高原低氧环境下非体外静脉转流原位肝移植术麻醉管理一例

患者,男,24岁,45kg,诊断为乙型肝炎性终末失代偿性肝硬化。在非体外静脉转流下行原位肝移植术。术前常规用药,麻醉选择气管内插管静吸复合全麻。诱导用咪唑安定10mg、芬太尼5μg·kg-1、异丙酚2mg·kg-1、哌库溴铵0.15mg·kg-1。维持期间断静推芬太尼、咪唑安定、哌库溴铵,安氟醚间断吸入。术中重视中心体温的调节,维持T在34.40℃±0.28℃。术中出血约     

Ebstein畸形矫治术的合理麻醉处理

目的 总结Ebstein畸形矫治术的麻醉处理经验。方法Ebstein畸形矫治术的麻醉处理19例。成人患者术前口服安定10mg,肌注东莨菪碱0．3mg,吗啡10mg;而12岁以下小孩诱导前肌注氯胺酮6～7mg／kg、东莨菪碱0．01mg／kg。全麻诱导静脉注射咪唑安定0．01—0．03mg／kg,依托咪酯0．1～0.3mg／kg,芬太尼5-10μg／kg,哌库溴铵O．1mg／kg麻醉诱导,吸入1MAC异氟醚。持续静脉输注异丙酚0.8—2μg／ml;间断给予芬太尼5～10μg／kg,哌库溴铵0．05mg／kg。结果麻醉平稳,所有患者术后症状明显改善,围术期无一例死亡。结论采用复合麻醉药物的处理．对Ebstein畸形矫治术具有良好的麻醉效果。     

加快静吸复合全麻术后清醒

作者采用静吸复合全麻后高流量氧供法，明显加快了清醒。ＡＳＡⅠ～Ⅲ级病人１１２例，男６７例，女４５例，年龄２１～７８岁，均系择期胸腹腔手术。全组病例用静吸复合全麻诱导用药为咪唑安定２～１０ｍｇ、芬太尼０．１ｍｇ、潘库溴铵４～８ｍｇ及异丙酚７０～１５０ｍ...     

全身麻醉患者术中知晓的临床研究

目的 分析全麻患者术中知晓发生情况,探讨术中知晓的预防措施.方法 根据手术中麻醉维持方法的不同,539例全麻下行择期外科手术患者分为三组:A组278例,采用分次静注芬太尼、咪唑安定、维库溴铵维持麻醉;B组119例,术中以微泵持续静注丙泊酚2～4 mg·kg1·h-1,间断静注芬太尼、咪唑安定、维库溴铵;C组142例,在A组静脉复合全麻基础上,持续吸入0.5%～2.5%异氟醚.分析术中知晓发生情况,计算术中知晓发生率.结果 539例全麻患者麻醉手术期间发生术中知晓28例,发生率为5.20%.其中,A组发生术中知晓19例(6.84%),明显高于B组的5例(4.20%)和C组的4例(2.82%)(P＜0.05).结论 用微泵持续静注适量丙泊酚的全凭静脉复合全麻或采用静-吸复合麻醉,可有效降低术中知晓的发生率.     

丙泊酚和普鲁卡因在静脉复合全麻中的比较

目的比较丙泊酚与普鲁卡因静脉复合全麻对血流动力学、术中意识及苏醒过程的影响。方法选择30例择期全麻非颅脑手术病人随机均分为两组：Ⅰ组诱导插管用丙泊酚2mg／kg、维库溴铵0．15mg／kg静注,全麻维持用0．2％丙泊酚静滴;Ⅱ组诱导插管用咪唑安定0．15mg／kg、维库溴铵0．15mg／kg静注,全麻维持用1％普鲁卡因静滴。测量诱导前、诱导后、插管时、术中及拔管前的HR、MAP;记录停药至睁眼及拔管的时间;观察术后恶心发生率,询问术中有无意识存在。结果气管插管时、术中及拔管前Ⅰ组HR、MAP较Ⅱ组稳定,Ⅱ组HR、MAP明显高于术前水平（P〈0．01）;Ⅰ组睁眼及拔管时间均明显短于Ⅱ组（P〈0．01）,且术后恶心率及术中意识发生率Ⅱ组高于Ⅰ组（P〈0．01）。结论丙泊酚静脉全麻比较普鲁卡因,具有诱导快、术中循环动力学稳定、苏醒迅速完全且无术中知晓、术后并发症少等优点。     

