异丙酚与依托咪酯在硬膜外阻滞复合静脉全麻中的比较

８０年代中期,我院开展联合麻醉（硬膜外阻滞加全麻）以来,并逐渐成为我院主要的麻醉方法之一,在１９９５年１月～１２月,仅普胸和肝肿瘤外科手术采用此种麻醉方法达１４９１例。本文比较两种不同的短效静脉全麻药在联合麻醉的诱导和维持阶段对血流动力学和病人术毕苏醒时间及苏醒质量的影响,探讨临床合理使用的方法。资料和方法一、病例选择和分组　肝脏外科手术病人１２０例,年龄２９～７０岁,ＡＳＡ１～２级,肝脏肿瘤直径＜８０ｍｍ。术前无心血管疾病史和慢性阻塞性肺疾患史,肝功能均在正常范围。随机将病人分为依托咪酯（Ｅ组…     

异丙酚与依托咪酯复合硬膜外阻滞对血糖和皮质醇的影响

目的和方法：１２０例ＡＳＡⅠ～Ⅱ级成年病人,按照全麻诱导和维持用药随机分成依托咪酯（Ｅ组,ｎ＝６０）和异丙酚（Ｐ组,ｎ＝６０）两组。两组病人均硬膜外穿刺置管,Ｅ组病人诱导用依托咪酯０２５ｍｇ／ｋｇ,维持时负荷剂量为２０μｇ·ｋｇ－１·ｍｉｎ－１,维持剂量为６μｇ·ｋｇ－１·ｍｉｎ－１;Ｐ组病人诱导用异丙酚１５ｍｇ／ｋｇ,维持时负荷剂量为１６０μｇ·ｋｇ－１·ｍｉｎ－１,维持剂量为５０μｇ·ｋｇ－１·ｍｉｎ－１。观察术中心血管反应、血浆皮质醇和血糖的变化。结果：异丙酚和依托咪酯静脉诱导后均可造成血压下降,异丙酚较为严重,但术中两组病人的血压脉率皆容易维持稳定。两组病人术中血糖随着手术进程缓慢升高,Ｐ组病人血浆皮质醇变化与血糖相似,而Ｅ组病人术中血浆皮质醇水平缓慢降低,直至术后２４小时方恢复。结论：在硬膜外阻滞复合异丙酚静脉全麻时,尽管手术创伤所致的心血管应激反应已经控制,但体内应激激素依然保持适度增高。而依托咪酯则抑制肾上腺皮质,致血浆皮质醇水平下降,不适合用作长期静脉麻醉的维持。     

依托咪酯对心功能损害病人麻醉诱导时血流动力学的影响

依托咪酯对循环系统几乎无不良影响。为此，我们将它用于心血管病患者的麻醉诱导，以评价其实用性和安全性。资料与方法５０例心脏病患者，男２８例，女２２例，年龄３４～９２岁，体重４６～８９ｋｇ。冠心病４５例，风心病３例，先天性心脏病２例。心功能Ⅲ～Ⅳ级，并存...     

依托咪酯复合舒芬太尼麻醉诱导对患者血流动力学及应激反应的影响

目的观察依托咪酯复合舒芬太尼麻醉诱导对患者血流动力学及应激反应的影响。方法将60例气管插管全麻下腹部手术患者,随机分为异丙酚组(A组)和依托咪酯组(B组),各30例,ASAⅠ~Ⅱ级。比较麻醉诱导各时段的血流动力学、血浆皮质醇(Cor)浓度和血糖(Glu)的变化。结果于麻醉诱导前(T0)、插管前即刻(T1)、插管后1 min(T2)、5 min(T3),测量每组患者的平均动脉压(MAP)、心率(HR),在各时点抽取动脉血监测Cor浓度和Glu。与T0比较,2组患者T1时点MAP、HR均明显下降(P0.05),差异有统计学意义。MAP、HR在T2、T3时点A组较B组低(P0.05),差异有统计学意义。A组插管后各时间点Cor浓度和Glu与B组比较差异无统计学意义(P0.05)。结论依托咪酯复合舒芬太尼麻醉诱导对患者血流动力学影响较小,更适于全麻手术患者的麻醉诱导。     

