胆囊结石患者全麻术中胆囊压力升高的影响因素分析

[摘要] 目的 探讨胆囊结石患者全麻术中胆囊压力升高的影响因素。方法 选择2014年1月至2015年12月大连大学附属中山医院收治的胆囊结石患者168例,分组观察单因素（结石部位、结石数量、最大结石直径、胆囊壁厚度、胆囊收缩功能、胆囊分隔）对全麻术中胆囊压力的影响。结果 168例患者中,胆囊腔内结石146例,胆囊管结石22例,两者压力差异有统计学意义（ t =8.033, P ＜0.001）。146例胆囊腔内结石中,胆囊壁厚3 mm共94例,4 mm共40例,5 mm及以上共12例,3 mm与5 mm以上压力相比,差异有统计学意义（ t =2.056, P =0.042）。134例胆囊壁厚小于5 mm中,单枚结石33例,2～10枚83例,≥11枚18例,平均压力组间差异无统计学意义（ P ＞0.05）;最大结石直径≤10 mm共79例,10～20 mm共40例,≥20 mm共15例,组间差异无统计学意义（ P ＞0.05）;胆囊排空指数≤30%共19例,30%～50%共24例,≥ 50%共55例,平均压力组间差异无统计学意义（ P ＞0.05）;有胆囊分隔27例,无胆囊分隔107例,两者压力差异无统计学意义（ P ＞0.05）。结论 胆囊管结石及胆囊壁增厚是引起全麻术中胆囊压力升高的主要因素。     

全麻术中急性肺不张一例

患者女,72岁,60kg,ASAⅢ级,术前诊断为结石性胆囊炎,拟在全麻下行电视腹腔镜胆囊切除术。术前检查：X线示右肺纹理增粗模糊,既往高血压病史数年,术前访视自诉偶有干咳,听诊心肺正常。未用术前药。入室后开放静脉输液,测血压200／90mmHg,心率120次／分,SpO2 95％,呼吸18次／分,经静脉诱导给予咪唑安定3mg、芬太尼0．2mg、维库溴铵6mg、依托咪酯20mg,     

术中经胆囊管胆道镜胆管探查、取石38例临床分析

目的探讨术中经胆囊管胆道镜胆管探查、取石的临床价值。方法 2014-01—2018-04间,睢县人民医院共成功实施38例经胆囊管胆道镜胆管探查、取石手术,其中开腹手术26例、腹腔镜手术12例。回顾性分析患者的临床资料。结果 38例患者均成功实施手术。开腹手术时间(98.50±12.78)min,术后住院时间(7.22±1.46)d。腹腔镜手术时间(118.46±10.66)min,术后住院时间(5.48±0.24)d。均未放置T管,术中胆道镜探查及出院时彩超扫查,均未见结石遗留。腹腔镜手术后发生1例胆漏,经充分引流,4天后痊愈。术后均随访8～12个月,未发现胆道遗留结石。结论在严格掌握适应证的前提下,经胆囊管胆道镜胆管探查、取石是安全、可行的。     

腹腔镜胆囊切除术中胆囊管结石的处理

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中胆囊管残株结石的预防方法。方法 2006年8月~2009年8月LC术中对25例胆囊管结石采用全面显露胆囊管并对其进行刮推、钳夹、切开、冲洗、造影等方法取石。结果 1例术后发现胆囊管残端有黄染,放腹腔引流2d后拔管;1例造影时发现在汇合部有一结石残渣用水冲出。无结石挤入胆总管病例。25例胆囊管结石全部取净。25例随访6~36个月,平均27.4月,未发现胆囊管株残结石的发生。结论对胆囊管认真解剖和探查,恰当的操作可有效预防胆囊管残株结石的发生。     

中药和腹腔镜胆囊切除治疗胆囊胆总管结石的临床观察

腹腔镜胆囊切除术已成为治疗胆囊结石和其它胆囊良性疾病的常用治疗方法 ,但对伴有胆总管结石 ,尤其是胆总管不扩张或扩张不明显的病人 ,应用腹腔镜技术很难完成。我院从 1998年 9月～ 2 0 0 0年 5月 ,选择了 37例胆囊结石伴胆总管结石病人 ,先应用利胆排石中药将胆总管结石排净后再实施腹腔镜手术 ,获得满意疗效 ,现报告如下。1　资料与方法1 1　对象　本组胆囊结石伴胆总管结石病人 37例 ,男 9例 ,女 2 8例 ;年龄 31～ 6 6岁 ,平均 4 4 6岁。均有胆道炎症反复发作史 ,无明显黄疸。多发胆囊结石并伴慢性炎症改变。胆总管无明显扩张 ,直径…     

