胸部手术后镇痛对通气功能的影响

比较三种不同镇痛方法对胸腔手术后的镇痛效果与通气功能改变。镇痛效果以硬膜外注吗啡组最好，持续时间最长，为２７．８±３．６２ｈ；胸腔内注布比卡因组的镇痛效果亦佳，但持续时间次之，为８．４±１．２ｈ；而哌替啶的镇痛效果相对较差，持续时间最短。给药后三组对ＶＴ均无明显改善，但硬膜外注吗啡组及胸腔内注布比卡因组均能明显改善ＶＣ，分别较给药前提高３３％和４５％     

氯胺酮吗啡硬膜外腔间断给药用于术后镇痛

术后吗啡硬膜外镇痛冈其旨定的镇痛效果在困内外得到广泛的使用．但由于其恶心呕吐．皮肤搔痒、尿潴留、呼吸抑制等副作用．限制了其临床中的应用。如何采用联合用药的方法．选择最佳的注药模式．以最低的有效药量达到最佳的镇痛效果．最少的副作用．成为当今热门的研究课题之一．氯胺酮与吗啡用于硬膜外术后镇痛效果已得到肯定．硬膜外间断给药的PCA方法因其可以减少麻醉药品及局麻药的用量．在临床应用中得以推广。本文旨在观察氯胺酮与吗啡伍用．硬膜外间断给药模式下是否可提高镇痛效果并减少副作用。     

开胸术后硬膜外注苏芬太尼止痛和对呼吸的影响

硬膜外注吗啡发生程度不等的呼吸抑制可高达75％。由于起效慢,所以用量往往偏大。苏芬太尼作用比芬太尼强5～7倍,脂溶性高,对μ受体亲和力大,从受体解离又较慢而且呼吸抑制轻微。为此,作者观察32例开胸手术病人,术后硬膜外注苏芬太尼的效果。此32例体质均为ASAⅠ～Ⅱ级,随机按双盲法分四组。术后硬膜外单次注苏芬太尼重组(n=6)30μg、Ⅱ组(n=9)50μg、Ⅲ组(n=7)75μg,均用盐水稀释至20ml,Ⅳ组(n=10)对照组不加苏芬太尼。观察期间不用镇静和鸦片类药     

0.1%罗比卡因与0.1%布比卡因持续硬膜外给药用于高龄病人TURP术后镇痛的研究

目的比较0.1%罗比卡因与0.1%布比卡因复合芬太尼持续硬膜外给药用于高龄病人前列腺手术后镇痛的效果及对呼吸循环功能的影响。方法20例ASAⅡ～Ⅲ级,年龄80～91岁,择期行经尿道前列腺摘除(TURP)的病人,随机均分为0.1%罗比卡因组(A组)和0.1%布比卡因组(B组)。于手术结束前经硬膜外导管2ml/h分别持续注入0.1%罗比卡因和0.1%布比卡因,同时辅助2μg/ml芬太尼,测定术后4、8、12、24hVAS,镇静评分,记录BP、HR、SpO2及不良反应。结果两组的镇痛效果相当,BP、HR、SpO2等生理指标差异无显著意义,均无呼吸抑制及恶心、呕吐发生。结论0.1%罗比卡因与0.1%布比卡因持续硬膜外给药用于高龄病人TURP术后镇痛效果相似,对呼吸循环影响相似。     

全麻肿瘤病人硬膜外超前镇痛与术后镇痛效果的比较研究

目的:观察全麻肿瘤手术病人硬膜外超前注入吗啡、氟哌利多的术后镇痛效果。方法:ASAⅠ-Ⅱ级择期上腹部手术病人40例,硬膜外穿刺成功注利多卡因5ml获确切阻滞平面后保留导管。随机分成两组。对照组于术终缝皮时经硬膜外导管注吗啡2mg、氟哌利多2.5mg;超前注药组于全麻诱导前经硬膜外导管注同剂量吗啡、氟哌利多。用视觉模拟评分(VAS)法评定术后4h、8h、12h、24h、48h、72h疼痛程度和术后镇痛时间。结果:术后镇痛时间对照组为28.42±13.73h;超前注药组20.81±19.17h,两者无显著差异(P>0.05)。VAS评分两组无差,VAS评分峰值超前注药组较对照组前移。结论:全麻肿瘤手术病人诱导前硬膜外注吗啡、氟哌利多与术终注同种药相比,镇痛效果无显著差异,而超前注药术后镇痛时间有提前和缩短趋势,提示在完善的全麻下,硬膜外注吗啡“超前镇痛”的作用尚待进一步研究。     

