不同剂量罗哌卡因对行腰麻-硬膜外联合麻醉的剖宫产妇RAAS及镇痛效果的影响

目的探讨不同剂量罗哌卡因对行腰麻-硬膜外联合麻醉的剖宫产妇肾素-血管紧张素-醛固酮系统(RAAS)及镇痛效果的影响。方法选取160例剖宫产妇,ASA分级为Ⅰ~Ⅱ级,麻醉方式均为腰麻-硬膜外联合麻醉,按照随机数字表法分为A、B、C、D四组,每组40例。A、B、C、D组分别给予8、10、12、15 mg的罗哌卡因进行麻醉,比较四组产妇术中麻醉效果、术后不良反应以及麻醉前(T_1)、切皮即刻(T_2)、胎儿娩出即刻(T_3)和手术完成即刻(T_4)的肾素活性(PRA)、血管紧张素Ⅱ(AT-Ⅱ)和醛固酮(ALD)水平,并比较新生儿脐带血气分析及1、5 min的Apgar评分。结果 B、C、D组术中麻醉效果明显优于A组(P0.05),D组术中麻醉效果明显优于B组(P0.05);B、C、D组T_2~T_4时刻血清PRA水平均明显低于A组(P0.05),D组T_2~T_4时刻血清PRA水平均明显低于B、C组(P0.05),C、D组T_2时刻血清AT-Ⅱ、ALD水平均明显低于A、B组(P0.05);四组新生儿1、5 min Apgar评分及p H、氧分压(PO2)、二氧化碳分压(PCO2)比较差异均未见统计学意义(P0.05);D组低血压发生率明显高于A、B、C组(P0.05)。结论 8、10、12、15 mg的罗哌卡因均可完成手术要求,对新生儿无明显影响,但10、12、15 mg的罗哌卡因镇痛效果更好,能够明显抑制RAAS的过度分泌,但随着剂量增大可能会增加低血压的发生风险。     

改良式腰-硬联合麻醉对剖宫产产妇心血管系统的影响

目的：观察改良式腰-硬联合麻醉对产妇术中心血管系统、术后镇痛及对胎儿的影响。方法选择ASAⅠ~Ⅱ级、年龄18~37岁的足月待产需行剖宫产术的孕妇130例，按日期随机分成改良方法组（观察组）和传统方法组（对照组）两组，各65例。观察组首先于T12~L1椎间隙行硬膜外穿刺、置管，再在L2~3椎间隙行蛛网膜下腔穿刺、注药；对照组仅在L2~3椎间隙硬膜外穿刺，成功后利用针内针技术行蛛网膜下腔穿刺、注药，然后再置入硬膜外导管。观察两组麻醉前、麻醉后5min、胎儿娩出即刻及娩出后5min的平均动脉压（MAP）、心率（HR）变化，以及胎儿脐带血气分析。结果两组麻醉前后MAP差异有统计学意义（P〈0.01），HR差异无统计学意义，脐带血气中乳酸两组差异有统计学意义（P〈0.05）、PO2和pH差异无统计学意义，术后镇痛评分差异有统计学意义（P〈0.01）。结论改良式腰-硬联合麻醉用于剖宫产术麻醉效果佳、对心血管系统影响少，有良好的术后镇痛作用，并对胎儿代谢影响少。     

0.125%布比卡因和罗哌卡因分娩镇痛对母婴PRA、AT-Ⅱ、ALD的影响

目的:研究0.125%布比卡因和罗哌卡因用于硬膜外自控分娩镇痛对母婴肾素-血管肾张素-醛固酮系统(RAAS)的影响.方法:90例ASAⅠ级健康初产妇随机分为3组,每组30例.A组行PCEA,采用0.125%布比卡因+2 μg/mL芬太尼;B组行PCEA,采用0.125%罗哌卡因+2μg/mL芬太尼;C组(对照组)为自然分娩、顺产产妇.分别于宫口开至2～3 cm镇痛前(T0)、宫口开至3～4 cm(T1)、宫口开全时(T2)、胎儿娩出后即刻(T3)、产后24 h(T4)抽取母体肘静脉血和胎儿娩出后即刻胎儿脐动、静脉血测定血清肾素活性(PRA)、血管紧张素Ⅱ(AT-Ⅱ)和醛固酮(ALD)浓度;评定镇痛效果,记录两组宫口开大2～3 cm至胎儿娩出的时间及新生儿娩出1 min、5 min的Apgar评分.结果:3组HR、SPO2、BP、RR变化及新生儿1 min、5 min时的Apgar评分差异均无显著性(P＞0.05);3组宫口开大2～3 cm至胎儿娩出的时间比较:C组＞A组＞B组(P＜0.05);A、B组于T1、T2、T4的母体PRA、AT-Ⅱ、ALD值均比T0、T3明显降低(P＜0.01),胎儿脐动、静脉血的PRA、AT-Ⅱ、ALD值A、B组差异不明显,但三者也明显低于母体T0、T3值(P＜0.01);相反C组于T0、T1、T2、T3的母体及胎儿脐动、静脉血的PRA、AT-Ⅱ、ALD值均比T4明显增高(P＜0.01),并明显高于A、B组(P＜0.01).结论:0.125%布比卡因和罗哌卡因用于硬膜外分娩镇痛时,只要镇痛效果满意,不会对母婴RAAS产生不良影响;从满足分娩镇痛要求看,罗哌卡因优于布比卡因.     

