异丙酚预防硬膜外阻滞阑尾手术牵拉反应效果观察

异丙酚为快速短效静脉麻醉药 ,连续硬膜外阻滞下静脉滴注对预防阑尾手术牵拉反应的应用效果 ,笔者作了初步观察 ,报告如下。１资料和方法选择７５例拟行阑尾切除术的患者 ,男性４５名 ,女性３０名 ,年龄２０～４８岁。术前肌注安定８～１０ｍｇ、阿托品０．４～０．５ｍｇ。选择Ｔ１１～１２椎间隙行硬膜外穿刺置管 ,２ %利多卡因局麻。随机分成三组 ,每组２５例 :Ⅰ组对照组 ,术中不加任何辅助药 ;Ⅱ组杜氟合剂组 ,于皮肤消毒时静注杜氟合剂(杜冷丁５０ｍｇ／ｍｌ、氟哌利多５ｍｇ／２ｍｌ)２．０～２．５ｍｌ;Ⅲ组异丙酚组 ,于切皮时先１…     

应用甲氧乙心安预防气管插管时的心血管副反应

气管插管时应用甲氧乙心安以探讨其对插管时的心血管副反应的预防。选择术前检查无心脏传导功能障碍及无低血容量的全麻手术病人２３例,分为治疗组和对照组。方法：术前均不用麻醉止痛药与镇静药,病人进入手术室后静滴术前药东莨菪碱０．３ｍｇ,对照组麻醉诱导静脉依次注射氟芬合剂（氟哌啶０．０８～０．１ｍｇ／ｋｇ,芬太尼３～４μｇ／ｋｇ）,咪唑安定０．２５～０．５ｍｇ／ｋｇ,琥珀酰胆碱１～２ｍｇ／ｋｇ。治疗组在使用氟芬合剂前先静脉缓注甲氧乙心安０．０４～０．０５ｍｇ／ｋｇ,其它用药同对照组,病人肌肉松弛后完成气管内插管。结果显示甲氧乙心安（治疗组）对气管插管刺激诱发心率增速的预防有明显作用。可有效预防由插管引发的短暂心动过速,降低心肌耗氧量。在麻醉期只要血容量充足则应用于麻醉诱导较为安全。但患器质性及传导功能障碍的心脏病人列为禁忌。     

曲马多用于小儿术后硬膜外腔镇痛的临床研究

目的：比较曲马多、哌替啶用于小儿硬膜外腔术后镇痛效果和副作用。方法：对８０例（ＡＳＡＩ－Ⅱ级）行硬膜外麻醉的患儿随机分成４组行术后硬膜外腔镇痛。Ａ组（ｎ＝２０）曲马多１．５ｍｇ／ｋｇ＋０．１２５％布比卡因的镇痛液５ｍｌ,Ｂ组（ｎ＝２０）曲马多１ｍｇ／ｋｇ＋０．１２５％布比卡因的镇痛液５ｍｌ;Ｃ组（ｎ＝２０）哌替啶０．７５％ｍｇ／ｋｇ＋０．１２５％布比卡因镇痛液５ｍｌ;Ｄ组（ｎ＝２０）单纯０．１２５     

相同MAC浓度的地氟醚和异氟醚对脑电图的影响

目的比较相同ＭＡＣ浓度的地氟醚和异氟醚对脑电图的影响。方法２０例２０～５０岁,ＡＳＡⅠ～Ⅱ级择期手术的病人,均不用术前药。麻醉诱导以静脉异丙酚２ｍｇ／ｋｇ,琥珀胆碱２ｍｇ／ｋｇ快速气管插管,单纯吸入地氟醚或异氟醚维持麻醉。控制呼吸,维持呼气末二氧化碳分压（ＰＥＴＣＯ２）在４７～６０ｋＰａ。以ＴＯＦ监测肌松,维持Ｔ４／Ｔ１＜２５％。以双导联方式监测脑电变化,观察呼气末麻醉药浓度在０５、０８、１０、１３和１５ＭＡＣ时的脑电边缘频率（ＳＥＦ）和双谱指数（ＢＩ）的改变。结果随ＭＡＣ的增加ＳＥＦ和ＢＩ逐渐减小,呈负性线性相关关系（ｒ分别为－０９５和－０９９,Ｐ＜００１）,两组间ＳＥＦ和ＢＩ无显著性差异（Ｐ＞００５）。结论地氟醚对脑电图的影响与异氟醚相似;ＥＥＧ对监测麻醉深度有一定指导意义。     

硬膜外麻醉下辅用咪哒唑仑和芬太尼对术中镇静及牵拉反应的影响

目的观察硬膜外麻醉下辅用咪哒唑仑和芬太尼对术中镇静及牵拉反应的效果。方法拟行择期上腹部手术120例．男76例，女44例，年龄19～68岁，体重48～70kg，ASA分级Ⅰ～Ⅱ级，随机分为A、B两组，每组60例，两组患者硬膜外阻滞平面及效果满意后，于手术切皮前5min缓慢静注辅助用药，A组咪哒唑仑0．06mg／kg、芬太尼1．0ug／kg；B组氟哌利多0．05mg／kg、芬太尼1．0ug/kg或哌替啶1mg／kg，监测并记录心率（HR）、平均动脉压（MAP）、脉搏血氧饱和度（SpO，），观察内脏牵拉反应以及改良警觉／镇静评分（OAA／S）。结果A组患者用药前与用药后5、10、30、60min及探查或牵拉内脏器官时HR、MAP、SpO：无明显变化（P〉0．05）；而且无牵拉不适并能对正常呼名有正常应答。结论咪哒唑仑和芬太尼作为硬膜外麻醉的辅助用药，对保持术中良好镇静及对抗内脏牵拉反应有确切满意的效果。     