经胆囊管行胆总管探查取石的临床应用

具有胆总管探查指征的病人，行胆总管切开探查／取石T管引流是肝胆外科传统术式。该术式操作相对复杂，还有住院时间长，医疗费用高，手术并发症多等缺点。笔者近十年来有选择地对72例具胆总管探查指征的病人，胆囊切除后经胆囊管人路行纤维胆道镜胆总管探查，并一期缝扎胆囊管，保持胆总管完整性，取得了良好的效果，现报告如下。     

术中经胆囊管胆道镜检查胆总管的临床探讨

目的 探讨术中经胆囊管入路胆道镜检查胆总管并治疗胆总管结石的可行性和安全性. 方法 对1998年10月至2005年5月间20例具有胆道探查指征的患者,施行经胆囊管置入胆道镜进行检查、取石,治疗后结扎胆囊管残端,胆总管内不置引流. 结果 成功19例,失败1例.其中发现结石15例,结石取净率100%(15/15),阴性检查4例.术中无胆道损伤,术后无胆漏等并发症,随访未发现残余结石. 结论 术中经胆囊管入路胆道镜检查与传统的经胆总管前壁切开入路相比,具有创伤小、安全、不损伤胆总管、免除患者术后带T管等优点.适用于胆囊结石合并胆总管小结石或胆道扩张可疑结石的患者,是比较理想的方法之一.     

胆囊结石时胆囊颈和胆囊管的组织学和组织化学改变

目的 了解胆囊结石病人胆囊颈和胆囊管的组织结构，粘液性质和分泌状态。方法 胆囊颈和胆囊管标本取材于２０例胆囊结石病人和１０例正常人的胆囊。取材后用１０％中性福尔马林固定，常规石蜡包埋。第个蜡块连续芬片５张，分别作ＨＥ，ＰＡＳ／ＡＢ２．５，醛品红／ＡＢ２．５，Ｍａｓｓｏｎ及Ｗｅｉｇｅｒｔ染色。光镜观察。结果 正常人的胆囊颈和胆囊管壁内也存在的腺体和平滑肌。胆囊结石时胆囊劲和胆囊管壁增厚，管腔变窄，占     

腹腔镜胆囊切除术中胆囊管结石的临床处理

胆囊颈管结石嵌顿可使腹腔镜胆囊切除术（Laparoscopic cholecystectomy,LC）变得复杂,由于黏连水肿,Calot三角解剖结构不清,容易造成胆管损伤等严重并发症。部分患者LC术后原发部位仍疼痛,常认为是胆囊切除术后综合征,而忽视了胆囊管结石残留的可能。我院2007年10月—2010年10月应用LC共治疗35例胆囊管结石,报道如下。     

Preoperative blood pressure and catecholamines related to hypothermia during general anesthesia

BACKGROUND: We previously demonstrated that preoperative blood pressure values affect intraoperative hypothermia during general anesthesia. We hypothesized that increased catecholamine secretion could be responsible for the relationship between preoperative blood pressure and hypothermia. METHODS: To evaluate the effect of preoperative systolic blood pressure (SBP) and plasma catecholamine levels on core temperature during general anesthesia, 40 male patients who were scheduled for open abdominal surgery were allocated to two groups: those whose preoperative SBP was 140 mmHg or greater (high SBP group, n = 20), and those whose SBP was less than 140 mmHg (normal SBP group, n = 20). Anesthesia was maintained with 0.4% isoflurane and opioids. RESULTS: The average age, height, and weight of the patients in the two groups did not differ. Preoperative SBP, mean blood pressure, diastolic blood pressure and heart rate in the high SBP group were significantly higher than those in the normal SBP group. Plasma norepinephrine concentrations in the high SBP group were significantly greater than those in the normal SBP group before and 1 h after the induction of anesthesia. Tympanic membrane temperatures in the normal SBP group started to decline further just after the induction of anesthesia, more so than that in the high SBP group. The vasoconstriction threshold in the normal SBP group was significantly lower than that in the high SBP group. CONCLUSION: These results suggest that the higher levels of preoperative catecholamine secretion contributed to the lesser degree of intraoperative hypothermia observed in the high SBP group.     

