老年感染性休克病人的麻醉处理（附30例临床报告）

报道老年感染性休克病人的麻醉处理30例．其中24例选用持续硬膜外麻醉，5例选用气管内插管静脉复合麻醉．1例选用静脉氯胺酮麻醉．麻醉效果较为满意。术后痊愈24例，死亡6例。讨论中重点强调了此类病人病情的危重性，并从麻醉前准备和用药，麻醉选择和麻醉维持，术中的监测和治疗，以及术后管理等几个方面介绍了对老年感染性休克病人围手术期处理的几点经验。     

腹部盆腔手术病人围术期胃粘膜pH值的变化

目的：探讨手术病人围术期胃粘膜ｐＨ值的变化及其意义。方法：６例全麻下行腹部盆腔手术的病人，用液体分压计在麻醉前，麻醉后３０分钟，术中，术毕，术后最初２４小时测定ｐＨｉ，同时经桡动脉，颈内静脉测定血液动力学，代谢和氧指标。结果：麻醉手术期间胃ｐＨｉ明显下降，且大多数低于７．３２，ｐＨ－ｇａｐ，ＣＯ２－ｐａｇ明显升高，在术后最初２４小时可恢复术前水平。     

急腹症与休克(附140例分析)

目的 探讨外科急腹症合并感染性或出血性休克时的临床处理。方法 回顾性分析１４０便急腹症与休克的临床资料。结果 １４０例病人中感染性休克占５５．７％，原发病多为急性梗阻性化脓性胆管炎（ＡＯＳＣ）；出血性休克占４４．３％，多为外伤性肝脾破裂出血。抗休克治疗后，１３１例经手术治疗，治愈率为６８．７％，非手术治疗９例，均死亡。治疗中发生急性呼吸窘迫综合征（ＡＲＤＳ）３４例，总发生率为２４．３％，计感染休克     

老年病人静脉复合全麻拔管期循环和呼吸变化的临床观测

老年病人静脉复合全麻拔管期循环和呼吸变化的临床观测胡凤珍＊费杭模＊静脉普鲁卡因复合麻醉是我国常用的麻醉方法，对手术结束后拔管期的生命指征变化和处理多有报道。本文观测了老年病人拔管期循环和呼吸功能改变，并与中青年病人作比较。资料和方法一般资料老年组５７...     

体外静脉转流下肝移植术的麻醉处理一例报道

我院于１９９３年对１例晚期肝硬化的病人在体外静脉转流下进行了同种异体肝移植手术，术中血流动力学稳定，现将麻醉方法和术中处理报告如下。麻醉经过和术中处理患者入室后先建立静脉通路，再作右侧桡动脉穿刺测压，连接心电图、血氧饱和度、呼气末二氧化碳监测仪等，麻...     

胆汁性肾病麻醉与术后急性肾功能衰竭的关系

报道梗阻性黄鱼合并胆汁性肾病（ＣＮ）３４例，术后死亡率２９．４％，急性肾功能衰竭（ＡＲＦ）发 生率４１．２％，ＡＲＦ死亡率为７１．４％。作者探讨了ＣＮ患者麻醉处理与术后ＡＲＦ关系，认为ＣＮ是术后 ＡＲＦ发生率和死亡率增高的病理基础，肾功能处于ＡＲＦ的前兆，麻醉手术有一定的危险性，ＡＲＦ发生 率与黄疸程度、麻醉方法和低血压持续时间有关。ＣＮ患者选择全麻优于连续硬膜外阻滞，对于重度黄疸 （和）或伴有感染性休克者应首选全麻。正确的麻醉处理是防止和减少术后ＡＲＦ的关键。     

输尿管结石腔内碎石术后并发感染性休克的防治分析

目的：探讨输尿管镜碎石术治疗输尿管结石术后并感染性休克的预防及治疗方法。方法对6例输尿管结石术后感染性休克患者进行回顾性分析，总结防治经验。结果6例患者经抗感染、体液复苏、应用血管活性药物等治疗，感染及休克症状得到控制，康复出院。结论术后密切观察病情，及早发现输尿管结石术后感染性休克患者，果断采取综合措施积极抢救，可有效防止患者因术后感染性休克死亡等严重医疗事件发生。     

