静吸复合麻醉中瑞芬太尼靶控输注系统的性能评价

目的评价腹腔镜手术病人静吸复合麻醉中瑞芬太尼靶控输注系统(Minto药代动力学参数)的性能。方法15例择期行腹腔镜手术,采用血浆靶控输注瑞芬太尼、吸入异氟烷和间断静脉注射维库溴铵维持麻醉。瑞芬太尼血浆目标浓度逐渐升高,每次浓度改变间隔时间30 min,目标浓度分别为3、6、9 ng/ml。于麻醉诱导前(空白对照血浆)和瑞芬太尼目标浓度改变后30 min时从桡动脉置管处采集血样,应用高效液相色谱质谱联用技术测定全血中瑞芬太尼浓度。采用执行误差(performance error,PE)的中位数(median performance error,MDPE)、PE绝对值的中位数(median absolute performance error,MDAPE)和摆动度(wobble)评价瑞芬太尼靶控输注系统的性能。结果瑞芬太尼靶控输注系统的MDPE、MDAPE和wobble分别为8.78%,16.11%和14.55%。实测浓度与目标浓度呈正相关(r=0.891,P=0.000),线性方程为Y∧=1.1046X 0.1837。结论瑞芬太尼靶控输注系统(Minto药代动力学参数)在临床应用浓度范围内能满足临床麻醉的要求。     

丙泊酚复合瑞芬太尼靶控输注麻醉对腹腔镜子宫肌瘤剔除术患者术中血流动力学及术后苏醒质量的影响

目的探讨丙泊酚复合瑞芬太尼靶控输注麻醉对腹腔镜子宫肌瘤剔除患者术中血流动力学及术后苏醒质量的影响。方法选取2016-05-2019-04间接受腹腔镜子宫肌瘤剔除术的200例子宫肌瘤患者,按随机数字表法分为2组,各100例。对照组予以丙泊酚复合瑞芬太尼持续静脉输注麻醉,观察组予以丙泊酚复合瑞芬太尼靶控输注麻醉。比较2组拔管时间,苏醒时间,拔管后5、10、30 min镇静评分(OAAS评分),以及入手术室即刻(T0)、插管即刻(T1)、手术开始后5min(T2)、术毕即刻(T3)时间点的平均动脉压(MAP)和心率(HR)。结果拔管后5、10 min观察组OAAS评分高于对照组,T1、T2时MAP、HR较对照组低,观察组波动较小,差异有统计学意义(P<0.05)。结论对腹腔镜子宫肌瘤剔除术患者采取丙泊酚复合瑞芬太尼靶控输注麻醉,能有效稳定术中血流动力学,提高苏醒质量。     

老年患者瑞芬太尼分步靶控输注复合异丙酚麻醉效果

目的 观察瑞芬太尼分步靶控输注全麻对老年患者腹腔镜下胆囊切除术时应激反应抑制、循环和苏醒的影响.方法 60例ASA Ⅰ一Ⅲ患者随机分成4组,每组15例.麻醉诱导时A组、B组、C组和D组分别给予0.06 ms/kg芬太尼、血浆靶浓度4.0μ/L输入芬太尼、血浆靶浓度4.0μg/L输入瑞芬太尼及血浆靶浓度从2.0μg/L分阶段增至4.0μg/L输入瑞芬太尼,同时给予血浆靶浓度3.0μg/L异丙酚及维库溴胺完成麻醉诱导.除B组在胆囊取出后停止芬太尼输入外,各组所有药物均在术毕时停止输入.予10、T1、T2、T3和T4点记录血流动力学参数及测定血清皮质醇、醛固酮和血糖浓度.记录苏醒拔管时间、术毕至出恢复审时间、拔管时OAA/S评分和从术毕至OAA/S评分达5分时间.记录麻醉手术过程中血管活性药物应用情况.结果 4组患者在麻醉诱导时MAP及HR均有不同程度下降,C组最为明显,MAP及HR分别下降至(59±12)mm Hg和(54±6)次/min(P<0.05);4组患者苏醒拔管时MAP及HR均增加,A、B两组增加显著,分别增高至(113±13)mm Hg、(81μ8)次.min和(110μ12)mm Hg、(80μ7)次/min(P<0.05);A、B两组T4点皮质醇、醛固酮浓度比T0点明显增高(P<0.05);C组阿托品、麻黄碱、艾司洛尔和乌拉地尔使用总次数为20次,比其余3组明显增加(P<0.05).C、D两组拔管时间、出恢复室时间和OAA/S评分至5分时间比A、B两组明显缩短(P<0.05);C、D两组拔管时OAA/S评分明显高于A、B两组(P<0.05).结论 瑞芬太尼TCI可有效抑制老年患者气管插管和上腹部手术等刺激引起的应激反应,苏醒迅速且质量高,分步TCI时循环更加平稳.     

