瑞芬太尼在神经外科手术麻醉中的应用

躁动和呛咳可诱发颅内灌注压及颅内压的急剧波动，是围手术期脑功能障碍的危险因素。如何减少围手术期躁动和呛咳成为神经外科麻醉处理的关键之一。瑞芬太尼是新合成的阿片扯受体激动剂，广泛应用于中小手术麻醉中。本研究拟在探讨瑞芬太尼应用于神经外科手术对患者苏醒期血流动力学、躁动和呛咳及清醒质量的影响，为临床神经外科麻醉提供参考。     

Narcotrend监测下舒芬太尼或瑞芬太尼复合异丙酚在唤醒麻醉中的应用

目的比较Narcotrend监测下靶控输注舒芬太尼或瑞芬太尼复合异丙酚在脑功能区唤醒麻醉中的效果。方法选择脑功能区手术病人40例,随机分为舒芬太尼（sufentanil,SF）组和瑞芬太尼（remifentanil,RF）组,每组20例。两组分别使用异丙酚复合SF或RF靶控输注诱导,插入喉罩行机械通气,在切口浸润麻醉和硬脑膜表面麻醉下,减少药物浓度使病人在功能定位和切除肿瘤过程中保持清醒。比较两组病人的血流动力学变化、Narcotrend监测下唤醒时间、唤醒质量,通过镇静评分（OAA/S）和视觉模拟评分法（VAS）评价两组是否能够提供合适的镇静和镇痛。结果两组均能在较短时间内唤醒病人,差异无统计学意义（P〉0.05）。插喉罩时,SF组的平均动脉压（MAP）高于RF组（P〈0.05）。在唤醒时,RF组心率和MAP明显高于基础值（P〈0.05）,SF组心率高于基础值（P〈0.05）,MAP稍低于基础值。苏醒后,SF组血压低于RF组（P〈0.05）。两组唤醒后的OAA/S评分无统计学差异（P〉0.05）,SF组唤醒后5min、10min、30min的VAS评分明显小于RF组（P〈0.05）。结论SF或RF联合异丙酚均能很好地应用于脑功能区唤醒手术,SF在病人苏醒后能提供更好的镇痛作用,且不延长病人苏醒时间,在苏醒后血流动力学稳定性方面更具有优势。     

舒芬太尼靶控输注用于神经外科肿瘤手术的疗效观察

目的探讨舒芬太尼靶控输注用于神经外科肿瘤手术麻醉中血流动力学变化和术后清醒的优缺点。方法 40例择期行开脑神经外科手术患者,随机分为2组,每组20例。I组采用芬太尼负荷量静注后间断静注给药方式,II组采用舒芬太尼靶控输注诱导及维持给药方式,2组患者术中全部采用丙泊酚复合(舒)芬太尼全凭静脉麻醉。术中根据血压、心率、体动及脑电双频指数(BIS)调整麻醉用量。观察记录麻醉诱导前(T0)、插管后5min(T1)、切皮(T2)、开颅骨(T3)、拔管后(T4)的SBP、DBP、HR,记录停药后患者自主呼吸恢复时间,呼之睁眼时间,拔管时间及拔管后10min、20min、30min的OAA/S(警觉/镇静评分)值。结果术中2组患者的BIS值均明显降低,维持40～60范围,2组比较差异无统计学意义(P>0.05)。各时点MAP、HR较平稳,出现明显波动,差异有统计学意义(P<0.05)。与I组比较,Ⅱ组苏醒时间及拔管时间明显降低(P<0.05),拔管后即刻OAAS评分升高,拔管后烦躁及恶心呕吐数减少(P<0.05)。结论舒芬太尼复合异丙酚把控输注静脉麻醉用于神经外科手术血流动力学稳定,苏醒期短,术后麻醉并发症少,能够取代芬太尼应用于神经外科麻醉。     

