2013年国际麻醉领域指南回顾

背景 麻醉学发展日新月异,麻醉指南的更新与发布对推动临床麻醉发展至关重要. 目的 介绍2013年国际麻醉学界内6部相关指南. 内容 将麻醉后恢复或管理、困难气道管理、手术室火灾预防或管理、围手术期严重出血管理及凝血功能异常患者区域麻醉风险评估共6部指南的概况、要点及精华予以回顾介绍. 趋向 熟悉麻醉领域内指南更新,既有助于麻醉医师更好地规范临床实践,也有助于在临床中思考与总结,以进一步提高临床麻醉安全,保证麻醉质量.     

2015年国际麻醉领域指南回顾

背景麻醉学发展日新月异,麻醉指南的更新与发布有助于推动临床麻醉工作。目的介绍2015年国际麻醉领域内多部指南及共识。内容对心肺复苏与心血管急救指南更新、成年人非预计困难气管插管管理指南、产科困难气管插管和插管失败的管理指南、围术期血液管理实践指南、肥胖外科手术患者的围术期管理指南、麻醉和恢复期监测标准建议等国内外近20部指南或共识的概况、要点予以介绍。趋向及时追踪掌握国际麻醉领域内指南,有助规范临床麻醉实践,保证临床麻醉安全实施。     

阻塞性睡眠呼吸暂停综合征的麻醉处理54例

我院 1997～ 2 0 0 0年行 5 4例阻塞性睡眠暂停综合征 (ＯＳＡＳ)患者 ,在全麻下实施悬雍垂腭咽成形术 (ＵＰＰＤ) ,现将有关麻醉处理报告如下。资料和方法本组 5 4例 ,男性 4 9例 ,女性 5例。年龄 2 7～ 5 4岁 ,身高 15 6～ 181ｃｍ ,体重6 7～ 130ｋｇ。其中有 4 1例在术前经多导生理记录仪进行呼吸监测 ,观察到在睡眠过程中 ,最长呼吸暂停时间为 38～2 33(80 2 3± 4 8 4 0 )ｓ ,ＳｐＯ2 在觉醒时为5 7～ 95 (88 5 5± 7 4 7) % ,在睡眠期间ＳｐＯ2 最低值为 30～ 6 9(5 4 6 5±12 31) % ,心率在睡眠期间最低值为 30～ 76 (5 3 4 8± …     

悬雍垂、腭咽成型术的麻醉体会

鼾症伴有阻塞性睡眠呼吸暂停综合征(OSAS)的病人通常行悬雍垂、腭咽成型术(UPPP)，以改善睡眠状态下气道梗阻。围术期麻醉处理有其特殊性和一定难度。我院2001年1月～2003年12月做悬雍垂、腭咽成型术(UPPP)13例，总结如下：     

托烷司琼预防全身麻醉术后恶心呕吐的观察

目的观察不同剂量的5-HT3受体拮抗剂托烷司琼对术后恶心呕吐(PONV)的作用时效,以寻求一种比较理想的止吐药物及合适的剂量预防和减少PONV的发生。方法择期全身麻醉手术120例,随机双盲分成对照组(A组,n=30),恩丹西酮8mg(B组,n=30),托烷司琼2mg(C组,n=30)及托烷司琼5mg(D组,n=30)。术毕观察给止吐药至第1次出现恶心呕吐的时间、各组发生恶心、呕吐的病人数、接受补救药的病人数、恶心的严重程度、病人对止吐药的满意度、头晕头痛、椎体外系症状等副作用。结果各组病人性别、体重、年龄、麻醉持续时间、术中生命体征等各组间比较差异无统计学意义(P>0.05)。各组发生恶心、呕吐和接受补救药物病人数,初次出现恶心的时间,恶心严重程度评分的比较中,托烷司琼均优于恩丹西酮,P<0.05。结论①托烷司琼的镇吐效果优于恩丹西酮;②托烷司琼2mg不仅可以减少药物用量、增强抗吐时效,而且能减少副作用的发生,是一种经济、有效、安全且值得推广应用的止吐方法。     

悬雍垂腭咽成形术麻醉方法的比较

阻塞性睡眠呼吸暂停综合征(OSAS)是最普通的睡眠呼吸障碍。其主要特性是睡眠中反复出现呼吸暂停,夜间睡眠打鼾,睡眠不足和白天嗜睡犤1犦。该病发病率高,常常与心血管系统和代谢系统及鼻部疾病相关联犤2犦,在围麻醉期中有较大的危险、困难和意外犤3犦。本院在近3年中,在插管全麻和局麻下已行悬雍垂软腭咽成形术(UPPP)69例,现报道如下。1临床资料1.1资料与方法:本组69例,均为择期病人。其中男性68例,女性1例;年龄4～69岁(平均49.06±13.09岁);体重15.1～119kg。临床症状分别有:呼吸暂停、憋醒、打鼾、白天嗜睡、头痛、记忆力下降、性格改…     

