Concentration-Response Relationships for Fentanyl and Sufentanil in Patients Undergoing Coronary Artery Bypass Grafting

Background: Concentration-response relationships for sufentanil and fentanly are undefined in patients undergoing coronary artery bypass grafting.

Methods: Separate studies of sufentanil and fentanyl were performed in lorazepam-premedicated patients undergoing coronary artery bypass grafting. Patients were assigned randomly to groups with different prebypass effect-site opioid concentrations targeted by computer-assisted infusion. The target sufentanil concentrations were 0.4 ng/ml (group LS, n = 11), 0.8 ng/ml (group MS, n = 10), and 1.2 ng/ml (group HS, n = 11); the target fentanyl concentrations were 5 ng/ml (group LF, n = 7), 10 ng/ml (group MF, n = 7), and 15 ng/ml (group HF, n = 6). Propofol at a dose of 1 mg/kg was administered at induction of anesthesia and isoflurane was used for hemodynamic control. Hemodynamics, end-tidal isoflurane concentration, and opioid concentration in arterial blood were measured at specific intervals.

Results: Intraoperative opioid concentrations were constant, averaging 0.71 +/- 0.13, 1.25 +/- 0.21, and 2.03 +/- 0.46 ng/ml for groups LS, M (S), and HS, respectively, and 7.3 +/- 1.1, 13.2 +/- 2.2, and 24.4 +/- 5.8 ng/ml for groups LF, MF, and HF, respectively (all mean +/- SD). Isoflurane requirements were significantly greater in group LS than in groups MS and HS and greater in group LF than in groups MF and HF. The serum opioid and end-tidal isoflurane concentrations were correlated significantly. There were no intergroup differences in hemodynamics.     

翼点入路切除侵袭性垂体腺瘤的术后护理

目的 提高经翼点入路切除侵袭性垂体腺瘤术治疗和护理效果.方法 对70例侵袭性垂体腺瘤患者行经翼点入路切除术.术后严密监测患者生命体征、神志、瞳孔及内分泌的变化,做好呼吸道的管理及尿崩症、电解质紊乱、癫痫及高热等并发症的护理.结果 手术均获成功;术后发生尿崩症54例,电解质紊乱42例,癫痫12例及高热6例.患者经对症处理除8例伴有长期尿崩症外,其余均好转.住院14～30 d,伤口均愈合,68例好转出院,2例死亡.随访6个月至4年,肿瘤复发16例,均行二次手术,恢复良好;68例均生存.结论 翼点入路到达鞍区距离短,对正常脑组织损伤小;术后严密的监测和高质量的护理是提高疗效的重要保证.     

3D 电视胸腔镜肺占位病变切除术

目的：探讨Storz 3D电视胸腔镜手术治疗肺部疾病的可行性。方法2013年7月应用Storz 3D电视胸腔镜分别行肺叶切除联合系统性淋巴结清扫和病变局部切除各2例。选择腋中线第7肋间为胸腔镜观察孔,腋前线第3或第4肋间2～3 cm切口为胸腔镜主操作孔,腋后线靠后第8或9肋间2 cm切口为第1副操作孔。佩戴3D偏振眼镜,在3D效果的手术画面上,行局部病灶切除或肺叶切除,恶性肿瘤者行系统性淋巴结清扫。结果4例均手术成功,无中转开胸,无术后并发症,无死亡。手术时间分别为36、38、72、90 min,出血量分别为5、10、35、80 ml,术后住院时间分别为3、3、5、7 d。术后随访2个月,均无并发症发生。结论 Storz 3D电视胸腔镜手术安全可行,相对于VATS,视野更逼真,操作更灵活稳定。     

Chlamydia pneumoniae in Atherosclerotic Lesions of Patients Undergoing Vascular Surgery

