Postoperative period in early activated patients after myocardial revascularization

The specific features of an early postoperative period were studied in 115 patients undergone myocardial revascularization who were divided into 3 groups according to the time of postoperative activation. Group 1 comprised 35 patients in whom tracheal extubation was made in the operating room 30-60 min after the end of the operation. Group 2 included 32 patients extubated 2-8 hours after admission to the resuscitation and intensive care unit (RICU); Group 3 consisted of 48 patients undergone tracheal intubation for more than 8 hours. The patients of this group received traditional anesthesia using ketamine, benzodiazepines, and large-dose fentanyl. The developed combined anesthesia with inhalational and intravenous anesthetics having their better pharmacodynamics, such as isoflurane, diprivan, tracrium, was used in 60.3% of the patients in Groups 1 and 2. The developed type of anesthesia using a high thoracic (T2-T4) epidural blockade as a basic component of anesthesiological maintenance was studied. In Group 2, the preextubation time was twice less than that in a control group (5.2 +/- 0.3 and 10.8 +/- 0.4 hours, respectively, p < 0.05). In groups with early extubation, the incidence of clinically significant cardiovascular disorders was less than that in the controls, which is indicative of better performance of the cardiovascular system. In Group 1, the frequency of reintubations for arterial hypoxemias was 2.8% and that of pneumonias and pulmonary microatelectasis was 2.5 times less as that in Group 3 (9%, p < 0.05). Chills occurred in 6, 4, and 15% of cases in Groups 1, 2, and 3, respectively (p < 0.05). A programme on early activation after aortocoronary bypass surgery could reduce the patients' stay at the RICU on an average by 24 hours without increasing the risk for postoperative complications.     

Combined inhalation and epidural anesthesia, during aortocoronary bypass surgery on beating heart

Aim of study is to compare efficiency and safety of different methods of combined inhalational and epidural anesthesia during aortocoronary bypass surgery on beating heart. Subjects and methods: 40 patients suffering from coronary heart disease were included in randomized study. Two methods of combined inhalational and epidural anesthesia were compared. The first group of 22 patients were administrated extended-release epidural anesthesia with Ropivacaine 0.3% in upper thoracic region and Sevoflurane as a volatile agent. Second group of 18 patients were administrated Isoflurane and epidural anesthesia. Monitoring: (Harvard standard of monitoring), BIS, invasive monitoring of hemodynamic, the dose of anesthetic gas, internal medical audit. Result of the study showed that all patient had same duration of surgery, level of unconsciousness (BIS 40-45%) dose of valiant anesthetic agents less than 1 MAC, same dose of Ropivacaine, minimal dose of opioids, quantity and quality of intravenous infusion therapy and same amount of vasopressors. It was discovered that Sevoflurane had influenced hemodynamic less than Isoflurane. The results of internal retrospective medical study showed safety of both methods of anesthesia. Sevoflurane allowed fast postoperative recovery on 1,74 times ,early extubation in theater on 1,64 times. Both methods of combined anesthesia epidural and inhalational presented good results and can be performed in coronary bypass surgery but for fast-track surgery and anesthesia use of Sevoflurane is better.     

Effects of anesthetics on oxidative stress changes in patients with high anesthetic risk in the perioperative period of coronary bypass surgery

The study included 44 patients who were divided into 3 groups according to the type of anesthesia. In group 1 patients (n = 15), initial anesthesia was accomplished by inhaled sevoflurane and intravenous fentanyl (2.5-3.5 microg/kg); basal anesthesia was performed with sevoflurane. In Group 2, midazolam, 0.1-0.15 mg/kg, fentanyl, 5.2 +/- 0.01 vg/kg, and ketamine, 0.85 +/- 0.13 mg/kg were given for induction. Basic anesthesia was carried out, by administering fentanyl in a dose of 4.71 +/- 0.4 microg/kg/hour, halothane, 0.5-1.5 ob %. In Group 3, midazolam, 1.2 +/- 0.01 mg/kg) and fentanyl, 7.8 +/- 0.6 microg/kg) were used to induce anesthesia. Basic anesthesia was effected with fentanyl, 5.31 +/- 0.5 microg/kg/hour, ketamine, and diprivan. Anesthetic management using halogen-containing inhalational anesthetics at coronary bypass surgery in patients at high anesthetic risk was ascertained to cause a significant reduction in the degree of manifestations of oxidative stress and facilitated a better intraoperative period. Sevorane was found to have the most significant effect on oxidative stress.     

