比较舒芬太尼和纳布啡复合丙泊酚静脉全麻用于无痛肠镜检查的效果

目的比较舒芬太尼和纳布啡复合丙泊酚静脉全麻用于无痛肠镜检查的效果。方法依据不同静脉全麻用药,将行无痛肠镜检查的96例患者分为2组,各48例。观察组采用纳布啡复合丙泊酚静脉全麻,对照组采用舒芬太尼复合丙泊酚静脉全麻。回顾性分析患者的麻醉资料。结果2组患者的麻醉诱导用时、肠镜检查用时、检查中的不良反应,以及检查后的苏醒时间、恢复时间比较,差异均无统计学意义(P>0.05)。麻醉苏醒后60 min内,观察组患者的恶心、呕吐等不良反应发生率低于对照组,差异有统计学意义(P<0.05)。结论对接受无痛肠镜检查的患者,纳布啡和舒芬太尼复合丙泊酚静脉麻醉均有良好的镇静、镇痛效果,但纳布啡复合丙泊酚静脉全麻患者苏醒后的不良反应少。     

瑞马唑仑复合丙泊酚对无痛胃镜检查患者膈肌运动的影响

目的 探讨超声监测下瑞马唑仑复合丙泊酚对胃镜检查患者膈肌运动的影响。方法选择2021年7—10月行无痛胃镜检查患者210例,男96例,女114例,年龄18～64岁,BMI 18～25 kg/m²,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组：瑞马唑仑复合丙泊酚组(R组)和丙泊酚组(P组),每组105例。两组分别于入室吸氧5 min后缓慢静脉注射布托啡诺0.01 mg/kg, 1 min后R组静脉注射瑞马唑仑0.2 mg/kg和丙泊酚0.5 mg/kg, P组静脉注射丙泊酚2 mg/kg,给药完成后即刻评估改良警觉/镇静(MOAA/S)评分,之后每30秒进行一次评估,直至MOAA/S评分≤3分时开始进镜操作。若进镜失败或给药2 min后MOAA/S评分仍≥4分,则追加丙泊酚0.5 mg/kg,直至MOAA/S评分≤3分,每次追加药物间隔时间≥1 min。记录注药前1 min(T₁)、操作开始即刻(T₂)、操作开始后1 min(T₃)、苏醒(T₄,Steward评分≥4分)时的H...     

不同时间膈肌超声对急性肠梗阻术后膈肌功能恢复的评估价值

通过超声检查评估急性肠梗阻术后机械通气24 h和48 h的膈肌功能恢复情况。选取2019年9月—2020年9月郴州市第一人民医院南院收治的67例急性肠梗阻术后患者,根据机械通气后有无合并脓毒症分为脓毒症组和非脓毒症组。在机械通气24 h及48 h收集患者血气分析结果,并进行膈肌超声检查记录膈肌偏移度（DE）、膈肌增厚分数（DTF）。对比分析不同时间各组临床指标的变化情况。脓毒症组的住院时间和机械通气时间均较非脓毒症组显著延长（t=3.096、4.796,P<0.01）。机械通气24 h,脓毒症组的DTF低于非脓毒症组,差异有统计学意义（t=3.929,P<0.001）,两组间DE差异无统计学意义（P>0.05）。机械通气48 h后,脓毒症组的DTF和DE均较非脓毒症组显著降低,差异有统计学意义（t=4.852、2.897,P<0.01）;此外,两组DTF和DE也均较机械通气24 h降低（P<0.05）。DTF可作为评估急性肠梗阻患者术后膈肌功能恢复的参考指标。     

