地尔硫卓预防冠心病病人气管插管心血管不良反应的临床研究

目的探讨地尔硫卓对冠心病病人气管插管心血管不良反应的预防作用。方法选择冠心病冠状动脉搭桥手术病人52例。随机分为两组：地尔硫卓组（n=24）麻醉诱导前2min静脉注射地尔硫卓0．2mg／kg;对照组（n=28）麻醉诱导前静脉注射等容量的生理盐水。记录给药前lmin、给药后2min、气管插管前、气管插管即刻、气管插管后lmin,3min和5min收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）、心率（HR）,并计算心率收缩压乘积RPP（HR×SBP）。插管前10min至插管后15min记录动态心电图变化。结果对照组在气管插管即刻和插管后各时点心率、平均动脉压、心率收缩压乘积明显高于插管前;而地尔硫卓组除了在插管后lmin心率明显增快外,在插管即刻和插管后各时点上述血流动力学参数无明显增高．且分别低于对照组。对照组插管后动态心电图ST段和／或T波改变的发生率为56％,地尔硫卓组为26％,两组间变化具有统计学差异（P〈0．05）。对照组有两例发生ST段改变,地尔硫卓组无ST段改变。结论气管插管可引起心血管不良反应,冠心病病人还可诱发一过性心肌缺血。诱导前静注地尔硫卓0．2mg／kg具有预防作用。     

氯胺酮辅助硬膜外麻醉在妇科腹腔镜手术中的应用

目的观察氯胺酮辅助硬膜外麻醉在妇科腹腔镜手术中的应用效果。方法 ASAⅠ-Ⅱ级妇科患者60例，于腹腔镜下行妇科手术，采用连续硬膜外麻醉，术前5～10min静脉注射哌替啶1mg／kg、异丙嗪0．5mg／kg强化麻醉，并在气腹前静脉注射氯胺酮0．5mg／kg，连续监测收缩压（SBP）、舒张压（DBP）、心率（HR）、脉搏氧饱和度（SpO2），并记录气腹前、气腹后15min、放气后5min的各参数值。结果60例患者麻醉效果均满意，患者术毕10min均呼之能应，无气腹和麻醉后相关并发症，术中SBP、DBP、HR、SpO2无明显波动（均P〉0．05）。结论氯胺酮辅助硬膜外麻醉用于妇科腹腔镜手术，患者气腹反应小，血流动力学平稳，术毕清醒快，安全可靠。     

黄芪精对麻醉犬一般药理学研究

目的:观察黄芪精对麻醉犬心血管系统和呼吸系统的影响。方法:戊巴比妥钠麻醉犬,记录给药前及给药后30、45、60、90、120、150、180 min收缩压(SBP)、舒张压(DBP)、平均动脉压(MBP)、心率(HR)、心电图(PR间期、QRS时限、QT间期、T波)、呼吸频率、呼吸幅度的变化。结果:黄芪精低中高三个剂量组对麻醉犬SBP、DBP、MAP、HR、PR间期、QRS时限、QT间期、T波、呼吸频率、呼吸幅度等指标均未见明显影响,与空白组比较,P0.05。结论:黄芪精对麻醉犬心血管系统和呼吸系统未见显著影响。     

瑞芬太尼复合异丙酚静脉麻醉用于输尿管镜下气压弹道碎石术

目的探讨瑞芬太尼联合异丙酚静脉麻醉在输尿管镜下气压弹道碎石术的麻醉效果。方法选择ASAⅠ～Ⅱ级在输尿管镜下行气压弹道碎石术的患者60例，瑞芬太尼0．5μg／kg异丙酚2mg／kg诱导后，改为瑞芬太尼0．05μg／（kg·min）、异丙酚3mg／（kg·h）维持。手术全程监测血压（SBP／DBP）、心率（HR）、氧饱和度（SpO2）、呼吸抑制情况、停药至意识恢复时间。结果全手术过程中无记忆、无痛；在麻醉过程中SBP、DBP、HR、SpO2有不同程度下降（P〈0．01），但均在正常范围内，且术后恢复至术前水平（P〉0．05），有心率减慢及呼吸抑制发生。结论瑞芬太尼复合异丙酚用于输尿管镜下气压弹道碎石术具有麻醉效果好、术后苏醒快的优点，但术中要加强监测，及时处理。     