人工流产术患者瑞芬太尼靶控输注复合异丙酚的效应

异丙酚常用于人工流产术,但异丙酚镇痛效果差。瑞芬太尼具有起效快、作用时间短、镇痛效果确切等特点,适用于门诊短小手术。异丙酚与阿片类药物复合应用时麻醉效应有相加作用。本研究拟观察人工流产术患者瑞芬太尼效应室靶控输注(TCI)复合异丙酚的效应,为临床应用提供参考。     

腹腔镜手术瑞芬太尼与丙泊酚靶控输注全凭静脉麻醉的临床应用

目的：评价丙泊酚和瑞芬太尼靶控输注全凭静脉麻醉在腹腔镜手术临床应用的可行性。方法：分析82例患者的临床资料。观察麻醉诱导和气管插管时的血压、心率以及术毕停药后患者自主呼吸恢复时间、呼之睁眼时间、拔管时间、定向力恢复时间和离开手术室时间。结果：麻醉诱导时收缩压由诱导前的（142±25）mmHg降至（103±21）mmHg,平均动脉压由（99±18）mmHg降至（65±15）mmHg,心率由（78±16）次/min降至（65±14）次/min,插管前后血压和心率无显著变化,无一例有插管反应。术毕停药后患者自主呼吸恢复时间为（13±6）min,呼之睁眼时间（9±5）min,拔管时间（14±7）min,定向力恢复时间（15±6）min,离开手术室时间（21±9）min。结论：瑞芬太尼与丙泊酚靶控输注全凭静脉麻醉用于腹腔镜手术时,麻醉诱导平稳,术中血流动力学稳定,术后恢复迅速。     

喉罩麻醉中靶控输注异丙酚复合瑞芬太尼效果观察

目的观察靶控输注异丙酚复合瑞芬太尼实施喉罩麻醉的效果。方法随机将86例接受喉罩麻醉的患者分为2组,各43例。对照组给予异丙酚靶控输注。观察组应用异丙酚复合瑞芬太尼靶控输注。比较2组患者(1)麻醉前(T_0)、喉罩置入前(T_1)、喉罩置入后1 min(T_2)、停药时(T_3)的SBP、DBP、HR。(2)术中不良反应例数、患者苏醒时间及异丙酚用量。结果 T_0、T_3时2组SBP、DBP及HR差异无统计学意义(P0.05)。T_1、T_2时点观察组SBP、DBP及HR的波动幅度优于对照组,术中不良反应、苏醒时间及异丙酚的用量少于对照组,差异均有统计学意义(P0.05)。结论与单纯应用异丙酚比较,靶控输注异丙酚复合瑞芬太尼实施喉罩麻醉,对患者血液动力学影响较小,不良反应发生率低,苏醒快及异丙酚的用量少,效果满意。     

