不同年龄患儿异丙酚的药代动力学

目的比较不同年龄患儿异丙酚的药代动力学。方法35例ASA Ⅰ或Ⅱ级患儿根据年龄不同分为3组,A组:<3岁;B组:≥3岁且<5岁;C组:≥5岁且<10岁。单次静脉注射异丙酚3 mg·kg-1后2、4、6、8、10、20、30、45、60、90、120、180 min抽取桡动脉血1 ml,高效液相色谱法检测血浆异丙酚浓度,经计算机软件拟合,得到各项药代动力学参数。结果三组患儿单次静脉注射异丙酚3 mg ·kg-1后血浆浓度下降迅速。与C组相比,A组的消除项指数常数较小,消除半衰期较长(P<0.01)。三组患儿的中央室分布容积分别为0.55、0.60、0.58 L·kg-1;总体清除率分别为0.015、0.016、0.020 L·kg-1·min-1;总体分布容积分别为8.0、6.5、6.2 L·kg-1,分布半衰期和速率常数(K12、K21、K10),组间比较差异均无统计学意义(P>0.05)。结论小于3岁患儿单次静脉注射3 mg·kg-1异丙酚后其药代动力学过程符合三室开放模型,除消除时间有所延长外,其余药代动力学参数与较大患儿一致。     

异丙酚对学龄前儿童静脉滴注氯胺酮药代动力学的影响

目的 探讨异丙酚对学龄对儿童静脉滴注氯胺酮药代动力学的影响。方法 １６例３．５－６岁行择期手术的学龄前儿童随机分为两组：Ｉ组为氯胺酮组：Ⅱ组为氯胺酮＋异丙酚组。Ｉ组采用异氟醚吸入诱导,ＩＩ组采用异丙酚诱导,气管插管后两组为静脉滴注氯胺酮３ｍｇ．ｋｇ＾－１．ｈ＾－１（０．０５％）同时吸入异氟醚行麻醉维持,应用反向高效液相色谱法测定氯胺酮血药浓度,采用中国药理学会编辑的３Ｐ９７软件计算药代动力学参数,     

兔异丙酚靶控输注的药代动力学

目的测定兔靶控输注(TCI)异丙酚药代动力学参数及引起不同麻醉深度所需的异丙酚血浆靶浓度。方法日本大耳兔20只,耳缘静脉注射10 mg·kg~(-1)异丙酚,抽取静脉注射后1、2、5、8、10、15、20、30、45、60 min动脉血各2 ml,通过高效液相色谱法测定异丙酚血药浓度,应用3P87药代动力学程序分析兔异丙酚药代动力学房室模型结构；随后将药代动力学参数代入TCI控制程序Stelpump中,以咀嚼反射消失作为浅麻醉标志,以夹尾后无体动反应为深麻醉标志,确定达到不同麻醉深度所需的异丙酚血浆靶浓度。结果兔异丙酚药代动力学模型为两室模型,中央室表观分布容积为(0．331±0．007)L·kg~(-1),中央室消除速率常数为(0．263±0．019)min~(-1),室间分布速率常数K_(12)、K_(21)分别为0．083±0．004、(0．060±0．009)min~(-1)。浅麻醉状态及深麻醉状态所需异丙酚血浆靶浓度分别为9．25±0．12、(11．63±0．29)μg·ml~(-1)。结论本研究确定了兔TCI异丙酚的药代动力学参数及维持不同麻醉水平血浆靶浓度。     

芬太尼对异丙酚静脉麻醉药代动力学和药效学的影响

目的 探讨芬太尼对异丙酚静脉麻醉药代动力学和药效学的影响。方法 ２０例开胸手术患者随机分为异丙酚复合芬太尼静脉麻醉组（Ａ组,ｎ＝１０）异丙酚静脉麻醉复合胸段硬膜外阻滞组（Ｂ组,ｎ＝１０）。测定术中和术后病人异丙酚血清浓度。记录意识消失,术后睁眼和定向时间及术后行为评分。结果 Ａ组消除相药代动力学参数Ｔ１／２βＭＲＴ,ＡＵＣ显著高于Ｂ组（Ｐ〈０．０５或０．０１）,Ａ组ＣＬ显著低于Ｂ组（Ｐ〈０．０１）     

