肥胖患者按理想体质量使用不同剂量顺苯磺酸阿曲库铵的肌松效应观察

目的观察肥胖患者按理想体质量给予不同剂量的顺苯磺酸阿曲库铵的肌松效应。方法将ASAⅠ~Ⅱ级的择期全身麻醉肥胖男性患者40例,按给药剂量不同分为两组,均按照理想体质量分别给予0.15 mg/kg、0.2 mg/kg的顺苯磺酸阿曲库铵麻醉诱导。采用CLMR IS-Ⅰ闭环肌松监测仪进行拇内收肌肌松监测,T1为0时气管插管。观察记录起效时间、临床作用时间、恢复指数以及气管插管条件评级。结果Ⅱ组起效时间比Ⅰ组短,两组差异有统计学意义(P0.05);作用时间Ⅱ组较Ⅰ组延长,两组差异有统计学意义(P0.05);Ⅱ组恢复时间较Ⅰ组延长,两组差异有统计学意义(P0.05);气管插管条件两组差异无统计学意义(P0.05)。结论顺苯磺酸阿曲库铵按照理想体质量计算的0.15 mg/kg剂量虽然起效时间延长,但不影响插管条件和手术操作,同时缩短肌松恢复时间,不易造成肌松残余,能够被临床接受。     

癫痫与非癫痫患者苯磺顺阿曲库铵的肌松时效观察

目的观察苯磺顺阿曲库铵应用于癫痫与非癫痫患者的肌松作用。方法 30例ASAⅠ~Ⅱ级择期行癫痫手术患者随机均分为A2[2倍的95%有效量(ED95)]组和A4(4ED95)组,30例ASAⅠ~Ⅱ级择期行开颅神经血管减压术的患者随机均分为B2(2ED95)组和B4(4ED95)组,各组患者在麻醉诱导后于5 s内经上肢静脉注入相应剂量的苯磺顺阿曲库铵。采用手掌式定量肌松监测仪监测拇内收肌颤搐变化,观察气管插管条件及苯磺顺阿曲库铵的肌松时效。结果 4ED95剂量的苯磺顺阿曲库铵(A4和B4)较2ED95剂量的苯磺顺阿曲库铵(A2和B2)起效时间缩短,无反应期和临床作用时间延长(P<0.05)。恢复指数无统计学差异(P>0.05)。相同剂量的苯磺顺阿曲库铵在癫痫组(A)较非癫痫组(B)起效时间无统计学差异(P>0.05),但无反应期、临床作用时间和恢复指数明显缩短(P<0.05)。结论 2ED95和4ED95的苯磺顺阿曲库铵均能完成癫痫和非癫痫患者的气管插管,且起效时间随剂量增加而缩短,作用时间随剂量增加而延长。同等剂量的苯磺顺阿曲库铵在癫痫患者中作用时间和恢复指数明显缩短。     

麻黄碱复合预注法对老年患者顺苯磺酸阿曲库铵起效时间和血流动力学的影响

目的比较麻黄碱预处理,小剂量顺苯磺酸阿曲库铵预注以及二者联用对老年患者顺苯磺酸阿曲库铵起效时间和血流动力学的影响。方法气管内插管全身麻醉下手术的老年患者60例,应用随机数字表法分为4组：麻黄碱组（E组）、小剂量顺苯磺酸阿曲库铵预注组（P组）、麻黄碱预处理复合小剂量顺苯磺酸阿曲库铵预注组（PE组）、对照组（C组）,每组各15例。P组和PE组静脉注射顺苯磺酸阿曲库铵0．015mg／kg。E组和PE组静脉注射麻黄碱70μg/kg。靶控输注异丙酚,静脉注射芬太尼诱导。随后E组和C组静脉注射顺苯磺酸阿曲库铵插管剂量0．15mg／kg,P组和PE组静脉注射剩余插管剂量。待肌颤搐反应消失后行气管插管。结果PE、C、E、P组起效时间[（164±28）s、（306±61）s、（187±31）s、（193±40）s比较差异有统计学意义,F=33．990,P〈0．01],PE组的起效时间明显短于C组、E组和P组且差异均有统计学意义（P〈0．01,P〈0．05）。诱导后各组收缩压（SBP）（F组内=35．783,P=0．000）、平均动脉压（MAP）（F自自=30．015,P=0．000）与同组诱导前比较均显著下降;PE组的SBP、舒张压（DBP）、MAP均显著高于C组（P均〈0．05）;E组的SBP、DBP、MAP也显著高于C组（P均〈0．05）;诱导后PE组和C组的心率（HR）比较差异有有统计学意义（P〈0．05）,C组HR较诱导前显著下降（P〈0．05）。诱导后血压降低C组有11例,P组有10例,而E组和PE组各有5例和4例,差异有统计学意义（χ^2=9．867,P〈0．05）。插管后血压升高E组有5例,PE组和P组各有4例,C组有3例,差异无统计学意义（χ^2=0．682,P〉0．05）。结论70μg／kg的麻黄碱可缓解老年患者异丙酚诱导时的循环抑制,复合小剂量顺苯磺酸阿曲库铵预注可进一步缩短其起效时间,适合于老年人。     

