腹腔镜胆囊切除术气腹对血流动力学和呼气末二氧化碳浓度的影响

目的：探讨腹腔胆囊切除术气腹对血流动力学和呼气末二氧化碳浓度的影响。方法：选择56例全麻下腹腔镜胆囊切除术患者连续监测气膜前后各时点心率，血压，血氧饱和度，呼气末二氧化碳浓度及心电图的变化，并进行比较。结果：气腹前与气腹后的心率，血氧饱和度比较无显著性差异（P＞0．05），气腹后10分钟血压，呼气末二氧化碳浓度逐渐升高，气腹后20分钟明显升高（P＜0．01），放气后10分钟呼气末二氧化碳浓度与气腹前比较明显升高（P＜0．01），结论：腹腔镜胆囊切除术气腹对血压，呼气末二氧化碳浓度有显著影响，术中应加强监测。     

FloTrac/Vigileo系统在腹腔镜胆囊切除患者围术期血流动力学监测中的运用

目的 将FloTrac/Vigileo系统用于腹腔镜胆囊切除术患者监测心输出量(CO),观察不同气腹压下血流动力学变化.方法 选择60例择期全麻下行腹腔镜胆囊切除术患者,按照随机数字表法分为三组,每组20例,A组气腹压8 mm Hg,B组气腹压12 mm Hg,C组气腹压15 mm Hg.Philips MP40监护仪监测心率(HR)、心电图(ECG)、血氧饱和度(SpO2),通过FloTrac传感器监测有创动脉血压,Vigileo监护仪接FloTrac传感器连续监测CO.分别记录麻醉诱导前入室静卧10 min后(T0)、气管插管后5 min(T1)、气腹后1 min(T2)、气腹后5 min改变体位时(T3)、气腹后20 min(T4)、气腹结束恢复体位后1 min(T5)、5 min(T6)、术毕拔管后5 min(T7)各时刻的MAP、HR及CO,观察并记录术中术后并发症.结果 与T0、T1时分别比较,各组患者HR、平均动脉压(MAP)在T2～T4时均显著增快和增高,以C组更为明显,差异有统计学意义(P<0.05),A、B两组MAP在T5时基本恢复至T0时水平,而C组至T6时才恢复至T0时水平.B组CO在T2、T3时与T0时相比明显降低,且T2时与A组比较差异有统计学意义(P<0.05),C组CO在T2～T4时与T0时相比显著降低,且T2～T4时与A组比较差异有统计学意义(P<0.05).C组术中出现1例偶发房性早搏,3例显著的心肌缺血改变,术后出现1例室性早搏.结论 气腹压12 mm Hg对腹腔镜胆囊切除术患者围术期血流动力学影响较小,FloTrac/Vigileo系统可以用于持续有效地监测患者血流动力学变化,为更早的临床诊断及决策创造了有利条件,优化围术期麻醉管理.     

二氧化碳气腹压力对心率、平均动脉压、血氧饱和度的影响及对策

目的观察不同压力对心率、平均动脉压、血氧饱和度的影响.方法将腹腔镜胆囊切除术患者40例随机分为A组(气腹压力为1.3～1.9 kPa),B组(气腹压力为2.0～2.5 kPa).结果B组气腹后20分钟各参数变化明显,与A组比较有显著差异(P＜0.05).结论腹腔镜胆囊切除术时,在一定范围内心率、平均动脉压和血氧饱和度的变化程度与二氧化碳气腹压成正比,术中适宜的气腹压力为1.3～1.9 kPa,并加强术中监测,及时调节气腹压力,必要时解除气腹.     