瑞芬太尼在神经外科手术麻醉中的应用

目的观察瑞芬太尼在神经外科麻醉中的效果。方法选择40例ASAⅠ~Ⅱ级择期行颅内肿瘤切除术的患者,随机分为A组(芬太尼)、B组(瑞芬太尼)各20例。A组以丙泊酚2 mg/kg,芬太尼3μg/kg,阿曲库铵0.5mg/kg诱导,术中间断给芬太尼0.1mg;B组以丙泊酚2 mg/kg,瑞芬太尼3μg/kg,阿曲库铵0.5mg/kg诱导,术中持续输注瑞芬太尼3~5μg/(kg.h);2组均持续泵注丙泊酚3~4mg/(kg.h),按需给阿曲库铵0.2~0.3mg/kg。结果A组插管及拔管期间呛咳发生率,各时点血流动力学变化及苏醒时间均有统计学意义(P<0.05)。结论神经外科手术应用瑞芬太尼可有效抑制应激反应,维持血流动力学稳定,缩短苏醒时间。     

靶控输注舒芬太尼和维库溴铵静脉麻醉用于神经外科手术对比分析

目的：对比靶控输注舒芬太尼和维库溴铵静脉麻醉用于神经外科手术的麻醉效果。方法选取2012-01-2013-12我院收治并接受神经外科择期手术的患者46例,随机等分为S组与V组,分别采用舒芬太尼靶控麻醉和维库溴铵静脉麻醉,对麻醉效果及并发症情况进行评估。结果 S组与V组麻醉前后 HR、CVP、SBP及DBP均明显降低（P＜0.05）。与V组比较,S组拔管时间明显缩短,VAS评分明显提高,并发症发生率明显降低。结论在神经外科手术中,舒芬太尼靶控麻醉较维库溴铵静脉麻醉具有更佳麻醉效果和较少的并发症,适合临床应用。     

瑞芬太尼复合丙泊酚麻醉在颅脑手术中的应用效果

目的分析瑞芬太尼复合丙泊酚麻醉在颅脑手术中的应用效果。方法将我院收治的68例颅脑手术患者随机分为观察组34例和对照组34例。术前2组均行咪达唑仑、维库溴铵、芬太尼、丙泊酚麻醉诱导;术中观察组行瑞芬太尼复合丙泊酚麻醉维持,对照组行芬太尼复合丙泊酚麻醉维持。监测2组患者麻醉诱导前即刻(T0)、气管插管前即刻(T_1)、气管插管后即刻(T_2)、切皮即刻(T_3)及拔管即刻(T_4)的HR及MAP;评价患者的苏醒质量;同时,监测患者的脑氧代谢指标。结果2组患者T_1时的HR及MAP指标值较T0时均下降(P均0.05);而在其他时刻,观察组HR及MAP指标值较T0时刻均无明显波动(P均0.05);但在T_3、T_4时刻,对照组HR及MAP指标值均高于T0时刻及观察组(P均0.05)。观察组平均术后睁眼时间、睁眼到定向力恢复时间及拔管时间均短于对照组(P均0.05)。另外,监测期间,观察组脑氧代谢指标均无明显波动(P均0.05);但对照组在麻醉维持后30min及麻醉药停用后5min,脑氧代谢指标与诱导前及观察组差异有统计学意义(P均0.05)。结论在颅脑手术中应用瑞芬太尼复合丙泊酚麻醉能有效保证患者血流动力学及脑氧代谢的稳定,且患者苏醒较快,能更好满足手术要求。     