不同剂量顺式阿曲库铵对全麻诱导期老年患者肌松效应的影响

目的 探讨全麻诱导期老年患者单次静脉注射不同剂量顺式阿曲库铵的肌松效应.方法 选择美国麻醉医师协会(ASA)病情分级Ⅰ～Ⅱ级择期手术的90例,随机分为3组,每组30例.Ⅰ组、Ⅱ组、Ⅲ组分别予顺式阿曲库铵0.1、0.15、0.2 mg/kg静脉注射,待4个成串刺激(TOF)的第1个肌颤搐(Tl)为0时行气管插管,并对插管条件进行评级.观察阻滞起效时间、TOF无反应期、阻滞维持时间、肌松恢复指数及体内作用时间.结果 3组T1最大阻滞程度及气管插管条件优良率比较差异无统计学意义(P＞0.05),肌松起效时间组间比较差异有统计学意义(P＜0.05),TOF无反应期、阻滞维持时间、肌松恢复指数、体内作用时间,组间比较差异均无统计学意义(P＞0.05).结论 老年患者全麻诱导期静脉注射不同剂量的顺式阿曲库铵,无组胺释放作用,对血流动力学无影响,随着剂量增大,起效时间明显缩短,气管插管条件均满意,但肌松恢复时间与剂量、年龄无关.     

阿曲库铵对肝硬化的麻醉药效学研究

目的探讨非去极化肌松药阿曲库铵用于肝硬化麻醉的肌松效应和安全性。方法将12例肝硬化行脾切除手术患者随机分为A、B组,12例行胃大部分切除术患者随机分为C、D组,每组6例。A、C组采用阿曲库铵2倍ED95（0.4 mg·kg^-1）麻醉,B、D组采用阿曲库铵3倍ED95（0.6 mg·kg^-1）麻醉。观察各组麻醉诱导前后生命体征的变化、插管条件及肌松效应。结果各组插管前后血流动力学均无明显改变（P〉0.05）;A、C组插管条件优率明显低于B、D组（P〈0.05）;A、C组起效时间较B、D组明显减慢,T1 95%恢复时间、4个成串刺激（TOF）比值恢复到70%的时间（T4/T1≥0.7）较B、D组明显缩短,差异均有统计学意义（P〈0.05）。结论阿曲库铵可以安全用于肝硬化患者的麻醉,3倍ED95剂量比2倍ED95剂量的起效更快。     

急性高容量血液稀释对顺式阿曲库铵起效时间的影响

目的观察在宫颈癌根治术中应用急性高容量血液稀释对顺式阿曲库铵起效时间的影响。方法选择行宫颈癌根治择期手术60例,年龄35-60岁,ASA分级Ⅰ～Ⅱ级,随机分为两组：AHH组（A组,n=30）和对照组（C组,n=30）,两组均在术前补充生理需要量,AHH组以15ml/kg用6%羟乙基淀粉酶130/0.4进行血液稀释,两组分别以用顺式阿曲库铵2倍ED95,3倍ED95,4倍ED95的剂量采用TOF-Watch○R SX肌松监测仪器监测肌松,比较两组的顺式阿曲库铵肌松作用的起效时间,气管插管条件及诱导期的血流动力学变化。结果与C组相比,A组肌松起效时间延长（P〈0.05）、CVP增高（P〈0.05）、MAP增高但无统计学意义（P〉0.05）,HR变化无统计学意义。结论 AHH可延长顺式阿曲库铵的起效时间而不会引起血液动力学的显著变化。     

