382例严重地震伤员救治的麻醉处理

目的 总结地震伤员手术治疗的急救及麻醉处理体会.方法 382例年龄2～91岁严重地震伤进行492台次手术;针对不同病情、年龄、手术方式等采用气管插管静-吸复合全麻、氯胺酮静脉复合麻醉、硬膜外阻滞、蛛网膜下腔阻滞及神经阻滞等麻醉方式,并分析了休克、挤压伤综合征、急性肾功能衰竭等地震危急伤情的术前准备、术中处理及临测.结果 术中血流动力学基本稳定,SpO2维持在92%～100%;治愈356例,好转23例,死亡3例.结论 术前积极的扩容抗休克、维护肾脏功能,加强术中监测、及时纠正水电解质和酸碱平衡紊乱,维持血流动力学稳定等是地震伤员安全渡过围术期的关键.     

Norepinephrine kinetics and dynamics in septic shock and trauma patients

Background. There is considerable variability in the inter-patientresponse to norepinephrine. Pharmacokinetic studies of dopamineinfusion in volunteers and in patients have also shown largevariability. The purpose of this study was to define the pharmacokineticsof norepinephrine in septic shock and trauma patients. Methods. After Ethical Committee approval and written informedfamily consent, 12 patients with septic shock and 11 traumapatients requiring norepinephrine infusion were studied. Norepinephrinedose was increased in three successive steps of 0.1 mg kg^–1min^–1 at 15-min intervals (20% maximum allowed increasein arterial pressure). Arterial blood was sampled before andat 0.5, 13, and 15 min after each infusion rate change and 30s, 1, 2, 5, 10, and 15 min after return to baseline dosing.Norepinephrine was assayed by HPLC. The pharmacokinetics weremodelled using NONMEM (one-compartment model). The effects ofgroup, body weight (BW), gender and SAPS II (Simplified AcutePhysiology Score II) [Le Gall JR, Lemeshow S, Saulnier F. Anew Simplified Acute Physiology Score (SAPS II) based on a European/NorthAmerican multicenter study. J Am Med Assoc 1993; 270: 2957–63]patients score on clearance (CL) and volume of distribution(V) were tested. Results. Group, gender, and BW did not influence CL or V. CLwas negatively related to SAPS II. CL and T_1/2 varied from 3litre min^–1 and 2 min, respectively, when SAPS II=20 to0.9 litre min^–1 and 6.8 min when SAPS II=60. Conclusion. In trauma patients and in septic shock patients,norepinephrine clearance is negatively related to SAPS II.     

食管癌手术的麻醉管理

食管切除术系目前风险最高的手术之一,良好的麻醉不但是术后患者迅速康复、减少并发症的保证．也是影响食管癌患者远期生存的潜在因素之一。但目前往往为食管外科医生所忽视。本文就术前禁食水及麻醉诱导,术中单肺通气与液体管理．术后早期拔管及镇痛等全过程与食管癌手术安全性的关系作一介绍,供大家参考。     

Anesthesia for trauma

Anesthesia of polytraumatized patients represents a considerable risk for them. The proper treatment of a polytraumatized patient comprises the rapid stabilisation of all his vital functions. At the same time, the attempt must be made to achieve a complete picture of all his injuries in order to be able to select a reliable and safe anesthetic procedure. Over and beyond this, a continuation of all intensive care measures, in particular the optimalization of blood volume, the maintenance of gas exchange, the support of the cardiac, and the balancing of the acid-base and electrolytes, is of the greatest importance for an effective treatment of the polytraumatized patient.     

Defining massive transfusion in civilian pediatric trauma

PurposeThe purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma.MethodsSeverely injured children (age ≤ 18 years, injury severity score ≥ 25) in the Trauma Quality Improvement Program research datasets 2014–2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR].ResultsOf the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25–17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96–9.16; p < 0.01).ConclusionAn MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.Type of StudyDiagnostic Test.Level of EvidenceIII.     

麻醉护理一体化模式在麻醉恢复室的应用效果

目的 探讨麻醉恢复室应用麻醉护理一体化模式的效果。方法 选取2020年2月-2022年2月本 院麻醉恢复室的80例患者为研究对象,根据护理方法不同分为对照组和观察组,各40例。对照组给予常 规麻醉后护理模式,观察组给予麻醉护理一体化模式,比较两组生命体征、疼痛程度、心理状态、苏醒 时间、拔管时间、术后并发症发生情况及护理满意度。结果 观察组护理后舒张压、收缩压、心率均优 于对照组（P＜0.05）;两组自主呼吸时间比较,差异无统计学意义（P＞0.05）;观察组呼之握拳时间、 呼之睁眼时间、拔管时间均短于对照组（P＜0.05）;观察组术后并发症发生率为5.00%,低于对照组的 25.00%（P＜0.05）;观察组护理满意度为92.50%,高于对照组的70.00%（P＜0.05）。结论 麻醉护理一体 化模式在麻醉恢复室的应用效果确切,护理效果较常规麻醉后护理模式更佳,有利于保持患者生命体征稳 定,减轻疼痛,改善患者的心理状态,同时可有效缩短患者苏醒时间、拔管时间,减少术后并发症的发生 几率,有利于提升护理满意度。     

Anesthesia for fucosidosis

Fucosidosis is an extremely rare, autosomal recessive lysosomal storage disease, characterized by a deficiency of the lysosomal hydrolase alpha fucosidase. We report a case of a 6-year-old child, diagnosed with fucosidosis type 2, who presented for dental rehabilitation under general anesthesia. Anesthesia was uneventful. Features of fucosidosis are discussed.     