异丙酚联合瑞芬太尼麻醉对颅脑手术患者麻醉复苏的影响

目的 观察瑞芬太尼和异丙酚联合液在颅脑手术麻醉中的应用价值.方法 选择ASA II级,无严重心肝肾病,择期行颅脑手术患者143例,随机分为异氟醚组(A组)120例,瑞芬太尼+异丙酚组(B组)123例.患者性别、年龄、身高、体质量、手术类型及时间均无明显差异.2组患者麻醉诱导均采用咪达唑仑0.15mg/kg,异丙酚2mg/kg,维库溴铵0.1mg/kg,芬太尼0.2mg方案.麻醉维持A组采用1%～2%异氟醚按需给予复合50%N2O;B组采用A组同浓度的异丙酚、N2O,手术开始前全程泵入0.2μg/(kg·min)瑞芬太尼至手术结束,结束前5min静脉推注1mg/kg曲马多.观察停止麻醉药给予后至拔管期间患者的呛咳发生率(数)、血流动力学及SPO2变化、苏醒时间等指标.结果 与A组拔管期间呛咳发生率(55%)相比,B组为5%(P＜0.05);且B组拔管期间血流动力学各指标及SPO2的变化也均较A组显著减少.2组的苏醒时间相比无显著差异.结论 颅脑手术围麻醉期应用瑞芬太尼和异丙酚可有效减少拔管期间呛咳的发生率,缩短清醒时间及提高手术质量.     

氯胺酮用于神经外科手术瑞芬太尼麻醉后痛觉过敏的临床研究

目的 评价应用氯胺酮缓解神经外科手术瑞芬太尼麻醉后痛觉过敏的有效性和安全性.方法 选择神经外科开颅手术患者100例,随机分为氯胺酮组(50例)和对照组(50例).麻醉维持采用瑞芬太尼0.1～0.2μg·kg-1·min-1和丙泊酚泵注,吸人七氟醚.缝皮时静脉给予0.5 mg/kg氯胺酮或生理盐水.记录两组患者拔管和苏醒时间、要求镇痛的患者人数、曲马多用量和不良事件.分别于苏醒后15 min、30 min、60min、120 min进行疼痛视觉模拟评分、Ramsay评分.结果 氯胺酮组要求镇痛人数和曲马多用量低于对照组(P＜0.05);患者苏醒后15 min Ramsay评分氯胺酮组显著大于对照组(P＜0.01),30 min视觉模拟评分对照组高于氯胺酮组(P＜0.05).结论 神经外科开颅手术后使用氯胺酮,可以有效缓解瑞芬太尼所致的痛觉过敏.

Abstract：

Objective To evaluate the preventive effects of ketamine on patients with postoperative hyperalgesia after remifentanil-based neurosurgical anaesthesia.Methods 100 patients undergoing craniotomy were randomly divided into two groups: ketamine group ( n =50) and saline group ( n =50).The anesthesia was induced sevoflurane.Ketamine was given before skin closing for inhibiting remifentanil -induced postoperative hyperalgesia.The emergence time, trachea extubation time, VAS, Ramsay scores were recorded and the tramadol consumption were compared.Results Patients required analgesia and tramadol consumption in ketamine group were significantly lower than those in saline group.Pain VAS scores in saline group were significantly higher than those in ketamine group at 30 minutes after emergency ( P ＜0.05).The Ramsay score in saline group at 15 minute after emergency was lower than that in ketamine group ( P ＜ 0.01 ).Conclusion Ketamine could prevent postoperative hyperalgesia after remifentanil- based neurosuegical anaesthesia.     

舒芬太尼与瑞芬太尼对神经外科手术麻醉苏醒期的影响

目的观察舒芬太尼与瑞芬太尼对神经外科手术麻醉苏醒期的影响。方法选取120例患者随机分成2组,对照组予以瑞芬太尼静脉复合麻醉,实验组予以舒芬太尼静脉复合麻醉,观察2组清醒时间、拔管时间、血液动力学指标变化、围拔管期不良反应、VAS疼痛评分及术后镇痛药物使用情况。结果实验组清醒时间、拔管时间明显高于对照组,但血流动力学指标显著优于对照组,围拔管期躁动、寒战明显低于对照组,拔管后5min、30min、1hVAS评分及术后24h使用镇痛药物比例均明显低于对照组(P0.05)。结论舒芬太尼在神经外科手术中的麻醉效果优于瑞芬太尼,值得临床推广。     