全身麻醉病人术后恶心呕吐原因分析及护理对策

全身麻醉病人手术后恶心呕吐是常见并发症，临床上有资料报道其发生率可高达２０％～８０％犤１犦。恶心呕吐的处理是临床护士应该关注的问题。笔者对１９９９年６月以来本单位的３２１例全身麻醉病人术后恶心呕吐情况，进行了回顾性分析。现报告如下。临床资料本组３２１例，男性１０３例，女性２１８例；年龄４～８７岁，平均年龄４５．５岁。其中胸部手术１２例，上腹部手术１１５例，下腹部手术１６７例，五官科手术２７例。这３２１例全身麻醉病人术后出现恶心呕吐１３１例，发生率４０％。其中男性３３例（１０％），女性９８例（３０…     

硬膜外麻醉偶合椎管内肿瘤致术后截瘫一例

患者 ,男 ,45岁。无明显诱因出现腰背部酸痛 ,伴左下肢放射痛 ,左下肢麻木 1年 ,夜间尤甚。Ｘ光片示Ｌ4～ 5根管狭窄。ＣＴ检查示Ｌ3～ 4 、Ｌ4～ 5椎间盘突出 ;左侧神经根受压。体检 :一般情况良好。Ｌ4～ 5棘突偏左压痛 ( ) ;左下肢直腿抬高试验 ( )。即在连续硬膜外麻醉下手     

阻塞性睡眠呼吸暂停低通气综合征的麻醉体会

对阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的治疗，近年来多主张在全麻下行悬雍垂腭咽成形术(UPPP)。由于患者具有肥胖的外表和与其不相符的狭窄气道，在全麻下行UPPP对气管插管和麻醉管理及术后处理都具有一定的风险和并发症。我院自2001年2月～2004年3月共实施134例UPPP手术，取得良好效果，现总结如下。     

悬雍垂腭咽成形术的麻醉处理

本文包括15例阻塞性睡眠呼吸暂停综合征（OSAS）患者，均在气管内插管全麻下施行悬雍垂腭咽成形术（UPPP）。OSAS患者多数伴随颈项粗短、肥胖、咽腔狭小等特点，由此常致麻醉诱导和气管内插管发生困难，风险极大。为探讨安全合理的麻醉诱导和插管方法，总结麻醉处理经过与体会，报道如下。     

Postdischarge nausea and vomiting: A review of current literature

Postoperative nausea and vomiting continues to occur in approximately one-third of patients who have surgery despite newer medications and emerging guidelines for care. There is a paucity of literature that relates to patients who experience postdischarge nausea and vomiting after outpatient surgery. The purpose of this article is to review the current knowledge in the area of postdischarge nausea and vomiting. The findings were that the problems with postdischarge nausea and vomiting (PDNV) have not been as thoroughly assessed and evaluated as nausea and vomiting immediately postsurgery. More research needs to be conducted in this population, as the rate of surgeries performed in this setting will only increase.     

Dexamethasone or combined with others for postoperative nausea and vomiting in children: A systematic review

Postoperative nausea and vomiting (PONV) is one of the most common and unpleasant postoperative complications in children. This study aims to evaluate the efficacy and safety of using dexamethasone alone or combined other drugs on the incidence of PONV in children. A systematic search of the literature was conducted from inception until March, 2019. Literature selection and data extraction were conducted by two independent reviewers. Statistical analysis was performed using the software package Review Manager Version 5.3.3. Twenty studies with total 2505 participants were included. The pooled analysis used a random-effect model showed that dexamethasone had significantly greater efficacy in incidence of POV and PON in postoperative 24 h than control. Subgroup analysis indicated the RR of dexamethasone ≥0.5 mg/kg group was the lowest compared subgroup dexamethasone ≤0.3 mg/kg and 0.3–0.5 mg/kg. There was no difference for early POV between dexamethasone and placebo groups. Dexamethasone combined with others also could significantly reduce the incidence of POV in postoperative 24 h. Few adverse effects were reported. This study indicates that dexamethasone is effective for preventing incidence of PONV in children. And multimodal approaches have shown more effectively to prevent the incidence of POV.     

