烧伤、冲击伤及烧冲复合伤后大鼠早期血清中性粒细胞弹性蛋白酶的变化及意义

Objective To explore the early changes in serum neutrophil elastase(NE) in rats with burn.blast injury or combined bum-blast injury and its significance.Methors A total of 176 male Spragne Dawley rats were randomly divided into four groups:control(C),burn(BU),blast injury(BL) and burn-blast combined injury(BB).Rats in C group were not injured.Animals in BU group were subjected to 25% TBSA full-thickness burn on back with 94℃ water for 12 seconds;Animals in BL group were inflicted with moderate blast injury with 5g 8701 compressed dynamite stick as the explosion source 75 cm away while left chest facing the explosive source;Rats in BB group were burned immediately after the blot injury similarly as in BL group.During the first 24 h post-injury,animals in BU and BB groups received intraperitoneal bronchoalveolar lavage fluid(BALF),water content of lung tissue and NE content in serum were determined at 0 h(C group),3 h,6 h,12 h,1 d,2 d,3 d,7 d post-injury.Results Protein concentration in BALF,water content of lung tissue and NE content in serum in SD rats of the injured groups were significantly higher than those in C group(P＜0.01 or P＜0.05),peaked within 2 d post-injury,especially at 2 d post-injury(NE content in serum:BU group,319.85±19.50,ng/ml;BL group,467.43±31.64 ng/ml;BB group,626.00±26.38 ng/ml vs.C group,78.53±25.10 ng/ml).Overall,protein concentration in BALF.water content of lung tissue and NE content in serum in BB group were significantly higher than BU and BL groups(P＜0.01 or P＜0.05).Correlation analysis showed that within 3 d post-injury.a significant positive correlation was found between the protein concentration in BALF,water content of lung tissue and NE content in serum(r=0.7910,0.8078,P＜0.05) in BU group.NE content in serum and protein concentration in BALF were significantly positively correlated in BB group(r=0.8672,P＜0.05).Conclusion NE may play an important role in early lung injury of burn or blast injury,especially in combined bum-blast injury.     

丙泊酚输注综合征研究进展

丙泊酚具有起效快、作用时间短、恢复迅速等优点，目前广泛应用于各类手术的麻醉诱导和维持，以及重症患者的镇静。其持续镇静作用在很大程度上能抑制严重烧、创伤导致的剧烈而持久的应激反应，降低危重患者的基础代谢率和静息能量消耗，改善脑代谢与全身代谢平衡，降低脑糖代谢和机体耗氧量。但在应用过程中，发现其有丙泊酚输注综合征（PRIS）的严重不良反应，应引起临床医师的重视。现就PRIS研究进展综述如下。     

可乐定对麻醉下大鼠皮质体感诱发电位N20波的影响

目的:探讨大鼠异丙酚麻醉中α2-NA受体激动剂可乐定对皮质体感诱发电位(SEP)N20波的影响。方法:将SD雄性大鼠20只按抽签法随机分为2组,单纯异丙酚A组:微量泵以10mg/(kg·h),60mg/(kg·h)的速度依次各静注45min,停止静注异丙酚直至动物清醒。B组除在输注异丙酚的同时腹腔内注射可乐定0.5mg/kg外,余和A组相同。分别监测麻醉前、中及苏醒期的皮层SEPN20波的潜伏期和波幅。结果:与基础值相比,两组药物对SEPN20波潜伏期均无显著影响;A组对SEPN20波的波幅无影响,B组降低SEPN20波的波幅。结论:异丙酚麻醉下α2-NA受体激动剂所引起SEPN20波波幅变化可能与镇痛机制有关。     

亚麻醉剂量氯胺酮联合芬太尼对大面积烧伤床旁换药老年病人疼痛评分及焦虑的影响

目的研究亚麻醉剂量氯胺酮联合芬太尼对大面积烧伤床旁换药老年病人疼痛评分及焦虑的影响。方法选取我院烧伤外科2016年1月至2018年1月深Ⅱ度、Ⅲ度烧伤老年病人138例,分为4组,A组(34例):凯纷+氯胺酮+盐酸右美托咪定; B组(34例):凯纷+芬太尼+盐酸右美托咪定; C组(35例):凯纷+芬太尼+氯胺酮+盐酸右美托咪定; D组(35例):凯纷(不愿接受无痛换药的病人)。观察并比较4组换药前后不同时刻视觉模拟评分(VAS)及心率(HR)、平均动脉血压(MAP)、血氧饱和度(Sp O2)水平变化。同时,观察病人换药后48 h内恶心呕吐、瘙痒、头晕的发生情况及焦虑状态。结果 A、B、D组换药完毕时、换药后2 h及换药后4 h VAS评分与换药前相比均升高(P0. 05); C组换药前、后VAS评分比较,差异无统计学意义(P0. 05); C组换药后各个时间点VAS评分均低于A、B、D组,差异均具有统计学意义(P0. 05)。4组换药后不同时刻HR、MAP、Sp O2及换药后48 h内不良反应的发生率比较差异均无统计学意义(P0. 05)。换药后24 h,4组医院焦虑抑郁量表(HADS)评分均明显下降(P0. 05),C组下降最明显,4组间比较,差异有统计学意义(P0. 05)。结论大面积烧伤床旁换药老年病人使用亚麻醉剂量氯胺酮联合芬太尼的镇痛效果较好,对生命体征影响小,可明显改善焦虑,值得临床进一步研究。     