老年患者顺式阿曲库铵不同用药方式的作用时效比较

目的观察顺式阿曲库铵两种不同用药方式在老年患者腹部手术中的肌松效应及对恢复速度的影响。方法 32例ASAⅡ～Ⅲ级择期老年腹部手术患者,随机分为两组（Ⅰ组和Ⅱ组,每组16例）。麻醉诱导均采用咪唑安定、异丙酚及芬太尼,以瑞芬太尼和异丙酚维持麻醉。Ⅰ组术中每当T1恢复到10%时单次静脉推注0.05～0.1mg/kg顺式阿曲库铵,Ⅱ组当T1恢复到5%时开始微量泵输注顺式阿曲库铵（2～3μg/（kg.min））,两组维持肌松T1〈10%,直到手术关腹后停止给药。术中记录肌松作用时间、最后注药或停药距T1为25%时间、恢复指数,并计算单位时间用药量。结果两组肌松效应和恢复指数相比均无统计学差异（P〉0.05）,单位时间用药量亦无统计学差异（P〉0.05）;最后注药或停药距T1为25%时间,Ⅰ组长于Ⅱ组（P〈0.05）。结论顺式阿曲库铵用于老年患者麻醉可产生良好的肌松效应,术中持续微量泵注射顺式阿曲库铵较为合理。     

46例老年患者全麻恢复期谵妄的病例分析

目的通过观察分析老年患者全麻恢复期谵妄的病例特点，探寻其有效的预防和治疗方法。方法对46例老年患者全麻恢复期谵妄的病例分析，并做如下处理：充分给氧；对于血压、心率平稳的患者，静脉注射氟哌利多0．02～0．025mg／kg，同时复合静脉注射异丙酚0．4～0．5mg／kg：对于低血压、心率极不平稳的患者，静注咪唑安定0．05～0．10mg／kg并维持循环稳定；必要时推注芬太尼2μg／kg。结果经上述处理后患者基本恢复安静；用药期间，均未发现有明显的锥体外系反应。无过敏性皮疹、低血压等短暂反应表现。结论氟哌利多可用于控制老年患者全麻恢复期谵妄，但使用时剂量不宜过大。另外，部分患者可试用小剂量咪唑安定或异丙酚．但应注意两者均可加重呼吸抑制。     

全身麻醉时机械通气对肺表面活性物质的影响

动物实验[1]提示,机械通气可能导致肺泡表面活性物质(PS)的改变。本文通过测定全麻机械通气前、后支气管肺泡灌洗液(BAL)中不同活性PS所含磷脂酰胆碱(PC)的量,并比较非活性PC与总PC的比值,以探讨全麻机械通气对PS的影响。材料与方法1.研究对象　ASA～级,心肺功能正常,无吸烟史,需全麻下行腹部及胸壁手术的患者8例,其中男2例,女6例,年龄24～52岁,体重55～70kg。2.麻醉方法　选择全麻复合硬膜外阻滞。以异丙酚2mg/kg、维库溴铵0.15mg/kg、芬太尼3μg/kg行全麻诱导,硬膜外间断注入2%利多卡因,静脉泵入咪唑安定150μg·kg-1·h-1,间断静…     

硬膜外阻滞复合全身麻醉应用于腹部大手术效果分析

目的:观察硬膜外阻滞复合全身麻醉应用于腹部大手术患者的可行性。方法:全麻诱导用咪唑安定0.1mg/kg,芬太尼3μg/kg,丙泊酚2mg/kg,维库溴铵0.1mg/kg。复合组于诱导前在T_(8～9)或L_(3～4)间隙行硬膜外穿刺置管,注入2％利多卡因5ml,平面确定后进行全麻诱导。全麻维持用丙泊酚2mg.kg~(-1),h~(-1)持续泵入,间断静注芬太尼和维库溴铵,并吸入安氟醚。用多功能监测仪监测心血管功能,记录术后躁动及药物用量。结果:复合组插管、切皮、拔管时的平均动脉压,心率上升幅度较对照组少。术后躁动率、药物用量显著低于对照组。结论:硬膜外阻滞复合全身麻醉应用于腹部大手术,术中血流动力学稳定、应激反应小,全麻药用量和手术后躁动减小。硬膜外术后镇痛有利于患者创口愈合、早日康复。     

