七氟醚复合舒芬太尼或雷米芬太尼静吸复合麻醉在先天性心脏病通道手术中的应用

目的观察七氟醚复合舒芬太尼或雷米芬太尼快通道麻醉在小儿先天性心脏病手术的应用。方法 60例先天性心脏病患者,男40例,女20例,年龄2～12岁,随机分为舒芬太尼组（SF组）、雷米芬太尼组（RF组）两组,每组30例。两组均用咪唑安定和维库溴铵诱导麻醉,SF组诱导用舒芬太尼1μg/kg,继之泵入舒芬太尼2～3μg/（kg·h）;RF组诱导用雷米芬太尼2μg/kg,继之泵入雷米芬太尼0.1～1μg/（kg·min）维持麻醉,两组均吸入七氟醚,间断静推维库溴铵。观察两组患者术前、术中、术后血流动力学变化,记录术后清醒时间、拔管时间、术后躁动情况。结果与T0比较,两组患者T4、T5HR明显增快（P〈0.05）,T1、T3、T4MAP下降（P〈0.05）;苏醒情况：SF组清醒时间、拔管时间较RF组长（P〈0.01）,RF组躁动发生率较SF组高（P〈0.05）。结论七氟醚复合舒芬太尼或雷米芬尼静吸复合麻醉均能为先天性心脏病手术提供安全、快捷的快通道麻醉。     

七氟醚复合雷米芬太尼快通道麻醉技术用于青少年脊柱侧弯后路矫形手术

目的 比较七氟醚复合雷米芬太尼与异氟醚复合芬太尼用于青少年脊柱侧弯后路矫形手术的麻醉效果.方法 择期行脊柱侧弯后路矫形手术的患者40例,ASA Ⅰ～Ⅱ级,年龄11～18岁.随机分为两组:异氟醚复合芬太尼组(A组)和七氟醚复合雷米芬太尼组(B组).A组以丙泊酚、芬太尼、维库溴铵和异氟醚维持麻醉;B组以丙泊酚、雷米芬太尼、维库溴铵和七氟醚维持麻醉.根据双频指数(BIS)和血流动力学反应调整麻醉深度.在唤醒前约30 min停用维库溴铵和镇痛药.要求唤醒时停用丙泊酚和吸人麻醉药,唤醒时间为停用丙泊酚和吸入麻醉药到患者双侧脚趾能动的时间.记录唤醒时间、唤醒质量及唤醒期间HR、SBP、DBP、BIS的变化.患者拔除气管导管清醒后随访患者对术中唤醒过程有无记忆.结果 患者的一般情况、唤醒期间HR、SBP、DBP和BIS两组问比较均无统计学差异.两组患者唤醒时BIS明显高于停药前(P＜0.001),但是术后随访发现所有患者对唤醒试验均无记忆.唤醒时间A组26.3 min±10.4 min,B组12.1 min±9.4 min,两组间比较差异有统计学意义(P＜0.01).唤醒成功时,两组的唤醒质量比较无统计学差异(P＞0.05).结论 七氟醚复合雷米芬太尼快通道麻醉技术适合用于行术中唤醒的青少年脊柱侧弯后路矫形手术,其唤醒时间短、术中血流动力学平稳.该麻醉条件下行BIS监测,有助于及时唤醒病人和唤醒后加深麻醉,亦有助于防止术中知晓.     

雷米芬太尼复合丙泊酚与芬太尼复合异氟醚在实施心脏手术快通道麻醉的比较

目的比较雷米芬太尼复合丙泊酚与芬太尼、丙泊酚复合异氟醚用于不停跳心脏手术患者麻醉的应激激素及血流动力学变化。方法26例患者随机均分为雷米芬太尼复合丙泊酚(RP组)和芬太尼复合异氟醚(FI组)两组。分别记录不同时点HR、MAP和血糖(Glu)数值,同时观察相应时点血浆皮质醇(Cor)及促肾上腺皮质激素(ACTH)反应。结果两组患者各观察点血流动力学及应激激素变化组间比较差异无统计学意义。两组患者血浆Cor、ACTH、Glu在心肺转流(CPB)后15min、停CPB后10min与诱导前比较差异有统计学意义(P<0.01),RP组患者术后清醒时间及拔管时间明显早于FI组(P<0.01),但ICU留观时间组间比较差异无统计学意义,且RP组术后疼痛发生率高于FI组(P<0.05)。结论雷米芬太尼复合丙泊酚实施不停跳心内直视手术麻醉,可维持术中血流动力学平稳,停药后清醒快,符合快通道心脏手术麻醉要求,但应加强术后镇痛。     

