静脉镇静镇痛技术在隆乳术中的临床应用

目的介绍静脉镇静镇痛技术在局部麻醉隆乳术中的应用效果和体会.方法将606例ASAⅠ、Ⅱ级隆乳术患者分为四组,分别采用负荷剂量后持续输注异丙酚-芬太尼(P-F组,n=56)、咪唑安定-芬太尼(M-F组,n=130)、异丙酚-芬太尼-氯胺酮(P-F-K组,n=68)或咪唑安定-芬太尼-氯胺酮(M-F-K组,n=352)复合液的给药方法,调整注速维持镇静深度在改良的警觉/镇静评分2或3分.结果四组患者术中的镇静镇痛效果均满意,呼吸循环功能基本稳定,均在停药3～10!min后清醒,但P-F-K组和M-F-K组患者的术中疼痛发生率及程度显著低于P-F组和M-F组.术后随访所有患者均对麻醉效果满意,仅P-F组和P-F-K组分别有11例和5例患者有模糊术中记忆.结论镇静镇痛技术是适用于隆乳局部麻醉手术简单、安全有效的理想麻醉方法,复合使用小剂量氯胺酮能明显减少术中疼痛的发生率,其中以咪-芬-氯复合镇静镇痛的术中疼痛和记忆发生率最低,程度最轻,是适于该手术的最佳镇静镇痛方法.     

静脉镇静镇痛复合肋间神经阻滞用于隆乳手术的临床观察

目的:观察静脉镇静镇痛复合肋间神经阻滞用于隆乳术的麻醉效果。方法:共60例行择期隆乳术的健康女性病人,随机采用负荷剂量后持续输注咪唑安定-芬太尼(M-F组,n=30)或咪唑安定-芬太尼-氯胺酮(M-F-K组,n=30)的方法,调整注速维持镇静深度在改良的OAA/S评分2～3分。所有病人行双侧T2～T7肋间神经阻滞。结果:两组病人术中呼吸循环功能稳定,镇静镇痛效果满意,以M-F-K组更为理想。两组病人均在停药后4～12min内清醒,时间无明显差别。术后24h随访所有病人均无术中记忆,对麻醉方法满意。结论:静脉镇静镇痛复合肋间阻滞具有镇痛良好,胸大肌松弛,病人痛苦小、恢复快、并发症少、无精神创伤等优点,是适合隆乳手术简单、安全有效的理想麻醉方法,以M-F-K镇静镇痛的效果更加理想。     

不同配伍异丙酚麻醉在人工流产手术中的应用

异丙酚近来广泛应用于人工流产术的麻醉。 但异丙酚镇痛作用弱,遇疼痛等强刺激时常需以深镇静来对抗;异丙酚作用时间相当短,遇手术时间长者用药量过大。本文旨在通过比较异丙酚复合应用芬太尼、咪唑安定、氯胺酮的临床效果,寻找一种最佳的配伍方案。     

异丙酚复合芬太尼静脉全麻在隆乳术中的应用

目的:观察异丙酚、芬太尼复合静脉全麻应用于门诊隆乳手术的麻醉效果。方法:ASAI～II级门诊行隆乳手术的患者60例,麻醉前30min给予阿托品0.5mg,诱导用芬太尼0.1mg,咪唑安定2mg,然后接微量注射泵按3～8mg/kg/h的速度泵注异丙酚达所需麻醉深度并维持,分离胸大肌时加芬太尼0.05mg,手术缝合时停止泵注异丙酚。记录麻醉前、麻醉后、手术开始时、分离胸大肌时、术毕时的SBP、DBP、SPO2、HR及术毕清醒时间,术中记忆、术后头晕、恶心、呕吐的发生例数。结果:组内各时点SBP、DBP、SPO2、HR比较无显著差异(P>0.05),24例苏醒期间有轻微头晕,8例有轻恶心,但无呕吐。结论:异丙酚复合芬太尼用于隆乳手术的麻醉镇静、镇痛效果好,过程平稳,对呼吸、循环功能干扰小,不良反应少,是一种较理想的麻醉方法。     

小剂量氯胺酮复合咪唑安定辅助腰硬联合麻醉的临床观察

目的观察小剂量氯胺酮复合咪唑安定辅助腰硬联合麻醉的效果。方法选择40例经腹子宫全切病人,随机分为氯胺酮复合咪唑安定组(A组)和芬太尼复合氟哌啶醇组(B组),在腰硬联合麻醉成功后,A组静脉给氯胺酮0.4mg/kg+咪唑安定0.05mg/kg,B组静脉给芬太尼1.0μg/kg+氟哌啶醇0.05mg/kg,观察并记录术中各时段SBP、DBP、SpO2、HR,记录术中镇静和遗忘情况,及抗牵拉反应效果。结果给药后A组各时段SBP、DBP、HR差异无统计学意义,B组给药后5min、15minSBP、DBP、HR值与术前相比下降明显(P<0.05),A组镇静及遗忘程度比B组好,两组都取得良好的抗牵拉效果,两组都无精神症状。结论小剂量氯胺酮复合咪唑安定辅助腰硬联合麻醉时,有良好的镇静和镇痛及遗忘作用,且无精神症状,应用效果良好。     