非胸腹部手术拔管时右侧膈肌运动的超声评价

目的 探讨应用床旁超声测量非胸腹部手术全身麻醉术后达到临床拔管指征时右侧膈肌运动幅度的临床效果. 方法 采用随机数字表法选择接受非胸腹部手术全身麻醉患者110例,分为男性组(56例)和女性组(54例),术前使用M型超声记录患者平静呼吸时膈肌运动幅度.术中依据HR、BP等调整用药,维持麻醉深度,手术结束前30 min停止追加肌肉松弛药,手术结束后患者进入PACU,使用2～5 MHz超声探头,右锁骨中线肋缘下以肝为声窗,用M型超声记录达到临床拔管指征平静呼吸时的膈肌运动幅度,拔管后10、30 min平静呼吸时膈肌运动幅度,并记录拔管时间、拔管时Ramsay镇静评分,患者持续抬头5s时间. 结果 与麻醉前[男(16.8±2.6) mm,女(14.6±1.6) mm]比较,拔管时[男(13.1±1.4) mm,女(12.4±1.2)mm]两组膈肌运动幅度差异有统计学意义(P＜0.05),拔管后10 min[男(15.7±2.7) mm,女(13.9±2.1) mm]、30 min[男(16.1±2.6) mm,女(14.3±2.0) mm]两组膈肌运动幅度差异均无统计学意义(P＞0.05);与拔管时比较,拔管后10、30 min两组膈肌运动幅度差异有统计学意义(P＜0.05);拔管后10 min与拔管后30 min比较,两组膈肌运动幅度差异无统计学意义(P＞0.05).两组拔管时间、Ramsay镇静评分、持续抬头5s时间比较,差异无统计学意义(P＞0.05). 结论 超声测量右侧膈肌运动有较高的可操作性和可重复性,在PACU对于评价麻醉恢复期膈肌功能的恢复具有可行性.     

纳布啡复合丙泊酚用于无痛人工流产术麻醉及术后镇痛效果观察

目的探讨纳布啡联合丙泊酚用于无痛人工流产术的麻醉及术后镇痛效果。方法选择2017-04—06间在郑州大学第二附属医院接受无痛人工流产术的68例早孕者,随机分为2组,各34例。F组应用芬太尼0.001 mg/kg+丙泊酚2 mg/kg,N组应用纳布啡0.15 mg/kg+丙泊酚2 mg/kg。观察麻醉前(T_1)、意识消失时(T_2)及清醒时(T_3)三个时点早孕者的MAP、HR及SpO_2的变化。记录其苏醒时间及T_3、苏醒后30 min(T_4)、苏醒后90 min(T_5)的疼痛VAS评分。比较2组早孕者的满意度(NRS)评分和不良事件发生例数。结果 N组T_3时的MAP及SpO_2明显优于F组(P0.05),丙泊酚用量及苏醒时间少于F组(P0.05),T_4及T_5时VAS评分明显低于F组(P0.05),对麻醉满意度明显高于F组(P0.05),呼吸抑制发生率明显低于F组(P0.05)。差异均有统计学意义。结论纳布啡联合丙泊酚用于无痛人工流产术的麻醉及术后镇痛,安全有效且不良反应少。     

纳布啡对行切痂植皮术烧伤患者氧化应激及全麻苏醒期躁动的影响

目的：探究纳布啡对烧伤患者行切痂植皮术后全麻苏醒期躁动及氧化应激反应的影响。方法：选取2021年3月—2022年3月我院收治并行切痂植皮术的烧伤患者72例,采用随机数字法分为纳布啡组（n=36）和对照组（n=36）。纳布啡组患者在全身麻醉诱导前10 min静脉注射0.20 mg/kg纳布啡,对照组给予等量生理盐水,比较两组躁动发生率,拔管前（T1）、拔管即刻（T2）、拔管后10 min(T3)、拔管后30 min(T4)的Richmond躁动-镇静评分（RASS）、Ramsay镇静评分,以及术前术后的氧化应激反应和苏醒时间,比较两组恶心呕吐、呼吸抑制、嗜睡、眩晕等不良反应发生情况。结果：与对照组比较,纳布啡组躁动发生率更低,T3、T4时RASS评分均降低,T1、T4时Ramsay镇静评分升高（P <0.05）;两组患者术前术后丙二醛（MDA）、脂质过氧化物（LPO）明显下降,超氧化物歧化酶（SOD）明显升高。术后苏醒期,纳布啡组SOD均高于对照组,MDA、LPO低于对照组（P <0.05）;两组苏醒时间、恶心呕吐、呼吸抑制、嗜睡、眩晕的不良反应发生率,无统计学差异（P>...     