老年急性肠梗阻病人的麻醉探讨

目的比较两种麻醉方法硬膜外复合全身麻醉(GE组)和单纯全麻(G组)在老年急性肠梗阻病人术中的应用,指导临床实践。方法本实验选择老年急性肠梗阻病人36例,分为硬膜外复合全身麻醉(GE组)和单纯全麻(G组),每组18例,GE组病人先进行硬膜外穿刺(T10-11),给于2%利多卡因5 ml,测定有效的麻醉平面后,开始常规诱导。两组病人均以芬太尼、维库溴铵、咪唑安定、异丙酚静脉诱导,麻醉维持以持续吸入异氟醚为主,G组辅以单次静注维库溴铵2-4 mg,芬太尼0.05-0.1 mg,GE组术中每1 h硬膜外腔追加0.5%布比卡因5 ml。观测诱导前、插管2 min、探查时、关腹时的SBP、DBP、HR、SPO2,记录催醒药和肌松拮抗药例数和拔管时间。结果插管2 min、探查时,GE组SBP、DBP均比诱导前显著降低(P<0.05),G组SBP、DBP均比诱导前显著升高(P<0.05),两组间比较,GE组SBP、DBP均比G组显著降低(P<0.01),除插管2min时,HR较明显升高外,两组病人各时点的HR、SpO2变化不明显。GE使用催醒药和肌松拮抗药例数明显减少,拔管时间明显缩短。结论硬膜外复合全身麻醉比单纯全麻应激反应小,清醒快,拔管早,不失为老年人急性肠梗阻病人的最佳选择。     

Approaches to anesthesia management of a patient during oncological pulmonary surgery

The results of lungs' excision in 82 patients made under a combined anesthesia of 2 types are comparatively analyzed. A surface low-level endobronchial narcosis by isoflurane was administered in 42 patients concurrently with a "high" epidural anesthesia by bupivakain and fentanyl. The other 40 patients received isoflurane and intravenous bolus injections of fentanyl concurrently with epidural anesthesia by morphine administered at the lumbar level. The epidural analgesia by bupivakain and fentanyl made at the thoracal level or by morphine made at the lumbar level was carried on in the early postoperative period. The results show both variations to ensure a reliable intraoperative anesthesia, a smooth recovery and a good postoperative analgesia. Better results were on the whole obtained by the variant of high epidural anesthesia/analgesia; however, the method of lumbar morphine administration has a number of advantages primarily related with its simplicity.     

Efficacy of various epidural analgesia regimens after lung surgery

A prospective study included 90 adult patients undergoing thoracic surgery. After placing an epidural catheter at the Th4-Th5 level, all the patients were randomized in 3 groups. Twenty-nine patients received controlled epidural analgesia (PCEA) with fentanyl, 2 microg/ml, in 0.2% bupivacaine solution (Group 1). In other groups, these analgesics were given either as bolus infections (Group 2; n = 30) or as a continuous epidural infusion of fentanyl, 2 microg/ml, in 0.2% bupivacane solution (Group 3; n = 27). Pain scores and the incidence of adverse effects were assessed within the first 24 hours after surgery. The data were compared using the Student's t-test and x2 test with Bonferroni correction; p < 0.017 was regarded as statistically significant. The VAS scores in coating were significantly lower in Group 1 than in Groups 2 and 3. The need for epidural opioids for adequate analgesia within the first 24 hours after surgery was significantly less in Group 1 than in Groups 2 and 3. There were no excessive sedation episodes in all the groups. In Group 2, the incidence of nausea was 20%. These adverse reactions were not found during PCEA and continuous infusion (p < 0.017). Opioid-induced pruritis was mostly (23%) observed in Group 2. Thoracic PCEA with fentanyl-bupivacaine solution provided adequate postoperative analgesia after thoracotomy and reduced the need for opioids. In addition, PCEA reduced the incidence of adverse reactions of opioids.     