高血压脑出血开颅血肿清除150例麻醉分析

本文报告高血压脑出血颅内血肿清除术150例麻醉处理。年龄50岁以上者104例,有高血压病人109例,冠心病史14例。昏迷100例。急诊手术147例。本组采用静脉复合或静吸复合麻醉。麻醉处理上应注意以下几点: 1.结合老年、急诊、术前脱水等特点掌握麻醉用药; 2.维护循环稳定,防止血压过低或过高,纠正心律失常; 3.加强呼吸管理,防止昏迷症人误吸,预防和处理支气管痉挛,深昏迷病人术终保留气管导管或气管造口。     

80岁以上高龄病人麻醉109例分析

本文分析总结109例80岁以上高龄住院手术病人的术前情况、麻醉选择、麻醉管理、麻醉中和麻醉后的并发症，认为年老因素不是手术麻醉的禁忌症，关键在于充分术前估计与准备，合理选择麻醉方法，正确实施麻醉，围术期密切监测与处理，以及预防麻醉并发症。这些综合处理对保证老年病人安全具有极为重要的意义。     

经皮肾镜碎石术后发生感染性休克28例分析

目的：分析经皮。肾镜碎石术（PCNL）后并发感染性休克的原因和防治措施。方法：回顾性分析2008年6月～2012年6月间行PCNI。后发生感染性休克28例患者的临床资料：男18例，女lO例。明确感染性休克诊断后立即行抗休克治疗，维持血容量和血流动力学稳定，同时行经验性抗感染治疗。结果：所有患者血压皆在24～96小时内逐渐恢复正常，术后3～6天内体温、血常规恢复正常。术后14天内均治愈出院。结论：感染性休克是PCNL后的一个严重并发症，术前采用抗生素有效抗感染、术中低压灌注并缩短手术时间、术后加强生命体征监测，可有效防治感染性休克的发生。     

A case of cardiac arrests before and after emergent exploratory laparotomy for panperitonitis

We report a case of cardiac arrest before and after emergent exploratory laparotomy for panperitonitis in an 84-year-old woman with a history of hypertension, gastric ulcer, uterine myoma and dementia. She complained of lower abdominal pain, and suffered from septic shock and DIC. The first cardiac arrest occurred after anesthesia induction. Following resuscitation, a left hemicolectomy and colostomy were performed. The second cardiac arrest occurred immediately after the operation. Cardiac arrest in this case may have been due to preexisting cardiac dysfunction enhanced by septic shock. Prompt preoperative evaluation of cardiac function is necessary for successful circulatory management during anesthesia induction for surgical patients in septic shock.     

Analysis of patients with septic shock due to urosepsis brought on by ureteral calculi

While a ureteral stone is a common disease, it occasionally causes urosepsis and septic shock. We analyzed 6 cases of septic shock due to urosepsis caused by a ureteral stone from August 1998 to September 2001. All patients were female, ranging in age from 38-76 years old (63.8 +/- 15.3). Stones ranged from 4 to 12 ml in size. The results of analysis of bacterial culture from blood and urine revealed E. coli in 4 cases, K. pneumoniae in 1 case and P. mirabilis in 1 case. Treatment, including intravenous transfusion, the administration of vasopressor drugs and antibiotics, and anti-disseminated intravascular coagulation (DIC) treatments were performed. Percutaneous nephrostomy in 4 cases and ureteral stent indwelling in 1 case were also used for the management of urinary tract. Extracorporeal shock wave lithotripsy (ESWL) was performed in 4 patients after improvement of general condition. Furthermore, the 3 most recent patients had also received therapy to remove endotoxins. All patients were diagnosed in a stone-free condition after a combination of these therapies. The mean recovery interval from shock condition to shock-free status seemed to be shorter in the patients that received the endotoxin removal therapy.     

Severe group a streptococcal infection and streptococcal toxic shock syndrome

PURPOSE: To review the literature on group A streptococcal toxic shock syndrome, (STSS). DATA SOURCE: Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched. PRINCIPAL FINDINGS: Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8-14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33-81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision. CONCLUSIONS: Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.     