去氧肾上腺素和麻黄碱在剖宫产术腰-硬联合阻滞麻醉中血压管理对母婴的影响

目的比较观察去氧肾上腺素和麻黄碱在剖宫产术腰．硬联合阻滞麻醉中纠正血压对母婴的影响。方法选择100例择期剖宫产手术产妇,足月妊娠,单胎,ASAI～Ⅱ级,随机分为去氧肾上腺素组（P组）和麻黄碱组（E组）,每组各50例。腰-硬联合阻滞后每分钟测量血压1次,当收缩压下降值超过麻醉前收缩压20％时,分别静脉给予等效剂量的去氧肾上腺素0．1mg（P组）和麻黄碱8mg（E组）,直至胎儿娩出。胎儿娩出即刻,取胎儿脐带动静脉血进行血气分析。期间观察产妇的血压、心率、脉搏氧饱和度、恶心、呕吐等情况。结果两组均能很好的纠正产妇的血压下降,两组麻醉中收缩压比较差异无统计学意义（P〉0．05）：E组心率麻醉中最大值与麻醉中最小值均大于P组（P均〈0．05）,E组的HR波动大于P组;E组恶心、呕吐的发生率高于P组（P〈0．05）;E组脐动静脉血pH值和碱剩余低于P组（P〈0．05）,PCO2高于P组（P〈0．05）。结论与麻黄碱相比,去氧肾上腺素在腰一硬联合阻滞麻醉剖宫产术中对母婴的影响更小。     

耳针辅助硬膜外麻醉对恶心呕吐反应的影响

目的：观察耳针联合硬膜外麻醉对剖宫产产妇恶心呕吐反应的影响。方法：剖宫产30例,随机分为单纯硬膜外麻醉组（EA组）和耳针联合硬膜外麻醉组（AEA组）。观察两组麻醉手术中发生恶心呕吐的情况。结果：AEA组恶心呕吐发生率较EA组低,两组间差异有统计学意义（P〈0.05）。结论：耳针辅助硬膜外麻醉能降低胃肠反应。     

腰硬联合麻醉对剖宫产产妇围术期凝血功能、RAAS活性及术后镇痛效果的影响

目的探讨腰硬联合麻醉对剖宫产产妇围术期凝血功能、RAAS活性及术后镇痛效果的影响。方法收集2013年6月至2016年1月在该院接受剖宫产分娩的产妇118例,按照随机数字表法分为观察组及对照组各59例,观察组产妇接受腰硬联合麻醉,对照组产妇接受硬膜外麻醉。手术前1d(T0)、剖宫产结束前10min(T1)、剖宫产术后6h(T2),采用全自动血凝分析仪测定凝血功能指标,采用放射免疫法测定肾素-血管紧张素-醛固酮系统(RAAS)功能指标。术后6h(T2)、术后12h(T3),采用痛阈测试仪测定疼痛指标。结果 T1、T2时,观察组产妇的凝血指标凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)、凝血酶凝固时间(TT)水平均显著高于对照组产妇,凝血酶原活动度(PTA)水平低于对照组产妇(P0.05);观察组产妇的血清RAAS指标肾素(R)、血管紧张素Ⅱ(ANGⅡ)、醛固酮(ALD)水平均低于对照组产妇(P0.05)。T2、T3时,观察组产妇的视觉模拟评分(VAS)评分值低于对照组产妇,痛阈、耐痛阈水平高于对照组产妇(P0.05)。结论腰硬联合麻醉可减少剖宫产创伤引起的产妇凝血、RAAS功能激活,且在术后镇痛方面效果更显著。     

不同麻醉方式对妊娠高血压综合征剖宫产术产妇血液流变学的影响及意义

【目的】探讨不同麻醉方式对妊娠高血压综合征（PIH）剖宫产术产妇血液流变学的影响。【方法]92例PIH剖宫产妇随机分为腰麻一硬膜外联合阻滞（CSEA）组和硬膜外阻滞（EB）组,分别给予相应的麻醉方式。在入室平静后、麻醉起效后和胎儿娩出后分别对其患者进行血液流变学检测。并对新生儿进行1min和5rainApgar评分。【结果】两组患者在年龄,孕周,ASA分级等方面差异无统计学意义（P〉0．05）。麻醉前,两组全血低切粘度相似（P〉0．05）;麻醉生效时,两组患者的全血低切粘度均下降,低于麻醉前（P〈0．05）,而CSEA组下降更明显（P〈0．05）;胎儿娩出时,两组的全血低切粘度较麻醉中没有明显改变,但仍较麻醉前低（P〈0．05）,并且CSEA组的全血低切粘度仍要低于EB组（P〈0．05）。全血中切粘度、全血高切粘度和血浆粘度三个指标,均显示出和一样的改变趋势。两组新生儿1min和5minApgar评分CSEA组均较EB组稍高,但未见有统计学差异（P〉0．05）。【结论】腰麻-硬膜外联合阻滞较硬膜外阻滞均能改善妊娠高血压综合征剖宫产术产妇的血液流变学状态,但腰麻-硬膜外联合阻滞更明显,对母儿更为有利。     

