咪唑安定联合芬太尼在结肠镜检查中的镇静镇痛效果及护理

目的探讨咪唑安定复合芬太尼在结肠镜检查中的镇静镇痛作用及护理支持。方法165例ASAⅠ～Ⅱ级患者随机分为2组：无痛结肠镜检查组（A，n=95），传统结肠镜检查组（B，n=70）。A组静脉推注咪唑安定0．05mg／kg、芬太尼1μg／kg，1～2min开始进行结肠镜检查；B组施行传统结肠镜检查。观察镇静、镇痛、满意、遗忘的程度、愿意再次检查调查及心率、血压、血氧饱和度的变化。结果A组注药开始检查后1minMAP、SpO2较注药前有明显下降（P〈0．01），5、10和15min时时段无显著性差异（P〉0．05），呼吸抑制（SpO2〈90％），发生率占3．2％；B组检查开始后1、5、10和15min时MAP及HR较检查前明显上升（P〈0．01）。A组93％患者达Ramsay2～3级清醒镇静镇痛。A组镇静、镇痛、满意及遗忘程度和愿意再次检查率均明显优于B组（P〈0．01）。结论咪唑安定联合芬太尼用于结肠镜检查中，可显著改善患者的耐受性，具有良好的镇静镇痛效果，是安全有效的；且护理支持中必须加强呼吸、循环监护及镇静观察。     

咪唑安定镇静遗忘术在隆胸术中的效果观察

目的 探讨咪唑安定能否使病人达到术中良好的镇静和顺行性遗忘作用。方法 选择隆胸住院病人80例，分A、B两组，A组用氯胺酮，B组用咪唑安定复合氯胺酮静脉麻醉，术中观察血流动力学变化与麻醉恢复期情况。结果 在麻醉过程中，B组各项观察指标明显优于A组，B组的术中知晓及梦幻的发生率为零，对手术中的情况无任何记忆。结论 咪唑安定复合静脉麻醉，能使病人达到镇静遗忘作用，是隆胸手术较理想的麻醉方法。     

咪唑安定联合芬太尼在结肠镜检查中的镇静镇痛效果及护理

目的 探讨咪唑安定复合芬太尼在结肠镜检查中的镇静镇痛作用及护理支持.方法 165例ASA Ⅰ～Ⅱ级患者随机分为2组:无痛结肠镜检查组(A,n=95),传统结肠镜检查组(B,n=70).A组静脉推注咪唑安定0.05 mg/kg、芬太尼1 μg/kg,1～2 min开始进行结肠镜检查;B组施行传统结肠镜检查.观察镇静、镇痛、满意、遗忘的程度、愿意再次检查调查及心率、血压、血氧饱和度的变化.结果 A组注药开始检查后1 min MAP、SpO2较注药前有明显下降(P＜0.01),5、10和15 min时时段无显著性差异(P＞0.05),呼吸抑制(SpO2＜90%),发生率占3.2%;B组检查开始后1、5、10和15 min时MAP及HR较检查前明显上升(P＜0.01).A组93%患者达Ramsay 2～3级清醒镇静镇痛.A组镇静、镇痛、满意及遗忘程度和愿意再次检查率均明显优于B组(P＜0.01).结论 咪唑安定联合芬太尼用于结肠镜检查中,可显著改善患者的耐受性,具有良好的镇静镇痛效果,是安全有效的;且护理支持中必须加强呼吸、循环监护及镇静观察.     

咪唑安定联合芬太尼在结肠镜检查中的镇静镇痛效果及护理

目的探讨咪唑安定复合芬太尼在结肠镜检查中的镇静镇痛作用及护理支持。方法165例ASAⅠ～Ⅱ级患者随机分为2组:无痛结肠镜检查组(A,n=95),传统结肠镜检查组(B,n=70)。A组静脉推注咪唑安定0.05mg/kg、芬太尼1μg/kg,1～2min开始进行结肠镜检查;B组施行传统结肠镜检查。观察镇静、镇痛、满意、遗忘的程度、愿意再次检查调查及心率、血压、血氧饱和度的变化。结果A组注药开始检查后1minMAP、SpO2较注药前有明显下降(P<0.01),5、10和15min时时段无显著性差异(P>0.05),呼吸抑制(SpO2<90%),发生率占3.2%;B组检查开始后1、5、10和15min时MAP及HR较检查前明显上升(P<0.01)。A组93%患者达Ramsay2～3级清醒镇静镇痛。A组镇静、镇痛、满意及遗忘程度和愿意再次检查率均明显优于B组(P<0.01)。结论咪唑安定联合芬太尼用于结肠镜检查中,可显著改善患者的耐受性,具有良好的镇静镇痛效果,是安全有效的;且护理支持中必须加强呼吸、循环监护及镇静观察。     

