嗜铬细胞瘤手术的麻醉进展

嗜铬细胞瘤是功能性分泌儿茶酚胺的交感-肾上腺系统肿瘤，起源于肾上腺髓质或从骨盆向颅底延伸的椎旁交感神经链。其临床表现主要是由于瘤体大量分泌儿茶酚胺作用于肾上腺素能受体所致，表现为高血压、心律失常及代谢异常等一系列症状。嗜铬细胞瘤术的麻醉处理较困难，风险大，因而明确术前诊断，术前准备充分，术中严密监测，     

嗜铬细胞瘤手术的麻醉管理

嗜铬细胞瘤嗜是一种以分泌儿茶酚胺为主的肿瘤,由于肿瘤细胞大量分泌肾上腺素和去甲肾上腺素,临床上主要以高血压、心律失常及代谢异常等症状为主。麻醉危险性较大,死亡率较高[1]。近年来随着麻醉技术和医疗设备不断提高,其麻醉危险性相对降低。我院自2003年4月～2005年3月共实施此类手术21例,现将术中麻醉管理总结如下:1临床资料1.1一般资料:全组21例,男12例,女9例,年龄15～54岁。左侧肿瘤4例,右侧肿瘤15例,双侧肿瘤2例,血压最高达210/140mmHg,心率最高130次/min,术前均行B超、CT及内分泌检查。1.2术前准备:术前常规用α肾上腺素受体阻滞…     

嗜铬细胞瘤手术的麻醉处理

1992年以来我院成功地进行了 9例肾上腺嗜铬细胞瘤手术 ,现将体会介绍如下。嗜铬细胞瘤的主要病理生理改变是血中儿茶酚胺增加、血压升高和慢性血容量不足。麻醉处理的关键是高血压危象、严重低血压及心律失常的预防和处理。做好充分的术前准备是保障术中循环稳定的基础。目前常使用的α和 β 受体阻断药有酚妥拉明、酚苄明及普奈洛尔。α受体阻断药可对抗儿茶酚胺引起的血管收缩作用 ,使血压下降。酚妥拉明为冠心病人所忌用。硝苯吡啶是一种新型合成的钙通道阻断药 ,以其能阻断钙离子通过血管平滑肌 ,抑制毛细血管肌张力 ,使血管扩张 ,降低…     

嗜铬细胞瘤患者围手术期麻醉处理

嗜铬细胞瘤是机体嗜铬组织内生长的一种分泌儿茶酚胺的肿瘤,其病理生理变化复杂,麻醉处理较为困难,麻醉及手术风险极大。2000年～2004年我科共完成嗜铬细胞瘤手术麻醉11例,现将围手术期麻醉处理总结如下：     

嗜铬细胞瘤手术的麻醉和管理

目的探讨嗜铬细胞瘤手术中血液动力学改变和麻醉及管理。方法16例患者均采用全麻加硬膜外麻醉方法,以2%利多卡因行硬膜外麻醉,以丙泊酚、芬太尼和维库溴铵等全麻。当收缩压超过150mmHg用硝普钠降压。收缩压低于90mmHg时用去甲肾上腺素升压。建立完善的血液动力学监测。结果所有患者均获充分的麻醉效果,安全完成麻醉和手术。12例采用硝普钠0.1~8.0(2.1±1.2)μg.kg-1.min-1降压,控制收缩压在120mmHg左右。9例采用去甲肾上腺素0.01~0.15(0.04±0.02)μg.kg-1.min-1升压,维持收缩压在100~120mmHg左右。结论适当偏深的麻醉,完善的监测以及根据血液动力学实施的降压和升压措施是保证患者安全的关键。     

不同麻醉方式与老年患者髋关节置换术后转归的相关性

目的 比较不同麻醉方式对老年患者髋关节置换术后转归的影响。
方法 回顾性分析2012年12月至2018年10月行髋关节置换术患者566例,年龄≥75岁,根据麻醉方式分为两组：全身麻醉组（G组,n=233）和蛛网膜下腔阻滞组（S组,n=333）。采用倾向评分将患者按1∶1匹配,得到组间协变量均衡样本。比较两组术中情况、术后并发症、转入ICU例数和住院时间。
结果 对患者一般资料进行匹配后,G组和S组各纳入患者225例。与G组比较,S组手术时间、麻醉时间、手术室停留时间明显缩短,心血管并发症、肺部感染、深静脉血栓形成/肺栓塞、术后谵妄、术后恶心呕吐、转入ICU率明显降低,住院时间明显缩短,术后头痛、尿潴留发生率明显升高（P<0.05）。
结论 对于老年髋关节置换术患者,蛛网膜下腔阻滞可以改善术后转归,加速术后康复进程。     