上、下腹部腹腔镜全麻手术中血流动力学及呼吸变化

目的:比较全麻下腹腔镜胆囊切除术与腹腔镜盆腔附件手术术中体位及气腹变化对血流动力学及呼吸的影响.方法:选择行择期腹腔镜下胆囊切除(LC组)与盆腔附件手术(GL组)患者各20例,静脉注射异丙酚、维库溴铵、芬太尼维持麻醉,持续监测血压(MAP)、心率(HR)、血氧饱和度、呼吸末二氧化碳分压(PETCO2)、心电图、气道压(Paw)等.于麻醉前(T0)、气腹前(T1)、气腹后仰卧位5 min(T2)、体位改变后即刻(T3)、体位改变5 min(T4)及气腹结束后仰卧位(T5)记录血流动力学指标及呼吸道压力指标,同时行血气分析.结果:两组MAP气腹后升高;组间无明显差异(P＞0.05).体位改变后,两组HR均有减慢趋势,但无统计学意义(P＞0.05).Paw与PETCO2气腹后较气腹前均升高,差异有统计学意义(P＜0.05);T4时点PETCO2组间比较差异有显著性(P＜0.05).pH值T4时点较麻醉前差异有统计学意义(P＜0.05),组间比较无明显差异.PaCO2气腹后较气腹前升高,差异有统计学意义(P＜0.05),T4时点组间比较差异有显著性(P＜0.05).结论:腹腔镜手术中体位变化对血流动力学有一定程度影响;气腹及体位变化对Paw与PETCO2影响明显.对于上、下腹部腹腔镜手术中麻醉管理应特别注意监测呼吸功能变化,防止出现高碳酸血症或呼吸性酸中毒.     

二氧化碳气腹压力对心率、平均动脉压、血氧饱和度的影响及对策

目的 观察不同压力对心率、平均动脉压、血氧饱和度的影响。方法 将腹腔镜胆囊切除术患者40例随机分为A组（气腹压力为1.3-1.9kPa)，B组（气腹压力为2.0-2.5kPa)。结果 B组气腹后20分钟各参数变化明显，与A组比较有显著差异（P＜0．05）。结论 腹腔镜胆囊切除术时，在一定范围内心率、平均动脉压和血氧饱和度的变化程度与二氧化碳气腹压成正比，术中适宜的气腹压力为1.3-1.9kPa，并加强术中监测，及时调节气腹压力，必要时解除气腹。     

悬吊式腹腔镜胆囊切除术对循环和呼吸的影响

目的观察悬吊式腹腔镜胆囊切除术对循环和呼吸功能的影响。方法选择40例择期行腹腔镜胆囊切除术患者,随机分成悬吊式组(A组)和CO2气腹组(B组),各组20例。全身麻醉诱导均采用咪唑安定、芬太尼、丙泊酚、司可宁,麻醉维持采用吸入七氟醚,静脉泵入丙泊酚,间断静脉推注维库溴铵。记录诱导前基础值(T0)、气管插管后即刻(T1)、悬吊腹壁(或CO2气腹)5min(T2)、25min(T3)、停悬吊或气腹后(T4)、平均动脉压(MAP)、心率(HR)、血氧饱和度、呼气末二氧化碳分压(PETCO2)、气道峰压(Ppeak)的变化。结果与T0比较,A组MAP、HR轻度升高,差异无统计学意义(P0.05);Ppeak轻度下降,与术前比较差异无统计学意义。B组MAP、HR、PETCO2、Ppeak明显升高,差异有统计学意义(P0.05),也高于A组相应各个时点,差异有统计学意义(P0.05)。结论悬吊式腹腔镜具有循环更稳定,呼吸更平衡等优点,更适宜心肺功能差的患者。     

不同体位二氧化碳气腹对呼吸参数的影响

目的 观察不同体位下腹腔镜手术二氧化碳气腹对患者呼气末二氧化碳分压(PETCO2)、气道峰压(Ppeak) 及气道平台压(PLAT)的影响.方法 A组:女性腹腔镜胆囊切除术60例,术中取头高足低20°~30°;B组:女性腹腔镜子宫切除术60例,术中取头低足高20°~30°.监测气腹前(T0)、气腹后体位改变前(T1)、体位改变后10 min(T2)、20 min(T3)及30 min(T4)时的PETCO2、Ppeak、PLAT.结果 T1、T2、T3、T4时与T0时比较两组PETCO2、Ppeak、PLAT明显升高(P<0.05);B组T2、T3、T4时的PETCO2、Ppeak、PLAT明显高于A组(P<0.05).结论 气腹与体位均使患者呼吸参数发生改变,特别是头低足高位呼气末二氧化碳分压、气道峰压及气道平台压升高更为明显.     