Anesthetic management of elderly patients aged 90 years or older

The authors experienced 55 cases of anesthetic management in 52 elderly surgical patients, 14 men and 38 women, aged 90 to 101 years with an average of 92.1 +/- 2.1 years for the past ten years. Surgical procedures included 38 cases of orthopedic, 14 cases of general surgical and 3 cases of ophthalmic operations. Thirteen cases out of them were emergency. General, epidural, spinal, and local anesthesia were applied in 34 cases, 18 cases, 2 cases, and one case out of these elderly patients, respectively. These general anesthesia consisted of total intravenous anesthesia with propopol, fentanyl and ketamine in 27 cases, sevoflurane with nitrous oxide in 4 cases, isoflurane with nitrous oxide or air in 2 cases, and thiopental anesthesia in one case. The elderly patients had past history of heart disease, dementia, hypertension, cerebral infarction/hemorrhage, diabetes mellitus and others. Their preoperative examinations revealed anemia, hypoproteinemia, renal hypofunction, serum electrolytes imbalance, and others. Vasopessors were given to 42% of the patients during anesthesia and surgery. Their postoperative complications included myocardial infarction, paroxysmal atrial fibrillation, hypotension following anemia, transient hemiparesis, delirium and so on. Two patients developed myocardial infarction postoperatively and died thereafter. The authors suggest that appropriate anesthetic management for elderly patients aged 90 years or older requires proper preoperative evaluation, sufficient vigilance of hemodynamics with direct arterial pressure measurement, reliable preparation of medical agents, and awareness of impairment of circulatory function and others by aging.     

Pseudomonas cepacia induced septic shock after propofol--a case report

We report a healthy young female who developed septic shock and multiple organ failure soon after receiving a cosmetic surgery for augmentation of breasts under general anesthesia. Blood cultures yielded the growth of pseudomonas cepacia. We describe the clinical course and investigate the causes of the septic shock. Contamination of propofol, the intravenous anesthetic agent, was suspected.     

全身麻醉药物选择与老年手术患者预后:吸入麻醉还是静脉麻醉

背景 随着社会人口的老龄化,需要接受手术治疗的老年患者越来越多,麻醉管理对老年患者预后的影响值得关注. 目的 回顾吸入麻醉与静脉麻醉对老年手术患者预后的影响. 内容 对于心脏手术患者,吸入麻醉可能较丙泊酚静脉麻醉更有优势,但需进一步多中心、大规模临床研究证实.在对术后近期脑功能的影响方面,不同研究的结果差异较大,还无法得出明确结论;在对术后远期脑功能的影响方面,全身麻醉可能伴随术后痴呆风险增加,但还有待前瞻性研究证实.在对恶性肿瘤患者术后机体免疫功能的影响方面,丙泊酚静脉麻醉可能优于吸入麻醉,但其临床意义有待阐明;麻醉药物对恶性肿瘤患者肿瘤侵袭性及远期预后的影响值得进一步研究. 趋向 吸入麻醉与静脉麻醉对老年手术患者预后的影响,需要进一步的研究证实.     

不同剂量右旋美托咪啶对老年患者全麻苏醒期躁动及气管拔管反应的影响

目的观察不同剂量右旋美托咪啶对老年患者苏醒期躁动及气管拔管反应的影响。方法选择择期上腹部手术老年患者80例,随机分为对照组,右旋美托咪啶干预D1、D2和D3组各20例。手术结束前5 min对照组静脉注射0.9%氯化钠注射液20 ml;D1、D2和D3组分别单次缓慢静脉注射右旋美托咪啶0.2μg/kg、0.3μg/kg、0.4μg/kg。结果对照组苏醒拔管期间平均动脉压、心率波动显著,D1、D2、D3组较平稳;四组躁动、呛咳发生率比较,差异有统计学意义(均P<0.05);D3组苏醒时间显著长于其他三组(均P<0.05)。结论单次静脉注射右旋美托咪啶0.3μg/kg可有效降低腹部手术老年患者麻醉苏醒期躁动发生率,减少气管拔管反应而不延长气管拔管时间。     