异丙酚配伍芬太尼用于小儿包皮环切手术的临床观察

目的 观察异丙酚配伍芬太尼应用在小儿包皮环切术的麻醉效果，以及在诱导时血压（BP）、心率（HR）、血氧饱和度（SpO2）的变化，验证其麻醉有效性及安令性。同期与传统阴茎根部注射局麻药效果比较，是否更具有优越性。方法 40例包皮过长或包茎儿童，随机分为芬太尼异丙酚组（Ⅰ组n=20）和阴茎根部阻滞组（Ⅱ组n=20），Ⅰ组静注芬太尼2μg／kg，异丙酚2～3mg／kg，待患儿意识消失后开始包皮环切手术，微泵持续注射异丙酚7～10mg／kg．h维持麻醉，根据患儿的麻醉深度作调整。Ⅱ组用1．2％利多卡因20ml在阴茎根部作神经阻滞。分别记录两组患儿麻醉前后的SBP、DBP、HR、SpO2的变化以及麻醉效果、并发症的发生率。结果Ⅰ组麻醉效果良好，两组Ⅰ级率相比较Ⅰ组明显高于Ⅱ组（P〈0．05），但诱导后SBP、DBP、HR、SpO2降低。而Ⅱ组5例有疼痛现象，需用镇痛药或改麻醉方法，术中SBP、DBP升高，HR增快。结论 芬太尼、异丙酚用于小儿包皮环切手术，麻醉起效快，镇痛效果好，苏醒迅速，优于阴茎根部神经阻滞。但诱导初期血压、血氧饱和度、心率都有不同程度的降低。     

瑞芬太尼与芬太尼对腹部手术患者麻醉气管插管血流动力学的影响

目的观察瑞芬太尼与芬太尼对腹部手术患者麻醉气管插管血流动力学的影响。方法择期行腹部手术病人42例，ASAⅠ～Ⅱ级、年龄18～72岁，随机分为瑞芬太尼组（R组，21例）、芬太尼组（F组，21例）；诱导方法：丙泊酚2mg／kg、罗库溴胺0．6mg／kg，其中R组用瑞芬太尼2μg／kg，F组采用芬太尼3μg／kg快速诱导；记录以下各时点的SBP、DBP、HR，麻醉诱导前1min（T0），诱导后1min插管前即刻（T1）及插管后1min（T2）、3min（T3），5min（T4）。结果R组SBP、DBP、HR在T1、T2、T3与基础值及与F组比较降低，差异分别为P〈0．01、P〈0．05，插管后5min回升至插管前水平。F组SBP、DBP在T1降低，T3恢复至插管前水平，HR差异无统计学意义。结论芬太尼、瑞芬太尼均能维持患者麻醉诱导插管时血流动力学稳定，瑞芬太尼抑制气管插管的应激反应优于芬太尼，但心率减慢、血压下降亦比芬太尼明显。     

艾司洛尔联合乌拉地尔预防光导纤维支气管镜引导经鼻气管插管应激反应的研究

目的研究艾司洛尔和乌拉地尔不同给药方式对光导纤维支气管镜（FOB）引导经鼻气管插管应激反应的预防作用。方法60例ASAⅠ-Ⅱ级经FOB引导经鼻气管插管麻醉手术的患者,随机分为四组,每组15例。A组为对照组;B组为艾司洛尔组（艾司洛尔1mg／kg）;C组为乌拉地尔组（乌拉地尔0．5mg／kg）;D组为艾司洛尔＋乌拉地尔组（艾司洛尔0．5mg／kg＋乌拉地尔0．25mg／kg）。用药组药物于诱导前5min静脉注射,对照组注射2ml生理盐水。麻醉诱导均用芬太尼、咪唑安定、丙泊酚和维库溴胺。插管完成后接麻醉机,吸入1％～2％的异氟醚及间断静注芬太尼和维库溴铵维持麻醉。分别记录给药前,给药后5min,插管后1min、3min、5min和10min的收缩压（SBP）、舒张压（DBP）和心率的值,并计算相应的收缩压和心率的乘积（RPP）值。结果血压：SBP、DBP与A组和给药前相比,给药后C、D组明显下降（P〈0．05）;插管后1min、3min,C、D组明显低于A组（P〈0．05）。心率：与A组和给药前相比,给药后B、D组明显降低（P〈0．05）;插管后1min、3min,B、D组明显低于A组（P〈0．05）。RPP值：与A组和给药前相比,B组（P〈0．05）、C组（P〉0．05）和D组（P〈0．05）均下降;插管后1min、3min、5min,D组明显低于A组（P〈0．05）;插管后1min、3min,B、C组均明显高于D组（P〈0．05）。结论联合应用艾司洛尔和乌拉地尔更能有效预防FOB引导经鼻气管插管应激反应的发生。     

