腹腔镜手术病人咪达唑仑-芬太尼-异丙酚麻醉诱导的优化配伍方案

目的 采用权重配方法探讨腹腔镜手术病人咪达唑仑、芬太尼、异丙酚复合麻醉诱导的优化配伍方案。方法选择ASAⅠ或Ⅱ级择期腹腔镜手术病人60例，男34例，女26例，年龄31～55岁。诱导药物的低效量和足量分别确定为咪达唑仑0．02、0．06mg／kg，芬太尼2、6μg／kg，异丙酚0．5、1．5mg／kg。根据权重配方法，将病人随机分配至3种药物不同剂量组合的6个配伍组（n=10）。连续监测脑电双频谱指数（BIS）、心率（HR）、平均动脉压（MAP）、脉搏血氧饱和度（SpO2）。各组依次静脉注射相应剂量咪达唑仑、芬太尼、异丙酚和罗库溴铵0．6mg／kg行麻醉诱导和气管插管。记录诱导前即刻、异丙酚注入后1、2min、插管即刻、插管后1、3、5、7min的BIS、MAP及HR。按权重配方法的剂量优化原则评判复合药效，分析各组份药的重要程度及相互作用的性质。结果以BIS为评价指标，当咪达唑仑0．06mg／kg、芬太尼5μg／ks、异丙酚1．0mg／kg配伍时，异丙酚为主药，异丙酚与咪达唑仑和芬太。尼具有相加性作用；以MAP为评价指标，当咪达唑仑0．06mg／kg、芬太尼5μg，kg、异丙酚1．5mg／kg配伍时，异丙酚为主药，异丙酚与咪达唑仑具有协同性作用，异丙酚与芬太尼具有相加性作用；以HR为评价指标，当咪达唑仑0．06mg／kg、芬太尼5μg／kg、异丙酚1．0mg／kg配伍时，芬太尼为主药，异丙酚与咪达唑仑和芬太尼具有协同性作用。结论腹腔镜手术病人咪达唑仑、芬太尼、异丙酚复合麻醉诱导在维持镇静方面为相加作用，在维持血液动力学稳定方面为协同作用；优化配伍方案为咪达唑仑0．06mg／kg、芬太尼5μg／kg、异丙酚1．5mg／kg。     

肛肠手术辅用力月西和丙泊酚的镇静遗忘作用

目的观察低位硬膜外麻醉下肛肠手术辅用力月西和丙泊酚的镇静和遗忘作用。方法对66例患者随机分为A、B两组,分别辅用力月西和丙泊酚,观察镇静和遗忘作用及血压、心率和呼吸变化。结果两组镇静评估的比较无显著性差异(P﹤0.05);遗忘率不同,B组患者遗忘率低于A组。结论丙泊酚和力月西辅用于低位硬膜外麻醉下肛肠外科手术,都达到了良好的镇静作用,力月西更具有良好的顺行性遗忘作用。     

十二指肠乳头括约肌切开胆总管取石术前静注咪唑安定对麻醉及手术效果的影响

目的　探讨在十二指肠乳头括约肌切开 (EST)胆总管取石术前静注咪唑安定的可行性及价值。方法　将 71例拟行 EST胆总管取石患者随机分为咪唑安定组 (试验组 ) 5 1例和对照组 (2 0例 ) ,两组术前均给予 6 5 4 -2 (10 mg)静脉注射 ,试验组同时静脉注射咪唑安定 (3～ 5 mg)。观察两组患者的进镜时间、麻醉程度 ,患者的反应与配合程度、自身感受程度 ,同时监测患者的血压、心率、血氧饱和度。结果　试验组进镜时间缩短、镇静程度适中、患者自身感受好 ,与对照组比较 ,差异有显著性 (P<0 .0 1) ;患者心血管及呼吸参数无明显变化。结论　EST胆总管取石术前静脉注射咪唑安定可提高麻醉效果 ,有利于提高患者配合的依从性 ,对血压、心率、血氧饱和度无明显影响     