胆囊结石治疗策略的争论与选择:胆囊切除还是保胆取石

胆囊结石是外科常见病。腹腔镜胆囊切除术已成为胆囊结石治疗的金标准,但其无法保留胆囊功能。保胆取石从保留胆囊功能的角度治疗胆囊结石,在理论上具有合理性,但需大量更高级别的临床证据来验证其可行性。目前应开展关于胆囊切除手术远期并发症的流行病学调查和保胆取石的前瞻性研究,用循证医学的证据验证各自的优缺点与适应证。应严格把握胆囊切除的指征,对于功能良好的胆囊应积极开展保胆取石的临床研究,反对遇到胆囊结石就切除胆囊,也反对不顾指征地盲目保胆取石。     

CSF pressure measurement during anesthesia: an unreliable technique

BACKGROUND: The measurement of cerebrospinal fluid (CSF) pressure is necessary for many clinical indications. Its accuracy may be compromised in frightened or uncooperative children who find it difficult to relax sufficiently. The aim of the present study was to evaluate possible effects of general anesthesia on CSF pressure values. METHODS: Lumbar puncture was performed under general anesthesia in 15 patients aged 4.5-20 years for the evaluation of headaches associated with a swollen optic nerve. Cerebrospinal fluid pressure was measured with a manometer when the patient was fully anesthetized (opening pressure) and then continuously recorded until the patient regained consciousness. The opening pressure was compared with the lowest pressure measured at the termination of the procedure (end-measurement pressure). RESULTS: Seventeen pressure measurements were performed in 15 patients. In all but two measurements, differences were noted between the opening and end pressure, ranging from 5 to 13 cmH(2)O. The opening pressure was abnormally high in 16 measurements, and the end pressure was abnormally high in seven. The difference between the two measurements was highly significant (P < 0.001). CONCLUSIONS: Lumbar puncture performed under general anesthesia may yield two pressure measurements. Many factors, such as hypercarbia and the anesthetic agent used, may influence the results. Owing to the dynamic changes in CSF pressure, measurements made under anesthesia may be unreliable.     

Pre-operative measurement of heart rate variability predicts hypotension during general anesthesia

BACKGROUND: Peri-operative hymodynamic instability is one of the major concerns for anesthesiologists when performing general anesthesia for individuals with autonomic dysfunction. The purpose of this study was to examine the potential usage of pre-operative measurement of heart rate variability (HRV) in identifying which individuals, with or without diabetes, may be at risk of blood pressure (BP) instability during general anesthesia. METHODS: We studied 46 patients with diabetes and 87 patients without diabetes ASA class II or III undergoing elective surgery. Participants' cardiovascular autonomic function and HRV were assessed pre-operatively, and hymodynamic parameters were monitored continuously intra-operatively by an independent observer. RESULTS: Only 6% of the participants were classified as having cardiovascular autonomic neuropathy (CAN) based on traditional autonomic function tests whereas 15% experienced hypotension. Total power (TP, P = 0.006), low frequency (LF, P = 0.012) and high frequency (HF, P = 0.028) were significantly lower in individuals who experienced hypotension compared with those who did not. Multivariate logistic regression analysis revealed that TP [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.05-0.47, P = 0.001] independently predicted the incidence of hypotension, indicating that each log ms2 increase in total HRV lowers the incidence of hypotension during general anesthesia by 0.15 times. After stepwise multiple linear regression analysis (R2= 11.5%), HF (beta = -11.1, SE = 2.79, P < 0.001) was the only independent determinant of the magnitude of systolic blood pressure (SBP) reduction at the 15th min after tracheal intubation. CONCLUSIONS: Spectral analysis of HRV is a sensitive method for detecting individuals who may be at risk of BP instability during general anesthesia but may not have apparent CAN according to traditional tests of autonomic function.     

