静脉全麻复合颈丛神经阻滞及术后镇痛对颈淋巴结结核患者术后呼吸、循环及T细胞亚群的影响

目的 观察静脉全麻复合颈丛神经阻滞及术后镇痛对颈淋巴结结核患者术后呼吸、循环及T细胞亚群的影响.方法 选择60例ASA Ⅰ或Ⅱ级择期行颈淋巴结结核病灶清除术的患者,随机均分为三组:A组(静脉全麻复合颈丛神经阻滞+患者自控颈丛镇痛),B组(静脉全麻复合颈丛神经阻滞+患者自控静脉镇痛(PCIA),C组(静脉全麻+PCIA).测定麻醉前30 min(T0)、术后4 h(T1)、24 h(T2)、2 d(T3)、3 d(T4)外周静脉血T淋巴细胞亚群CD3+、CD4+、CD8+百分比;观察T0～T3时、VT、肺活量(Vc)、RR、SpO2、MAP和HR;记录T1～T3时疼痛、镇静评分.结果 T1、T2时三组患者CD3+、CD4+、CD4+/CD8-均明显下降(P<0.05);A组T4时各免疫指标恢复至术前水平;B组和C组T1时RR较T0时明显增快(P<0.05),而T2时SpO2、Vc均较T0时明显下降(P<0.05),A组T1时RR低于B、C组(P<0.05),而V1高于B、C组(P<0.05),A组T1、T2时Vc、SpO2均高于B、C组(P<0.05);A组术后T1～T3时MAP、HR均无明显改变.结论 静脉全麻复合颈丛神经阻滞及术后镇痛可减轻颈淋巴结结核患者术后免疫功能的抑制,并改善呼吸、循环功能.     

术后硬膜外镇痛和静脉镇痛对老年高血压患者全髋置换术后应激反应的影响

目的比较硬膜外镇痛与静脉镇痛对老年高血压患者全髋置换术后应激反应的影响。方法 30例择期全髋置换术后的高龄患者随机均分为三组:对照组(A组)、术后静脉镇痛(PCIA)组(B组)、术后硬膜外镇痛(PCEA)组(C组)。观察患者术后8、12、24及48h的镇痛效果,记录术前(T1)、术毕(T2)、术后24h(T3)及术后48h(T4)的血流动力学和应激激素的变化。结果 T2～T4时A组的SBP、DBP明显高于、HR明显快于T1时(P<0.05或P<0.01)。T3时B、C组内皮素(ET)、心房利钠肽(ANP)显著低于A组(P<0.05或P<0.01),T4时C组ET明显低于A组,B、C组ANP仍明显低于A组(P<0.05或P<0.01);T3、T4时C组皮质醇(Cor)、促肾上腺皮质激素(ACTH)明显低于A组(P<0.05或P<0.01)。结论 PCEA及PCIA均能有效控制术后疼痛,维持血流动力学稳定,降低术后应激激素水平,而硬膜外镇痛较静脉镇痛对高龄高血压患者镇痛效果更平稳。     

全麻复合胸段硬膜外阻滞对不停跳冠状动脉搭桥术后患者T淋巴细胞亚群的影响

目的 观察全麻复合胸段硬膜外阻滞对不停跳冠状动脉搭桥术(OPCABG)后患者T细胞亚群及止浆皮质醇的影响.方法 22例择期行OPCABG患者随机分为全麻组(A组)和全麻复合硬膜外阻滞组(E组),每组11例,术后均采用吗啡静脉镇痛(PCIA).分别于麻醉前(T1)、术毕(T2)、术后第1天(T3)及第3天(T4)抽取外周静脉血,用流式细胞仪(FCM)检测T淋巴细胞亚群变化,以化学发光法测血浆皮质醇.结果 与T1比较,两组血浆皮质醇在T2和T3均明显升高(P＜0.05),但E组患者升高程度明显低于A组(P＜0.05).两组T2和T3 CD3 、CD4 和CD4 /CD8 均较T1明显下降(P＜0.05).但与E组比较,A组T3及T4 CD3 、CD4 、CD4 /CD8 下降更明显(P＜0.05),且E组患者T淋巴细胞亚群在T4已恢复至T1水平(P＞0.05).结论 全麻对OPCABG后患者细胞免疫功能有抑制作用,复合胸段硬膜外阻滞将减轻此抑制的程度.     