小剂量氯胺酮抑制胆囊手术中内脏牵拉反应的效果观察

目的 为寻找一种解决胆囊手术中内脏牵拉反应的补充方法。方法 术中出现内脏牵拉反应时，缓慢静注氯胺酮２０～２５ｍｇ（０．３～０．４ｍｇ／ｋｇ），必要时以相同剂量再注一次。术中持续鼻导管吸氧２Ｌ／ｍｉｎ，并监测ＢＰ、Ｐ、ＳｐＯ２。结果 ６０例内脏牵拉反应的患者，用氯胺酮均１分钟后入睡，牵拉反应消失，其中８例用药２次。术毕６０例全部清醒，未见精神症状。结论 小剂量氯胺酮可消除连续硬膜外强化麻醉胆囊牵拉反     

腹腔镜胆囊切除术的麻醉选择

目的比较硬膜外阻滞麻醉复合哌替啶一氟哌利多合剂强化麻醉和全身麻醉（全麻）下腹腔镜胆囊切除术气腹过程对腹腔镜胆囊切除术患者呼吸循环的影响。方法将70例腹腔镜胆囊切除手术患者随机分为A、B两组,每组35例,A组于硬膜外阻滞麻醉平面满意后,静脉注入哌一氟合剂（哌替啶1mg／kg,氟哌利多0．1mg／kg）;B组行气管内插管全身麻醉。观察两组病例麻醉效果及CO2气腹对呼吸循环的影响。结果气腹后20min与气腹前比较,两组的各项指标均有差异,尤以硬膜外阻滞麻醉组变化明显,表现为收缩压（SBP）、脉搏氧饱和度（SpO2）、动脉氧分压（PaO2）、动脉血氧饱和度（SaO2）下降,动脉二氧化碳分压（PaCO2）升高（P〈0．01）;心率（HR）增加（P〈0．05）。结论全身麻醉气管插管控制呼吸,是该术式较为安全的麻醉选择。     

异丙酚氯胺酮辅助硬膜外阻滞抗牵引反应的临床观察

作者在使用小剂量哌氟合剂基础上辅用小剂量氯胺酮或异丙酚治疗腹部手术时的牵拉反应均达到满意效果.结果报告如下.     

痛立消用于吸入麻醉苏醒期镇痛

择期中、大型腹部手术病人，男２２例，女１８例，年龄３６～５９岁，体重５７～８２ｋｇ，随机分为两组。麻醉：安定，芬太尼，琥珀胆碱诱导，吸入氧气、氧化亚氮和安氟醚维持麻醉。在手术行关腹时分别给病人肌注痛立消６０ｍｇ（Ⅰ组ｎ＝２０）或安慰剂（生理盐水）２ｍｌ（Ⅱ组ｎ＝２０）。结果：在麻醉后苏醒期，两组病人的意识和自主呼吸恢复时间近似，Ⅰ组病人：镇痛有效率１００％，镇痛持续时间１２．３±６．１８ｈ，无肌颤痛。Ⅱ组：病人躁动，伤口疼痛，肌颤痛８例。两组呼吸频率和呼气末二氧化碳均存在显著性差异（Ｐ＜０．０１，Ｐ＜０．０５）。Ⅰ组苏醒期的心率和收缩压与术前比较无显著性改变（Ｐ＞０．０５），而Ⅱ组则存在显著性改变（Ｐ＜０．０１）。     

布托啡诺减轻阑尾切除术中牵拉反应的临床观察

目的评价布托啡诺减轻硬膜外阻滞下阑尾切除术中牵拉反应的临床有效性和安全性。方法选择在硬膜外阻滞下行阑尾切除术患者共90例,年龄18～60岁,无明显心肺疾病,随机分成三组,即对照组（C）、布托啡诺组（B）、度氟合剂组（D）,每组30例。于切皮时B组静注布托啡诺0．02mg／kg,D组静注度氟合剂（度冷丁50mg＋氟哌利多5mg）1／2,C组不予任何药物。观察注药前、注药后10min、探查牵拉阑尾时和术毕MAP、HR、RR、SpO2;评估术中牵拉反应;RSS法评定术中镇静状态;记录各种不良反应。结果B组患者生命征的变化较C、D组更为平稳;术中牵拉反应C组较B、D组明显,镇静差,B、D组间比较无明显差异;D组呼吸抑制发生率最高,B、D组间头晕、恶心、呕吐、瘙痒等不良反应无明显差异。结论布托啡诺可以有效地减轻阑尾切除术中的牵拉反应,不良反应少。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.