罗库溴铵和阿曲库铵肌松作用的对比研究

目的 比较两种短效非去极化肌松药罗库铵在妇科腹腔镜手术全麻中的肌松作用。方法 选择妇科腹腔镜手术病人40例，术前检查无明显肝肾功能损害。随机分罗库溴铵组（Ⅰ组，n1=20例）和阿曲库铵组（Ⅱ组，n2=20例）。麻醉诱导；静注咪唑安定0.1mg/kg，芬太尼5μg/kg，琥珀胆碱1.5mg/kg，丙泊酚1.5mg/kg，经口明视插管，接Datex-OhmedaAS/3麻醉机，用TOF-guard肌松监测仪（丹麦），采用TOF刺激模式，当肌颤搐恢复至T125%时，静注罗库溴铵0.8mg/kg或阿曲库铵0.5mg/kg维持肌松；当T15%-10%时，分别追加罗库溴铵0.4mg/kg或阿曲库铵0.2mg/kg。麻醉维持丙泊酚80-120mg/h和苏太尼40-60μg/h速率用微量注射泵静脉注射，同时吸入氧化亚氮（N2O：O2为1：1）。结果 I组起效时间明显较Ⅱ组短，并且T125%时间，T190%时间以及恢复指数均较Ⅱ组短。Ⅱ组的循环变化主要表现在注药后1，3，5分钟的SBP较注射前呈明显下降，5分钟后呈回升趋势，结论 罗库溴铵比阿曲库铵肌松起效快，恢复较迅速，对循环影响小，是内腔镜手术麻醉时的良好肌松药选择。     

Accidental epidural administration of vecuronium

We report a case of accidental epidural injection of vecuronium during cholecystectomy in a 55-year-old man (63 kg, 158 cm). Following 3 ml of lidocaine 1% as an epidural test dose, inadvertent epidural (T7-8) injection of vecuronium 4.25 mg instead of ropivacaine occurred. After immediate removal of the syringe containing vecuronium, 10 ml of ropivacaine 0.375% was injected epidurally. Intubation was performed under propofol infusion using a target-controlled infusion system with intravenous vecuronium 10 mg. There was a 3 min interval between inadvertent epidural and intravenous injection of vecuronium. Anesthesia was maintained with propofol infusion (2.6-3.0 microg x ml(-1)) titrated to maintain bispectral index between 35-55 and buprenorphine 0.16 mg with 40% oxygen in air. T1 response in the train-of-four (TOF) appeared 87 min after epidural vecuronium injection. Ten minutes later, additional vecuronium 0.5mg was required due to bucking. Seven minutes after that, T1 in the TOF reappeared and the operation was finished. Twenty-three minutes after the additional vecuronium, 4 responses in the TOF were obtained. Following reversal with atropine 1.0 mg and neostigmine 2.0 mg, the patient was able to sustain head lift and handgrip, and to protrude the tongue fully awake. The patient was extubated 124 min after epidural vecuronium injection. There was no memory of back pain during epidural vecuronium injection. There was no postoperative respiratory insufficiency or neurological disorder. We suspect the duration of action of epidural vecuronium is approximately twice that of intravenous injection and becomes prolonged with higher doses and advanced age.     

