右美托咪定用于重症肺炎患儿机械通气的研究

目的:探讨右美托咪定用于重症肺炎患儿机械通气的镇静效果及安全性。方法:将接受机械通气治疗的重症肺炎患儿随机分为4组,分别为小剂量右美托咪定组[Ds组,0.3μg/(kg·h),47例]、大剂量右美托咪定组[Dm组,0.7μg/(kg·h),45例]、小剂量咪达唑仑组[Ms组,2μg/(kg·min),48例]和大剂量咪达唑仑组[Mm组,5μg/(kg·min),49例]。观察各组镇静指标、机械通气指标、生命体征变化、不良反应发生率。结果:(1)各组镇静情况比较:4组达镇静目标时间、停药后苏醒时间、镇静评分、需追加药物人数比较差异有统计学意义(P0.05),Dm组达镇静目标时间最快,Ds组及Dm组均较Ms组、Mm组更快苏醒,Ds组、Dm组、Ms组均可维持适宜镇静评分,Dm组需追加药物比例最低,Ms组需追加药物比例最高;(2)机械通气情况比较:4组患儿机械通气时间、拔管时间比较差异有统计学意义(P0.05),Dm组机械通气时间最短,Ds组及Dm组机械通气时间均要低于Ms组、Mm组;Ds组拔管时间最短,Ds组及Dm组拔管时间均要短于Ms组和Mm组;4组患儿机械通气前、机械通气12h的氧合情况比较差异无统计学意义(P0.05),机械通气24、36、48h氧合情况比较差异有统计学意义(P0.05);(3)4组患儿镇静前心率、呼吸频率、平均动脉压比较差异无统计学意义(P0.05),其后T1、T2、T3、T4时间点心率比较差异有统计学意义(P0.05),Dm组心率下降最明显(P0.05);T1、T2、T3、T4时间点呼吸频率比较差异有统计学意义(P0.05);4组患儿在不同时间点平均动脉压相比均差异无统计学意义(P0.05);(4)4组患儿心动过缓、低血压发生率比较差异无统计学意义(P0.05),4组患儿谵妄发生率比较差异有统计学意义(P0.05),Mm组谵妄发生率最高(P0.05)。结论:右美托咪定用于机械通气的重症肺炎患儿,可以达到适宜的镇静效果,停药后能迅速苏醒、拔管,有效减少机械通气时间,且不良反应发生率低。右美托咪定镇静是PICU内重症肺炎患儿机械通气的优先选择。     

右美托咪啶和异丙酚对脊柱后路手术患者苏醒期躁动的影响比较

目的:以异丙酚为对照,探讨右美托咪啶对脊柱后路手术患者苏醒期躁动的影响。方法:将65例择期行脊柱后路手术美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级的患者随机分为异丙酚组(P组,n=32)组和右美托咪定组(DEX组,n=33)。两组于气管插管后分别以60μg/(kg·h)、0.5μg/(kg·h)的速率输注异丙酚、右美托咪定至手术缝合切口前。两组均于麻醉诱导前10 min(T0)、手术完成缝合切口皮肤(T1)及拔除气管导管(T2)时检测血浆C-反应蛋白(CRP)和肿瘤坏死因子-α(TNF-α)水平;记录两组苏醒期躁动的发生率及躁动程度;采用Ramsay评分评价镇静效果。结果:DEX组T1、T2观察点的CRP和TNF-α水平均低于P组,差异有统计学意义(P0.05),两组T1、T2观察点的CRP、TNF-α水平均高于T0时(P0.05);DEX组苏醒期躁动的发生率低于P组(48.5%比78.1%,P0.05),以重度躁动最为明显(3.0%比18.8%,P0.05),轻、中度躁动两组差异无统计学意义(P0.05);DEX组术毕即刻及术后6 h、12 h和24 h的Ramsay评分均高于对照组(P0.05)。结论:右美托咪定可降低脊柱后路手术患者苏醒期躁动程度及发生率,抑制炎性反应及提高镇痛效果,疗效优于异丙酚。     