The pathophysiological implications of Chlamydia pneumoniae in atherosclerotic lesions and its contribution to atherosclerotic complications remain unclear. Therefore, the purpose of the present study was to evaluate whether or not there is an association between the presence of Chlamydia pneumoniae in atherosclerotic lesions and the clinical manifestations as well as risk factors of atherosclerotic disease in patients undergoing vascular surgery. Specimens from atherosclerotic arteries were collected during endarterectomy of the carotid artery (n = 15), endarterectomy of the femoral artery (n = 19), or repair of an abdominal aortic aneurysm (n = 28). Detection of Chlamydia pneumoniae was performed by using immunohistochemical staining (IHC) with specific antibodies. Clinical manifestations of atherosclerotic disease were defined by the presence of cardiovascular risk factors, coronary heart disease, and previous vascular surgery. Inflammatory serum markers were determined in all patients prior to surgery. The specimens of all 62 patients revealed severe atherosclerosis in histological examination and a positive IHC was observed in 41 samples (66%). There were no differences regarding cardiovascular risk factors, coronary heart disease, events of previous vascular surgery, or inflammatory serum markers when comparing patients with positive and negative IHC. In conclusion, our findings showed no correlation between clinical or laboratory parameters of atherosclerosis and the presence of Chlamydia pneumoniae in atherosclerotic lesions. Therefore, Chlamydia pneumoniae appears to be a concomitant phenomenon rather than a causative principle in atherosclerosis.     

瑞芬太尼和丙泊酚靶控输注用于老年患者妇科腹腔镜手术麻醉的研究

目的对行妇科腹腔镜手术的不同年龄的患者采用瑞芬太尼、丙泊酚靶控输注进行诱导和维持,观察此麻醉方式的临床疗效。方法60名ASAⅠ～Ⅲ级、行择期妇科腹腔镜手术的患者,分为Ⅰ组（〈65岁）和Ⅱ组（≥65岁）,每组30例。麻醉诱导,Ⅰ组瑞芬太尼靶效应室浓度4 ng/ml,Ⅱ组瑞芬太尼靶浓度2.5 ng/ml,2组丙泊酚血浆靶浓度从2.0μg/ml逐渐升高至意识消失,气管插管后根据脑电双频指数（BIS）和血流动力学参数变化调整丙泊酚和瑞芬太尼的靶浓度。记录患者诱导和维持阶段丙泊酚和瑞芬太尼靶浓度、收缩压（SBP）、舒张压（DBP）、心率（HR）及苏醒时间。结果Ⅱ组患者意识消失时丙泊酚靶血药浓度明显低于Ⅰ组[（2.5±0.4）μg/ml vs（3.2±0.5）μg/ml,t=5.988,P=0.000],维持过程中Ⅱ组平均丙泊酚靶浓度低于Ⅰ组[（2.1±0.5）μg/ml vs（2.7±0.7）μg/ml,t=3.820,P=0.000],维持过程中Ⅱ组瑞芬太尼靶浓度明显低于Ⅰ组[（0.19±0.06）ng/ml vs（0.32±0.06）ng/ml,t=8.391,P=0.000]。2组诱导后SBP明显下降,气管插管后回升,术中维持稳定。2组DBP、HR的波动无统计学意义。2组血管活性药的应用例数差异无显著性。Ⅱ组麻醉恢复时间长于Ⅰ组（P〈0.05）。结论根据监测数据个体化地调整丙泊酚和瑞芬太尼的靶浓度,能够使行妇科腹腔镜手术老年患者的血流动力学波动范围和麻醉深度维持在与中青年近似的水平,但老年患者苏醒时间仍延长。     

可乐定对心脏手术病人芬太尼需用量及血流动力学反应的影响

２０例择期心脏手术病人，随机分为可乐定组与对照组（各１０例），可乐定组病人术前６０ｍｉｎ口服可乐定５μｇ／ｋｇ，术中用芬太尼使病人ＭＡＰ、ＨＲ维持在麻醉前基础值±１５％，脑电频率维持在０．５～３Ｈｚ范围内。结果发现，可乐定组术中芬太尼用量（２６．２±２．４８μｇ／ｋｇ）较对照组（３５．８±３７．４μｇ／ｋｇ）减少了３７％（Ｐ＜０．０１）；可乐定组病人术中ＭＡＰ、ＨＲ变化也明显比对照组平稳（Ｐ＜０．０５、Ｐ＜０．０１）。说明麻醉前应用可乐定能明显减少术中芬太尼用量，使病人术中血流动力学反应保持平稳。     

半离体肝切除余肝自体移植术治疗肝占位性疾病

目的总结半离体肝切除余肝自体移植术治疗肝占位性病变的体会。方法回顾性分析5例接受半离体肝切除余肝自体移植患者的临床资料,其中肝多发血管瘤2例,肝癌3例。结果5例患者术程顺利,术后未出现肝性脑病、肝创面大出血等严重并发症;术后平均11 d肝功能指标完全正常,术后10~26 d出院。1例随访20个月,肝功能正常且CT显示无肿瘤复发迹象,生活质量高;1例随访14个月,肝功能完全正常且无新发血管瘤;其余患者目前肝功能完全正常,各项情况稳定,已痊愈出院,尚在观察中。结论半离体肝切除余肝自体移植术是治疗常规手术无法切除的肝占位性病变的一种有效方法。     