Management of shock in trauma

Shock is defined as failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. Haemorrhagic shock is most commonly associated with trauma. Haemorrhage is a leading cause of preventable death in trauma and over the past two decades there has been an increasing understanding of the pathophysiological processes that occur in major haemorrhage associated with trauma. This has been fundamental to the development of the current approach to management of traumatic shock, known as damage control resuscitation (DCR). DCR encompasses three key resuscitative strategies, permissive hypotension, haemostatic resuscitation (the use of blood products as primary resuscitative fluids) and damage control surgery. The implementation of DCR alongside the creation of trauma networks has been revolutionary in the management of the shocked trauma patient.     

主动脉瓣关闭不全合并巨大左心室麻醉的处理

目的 总结既往主动脉瓣关闭不全合并巨大左心室的麻醉经验.方法 术前30 min肌注吗啡10 mg,东莨菪碱0.3 mg.根据患者反应和血流动力学变化,静脉给予依托咪酯0.1～0.2mg/kg,舒芬太尼1μg/kg,哌库溴铵0.1 mg/kg分次给药,缓慢诱导经口明视插管.根据血气结果调整呼吸参数,维持术中血气在正常范围.吸入1.0%～1.5%异氟醚,间断静脉注射舒芬太尼和哌库溴铵维持麻醉.连续监测心电图、有创血压、脉搏血氧饱和度、呼吸末二氧化碳分压、中心静脉压、体温.结果 术后均无室颤及其他恶性心律失常发生,均康复出院.结论 术前处理重点保证足够的前负荷,维持较快的心率,适度减轻后负荷,适度强心.术后处理重点保证足够的前负荷,早期继续使用多巴胺等正性肌力药物进行辅助,使用硝酸甘油扩张冠脉.     

Management of shock in trauma

Shock is defined as failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. Haemorrhagic shock is most commonly associated with trauma. Haemorrhage is a leading cause of preventable death in trauma and over the past two decades there has been an increasing understanding of the pathophysiological processes that occur in major haemorrhage associated with trauma. This has been fundamental to the development of the current approach to management of traumatic shock, known as damage control resuscitation (DCR). DCR encompasses three key resuscitative strategies: permissive hypotension, haemostatic resuscitation (the use of blood products as primary resuscitative fluids) and damage control surgery. The implementation of DCR alongside the creation of trauma networks has been revolutionary in the management of the shocked trauma patient.     

脑动脉瘤破裂出血手术的麻醉处理

目的：探讨脑动脉瘤破裂出血围手术期的麻醉处理。方法：采用静脉快速诱导气管内插管、普鲁卡因静脉复合全麻、控制性降压等方法处理。结果：２６例患者术后无１例并发再出血，２例死于脑血管痉挛，２例偏瘫，２例巨大复杂后交通动脉瘤的患者在深低温体外循环下手术获得成功，余２２例痊愈出院。结论：围手术期麻醉处理关键是：采取有效措施防止再出血和脑血管痉挛，深低温体外循环、控制性降压、降低颅内压、脑室穿刺引流术等均有利于提高治愈率。     

慢性血栓性肺动脉高压病人血栓内膜剥脱术的麻醉管理

本院1997年-2008年行肺动脉血栓内膜剥脱术的慢性血栓性肺动脉高压病人52例,男性41例,女性11例,年龄33～67岁,术前心功能Killip分级Ⅱ～Ⅳ级.麻醉诱导:静脉注射依托咪酯、芬太尼或舒芬太尼、罗库溴铵或维库溴铵,必要时静脉注射小剂量咪达唑仑,根据病人心功能状况和麻醉诱导中血液动力学变化调整给药剂量.气管插管后行机械通气,并放置Swan-Ganz导管.术中监测经食管超声心动图、鼻咽温和膀胱温.麻醉维持:以大剂量芬太尼或舒芬太尼为主,必要时吸入低浓度异氟烷或七氟烷.深低温低流量灌注或停循环条件下,行双侧肺动脉血栓内膜剥脱术.体外循环期间维持红细胞压积18%～25%.缓慢复温,保持鼻咽温与膀胱温之差小于5℃.停体外循环时维持血红蛋白浓度>100 g/L.体外循环后,给予相应的循环和呼吸支持,并行抗肺动脉高压处理.术毕循环和肺气体交换功能稳定后送外科ICU.肺血管血栓内膜剥离后肺出血6例(12%);术后持续性肺动脉高压35例(67%);术后出现神经系统并发症7例(14%);术后感染4例(8%);术后住院死亡8例(15%).