右美托咪定对颅内动脉瘤介入治疗患者血流动力学的影响

[目的]评估右美托咪定对全身麻醉下颅内动脉瘤介入治疗患者血流动力学及苏醒质量的影响.[方法]将本院全身麻醉下行动脉瘤栓塞术、ASA分级Ⅰ~Ⅱ级患者40例随机均分成两组(n=20),两组麻醉和诱导方法相同.右美托咪定组于麻醉诱导前15 min静脉输注右美托咪定0.6μg/(kg·10 min),继之0.4μg/(kg·h)持续输注;生理盐水组患者则静脉泵注相同剂量生理盐水.记录输注前、输注10 min、插管后、手术结束、拔管前、拔管后即刻及拔管后5 min、10 min时患者的平均动脉压(MAP)和心率(HR),苏醒时间、拔管时间、拔管时躁动、呛咳评分及拔管后10 min时Ramsay镇静评分.[结果]两组患者手术时间、苏醒和拔管时间相比较差异均无显著性(P>0.05).气管插管、拔管前、拔管即刻及拔管后5 min右美托咪定组患者MAP、HR显著低于生理盐水组患者(P均<0.05);拔管后10 min时Ramsay镇静评分高于生理盐水组患者,而呛咳反应评分、拔管即刻躁动评分均显著低于生理盐水组患者(P<均0.05).[结论]颅内动脉瘤介入治疗患者麻醉诱导前输注负荷剂量右美托咪定0.6μg/(kg·10 min)、术中以0.4μg/(kg·h)维持可稳定患者血流动力学,同时提高患者苏醒质量.     

右美托咪定对单肺通气患者围术期末梢灌注指数和肺内分流的影响

目的评价右美托咪定对单肺通气患者围术期末梢灌注指数(TPI)和肺内分流的影响。方法择期需单肺通气的胸科手术患者60例,ASA分级Ⅰ级或Ⅱ级,年龄18~64岁,BMI 22~25 kg/m2,采用随机数字表法将其分为2组(n=30):对照组(C组)和右美托咪定组(D组)。D组于麻醉诱导前经10 min静脉输注右美托咪定1μg/kg(40 ml);C组给予等容量生理盐水。麻醉诱导:靶浓度为4μg/ml靶控输注(TCI)异丙酚,静脉注射舒芬太尼0.5μg/kg(C组)或0.3μg/kg(D组)和罗库溴铵1 mg/kg。麻醉维持:D组TCI异丙酚,血浆靶浓度3.5μg/ml,静脉输注右美托咪定0.4μg·kg-1·h-1,必要时静脉输注舒芬太尼;C组TCI异丙酚,血浆靶浓度3.5μg/ml,必要时静脉输注舒芬太尼。于麻醉诱导前(T0)、气管插管前即刻(T1)、气管插管后即刻(T2)、切皮即刻(T3)单肺通气0.5 h(T4)、1 h(T5)、双肺通气后30 min(T6)、术毕(T7)时采集动脉血样测定动脉血气,计算呼吸指数(RI)、氧合指数(OI)及肺内分流率(QS/Qt),记录TPI、低频功率(LF)和高频功率(HF),计算LF/HF的比值,记录心血管事件的发生情况。结果与C组比较,D组T3~T7时TPI值升高(P<0.05);T4~T6时RI降低,OI升高,LF/HF降低,QS/Qt降低,心血管事件发生率降低。结论右美托咪定可减轻单肺通气所致肺损伤,改善单肺通气患者微循环,其机制可能与降低交感神经张力有关。     

右美托咪啶对老年胸腔镜下食管癌手术患者心肌氧供需平衡的平衡影响

目的 对照研究不同剂量右美托咪啶(DEX)对老年胸腔镜下食管癌手术患者心肌氧供需平衡的影响.方法 60例符合研究条件的65岁以上老年患者,随机平均分成低剂量DEX(L组)组(0.5μg/kg,15 min内泵入),高剂量DEX(H组)组(1.0μ g/kg,15min内泵入)以及生理盐水(N组)对照组(与研究组同等速率泵入),实验组维持量均为0.5μg/( kg·h).所有患者输注前均静脉补充5 nL/(kg·h)乳酸钠林格注射液,同时完成桡动脉监测与右颈内静脉放置漂浮导管.记录有创监测稳定后10min (T1)、DEX负荷量输注开始5min(T2)、DEX负荷量输注开始10min(T3)、DEX负荷量输注开始15 min(T4)、DEX维持输注30 rnin(Ts)5个时间点的血流动力学指标,计算心率与收缩压乘积(RPP),抽取桡动脉和肺动脉血进行动脉血气分析,计算氧供(DO2)和氧耗(VO2).结果 各组患者一般情况比较差异无显著性(P＞0.05).与对照组比较,L、H纽内HR变化呈现降低趋势,T3、T4、T5时点较T1均出现HR显著降低(P＜0.05),L、H两组间比较差异无显著性；L组患者MAP组内变化差异无显著性,与L组相比,H组T3、T4、T5时点MAP显著降低(P＜0.05),T5时点较其他时点以及其他组显著降低(P＜0.05).L组内DO2比较差异均无显著性,两组VO2在T3、T4、T5时点均较T1显著降低,与L组相比较,H组T5时点DO2显著降低(P＜0.05).结论 小剂量右美托咪啶输注可显著降低老年胸腔镜下食管癌手术患者心肌氧耗量,对血液动力学影响小,改善心肌氧供.大剂量右美托咪啶显著降低心肌氧耗量,降低平均动脉压,对血液动力学有一定影响,可能降低心肌氧供.     