吸入七氟醚与丙泊酚复合雷米芬太尼麻醉在全胃切除手术中的比较

目的 比较七氟醚吸入与丙泊酚复合雷米芬太尼麻醉在全胃切除手术中的应用效果.方法 40例ASA Ⅰ或Ⅱ级择期全胃切除术患者随机均分为七氟醚组(S组)和丙泊酚复合雷米芬太尼组(P组).记录围麻醉期各时点的血流动力学、脑电双频指数(BIS)、麻醉药浓度及用量、麻醉恢复期时间和苏醒期不良反应.结果 麻醉期两组DBP、MAP、HR均较麻醉前显著下降(P<0.05).两组患者术中均能维持足够的麻醉深度(BIS 45～60),术中血流动力学平稳.麻醉恢复期P组躁动、呛咳发生率明显低于S组(P<0.05).结论 七氟醚吸入麻醉或丙泊酚复合雷米芬太尼静脉麻醉均可安全应用于全胃切除手术.     

雷米芬太尼-七氟醚静吸复合全麻在腹腔镜手术的应用

目的观察雷米芬太尼-七氟醚静吸复合全麻在腹腔镜手术的应用中对血流动力学的影响。方法35例全麻下腹腔镜胆囊或妇产科手术病人,男6例,女29例,ASAⅠ或Ⅱ级,以雷米芬太尼1μg/kg、咪唑安定2～3mg、丙泊酚1～2mg/kg、维库溴铵8mg作麻醉诱导后气管插管;麻醉维持为雷米芬太尼0.2μg·kg-1·min-1、丙泊酚2mg·kg-1·min-1微量输注泵恒速输入,吸入1%～2%七氟醚,间断追加维库溴铵4mg。记录诱导前后血流动力学变化。结果注入雷米芬太尼后BP和HR明显下降,注入丙泊酚后进一步下降,气管插管后明显回升,切皮时较插管后下降。气腹后CO、每搏量(SV)和心脏指数(CI)均明显下降;随后逐步回升,放气后恢复或高于基础水平。结论雷米芬太尼和七氟醚均起效快、作用时间短,无蓄积,适用于腹腔镜下的短小手术。     

喉罩-雷米芬太尼复合七氟醚或丙泊酚麻醉在烧伤整形术中的应用

目的 比较喉罩-雷米芬太尼联合七氟醚与喉罩-雷米芬太尼联合丙泊酚两种麻醉方法在整形手术中应用的优缺点.方法 30例择期疤痕切除植皮术患者,随机均分为喉罩-雷米芬太尼联合七氟醚(S)组与喉罩-雷米芬太尼联合丙泊酚(P)组.静脉诱导置人喉罩后,S组静脉泵入0.15μg·kg-1·min-1雷米芬太尼及吸入2%～3%七氟醚维持麻醉.P组患者通过外周静脉泵入雷米芬太尼0.15μg·kg-1·min-1及丙泊酚6～8 mg·kg-1·h-1维持麻醉.记录患者术中生命体征、苏醒时间、术中及术后并发症发生情况.结果 麻醉诱导后两组患者MAP及HR均明显低于麻醉前水平(P<0.05),S组MAP、HR在切皮前已恢复到术前水平,而P组术中各个时点MAP及HR仍明显低于麻醉前水平及对应时间点的S组(P<0.05).结论 与喉罩-雷米芬太尼联合丙泊酚比较,喉罩-雷米芬太尼联合七氟醚用于烧伤整形手术具有血流动力学更稳定、麻醉更平稳等优点.     

芬太尼对七氟醚麻醉诱导的影响

研究了２０例择期手术病人单吸七氟醚或七氟醚复合静注芬太尼麻醉诱导对呼吸、循环，量化脑电，肌 电活动及插管反应的影响。结论静注芬太尼复合七氟醚吸入明显协同诱导效率，在临床上优于单吸七氟醚诱导。     

雷米芬太尼复合丙泊酚靶控输注快通道心脏麻醉在瓣膜置换术中的应用

近年来"快通道"技术已应用于心脏外科麻醉,即应用短效麻醉药物尽可能实施病人术后早期拔管,缩短病人在ICU监护时间和住院时间,以降低病人医疗费用[1].雷米芬太尼复合丙泊酚是目前"快通道"心脏手术麻醉理想的复合用药.     