Dose requirements of pentazocine during abdominal surgery in total intravenous anesthesia using propofol

BACKGROUND: To determine the dose requirements of pentazocine when administered as a single bolus dose in total intravenous anesthesia with propofol for abdominal surgery. METHODS : One hundred and fifty-six patients scheduled for abdominal surgery were analyzed retrospectively. Patients were classified into three groups according to duration of the operation ; under 120 min (Group 1, n=87) ; 120-240 min (Group 2, n=56) ; over 240 min (Group 3, n=13). Anesthesia was induced with propofol using target controlled infusion method, and was maintained with propofol infusion, pentazocine as a single dose before incision, and intermittent administration of vecuronium with 40% oxygen in air. RESULTS: Dosage of pentazocine was significantly increased according to length of the operation. The maintenance doses of propofol were not different among the three groups. Awakening time in about 80% of patients in each group was within 15 minutes. There are no severe complications. CONCLUSIONS : Total intravenous anesthesia with propofol and pentazocine is useful to stabilize hemodynamics and to achieve rapid recovery. For the operation within 120 min, 0.7 mg x kg(-1) of pentazocine is necessary whereas 0.8 mg x kg(-1) of pentazocine is needed in the operation of 120-240 min.     

盐酸戊乙奎醚对老年患者非心脏手术后早期认知功能的影响

目的 观察术前应用盐酸戊乙奎醚0.02 mg/kg对老年患者全麻下非心脏手术后早期认知功能的影响.方法 选择全麻下行择期非心脏手术且年龄＞65岁的老年患者60例,随机分为盐酸戊乙奎醚组和对照组.盐酸戊乙奎醚组在麻醉诱导前10 min静脉注射盐酸戊乙奎醚0.02mg/kg;对照组则给等容积生理盐水.麻醉诱导后持续微量泵注射丙泊酚及瑞芬太尼、间断注射阿曲库铵维持麻醉.分别在麻醉前和麻醉后3d采用简易智力量表进行神经心理学评估.结果 因各种原因,仅有41例患者完成全部测试,其中盐酸戊乙奎醚组20例,对照组21例.盐酸戊乙奎醚组术后认知功能障碍( POCD)发生率为35.0％,对照组为38.1％,两组间差异无统计学意义.结论 术前静脉注射0.02 mg/kg盐酸戊乙奎醚对老年患者非心脏手术POCD发生率无显著影响.     

A case of coronary artery spasm during epidural anesthesia with continuous infusion of propofol

A 50-year-old male patient was scheduled for left partial pulmonary resection and biopsy. The patient had neither complication nor history of ischemic heart disease. After arriving in the operation room, an epidural catheter was inserted into the epidural space at the T 4-5 intervertebral space. Anesthesia was induced with intravenous propofol 100 mg, fentanyl 100 microgram and vecuronium 6 mg and then a double lumen endotracheal tube was inserted. Anesthesia was maintained with O2 and air (FIO2 0.3-1.0), continuous infusion of propofol, intermittent intravenous administration of fentanyl and epidural injection of 1% lidocaine. Forty-five minutes after the start of operation, ECG showed an elevation of ST segment and soon it passed into ventricular tachycardia and ventricular fibrillation. The patient was treated with cardiopulmonary resuscitation. Fifteen minutes later, ECG returned to sinus rhythm but the elevation of ST segment remained. We considered that these cardiac events were due to coronary spasm, and started continuous infusion of nitroglycerin and nicorandil. One hour later, ST segment returned to normal. The possible inducing factors in this case were altered balance between sympathetic and parasympathetic nervous activity caused by infusion of propofol and epidural block, and alpha-stimulation caused by ephedrine.     

异丙酚对腹腔镜胆囊切除病人术后恶心呕吐的防治作用

目的 探讨异丙酚的镇吐作用及可能的作用机制。方法 60例ASAⅠ－Ⅱ级行择期腹腔镜胆囊切除术患者,随机分为三组;对照组（C组）行常规气管插管吸入全麻,恩丹西酮组（O组）入室后静脉注射恩丹西酮4mg,其他处理C组,异丙酚组（P组）诱导插管同C组,麻醉维持用异丙酚微泵静滴。分别测定入室（基础值）、气管插管后、术毕、术后6h血浆胃动素的水平,并观察术后恶心呕吐程度及发生率。结果 C组20例中9例发生Ⅱ－Ⅲ级恶心、呕吐,发生率为56．7％,O组为4例,P组为3例,发生率分别为20％、13．3％。围术期胃动素水平：C组术毕明显高于基础值（P＞0．01）,术后P明显低于C组及O组。结论 异丙酚静脉麻醉能降低腹腔镜胆囊切除术后恶心呕吐发生率,可能与抑制血浆胃动素合成及分泌有关。     