瑞芬太尼全凭静脉麻醉的临床应用

本文是我院瑞芬太尼-丙泊酚全凭静脉麻醉或复合硬膜外阻滞临床实践的总结。内容凸现了小剂量协同用药的特色。在这一原则的指导下，文章介绍了各类手术的最适切入剂量和瑞芬太尼-丙泊酚静脉麻醉诱导，维持过程中克服循环抑制的各项措施；文章同时介绍了临床常用的中效非去极化肌松剂如何与之匹配应用的问题；文章还报道了瑞芬太尼与丙泊酚混合应用的可行性研究以及适应各类手术的组方：为了方便基层应用，还介绍了剂量-容量转换的规律及静滴应用的配方。     

丙泊酚复合瑞芬太尼靶控静脉麻醉与静吸复合麻醉用于腹腔镜手术效果比较

目的比较丙泊酚复合瑞芬太尼靶控静脉麻醉与静吸复合麻醉用于腹腔镜手术的效果。方法选取100例行择期腹腔镜手术的患者,根据不同麻醉方法分为2组,各50例。观察组实施丙泊酚复合瑞芬太尼靶控静脉麻醉,对照组给予静吸复合麻醉。对2组的麻醉效果进行分析比较。结果在麻醉诱导期及术中,观察组患者的HR、SBP、DBP及MAP均显著优于对照组;术后观察组患者的呼吸恢复时间、睁眼时间、拔管时间均明显优于对照组。差异均有统计学意义(P0.05)。结论与静吸复合麻醉比较,丙泊酚复合瑞芬太尼靶控静脉麻醉用于腹腔镜手术,患者血液动力学指标更加稳定,易于控制麻醉深度,患者的苏醒质量高,麻醉效果满意。     

丙泊酚靶控输注复合瑞芬太尼麻醉在老年病人手术中的临床应用

目的 通过BIS监测丙泊酚靶控输注复合瑞芬太尼麻醉在老年病人手术中的临床应用探讨适合于老年病人的最佳丙泊酚一瑞芬太尼靶浓度.方法 选择ASA Ⅰ-Ⅲ级、年龄≥65岁老年病人60例,随机分为3组,每组20例:(1)组,丙泊酚血浆Ct(Ctpro)2 mg/L;(2)组,Ctpro 3 mg/L;(3)组,ctpro 4 mg/L.三组的瑞芬太尼血浆Ct(CtR)都是5 μg/L.用TCI泵进行丙泊酚分步诱导,当Ctpro达所设值时,开始瑞芬太尼靶控输注,静注琥珀胆碱插管,观察BIS变化.术中维持每组所设Ctpro和CtR.如果HR＜50 bpm,静注阿托品;SBP＜基础值的30%,静注麻黄碱;SBP＞基础值30%或者HR＞90 bpm,增加Ctpro.术中观察麻醉前、诱导、插管、插管后5 min及术中血液动力学变化;麻醉诱导及术中阿托品、麻黄素的使用情况;术毕清醒时间及拔管时间;术后并发症的发生率.结果 SBP:第(1)组病人插管时、插管后5 min及术中SBP明显升高,与麻醉前相比P＜0.01;第(2)组和第(3)组病人诱导、插管后5 min及术中SBP明显降低,与麻醉前相比P＜0.01,其中第(3)组更明显.HR:第(1)组病人诱导时HR明显降低,而插管时却明显升高,与麻醉前相比P＜0.01;第(2)组病人诱导和插管后5 min明显降低,与麻醉前相比P＜0.01;第(3)组病人诱导、插管及术中均明显降低,与麻醉前相比P＜0.01.BIS:三组病人的BIS值在诱导、插管、插管后及术中与麻醉前相比均明显降低,P＜0.01.麻醉诱导及术中第(3)组患者阿托品、麻黄素的使用率明显高于另外两组,P＜0.01.术毕三组患者清醒时间、拔管时间、并发症的发生率相比无统计学差异.结论 BIS监测下丙泊酚靶控输注复合瑞芬太尼麻醉应用于老年病人手术,术毕清醒快、拔管早,术后并发症少.其中麻醉诱导阶段Ctpro3.0 mg/L+CtR5.0 μg/L组血流动力学较为稳定,麻醉维持阶段ctpro2.0 mg/L～3.0 mg/L+CtR5.0 μg/L组血流动力学较为稳定.     