胸段硬膜外阻滞联合全麻在快速康复外科中的应用性研究

目的探讨在快速康复外科理念指导下的胸段硬膜外联合全麻对术中应激反应、循环状态以及术后肠功能恢复的影响。方法 44例结直肠癌择期手术的患者随机分为两组:单纯全麻组(Ⅰ组,n=22)、胸段硬膜外阻滞加全麻组(Ⅱ组,n=22)。测定麻醉前、插管后1 min、手术切皮时、切皮后1 h、拔管后1 min血清皮质醇(Cor)、肾上腺素(E)和血糖(Glu)水平,记录循环指标、全麻用药量、术后苏醒时间与拔管时间及术后肠功能恢复时间。结果Ⅰ组Glu于切皮前高于Ⅱ组(P0.05),手术1 h显著高于Ⅱ组(P0.01),Cor与Glu变化一致,Ⅰ组E在气管插管后和拔管后明显升高,Ⅱ组术中较平稳;Ⅰ组平均动脉压(MAP)、心率(HR)手术切皮前及术中1 h波动较大,Ⅱ组术中较平稳,两组差异有统计学意义(P0.05),Ⅱ组的全麻用药明显少于Ⅰ组(P0.01),Ⅱ组术毕拔管时间、清醒时间及通气时间明显短于Ⅰ组(P0.05)。结论在快速康复外科理念指导下的胸段硬膜外联合全麻可明显减轻结直肠手术患者的应激反应,并能有效地促进术后肠功能恢复。     

Comparative assessment of general and regional anesthesia during total endoprosthetic operations on the knee joint

The present paper comparatively analyzes anesthetic support in 91 patients during a total endoprosthetic operation on the knee joint. All the patients were conventionally divided into 4 groups: (1) those (n=7) in whom the operation had been made under general anesthesia (nitrous oxide, ketamine, seduxen, droperidol, and fentanyl); (2) those (n=36) who had been operated on under epidural anesthesia; (3) those (n=24) who had intraoperatively received spinal (subarachnoidal) anesthesia; (4) those (n=24) whom had been intraoperatively given combined spinal and epidural anesthesia. The study established that the above-mentioned general anesthesia failed to produce a steady-state hemodynamics; the earliest postoperative period being accompanied by a significant pain syndrome, which required the use of narcotic analgesics. In Group 2, due to the specific features of the impact of epidural anesthesia itself on different innervation links (A, B, and C), susceptibility to hypotension and the adequacy of this mode of anesthesia were observed, which required the intraoperative additional administration of narcotic agents to enhance anesthesia. Group 3 was marked by a relative postoperative stability of parameters, but a significant pain syndrome is observed in the earliest postoperative period. The best results were obtained in Group 4 patients undeigone a combined spinal and epidural anesthesia. The component of subarachnoidal (spinal) anesthesia Marcaine Spinal provided a sufficient intraoperative analgesic effect and the component of epidural anesthesia induced virtually no pain syndrome under continuous epidural block.     

小剂量芬太尼在胸科手术全麻复合高胸位硬膜外阻滞中的应用

目的观察胸科手术小剂量芬太尼在全麻复合高胸位硬膜外阻滞中的麻醉作用。方法40例科手术患者随机分为实验组(GE组)和对照组(GA组),GE组为全麻复合高胸位硬膜外阻滞,单纯全麻组为GA组,记录术中麻醉药用量,术毕苏醒时间和血压(BP)、心率(HR)。脑电双频指数(BIS)和白细胞介素-6(IL-6)。结果2组麻醉效果均满意,术毕拔管时间和异丙酚用量GE组显著小于GA组(P<0.05),血压、心率GE组均低于GA组,2组IL-6术后均比术前升高,但2组间无显著性差异,BIS值均在手术应在的常规范围内,但拔管时GE组略高于GA组。结论小剂量芬太尼在全麻复全高胸位硬膜下阻滞下胸科手术中能达到满意的麻醉效果。     