右美托咪定对老年高血压患者腹腔镜结肠癌根治术中血流动力学的影响

目的比较不同剂量右美托咪定对老年高血压患者腹腔镜结肠癌根治手术中血流动力学的影响。方法选择行腹腔镜结肠癌根治术的老年高血压患者87例。按随机数字表法将分为右美托咪定1组(D1组)、右美托咪定2组(D2组)及生理盐水组(S组)每组29例。D1和D2组静脉泵注右美托咪定0.2、0.4μg/(kg·h),S组则静脉泵注生理盐水10 ml/h。所有患者均自麻醉诱导前10 min开始持续泵注直至手术完成前30 min停止。比较三组麻醉时间、拔管时间和麻醉恢复室(PACU)停留时间;入手术室时(T_0)、插管前1 min(T_1)、插管即刻(T_2)、插管后1 min(T_3)、手术结束时(T_4)、拔管后1 min(T_5)、离开PACU(T_6)时平均动脉压(MAP)、心率(HR);手术过程中高血压的发生次数;PACU中Ramsay镇静评分、疼痛评分、不良反应发生情况。结果 D1和D2组T2~6MAP、HR以及疼痛评分,发生血压升高及寒战的次数均低于S组(P0.05)。D2组拔管时间、PACU停留时间大于S组和D1组。三组Ramsay镇静评分D2组D1组S组,c差异均有统计学意义(P0.05)。结论右美托咪定0.2及0.4μg/(kg·h)泵注有利于老年高血压患者在腹腔镜结肠癌根治术中血流动力学稳定,镇静效果良好,且麻醉安全性较高。0.2μg/(kg·h)右美托咪定不延迟患者拔管及苏醒时间,更适用于老年高血压患者。     

不同剂量右旋美托咪定对术后谵妄和镇痛的影响

目的:探讨不同剂量右旋美托咪定(dexmedetomidine,DEX)对全身麻醉患者术后谵妄和镇痛的影响.方法:选取复旦大学附属肿瘤医院2012年7月至2013年1月全麻下行结直肠癌根治术的患者90例,随机分为3组:高剂量DEX组(D1组),患者在全身麻醉诱导前10 min内以1.0 μg/kg剂量静脉输注DEX并以0.4μg/(kg·h)持续输注至术毕;低剂量DEX组(D2组)术前10 min内以0.5 μg/kg剂量静脉输注DEX并以0.2 μg/(kg·h)持续输注至术毕;对照组(C组)以0.9％氯化钠溶液代替DEX.观察记录3组患者的心率、血压、脉搏氧饱和度、术后谵妄分级量表评分、术后疼痛视觉模拟评分、术后24 h镇痛泵有效按压次数、术后镇痛药用量.结果:D1组和D2组患者术后谵妄分级量表评分均较C组患者明显降低[(9.01±3.26)、(13.96±4.03)比(16.37±4.61),均P＜0.05],且D1组患者比D2组患者降低更为显著(P＜0.05).D1组患者与D2组患者相比,术后疼痛视觉模拟评分[(2.5±0.5)比(3.4±0.6),P＜0.05]、术后24 h镇痛泵有效按压次数[(24±3)比(36±4),P＜0.05]和术后镇痛药用量[(54.5±16.5)比(65.0±20.0),P＜0.05]均明显降低;而D2组患者与C组患者相比,术后疼痛视觉模拟评分、术后24 h镇痛泵有效按压次数和术后镇痛药用量差异均无统计学意义.结论:与对照组相比,不同剂量DEX均可显著减少全身麻醉患者谵妄的发生率,高剂量DEX组与低剂量DEX组相比,术后谵妄分级量表评分降低更为显著,高剂量DEX可明显改善患者术后镇痛效果.     