腰-硬联合阻滞复合浅全麻在妇科腹腔镜手术的临床应用研究

目的:探讨腰-硬联合阻滞(combined spinal epidural anesthesia,CSEA)技术辅以静脉浅全麻在妇科腹腔镜手术中的临床麻醉效果及安全性。方法:在腰-硬联合阻滞后分别予以力月西、杜氟合剂、异丙酚辅助麻醉施行腹腔镜妇科手术;回顾分析269例妇科腹腔镜手术的临床麻醉数据,进行统计分析,分析其麻醉效果、副作用。结果:术中麻醉效果良好,镇静充分,DBP、SBP、HR指标在CSEA后10min内有变化但平稳(P>0.05),均在正常范围;CO2气腹后10min与气腹前比较,HR增快,有统计学意义(P<0.05),RR加快、PETCO2升高,有统计学意义(P<0.01),两者变化最为显著,但仍可维持在正常范围,而SpO2变化幅度不显著(P>0.05),在气腹30min后,各项指标均有所改善,排气后10min各项指标与气腹前比较无统计学意义(P>0.05),269例患者均顺利完成妇科腹腔镜手术,无一例发生麻醉并发症及意外。结论:在妇科腹腔镜手术中,应用腰-硬联合阻滞辅以静脉浅全麻,在强化麻醉管理、充分吸氧的前提下能很好的控制血流动力学和呼吸功能的变化而维持正常的生命体征,麻醉效果良好,可在选择适应证的前提下推广应用。     

呼气末二氧化碳分压监测在全麻拔管后苏醒期患者中的应用

目的 探讨呼气末二氧化碳分压监测在全身麻醉拔管后苏醒期患者中的应用效果。方法 选取全身麻醉手术结束拔除气管导管转入麻醉后苏醒室观察的320例患者为研究对象,采用随机数字表法分为对照组和观察组各160例。对照组常规单孔鼻导管吸氧3 L/min并持续监测心电图、呼吸、无创血压、血氧饱和度;观察组在对照组基础上持续监测呼气末二氧化碳分压数值和波形的变化并及时给予护理干预。比较两组低氧血症发生情况、高碳酸血症和呼吸暂停检出率、面罩加压给氧率和苏醒时间。结果 观察组低氧血症程度、面罩加压给氧率显著低于对照组,高碳酸血症、呼吸暂停检出率显著高于对照组,苏醒时间显著短于对照组(P<0.05,P<0.01)。结论 对麻醉后苏醒期拔除气管插管的患者,呼气末二氧化碳分压监测可及时发现呼吸暂停、高碳酸血症等呼吸异常事件,降低低氧血症的发生率,提高麻醉苏醒的安全性,缩短苏醒时间。     

全身麻醉中连续无创动脉血压监测与有创动脉血压监测的比较

目的 评价麻醉期间TL-300系统测得的连续无创血压(continuous non-invasive arterial pressure,CNAP)和有创血压(invasive arterial pressure,IAP)监测的一致性和安全性.方法 择期全身麻醉手术患者72例,麻醉诱导前将动脉导管置入非优势手的桡动脉内行IAP监测,另一侧手臂连接TL-300系统行CNAP监测,记录IAP及相应时间点CNAP,以及相关的并发症.结果 CNAP与IAP所测SBP、DBP和MAP偏倚分别为(-0.6±7.0)、(-7.8±9.8)和(-5.8±6.2)mmHg(1 mmHg=0.133kPa),一致性界限分别为-14.6～13.4 mmHg、-27.4～11.8 mmHg、-18.2～6.6 mmHg,在其相应的一致性界限范围内所占比值分别为95.2％、96.1％和94.9％.两种BP监测方法的SBP、DBP和MAP的相关系数r分别为0.927、0.711和0.903 (P＜0.01).均未发生肢体缺血、坏死、感觉异常.结论 TL-300CNAP和IAP比较,有较高的相关性和一致性,提供无创实时连续、准确的BP监测,可安全用于全身麻醉手术患者.     

Regional versus general anesthesia in high-risk surgical patients: The need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

全麻苏醒期代谢改变

目的　探讨麻醉苏醒期的代谢改变。方法　 2 0例颅脑和胸腹部手术的全麻病人在分别于诱导前、插管后 1 5分钟、切皮时、拔管前即刻和拔管后 1 5分钟测定呼吸频率 (RR)、潮气量(VT)、吸入气氧分数 (FIO2 )、呼出气氧分数 (FEO2 )、吸入气CO2 分数 (FICO2 )和呼出气CO2 分数(FECO2 ) ,同时测定血压、心率和SpO2 。结果　大部分病人在苏醒过程中有躁动、挣扎、不耐受导管和痛苦等表现。在拔管前即刻心率、收缩压乘积显著增加 (1 968 44± 31 0 33) ,拔管后 1 5分仍高于基础水平。拔管前即刻RR和MV明显增加。拔管前即刻 VO2 和 VCO2 均显著增加 ,同时产热量也增加。拔管后 1 5分钟这三种参数仍未恢复至基础值。结论　苏醒期存在明显应激反应和代谢改变 ,因素是多方面的 ,应采取综合性措施加以防治