舒芬太尼用于鼻内镜局部麻醉手术中的临床研究

目的 探讨舒芬太尼在鼻内镜手术复合麻醉中应用的有效性和安全性.方法 对200例鼻窦炎伴有鼻息肉(Ⅱ型2期)或伴鼻中隔偏曲患者行鼻内镜手术,随机分为4组:咪唑安定组(Ⅰ组),咪唑安定加芬太尼组(Ⅱ组),咪唑安定加舒芬太尼组(Ⅲ组),用药后均达OAA/S镇静评分3分;Ⅳ组为咪唑安定加舒芬太尼,用药后OAA/S镇静评分4分.记录各组用药前(T_0)、局部麻醉时(T_1)、开鼻窦时(T_2)、鼻腔填塞时(T_3)患者血压、心率、血氧饱和度的变化.记录T_1、T_2、T_3各个时点VRS评分,比较术中各组呛咳例数、术中遗忘的例数.结果 Ⅰ组T_1时MAP、HR较T_0显著下降.Ⅱ、Ⅲ、Ⅳ组T_1、T_2、T_3时MAP、HR较T_0均有明显下降(P<0.05).Ⅳ组较前3组需要吸氧的例数少(P<0.05).Ⅰ组T_1和T_3时口述描绘评分较其他3组高(P<0.05),而Ⅲ组和Ⅳ组T_1、T_3时较Ⅱ组低(P<0.05),Ⅲ组较Ⅳ组差异无显著性.Ⅰ组、Ⅱ组、Ⅲ组呛咳例数明显较Ⅳ组多(P<0.05),4组遗忘例数差异无显著性.结论 舒芬太尼复合咪唑安定在鼻内镜局部手术中的应用合适的镇静深度是OAA/S镇静评分4分,此时血流动力学平稳,呼吸抑制轻,镇镇、镇痛、遗忘效果满意.     

异丙酚、咪唑安定在无痛电子支气管镜检查中的镇静作用与安全性评价

目的研究异丙酚、咪唑安定分别复合芬太尼麻醉用于无痛电子支气管镜检查的效果及安全性。方法选择300例电子支气管镜检查患者,随机分成3组,A组异丙酚复合芬太尼麻醉、B组咪唑安定复合芬太尼麻醉、C组（对照组）静脉注射生理盐水10ml;观察每组的镇静效果及检查前、检查中（给药后）及完全清醒的血压、心率、呼吸、血气分析。结果镇静结果显示A、B组均无痛苦及任何不适应感觉,但B组呛咳（42例）、躁动（56例）、检查中断（39例）的发生率明显高于A组（11例,13例,11例）（均P〈0．01）;C组均感觉恐惧及痛苦;检查中A、B两组血压、呼吸呈下降趋势,心率由检查前的增快降至正常水平,C组血压、心率明显升高。3组血压、呼吸、心率比较差异具有统计学意义（P〈0．01）,3组检查前后氧分压（PaO2）均明显下降,3组比较差异具有统计学意义（P〈0．01）,但二氧化碳分压（PaO2）、pH值在3组中有轻度升高趋势,仅B组PaO2检查前后有统计学意义（P〈0．01）。结论异丙酚复合芬太尼麻醉在无痛支气管镜检查中减少了躁动、呛咳、屏气引起的检查中断,镇静效果优于咪唑安定,相对安全、无痛苦,值得荐用。     