国人异丙酚群体药代动力学参数

目的用NONMEN程序研究国人异丙酚群体药代动力学,并定量分析性别、年龄和体重的影响。方法76例行择期手术患者(男37例、女39例、年龄19～77岁、体重39～86 kg、ASA I～Ⅱ级),共1 459个血液标本。用NONMEN方法分析清除率和分布容积的个体间变异以及年龄、体重和性别的影响。结果 可用三室模型模拟异丙酚的药代动力学。体重影响异丙酚的中央室、浅外周室和深外周室的清除率以及中央室的分布容积,而浅外周室和深外周室的分布容积保持不变。体重60 kg的成人,上述药代参数的估计值分别为:1.56L·min-1,0.737 L·min-1、0.360L·min-1、12.1 L、43L、213 L。老人随年龄的增大而清除率和中央室分布容积减小。结论 国人异丙酚的药代动力学可用三室模型描述,年龄和体重可影响模型参数,因此根据患者的个体药代参数可改善靶控输注的精密度。     

心肺转流下室间隔缺损修补术患儿单个核细胞的变化

目的探讨室间隔缺损(VSD)患儿心肺转流(CPB)前后单个核细胞的变化。方法 CPB下行VSD修补术的患儿32例,分别于麻醉诱导后(T0)、停CPB即刻(T1)、术后第1天(T2)、第3天(T3)及第7天(T4)采集静脉血标本,应用流式细胞仪测定CD3+、CD4+、CD8+、CD19+、CD14+、CD16+CD56+细胞百分率;采用组织化学方法进行核仁组成区嗜银蛋白(AgNORs)染色并在全自动数码显微镜下测定其直径,计算每个细胞核中AgNORs的个数。结果与T0时比较,T1~T3时CD3+、CD4+均明显降低(P<0.05或P<0.01);T1时CD19+、CD14+明显降低(P<0.05或P<0.01),CD16+CD56+明显升高(P<0.01);T2时CD4+/CD8+明显降低(P<0.01),CD16+CD56+仍明显升高(P<0.01);T4时仅CD14+升高(P<0.05),其它指标均恢复到T0时水平。AgNORs形态类型为单一型,大都呈规则的圆形,CPB前后形态和数量无明显变化。结论单个核细胞的数量减少是细胞免疫功能受抑制的主要因素。     

等容量血液稀释对犬异丙酚药代动力学的影响

目的观察等容量血液稀释对犬异丙酚药代动力学的影响。方法13只雄性犬随机分为对照组(n=7)与等容量血液稀释组(n=6)。静脉注射地西泮0.5 mg/kg、氯胺酮5mg/kg麻醉后, 股静脉与股动脉穿刺,乳酸钠林格氏液5—7 ml·kg-1·h-1持续静脉滴注。麻醉后0.5 h等容量血液稀释组由股动脉放血,同时经股静脉1:1快速输入6%羟乙基淀粉,直至红细胞压积达25%。两组持续恒速静脉输注异丙酚10mg·kg-1·h-130 min,分别于输注2、5、10、15、20、30、31、32、35、40、50、70、90、120、150、180、240、300min采动脉血,测定异丙酚血浆浓度并计算药代动力学参数。一周后两组均根据各自药代动力学参数靶控输注异丙酚60 min,分别于靶控输注5、15、30、45、60 min测定两组异丙酚血浆浓度、游离浓度、脑脊液浓度及脑组织含量。结果与对照组比较,恒速给药时等容量血液稀释组异丙酚血浆浓度降低,中央室分布容积、稳态分布容积与全身清除率均升高(P<0.05或0.01);靶控输注时两组异丙酚血浆浓度与血浆靶浓度一致,但等容量血液稀释组异丙酚游离药物浓度、脑脊液浓度、脑组织含量及脑/血浆分配系数升高(P<0.05),脑/血浆分配系数与游离药物百分比[异丙酚游离浓度/(异丙酚游离浓度 异丙酚血浆浓度)]呈正相关(r=0.87,P<0.05)。结论等容血液稀释提高了异丙酚中央室分布容积、稳态分布容积和全身清除率,降低了分布项系数和浓度-时间曲线下面积,中枢药物浓度升高,可能导致药效增强。     

