电视胸腔镜下脊椎前路手术的麻醉处理

目的：总结胸腔镜技术应用于脊柱前路手术的麻醉经验。方法：回顾性分析55例胸腔镜下脊柱手术麻醉所采用的双腔支气管导管的应用。结果：单肺通气后42例SpO2≥99％；10例经改变呼吸参数或调整双腔管位置或经患侧吸入2L／min纯氧，SpO2≥96%。3例术中单肺通气不能维持正常SpO2，改单、双侧通气交替进行，完成手术。结论：胸腔镜下脊柱前路手术，需健侧单肺通气，术侧肺萎缩，术野暴露清晰。故双腔支气管导管插管一定到位，术中需严密观察，加强呼吸管理，避免单肺通气时低氧血症，这是手术成败与病人术中生命安危的关键。     

电视胸腔镜手术治疗自发性气血胸20例

目的：探讨电视胸腔镜下手术治疗自发性气血胸的临床疗效。方法：选择内科治疗无改善或放置胸腔闭式引流后长期持续排气的２０例自发性气血胸患者,全部采用双腔气管插管静复合麻醉,术中单侧通气的麻醉方法,行单侧肺大泡切除１４例,非同期肺大泡切除４例,双人则同包切除１例,右上肺叶切除１例。结果：手术平均时间７８．９６ｍｉｎ、术中出血平均为５９．０９ｍｌ,术后平均２天拔除胸管。术后复查,所有患者气胸消失,肺复张良     

电视胸腔镜下胸交感神经切断术15例麻醉体会

目的：总结电视胸腔镜下行胸交感神经切断术治疗手汗症的麻醉管理。方法：15例患者,全身麻醉。插入双腔支气管导管。术中术侧肺完全萎陷,确保对侧良好的单肺通气。术中监测SDP、DBP、MAP、HR、ECG、SpO2、BP、PETCO2和手术前后手温度变化。结果：手术结束时心率减慢,血压在膨肺时下降。切断胸交感神经后手温升高。结论：成功的麻醉、支气管导管的准确对位及良好的单肺通气是手术成功的前提。     

胸腔镜下行肺癌手术的麻醉处理

目的总结胸腔镜下行肺癌手术的麻醉处理。方法所有患者均静脉快速诱导插入双腔支气管进行间歇正压通气(IPPV),单肺通气时采用IPPV加呼气末正压呼吸(PEEP)及萎陷肺持续正压通气(CPAP),并调整呼吸参数。结果所有患者双腔支气管插管经纤支镜调整定位良好,肺萎陷满意。动脉血氧饱和度(SpO2)、呼气末二氧化碳分压(PETCO2)维持正常范围。结论胸腔镜手术麻醉的关键是双腔管分隔完全,患侧肺萎陷满意。进行有效的单肺管理能使患者顺利度过围术期。     

电视胸腹腔镜联合食管癌根治术的麻醉处理

目的 探讨电视胸腔镜、腹腔镜联合下食管癌根治术的麻醉处理方法,评价其疗效和安全性.方法 所有病例均采用全身麻醉双腔支气管插管复合硬膜外阻滞,T8～9硬膜外穿刺置管,使用F35～39Robertshow双腔支气管导管,采用纤维支气管镜准确定位,胸腔镜进行探查时即行单肺通气,腹腔镜气腹和颈部操作时行双肺通气,术中硬膜外阻滞联合静吸复合维持麻醉.结果 12例电视胸、腹腔镜食管癌根治术均在全身麻醉双腔支气管插管复合硬膜外阻滞下完成,麻醉效果满意,血流动力学维持平稳,呼气末二氧化碳(PETCO2)均小于45 mm Hg(1 mm Hg=0.133 kPa),手术时间(330.6±39.5)min,单肺通气时间(82.5±20.4)min,术中估计失血量(210.9±130.5)mL.结论 采用全身麻醉双腔支气管插管复合硬膜外阻滞行电视胸、腹腔镜联合下食管癌手术,麻醉效果理想,手术安全,值得推广应用.     