腰-硬联合麻醉对剖宫产产妇呼吸参数的影响

目的：探讨腰-硬联合麻醉对剖宫产产妇呼吸功能的影响。方法：30例美国麻醉医师学会（ASA）Ⅰ～Ⅱ单胎足月孕妇,在腰-硬联合麻醉下行剖宫产术,用面罩紧闭法测量孕妇在人室后平卧位（T1）,麻醉完成后仰卧即刻（T1）、5rain（T2）、10min（T3）,胎儿取出后1min（T4）、5min（T5）和10min（T6）时的呼吸频率（RR）、潮气量（VT）、分钟通气量（VE）、呼气末二氧化碳分压（PETCO2）、1秒率（V1．0）、呼吸比（E：I）等参数的变化。结果：与基础值（T0）相比较,PETCO2于各个观察时间点均明显降低（P〈0．01）;T1、T2、T6时VE明显降低;T1时的VT亦降低（P〈0．05）。结论：腰-硬联合麻醉能使剖宫产产妇的VE、PETCO2明显降低,缓解产妇的过度通气,降低其氧耗量,且不会对产妇呼吸功能产生不利影响。     

右美托咪啶抑制术中止血带所致心血管反应的临床研究

目的：探讨右美托咪啶对全麻下外科手术中肢体应用止血带辅助止血所致心血管反应的抑制作用.方法：38例患者全麻下行下肢骨科手术,随机分为右美托咪定组（DEX组,n=19）和对照组（n=19）.DEX组麻醉开始前静脉输注负荷剂量右美托咪啶1 μg/kg,10 min输注完毕后以0.5 μg·kg-1·h-1持续输至术毕;对照组以相同方法输注等量生理盐水.负荷剂量输完后两组采用相同的麻醉诱导和维持方法.于患者入手术室后（T0）,止血带充气前（T1）,充气后10 min（T2）、20 min（T3）、30 min（T4）、40 min（T5）、50 min（T6）、60 min（T7）,松开止血带后5min（T8）、10 min（T9）,记录有创收缩压（ISBP）、有创舒张压（IDBP）、心率、脑电双频谱指数（BIS）值,并记录停药至自主呼吸恢复及拔管所用时间.结果：与T0比较,T1时两组血压、心率、BIS值都明显降低（P〈0.05）,但两组间比较差异无显著性（P〉0.05）;与T1比较,对照组T3～T8时ISBP、IDBP、心率增高,T7达到峰值（P〈0.05或〈0.01）,DEX 组T1～T9时无显著变化（P〉0.05）.与DEX组比较,对照组T3～T8时ISBP、IDBP升高,T4～T9时心率增快（P〈0.05或〈0.01）.两组自主呼吸恢复时间、拔管时间差异均无显著性（P〉0.05）.结论：右美托咪啶可有效抑制全麻下应用肢体止血带所致的心血管反应,对患者苏醒时间无影响.     

烧伤、冲击伤及烧冲复合伤后大鼠早期血清中性粒细胞弹性蛋白酶的变化及意义

Objective To explore the early changes in serum neutrophil elastase(NE) in rats with burn.blast injury or combined bum-blast injury and its significance.Methors A total of 176 male Spragne Dawley rats were randomly divided into four groups:control(C),burn(BU),blast injury(BL) and burn-blast combined injury(BB).Rats in C group were not injured.Animals in BU group were subjected to 25% TBSA full-thickness burn on back with 94℃ water for 12 seconds;Animals in BL group were inflicted with moderate blast injury with 5g 8701 compressed dynamite stick as the explosion source 75 cm away while left chest facing the explosive source;Rats in BB group were burned immediately after the blot injury similarly as in BL group.During the first 24 h post-injury,animals in BU and BB groups received intraperitoneal bronchoalveolar lavage fluid(BALF),water content of lung tissue and NE content in serum were determined at 0 h(C group),3 h,6 h,12 h,1 d,2 d,3 d,7 d post-injury.Results Protein concentration in BALF,water content of lung tissue and NE content in serum in SD rats of the injured groups were significantly higher than those in C group(P＜0.01 or P＜0.05),peaked within 2 d post-injury,especially at 2 d post-injury(NE content in serum:BU group,319.85±19.50,ng/ml;BL group,467.43±31.64 ng/ml;BB group,626.00±26.38 ng/ml vs.C group,78.53±25.10 ng/ml).Overall,protein concentration in BALF.water content of lung tissue and NE content in serum in BB group were significantly higher than BU and BL groups(P＜0.01 or P＜0.05).Correlation analysis showed that within 3 d post-injury.a significant positive correlation was found between the protein concentration in BALF,water content of lung tissue and NE content in serum(r=0.7910,0.8078,P＜0.05) in BU group.NE content in serum and protein concentration in BALF were significantly positively correlated in BB group(r=0.8672,P＜0.05).Conclusion NE may play an important role in early lung injury of burn or blast injury,especially in combined bum-blast injury.     