雷米芬太尼在非体外循环冠状动脉搭桥术"快通道"麻醉中的应用

目的 研究雷米芬太尼用于非体外循环下冠状动脉搭桥术"快通道"麻醉的临床效果.方法 48例行非体外循环下冠状动脉搭桥术患者随机均分为雷米芬太尼组(R组)和芬太尼组(F组).记录两组诱导前(T0)、插管后2 min(T1)、切皮后2 min(T2)、锯胸骨后2 min(T3)、关胸时(T4)、手术结束后30min(T5)的HR,MAP、CVP,肺小动脉楔压(PAWP)、肺毛细血管楔压(PCWP)、术后拔管时间、ICU停留时间和住院时间.结果 R组与F组比较血流动力学和住院时间差异无统计学意义.R组在拔管时间和ICU停留时间上显著短于F组(P<0.01).结论 雷米芬太尼用于非体外循环下冠状动脉搭桥术"快通道"麻醉安全性高、效果明显.     

七氟醚复合雷米芬太尼麻醉用于开颅肿瘤切除术的观察

吸入麻醉在神经外科手术中的麻醉维持是比较传统的麻醉方法。近几年来全凭静脉麻醉（TIVA）,特别是目标靶控输注（TCI）的应用逐渐增多。神经外科手术时间往往较长,麻醉维持过程中药物的选择关系到麻醉过程的平稳和术后恢复。为了寻求更加完美的麻醉方案,我们对择期开颅肿瘤切除手术的患者采用所谓的“三明治”麻醉方法,     

气道表面麻醉联合静注瑞芬太尼用于鼻内窥镜手术

目的 研究气道黏膜表面麻醉对鼻内窥镜手术静注瑞芬太尼控制性降压的影响.方法 60例ASA Ⅰ或Ⅱ级接受鼻内窥镜手术的患者随机均分为两组:表面麻醉联合全麻组(C组)与单纯全麻组(S组).以调节瑞芬太尼静脉输注速度为主要降压手段.C组气管导管尖端与套囊表面涂抹利多卡因软膏,并于气管插管前气管内注入2％利多卡因3 ml,手术开始前以1％丁卡因棉片行鼻腔黏膜表面麻醉.S组单纯全麻,未行表面麻醉.比较两组达同样降压目标和全麻深度所需全麻用药量、血管活性药频率、气管插管及拔管心血管反应、苏醒时间以及苏醒期疼痛程度.结果 C组所需全麻药用量、血管活性药的频率、气管插管和拔管心血管反应及苏醒期严重疼痛和烦躁发生率均低于S组(P＜0.01);C组苏醒时间短于S组(P＜0.05).结论 气道黏膜表面麻醉联合瑞芬太尼可有效达到降压目标,降低全麻用药量,减少气管插管及拔管心血管反应,提高苏醒期舒适度.     

A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery

OBJECTIVE: To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, randomized, controlled clinical trial. SETTING: Referral center for cardiothoracic surgery at a university hospital. PARTICIPANTS: Patients (n = 24) undergoing first-time elective CABG surgery. INTERVENTIONS: Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 microg/kg bolus followed by 0.25 to 1 microg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 microg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled. MEASUREMENTS AND MAIN RESULTS: Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 +/- 82 minutes and 258 +/- 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 +/- 3 mg in the RITM group and 16 +/- 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO(2) and PaCO(2) after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups. CONCLUSION: Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation.     

七氟醚静吸复合麻醉控制性降压用于鼻内窥镜手术的临床观察

目的探讨七氟醚静吸复合麻醉控制性降压用于鼻内窥镜手术的安全性和可行性。方法选择择期鼻内窥镜手术患者40例,ASA Ⅰ或Ⅱ级,无凝血功能障碍,随机均分为控制性降压组(Ⅰ组)和非控制性降压组(Ⅱ组)。两组麻醉诱导均为咪唑安定、丙泊酚、维库溴铵、芬太尼;麻醉维持为七氟醚、芬太尼、丙泊酚、维库溴铵。术中Ⅰ组手术开始后逐渐增加七氟醚浓度至目标血压(MAP70mmHg),并维持在65~75mmHg。比较两组术中出血量?手术时间,术中监测心电图、有创MAP、HR和SpO2,记录时点为手术开始前即刻(T0)?手术20min(T1)、手术结束后10min(T2)。于手术结束后30min行血气分析。结果与T0时比较,Ⅰ组T1时MAP显著下降(P<0.01),T2时回升。T1时Ⅰ组MAP较Ⅱ组显著下降(P<0.01)。两组各时点HR差异无统计学意义。Ⅰ组比Ⅱ组手术出血量明显减少(P<0.01)。Ⅰ组比Ⅱ组手术时间明显缩短(P<0.01)。两组血气分析值均在正常范围,两组均未出现心律失常及心肌缺血征象。结论七氟醚静吸复合麻醉控制性降压用于鼻内窥镜手术能有效减少出血量,缩短手术时间,无明显并发症及不良反应。     