冠状动脉介入术患者的意识镇静及其对血流动力学的影响

目的 观察镇静药物咪唑安定及芬太尼在冠状动脉介入术应用中的安全性及其对血流动力学的影响.方法 150例行冠状动脉介入术患者,随机分为3组:50例在常规局部麻醉前给予生理盐水5ml静脉注射(对照组),50例给予0.04 mg/kg咪唑安定用生理盐水稀释至5 ml静脉缓慢注射(咪唑安定组),50例给予咪唑安定0.02 mg/kg联合芬太尼1.2μg/kg用生理盐水稀释至5 ml缓慢注射(联合芬太尼组),观察3组患者HR、血压、经皮血氧饱和度、患者镇静程度评分及脑电双频谱指数(BIS)变化,术后对患者镇静满意程度及术中相关并发症情况进行随访.结果 3组给药前MAP和HR差异均无统计学意义(F分别为3.34和2.98,P均>0.05),对照组术中MAP为(95.7±14.5)mm Hg,显著高于术前[(85.4±15.3)mm Hg,t=4.34,P<0.01],术中HR为(83.3±23.4)次/min,与给药前[(78.4±22.7)次/min]比较差异有统计学意义(t=3.37,P<0.01).对照组、咪唑安定组和联合芬太尼组术中BIS评分分别为(90.5±7.2)分、(75.5±12.8)分和(72.3±14.1)分,术后24 hVAS评分分别为(53.5±25.4)分、(58.8±18.2)分和(71.9±16.8)分,组间比较差异均有统计学意义(F分别为10.89和8.56,P均<0.01).结论 冠状动脉介入术前使用小剂量的咪唑安定及芬太尼可以缓解患者紧张焦虑情绪,提高手术耐受性及安全性,对血流动力学无明显影响.     

异丙酚复合芬太尼、咪唑安定在胃镜检查治疗中的应用分析

目的分析和探讨异丙酚复合芬太尼、咪唑安定用于胃镜检查的效果、安全性及可行性。方法回顾性分析本院3300例胃镜检查,尤其对近2年来无痛胃镜检查的临床资料。选择ASAⅠ—Ⅱ胃镜检查者120例,其中男85例,女55例,年龄30～50岁,体质量46～75kg,随机分三组,每组40例,异丙酚组（A组）,芬太尼＋异丙酚（B组）,咪唑安定＋芬太尼＋异丙酚（C组）,分别观察插管情况,有无呕吐,呛咳,流泪,肢体活动,镇静及镇痛效果。结果与A组、B组比较,C组入睡时间缩短,苏醒时间及定向力恢复时间延长（P〈0．01）,C组流泪,呛咳,肢体活动,入镜有阻力及需追加异丙酚的发生率也低于A组和B组。结论异丙酚复合芬太尼、咪唑安定用于胃镜检查术时可以增强镇静及镇痛作用,降低术中焦虑,极大的减轻了异丙酚对血流动力学的影响,同时并不增加其不良反应,深受患者及医务人员的欢迎。     

咪唑安定在机械通气病人镇静中的临床观察

目的：探讨咪唑安定在ICU机械通气中的镇静效果、血流动力学变化及不良反应。方法：选择60例需机械通气病人。无意识障碍，无严重心肝肾功能障碍。随机分为两组。以异丙酚做对照，咪唑安定组（Ⅰ组）以0．1mg/kg为诱导量，以0．03—0．2mg/kg/h速率持续输注；异丙酚组（Ⅱ组）以1mg／kg为诱导量，以1．0—2．5mg/kg/h速率持续输注。观察两组对呼吸循环的影响，镇静期间Ramsay评分及苏醒时间、用药剂量的差异。结果：两组镇静Ramsay评分满意，血流动力学无显著差异，Ⅰ组部分病人出现耐药，有镇静延迟现象；Ⅱ组苏醒迅速．可尽早拔管。结论：两组对机械通气患者镇静效果、血流动力学变化无显著差异。对中长期镇静病人，宜选择咪唑安定为镇静药。     

咪唑安定清醒镇静用于纤支镜检查及最佳剂量的探讨

目的：研究度冷丁50mg配伍不同剂量的咪唑安定用于支纤维的镇静作用及对呼吸循环的影响，并探讨其最佳剂量。方法：120例拟行支纤镜检患者（ASAI－Ⅱ级），随机分为对照组、度冷丁50mg 咪唑安定0.04mg/kg、度冷丁50mg 咪唑安定0.06mg/kg三组，观察其镇静分级，检查过程中的感受情况、遗忘程度，检查后的满意度，并记录检查中脑电图双频指数分析（BIS值）、血压、脉搏血氧饱和率及心电图的变化。结果：与对照组相比，度冷丁50mg 咪唑安定0.06mg/kg组的效果明显优于未用药组和度冷丁50mg 咪唑安定0.04mg/kg组，其镇静程度明显，遗忘程度高，对呼吸循环功能影响较小。结论：度冷丁50mg 咪唑安定0.06mg/kg用于清醒镇静支纤维镜检是完全有效的，且为最佳剂量。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.