Post-anesthesia Recovery after Infusion of Propofol with Remifentanil or Alfentanil or Fentanyl in Morbidly Obese Patients

Background: The type of opioid used during general anesthesia in the morbidly obese influences recovery and the postoperative period. In a randomized clinical trial, the postoperative recovery profile and early period after general anesthesia with remifentanil, fentanyl and alfentanil were compared in morbidly obese patients. Material and Method: 60 morbidly obese patients with BMI >35 kg/m² (mean 43.31) undergoing open Roux-en-y gastric bypass were randomly divided into 3 groups: remifentanil (R), fentanyl (F), and alfentanil (A). Dosage of opioids was based on ideal body weight (IBW): fentanyl 5 mcg/kg for intubation followed by infusion of 0.025-0.05 mcg/kg/min; alfentanil 15 mcg/kg initially, then 1.0-1.5 mcg kg/min; and remifentanil 1 mcg/kg followed by infusion of 0.25-1.5 mcg/kg/min. Anesthesia was induced with infusion of propofol and oxygen with N₂O (1:1). After anesthesia, the duration to response to verbal command, spontaneous respiration, adequate respiration, and safe extubation were recorded.The incidence of postoperative nausea and vomiting were recorded. Using verbal scale for evaluation of postoperative pain, the early postoperative analgesia requirements were assessed. Results: Demographic profiles and duration of procedure did not differ between groups. A total dose of propofol was significantly lower in Group R compared with Groups A and F (P <0.05). Duration to spontaneous respiration, adequate respiration and safe extubation were significantly shorter in Group R compared with Group F (P <0.05). Shortly after anesthesia, significantly more patients in Group R required additional dose of analgesic than in Group F (P <0.05). Postoperative nausea and vomiting (PONV) occurred significantly more often in Group R compared with Group F (P <0.05). Recovery profile of Group A was more similar to Group R, and postoperative pain and PONV evaluation more similar to Group F. Conclusion: In morbidly obese individuals, alfentanil or fentanyl and remifentanil can be safely used, but there is a higher rate of PONV and postoperative pain in the remifentanil group.     

颅底病变手术与缺损修复术患者围术期护理

目的 探讨颅底病变手术与缺损修复术围术期的护理措施。方法 对430例行颅底病变手术与缺损修复术的患者术前进行针对性心理疏导．手术区与供皮区的皮肤准备及全麻常规准备；术后加强生命体征监测．观察脑脊液漏、面瘫、感音神经性聋等症状，实施相应的护理。结果 428例均治愈出院；2例因病变累及颈内动脉．手术时血管破裂．行颈内动脉和颈总动脉结扎．术后发生脑疝而死亡。无1例发生护理并发症。结论 颅底病变的手术治疗风险极大，而精心、细致、周到的护理是手术成功的重要保证。     

颅底病变手术与缺损修复术患者围术期护理

目的探讨颅底病变手术与缺损修复术围术期的护理措施.方法对430例行颅底病变手术与缺损修复术的患者术前进行针对性心理疏导,手术区与供皮区的皮肤准备及全麻常规准备;术后加强生命体征监测,观察脑脊液漏、面瘫、感音神经性聋等症状,实施相应的护理.结果 428例均治愈出院;2例因病变累及颈内动脉,手术时血管破裂,行颈内动脉和颈总动脉结扎,术后发生脑疝而死亡.无1例发生护理并发症.结论颅底病变的手术治疗风险极大,而精心、细致、周到的护理是手术成功的重要保证.     

超声引导经皮穿刺活检诊断乳腺占位性病变的可行性及有效性分析

目的:探讨乳腺占位性病变诊断中超声引导经皮穿刺活检的可行性及有效性。方法:选取2017年1月—2018年11月我院收治的102例乳腺占位性病变患者,对患者进行超声引导经皮穿刺活检和超声活检诊断,并以病理诊断为参考依据。分析乳腺占位病变超声诊断价值和乳腺占位性病变超声经皮穿刺活检的诊断价值,比较超声活检诊断和乳腺占位性病变超声引导诊断价值。结果:超声诊断与病理诊断结果无明显差异(P>0.05),超声引导活检诊断与病理诊断结果无明显差异(P>0.05),超声活检诊断和乳腺占位性病变超声引导诊断在灵敏度、特异度、符合率、漏诊率和误诊率方面存在显著差别(P<0.05),超声引导经皮穿刺活检的诊断效能优于超声诊断。结论:对乳腺癌患者进行超声引导经皮穿刺活检,不仅诊断效果理想,而且大大降低了患者诊断过程的漏诊率和误诊率,提高了诊断准确度,降低了并发症的发生。     

