持续泵注不同剂量右旋美托咪定缓解食管癌手术患者麻醉苏醒期副作用

目的 观察持续泵注不同剂量右旋美托咪定(dexmedetomidine,DEX)对缓解食管癌手术患者麻醉苏醒期副作用的影响. 方法 60例食管癌手术患者按随机数字表法分为DEX 1组(D1组)、DEX 2组(D2组)和对照组(C组),每组20例.麻醉诱导前10 min D组泵注DEX 0.8 μg/kg,然后D1组、D2组分别以0.4μg·kg-1 ·h-1和0.2μg·kg-1·h-1持续泵注至术毕,同期C组给予等量生理盐水.记录患者入麻醉后苏醒室时(T1)、拔管即时(T2)以及拔管后5 min(T3)的平均动脉压(mean artery pressure,MAP)、心率(heart rate,HR)和苏醒时间.血压＞180 mm Hg/100 mm Hg(1 mm Hg=0.133 kPa)给予盐酸乌拉地尔注射液25 mg,HR＞110次/min给予盐酸艾司洛尔注射液20 mg,同时观察躁动评分和Ramsay评分. 结果 苏醒时间D1组[(30.3±4.7) min]明显长于D2组和C组(P＜0.05).D1组T2时MAP[(88±8) mm Hg]和HR[(79±5)次/min]以及D2组T2时MAP[(93±8) mm Hg]和HR[(81±6)次/min]均显著升高(P＜0.05),T3时MAP和HR回复至入麻醉后苏醒室时水平.C组T2时MAP[(117±12) mm Hg]和HR[(107±8)次/min]以及T3时MAP[(108±9) mm Hg]和HR[(118±11)次/min]也显著高于入麻醉后苏醒室时(P＜0.05).C组乌拉地尔和艾司洛尔的使用率显著多于D组(P＜0.05),D1组和D2组的躁动评分分别是(1.2±0.8)和(1.4±0.6),显著低于C组(P＜0.05);D1组和D2组的镇静评分分别是(4.5±1.2)和(4.0±0.7),显著高于C组(P＜0.05). 结论 麻醉诱导前10 min泵注DEX 0.8 μg/kg,术中持续泵注0.2 μg·kg-1·h-1 DEX能缓解食管癌手术患者苏醒期副作用,既不影响苏醒又能很好地抑制术后躁动.     

右美托咪定取代丙泊酚麻醉用于青少年脊柱侧凸手术的临床研究

目的 观察右美托咪定完全取代丙泊酚麻醉应用于青少年脊柱侧凸矫形手术对麻醉深度、唤醒试验、麻醉恢复及副反应的影响. 方法 择期行脊柱侧凸后路矫形手术患者60例,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,完全随机分组法分为两组,每组30例:右美托咪定组(Ⅰ组)采用右美托咪定负荷剂量1 μg/kg 10 min,继以0.25 μg·kg-1·h-1输注,丙泊酚组(Ⅱ组)采用丙泊酚起始100 μg· kg-1 ·min-1,两组均根据脑电双频指数(bispectral index,BIS)值调整使其维持在40～50,并配合使用瑞芬太尼0.4 μg· kg-1· min-1和顺式阿曲库铵1 μg· kg-1· min-1.术中以硝酸甘油进行控制性降压将平均动脉压(MAP)维持在60 mm Hg～70 mm Hg(1 mm Hg=0.133 kPa).肌肉分离完毕后停止使用顺式阿曲库铵,矫形完毕开始唤醒试验.记录两组术中唤醒时间和气管拔管时间及唤醒和苏醒时的Ramsay镇静评分、Riker躁动评分.记录Ⅰ组右美托咪定用量和两组有无术中知晓及恶心呕吐、寒战发生率. 结果 Ⅰ组术中唤醒和麻醉恢复时Riker评分[4.00(0.25)和4.00(1.00)]均低于Ⅱ组[4.50(1.00)和4.00(1.25)] (P＜0.05).两组Ramsay评分、唤醒时间、拔管时间、恶心呕吐和寒战发生率差异无统计学意义(P＞0.05).Ⅰ组右美托咪定用量为(2.4±0.5) μg· kg-1·h-1,Ⅱ组丙泊酚用量为(86±12) μg·kg-1· min-1.两组患者均未发生术中知晓. 结论 右美托咪定取代丙泊酚配合瑞芬太尼、硝酸甘油维持的全凭静脉麻醉在BIS监测下应用于青少年脊柱侧凸矫形手术镇静深度充分,可以优化术中唤醒和术后复苏质量且未增加副作用.     