依托咪酯和异丙酚复合麻醉对腹部手术患者脑氧代谢影响的比较

目的 比较依托咪酯和异丙酚复合麻醉对腹部手术患者脑氧代谢的影响.方法 择期全麻下拟行腹部手术患者36例,ASA Ⅰ或Ⅱ级,随机分为异丙酚复合麻醉组(P组)和依托咪酯复合麻醉组(E组),每组18例.两组均静脉注射咪达唑仑0.08 mg/kg、芬太尼3μg/kg、维库溴铵0.1 mg/kg,P组静脉注射异丙酚1.5 mg/kg、E组静脉注射依托咪酯0.3 mg/kg行麻醉诱导,P组静脉输注异丙酚4～6mg·kg-1·h-1、E组静脉输注依托咪酯0.4～0.7 mg·kg-1·h-1,术中均间断注射维库溴铵和芬太尼维持麻醉.分别于麻醉前(T1)、气管插管后即刻(T2)、手术开始30 min(T3)及术毕即刻(T4)时监测HR、MAP和SpO2,抽取桡动脉血和颈内静脉球部血样行血气分析,测定乳酸浓度,计算动脉血氧含量(CaO2)、颈内静脉氧含量(cjvO2)、脑氧摄取率(CERO2).结果 两组HR、MAP和SpO2均在正常范围内.与T1时相比,两组SaO2、SjvO2、PaO2、PjvO2升高,T2-4时Da-jvO2和CERO2降低(P<0.01);两组问比较各时点SaO2、SjrO2、PaO2、PjvO2、CaO2、CjvO2、Da-jvO2、CERO2及乳酸水平差异均无统计学意义(P>0.05).结论 依托眯酯和异丙酚复合麻醉均可降低腹部手术患者的脑氧代谢率,且无明显差别.     

比较异丙酚和依托咪酯对心脏瓣膜置换术患者过氧化脂质和超氧…

观察异丙酚对心脏瓣膜置换术患者过氧化脂质和超氧化物歧化酶的影响。方法：２０例瓣膜置换术患者分为异丙酚组和依托咪酯组。分别在心肌缺血再灌注前后取血做过氧化脂质和超氧化物歧化酶测定，同时记录心电图和平均动脉区。结果：过氧化脂质在异丙酚组主动脉插管时下降，主动脉开放后升高，均有显著差异。     

联合应用异丙酚和依托咪酯麻醉诱导和喉罩置入对血流动力学变化的影响

目的比较三种不同的麻醉诱导方法(丙泊酚、依托咪酯、丙泊酚+依托咪酯)在择期手术中对血流动力学变化的影响。方法将105例筛选患者随机分成三组,A组接受丙泊酚,B组接受依托咪酯,C组给予异丙酚和依托咪酯。麻醉诱导前后和喉罩置入前后对三组患者血压、心脏率、血氧饱和度(SaO2)、二氧化碳(Etco2)监测和脑电双频指数(BIS)监测值进行记录和比较。结果三组患者BIS、SaO2、Etco2测量值未发现显著差异。麻醉诱导和喉罩置入后,A组患者收缩压、舒张压和平均动脉压明显低B组和C组(P0.05),A组心率也较低,但差异无统计学意义。结论联合应用依托咪酯与丙泊酚麻醉诱导对血流动力学的稳定性影响明显小于单独给药,为喉罩置入提供理想条件。     

上胸部单侧和双侧硬膜外阻滞对血流动力学影响的比较

上胸段硬膜外阻滞行乳癌根治术,国内应用颇多,但对循环和呼吸系统的不良影响为人们所瞩目。选择性单侧硬膜外的影响如何至今尚未有报告。作者等从1986年开始,对上胸段单侧硬膜外阻滞行乳癌根治术的患者于阻滞前后进行了血流动力学的对比研究,现报告如下。     

咪唑安定和依托咪酯静脉诱导对冠脉搭桥病人血流动力学和氧…

目的；观察咪唑安定和依托咪唑诱导对冠心病人血流动力学和氧代谢的影响，方法：３０例行冠脉搭桥手术的病人，随机分为Ｅ组（依托咪酯组，ｎ＝１５）和Ｍ组（咪唑安定组，ｎ＝１５）在两组病人分别给予咪唑安定或依托米酯直至睫毛反射消失，继之根据动脉压的变化给予哌库溴胺和芬太尼诱导麻醉，气管插管，观察诱导前，中，后两组病人血流动力学和整体氧代谢的改变，麻醉诱导使两组病人ＨＲ，ＭＡＰ，ＳＶＲＩ，ＰＶＲＩ和ＶＯ２Ｉ均     