食管癌切除术病人不同靶浓度瑞芬太尼复合异丙酚靶控输注的麻醉效果

靶控输注(TCI)瑞芬太尼和异丙酚是近几年中应用较多的静脉麻醉方法,两药的便携式TCI系统在国内已经用于临床(TCI-Ⅰ型靶控输注泵),但有关瑞芬太尼TCI合适靶浓度国内外报道不一。本研究拟通过比较食管癌切除术病人三种血浆靶浓度瑞芬太尼复合异丙酚TCI麻醉下血浆儿茶酚胺浓度及血液动力学的变化,探讨合适的瑞芬太尼血浆靶浓度。     

两种麻醉方法对直肠癌患者术后免疫功能的影响

目的:观察两种麻醉方法下直肠癌患者术后免疫功能的变化.方法:选择40例直肠癌手术病人,随机分为两组,每组20例:A组采用静脉麻醉;B组采用硬膜外阻滞复合静脉全麻.分别于麻醉前(T0)、切皮后2h(T1),术后6h(T2)、术后48 h(T3)测定CD4+%、CD8+%、血清白介素-2(IL-2)和可溶性白介素-2受体(sIL-2R).结果两组CD4+%、CD4+/CD8+比值JL-2水平下降(P＜0.05),T1至T3时B组CD4+%明显高于A组(P＜0.05),T2至T3时B组CD4+/CD8+比值、IL-2水平明显高于A组(P＜0.05);两组sIL-2R水平A组T1时显著高于T0,T2达最高峰;而B组各时间点与T0比较差异无统计学意义(P＞0.05);两组间比较,T1至T3时A组sIL-2R水平明显高于B组(P＜0.05).结论:硬膜外阻滞配合全麻可减轻围手术期直肠癌患者的细胞免疫功能抑制.     

Effects of resuscitation fluids on T cell immune responses

This study was designed to determine whether dextran, gelatin or hydroxyethyl starch-based colloidal resuscitation fluids (CRF) are inhibitory to T lymphocyte activation and mitogenesis in vitro. Isolated peripheral blood lymphocytes from normal donors were activated with mitogen (PHA) and cultured in up to 50% v:v CRF. Dual-label flow cytometry for CD69 and CD25 were used to assess early and full T cell activation responses, respectively, and thymidine incorporation was used to assess mitogenesis. T cell activation and mitogenic responses were not inhibited in the presence of CRF, implying that any systemic immunodepression associated with CRF infusion is not directly related to CRF-mediated impairment of T cell activation.      

瑞芬太尼术后镇痛对肿瘤患者T淋巴细胞亚群的影响

目的观察瑞芬太尼和芬太尼术后镇痛对肿瘤患者T淋巴细胞亚群的影响。方法肿瘤手术患者40例,ASAⅠ或Ⅱ级,随机均分为瑞芬太尼组(R组)和芬太尼组(F组),两组患者均行静-吸复合麻醉。两组术毕分别采用瑞芬太尼或芬太尼行静脉自控镇痛(PCIA),于麻醉前、术后24、48、72 h抽血测定患者T淋巴细胞亚群(CD3+、CD4+、CD8+),并行VAS评分。结果两组患者术后VAS评分差异无统计学意义。术后24 h两组患者CD3+、CD4+、CD4+/CD8+均显著低于麻醉前(P<0.05)。术后48 h R组CD3+、CD4+、CD4+/CD8+已恢复到麻醉前水平,而F组仍明显低于麻醉前和R组(P<0.05)。术后72 h两组T淋巴细胞亚群均恢复至麻醉前水平。结论瑞芬太尼术后静脉自控镇痛能减轻肿瘤患者术后免疫抑制,对机体免疫功能有一定的保护作用。     