Recovery after anesthesia with remifentanil combined with propofol, desflurane, or sevoflurane for otorhinolaryngeal surgery

Because no previous investigation has directly compared the combination of remifentanil (REM) and a hypnotic with that of REM and the newer volatile anesthetics, we studied recovery characteristics and patient satisfaction after the combination of REM with propofol (PRO), desflurane (DES), or sevoflurane (SEVO). One hundred twenty patients were randomly assigned to receive anesthesia with either REM/PRO, REM/DES, REM/SEVO, or thiopental/alfentanil/isoflurane/N(2)O (control group) for ear, nose, and throat surgery (n = 30 each). In the REM groups, the dosage of PRO (75 microg. kg(-1). min(-1)), and of DES or SEVO (0.5 minimum alveolar anesthetic concentration) was kept unchanged, and REM was titrated to hemodynamic response. The control group was managed according to standard practice. Early recovery (times to eye opening, extubation, and statement of name and date of birth) was predictably faster and more complete in the REM groups compared with the control group. However, late recovery (times to discharge from postanesthesia care unit and hospital) and overall patient satisfaction were not different among groups. No clinically relevant differences existed among the three REM groups. In conclusion, the combination of REM infusion with small-dose DES, SEVO, or PRO is characterized by predictably rapid, early recovery. However, late recovery and patient satisfaction are comparable to a conventional anesthetic technique. IMPLICATIONS: Remifentanil anesthesia, combined with small-dose propofol, desflurane, or sevoflurane, enables predictably fast and smooth early recovery after ear, nose, and throat surgery. Despite such faster, early recovery and less need for postoperative analgesic and antiemetic medication, late recovery was comparable among the remifentanil combination groups and the control group.     

Combination of intrathecal morphine and remifentanil infusion for fast-track anesthesia in off-pump coronary artery bypass surgery

OBJECTIVE: The purpose of this study was to assess the combination of intrathecal morphine and remifentanil infusion with isoflurane in off-pump coronary artery surgery, with a focus on postoperative analgesia and fast-tracking. DESIGN: Prospective, randomized, controlled, blinded clinical study. SETTING: University hospital. PARTICIPANTS: Forty-six patients who underwent elective off-pump coronary artery bypass grafting. INTERVENTIONS: Patients were randomly assigned to receive remifentanil infusion alone (control group, n = 23) or remifentanil infusion plus 10 microg/kg of intrathecal morphine (ITM group, n = 23). Induction and maintenance anesthesia were the same in both groups. Maintenance therapy was remifentanil infusion (0.25-1 microg/kg/min) and 0.5% to 1.5% isoflurane, with adjustments according to hemodynamics. After extubation, intravenous patient-controlled analgesia with morphine (1-mg bolus and 5-minute lockout) was administered, and Wilson sedation scores, visual analog pain scores (scale, 0-100 mm) at rest and during coughing, and cumulative morphine consumption were assessed at 1, 2, 4, 8, 12, 24, and 48 hours. Examiners were unaware of patients' group identities. Anesthetic recovery parameters and opioid-related, spinal anesthesia-related, and cardiac complications were recorded. MEASUREMENTS AND MAIN RESULTS: There were no differences between the groups' intraoperative hemodynamic or anesthetic recovery findings. Pain scores and morphine consumption were significantly lower in the ITM group at all time points after extubation (p = 0.0001-0.05). Group frequencies of opioid-related and cardiac complications were similar. No patient had central neuroaxial hematoma or post-spinal tap headache. CONCLUSION: In the setting of isoflurane anesthesia for off-pump coronary artery bypass grafting, ITM combined with remifentanil infusion provides better postoperative analgesia than does remifentanil infusion alone, and does not improve or negatively affect fast-tracking.     

