gas sampling. This protocol was reliable and detected six episodes of bradypnoea, 13 of hypercapnia and 23 of oxygen desaturation occurring in 39 patients (1.8% of all spontaneously breathing patients) . Two patients required naloxone injection and none had long-term sequelae. Hypotension due to epidural bupivacaine 0.0625% and fentanyl 3.3 μg.ml⁻¹ infusion occurred in four patients (1.2%), all with a sensory block higher than T₅. They readily responded to fluid infusion and ephedrine (two patients). Postoperative nausea or vomiting occurred in 723 (28.8%) and 380 (15.1%) patients, respectively. Odds ratio analysis showed that the risk factors for postoperative nausea and vomiting were: female gender, gynaecological operations, nongeriatric patients and systemic analgesia. Postoperative nausea and vomiting decreased analgesic efficacy by discouraging the use of patient-controlled analgesia and was regarded as equally distressing as pain. Other side-effects included: pruritus in 182 patients; dizziness in 333 and lower limb weakness in 73 (21.2% of patients receiving epidural local anaesthetics). It is concluded that a standard monitoring and management protocol, an experienced nursing team and reliable Acute Pain Service coverage is mandatory for the safe use of modern analgesic techniques.     

In vitro contracture test for diagnosis of malignant hyperthermia following the protocol of the European MH Group: Results of testing patients surviving fulminant MH and unrelated low-risk subjects

Background: Determination of sensitivity and specificity of the in vitro contracture test (IVCT) for malignant hyperthermia (MH) susceptibility using the European MH Group (EMHG) protocol has been performed in some laboratories but only on a small sample from the combined EMHG. Thus, the purpose of the present study was to determine combined EMHG sensitivity and specificity of the test. Methods: Results of IVCT of patients with previous fulminant MH and normal, low-risk subjects (controls) were collected from 22 centresof the EMHG. IVCT was performed according to the EMHG protocol. Patients were included inthe study if the clinical crisis had a score of at least 50 points with the Clinical Grading Scale. Low-risk subjects were included provided they did not belong to a family with known MH susceptibility, they had not developed any signs of MH at previous anaesthetics, and they did not suffer from any neuromuscular disease. For inclusion of both MH patientsand low-risk subjects, at least 1 muscle bundle in the IVCT should have twitches of 10 mN(1 g) or more. For evaluation of individual tests, only muscle bundles with twitch heights of 10 mN (1 g) or more were used. Results: A total of 1502 probands had undergone IVCT because of a previous anaesthesia with symptoms and signs suggestive of MH. Of these, 119 had clinical scores of 50 and above. From these 119 MH-suspected patients and from 202 low-risk subjects, IVCT data were collected. Subsequently, 14 MH-suspected patients were excluded from further analysis for thefollowing reasons: In 3 patients, the suspected MH episode could be fully explained by diseases other than MH; in 11 MHS patients, IVCT was incomplete (n=l), data were lost (n=3), or none of the muscle bundles fulfilled twitch criteria (n=7). Of the remaining 105 MH-suspected patients, 89 were MHS, 10 MHEh, 5 MHEc, and one MHN. Thus, we observed a diagnostic sensitivity of the IVCT of 99.0% if the MHE group is considered susceptible(95% confidence interval 94.8–100.0%). Of the 202 low-risk subjects, 3 were MHS, 5 MHEh, 5 MHEc, and 189 MHN. This gives a specificity of the IVCT of 93.6% (95% confidence interval 89.2–96.5%). Conclusion: The IVCT for diagnosis of MH susceptibility in Europe has a high sensitivity and a satisfactory specificity.     

41例气管切开手术后护理体会

目的:总结气管切开术后护理体会.方法:探讨41例气管切开术后患者的心理护理、并发症的防范和护理要点.结果:2例死于各自原发病,39例患者在术后8～128天内顺利拔管.结论:规范的术后护理对保证气管切开术后效果起着至关重要的作用.     