米库氯铵与顺苯磺酸阿曲库铵在腹腔镜手术围拔管期的临床观察

目的探讨持续输注米库氯铵较顺苯磺酸阿曲库铵在妇科腹腔镜手术中的应用是否具有优越性。方法选择拟行择期妇科腹腔镜手术的女性患者60例,ASAⅠ-Ⅱ级,随机分成持续输注顺苯磺酸阿曲库铵组（C组）和持续输注米库氯铵组（M组）,每组30例。经闭环肌松注射系统给予肌松药,采用4个成串刺激尺神经,通过拇内收肌的收缩反应以监测TOFr值（T4/T1）。记录两组患者围拔管期血流动力学变化、脑电双频指数（BIS）、神经肌肉功能的恢复及术后不良反应等。结果 C组与M组围拔管期血流动力学指标的变化无显著性差异（P〉0.05）;在手术结束即刻（T1）及拔管即刻（T2）两个时间点M组的BIS值高于C组且PETCO2值明显低于C组,差异有统计学意义（P〈0.05）;M组的TOFr恢复至25%、恢复指数时间、TOFr恢复至90%、术毕至拔除气管导管时间,苏醒室停留时间均明显小于C组（P〈0.05）;且M组肌松起效时间明显快于C组,增药次数及单位时间内用药量明显多于C组,差异有统计学意义（P〈0.05）;M组发生术后肌松残余者较C组少。结论经闭环肌松注射系统输注米库氯铵在围拔管期神经肌肉功能恢复快,术后肌松残余者少且不良反应轻微,较顺苯磺酸阿曲库铵更适合应用于腹腔镜手术。     

闭环肌松注射系统在老年患者腹部手术中的应用

目的评价闭环肌松注射系统在老年患者腹部手术中应用的临床效果及安全性。方法将择期拟在全麻下行腹部手术的老年患者60例随机分为A组(闭环肌松注射系统)和B组,每组30例。A组采用闭环肌松注射系统给予肌松药罗库溴铵,B组推注罗库溴铵。比较2组患者入室、气管插管、切皮、剖腹探查、关腹、气管拔管6个时间点(T1~T6)的各项生命体征、肌松药使用总量、肌松药起效时间、气管插管条件评级、苏醒时间。结果 A组肌松起效时间、肌松药用量、自主呼吸恢复时间、拔管时间均明显短于、低于B组(P0.05);2组改良KRIGE评级无明显差异(P0.05)。结论闭环肌松注射系统用于老年患者麻醉可以减少肌松药的用量,缩短起效时间。     

顺式阿曲库铵在新生儿腹腔镜下先天性巨结肠根治术中的应用

[目的]探讨顺式阿曲库铵(简称阿曲库铵)应用于新生儿的药效学特点.[方法]择期行腹腔镜下先天性巨结肠根治术的新生儿60例,于5 s内静注2ED95(Ⅰ组)或3ED95(Ⅱ组)顺式阿曲库铵(n=30),记录拇内收肌肌颤搐高度并对插管条件进行评级.观察阻滞起效时间、TOF无反应期、阻滞维持时间、肌松恢复指数与体内作用时间.[结果]Ⅱ组气管插管时肌松阻滞和插管条件较Ⅰ组好.肌松起效时间Ⅱ组(90.5 s)较Ⅰ组(145.5 s)短(P＜0.01).TOF无反应期、阻滞维持时间和体内作用时间两组比较均有显著性差异(P＜0.05).两组肌松恢复指数无显著差异(P＞0.05).[结论]3ED95诱导剂量应用于新生儿起效快且插管条件佳,且TOF无反应期、阻滞维持时间和体内作用时间均较2 ED95的时间长.两组恢复指数无明显差异.     

国产顺式阿曲库铵用于梗阻性肾病患者麻醉的药效学观察

【目的】观察非去极化肌松药顺式阿曲库铵用于梗阻性肾病患者麻醉中的肌松效应。【方法】18倒梗阻性骨病患者行单侧肾脏或输尿管切开取石术,随机分为顺式阿曲库铵Ⅰ组（2倍ED95组）、Ⅱ组（3倍ED95组）,对照组为18例行腹部手术患者随机分为顺式阿曲库铵Ⅲ组（2倍ED95组）、Ⅳ组（3倍ED95组）。观察患者气管插管条件、肌松效应。【结果】Ⅰ、Ⅲ组插管条件为优的比率明显低于Ⅱ、Ⅳ组（P〈0．05）;Ⅰ组、Ⅲ组起效时间大于Ⅱ组、Ⅳ组,但是T175％恢复时间、TOF比值恢复到70％的时间明显短于Ⅱ组、Ⅳ组（P〈0．05）。【结论】3倍ED95剂量的顺式阿曲库铵比2倍ED95剂量起效更快,插管条件更好;能安全应用于肾功能障碍患者。     

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.     

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.     

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.     

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.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.