老年病人开胸术后PCEA与PCIA的效果及对呼吸功能的影响

目的比较老年病人食管癌开胸术后布比卡因、芬太尼硬膜外自控镇痛(PCEA)与芬太尼静脉自控镇痛(PCIA)临床效果及对呼吸功能的影响。方法60例65岁以上ASAⅠ～Ⅱ级择期开胸手术的食管癌病人随机分为两组,每组30例,PCEA组选用0.2%布比卡因加0.0002%芬太尼硬膜外镇痛,PCIA组选用0.001%芬太尼加0.005%氟哌利多静脉镇痛。观察镇痛效果、镇静程度、舒适评分、不良反应,监测RR、SpO2、MAP、HR。并于术前和术后24h测定呼吸功能的变化。结果两组病人视觉模拟评分(VAS)评分均较低,PCIA组高于PCEA组但无明显差异(P>0.05),PCIA组Ramesay法(RSS)镇静评分显著高于PCEA组(P<0.05),布氏评分法(BCS)舒适评分明显低于PCEA组(P<0.05),恶心、呕吐、皮肤瘙痒等的发生率显著高于PCEA组(P<0.05),两组病人对术后镇痛总体满意度评估优秀者PCEA组明显多于PCIA组(P<0.05);两组术后呼吸频率和SpO2均在正常范围,无呼吸抑制发生,PCEA组呼吸功能改善明显优于PCIA组(P<0.05)。结论对于食管癌开胸手术的老年病人,硬膜外布比卡因与静脉芬太尼自控镇痛均安全可行,镇痛效果满意,改善了呼吸功能,综合总体镇痛质量,PCEA组优于PCIA组,但PCEA镇痛需加强硬膜外导管的管理。     

地塞米松减少手术后硬膜外吗啡镇痛引起的恶心呕吐

目的　观察静脉注射地塞米松 (Dex)对减少手术后与硬膜外吗啡镇痛有关的恶心呕吐发生率的作用。方法　随机双盲选择 87例在硬膜外麻醉下行腹部手术的女性病人进行观察。所有病人在手术后均接受硬膜外吗啡镇痛。Dex组病人 (n =41)在手术后静注Dex 8mg ,对照组病人 (n=46 )则给予等量生理盐水。结果　在手术后 2 4小时内 ,Dex组病人手术后总的恶心呕吐发生率为2 6 8% ,明显低于对照组病人的 43 5 % (P <0 0 1)。两组病人之间手术后皮肤瘙痒的发生率无明显差异 ,Dex也不影响手术后硬膜外吗啡的镇痛作用。结论　预防性静脉注射Dex是一种减少与硬膜外吗啡镇痛有关的恶心呕吐并发症的有效方法     

曲马多静脉输注用于开胸手术后镇痛

曲马多通过刺激阿片类 μ受体及调节中枢单胺能疼痛抑制通路的协调作用来完成镇痛作用。近年来的研究表明 ,在适当剂量下它的镇痛作用等于吗啡或稍弱于吗啡或等于芬太尼[1 ] 。本研究用单一曲马多静脉输注用于开胸手术后镇痛 ,并与吗啡硬膜外镇痛作了比较 ,以阐释曲马多的镇痛强度。资料与方法一般资料　 6 0例开胸中下段食管癌或贲门癌切除术病人 ,均为男性 ,ASAⅠ～Ⅱ级 ,年龄 (5 6 0± 5 7)岁 ,体重(6 5 0± 1 1 6 )kg。术前 36h未用任何镇痛药物。麻醉方法与用药　先行硬膜外T7～ 8穿刺置管 ,用 2 %利多卡因 ,阻滞平面在T4～T1 0…     

老年人上腹手术联合应用超前镇痛与PCEA的效果及其对呼吸功能的影响

目的：观察老年人上腹手术联合应用超前镇痛与病人自控硬膜外腔镇痛（PCEA）的效果及其对呼吸功能的影响。方法：41例65岁以上择期上腹手术老年病人，随机分为三组，Ⅰ组（对照组，n=11）：按临床术后习用哌替啶50mg按需肌肉注射镇痛；Ⅱ组（n=15）：切皮后30min硬膜外腔流向吗啡1.5mg 0.5%布比卡因6-7ml镇痛；Ⅲ组（n=15)：切皮前30min硬膜外注腔注射吗啡1.5mg 0.5%布比卡因6-7ml超前镇痛组。Ⅱ、Ⅲ组于手术后均采用PCEA继续镇痛治疗。比较3组术后镇痛的效果，分别测定术前和术后1d、3d、5d及7d的呼吸功能。结果：Ⅲ组术后病人的吗啡用量减少，VAS评分量低，呼吸功能改善最为明显，尤其是小气道功能改善最为显著。结论：老年人上腹手术联合应用超前镇痛与术后PCEA，可改善术后的呼吸功能，不良反应少。     

氯胺酮与吗啡超前镇痛对内脏牵拉痛及术后镇痛的影响

目的探讨氯胺酮与吗啡复合液硬膜外超前镇痛对抑制手术内脏牵拉痛的影响及术后镇痛情况的影响。方法60例ASAⅠ~Ⅱ级择期全子宫切除术患者,均于硬膜外麻醉下行全子宫切除术。随机分为两组,每组30例,即Ⅰ组(对照组):术前不施行超前镇痛;Ⅱ组(实验组):切皮前10 min将氯胺酮30 mg与吗啡2 mg用生理盐水稀释成5 ml注入硬膜外腔。所有患者术后均行自控硬膜外镇痛(PCEA)。镇痛药物为0.15%罗哌卡因+5 mg吗啡,共100 ml。观察两组患者术中牵拉反应、术后镇痛情况及并发症。结果Ⅱ组用药对抑制术中牵拉痛的效果明显优于Ⅰ组(P<0.01);Ⅱ组PCEA泵首次触发时间较Ⅰ组显著延长(P<0.01),48 h内有效触发次数显著减少(P<0.01),24 h PCEA泵总用量明显减少(P<0.05),术后并发症无明显差异。结论氯胺酮与吗啡硬膜外超前镇痛能明显抑制术中牵拉痛,提供良好的术后镇痛效果,减少阿片类药物的用量。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.