胶体扩容对异氟醚-硬膜外阻滞复合麻醉时肝血流的影响

目的：探讨硬膜外阻滞复合异氟醚吸入全麻对血流动力学和肝血流的影响及其静脉输入3.5%尿素交连明胶（UG）的作用。方法：18只犬分两组，行胸段硬膜外阻滞后吸入0.5和1.0MAC异氟醚。实验组硬膜外阻滞前开始静脉输入UG12ml/kg。监测体循环、肺循环、肝动脉、门静脉血流动力学。肝血流用电磁血流仪测定。结果：对照组硬膜外阻滞后BP、HR、肝动脉阻力和门静脉血流均下降，加吸0.5MAC异氟醚使外周血管阻力（SVR）、肺动脉压和门静脉压降低；1.0MAC后心排血量下降、肝动脉血流也比0.5MAC时减少。心博量（SV）于吸入异氟醚后有所升高。实验组硬膜外阻滞后HR减慢、SV、增加而SVR下降，肝脏循环稳定。吸入异氟醚后全身和肝脏血流动力学变化显著轻于对照组。结论：硬膜外阻滞后，随异氟醚浓度升高，体循环、肺循环、肝动脉、门静脉血流动力学发生显著变化；胶体液扩容对比有明显的防治作用。     

Effects of Anemia and Hypotension on Porcine Optic Nerve Blood Flow and Oxygen Delivery

Background: Perioperative ischemic optic neuropathy occurs after major surgical procedures, which are often associated with hypotension, anemia, or venous congestion. However, the effects of these conditions on optic nerve (ON) blood flow are unknown and cannot be studied adequately in humans.

Methods: Farm-raised pigs were anesthetized with isoflurane, kept normocapnic and normothermic, and subjected to conditions of euvolemic or hypovolemic hypotension (mean arterial pressure 50-55 mm Hg), anemia (hematocrit 17%), venous congestion, and combinations thereof. Control animals were kept euvolemic and normotensive for the entire experiment. Fluorescent microspheres were used to measure cerebral blood flow (CBF) and ON blood flow at baseline and after experimental conditions, and to calculate oxygen delivery (DO2).

Results: No significant changes in CBF or ON blood flow or DO2 occurred with euvolemic hypotension (n = 5), compared with controls (n = 12). Hypovolemic hypotension (n = 4) resulted in stable CBF and cerebral DO2, but significant reductions in ON DO2 (P = 0.032). The significant increase in CBF associated with anemia (n = 6) resulted in stable cerebral DO2. In contrast, ON blood flow did not significantly change with anemia, with (n = 5) or without (n = 6) euvolemic hypotension, resulting in significant reductions in ON DO2 (P < 0.01).     

连硬阻滞和全麻病人异丙酚的血药浓度测定

目的与方法：应用荧光光光谱法测定连硬阻滞和全麻病人静注新型静脉麻醉药异丙酚的血药浓度以及一次静脉给药后人体内药代动力学参数。结果：异丙酚投入量与测得的荧光强主间有良好的线性关系。血药浓度－时间曲线方程为：Ｃ＝０．２１０６Ｆ－７．１９３３。结论：异丙酚在两组病体内过程符合药代动力学三室模型。     

Effects of Sevoflurane, Propofol, and Adjunct Nitrous Oxide on Regional Cerebral Blood Flow, Oxygen Consumption, and Blood Volume in Humans

Background: Anesthetic agents, especially volatile anesthetics and nitrous oxide (N2O), are suspected to perturb cerebral homeostasis and vascular reactivity. The authors quantified the effects of sevoflurane and propofol as sole anesthetics and in combination with N2O on regional cerebral blood flow (rCBF), metabolic rate of oxygen (rCMRO2), and blood volume (rCBV) in the living human brain using positron emission tomography.

Methods: 15O-labeled water, oxygen, and carbon monoxide were used as positron emission tomography tracers to determine rCBF, rCMRO2 and rCBV, respectively, in eight healthy male subjects during the awake state (baseline) and at four different anesthetic regimens: (1) sevoflurane alone, (2) sevoflurane plus 70% N2O (S+N), (3) propofol alone, and (4) propofol plus 70% N2O (P+N). Sevoflurane and propofol were titrated to keep a constant hypnotic depth (Bispectral Index 40) throughout anesthesia. End-tidal carbon dioxide was strictly kept at preinduction level.

Results: The mean +/- SD end-tidal concentration of sevoflurane was 1.5 +/- 0.3% during sevoflurane alone and 1.2 +/- 0.3% during S+N (P < 0.001). The measured propofol concentration was 3.7 +/- 0.7 [mu]g/ml during propofol alone and 3.5 +/- 0.7 [mu]g/ml during P+N (not significant). Sevoflurane alone decreased rCBF in some (to 73-80% of baseline, P < 0.01), and propofol in all brain structures (to 53-70%, P < 0.001). Only propofol reduced also rCBV (in the cortex and cerebellum to 83-86% of baseline, P < 0.05). Both sevoflurane and propofol similarly reduced rCMRO2 in all brain areas to 56-70% and 50-68% of baseline, respectively (P < 0.05). The adjunct N2O counteracted some of the rCMRO2 and rCBF reductions caused by drugs alone, and especially during S+N, a widespread reduction (P < 0.05 for all cortex and cerebellum vs. awake) in the oxygen extraction fraction was seen. Adding of N2O did not alter the rCBV effects of sevoflurane and propofol alone.     