直肠癌肠造口患者自我隐瞒现状及影响因素分析

目的了解直肠癌肠造口患者的自我隐瞒现状并分析相关影响因素。方法应用一般资料调查问卷、自我隐瞒量表、医学应对方式问卷和社会影响量表对广州市4所医院门诊及病房的220例直肠癌肠造口患者进行问卷调查。结果直肠癌肠造口患者的自我隐瞒得分为(30.44±10.58)分,72例(32.72%)达高水平。单因素分析结果显示,家庭所在地、婚姻状况、职业情况以及个人月收入影响患者的自我隐瞒倾向,差异有统计学意义(P0.01)。多元线性回归分析结果显示,病耻感、应对方式中的屈服维度进入回归方程,可共同解释总变异的66.80%(P0.01)。结论直肠癌肠造口患者自我隐瞒处于中等水平,其中32.7%处于高水平,病耻感和应对方式是其影响因素。建议构建医护患交流平台,加强指导与鼓励,帮助患者正确面对,降低病耻感。     

轻度低温对直肠癌根治术患者细胞免疫功能的影响

目的 评价轻度低温对直肠癌根治术患者细胞免疫功能的影响.方法 择期拟行直肠癌根治术患者50例,ASA分级Ⅰ或Ⅱ级,年龄30～64岁,采用随机数字表法,将其随机分为轻度低温组和常温组,每组25例.分别于麻醉前1 h(T1)、手术结束时(T2)、术后24 h(T3)及术后第7天(T4)采用流式细胞仪测定血清Th1型、Th2型细胞因子水平,计算Th1/Th2比值.结果 与T1时比较,常温组T4时血清Th2型细胞因子平降低,Th1/Th2比值升高,轻度低温组T2.3时血清Th1型细胞因子水平及Th1/Th2比值降低,血清Th2型细胞因子水平升高(P＜0.05);与常温组比较,轻度低温组T2-4时血清Th1型细胞因子水平及Th1/Th2比值降低,血清Th2型细胞因子水平升高(P＜0.05).结论 轻度低温可降低机体抗肿瘤的细胞免疫功能.     

Adoptive immunotherapy of advanced cancer patients with immune RNA-sensitized lymphocytes

Tumor cell suspension was prepared from resected tumor tissue of various cancer patients. I-RNA was extracted from lymphoid tissues of rabbits immunized with each tumor cell and CFA. Autologous (in some cases, allogeneic) lymphocytes were prepared with blood cell separator and incubated with I-RNA, then, returned to himself. Twenty five cases of non-curatively resected gastric cancer (group A), 27 cases of stage II-IV of esophageal carcinoma (group B), 21 of lung cancer (group C), 14 of colorectal cancer (group D) and 37 cases with metastatic lesions (group E) were treated with this schedule. Five year cumulative survival rate was 21% in group A, 23% in group B, 46% in group C and 61% in group D, respectively. One case of CR and 5 of PR were recognized in group E. In many cases of the responder, lymphocyte count, ratio of Leu 4+, 3a+ subset in the peripheral bloods increased and skin reaction to autologous tumor cell extract, LAI and LMI became to positive. Interferon activity was also increased in the responder. It was reported on the preliminary study of combination treatment with I-RNA sensitized lymphocytes and IL-2.     