纳布啡联合罗哌卡因切口浸润多模式镇痛对颅脑外科手术患者全麻苏醒期躁动的影响

目的探讨纳布啡联合罗哌卡因切口浸润的多模式镇痛对颅脑外科手术患者苏醒期躁动的影响。方法选择ASA I或Ⅱ级择期行颅脑肿瘤切除术的全麻患者60例,采用随机双盲设计方法分成4组,每组15例。罗哌卡因组(R组):手术切皮前10 min用0.5%罗哌卡因20 m L行切口浸润,手术结束前30 min静注生理盐水2 m L;纳布啡组(N组):切皮前10 min用生理盐水20 m L行切口浸润(1∶200 000肾上腺素),手术结束前30 min静注纳布啡10 mg;罗哌卡因+纳布啡组(RN组):手术切皮前10 min用0.5%罗哌卡因20 m L行切口浸润,手术结束前30 min静注纳布啡10 mg;对照组(C组):切皮前10 min用生理盐水20 m L行切口浸润(1∶200 000肾上腺素),手术结束前30 min静注生理盐水2 m L。记录用药前(T0)、手术结束时(T1)、拔管时(T2)、拔管后10 min(T3)患者MAP、HR和Sp O2的变化。观察患者在PACU的RSS躁动评分、拔管后Ramsay镇静评分、VAS疼痛评分和药物的不良反应。结果与T0时刻比较,R组T2时刻MAP升高,C组T2、T3时刻和HR升高(P0.05);与C组比较,R组、N组、RN组T2和T3时刻MAP和HR降低(P0.05);与R组比较,N组、RN组T2时刻MAP和HR降低(P0.05)。R、N、RN三组患者躁动发生率和评分低于C组(P0.05),而RN组又明显低于R组和N组(P0.05)。与R组和C组相比,T0时刻N组和RN组的Ramsay镇静评分升高(P0.05),无镇静过度的发生。与C组比较,R、N、RN组拔管后疼痛VAS评分显著降低,且RN组低于R组和N组(P0.05)。结论纳布啡联合罗哌卡因切口浸润,镇痛效果肯定,可减少颅脑外科手术患者全麻苏醒期躁动的不良影响。     

右美托嘧啶和芬太尼联合丙泊酚在无痛结肠镜检查中的应用

目的研究右美托嘧啶和芬太尼联合丙泊酚在无痛结肠镜检查中的应用,评价其实用性及安全性。方法门诊结肠镜检查患者80例,随机分成右美托嘧啶+丙泊酚组(D组)和芬太尼+丙泊酚组(F组),应用Ramsay镇静评分和脑电双频指数(BIS)对两组患者术中镇静镇痛效果进行观察。记录检查前(T0)、插镜时(T1)、检查后5min(T2)、检查毕(T3)、检查后30分钟(T4)患者的心率(HR)、平均动脉压(MAP)和血氧饱和度(SpO2)、脑电双频指数(BIS)及镇静深度评分(Ramsay),以及麻黄碱、阿托品的使用情况和呛咳、恶心、呕吐等并发症的发生人数。结果 T0～T4时段HR、MAP、BIS、Ramsay镇静评分D组与F组无明显差异(P>0.05),T1～T3时段D组SpO2明显高于F组(P<0.05),麻黄碱及阿托品使用次数两组无明显差异,呛咳、恶心、呕吐发生人数D组明显低于F组(P<0.05)。结论右美托嘧啶+丙泊酚更适合用于无痛结肠镜检查。     

丙泊酚用于无痛胃镜检查术中纳布啡最佳剂量的选择

目的探讨在无痛胃镜检查术中使用纳布啡复合丙泊酚静脉麻醉时,纳布啡的最佳剂量。方法无痛胃镜检查病人250例,随机分成3组,N1组78例,纳布啡0.10 mg/kg;N2组89例,纳布啡0.15 mg/kg;N3组83例,纳布啡0.20 mg/kg)。记录各组患者麻醉前(T0)、置入胃镜时(T1)、退出胃镜时(T2)时收缩压(systolic pressure,SBP)、心率(heart rate,HR)、脉搏血氧饱和度(pulse oxygen saturation,SpO_2),并记录术中丙泊酚用量、胃镜检查时间,停药后苏醒时间、术中麻醉效果、术中辅助呼吸例数、术后恶心呕吐、离院时间、离院时眩晕例数等。结果 N2组、N3组麻醉效果优良率分别为93.3%和94.0%,N1组为82.1%,N2组、N3组优于N1组。N3组病人离院时眩晕人数多于N1、N2组,差异有统计学意义(P0.05);3组病人术中辅助呼吸、术后恶心呕吐例数比较差异均无统计学意义(P0.05)。N2、N3组病人丙泊酚用量较N1组减少,苏醒时间也较N1组缩短,同时N3组病人离院时间较N1组、N2组延长,差异有统计学意义(P0.05)。结论以0.15 mg/kg纳布啡复合适当剂量的丙泊酚,能有效地保证麻醉效果,同时尽量减少麻醉的不良反应。     