电视胸腔镜手术的麻醉处理

目的：探讨电视胸腔镜手术（VATS）的麻醉处理、术中安全性及并发症的情况。方法：VATS患者68例，静脉快速诱导下插入双腔支气管导管，用听诊法和纤支镜进行定位。术中单肺通气，多功能监护仪监测循环和呼吸。结果：全部68例患者无麻醉手术死亡，平均单肺通气时间55min，全组并发一过性低氧血症11例,复张性肺水肿3例。结论：VATS麻醉应做好术前准备，保持良好的双肺隔离，加强围术期的监测，才能减少并发症，提高麻醉质量     

单双腔插管对胸腔镜下交感神经切除的血气对比

目的:观察单腔和双腔插管在电视胸腔镜(VATS)下胸交感神经切除(TES)时的血气变化.方法: 对46例手汗症病人在胸腔镜下行双侧胸交感神经切除,随机分为2组,A组19例为双腔插管,术中给予单肺通气,B组27例则选择单腔插管,术中给予3～5 cmH2O的二氧化碳胸腔正压.两组患者麻醉前、插管时、以及手术开始后分别按两侧胸腔先后手术次序记录1、3、5、10、15 min血气、BP、P、经皮氧饱和度(SpO2)、PetCO2变化.结果: 两组病人术中SpO2、动脉血氧分压(PaO2)、动脉血氧饱和度(SaO2)与麻醉前相比由于纯氧供应而明显升高,但随手术时间延长而下降,动脉血二氧化碳分压(PaCO2)随手术时间延长有升高趋势,但在正常范围,MAP除插管时及第二侧手术10、15 min有显著升高外,前后差异无显著性;A组与B组之间相比除SpO2有显著差异外,其余之间差异均无显著性,且两者的血气结果均在正常范围.结论: 胸腔镜下交感神经切除时单腔和双腔插管在保证手术视野的情况下均能较好地保证术中患者的通气功能和生命体征,但单腔插管能更简单,更经济地完成手术要求.     

双腔支气管插管单肺通气麻醉在胸科手术中的应用探讨

目的探讨双腔支气管插管单肺通气麻醉在胸科手术中的应用。方法60例普胸手术病人均选择双腔支气管导管进行麻醉。结果全部病人麻醉效果满意,无气道损伤并发症。听诊法1次插管成功38例,成功率65.5%,2次成功20例。插管后纤维支气管镜检查发现,导管到位率为30例(51.7%);改变体位后14例听诊肺隔离不满意。结论使用双腔管的优点:在胸外科手术时,能使术侧肺(或患肺)与健侧肺的通气完全分开,在胸外科麻醉中具有推广的价值。     

胸腔镜下保留自主呼吸与全身麻醉单肺通气肺大泡切除术的疗效比较

目的:探讨对比胸腔镜下保留自主呼吸与全身麻醉单肺通气肺大泡切除术术中及术后对循环和呼吸的影响。方法:选取2016年1月至2017年12月符合条件的60例肺大泡患者,均分为两组。对照组接受全身麻醉单肺通气肺大泡切除术,观察组接受保留自主呼吸肺大泡切除术。记录并比较两组手术时间、术后复苏时间、住院时间,不同时间段的动脉血二氧化碳分压(partial pressure of carbon dioxide,PaCO2)、动脉血氧分压(partialarterialoxygenpressure,PaO2),每搏量(strokevolume,SV)、心输出量(cardiacoutput,CO)、有创平均动脉压(Invasivemeanarterialpressure,MAP)、心率(heart rate,HR)以及并发症发生情况。结果:观察组手术时间长于对照组,术后复苏时间及住院时间均短于观察组,差异均有统计学意义(P0.05)。手术开始前两组各项心肺指标差异均无统计学意义(P0.05)。手术开始15,30 min后及手术结束30 min后SV,CO,PaCO2,PaO2,MAP,H R指标观察组优于对照组(P0.05)。结论:相比于全身麻醉单肺通气,保留自主呼吸方案能有效避免气管插管造成的呼吸道机械性损伤及异物造成的呼吸道感染,其对每搏量、心输出量、心率、动脉压等心肺功能影响较少,有利于动脉血PaCO2和PaO2保持在正常水平。     

电视胸腔镜手术在基层医院的临床应用体会（附46例报告）

电视胸腔镜手术（ＶＡＴＳ）是一种胸部疾病诊断和治疗的微创新技术。１９９７年２月以来,我们共开展ＶＡＴＳ４６例,现总结如下。１临床资料本组男３６例,女１０例。年龄４～７５岁。平均３９．３岁。均采用静吸复合麻醉,双腔插管术中单肺通气４０例,单腔管双肺通气...     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.