不同剂量艾司洛尔预防双腔支气管内插管时心血管反应的临床研究

目的观察不同剂量的艾司洛尔对预防双腔支气管内插管时心血管反应的临床效果及合适剂量。方法选择ASAⅠ～Ⅱ级开胸手术患者60例,随机分为三组,每组20人。A组：注射生理盐水10ml（对照组）,B组：静脉注射艾司洛尔0．5mg／kg,C组：静脉注射艾司洛尔1mg／kg,记录麻醉诱导前（基础值）、诱导后2min、插管后即刻、插管后2min、5min、10min的收缩压（SBP）、舒张压（DBP）、心率（HR）,计算各对应时点HR和收缩压（SBP）的乘积（RPP）。结果与基础值相比,诱导后2min三组SBP、DBP、HR和RPP均较基础值显著降低（P〈0．05）,B组降低的程度比A组更甚,但不及c组低;气管插管后即刻,A组、B组的SBP、DBP、HR和RPP显著升高（P〈0．05）,但B组增高的程度明显低于A组（P〈0．05）,而C组保持稳定;插管后2min、5min、10min三组SBP、DBP、HR和RPP随时间逐渐趋于基础值,但B、C组仍低于A组（P〈0．05）。结论应用0．5mg／kg和1mg／kg两种剂量的艾司洛尔均能有效抑制双腔支气管内插管引起的心血管反应,但1mg／kg艾司洛尔为合适剂量,且血流动力学稳定。     

喷他佐辛在健忘镇痛慢诱导麻醉中对气管插管应激反应的影响

目的：探讨喷他佐辛对健忘镇痛慢诱导麻醉气管插管应激反应的影响。方法：选择ASAⅠ或Ⅱ级、择期全麻腹部手术患者40例,随机分为对照组芬太尼组（F,n＝20）、喷他佐辛组（P,n＝20）。两组患者均静注咪达唑仑0．03 mg／kg,随后分别静注芬太尼2μg／kg,喷他佐辛0．8 mg／kg。给药5 min后环甲膜穿刺注入1％丁卡因注射液2 mL行喉部表面麻醉,喉麻3 min时在直视下行气管内插管。记录患者T0、T1、T2、T3、T4、T5、T6各时刻的HR（心率）、SBP（收缩压）、DBP（舒张压）、SpO2（血氧饱和度）、BIS（脑电双频指数）;并记录各时刻的镇静程度。结果：两种药物都能有效的抑制穿刺及插管时血压、心率等应激反应,但喷他佐辛组在慢诱导麻醉插管过程中对心血管系统的影响明显优于芬太尼组。结论：0．8 mg／kg喷他佐辛用于健忘镇痛慢诱导麻醉中有效抑制气管插管应激反应且不良反应发生率低。     

两种麻醉方式在颈淋巴结结核手术中的麻醉效果对比研究

目的：探讨不同麻醉方法在颈淋巴结结核手术中的应用。方法选取成都市公共卫生临床医疗中心2012年3月至2013年9月收治的100例颈淋巴结结核患者,随机分为两组（A、B组）,A组分别静脉注射瑞芬太尼（0．5～1μg／kg）和异丙酚（0．3～0．4mg／kg）维持麻醉,B组分别静脉注射氯胺酮（1～2mg／kg）和异丙酚（0．3～0．4 mg／kg）维持麻醉,比较两组患者术中脉搏血氧饱和度（SpO2）、收缩压（SBP）、舒张压（DBP）、心率（HR）,术毕苏醒情况及不良反应等指标。结果 A组患者SBP、DBP、HR和SpO2在诱导后、切皮时、搔刮病灶期间、手术结束时与入室时比较,差异无统计学意义（P＞0．05）;B组患者SBP、DBP、HR和SpO2在诱导后、切皮时、搔刮病灶期间、手术结束时与入室时比较,差异有统计学意义（P＜0．05）;与B组相比,A组患者苏醒时间明显缩短,不良反应发生率降低70％以上,术毕5 min Aldert评分明显高于B组（P＜0．05）。结论瑞芬太尼复合异丙酚和氯胺酮复合异丙酚均可用于颈淋巴结结核的手术麻醉,而前者麻醉效果及安全性均优于后者。     

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.     

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.     

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.     

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.