帕洛诺司琼用于预防术后恶心呕吐的研究进展

背景 5-羟色胺3(5-HT3)受体拮抗剂特别是第2代5-HT3受体拮抗剂帕洛诺司琼对术后恶心呕吐(postoperative nausea and vomiting,PONV)具有较好的预防作用,其药理学机制及临床应用状况近年来有了较为深入的研究和临床应用.目的 分析总结帕洛诺对各类手术PONV的预防效果及其作用机制.内容 第2代5-HT3受体拮抗剂帕洛诺司琼具有高度亲和性、长效性、副作用少等优点,通过阻断5-HT3与外周或中枢神经元的5-HT3受体结合,阻断迷走神经传入呕吐中枢和第四脑室化学感受区触发带,抑制呕吐反射,临床应用其预防PONV的高效性不断得到认可. 趋向 深入探讨其药理机制、副作用、预防PONV的临床应用等方面,以供临床工作者更加合理地应用其预防PONV.     

枢复宁预防全麻腹部手术后恶心和呕吐的临床研究

全麻患者术后常易发生恶心、呕吐，枢复宁有抗呕吐作用。随机选择１００例腹部外科手术患者，分为枢复宁组（４ｍｇ，ｎ＝５０）和安慰剂组（生理盐水，ｎ＝５０），诱导前静注枢复宁或安慰剂，注速１分钟，双盲法观察术后２４小时抗恶心、呕吐效果及副作用。结果表明，用药组恶心、呕吐发生率（１８％，０）明显低于安慰剂组（５０％，４０％）（Ｐ＜０．０１），两组患者的平均动脉压、经皮血氧饱和度，呼吸频率和心率，血液成分，肝、肾功能无明显改变。因此，枢复宁适用于腹部外科患者术后恶心、呕吐的防治。     

Effect of obstructive sleep apnea on type 2 diabetes mellitus: A comprehensive literature review

Obstructive sleep apnea (OSA) is frequently associated with obesity and metabolic syndrome. Also frequently associated with metabolic syndrome is type 2 diabetes mellitus (T2DM). Therefore, it is common to find OSA and T2DM together in individuals with metabolic syndrome. Additionally, both OSA and T2DM have a common pathophysiological link with development of insulin resistance. Individuals with severe insulin resistance are likely to have inadequate glycemic control. Long standing poorly controlled T2DM is associated with debilitating microvascular complications such as retinopathy, nephropathy, neuropathy and macrovascular complications such as coronary artery and cerebrovascular disease. There is extensively published literature exploring the cause-effect relationship between OSA and T2DM. In this article we provide an in-depth review of the complex pathophysiological mechanisms linking OSA to T2DM. Specifically, this review focusses on the effect of OSA on the microvascular complications of T2DM such as retinopathy, nephropathy and neuropathy. Additionally, we review the current literature on the effect of continuous positive airway pressure use in individuals with T2DM and OSA.     

Intravenous dexamethasone for prophylaxis of postoperative nausea and vomiting after administration of long‐acting neuraxial opioids: a systematic review and meta‐analysis

Long‐acting neuraxial opioids provide excellent analgesia after surgery, but are associated with higher rates of postoperative nausea and vomiting. Dexamethasone effectively prevents postoperative nausea and vomiting after general anaesthesia, but its value in patients receiving long‐acting neuraxial opioids is undetermined. Therefore, the objective of this meta‐analysis was to assess the prophylactic anti‐emetic efficacy of intravenous (i.v.) dexamethasone in this population. The study methodology followed the PRISMA statement guidelines. The primary outcome was the need for rescue anti‐emetics during the first 24 postoperative hours, analysed according to the dose of dexamethasone (low‐dose 2.5–5.0 mg; intermediate dose 6.0–10.0 mg), timing of administration (beginning or end of surgery) and route of long‐acting opioid administration (intrathecal or epidural). Additionally, the rates of complications (restlessness, infection, hyperglycaemia) were sought. Thirteen trials were identified, representing a total of 1111 patients. When compared with placebo, intravenous dexamethasone reduced the need for rescue anti‐emetics (risk ratio (95%CI) 0.44 (0.35–0.56); I² = 43%; p < 0.00001; quality of GRADE evidence: moderate), without differences between dexamethasone doses (p for sub‐group difference = 0.67), timing of administration (p for sub‐group difference = 0.32) or route of long‐acting opioid (p for sub‐group difference = 0.10). No patients developed infection or restlessness among trials that sought these complications. No trial measured blood glucose levels. In conclusion, there is enough evidence to state that intravenous dexamethasone provides effective anti‐emetic prophylaxis during the first 24 postoperative hours in patients who receive long‐acting neuraxial opioids.     