Cardiovascular effects of a combination of vecuronium and low-dose fentanyl in atropinized and non-atropinized subjects]

The cardiovascular effects of the pharmacologic association of low-dose fentanyl (2 micrograms/kg) and vecuronium (120 micrograms/kg) have been studied in 38 ASA I and II atropinized and non-atropinized patients scheduled for abdominal surgery during induction of anaesthesia with thiopentone or propofol. Whatever the induction agent used, heart rate was consistently reduced in patients not receiving an anticholinergic drug, while it was unchanged in patients treated with atropine intravenously. In non-atropinized patients impressively lower minimum heart rates were observed during induction of anaesthesia with thiopentone. In this last group one patient suffered from a cardiac arrest resolved without sequelae. In patients treated with the association between vecuronium and low doses of fentanyl a pretreatment with atropine is always indicated. Propofol seems to be a better induction agent than thiopentone.     

不同全麻下腹腔镜结肠癌切除术病人围术期细胞免疫功能的比较

目的 比较在相同麻醉深度下不同全麻对腹腔镜结肠癌切除术病人围术期细胞免疫功能的影响.方法 择期行腹腔镜结肠癌切除术的病人90例,年龄40～64岁,体重50～85 kg,性别不限,ASA分级Ⅰ或Ⅱ级.采用分层随机法,将患者随机分为3组(n＝30):全凭静脉麻醉组(Ⅰ组)、吸入全麻组(Ⅱ组)和静吸复合全麻组(Ⅲ组).Ⅰ组静脉注射咪达唑仑、舒芬太尼和维库溴铵,TCI异丙酚和瑞芬太尼麻醉诱导;TCI异丙酚和瑞芬太尼,间断静脉注射维库溴铵维持麻醉.Ⅱ组吸入七氟醚麻醉诱导,吸人七氟醚,间断静脉注射维库溴铵维持麻醉.Ⅲ组静脉注射咪达唑仑、舒芬太尼和维库溴铵,TCI异丙酚和瑞芬太尼麻醉诱导,TCI异丙酚和瑞芬太尼,吸入七氟醚,间断静脉注射维库溴铵维持麻醉.术中采用Narcotrend指数监测麻醉深度,维持Narcotrend指数37 ～ 64.于麻醉诱导前30min(T0)、切皮后2 h(T1)、术毕(T2)和术后24 h(T3)时采外周静脉血样,采用流式细胞术测定T淋巴亚群CD3+、CD4+、CD8+和NK细胞的水平,计算CD4+/CD8+.结果 与T0时比较,Ⅱ组T2时CD3+、CD4+、CD4+/CD8+和NK细胞水平降低,Ⅲ组T2时NK细胞水平降低(P<0.05);与Ⅰ组比较,T2时Ⅱ组CD3+、CD4+、CD4+/CD8+和NK细胞水平降低,Ⅲ组NK细胞水平降低(P＜0.05);与Ⅲ组比较,T2时Ⅱ组CD3+和CD4+水平降低(P<0.05).结论 与吸入麻醉和静吸复合麻醉比较,静脉注射咪达唑仑、舒芬太尼和维库溴铵,TCI异丙酚和瑞芬太尼麻醉诱导,TCI异丙酚和瑞芬太尼,间断静脉注射维库溴铵维持麻醉对腹腔镜结肠癌切除术病人围术期细胞免疫功能的抑制程度低.     