Prediction of severe postoperative complications in patients admitted to neuroanaesthesia

The purpose of this study was to identify factors which will predict the risk of severe postoperative complications in individual patients in a neurosurgical unit. Eleven risk factors were investigated in 363 neurosurgical patients, of whom 40 (11%) developed postoperative complications requiring mechanical ventilation for more than 24 h in an intensive care unit, 16 were found to be severely disabled or in a vegetative state at follow-up 1 month after admission, and 28 patients died. By applying stepwise, logistic regression analysis to the patient's data, we were able to select two significant risk variables, i.e. the Glasgow Coma Scale (GCS) 8 or less preoperatively and emergency anaesthesia. The presence of GCS 8 or less on the consciousness scale was associated with postoperative complications in approximately 40% of the cases. Emergency patients with severe neurological damage had the greatest risk of postoperative complications (93%). Fatal outcome for patients with postoperative complications was seen in 40% of the cases.     

Gastric ulceration caused by heater probe coagulation

A double-contrast upper gastrointestinal examination on a woman who had undergone endoscopic heater probe therapy one day earlier for multiple arteriovenous malformations revealed shallow, irregular, and linear ulcers at the sites of heater probe coagulation. Multiple shallow ulcers may therefore develop as a direct complication of heater probe therapy. Radiologists should be aware of this complication to avoid diagnostic confusion in these patients.     

神经内镜手术后发热反应的临床观察及其意义

目的总结和分析神经内镜术后发热反应的特点。方法回顾性分析88例符合纳入标准的行神经内镜手术治疗病人的临床资料。将病人按手术方式分为5组：外侧裂蛛网膜囊肿造瘘组（SAC）、脑室内蛛网膜囊肿切除组（VAC）、透明膈造瘘组（SPF）、第三脑室底造瘘组（ETV）、脉络丛烧灼术组（CPC），分别总结各组病人的术后发热反应特点。结果术后发热反应以CPC组最重。术后达到最高体温的时间所有病人均不超过术后第3天。ETv组术后最高体温可出现在手术后当El的数小时内．而非ETv组病人无此现象。结论电凝烧灼、坏死组织残留、下丘脑刺激、脑脊液循环能力等多种因素．使神经内镜手术后可出现不同程度的发热反应。     

颈丛阻滞下行颈动脉内膜剥脱术--附32例分析

目的观察颈丛阻滞下行颈动脉内膜剥脱术的效果.方法 28名ASAⅡ～Ⅲ级患者行32例颈动脉内膜剥脱术,采用深浅丛联合阻滞,观察围术期血液动力学指标变化,分流管放置率和并发症情况.结果 麻醉后血压和心率与麻醉前相比差异有显著性(P＜0.05),其它时点与麻醉前相比差异无显著性(P＞0.05).颈动脉夹闭前后收缩压和心率的波动性的差异无显著性(P＞0.05).围术期高血压的发生率为50.0%,低血压6.25%,心动过速28.1%,心动过缓6.25%,分流管放置率6.25%.患者满意率84.4%.无1例改用全麻,无严重围术期并发症.结论颈丛阻滞是颈动脉内膜剥脱术安全、有效的麻醉方法.     

Removal of laryngeal mask airway: airway complications in children,anaesthetized versus awake*

The laryngeal mask airway (LMA) must be inserted during deep anaesthesia. There are no guidelines concerning the removal of LMA, i.e., in awake or anaesthetized patients. The aim of this randomized prospective study was to compare the incidence of respiratory complications after LMA removal in anaesthetized or awake paediatric patients. Sixty children (ASA PS I or II), ranging from 4 months to 12 years of age, were studied. In patients breathing spontaneously, anaesthesia was induced and maintained with nitrous oxide, oxygen and halothane. Patients were randomly divided into two groups: group 1 removal of LMA in awake patients, or group 2 removal of LMA in anaesthetized patients, i.e., in patients receiving halothane at an alveolar concentration of 2 MAC adjusted for age and oxygen for 5 min. In both groups, patients received 100% oxygen after removal of LMA. After removal the incidence of respiratory complications was highest (P < 0.05) in group 1. Therefore, in healthy children undergoing elective surgery, the authors conclude that it is safer to perform the LMA removal in anaesthetized patients.