异丙酚复合芬太尼妇科门诊手术麻醉中熵指数的应用

目的：观察妇科门诊异丙酚复合芬太尼麻醉中熵指数-反应熵和状态熵的变化。方法：ASAⅠ-Ⅱ级妇科门诊无痛刮宫或人流患者30例．入室后常规监测,然后静脉给予芬太尼（1μg·kg）和异丙酚（2-2．5mg·kg）。记录麻醉前和麻醉后直至苏醒期间RE、SE、MAP、HR、SP02,OAA／S。结果：与麻醉前相比,麻醉后1、2,3．4、5,6、7min各观察点MAP、RE．SE、OAA／S均下降（p〈0．05或0．01）;HR的变化幅度正常;与SE相比RE在各观察点均升高（p〈0．01）。结论：熵指数能较好地反映异丙酚复合芬太尼麻醉的深度。     

脑内病变导航手术中脑和病变移位规律初探

目的探讨大脑半球脑内病变导航手术中脑和病变移位的规律与对策。方法大脑内病变20例，术中住硬脑膜打开前、后用导航仪测出硬脑膜和脑表面标记点的差值，为病变切除前的脑移位量：对病变边界可辨的13例患者测量病变移位量。分析脑和病变移位的方向、程度及其影响因素。结果术中寻找病变成功率为100％，全切率75．0％。术中脑移位平均9．62（1～16）mm。病变边界可辨者病变移位量平均6．54（0～13）mm。其中，病变向骨窗方向移位者11例，向深部移位者1例。结论对丁边界清楚的脑内病变，应用导航的目的主要是准确找到病变。对于边界不清者，要引导术者寻找增强影像所湿示的病变边界、引导伞切，因此更需注意脑和病变移位问题。脑移位与病变体积、占化效应和颅内压有关。病变移位与脑移位方向一致，移位量小于脑移位量。     

乳管镜与彩色多普勒超声结合对导管内占位性病变的诊断

目的评价乳管镜结合彩色多普勒超声（彩超）对未扪及肿块的导管内占位性病变的诊断价值。方法对69例乳头溢液行乳管镜和彩超检查的手术病例,将乳管镜和彩超结果与病理结果进行比较。结果乳管镜诊断的病理符合率为73.9%（51/69）;乳管镜结合彩超诊断的病理符合率81.2%（56/69）,二者无统计学差异（Z=0.824,P=0.410）。乳管镜诊断乳管内占位的病理诊断符合率为78.5%（51/65）,乳管镜结合彩超诊断的病理符合率83.1%（54/65）,二者无统计学差异（Z=0.443,P=0.658）。结论与单纯乳管镜相比,乳管镜结合彩超对未扪及肿块的导管内占位性病变诊断的病理符合率并无提高,可能与样本例例数少有关。     

Lorazepam and High-Dose Fentanyl Anaesthesia: Effects on Haemodynamics and Oxygen Transportation in Patients Undergoing Coronary Revascularization

The effects of intravenous lorazepam (0.05 mg/kg) on haemodynamics and oxygen transportation were studied in a group of 11 patients undergoing a coronary artery bypass grafting operation with high-dose fentanyl anaesthesia and compared to the changes in another group of 11 patients receiving the same anaesthesia, but saline instead of lorazepam. The measurements were made under stable haemodynamic conditions before the injection of lorazepam or saline, and repeated 5, 20 and 40 min after the injection. Lorazepam caused a slight decrease in the systemic and pulmonary arterial pressures and in the left ventricular stroke work index, as compared to the control group. The ECG or the rate-pressure product did not show changes indicative of myocardial oxygen supply/demand imbalance in either group. There was a similar decrease in the systemic oxygen transportation and an increase in the arterio-venous oxygen content difference in both groups, but the unchanged systemic oxygen consumption and arterial lactate level suggest a well-maintained tissue oxygenation. It is concluded that intravenous lorazepam does not cause important haemodynamic untoward effects as an adjunct to high-dose fentanyl anaesthesia in patients undergoing coronary artery bypass grafting.