鼻内镜手术患者异丙酚复合瑞芬太尼控制性降压的可行性

目的探讨鼻内镜手术患者异丙酚复合瑞芬太尼控制性降压的可行性。方法择期行鼻内镜手术患者30例,ASAⅠ或Ⅱ级,随机分为2组(n=15):对照组(Ⅰ组)和降压组(Ⅱ组)。两组均采用静脉注射咪达唑仑、异丙酚、瑞芬太尼和维库溴铵麻醉诱导,持续输注异丙酚和瑞芬太尼、间断静脉注射维库溴铵麻醉维持。桡动脉穿刺置管监测有创动脉血压(MAP)。Ⅰ组不施行控制性降压,Ⅱ组于手术开始时降压,瑞芬太尼初始速率为0.25μg·kg-1·min-1,每隔2分钟增加0.1μg·kg-1·min-1,直到降至靶目标血压,维持MAP 50～70 mm Hg至手术结束。分别记录控制性降压开始即刻(T0)、30 min(T1)和停止降压20min(T2)的HR、MAP,并于各时点抽桡动脉血行血气分析和乳酸测定。用评分法评定术野的质量。结果与Ⅰ组相比,Ⅱ组手术时间缩短(P<0.05),术野质量提高0.05)。两组均无心血管不良事件发生。结论异丙酚复合瑞芬太尼用于鼻内镜手术患者控制性降压安全、有效。     

Prospective,randomized cost analysis of anesthesia with remifentanil combined with propofol,desflurane or sevoflurane for otorhinolaryngeal surgery

BACKGROUND: In the era of cost containment, cost analysis should demonstrate the cost-effectiveness of new anesthetic drugs. METHODS: This single-blind, prospective, randomized study compared the costs of three remifentanil (REM)-based anesthetic techniques with a conventional one in 120 patients undergoing otorhinolaryngeal surgery. The patients were randomized (n=30 each group) to either receive a combination of REM with propofol, desflurane or sevoflurane, or a conventional anesthetic with thiopentone, alfentanil, isoflurane and N2O. RESULTS: The costs for anesthetic and nonanesthetic drugs and for disposables were twice as high in the three REM-based groups as in the conventional group (REM/PRO 0.51 Euro;/min, REM/DES 0.42 Euro;/min, and REM/SEVO 0.41 Euro;/min vs. 0.18 Euro;/min in the ALF/ISO/N2O group; P<0.05). Wastage of intravenous drugs accounted for up to 40% of total costs. In all REM groups, early recovery was predictably faster and more complete (P<0.05). Patient satisfaction was equally high (90-97%) in all groups, with less nausea in the REM/PRO group. CONCLUSION: This study demonstrates that REM-based anesthetic techniques are more expensive than a conventional technique using alfentanil, isoflurane and N2O. This is the result of higher costs of anesthetic and nonanesthetic drugs and of disposables. The wastage of intravenous drugs contributes considerably to these costs.     

Mastocytosis: general anesthesia with remifentanil and sevoflurane

Mastocytosis is a disorder with potential anaesthesia complications. Reviewing the literature, anaesthetic management of mastocytosis is controversial. We report the successful use of remifentanil and sevoflurane in a woman with systemic mastocytosis. No reaction nor histamine release was observed in these cases.     

瑞芬太尼全麻复合硬膜外麻醉用于开胸手术的临床观察

目的 观察瑞芬太尼全麻复合硬膜外麻醉在开胸手术中的应用效果和安全性. 方法 200例择期行开胸手术患者,ASA Ⅰ～Ⅱ级,按完全随机分组方法分为两组,瑞芬太尼组(R组)与芬太尼组(F组),均采用硬膜外复合气管插管全麻,R组与F组分别采用瑞芬太尼和芬太尼麻醉,观察术前(T0)、气管插管后1 min(T1)、5 min(T2)、切皮(T3)和术后5 min(T4)的血压、心率、血氧饱和度和血中皮质醇水平,记录术后拔管时间及患者的认知能力恢复情况. 结果 两组气管插管反应发生率相比较,F组(14/26,53.8%)明显高于R组(4/26,15.4%)(P<0.05).结论 瑞芬太尼较芬太尼能更好地抑制气管插管引起的应激反应,术后患者较早恢复认知能力,且瑞芬太尼静脉全麻复合胸段硬膜外阻滞能提供有效的镇痛和抑制手术刺激引起的血流动力学反应,术后苏醒快,有利于患者术后排痰,康复快.