The Role of Diastolic Pump Flow in Centrifugal Blood Pump Hemodynamics

We tried to verify the hypothesis that increases in pump flow during diastole are matched by decreases in left ventricular (LV) output during systole. A calf (80 kg) was implanted with an implantable centrifugal blood pump (EVAHEART, SunMedical Technology Research Corp., Nagano, Japan) with left ventricle to aorta (LV-Ao) bypass, and parameters were recorded at different pump speeds under general anesthesia. Pump inflow and outflow pressure, arterial pressure, systemic and pulmonary blood flow, and electrocardiogram (ECG) were recorded on the computer every 5 ms. All parameters were separated into systolic and diastolic components and analyzed. The pulmonary flow was the same as the systemic flow during the study (p > 0.1). Systemic flow consisted of pump flow and LV output through the aortic valve. The ratio of systolic pump flow to pulmonary flow (51.3%) did not change significantly at variable pump speeds (p > 0.1). The other portions of the systemic flow were shared by the left ventricular output and the pump flow during diastole. When pump flow increased during diastole, there was a corresponding decrease in the LV output (Y = -1.068X + 51.462; R(insert)(2) = 0.9501). These show that pump diastolic flow may regulate expansion of the left ventricle in diastole.     

Effects of Endothelin-1 on Hepatic Blood Flow

Endothelin-1 belongs to a family of potent vasoconstrictors, recently isolated from endothelial cells. Endothelin-1 has a variety of hepatic effects and hepatic clearance from the circulation is important. Elevated plasma concentrations of Endothelin-1 are found after orthotopic liver transplantation and in cirrhosis with ascites.This study in piglets on hepatic bloodflow was designed to compare differences in effects between central venous and intraportal injection of endothelin-1, and to evaluate effects of repeated injections. Central venous injection of endothelin-1 caused a larger reduction in portal vein flow, while intraportal injection caused a larger increase in portal vein pressure. Repeated injections resulted in a reduction in portal vein flow and an increase in portal vein vascular resistance.     

不同剂量异丙酚和硫喷妥钠静脉注射对血流动力学的影响

目的：研究异丙酚对血流动力学影响。方法：３０例病人（ＡＳＡⅠ～Ⅱ级）随机分为三组，第１组硫喷妥钠用量为５ｍｇ／ｋｇ，第２、３组异丙酚剂量分别为１．５ｍｇ／ｋｇ和２．５ｍｇ／ｋｇ，用阻抗法观察ＭＡＰ、ＨＲ、ＣＯ、ＣＩ、ＳＶ、ＳＩ、ＴＦＩ、ＶＥＴ、ＳＶＲ的变化。结果：注药后１０ｍｉｎＣＯ、ＣＩ、ＳＶ、ＳＩ等值在第１组下降２０％～３０％，第２组下降少于１０％，而第３组下降１０％～２０％。结论：异丙酚对循环系统影响轻于硫喷妥钠。     

Effects of Hypothermia,Hemodilution, and Pump Oxygenation on Organ Water Content,Blood Flow and Oxygen Delivery,and Renal Function

Hypothermia, hemodilution, and the pump-oxygenator each contribute important effects during cardiopulmonary bypass. We studied their separate effects with a 2³ factorial, completely fixed experimental design in 16 adult male mongrel dogs. Animals undergoing hypothermia were cooled to 25° ± 1°C. In dogs having hemodilution, hematocrit was adjusted to 25 ± 2%. An analysis of variance was used to determine the effects of hypothermia, hemodilution, and pump oxygenation. The experiments show that hemodilution produces increased water content in tissue and that edema is greatest in heart and gastrointestinal organs. The pump-oxygenator decreased flow to the subendocardium, whereas hemodilution increased subendocardial flow. Both hypothermia and pump oxygenation diminished flow to the outer kidney cortex, and hemodilution augmented flow to this region.Hypothermia and pump oxygenation decreased and hemodilution raised renal free-water clearance. Although none affected glomerular filtration rate, hypothermia increased filtration fraction while hemodilution diminished it. Hypothermia lessened cerebral cortical flow, an effect opposite that of hemodilution. Thus, hemodilution opposes the adverse effect of hypothermia or pump oxygenation on blood flow, oxygen delivery, or renal function. Increased water content in gastrointestinal organs and myocardium accompanies the beneficial vascular and renal effects of hemodilution.