舒芬太尼复合纳布啡用于剖宫产术后自控静脉镇痛的效果

目的研究舒芬太尼复合纳布啡用于剖宫产术后患者自控静脉镇痛(PCIA)的效果。方法选择2016年1月至2017年3月于本院行剖宫产手术的初产妇150例,年龄20～35岁,体重54～89kg,ASAⅠ或Ⅱ级,随机将产妇分为三组,每组50例。舒芬太尼组(S组):舒芬太尼2μg/kg+托烷司琼10mg;纳布啡组(N组):纳布啡2mg/kg+托烷司琼10mg;舒芬太尼复合纳布啡组(SN组):舒芬太尼1μg/kg+纳布啡1mg/kg+托烷司琼10mg。记录术后1、3、6、9、12、24和36h静息和咳嗽时的疼痛VAS评分及镇静Ramsay评分;PCIA实际按压次数;恶心呕吐、呼吸抑制等不良反应的发生情况。结果三组静息时VAS评分、镇静Ramsay评分和呼吸抑制发生率差异无统计学意义;SN组咳嗽时VAS评分明显低于S组和N组(P0.05)。SN组PCIA实际按压次数明显少于S组、N组(P0.05)。N组和SN组恶心呕吐发生率明显低于S组(P0.05)。结论舒芬太尼复合纳布啡用于剖宫产术后PCIA可获得满意的镇痛效果。     

Late Presentation of a Traumatic Rupture of the Diaphragm with Gastric Volvulus in a Child: Report of a Case

Rupture of the diaphragm following blunt trauma is rare in children. A late presentation of a left diaphragmatic rupture with gastric volvulus is also highly exceptional. The authors report the case of a 5-year-old boy with a left diaphragmatic rupture, who presented with acute respiratory distress and volvulus of the herniated stomach 6 months after injury. The features of this uncommon entity are discussed with special emphasis on early diagnosis. It is concluded that repeated chest radiographs during hospitalization, as well as some days after discharge, should be obtained in trauma patients to detect a slowly increasing herniation.     

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTIONPenetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.PRESENTATION OF CASEA 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.DISCUSSIONWe review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.CONCLUSIONA high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.     

Predictors of outcome in patients with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation

Background

The role of extracorporeal membrane oxygenation (ECMO) in patients with congenital diaphragmatic hernia is still evolving. The use of ECMO is invasive with potential complications during instrumentation for cannulation and heparinization. There are no reliable predictors of outcome in patients requiring ECMO. We aimed to identify (a) the factors that could predict outcome and (b) the incidence and relation of complications during ECMO to outcome.

Methods

“Pre” ECMO (age, sex, birth weight, blood gasses, and ventilator settings) and “on” ECMO variables (mode of ECMO, use of nitric oxide, surfactant, liquid ventilation, inotropes, timing of repair, and complications on ECMO) were analyzed to identify predictors of outcome.

Results

Fifty-two patients were included. The overall survival was 58%. Mean duration of ECMO (181 ± 120 vs 317 ± 156 hours, P = .001), use of nitric oxide (6 vs 10, P = .049), and renal complications (4 vs 14; P < .001) differed between survivors and nonsurvivors. The survival of patients requiring ECMO support for more than 2 weeks is significantly lower than that of patients requiring ECMO support for less than 2 weeks (18% vs 68%, P = .005). Multiple logistic regression revealed ECMO duration of 2 weeks or more and renal complications to be associated with mortality.

Conclusion

No pre-ECMO variable could be identified as predictor of mortality. Prolonged duration of ECMO and renal complications on ECMO were independently associated with mortality.     