两种麻醉方法对直肠癌患者术后免疫功能的影响

目的:观察两种麻醉方法下直肠癌患者术后免疫功能的变化.方法:选择40例直肠癌手术病人,随机分为两组,每组20例:A组采用静脉麻醉;B组采用硬膜外阻滞复合静脉全麻.分别于麻醉前(T0)、切皮后2h(T1),术后6h(T2)、术后48 h(T3)测定CD4+%、CD8+%、血清白介素-2(IL-2)和可溶性白介素-2受体(sIL-2R).结果两组CD4+%、CD4+/CD8+比值JL-2水平下降(P＜0.05),T1至T3时B组CD4+%明显高于A组(P＜0.05),T2至T3时B组CD4+/CD8+比值、IL-2水平明显高于A组(P＜0.05);两组sIL-2R水平A组T1时显著高于T0,T2达最高峰;而B组各时间点与T0比较差异无统计学意义(P＞0.05);两组间比较,T1至T3时A组sIL-2R水平明显高于B组(P＜0.05).结论:硬膜外阻滞配合全麻可减轻围手术期直肠癌患者的细胞免疫功能抑制.     

全麻复合硬膜外麻醉及术后硬膜外镇痛对食管癌患者术后T细胞亚群及循环、呼吸的影响

目的探讨静脉全麻复合硬膜外麻醉(CGEA)及患者自控硬膜外镇痛(PCEA)对食管癌患者术后 T 细胞亚群及循环、呼吸的影响。方法选择60例 ASA Ⅰ或Ⅱ级择期行食管癌根治术的患者,随机均分为三组。A 组行 CGEA 及术后 PCEA,B 组行 CGEA 及术后患者自控静脉镇痛(PCIA),C 组行全凭静脉麻醉及术后 PCIA。分别于麻醉前30 min(T_0)、术后4 h(T_1)、1 d(T_2)、2 d(T_3)、3 d(T_4)、7 d(T_5)取外周静脉血2 ml,用流式细胞仪测定 T 淋巴细胞亚群,并观察各时间点循环、呼吸指标以及疼痛、镇静评分。结果三组患者 T_1～T_3时 CD3~ 、CD4~ 、CD8~ 、CD4~ /CD8~ 均明显下降(P<0.05)。B、C 组 RR 在T_1时明显快于 A 组(P<0.05)。T_4时 A 组 T 淋巴细胞亚群恢复至 T_0,B 组和 C 组 T_5时 CD3~ 、CD4~ 、CD8~ 、CD4~ /CD8~ 均基本恢复。结论 CGEA 辅以术后PCEA 可改善食管癌患者术后呼吸、循环功能并减轻免疫功能的抑制。     

术后硬膜外镇痛对老年患者血小板膜糖蛋白的影响

目的　观察术后硬膜外镇痛对老年患者血小板膜糖蛋白的影响 ,探讨其对部分血小板功能的作用。方法　 98例择期手术的老年患者 ,随机分为镇痛组 (E组 )和对照组 (C组 ) ,每组 4 9例 ,镇痛组采用全麻联合硬膜外麻醉 +术后持续硬膜外输注镇痛 ,对照组采用复合全麻 +术后间断肌注哌替啶镇痛。分别于麻醉前、手术结束 1h和术后 2 4h抽取肘静脉血 ,采用流式细胞术双色免疫荧光染色测定血小板表面CD4 1/CD6 1、CD6 2P、CD6 3的表达量 ,同时测定血浆皮质醇和血糖水平 ,监测记录血压和心率。术后采用视觉模拟评分 (VAS)法评定镇痛效果。结果　对照组术后CD6 2P、CD6 3、CD4 1/CD6 1明显增高 ,与术前比较有显著性差异 (P <0 0 5 ) ,与镇痛组比较差异也有显著性意义 (P <0 0 5 )。结论　术后硬膜外持续输注镇痛安全可靠 ,可有效地抑制机体应激反应 ,阻滞交感神经兴奋 ,缓解血小板活化 ,是改善老年患者术后高凝状态的有效方法之一。     

全麻复合硬膜外麻醉和镇痛在创伤性湿肺连枷胸手术中的运用

目的探讨采用不同麻醉和镇痛方式对创伤性湿肺连枷胸手术患者术中血糖、皮质醇水平的影响以及术后清醒拔管时间、术后镇痛的效果和血氧饱和度(Sp O2)的变化情况,以及术后肺部感染情况和住院天数。方法 50例行创伤性湿肺连枷胸择期手术患者,随机均分为全麻复合胸段硬膜外阻滞及术后硬膜外镇痛组(A组)和全身麻醉及术后静脉镇痛组(B组)。分别记录麻醉前(T0)、切皮后10分钟(T1)、第一根肋骨复位内固定时(T2)、术毕(T3),四个时间点测定血清血糖、皮质醇的值。分别记录麻醉前、术后2、8、12、24、36、48小时指脉搏Sp O2的数值和VSA(视觉模拟评分法)评估镇痛效果以及术后肺部感染情况和住院天数。结果两组血糖、皮质醇在T0时刻无明显差异(P>0.05),在T1~T3时刻A组明显低于B组(P<0.05)。两组术前VSA的数值无明显差异(P>0.05),术后各时点VSA的数值A组明显低于B组(P<0.05);两组术前Sp O2的数值无明显差异(P>0.05),术后各时点Sp O2的数值A组明显高于B组(P<0.05)。术后清醒拔管时间A组明显少于B组(P<0.05)。术后肺部感染的例数以及住院天数A组明显少于B组(P<0.05)。结论在创伤性湿肺连枷胸手术中,使用全麻复合硬膜外麻醉和镇痛能有效的抑制手术引起的应激反应,与静脉镇痛相比能明显减轻术后的疼痛,有利于患者的咳嗽排痰,改善患者的呼吸,促进患者的康复。     