嗜铬细胞瘤麻醉近况

概述了嗜铬细胞瘤近年来诊断及定位进展,并能预测恶变情况。并介绍了新型吸入麻醉药及静脉麻醉药应用于该手术的经验,及连续硬膜外阻滞复合全麻的应用趋势。对术中高血压危象的处理分别介绍了新型肾上腺素能阻滞药及钙通道阻滞药的应用,硫酸镁及其他扩血管药的应用经验。     

嗜铬细胞瘤麻醉近况

概述了嗜铬细胞瘤近年来诊断及定位进展，并能预测恶变情况。并介绍了新型吸入麻醉药及静脉麻醉药应用于该手术的经验，及连续硬膜外阻滞复合全麻的应用趋势。对术中高血压危象的处理分别介绍了新型肾上腺素能阻滞药及钙通道阻滞药的应用，硫酸镁及其他扩血管药的应用经验。     

后腹腔镜手术治疗嗜铬细胞瘤

目的探讨后腹腔镜手术治疗嗜铬细胞瘤的适应证及手术安全性. 方法采用后腹腔镜手术治疗肾上腺嗜铬细胞瘤患者15例(双侧2例),腹主动脉旁嗜铬细胞瘤1例.对照组为开放手术治疗的肾上腺嗜铬细胞瘤16例,腹主动脉旁嗜铬细胞瘤1例.结果后腹腔镜手术组16例患者行后腹腔镜手术18例次,17例次取得成功,1例因术中出血改行开放手术.肿瘤最大径2.0～6.5(3.8±1.6)cm.手术时间45～150(85±31)min,出血量10～100(32±22)ml.术后吗啡用量0～40(12.5±7.8)mg;术后恢复进食时间1～3(1.8±0.7)d;下床活动时间2～3(2.3±0.5)d;术后住院时间4～9(6.5±1.3)d.开放手术组肿瘤最大径1.5～6.0(4.3±1.3)cm.手术时间90～240(155±39)min,出血量50～600(273±105)ml,9例输血.术后吗啡用量10～120(61±24)mg;术后恢复进食时间2～4(2.9±0.5)d;术后下床活动时间3～6(4.8±0.7)d;术后住院时间8～11(8.8±0.9)d.结论对于有一定腹腔镜手术经验者,后腹腔镜手术并不增加嗜铬细胞瘤手术的危险性,且具有手术时间短、出血少、创伤小、疼痛轻、康复快等优点.该法有望成为治疗肾上腺嗜铬细胞瘤的首选手术方法.     

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.     

不同液体复苏对重症急性胰腺炎患者预后的影响分析

目的探讨不同液体复苏对重症急性胰腺炎患者预后的影响。方法回顾性分析2009年3月-2012年10月我院SICU 172例重症急性胰腺炎患者的临床资料,根据患者入院后24h内液体复苏量将患者分成A组与B组,各86例。A患者给予充分性液体复苏治疗,B组患者给予限制性液体复苏治疗,比较两组患者的临床治疗效果和预后。结果 A组患者的急性肾损伤（AKI）发生率、AKI持续时间、肌酐峰值及连续肾脏替代疗法（CRRT）使用率均较B组有明显升高,两组比较具有统计学意义（P〈0.05）;A组患者与B组患者在多器官功能衰竭综合征（MODS）发生率、CRRT使用时间、机械通气率、开腹手术率、住院时间及死亡率等方面无统计学意义（P〉0.05）。结论对于重症急性胰腺炎患者给予限制性液体复苏能够显著降低患者的AKI发生率和持续时间以及肌酐峰值,减少CRRT的使用率,减少并发症的发生,较充分性液体复苏具有更好的临床疗效,对于重症胰腺炎患者疾病的治疗和预后具有重要的意义。     

Postoperative delirium after general anesthesia vs. spinal anesthesia in geriatric patients

BACKGROUND: Influence of the type of anesthesia on postoperative delirium was examined in geriatric patients with femoral neck fracture. METHODS: Forty patients aged 70 or more were randomly allocated to receive either general anesthesia (sevoflurane, nitrous oxide in oxygen, G group, n = 21) or spinal anesthesia (0.5% bupivacaine, S group, n = 19). G group received the oxygen therapy during the 12-hour postoperative period. Postoperative assessments included the rate of postoperative delirium during the 4-day postoperative period, oxygen saturation during the 18-hour postoperative period, the value of hemoglobin at 1 postoperative day and the number of analgesics requirements during the 4-day postoperative period. RESULTS: The rate of postoperative delirium was similar between the two groups during the 4-day postoperative period. However, that of S group tended to be higher during the 1-day postoperative period. Postoperative analgesic effect and the value of hemoglobin at 1 postoperative day were similar between the two groups. Oxygen saturation was similar between the two groups except 6 hours after the operation. CONCLUSIONS: The type of anesthesia, general or spinal, does not affect the postoperative delirium in geriatric patients with femoral neck fracture.     