腰硬联合麻醉与硬膜外麻醉对重度子痫前期剖宫产产妇血流动力学和新生儿apgar评分的影响

目的对比研究腰硬联合麻醉与硬膜外麻醉应用于重度子痫前期剖宫产患者,对产妇血流动力学和新生儿apgar评分的影响。方法选取2013年1月至2015年6月在我院治疗的重症子痫前期患者,将其随机分为2组,两组患者均采用剖宫产术结束妊娠。硬膜外麻醉组(EA组)40例患者纳入研究,腰硬联合麻醉组(CSEA组)37例患者纳入研究。比较两组患者在麻醉前(T0)、麻醉平稳后(T1)、开始手术时(T2)、胎儿娩出后(T3)、手术结束时(T4)的平均动脉压(MAP)、心率(HR)及指脉氧(SpO2)各指标的差异;并比较两组患者的麻醉效果及胎儿娩出后1min和5min时的apgar评分。结果麻醉前(T0),两组患者的MAP、HR及SpO2的差异无统计学意义(P0.05);麻醉过程中,两组患者仅在胎儿娩出后(T3)的HR有统计学差异(P0.05),其余各时间点的各指标差异无统计学意义(P0.05)。CSEA组患者麻醉起效时间及达到最高阻滞平面时间均明显短于EA组(P0.05),但麻黄碱用量明显多于EA组(P0.05)。两组胎儿在娩出后1min及5min时的apgar评分差异均无统计学意义(P0.05)。CSEA组的牵拉不适感发生率低于EA组(P0.05),其余不良反应未见明显差别(P0.05)。结论与硬膜外麻醉相比,腰硬联合麻醉应用于重度子痫前期剖宫产患者,对产妇血流动力学和新生儿apgar评分无明显影响,但有助于缩短麻醉诱导时间,缓解牵拉不适感。     

小剂量氯胺酮在剖宫产硬膜外麻醉中的应用

目的观察在剖宫产中应用小剂量氯胺酮对产妇及新生儿安全性的影响。方法将美国麻醉师协会（ASA）1～2级，年龄35岁以内，行硬膜外麻醉的产妇100例分甲乙两组，每组50例，甲组胎儿娩出前给产妇静脉注射氯胺酮0．3～0．5mg／kg，观察两组胎儿娩出时产妇的视觉模拟法（VAS）评分，新生儿Apgar评分及术后10～20小时产妇VAS评分。结果甲组产妇术中紧张疼痛明显消失，两组新生儿Apgar评分差异无显著性意义（P〉0．05），术后10～20小时两组产妇VAS评分差异有显著性意义（P〈0．05）。结论小剂量氯胺酮对产妇及新生儿安全，可降低术中及术后产妇VAS评分。     

低浓度罗哌卡因联合芬太尼镇痛分娩对产妇皮质醇的影响

目的探讨低浓度罗哌卡因镇痛分娩对产妇皮质醇及胎儿的影响。方法60例初产妇随机分为对照组和镇痛组，镇痛组30例用0．06％的罗哌卡因联合芬太尼，以硬膜外阻滞麻醉方式，对产妇分娩时进行麻醉镇痛处理；对照组30例未行分娩镇痛。观察2组产妇分娩时疼痛效果、运动阻滞程度、分娩方式和新生儿情况，测定产妇静脉血及脐血中皮质醇含量。结果镇痛组疼痛视觉模拟评分（VAS）明显低于对照组，差异有统计学意义（P〈0．01）。2组下肢运动神经阻滞评分差异无统计学意义（P〉0．05）。镇痛组用药后活跃期缩短，与对照组比较差异有统计学意义（P〈0．05）；镇痛组第2产程较对照组时间长，但差异无统计学意义（P〉0．05）；2组剖宫产率差异无统计学意义（P〉0．05）。2组新生儿出生后1、5min Apgar评分比较差异均无统计学意义（均P〉0．05）。对照组皮质醇含量较分娩前差异有统计学意义（P〈0．05）。镇痛组镇痛后皮质醇含量与对照组比较差异有统计学意义（P〈0．01）；脐血中皮质醇含量较对照组低，产后_d皮质醇明显下降，与产前比较差异均有统计学意义（均P〈0．01）；2组产妇产后皮质醇比较差异无统计学意义（P〉0．05）。结论用0．06％的罗哌卡因联合芬太尼镇痛分娩是理想的分娩方式。     

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.