舒芬太尼复合艾司洛尔对腹腔镜胆囊切除术二氧化碳气腹期间的影响

目的评价舒芬太尼复合艾司洛尔对腹腔镜胆囊切除术二氧化碳气腹期间心血管反应和脑电双频指数(BIS)的影响。方法 2010年1月-2011年12月间,选择美国麻醉医师协会分级Ⅰ～Ⅱ级择期腹腔镜胆囊切除术患者90例,随机分为芬太尼组(A组)、舒芬太尼组(B组)和舒芬太尼+艾司洛尔组(C组)。A组用芬太尼4μg/kg,B、C组用舒芬太尼0.6μg/kg麻醉诱导后气管插管,机械通气;C组在气腹前加用艾司洛尔。3组均常规静脉注射咪达唑仑0.1 mg/kg、丙泊酚2 mg/kg和维库溴铵0.1 mg/kg。分别记录各组在气腹前(T1)、气腹30 s(T2)、气腹5 min(T3)、气腹15 min(T4)时的收缩压、舒张压、平均动脉压、心率、血氧饱和度和BIS值。结果 T1时C组收缩压、舒张压、心率、BIS值最低,各组间差异无统计学意义(P>0.05);T2、T3、T4时A组收缩压、舒张压、心率、BIS明显增加,B组有所上升,ⅢC组各时段变化不明显。A组与B组、B组与C组间差异有统计学意义(P<0.05)。结论舒芬太尼复合艾司洛尔能更好地预防腹腔镜胆囊切除术二氧化碳气腹期间心血管反应和抑制BIS的增加。     

全凭静脉麻醉下喉罩与气管插管在妇科腹腔镜手术中应用观察

目的:比较全凭静脉麻醉下喉罩、气管插管2种通气方法在妇科腹腔镜手术中应用的安全性、可靠性.方法:ASA Ⅰ～Ⅱ级行妇科腹腔镜手术患者220例,随机分为A,B组,每组各110例.A组采取喉罩下全凭静脉麻醉,B组为气管插管下全凭静脉麻醉,监测记录插管前后心率、血压,气腹前、气腹后5 min平均气道压力、呼气末二氧化碳分压,记录术中及术后腹胀,咽喉痛等并发症.结果:A组置入喉罩前后心率、血压比较差异无统计学意义(P>0.05),B组插管后心率,血压高于插管前(P<0.05);气腹后A、B组平均气道压力和呼气末二氧化碳分压均高于气腹前(P<0.05),2组气腹前、气腹后5 min平均气道压力和呼气末二氧化碳分压比较差异无统计学意义(P>0.05).B组并发症发生率高于A组(P<0.05).结论:腹腔镜手术中使用喉罩下全凭静脉麻醉安全性好,血流动力学平稳,并发症少.     

腹腔镜手术方式和体位对老年病人呼吸循环的影响及护理

[目的]探讨不同腹腔镜手术方式和体位对老年病人呼吸循环的影响及护理。[方法]选择60岁以上、ASAⅠ级或ASAⅡ级腹腔镜手术病人90例,分为3组,每组30例。A组为仰卧头高足低位,B组为仰卧头低足高位,C组为侧卧位。监测病人气腹前后不同时间点[安置体位后气腹前5min(T0)、气腹后10 min(T1)、气腹后30 min(T2)、气腹后60min(T3)]的心率(HR)、平均动脉压(MAP)、脉搏血氧饱和度(SpO2)、动脉血二氧化碳分压(PaCO2)、呼吸末二氧化碳分压(PET CO2)、气道峰压(Ppeqk)。[结果]3组HR均有减慢趋势,HR、SpO2各时间点比较差异无统计学意义。3组MAP气腹后升高,A、B两组在T1和T2时点与T0比较差异有统计学意义(P0.05)。B组在T1,T2,T3时点PaCO2,PET CO2,Ppeak高于A组与C组(P0.05)。组内比较在T1,T2,T3时PaCO2,PET CO2均较T0时明显升高。B、C两组Ppeak在T1,T2,T3时点均较T0显著升高(P0.05)。[结论]3种腹腔镜手术方式和体位对心率的影响相似,下腹部手术血压影响程度大于上腹部手术,气腹时间延长及压力增加直接影响呼吸各参数值的变化,头低足高位对呼吸功能影响尤显突出。建议老年病人使用低CO2气腹压力为宜。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.