严重烧伤家兔不同病理期丙泊酚的药代动力学差异

目的 了解严重烧伤家兔在休克期与高代谢期丙泊酚的药代动力学特征和差异.方法 将20只新西兰大白兔按随机数字表法分为烧伤组和假伤组,每组10只.将烧伤组家兔造成30%TBSA的Ⅲ度烫伤(以下称烧伤),伤后即刻复苏;6 h后静脉注射5.1 mg/kg丙泊酚,分别于注药后1、3、 5、 10、15、20、30、45、60、90 min于左侧颈外静脉取血1.5 mL;1周后重复上述注药及标本采集过程.假伤组家兔除致假伤外,其他处理同烧伤组.用高效液相色谱仪集中检测2组家兔血浆丙泊酚浓度,采用3P97实用药代动力学计算程序处理血浆药物浓度-时间数据,拟合药代动力学模型并求算参数. 结果 烧伤组家兔药物浓度-时间数据符合二房室模型,假伤组符合三房室模型.休克期,与假伤组家兔中央室分布容积[Vc,(3.1±1.5)L/kg]、曲线下面积[AUG,(25±7)mg·min·L~(-1)]、消除相半衰期[tl/2β,(113.4±93)min]、总清除率[CLs,(110±50)mL·kg~(-1)·min~(-1)]比较,烧伤组Vc[(8.8±4.2)L/kg]与AUC[(44±10)mg·min·L~(-1)]增大(t值分别为3.191与3.668,P值均小于0.01),tl/2β[(339±258)min]延长(t=2.932,P<0.05),CLs[(40±30)mL·kg~(-1)·min~(-1)]降低(t=-3.013,P<0.05).高代谢期,烧伤组家兔CLs[(180±40)mL·kg~(-1)·min~(-1)]显著高于假伤组[(90±30)mL·kg~(-1)·min~(-1),t=-3.013,P<0.05].与本组休克期比较,烧伤组家兔高代谢期Vc[(4.1±1.3)L/kg]与AUC[(24±5)mg·min·L~(-1)]显著减小(t值分别为2.979与3.766,P值均小于0.01),分布相半衰期[t1/2α,休克期为(16.1±13.1)min、高代谢期为(8.3±2.5)min]、t1/2β[(55±19)min]明显缩短(t值分别为9.065与8.795,P值均小于0.01),而CLs则显著增加(t=4.238,P<0.01). 结论 严重烧伤家兔休克期与高代谢期丙泊酚药代动力学差异较大,休克期以Vc、AUC增大,t1/2α、t1/2β延长,CLs降低为特点;高代谢期以CLs显著增加为特点.     

PiCCO心肺容量监护仪在危重烧伤患者血流动力学监测中的临床应用

目的 研究PiCCO心肺容量监护仪在危重烧伤患者的休克期和围术期应用的可行性.方法 选取2008年5月-11月住院治疗的大面积危重烧伤患者10例,烧伤面积82.5%±15.7%,均在入院后3d内即行手术切痂,分别于休克期和围术期采用PiCCO进行血流动力学检测,项目包括平均动脉压(MAP)、心排出量指数(CI)、心功能指数(CFI)、胸腔内血容量指数(ITBI)、外周血管阻力指数(SVRI)、血管外肺水含量指数(ELWI),其中休克期监测6例次,围术期监测10例次.结果 所有导管均留置成功,留置时间3.0±0.4d,导管尖细菌培养均为阴性,未发生导管并发症.患者烧伤后CI、CFI、ITBI均低于正常水平,SVRI高于正常水平,而后随着液体复苏的进行,36h后各项指标均逐渐恢复正常;MAP和EVLW无明显变化(P>0.05).在围术期,经过严密的心肺容量监护,所有患者在休克期及感染期切痂过程中,除SVRI在切痂后显著降低、CFI在切痂后明显升高(P<0.05)外,余各项血流动力学指标均较平稳.结论 采用PiCCO对严重烧伤患者的休克期和围术期进行血流动力学监测,可有效协助液体复苏及维护围术期患者生命体征的稳定.