丙泊酚、氯胺酮全凭静脉麻醉应用于烧伤病人的临床研究

目的:研究微量注射泵输注丙泊酚和氯胺酮全凭静脉麻醉在烧伤患者切痂植皮手术中的临床效果。方法:选择期手术患者,随机分为丙泊酚、氯胺酮组(P·K组)和咪达唑仑、氯胺酮组(M·K组)。P·K组术前10min首次静注丙泊酚2mg·kg和氯胺酮2mg·kg。M·K组术前10min首次静注咪达唑仑0 2mg·kg、氯胺酮2mg·kg ,随后两组以微量注射泵输注控制在P·K组丙泊酚6 6 . 6 6 μg·kg-1·min-1和氯胺酮4 1 .6 6 μg·Kg-1·min-1。记录注药后5、10min、切痂、取皮、植皮及停药后5、10min各时段无创血压(MAP)心率(HR)脉搏氧饱和度(SpO2 )及两组氯胺酮用药量变化。结果:P·K组氯胺酮用药量比M·K组少,P·K组MAP和HR无明显变化(P >0 . 0 5 ) ,M·K组MAP、HR均较麻醉前升高(P <0 . 0 1) ,两组SpO2 于诱导注药后均有一过性下降,数分钟恢复正常,两组比较差异无显著意义(P >0 . 0 5 )。结论:微量注射泵输注丙泊酚和氯胺酮全凭静脉麻醉安全可行,副作用小,可控性强,适用于烧伤患者切痂植皮手术。     

咪达唑仑对剖宫产术初产妇情绪和记忆的影响

目的 探讨咪达唑仑对剖宫产手术产妇情绪和记忆的影响.方法 72例择期剖宫产术产妇随机分成4组,Ⅰ、Ⅱ和Ⅲ组麻醉前30 min分别肌注咪达唑仑0.05、0.06和0.07 mg/kg,Ⅳ组肌注生理盐水1.5 ml,同时肌肉注射阿托品0.01 mg/kg.于注药前和注药后30 min进行焦虑视觉类比试验(AVAT)、状态焦虑问卷(SAI)测试及Ramsay镇静水平评估.将麻醉准备到手术结束过程分为5阶段,每项告知产妇,记录剖宫产术后4 h产妇能准确回忆的项目.结果 注药后30 min时,Ⅰ～Ⅲ组AVAT分别下降36.4%、43.2%和43.1%;SAI分别下降20.9%、24.8%和26.9%,均获得Ramsay 2～4级镇静水平.Ⅰ～Ⅲ组和Ⅳ组比较记忆保留组间差异均有统计学意义(P均＜0.01).Ⅰ～Ⅲ组以遗忘静脉穿刺过程的居多,4组产妇对椎管内麻醉穿刺和新生儿娩出后性别识别两过程全部记忆完觋整.结论 剖宫产手术前给予咪达唑仑0.05～0.07 mg/kg,对产妇有良好的镇静和抗焦虑作用,对外显记忆有一定程度的影响,其中对信息量小和关注程度低的信息能产生顺行性遗忘作用,能保留信息量大和关注程度高的信息的完整记忆.     

Defensive reactions are counteracted by midazolam and muscimol and elicited by activation of glutamate receptors in the inferior colliculus of rats

 The inferior colliculus is involved in conveying auditory information of an aversive nature to higher cortical structures. Gradual increases in the electrical stimulation of this structure produce progressive aversive responses from vigilance, through freezing, until escape. Recently, we have shown that microinjections of NMDA into the inferior colliculus mimic these aversive effects and that the neural substrates responsible for learned escape behavior in the inferior colliculus are regulated by GABA−benzodiazepine mechanisms. In the present study, we extend these observations showing that unlearned aversive responses are also depressed by muscimol and midazolam, both GABA-benzodiazepine agonists, and that microinjection of glutamate, an excitatory amino acid, into the inferior colliculus can trigger freezing responses. Electrical stimulation of the inferior colliculus of rats placed inside an open field allowed the determination of thresholds for the aversive responses, alertness, freezing and escape. Systemic administration (3 and 5.6 mg/kg) as well as microinjections into the inferior colliculus of the anxiolytic compound midazolam (10, 20 and 40 nmol) caused increases in threshold for these aversive responses. Similar results were obtained following microinjections of the GABA-A agonist muscimol (0.1, 1 and 5 nmol) into this brainstem structure. Microinjections of low doses of glutamate (5 nmol), presumed to activate mainly AMPA/kainate receptors, into the ventrolateral division of the central nucleus of the inferior colliculus of rats placed inside a circular arena induced aversive reactions, characterized by freezing responses. However, higher doses of glutamate caused no apparent effects. GDEE, an AMPA/kainate receptor antagonist, inhibited, whereas AP7, a NMDA receptor antagonist, did not influence these responses. It is suggested that GABA-benzodiazepine processes modulate the expression of defensive reactions in the inferior colliculus and that activation of fast-acting excitatory amino acid receptors in this midbrain region can trigger the initial steps of the defense reaction without eliciting the motor explosive behavior usually seen following the activation of NMDA receptors. Received: 13 May 1998 / Final version: 12 August 1998     

The hedonic impact and intake of food are increased by midazolam microinjection in the parabrachial nucleus