丙泊酚靶控输注复合舒芬太尼在脑胶质瘤切除术中的应用

目的探讨不同剂量舒芬太尼复合丙泊酚靶控输注麻醉对脑胶质瘤切除术患者镇痛及神经损伤的影响。方法将75例择期脑胶质瘤切除术患者,随机数字表简单随机分组为A组(n=37)和B组(n=38);2组均采用相同的麻醉诱导(丙泊酚+舒芬太尼+罗库溴铵),麻醉诱导后,舒芬太尼靶浓度A组为0.1 ng/mL,B组为0.25 ng/mL,麻醉维持采用舒芬太尼复合丙泊酚靶控输注。记录患者围术期麻醉药物用量、术后补救镇痛及不良反应情况,分别于麻醉诱导前(T_0)、手术结束时刻(T_1)、术后1 h(T_2)、术后12 h(T_3)、术后24 h(T_4)采用酶联免疫吸附法测定患者血清S-100β蛋白(S100β)、神经元特异性烯醇化酶(NSE)水平。结果丙泊酚及舒芬太尼用量比较差异无统计学意义(P0.05);而B组术后补救镇痛率明显低于A组(15.79%vs 48.65%,P0.05)。T_0时刻,2组血清S100β、NSE水平比较差异无统计学意义(P0.05);而在T_1、T_2、T_3、T_4时刻,B组S100β、NSE水平均明显低于A组(P0.05)。2组术后不良反应发生率比较差异无统计学意义(P0.05)。结论与0.1 ng/mL靶浓度相比,舒芬太尼靶浓度0.25ng/mL复合丙泊酚靶控输注麻醉能够提高镇痛效果,并减轻患者神经损伤,且不增加不良反应。     

舒芬太尼联合瑞芬太尼在全凭静脉麻醉的临床应用效果

目的评价舒芬太尼联合瑞芬太尼在全凭静脉麻醉(total intravenous anesthesia,TIVA)的临床应用效果。方法以我院收治的84例择期手术患者为研究对象,按照入院顺序,采用随机队列插入法分为对照组、观察组各42例,均给予咪唑安定+舒芬太尼+丙泊酚+维库溴铵诱导麻醉,对照组给予丙泊酚+舒芬太尼维持麻醉,观察组以丙泊酚+瑞芬太尼维持麻醉,对比手术进程相关指标、围术期麻醉相关不良事件发生情况以及在停止输注后至拔管前AAI、OAA/S水平。结果 2组苏醒时间、拔管时间、麻醉维持时平均动脉压水平差异无统计学意义(P0.05);观察组苏醒时HRVI水平高于对照组,差异有统计学意义(P0.05);观察组围术期麻醉相关不良事件例次率低于对照组,差异有统计学意义(P0.05);术毕时,2组AAI、OAA/S水平高于停止输注时,观察组高于对照组,差异具有统计学意义(P0.05)。结论在TIVA中应用舒芬太尼诱导联合瑞芬太尼复合丙泊酚维持麻醉,相对于舒芬太尼诱导联合丙泊酚维持麻醉,虽对手术进程影响不明显,但有助于血流动力学稳定,提高苏醒质量,降低不良事件发生风险,适用于风险相对较高的患者。     

瑞芬太尼与异丙酚在无抽搐电休克治疗中的联合应用

目的：研究单次静注瑞芬太尼与异丙酚对无抽搐电休克治疗（MECT）患者的血流动力学的影响。方法：抑郁症患者60例,随机分为瑞芬太尼合用异丙酚组和单用异丙酚组。每组30例,麻醉诱导采用静注长托宁1．0mg,异丙酚1．5mg／kg后,两组分别予生理盐水或瑞芬太尼1μg／kg。结果：单用组治疗后各项参数明显升高,持续3min,合用组治疗后1min各指标与麻醉前值比较明显上升,但治疗后3min即恢复。结论：瑞芬太尼与异丙酚联合运用,可有效抑制MECT时的血流动力学反应。     