不同剂量右美托咪定对机械通气患者镇静效果和血流动力学的影响

目的:观察不同剂量右美托咪定对机械通气患者镇静效果和血流动力学的影响.方法:入监护室行机械通气的咽成形术后患者45例,随机分为A、B、C组,每组15例,按分组静脉微泵给予右美托咪定.A组:负荷剂量0.5μg/kg,维持剂量0.2μg(kg·h);B组:负荷剂量0.75μg/kg,维持剂量0.3μg/(kg·h);C组:负荷刺量1.0μg/kg,维持剂量0.4μg/(kg·h).如患者躁动,静脉单次给予吗啡5 mg.机械通气24 h后,停止右美托咪定榆注,待患者完全清醒,肌力恢复,满足拔管条件后拔除气管导管.观察并记录给药前即刻(T0)、给药结束后即刻(T1)、给药后30 min(T2)、给药后1 h(T3)、给药后6 h(T4)、给药后12 h(T5)、给药后24 h(T6)的无创动脉血压和心率,观察并记录上述各时点的镇静评分(Ramsay分级法),记录各组吗啡的总用量,观察并记录各组停止右美托咪定榆注后至拔管所需时间.结果:血流动力学:A、B、c组部分时点动脉血压、心率较T0有所改变,差异有统计学意义;C组与A、B组间部分时点动脉血压、呼吸频率差异有统计学意义(P＜0.05).镇静评分:A、B、C各组各时点镇静评分与T0时比较差异无统计学意义;A、B、C各组相同时点镇静评分差异无统计学意义(P＞0.05).吗啡总用量:A、B、C各组吗啡总用量差异无统计学意义(p＞0.05).拔管所需时间:B组与A组之间,C组与B、A组之间拔管所需时间差异有统计学意义(P＜0.05).结论:随着右美托咪定给药剂量的增加,血流动力学变化加剧,拔除气管导管时间延长,但没有加深镇静程度.     

右美托咪定对术后导尿管相关膀胱刺激征的影响

目的 观察不同剂量右美托咪定对术后导尿管相关膀胱刺激征(CRBD)的影响，探讨右美托咪定与术后膀胱刺激征症状的量效关系，为临床选择适宜剂量提供依据。方法 选取择期全麻手术计划导尿的男性患者303例，分为生理盐水对照组(A组)、右美托咪定0.2μg/(kg·h)组(B组)、0.4μg/(kg·h)组(C组)和0.6μg/(kg·h)组(D组)。B、C、D组均在诱导前输注负荷剂量右美托咪定1μg/kg(10 min内泵注完成)，后分别以0.2μg/(kg·h)、0.4μg/(kg·h)、0.6μg/(kg·h)的剂量泵注，A组给予等量生理盐水，手术结束前30 min停止。于恢复室(T₀)、术后1 h(T₁)、6 h(T₂)、24 h(T₃)评估患者CRBD的发生率及严重程度。记录术中药物使用情况及术后不良反应。结果 CRBD比较，在T₀、T₂时A组与B、C、D三组相比差异有统计学意义(P <0.05)；在T₁时A组与B、C、D三组以...     

右美托咪啶和咪达唑仑对机械通气患者呼吸和循环影响的比较

目的 比较右美托咪啶(DEX)和咪达唑仑对机械通气患者呼吸和循环的影响.方法 将内科重症监护病房机械通气镇静的62例患者随机(随机数字法)分为两组,咪达唑仑组38例和DEX组24例.咪达唑仑组静脉注射咪达唑仑0.05 mg/kg负荷量,注药时间为30～60 s,再以0.05～0.15 mg/(kg·h)持续静脉泵入;DEX组在超过10 min内,给予负荷量1.0μg/kg,之后注射泵0.2～0.7.μg/(kg·h)持续静脉泵入.以Ramsay分级,维持理想的镇静深度Ⅲ～Ⅳ级,比较观察两组患者镇静前、镇静后10 min、30 min、2h的心率以及平均动脉压、呼吸频率、脉搏血氧饱和度.结果 2种药物镇静后呼吸频率、心率较镇静前下降,差异具有统计学意义(P＜0.05),而血氧饱和度较镇静前升高,差异具有统计学意义(P＜0.05);DEX组镇静前后血压差异无统计学意义,而咪达唑仑组镇静前血压为(83.11±12.95) mm Hg(1mm Hg=0.133 kPa),镇静后10min为(74.13±12.50) mm Hg,差异具有统计学意义(P＜0.05).而镇静后30 min、2h血压分别为(80.53 +12.93) mm Hg、(82.47±12.15) mm Hg,差异无统计学意义.结论 DEX和咪达唑仑对机械通气患者呼吸影响相当,DEX对循环的影响较咪达唑仑小.     

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.     

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.     

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.     

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.