Spinal anesthesia versus intravenous sedation for transvaginal oocyte retrieval: reproductive outcome, side-effects and recovery profiles

Transvaginal ultrasonically guided oocyte retrieval is commonly performed as part of in vitro fertilization efforts. The impact of anesthetic management on patient outcome from this procedure has not been well characterized. At our institution, patients are offered a choice of either heavy intravenous sedation or spinal anesthesia with minimal or no sedatives. In this pilot study, we retrospectively reviewed the anesthetic management, reproductive outcome and recovery room experience for all patients having oocyte retrieval during a 2-year interval (n = 95). Fifty-one oocyte retrievals were performed under spinal anesthesia, while 44 patients received solely intravenous sedatives. Both groups had similar reproductive outcomes. The intravenous sedation group required a significantly longer period until recovery room discharge criteria were met (P = 0.03), and were more likely to have postoperative emetic episodes (46% versus 6% in the spinal anesthesia group: P < 0.01). Two unplanned hospital admissions occurred in the intravenous sedation group: both were related to uncontrolled nausea and vomiting. We conclude that spinal anesthesia may have advantages over intravenous sedation for oocyte retrieval.     

Use of protein C concentrate in pediatric patients with sepsis

AIM: Protein C (PC) is a plasma glycoprotein implicated in modulating coagulation and inflammation. Its levels decrease in sepsis and related diseases, where it has also proved to be a prognostic indicator of outcome. Infusion of exogenous PC, although not able to decrease mortality in severe sepsis and septic shock, can safely resolve the coagulation imbalances related to these pathological states. METHODS: A retrospective study was performed about utilisation of PC in severe sepsis and septic shock patients in three italian PICUs during a one-year period. Data from 29 patients were analysed. Age, PIM 2, mortality and length of stay were compared between treated and non treated patients. Treated patients were also analysed for PC dosage received, length of treatment, and modification of hemocoagulation parameters, before PC infusion and every 24 hours. RESULTS: In treated patients, the activity of PC, PT and PTT activity and fibrinogen improved significantly from basal to day 5 (p<0.05). Diminution of d-dimer was not quite significant (p=0.0514). Rise in platelets count and antithrombin III activity was not significant. No adverse reactions related to Protein C concentrate were observed. No difference in mortality was observed between the two groups. CONCLUSIONS: Although PC is included in guidelines for management of severe sepsis and septic shock, only 38%, of observed patients received PC treatment. Even in the treated group, patients received a lower dosage of PC, and for a shorter period, than recommended. In accordance to previous studies, we did not observe differences in mortality between treated and untreated patients. Our results showed a significant increase in plasma PC activity, following infusion of PC concentrate. This increase in PC appeared sufficient to restore some, but not all, of the abnormalities in the coagulation system. A large randomized, phase 3, placebo-controlled trial in children with severe sepsis and septic shock is advisable to establish effective role of therapy with PC in reducing mortality of these patients.     

Cytokine serum level during severe sepsis in human IL-6 as a marker of severity.

Forty critically ill surgical patients with documented infections were studied during their stay in an intensive care unit. Among these patients, 19 developed septic shock and 16 died, 9 of them from septic shock. Interleukin 1 beta (IL-1 beta), tumor necrosis factor (TNF alpha), and interleukin 6 (IL-6) were measured each day and every 1 or 2 hours when septic shock occurred. Although IL-1 beta was never found, TNF alpha was most often observed in the serum at a level under 100 pg/mL except during septic shock. During these acute episodes TNF alpha level reached several hundred pg/mL, but only for a few hours. In contrast, IL-6 was always increased in the serum of acutely ill patients (peak to 500,000 pg/mL). There was a direct correlation between IL-6 peak serum level and TNF alpha peak serum level during septic shock and between IL-6 serum level and temperature or C-reactive protein serum level. Moreover, IL-6 correlated well with APACHE II score, and the mortality rate increased significantly in the group of patients who presented with IL-6 serum level above 1000 pg/mL. Thus, IL-6 appears to be a good marker of severity during bacterial infection.