丙泊酚复合咪唑安定和/或芬太尼在胆道镜操作过程中的镇静作用

目的研究丙泊酚复合咪唑安定和/或芬太尼用于胆道镜操作过程中的镇静效果。方法选择18~65岁行胆道镜的患者90例,随机分为三组:PF组(n=31),首次静注芬太尼0.05 mg+丙泊酚1 mg/kg;PM组(n=29),首次静注咪唑安定2 mg+丙泊酚1 mg/kg;PMF组(n=30),首次静注芬太尼0.05 mg+咪唑安定2 mg+丙泊酚1 mg/kg。各组根据需要追加丙泊酚每次20~30 mg。记录心率、血压、脉搏血氧饱和度、镇静分级,观察患者症状及记忆缺失情况。结果用药后1 min三组患者都能达到满意的镇静效果(镇静分级2~3级);所有患者停药后17 min完全清醒,PF组恢复时间最短(P<0.01),但有21例(67.7%)对操作过程有记忆,只有15例(48.4%)患者对麻醉镇静的方法感到很满意。结论丙泊酚复合咪唑安定和/或芬太尼在胆道镜操作中镇静效果更好,无明显不良反应。     

丙泊酚复合咪唑安定和/或地佐辛在纤维支气管镜检查中的镇静作用

目的:研究丙泊酚复合咪唑安定和/或地佐辛用于纤维支气管镜检查中的镇静、镇痛效果.方法:选择18-65岁行纤维支气管镜的患者60例,随机分为三组:PD组(n=21),首次静注地佐辛5mg+丙泊酚1mg/kg; PM组(n=19),首次静注咪唑安定2mg+丙泊酚1mg/kg; PMD组(n=20),首次静注地佐辛5mg+咪唑安定2mg+丙泊酚1mg/kg.各组根据需要追加丙泊酚每次20-30mg.记录心率、血压、脉搏血氧饱和度、镇静分级,观察患者症状及记忆缺失情况.结果:用药后一分钟三组患者都能达到满意的镇静效果(镇静分级2-3级)；所有患者停药后15分钟完全清醒,PD组恢复时间最短(P＜0.01),但有11例(52.4％)对操作过程有记忆,只有10例(47.6％)患者对麻醉镇静的方法很满意.结论:丙泊酚符合咪唑安定和/或地佐辛在纤维支气管镜检查中镇静效果更好,无明显不良反应.     

小剂量氯胺酮应用于隆乳术麻醉效果观察

隆乳术是一种可在门诊进行的美容手术,以往均在局部麻醉下完成,由于患者对疼痛耐受性较差,手术过程较痛苦,且随着生活水平的不断提高,人们对生存质量的要求也愈来愈高.为减轻患者痛苦,我院将小剂量氯胺酮复合异丙酚、芬太尼静脉全身麻醉,应用于门诊隆乳手术,取得了较好的效果.现报道如下.     

靶控输注异丙酚和瑞芬太尼静脉麻醉在隆乳手术中的应用

目的：观察异丙酚复合瑞芬太尼靶控静脉全麻（Target controlled infusion,TCI）用于门诊隆乳手术的麻醉效果。方法：ASAⅠ～Ⅱ级门诊隆乳手术患者60例,随机分为异丙酚复合瑞芬太尼靶控输注组（RP组,n=30）和氯胺酮恒速输注组（K组,n=30）。观察两组患者的术后初醒时间,准确定向时间、离院时间;术中体动程度和次数、术者评价的麻醉效果、呼吸抑制评分和HR、MAP、SpO2及术后并发症的发生情况。结果：两组患者初醒时间、准确定向时间、离院时间有明显差异,RP组明显小于K组（P〈0.05）。麻醉效果评分RP组好于P组（P〈0.05）,且其体动程度评分和次数均低于K组（P〈0.05）,两组间呼吸抑制评分无明显差异（P〉0.05）。RP组术中HR、MAP的变化较K组平稳,差异有显著性（P〈0.05）。RP组恶心、呕吐及不良记忆等术后并发症的发生也明显少于K组（P〈0.05）。结论：异丙芬复合瑞芬太尼芬TCI输注用于隆乳手术,镇静、镇痛效果好,循环更稳定,术后恢复快,不良反应少,是门诊隆乳手术理想的麻醉方法。     

胃镜检查术患者异丙酚复合咪唑安定、芬太尼麻醉的效果

单纯使用异丙酚对无痛胃镜检查术患者呼吸循环影响大，胃镜刺激引起的咽部反应和肢体活动多见，镇静作用维持时间短，遗忘效果不完善。本研究拟通过观察胃镜检查术患者异丙酚复合咪唑安定、芬太尼麻醉的效果，为临床应用提供参考。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.