全麻复合硬膜外阻滞及术后镇痛对开胸围术期循环和内分泌功能的影响

目的:观察全麻联合硬膜外阻滞及术后镇痛对开胸围术期循环和内分泌功能的影响.方法:将80例开胸手术病人,随机分为全麻复合硬膜外阻滞(TEA组)和单纯全麻(GA组)各40例.TEA组术后硬膜外镇痛48 h;GA组术后必要时肌注哌替啶镇痛.分别测定入室基础值(T0)、诱导插管后(T1)、切皮后(T2)、手术探查时(T3)、肿瘤切除后(T4)、术毕即刻(T5)、术后24 h(T6)、术后48 h(T7)各时段的MAP、HR和同一时段抽取静脉血测定皮质醇、胰岛素和血糖浓度变化.结果:GA组围术期的MAP在T2、T3、T5、T6和HR在T2、T5、T6时段均显著高于T0水平或TEA组同一时段(P＜0.05或P＜0.01);皮质醇在T3、T5、T6时段GA组明显高于TEA组(P＜0.01或P＜0.05);胰岛素仅在T3时段GA组显著高于TEA组(P＜0.01);血糖浓度GA组在T2、T3、T4、T5、T6、T7时段均分别较T0或TEA组同一时段显著升高(P＜0.01).结论:全麻联合硬膜外阻滞可有效缓解开胸手术应激反应,对循环和内分泌影响小,同时术后镇痛可减轻围手术期糖代谢紊乱.     

胸椎旁阻滞对开胸患者开胸前心功能及术后情况的影响

目的 观察胸椎旁阻滞对开胸患者开胸前心功能的影响、术后镇痛及不良反应发生情况.方法 开胸手术患者90例,随机均分为全麻组(I组)、硬膜外阻滞复合全麻组(Ⅱ组)和胸椎旁阻滞复合全麻组(Ⅲ组).Ⅱ、Ⅲ组根据手术切口部位在全麻前20 min行相应的硬膜外或胸椎旁间隙给药.采用血流动力学监护仪分别于进入手术室后安静状态(T0)、硬膜外或胸椎旁间隙阻滞20 min(T1)、全麻诱导后插管前(T2)、气管插管后(T3)4个时段监测三组HR、无创MAP、心排血量(CO)、心脏指数(CI)、加速度指数(ACI)、外周血管阻力(SVR)和收缩时间比率(STR),同时记录ECG和SpO2;并观察术后镇痛情况及不良反应.结果 T2时I和Ⅱ组HR、MAP、CI、CO、SVR、ACI较T0和Ⅲ组明显下降(PcC0.05);STR较Ⅲ组明显上升(P＜0.05).Ⅲ组心电图ST段下移的发生率明显低于I组和Ⅱ组(P＜0.05).三组患者对术后镇痛满意率相似.Ⅲ组患者术后并发症明显少于I组和Ⅱ组(P＜0.05).结论 全麻及硬膜外阻滞复合全麻对开胸患者心功能影响大,术后并发症较多;而椎旁阻滞系单侧脊神经阻滞,复合全麻对心功能和呼吸功能影响相对较轻,适宜于单侧开胸手术及术后镇痛治疗.     

不同术后镇痛方式对手术患者恢复期心肌缺血的影响

目的研究硬膜外镇痛与静脉镇痛对手术患者恢复期心肌缺血的影响。方法39例行择期腹部手术的患者随机分成两组:硬膜外镇痛组(R组),16例,术中全麻复合硬膜外麻醉,术后硬膜外镇痛;静脉镇痛组(M组),23例,术中全麻,术后静脉吗啡镇痛。维持两组Price-Henry疼痛评分≤3分。所有患者接受24 h动态心电图监测48 h。两组患者在入手术室安静平卧10 min、入SICU后2 h、术后第1天晨、术后第2天晨采集静脉血测定皮质醇浓度。结果术后48 h内,R组心肌缺血发生率比M组低(P<0.05),在术后各时点,R组的皮质醇浓度低于M组(P<0.05)。结论与静脉镇痛相比较,硬膜外镇痛明显减轻应激反应,减少术后心肌缺血发生率。     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.