梗阻性黄疸病人靶控输注异丙酚的药代动力学

目的 探讨梗阻性黄疸病人靶控输注（TCI）异丙酚的药代动力学。方法 择期手术病人24例，ASAI或Ⅱ级，按胆红素水平分成3组（n=8），对照组：血清总胆红素（sTBL）〈17.1μmol／L；轻度梗阻性黄疸组（B组）：17．1／μmol／L≤sTBL≤171．1μmol／L；中重度梗阻性黄疸组（C组）：sTBL〉171．1μmol／L。三组均以血浆靶浓度3．0μg／ml TCI异丙酚直至手术结束。分别于以下时点取桡动脉血：TCI开始后0．5、1、2、4、6、8min、麻醉维持过程中每隔15min、停止TCI后即刻、2、4、6、8、10、20、30、40、50、60、90、120、180、240、300、360min，用高效液相色谱荧光法测定血浆异丙酚浓度，用NONMEM软件分析药代动力学参数。结果 TCI异丙酚的群体药代动力学大部分（18／24）最适合用三室模型来描述，小部分（6／24）最适合用二室模型来描述。三组间异丙酚的药代动力学参数比较差异无统计学意义（P〉0．05）。结论 TCI异丙酚药代动力学绝大部分适合用三室模型，小部分适合用二室模型来描述；梗阻性黄疸对异丙酚的药代动力学没有影响。     

全麻手术患者异丙酚的药代动力学

为探讨异丙酚的药代动力学指标，选择８例全麻成人择期手术患者，单次静脉注射异丙酚２ｍｇ／ｋｇ后，用高效液相色谱法测定血浆中异丙酚浓度，采用ＰＫＢＰ－ＮＩ程序进行数据处理。结果表明药代动力学符合三室开放模型，回归分析取得药代动力学参数，Ｔ１／２α＝０．０１１ｈ，Ｔ１／２β＝０．１９３ｈ，Ｔ１／２γ＝２．６３０ｈ，Ｖｄ＝０．１７５Ｌ／ｋｇ，Ｋ１０＝１０．４０ｈ，Ｋ３１＝０．６６０ｈ，表明异丙酚消除块，分     

体外循环下小儿肌部室间隔缺损的镶嵌治疗

目的 探讨镶嵌模式(hybrid procedure)治疗小儿肌部室间隔缺损(Mvsd)的手术方法及临床应用.方法 2006年1月至2010年6月,在体外循环心内直视手术下采用手术及封堵相结合的镶嵌技术矫治小儿Mvsd 45例,其中男20例,女25例;年龄52天～12岁;体重3～32 kg.7例为单个Mvsd,38例为多发性VSD.同时合并大血管错位(D-TGA)1例、法洛四联症(TOF)2例、肺动脉狭窄(PS)3例、动脉导管未闭(PDA)6例、房间隔缺损(ASD)6例、主动脉缩窄1例.均在心脏停跳后直视下将导引钢丝经三尖瓣孔自心脏右室面穿过VSD至左室面,直视下置入导引器,然后送入封堵器,完成Mvsd封堵.多发性VSD 38例,予自体心包片修补膜周部等较大的VSD,心内其他畸形同期完成矫治.结果 42例置入单枚封堵器(直径4～10 mm)、3例置入双枚封堵器(直径4～7 mm).手术经过顺利,术前左室射血分数(EF)均在正常范围,术后1天小于8月龄组EF均值低于正常,大于8月龄组EF正常,两者差异有统计学意义.术后常规每天给予5 mg/kg肠溶阿司匹林3～6个月.术后随访超声检查示封堵器位置无偏移,无残余分流,无二尖瓣、主动脉瓣反流、Ⅲ度传导阻滞及新发心律失常等.术后因重症感染放弃治疗1例,无远期死亡病例.结论 体外循环下镶嵌技术治疗小儿 Mvsd明显降低了围手术期并发症及病死率,简化了手术过程,降低了手术风险,是一种安全、有效的方法.