复合异丙酚时不同靶浓度瑞芬太尼对神经外科手术患者脑电双频谱指数的影响

目的 探讨复合异丙酚时不同效应室靶浓度瑞芬太尼对神经外科手术患者脑电双频谱指数(BIS)的影响.方法 择期拟行额颞部开颅手术患者15例,年龄18～64岁,体重50～85 kg,ASA Ⅰ或Ⅱ级.先靶控输注异丙酚,效应室靶浓度为3μg/ml,效应室浓度达预设浓度后靶控输注瑞芬太尼,效应室靶浓度分别为2、3、4、5、6、7、8 ng/ml,效应室浓度依次达预设浓度时记录血压(BP)、平均动脉压(MAP)、心率(HR)和BIS.瑞芬太尼效应室浓度达5 ng/ml时行气管插管和机械通气,于气管插管前即刻和气管插管后即刻记录BP、MAP、HR和BIS.结果 与基础值比较,异丙酚效应室浓度3μG/ml 和瑞芬太尼不同效应室浓度时BIS降低(P<0.05或0.01);与异丙酚效应室浓度3μg/ml时比较,瑞芬太尼效应室浓度≥6 nG/Ml时BIS降低(P<0.05或0.01).结论 复合异丙酚时靶控输注瑞芬太尼效应室浓度≥6 ng/ml时可降低神经外科手术患者的BIS.     

Effect of early restrictive fluid resuscitation on inflammatory and immune factors in patients with severe pelvic fracture

Purpose: To study the effect of early restrictive fluid resuscitation (EFR) on inflammatory and immune factors in patients with severe pelvic fracture (SPF). Methods: A total of 174 SPF patients in the Department of Orthopaedics, the First Affiliated Hospital of Chengdu Medical College from July 2015 to June 2018 were involved in this study and divided into EFR group (n = 87) and control group (n = 87) using the random number table method. Conventional fluid resuscitation (CFR) was performed in control group, and EFR was performed in EFR group. The incidences of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) during rescue, successful rescue rate, blood transfusion volume, fluid input, and resuscitation time were compared between the two groups. The parameters including prothrombin time (PT), hematocrit (HCT), platelet (PLT) and blood lactate (BL) at the 4th hour after fluid resuscitation were recorded. The levels of inflammatory factors (TNF-a, IL-6, CRP) and immune factors (CD3þ, CD4þ, CD8þ, CD4þ/CD8þ) were compared between the two groups before treatment and 7 days after treatment. The revised acute physiologic and chronic health evaluation system and the sequential organ failure assessment scores were adopted for evaluation before treatment and 7 days after treatment. Results: The incidences of ARDS and MODS during rescue in EFR group were significantly lower than those in control group (p = 0.015 and 0.010 respectively), and the successful rescue rate in EFR group was significantly higher than that in control group (p = 0.011). The blood transfusion volume, fluid input, resuscitation time in EFR group were significantly lower than those in control group (p = 0.016, 0.002 and 0.001 respectively). At the 4th hour after fluid resuscitation, PT and BL in EFR group were significantly lower than those in control group (p = 0.021 and 0.003 respectively), while HCT and PLT in EFR group were significantly higher than those in control group (p = 0.016 and 0.021 respectively). On day 7 after treatment, TNF-a, IL-6, CRP and CD8þ in EFR group were significantly lower than those in control group (p = 0.003, 0.004, 0.007 and 0.003 respectively), while CD3þ, CD4þ and CD4þ/CD8þ in EFR group were significantly higher than those in control group (p = 0.004, 0.000, 0.007 respectively). On day 7 after treatment, the revised acute physiologic and chronic health evaluation (APACHE) system and the sequential organ failure assessment (SOFA) scores in EFR group were significantly lower than those in control group. Conclusion: EFR can effectively eliminate inflammatory factors, improve immune function, maintain the stability of blood components, reduce the incidences of ARDS and MODS, and elevate the successful rescue rate in patients with SPF.     

手术者因素对直肠癌病人术后性功能的影响

目的探讨手术者因素对直肠癌病人术后性功能的影响。方法回顾性分析1997年10月至2004年7月共105例男性直肠癌手术的随访资料。将105例病人随机分为5组,由5位医生作为术者完成手术,对其术后性功能障碍的发生率进行比较。结果直肠癌术后性功能障碍总发生率为35.2%,各手术组性功能障碍的发生率分别为15.4%、35.7%、57.9%、52.6%和15.4%,差异有显著性意义(χ2=13.5,P=0.009)。结论手术者因素对直肠癌病人术后性功能有显著影响,提高直肠癌术中保留盆腔自主神经的认识有助于降低术后性功能障碍的发生率。