On-line monitoring of end-tidal propofol concentration in anesthetized patients

BACKGROUND: Propofol (2,6-diisopropylphenol) has some volatility, so it can be detected in expired breath of individuals receiving intravenous propofol. This study measured volatile propofol exhaled by patients and investigated the relation between exhaled and plasma propofol concentrations. METHODS: Nineteen patients with American Society of Anesthesiologists physical status I or II who were undergoing elective surgery participated in this two-part study. In study 1 (n = 11), anesthesia was induced with 2 mg/kg propofol, 0.1 mg/kg vecuronium, and 2 microg/kg fentanyl. After intubation, propofol was administered continuously for 60 min at each of three rates: 3, 6, and 9 mg x kg(-1) x h(-1). Blood samples were obtained just before each change in the infusion rate, and the plasma concentrations of propofol were measured. The exhaled propofol concentration was measured continuously by means of proton transfer mass spectrometry. End-tidal propofol concentrations during blood sampling were averaged and compared with plasma propofol concentrations. In study 2 (n = 8), after induction of anesthesia, patients received a bolus injection of 2 mg/kg propofol, and the exhaled propofol concentration was measured. RESULTS: Volatile propofol was detected in expired gas from all study patients. From study 1, the authors obtained 24 paired data points, i.e., concentrations of end-tidal and plasma propofol. With Bland-Altman analysis, bias +/- precision was 5.2 +/- 10.4 with 95% limits of agreement of -15.1 and 25.6. In study 2, the exhaled propofol concentration curve showed an obvious peak in all patients. CONCLUSIONS: Agreement between plasma and exhaled propofol concentrations suggests that proton transfer mass spectrometry can be used for real-time propofol monitoring.     

术前静脉注射帕瑞昔布钠对胸外科手术病人术后镇痛效果的影响

目的 探讨术前静脉注射帕瑞昔布钠对胸外科手术病人术后镇痛效果的影响.方法 拟在全身麻醉联合胸段硬膜外阻滞下行胸外科手术病人90例,年龄38～76岁,身高154～181 cm,体重44～82 kg,ASA分级Ⅰ～Ⅲ级.按随机数字表法分为3组(n=30):A组切皮前30 min静脉注射生理盐水2 ml;B组拔除气管导管后静脉注射帕瑞昔布钠40 mg(生理盐水稀释至2 ml);C组切皮前30 min静脉注射帕瑞昔布钠40 mg.经T6,7行硬膜外阻滞,采用舒芬太尼-维库溴铵-异丙酚行麻醉诱导和维持.术后均采用0.125%罗哌卡因和舒芬太尼0.5ug/ml行PCEA,维持VAS评分≤3分.于术后4、12、24、48 h时行BCS舒适度评分,记录术中和术后48 h内阿片类镇痛药用量、不良反应的发生情况.结果 与A组比较,B组和C组术后48 h内舒芬太尼用量减少(P＜0.05),B组术后4 h时BCS舒适度评分升高,C组术后各时点BCS舒适度评分升高,术中舒芬太尼用量减少(P＜0.05).与B组比较,C组BCS舒适度评分升高,术中及术后48 h内舒芬太尼用量减少(P＜0.05).三组不良反应发生率比较差异无统计学意义(P＞0.05).结论 术前静脉注射帕瑞昔布钠40 mg可减少胸外科手术病人围术期阿片类镇痛药物用量.     

异氟烷对癫痫和非癫痫病人脑电图的影响

目的 比较不同呼气末异氟烷浓度时癫痫及非癫痫病人电图及棘波的变化。方法 14例癫痫需行手术治疗及10例大癫痫开颅手术病人,以0．7MAC的异氟烷维持麻醉,术中置入硬膜电极后,调整蒸发器刻度,分别控制呼气未异氟烷浓度于0．7MAC、1．0MAC、1．3MAC及1．5MAC,并各稳定15min后,描记脑电图。结果 癫痫病人1．0MAC异氟烷时棘波的频率与0．7MAC时相比无明显变化,而1．3MAC和1．5MAC时的棘波的频率明显少于0．7MAC（P＜0．01）。非癫痫病人在0．7MAC、1．0MAC及1．3MAC异氟烷时均无棘波出现,于1．5MAC时有一例出现棘波。随着呼气末异氟烷浓度的升高所有病人的α和β波逐渐减少,而δ波增多。结论 癫痫手术用异氟烷维持麻醉,术中需行皮层脑电图监测 时,将异氟烷麻醉深度维持于0．7－1．0MAC较为适宜,以保证癫痫源灶准确的定位及手术切除范围。