胸段硬膜外阻滞联合全麻在快速康复外科中的应用性研究

目的探讨在快速康复外科理念指导下的胸段硬膜外联合全麻对术中应激反应、循环状态以及术后肠功能恢复的影响。方法 44例结直肠癌择期手术的患者随机分为两组：单纯全麻组（Ⅰ组,n=22）、胸段硬膜外阻滞加全麻组（Ⅱ组,n=22）。测定麻醉前、插管后1 min、手术切皮时、切皮后1 h、拔管后1 min血清皮质醇（Cor）、肾上腺素（E）和血糖（Glu）水平,记录循环指标、全麻用药量、术后苏醒时间与拔管时间及术后肠功能恢复时间。结果Ⅰ组Glu于切皮前高于Ⅱ组（P〈0.05）,手术1 h显著高于Ⅱ组（P〈0.01）,Cor与Glu变化一致,Ⅰ组E在气管插管后和拔管后明显升高,Ⅱ组术中较平稳;Ⅰ组平均动脉压（MAP）、心率（HR）手术切皮前及术中1 h波动较大,Ⅱ组术中较平稳,两组差异有统计学意义（P〈0.05）,Ⅱ组的全麻用药明显少于Ⅰ组（P〈0.01）,Ⅱ组术毕拔管时间、清醒时间及通气时间明显短于Ⅰ组（P〈0.05）。结论在快速康复外科理念指导下的胸段硬膜外联合全麻可明显减轻结直肠手术患者的应激反应,并能有效地促进术后肠功能恢复。     

Delayed respiratory depression following fentanyl anesthesia for cardiac surgery

High-dose fentanyl anesthesia is widely used in cardiac surgery. Its immediate side-effects are well known. However, its late adverse effect manifested by extreme truncal rigidity, decreased chest wall compliance, hypoventilation, respiratory acidosis and hemodynamic instability is not sufficiently appreciated. Of 380 patients who underwent aortocoronary artery bypass under high-dose (100 micrograms/kg) fentanyl anesthesia, 29 (7.6%) developed the sudden onset of extreme thoracic and abdominal rigidity, leading to respiratory depression 2 to 6 h postoperative, after an apparently normal recovery from the anesthesia. In 15 patients, a high plasma level of fentanyl (5.2 to 7.8 ng/ml) correlated with the clinical events. Administration of naloxone or a muscle relaxant rapidly reversed this late complication of fentanyl, thought to be due to re-entry of fentanyl into plasma from deposits in adipose tissue, muscle and the GI tract, leading to a secondary peak in plasma fentanyl. It is more likely to be encountered when hypothermia, rewarming, and acidosis occur in the postoperative period. Awareness of this life-threatening complication is critical in patients undergoing surgery with fentanyl anesthesia.     

硬膜外辅助全麻与静吸全麻下100例消化道肿瘤患者的麻醉可行性对比

目的比较硬膜外辅助全麻与静吸全麻下消化道肿瘤患者手术的临床疗效和不良反应,为今后手术患者提供更好的麻醉方法。方法选取本院就诊行手术治疗的消化道肿瘤患者100例,按照随机原则分为静吸全麻组和硬膜外辅助组。2组均使用气管内插管进行全麻,硬膜外辅助组在全麻的基础上使用利多卡因进行硬膜外阻滞,比较2组在手术完毕后拔管时间,以及术后的恶心呕吐、心律失常、血压升高的不良反应情况,综合评定2种麻醉方法的疗效。结果硬膜外辅助组麻醉后的拔管时间明显比静吸全麻组短,术后发生并发症的情况少于静吸全麻组。结论对消化道肿瘤患者采用静吸全麻复合利多卡因硬膜外麻醉取得了满意的麻醉效果。     