神经外科麻醉对体感诱发电位的影响

目的探讨神经外科手术麻醉对体感诱发电位（SEP）的影响,以期为麻醉和手术处理提供依据。方法随机抽取我科17例全麻手术病人,分成颅内疾病手术组（A组）与脊柱、脊髓疾病手术组（B组）,于术前、麻醉（诱导完成）、术始、术中、术毕和术后6个时程连续监测SEP的潜伏期、波幅及波形并记录。结果麻醉后SEP潜伏期延长5.96%,波幅下降24.00%,未出现波形消失的情况。结论麻醉抑制SEP,表现为潜伏期延长和波幅下降,但未出现波形消失的情况。     

靶控输注丙泊酚与瑞芬太尼复合Narcotrend监测在唤醒开颅中的应用

目的探讨Narcotrend监测在唤醒开颅麻醉中的应用价值。方法30例需行脑功能区手术病人随机等分为监测组与非监测组，监测组病人监测Narcotrend分级（NT）及指数（NI），非监测组不进行Narcotrend监测。麻醉方法均选用丙泊酚联合瑞芬太尼靶控输注，监测组至NI≤46、非监测组当病人意识消失后，置入喉罩；术中监测组维持NI≤46，非监测组根据血流动力学调整丙泊酚浓度维持麻醉。处理硬脑膜时，丙泊酚和瑞芬太尼开始减量，病人呼唤睁眼后，拔出喉罩。记录置入喉罩时和唤醒时丙泊酚效应室浓度（Ce），置入喉罩前1min、即刻的平均动脉压、心率，监测组NI及减浅麻醉至呼唤睁眼时间，比较两组间各参数的差异。结果监测组诱导所需丙泊酚浓度小于非监测组，P〈0．05。监测组唤醒时间（10．3±3．0）min明显短于非监测组（14．6±3．0）min，P〈0．01。置入喉罩前后两组血流动力学波动不明显，NI与丙泊酚浓度呈明显的负相关。结论唤醒开颅时，在Narcotrend指导下，可以显著降低丙泊酚所需靶浓度，增加唤醒的可控性。     

CT血管造影结合导航技术在神经外科手术中的应用

目的评价CT血管造影（CTA）结合导航技术在神经外科手术的应用价值。方法回顾性分析16例通过CTA结合导航技术进行神经外科手术的病人资料,其中脑膜瘤9例,胶质瘤4例,脑动静脉畸形2例,上皮样血管内皮细胞瘤1例。术前CTA重建颅内病灶、周围血管、脑组织及颅骨图像,CTA采集的图像与Brian-lab导航系统融合,设计手术入路,术中实时指导手术。结果脑膜瘤达SimpsonⅠ级切除2例,Ⅱ级切除7例。胶质瘤、脑动静脉畸形和上皮样血管内皮细胞瘤均镜下全切除。结论 CTA结合导航技术能提供无创、准确的神经影像信息,指导颅内病灶切除,同时保护脑血管及脑组织,对神经外科手术有指导意义。     

术中超声在显微神经外科手术中的应用

目的探讨术中超声技术在颅内病变显微外科手术中的应用。方法显微神经外科手术治疗颅内幕上病变42例,采用术中超声技术确定病变的解剖边界,了解病变与周围结构的关系,确定皮质切口,实时动态监测指导病变切除范围及判断病变切除程度。结果病变定位准确率达100%。全切除38例,次全切除4例。术后病理显示:胶质瘤21例,脑膜瘤6例,颅内血肿7例,转移瘤5例,海绵状血管瘤3例。术后偏瘫加重2例,失语加重1例;未发生与术中超声扫描相关的并发症。术后3个月复查MRI31例,MRI显示病变切除程度与术中超声结果符合28例(90.1%)。结论术中超声作为一种实时、无创、简便的辅助检查方法,可帮助术者精确定位,提高手术安全性和治疗效果,具有很高实用价值。     

Monosialoganglioside 1 may alleviate neurotoxicity induced by propofol combined with remifentanil in neural stem cells