创伤性膈疝的诊断和治疗

目的 总结创伤性膈疝的诊治经验。方法 回顾性分析自１９７２年１月至１９９８年８月４家医院收治的８５例创伤性膈疝,其发生原因为穿透性损伤４３例,闭合性损伤４２例,９５．３％的病人合并其它脏器损伤。手术治疗采用剖胸术１１例,剖腹术７２例,剖腹后剖胸术２例。结果 术前确诊５８例,全组治愈７８例,死亡７例,病死率８．２％。     

Diaphragmatic hernia associated with double pulmonary sequestration

The association of pulmonary sequestration with diaphragmatic hernia is an infrequent but well known situation. We report a rare case in which the diaphragmatic malformation was accompanied by two extralobar pulmonary sequestrations.     

创伤性膈疝28例临床分析

目的总结创伤性膈疝的诊治经验。方法回顾分析1990年1月～2004年8月28例创伤性膈疝临床资料。其中开放性损伤7例,闭合性损伤21例。结果术前确诊19例（67．9％）,治愈25例。死亡3例（10．7％）,2例死于出血性休克,1例死于多器官功能障碍综合征（MODS）。结论胸部X线和CT检查是诊断创伤性膈疝的重要方法。早期诊断、及时手术,正确处理合并脏器伤是提高治愈率的关键。     

创伤性膈疝26例诊治分析

目的 总结创伤性膈疝的诊治经验。方法 回顾性分析26例创伤性膈疝临床资料,其中开放性损伤7例,闭合性损伤19例。92.3％(24/26)的病人合并其它脏器损伤。手术采用剖腹术16例,剖胸术6例,胸腹联合切口4例。结果 术前确诊19例(73.1％),治愈24例,死亡2例。结论 创伤性膈疝一经确诊应尽早手术治疗。胸部X线检查最具诊断价值。早期诊断、尽早手术修补膈肌裂口,及时、正确地处理合并脏器伤是提高治愈率的关键。     

Congenital unilateral diaphragmatic eventration in an adult: A rare case presentation

We present a rare case of 32 year old female with congenital diaphragmatic eventeration female presenting in an adult. She had symptoms of intermittent dyspnea and occasional epigastric discomfort. Patient had no previous history of trauma. Physical examination showed bowel sound involving the left hemithorax. Imaging modalities confirmed the diagnosis of a congenital left diaphragmatic eventeration. Patient underwent plication of the diaphragm using the abdominal approach. Intra-operatively, the left diaphragm was attenuated. Plication was done with 1st layer of imbricating silk heavy sutures buttressed by a second layer of interrupted absorbable sutures. She post-operatively had atelectasis on the left lung. Incentive spirometry and deep breathing exercises were started with resolution of the atelectasis after 1 week post-operatively. Patient had an unremarkable post-operative stay with resolution of symptoms. There are reports that diaphragmatic eventration diagnosed even as late 70 years old, highlighting the dogma that this is an asymptomatic disorder does not need all the time surgical therapy. But we still recommend surgical therapy as soon as diagnosis is confirmed. In this patient, there was no recurrence of symptoms after a follow-up of 2 years. Whether surgery indeed improved lung functions in these vastly asymptomatic patients, these questions could be an active area of research in the long term outcomes of these patients.     

Laparoscopic repair of congenital diaphragmatic hernia with prosthesis: a case report

We report here our experience in the treatment of a large congenital diaphragmatic hernia, an uncommon pathology, approachable by laparoscopy. The patient was a 33-year-old woman with trisomy 21 syndrome, who only complained of colicky abdominal pain and a cough for 7 months before the hospitalization. Thoracic and abdominal CT scans showed a large anteromedial diaphragmatic hernia with slippage of the colon into the mediastinum and posterior displacement of the cardiovascular structures. The patient underwent laparoscopic repair of the hernia. The colon was put back in the abdomen; the defect (8×4 cm) was repaired by a Composix mesh (PTFE-polypropylene), fixed to the diaphragm by nonabsorbable stitches and staples. The patient was discharged on the third postoperative day. The postoperative course was uneventful. Follow-up at 18 months didn't show any complications or recurrence. We believe laparoscopic repair of diaphragmatic hernia to be the elective surgical choice, because of its technical feasibility and certain intra- and postoperative advantages. Electronic Publication