Abstract：

Objective To summarize the technique and clinical experience of hybrid procedure under cardiopulmonary bypass (CPB) in children with muscular ventricular septal defect (mVSD). Methods From January 2006 to June 2010, 45 cases of mVSD underwent hybrid procedure with CPB. mVSDs were closed with devices under direct vision in 45 cases. Of them, there were 20 males and 25 females. They ranged from 52 days to 12 years [mean (2.05 ±2.48) year] in age and from 3 to 30 kg [(11.93 ±7.70)kg] in body weight. Preoperatively, most of children were highly susceptible to respiratory tract infections. The hybrid approach was used in all patients with CPB under the guidance of transesophageal echocardiography (TEE). The diameter of mVSDs ranged from 2 to 7 mm under TEE. Of 45 cases, 40 patients had increased rates of pulmonary blood flow. 29 patients had left axis deviation and 12 cases had sinus arrhythmia on electrocardiography (ECG). 19 had other congenital heart lesions, including transposition of great arteries in 1 case, tetralogy of Fallot in 2, pulmonary artery stenosis in 3, patent ductus arteriosus in 6, atrial septal defects in 6) and aorta coactation in 1. The quantity of VSDs were from 1 to 7 (single, in 7; two, in 24 case; three, in 8 case; four, in 5 case and seven, in lease. 37 patients were combined with pulmonary hypertension in our cohort. 38 patients with another large VSD and 19 with other congenital heart lesions were required surgical repair at sometime. Results The hybrid procedures were undertaken in all 45 cases of this cohort. All cases were successful and no deaths occurred during operation. A total of 48 devices were implanted in 45 patients, including single devices in 42 cases (device size ranged from 4 to 10 mm) and two devices in 3 cases (device size ranged from 4 -7 mm). The average time on CPB was (58.28 ±20.70) min , while aortic crossclamp time was(34. 94 ± 14.75) min. In addition, the time on mechanical ventilation postoperatively ranged from 2 hours to 6 days. Compared to the older children, 20 infante aged less than 8 monhad a significant difference in cardiac function in the early postoperative period. One infant was given up treatment because of serious infection. Anather cases recovered with the use of supportive treatment, such as using vasoactive agents, digoxin, inhaling nitric oxide, diuresis, and so on. The enteric-coated aspirin was given at dose of 5 mg ? kg -1. day -1 for a period of 3 to 6 months as usual postoperatively. All patients attended follow-up at 1 week, 1 month, 3 months, 6 months, 1 year and 2 years post-procedure. No major complications were encountered during this period. All cases were no instance of migration of any of the devices, residual shunt, aortic regurgitation, atrioventricular valve dysfunction, Ⅲo atrial-ventricular conduction block, new arrhythmia, and so on. There are no death in long-term follow-up. Conclusion Hybrid procedure is safe and effective for the closure of congenital heart defects in children.     

Hybrid procedure with cardiopulmonary bypass for muscular ventricular septal defects in children

Objective: To summarize the technique and clinical experience of the hybrid procedure with cardiopulmonary bypass in children with muscular ventricular septal defect (mVSD). Methods: From January 2006 to June 2010, 45 cases of mVSD underwent hybrid procedures with cardiopulmonary bypass (CPB) under the guidance of transesophageal echocardiography. mVSDs were closed with devices under direct vision in the 45 cases. Fourteen patients had another lesion that required surgical repair. Large membranous VSDs were closed with a pericardial patch after the initiation of CPB in 38 cases. Results: Out of the 45 cases, 42 had only one occluder and three had two occluders. The size of the device for mVSD closure ranged from 3 to 8 mm. All cases recovered smoothly after treatment without residual shunting, aortic or mitral valve regurgitation, or restriction of surrounding structures. All the children survived the operation with no late deaths during the follow-up. Conclusion: The hybrid procedure is safe and effective for the closure of congenital heart defects in children.     