不同药物治疗全麻患者苏醒期躁动的疗效比较

目的 比较芬太尼,曲马多、布托啡诺和帕瑞昔布对全麻患者苏醒期躁动的治疗作用,探讨患者术后躁动治疗的合理化用药方案.方法 全麻后出现苏醒期躁动的ASA Ⅰ或Ⅱ级成年患者120例,随机均分为四组:芬太尼组(F组)、曲马多组(T组)、布托啡诺组(B组)和帕瑞昔布组(P组),分别给予静脉注射芬太尼1 μg/kg、曲马多1 mg/kg、布托啡诺20 μg/kg和帕瑞昔布40 mg进行治疗.各组患者分别在用药前后进行VAS评分、Prince-Henry疼痛评分、Ramsay镇静评分和RSS躁动评分以评价药物治疗效果,记录患者可能的术后躁动诱发因素和麻醉后恢复室(PACU)停留时间.结果 疼痛与导尿管刺激是引起苏醒期躁动的主要原因,T组躁动缓解率低于其他三组(P＜0.05).与用药前比较,四组患者用药后VAS评分和Prince-Henry疼痛评分均降低(P＜0.05),而用药后T组VAS评分高于其他三组(P＜0.05),用药后四组患者的Ramsay镇静评分较用药前均明显升高,其中B组患者高于其他三组(P＜0.05).B组患者在PACU停留时间长于其他三组(P＜0.05).结论 帕瑞昔布是治疗苏醒期躁动较为安全有效的药物,芬太尼有可能会导致患者发生一过性呼吸抑制,布托啡诺町延长患者在PACU的停留时间,而曲马多对苏醒期躁动的治疗效果欠佳.     

Free lidocaine concentrations during continuous epidural anesthesia in geriatric patients

BACKGROUND AND OBJECTIVES: To evaluate the effects of aging on lidocaine pharmacokinetics, the plasma concentrations of total and free lidocaine and its metabolites were measured during continuous thoracic epidural anesthesia in middle-aged (age 41 +/- 9 years, n = 7) and elderly (age 72 +/- 2 years, n = 7) male patients. METHODS: After establishment of general anesthesia, 7 mL 1.5% lidocaine with epinephrine 1:200,000 was injected into the epidural space and subsequently infused at a rate of 5 mL/h for 5 hours. Plasma concentrations of total and free lidocaine, monoethylglycinexylidide (MEGX), and glycinexylidide (GX) were measured at 10, 15, 20, 30, 45, 60, 90, 120, 150, 180, 240, and 300 minutes after initial lidocaine injection using high-performance liquid chromatography (HPLC) with ultraviolet (UV) detection. RESULTS: The elderly group showed a stronger upward trend in the corrected free lidocaine concentrations and lower corrected total MEGX concentrations than the middle-aged group. CONCLUSIONS: Lidocaine metabolite activity in the elderly male patients was lower than that in the middle-aged male patients. Free lidocaine concentration is prone to increase in elderly patients. Caution must be exercised during continuous thoracic epidural anesthesia combined with general anesthesia in geriatric patients.     

Inhalation anesthesia or "balanced anesthesia"? A comparative perioperative study in geriatric patients

During a prospective randomized trial, 50 geriatric patients underwent surgery for a fractured femoral neck. The perioperative circulatory and respiratory effects of anesthesia with enflurane or balanced anesthesia with enflurane and fentanyl were compared. We were particularly looking for postoperative respiratory depression after a standard dose of fentanyl given during balanced anesthesia. Method. In 25 patients anesthesia was induced with 0.2 mg/kg etomidate and 1 mg/kg succinylcholine and maintained with 0.15 mg/kg alcuronium and enflurane. Twenty-five patients received a additional dose of 5 micrograms/kg fentanyl divided into 0.1 mg/kg 2 min before endotracheal intubation and the remainder 5 min before the start of surgery. Systolic and diastolic arterial pressures, heart rate, central venous pressure, hemoglobin, hematocrit, and electrolytes were measured and arterial blood gases were analyzed. Results. There was no important difference between the two methods: during careful use of both techniques circulation remained stable. No marked postoperative respiratory depression occurred even after 5 micrograms/kg fentanyl. Conclusions. Both anesthetic procedures are suitable for hip surgery in elderly patients. In the early postoperative period geriatric patients should be observed carefully in the recovery room for at least 2 h. In some patients--especially if fentanyl is used intraoperatively--this time must be prolonged.