胸段硬膜外阻滞对冠脉搭桥术预后影响的系统评价

目的系统评价胸段硬膜外阻滞对冠脉搭桥术预后的影响。方法电子检索PubMed、EBSCO、Springer、Ovid、CNKI等数据库,纳入1990～2009年间关于冠脉搭桥手术行胸段硬膜外阻滞联合全麻和传统的单纯全麻预后比较的RCT,按Cochrane系统评价方法对纳入文献进行质量评价和资料提取,采用RevMan软件进行Meta分析。结果共纳入16篇RCT,包括1？316例患者。Meta分析结果显示：胸段硬膜外阻滞联合全麻与传统单纯全麻相比,术后拔气管插管时间缩短[MD=–332.43,95%CI（–640.19,–24.68）,P=0.03],术后第一天静息疼痛VAS[MD=？–1.23,95%CI（–2.19,–0.27）,P=0.01]、术后第一天运动疼痛VAS[MD=？–2.52,95%CI（–4.65,–0.39）,P=0.02]和术后第二天运动疼痛VAS[MD=？–1.5,95%CI（–2.56,–0.43）,P=0.006]降低,术后心肌缺血发生率降低[RR=0.53,95%CI（0.29,0.97）,P=0.04];而在术后心梗、房颤发生率、死亡率和肺功能方面两组间差异无统计学意义。结论冠脉搭桥手术行胸段硬膜外阻滞联合全麻较传统的单纯全麻能明显缩短术后拔气管插管时间,明显降低术后疼痛VAS,降低术后心肌缺血发生率。对于术后心梗、房颤发生率,死亡率和肺功能的影响尚需开展更多深入研究来证实。     

七氟烷预处理对心肺转流术后早期肺损伤的影响

目的：观察七氟烷预处理对心肺转流术（cardiopulmonary bypass,CPB）后早期肺损伤的影响及其机制。方法：择期CBP下行心脏瓣膜置换术的患者16例,随机分为对照组（C组）和七氟烷组（S组）,每组8例。两组均采用静脉注射芬太尼、咪唑安定、维库溴铵维持麻醉,S组分别在CPB开始前吸入七氟烷达1.3最小肺泡浓度（MAC）后维持时间大于30min,洗脱15min,而C组只吸入纯氧。分别于麻醉诱导后10min（T1）,上下腔静脉开放30min（T2）、180min（T3）采桡动脉血进行血气分析并计算肺泡动脉氧分压差（PA-aDO2）、氧合指数（OI）、呼吸指数（RI）,测定血清中的肿瘤坏死因子-α（TNF-α）、P-选择素（P-selectin）浓度。关胸前每组取2例患者少量肺组织查缝隙连接蛋白CX43的表达及作肺组织病理学检查。结果：与T1时点比较,两组T2、T3时点TNF-α、P-selectin水平均明显升高（P〈0.05）,C组T3时点RI值明显增高（P〈0.01）;与C组比较,S组T2、T3时点TNF-α、P-selectin升高幅度较C组低（P〈0.05）,T3时点RI值S组低于C组（P〈0.05）。肺CX43分布与着色两组差异无统计学意义。两组肺组织病理检查均可见肺泡结构破坏及渗出液,肺泡腔中性粒细胞及红细胞浸润,但C组明显比S组严重。结论：七氟烷预处理抑制TNF-α、P-selectin的释放,抑制CBP后肺炎性反应,对CPB后早期肺损伤具有一定的保护作用。     

硬膜外阻滞复合浅全麻用于老年高血压病患者开胸手术

目的观察硬膜外阻滞复合浅全麻对老年高血压患者开胸手术血流动力学变化、术中知晓及苏醒时间的影响。方法择期开胸手术的老年高血压患者60例,随机分为单纯全麻组（Ⅰ组）和浅全麻复合硬膜外阻滞组（Ⅱ组）,监测两组患者术中的血流动力学变化和ECG的变化及全麻药用量和苏醒时间。结果Ⅰ组出现明显的心血管反应,尤以插管及拔管时显著高于基础值（P〈0．05）,Ⅱ组各时点血流动力学稳定,与I组比较有显著差异（P〈0．05）,心肌缺血有所改善,全麻药用量明显少于Ⅰ组（P〈0．01）,术后清醒及气管拔管时间与Ⅰ组比较明显缩短（P〈0．01）。结论硬膜外阻滞复合浅全麻可减轻应激反应,循环状态稳定,全麻用药量减少,苏醒快,是老年高血压患者开胸手术的首选麻醉方法。     