230例婴幼儿室间隔缺损的外科治疗

目的 探讨外科手术治疗婴幼儿室间隔缺损（ＶＳＤ）的结果和经验。方法 对１９９０年２月至１９９７年１２月的２３０例婴幼儿ＶＳＤ修补术进行总结。年龄３￣３６个月,体重３．２￣１５．５ｋｇ。膜周部ＶＳＤ１９２例,干下型ＶＳＤ３６便,膜周部并肌部ＶＳＤ２例,术前中度以上肺动脉高压１５０例（６５．２％）。结果 全组手术死亡１３例,手术病死率为５．６５％。手术死亡的主要原因为肺动脉高压危象和严重心律失常。术后     

小婴儿巨大室间隔缺损的外科治疗

目的 报告３９例出生６个月以内小婴儿巨大型空间隔缺损的外科治疗经验。方法 体外循环下除４例经肺动脉切口外其余均经右房切口,行补片缝合修补空间隔缺损。其中合并动脉导管未闭５例、房间隔水平分流１２例和右室流出道狭窄２例均同期矫治。结果 ３９例病儿均痊愈出院。结论 巨大型空间隔缺损的小婴儿出现顽固性心力衰竭、药物治疗无明显效果或生长发育停滞及肺动脉高压时即应手术。尽可能完善的围术期处理是降低病死率的重要     

小儿多发室间隔缺损临床分析

目的 总结小儿单纯性多发室间隔缺损外科治疗的经验教训,以提高对本病的诊治水平。方法 回顾性分析21例多发性室间隔缺损患儿的临床诊治资料。结果 本组患儿诊断准确率95．2％,病死率9．5％,无残余漏发生。2例术后早期出现Ⅲ度房室传导阻滞。结论 小儿多发肌部室间隔缺损,行手术矫治疗效满意;术前详细的心脏彩色血流图检查和术中仔细探察,对于提高本病诊断准确率,防止手术后残余漏至关重要。     

室间隔缺损修补术后残余漏的外科治疗

目的　总结室间隔缺损 (室缺 )修补术后残余漏的外科治疗经验 ,探讨残余漏的易发部位。方法　 1979年 1月至 2 0 0 3年 5月对 37例室间隔缺损术后残余漏患者行手术治疗 ,单纯室间隔缺损术后残余漏 19例、法洛四联症术后室间隔残余漏 17例、右心室双出口术后室间隔残余漏 1例 ,占同期心脏手术的 0 2 1% (37/ 180 0 0 )。其中男 2 6例、女 11例 ,年龄 3个月～ 5 3岁 ,平均 (16± 12 )岁。全组以室缺术后再度出现心脏杂音并行超声心动图检查确诊。手术用补片修补残余漏 2 6例 ,直接缝合残余漏 11例。结果　手术死亡 2例 ,病死率 5 % (2 / 37) ;手术成功 35例 ,术后随访 3个月～ 15年 ,疗效满意。结论　室间隔缺损修补术后残余漏多见于三尖瓣隔瓣根部 ,其次为第二和第一转移针处 ;室间隔缺损残余漏二次手术效果良好。     

Double patch technique for repairing postinfarction ventricular septal defect

We report 2 cases in which the double patch technique was used to repair an anterior postinfarction ventricular septal defect. To do this, we modified infarct exclusion as follows: In addition to a conventional patch excluding the infarcted muscle, another small patch is used to directly close the septal defect. Gelatin-resorcin-formal glue is applied between the double patches, which prevent the glue from being washed away and enhance it to polymerize stably, thereby rapidly stabilizing the infarcted myocardium with the endocardial patch. Echocardiography immediately after operation showed the infarcted septum had completely adhered to the endocardial patch. Both patients demonstrated satisfactory postoperative hemodynamics. Although 1 patient did well, the other died 6 months postoperatively due to complications of pneumonia and gastrointestinal bleeding secondary to colon carcinoma. This double patch technique appears useful, although further experience is needed to verify its safety and efficacy.