Benzodiazepines have been reported to induce eating when administered into the brainstem of rats (either the fourth ventricle or the parabrachial nucleus). Benzodiazepines in the brainstem also have been reported to enhance the hedonic impact of taste, as measured by hedonic/aversive taste reactivity patterns, when administered to the fourth ventricle. The present study examined whether the parabrachial nucleus in particular is a brainstem site of the benzodiazepine-produced enhancement of eating and palatability. Food intake (cereal mash) was measured after brainstem microinjections of midazolam or vehicle (0.0, 7.5, and 15.0 microg) into the parabrachial nucleus, the nucleus of the solitary tract, the pedunculopontine tegmental nucleus, or the fourth ventricle (60 microg). We used the taste reactivity paradigm to measure hedonic/aversive affective reactions elicited from rats by oral infusions of a bittersweet solution (7% sucrose-0.01% quinine). Positive hedonic reactions and negative aversive reactions to sucrose-quinine were also measured after microinjections of midazolam (0.0, 7.5, and 15 microg) into the parabrachial nucleus. Midazolam increased food intake and selectively enhanced positive hedonic taste reactivity patterns to the bittersweet solution when microinjections were delivered to the parabrachial nucleus. When administered to the other brainstem sites at the same doses, however, midazolam had no effect. We therefore conclude that the parabrachial nucleus can mediate the benzodiazepine-induced enhancement of the hedonic impact of taste as well as mediating the enhancement of eating behavior.     

咪唑安定复合芬太尼在硬膜外麻醉中的应用

目的探讨咪唑安定(力月西,Midazolam)与芬太尼(Fentanyl)联合在硬膜外麻醉中的镇静程度、遗忘及抑制内脏牵拉反应的作用。方法将择期腹部手术行硬膜外麻醉患者60例,随机分为2组(Ⅰ,Ⅱ组)各30例,Ⅰ组静注咪唑安定(力月西)0.04 mg/kg,2 min后静注芬太尼0.75μg/kg;Ⅱ组静注氟哌定0.05 mg/kg 芬太尼0.75μg/kg。两组术中酌情追加首次剂量的1/3~1/2。注药后不同时段记录镇静情况,以改良警觉/镇静观察评分法(OAA/S),观察HR、SBP、DBP和SPO2及术中牵拉反应情况。结果两组在术中的镇静效果无差异,术毕Ⅰ组较Ⅱ组苏醒快,能产生较深的遗忘作用,且能更好的抑制内脏牵拉反应。结论只要加强术中管理,咪唑安定(力月西)复合芬太尼在硬膜外麻醉中能够替代芬氟合剂。     

咪达唑仑治疗儿童癫痫持续状态及惊厥频繁发作的临床研究

目的研究咪达唑仑持续静脉滴注治疗癫痫持续状态[SE,包括难治性癫痫(R SE)]及频繁惊厥发作(FCS)的临床疗效,同时探讨其安全有效剂量及副作用。方法选取收入院的SE及FCS患儿205例为观察对象,随机分为两组,治疗组103例,给予咪达唑仑持续静脉滴注;对照组102例,应用传统的一线抗癫痫药(AED s)治疗。同时将两组疗效进行对照研究,观察治疗组的最大、最小用药剂量,副反应,51例患儿进行脑电图监测。结果治疗组疗效明显高于对照组(P<0.01),治疗组的咪达唑仑安全有效剂量为1￣8μg.kg-1.m in-1,在治疗剂量下未见明显副作用,37例痫样放电随着临床发作的终止消失,14例随着发作次数的减少而减少。结论持续静脉滴注咪达唑仑治疗SE及FCS安全、可靠、有效,且常规一线AEDs治疗无效后该药仍有效,故该药可推荐为治疗癫痫持续状态及频繁惊厥发作的最佳选择。     

咪达唑仑对七氟烷镇痛和催眠作用的影响

目的观察咪达唑仑对七氟烷镇痛和催眠作用的影响。方法将40只小鼠随机均分成四组:生理盐水(NS)组、咪唑安定+NS组(M组)、NS+七氟烷组(S组)和咪达唑仑+七氟烷组(MS组)。实验方法:咪达唑仑2.7 mg/kg腹腔注射;甩尾法、催眠实验中分别腹腔注射七氟烷2.1、3.8 ml/kg;扭体法实验中皮下注射七氟烷3.0 ml/kg。甩尾法记录小鼠尾巴自进入水中到甩出水面的时间(甩尾潜伏期,TFL);扭体法观察小鼠腹腔注射1%冰醋酸0.1 ml/10 g后,15 min内的扭体次数;催眠实验记录小鼠翻正反射消失至恢复的时间(睡眠时间)。结果与NS组比较,S组、MS组TFL和睡眠时间延长,扭体次数减少(P<0.05);与S组比较,MS组TFL和睡眠时间明显延长,扭体次数减少(P<0.05)。结论咪达唑仑可增强七氟烷的镇痛及催眠效应。