Efficacy of prophylactic intravenous granisetron in postoperative emesis in adults

Purpose This randomized, double-blind, placebo-controlled trial evaluated the efficacy, safety, and optimal dose of granisetron in the prophylactic control of postoperative nausea and vomiting in patients undergoing gynecologic surgery or cholecystectomy.Methods Three-hundred and fifteen patients (age, 20–65 years) received intravenous granisetron (1mg or 3mg) or placebo immediately before the end of anesthesia. After treatment, patients were observed for 24h, and the occurrence of nausea and vomiting was recorded and safety was assessed. The no-vomiting rate, time-to-first vomiting episode, and severity of nausea were recorded.Results The no-vomiting rates in patients receiving granisetron 1mg and 3mg were significantly higher than that in the placebo group (83.7%, 78.8%, and 57.9%, respectively; P = 0.0004 for 1mg vs placebo, P = 0.001 for 3mg). Time-to-first vomiting episode was longer in the granisetron 1-mg and 3-mg groups than in the placebo group (time-to-event analysis, Kaplan-Meier, log-rank test; 83.2%, 80.1%, and 59.1%, respectively; P = 0.0002 and P = 0.0010). The severity of nausea was also less in granisetron-treated patients (25.2%, 11.5%, and 15.4% severe nausea incidence for placebo, granisetron 1mg, and granisetron 3mg, respectively; P = 0.00003 and P = 0.002). Fewer rescue medications were required in the two granisetron-treated groups compared with those receiving placebo. Adverse events were similar in all groups. No differences in efficacy or safety were observed between granisetron doses.Conclusion Granisetron is well-tolerated and more effective than placebo in the prophylactic control of nausea and vomiting after surgery. This study suggests that the optimum dose of granisetron is 1mg.*See Appendix.     

右美托咪定预防术后恶心呕吐的研究进展

背景 术后恶心呕吐(postoperative nausea and vomiting,PONV)发生率为20％～80％,右美托咪定(dexmedetomidine,Dex)是一种新型的高选择性α2肾上腺素受体激动剂,近来研究提示,Dex可能在预防和治疗PONV中发挥作用.目的 了解Dex预防和治疗PONV的效果.内容 综合相关文献,从Dex防治PONV的机制、优势、最佳剂量、应用时间、给药途径等方面探讨其防治PONV的效果.趋向 Dex有望成为减少PONV发生的一种新的药物选择.     

星状神经节阻滞对腹腔镜全子宫切除术患者术后睡眠质量和恶心呕吐的影响

目的 观察超声引导下右侧星状神经节阻滞（SGB）对腹腔镜全子宫切除术患者术后睡眠质量和恶心呕吐（PONV）的影响。
方法 选择择期行腹腔镜全子宫切除术患者98例,年龄42～74岁,BMI 19～25 kg/m ²,ASAⅠ或Ⅱ级。采用随机数字表法分为两组：全身麻醉联合SGB组（S组）和全身麻醉组（GA组）,每组49例。S组于麻醉诱导前在超声引导下行右侧SGB,注入 0.2%罗哌卡因5 ml,GA组不行SGB。两组采用相同的全身麻醉方法和麻醉药物。记录术前1 d、手术当日、术后1 d的匹兹堡睡眠质量指数（PSQI）。记录术后24 h PONV分级和止吐药补救情况。记录术后24 h活动时VAS疼痛评分、镇痛药补救情况、术后首次下床活动时间和术后住院时间。记录局麻药中毒、全脊髓麻醉、气胸、臂丛神经阻滞等SGB相关并发症发生情况。
结果 与GA组比较,S组手术当日、术后1 d PSQI评分、POSD发生率明显降低（P＜0.05）,PONV 0级、1级发生率明显升高,PONV 2级、3级、4级发生率、止吐药补救率明显降低（P＜0.05）,术后24 h活动时VAS疼痛评分明显降低（P＜0.05）,术后首次下床活动时间明显缩短（P＜0.05）。两组补救镇痛情况、术后住院时间差异无统计学意义。S组无一例出现局麻药中毒、全脊髓麻醉、气胸、臂丛神经阻滞等SGB相关并发症。
结论 右侧星状神经节阻滞可有效改善腹腔镜全子宫切除术患者的术后睡眠质量,降低术后恶心呕吐的发生率及严重程度,减轻术后疼痛。