State of the sympathoadrenal system and hemodynamics in children during congenital heart defect surgery with high thoracic epidural anesthesia using lidocaine-clofelin

Effects of high thoracic epidural anesthesia (HTEA) on the hemodynamics and sympathoadrenal system were studied in patients during cardiopulmonary bypass surgery. In 55 patients aged 1-14 years, HTEA was used in combination with oxygen-air-halothane anesthesia. In one group lidocaine and fentanyl were used for HTEA and in another clonidine and lidocaine. In the control, standard intravenous fentanyl-diazepam anesthesia was combined with oxygen-air-halothane anesthesia. In the clonidine-lidocaine group the endocrine stress response was decreased in comparison with other groups even without narcotics; hemodynamics was stable even in patients with NYHA class III-IV.     

全麻并硬膜外阻滞对开胸术老年患者肺功能的影响

【目的】探讨全麻气管插管术合并硬膜外阻滞对开胸手术的老年患者早期肺功能的影响。【方法】将46例老年胸科手术患者,随机分为试验组（A组,n=23）和对照组（B组,n=23）A组用全麻加硬膜外阻滞,B组仅用全麻。观察两组患者的肺活量△VC（L）、二氧化碳分压△PaCO2（mmHg）、动脉血管分压△PaO2（mmHg）。【结果】两组病例术后镇痛评分、肺功能指标和对照组比较差异有统计学意义。【结论】全麻合并硬膜外阻滞术后有利于早期咳嗽排痰,促进肺功能恢复。     

芬太尼和瑞芬太尼用于肾移植麻醉的比较

目的比较肾移植麻醉时使用芬太尼、瑞芬太尼时安全性和有效性。方法36例患者随机分为芬太尼组和瑞芬太尼组。观察血流动力学变化;术毕自主呼吸恢复时间,呼之睁眼时间,拔管时间,定向力恢复时间;观察拔管后即刻、拔管后30 min1、h3、h和24 h的意识状态(OAAS),认识功能测试(MMSE);观察术后不良反应的发生率等。结果麻醉诱导期瑞芬太尼组患者血流动力学变化幅度显著小于芬太尼组(P<0.05)。瑞芬太尼组患者自主呼吸恢复时间,呼之睁眼时间,拔管时间,定向力恢复时间均早于芬太尼组(P<0.05)。瑞芬太尼组拔管后即刻、拔管后30 min1、h、3 h的OAAS及MMSE评分均高于芬太尼组(P<0.05)。结论瑞芬太尼麻醉诱导更加平稳,术中血流动力学稳定,苏醒质量优良。     

Combined monitoring of the central and autonomic nervous system during operations on the liver and pancreas

Thirty patients from 3 groups that differed only in the scope of monitoring were examined to study the efficiency of combined neurophysiological and autonomic nervous monitoring in the assess of the quality of anesthesiological protection during highly traumatic surgical interventions made in abdominal patients under combined general anesthesia based on long-term graded epidural naropine (3 mg/ml) infusion at the thoracic level Addition of the Harvard standard with monitoring the information saturation of EEG made it possible to maintain the depth of anesthesia, by reducing the dose of dormicum by 20% (p < 0.05). The use of combined monitoring of EEG information saturation and the tension index after R. M. Bayevsky could reduce the dose of fentanyl by 2.3-2.7 times (p < 0.05) and the incidence of critical cardiovascular incidents by 39% (p < 0.05).     

Experience with epidural anesthesia during myocardial revascularization operations

The paper presents the results of 213 myocardial revascularization using epidural anesthesia. The used anesthesiological protocol combining intravenous proforol sedation and epidural naropine block proved to be effective and safe and ensured adequate anesthesia that made possible myocardial revascularization both without using extracorporeal circulation (transmyocardial laser revascularization, mini-invasive myocardial revascularization) and with complex repairs of the geometry of the left ventricle and cardiac valvular apparatus and provides a means for the activation of patients and extubation on the operating table in the absence of surgical complications, hemorrhages, and extracorporeal circulation procedures even after reconstructive surgery.