Monosialoganglioside 1(GM1) is the main ganglioside subtype and has neuroprotective properties in the central nervous system. In this study, we aimed to determine whether GM1 alleviates neurotoxicity induced by moderate and high concentrations of propofol combined with remifentanil in the immature central nervous system. Hippocampal neural stem cells were isolated from newborn Sprague-Dawley rats and treated with remifentanil(5, 10, 20 ng/m L) and propofol(1.0, 2.5, 5.0 μg/m L), and/or GM1(12.5, 25, 50 μg/m L). GM1 reversed combined propofol and remifentanil-induced decreases in the percentage of 5-bromodeoxyuridine(+) cells and also reversed the increase in apoptotic cell percentage during neural stem cell proliferation and differentiation. However, GM1 with combined propofol and remifentanil did not affect β-tubulin(+) or glial fibrillary acidic protein(+) cell percentage during neural stem cell differentiation. In conclusion, we show that GM1 alleviates the damaging effects of propofol combined with remifentanil at moderate and high exposure concentrations in neural stem cells in vitro, and exerts protective effects on the immature central nervous system.     

Percentage of beta 2 band power of quantitative pharmaco-electroencephalography decreases in propofol anesthetized rabbits****★ A dose-dependent analysis

BACKGROUND: Quantitative pharmaco-electroencephalography can be used for studying the dose-effect and time-effect relationships of drugs affecting central nervous system. Therefore, it may become an effective means for monitoring the anesthetic degree of anesthetic drug in the operation. OBJECTIVE: To observe the dose-effect relationship of propofol influencing β2-band power of quantitative pharmaco-electroencephalography in rabbits. DESIGN: A randomized block design. SETTING: Department of Anesthesiology, Xuzhou Medical College. MATERIALS: Thirty-six healthy adult rabbits of either gender, weighing （2.4±0.5）kg, of clean grade, were provided by the Laboratory Animal Center of Xuzhou Medical College. The involved rabbits were randomly divided into 3 groups with 12 in each by table of random digit: high-dose propofol group, moderate-dose propofol group, and low-dose propofol group. The protocol was carried out in accordance with animal ethics guidelines for the use and care of animals. METHODS: This study was carried out in the Department of Anesthesiology, Xuzhou Medical College between August 1999 and April 2000. Rabbits in the high-dose propofol group, moderate-dose propofol group, and low-dose propofol group were injected with 10, 5 and 2.5 mg/kg propofol (ZENECA Company, British, Batch No. 032000), respectively. Before and after intravenous administration of propofol, percentage of β2-band power of quantitative pharmaco-electroencephalography was measured, and the latent and persistent periods when rabbit righting reflex disappeared were observed by quantitative pharmaco-electroencephalography and power spectrum analysis. MAIN OUTCOME MEASURES: ①Percentage of β2-band power of quantitative pharmaco-electroencephalography. ②Latent period and persistent period of abolition of righting reflex of rabbits. RESULTS: Thirty-six rabbits were involved in the final analysis. ①Effect of propofol on righting reflex of rabbits: Righting reflex disappeared within 1 minute after the rabbits being intravenously injected with propofol. The higher dose, the shorter latent period (r =–0.94, P < 0.01), and the longer persistent period (r =0.79, P < 0.01). Both latent period and persistent period had good correlation with propofol dose. ② Effect of propofol on the percentage of β2-band power of quantitative pharmaco-electroencephalography: In the low-dose propofol group, no significant changes in the percentage of β2-band power of quantitative pharmaco-electroencephalography existed between before and after administration within 30 minutes (P > 0.05). In the moderate-dose propofol group, the percentage of β2-band power of quantitative pharmaco-electroencephalography in each brain region except for left and right frontal areas was significantly decreased within 30 s to 5 minutes (P < 0.05), and recovered to the level before administration 10 minutes later. In the high-dose propofol group, the percentage of β2-band power of quantitative pharmaco-electroencephalography in each brain region was significantly decreased from 20 s to 5 minutes after administration (P < 0.05–0.01), and that was gradually recovered to the level before administration 5 to 10 minutes after administration. This tendency was basically the same as the changes of latent period and persistent period. CONCLUSION: Propofol decreases the percentage of β2-band power of quantitative pharmaco- electroencephalography in dose-dependent manner. It indicates that β2-band power might become one of indexes for reflecting the anesthetic degree of propofol.