艾司洛尔或尼卡地平联合容量填充对全凭静脉麻醉丙泊酚用量的影响

目的 探讨艾司洛尔或尼卡地平联合诱导期容量填充对全凭静脉麻醉丙泊酚用量的影响.方法 择期行脊柱手术的患者36例,随机均分为三组:艾司洛尔组(E组)于诱导前2 min静注艾司洛尔1 mg/kg,继之以100 μg·kg-1 ·min-1微量泵输注至术毕;尼卡地平组(N组)于诱导前2min静注尼卡地平10 μg/kg,继之以1 μg·kg-1 ·min-1微量泵输注至术毕;生理盐水组(C组)于相同时间点给予等量生理盐水.三组患者均于给予血管活性药物开始20 min内快速静滴羟乙基淀粉130/0.4 10ml/kg行容量填充.麻醉诱导和维持均采用TCI丙泊酚和舒芬太尼,调节丙泊酚效应室浓度使术中BIS值维持在40～60.记录丙泊酚用量,清醒和拔管时间.结果 与C组比较,E组和N组丙泊酚用量显著减少(P＜0.05),清醒和拔管时间明显缩短(P＜0.05).结论 艾司洛尔或尼卡地平联合诱导期容量填充不仅有利于维持血流动力学的平稳,而且能够明显减少全凭静脉麻醉丙泊酚用量,缩短清醒和拔管时间.     

尼卡地平、乌拉地尔和艾司洛尔对全麻诱导期间压力反射敏感性的影响

目的 观察尼卡地平、乌拉地尔和艾司洛尔对原发性高血压(EH)患者全麻诱导期间压力反射敏感性(BRS)的影响.方法 全身麻醉F行择期手术EH患者62例,随机分为四组,分别于诱导前2min静注尼卡地平0.5μg/kg(N组,15例)、乌拉地尔0.5 mg/kg(U组,16例)、艾司洛尔0.25 mg/kg(E组,16例)和牛理盐水(c组,15例).用相同药物进行全麻诱导.于诱导前、插管前即刻,以及插管后5、10、15、20、30 min不同时点静注硝普钠50～100μg.使SBP下降15～25mm Hg,记录SBP下降期间RR间期的变化,计算BRS.结果 N组、U组和C组插管前后各时间点BRS与基础值比较明显降低(P<0.05或P<0.01),N组中各时点BRS又明显低于C组(P<0.05),而E组明显高于C组(P<0.05).结论 伞麻诱导可降低EH患者的BRS;尼卡地平可使BRS进一步降低,乌拉地尔则无显著影响,而艾司洛尔则使伞麻诱导期的BRS升高.     

瑞芬太尼控制性降压对胃癌根治术患者脑氧代谢的影响

目的 探讨瑞芬太尼控制性降压对胃癌根治术患者脑氧代谢的影响.方法 择期行胃癌根治术患者42例,ASA Ⅰ或Ⅱ级,年龄30～64岁,性别不限,体重指数<30 kg/m2,随机分为3组(n=14):对照组(C组)、瑞芬太尼控制性降压组(R组)和硝普钠控制性降压组(N组).麻醉诱导:静脉注射咪达唑仑0.1 mg/kg、芬太尼5 μg/kg、维库溴铵0.08 mg/kg和异丙酚2 mg/kg,气管插管后行间歇正压机械通气,潮气量8～10 ml/kg,呼吸频率12次/min,吸呼比1:1.5,维持呼气末二氧化碳分压30～35 mm Hg.麻醉维持:静脉输注异丙酚50～100 μg·kg-1·min-1和瑞芬太尼0.1 μg·kg-1·min-1,吸入异氟醚(呼气末浓度1.1%),间断静脉注射维库溴铵0.04 mg/kg.开腹膜时C组瑞芬太尼输注速率不变;R组瑞芬太尼输注速率每分钟增加0.05 μg·kg-1·min-1;N组静脉输注硝普钠1 μg·kg-1·min-1,1 min后每分钟增加0.5 μg·kg-1·min-1.R组和N组MAP降至麻醉诱导前的70%但不低于50 mm Hg.记录控制性降压诱导时间和血压恢复时间;于麻醉诱导前、降压前即刻、降压达目标血压10、30 min和停止降压20 min时,记录MAP和HR;采集桡动脉和颈内静脉球部血样行血气分析,计算动脉血氧含量(CaO2)、静脉血氧含量(CjvO2)、动脉.静脉血氧含量差(Da-jvO2)、脑氧摄取率(CERO2)和动脉-静脉乳酸含量差(Da-jvL).结果 R组控制性降压诱导时间和血压恢复时间长于N组,但血压较N组稳定(P<0.05);与C组比较,R组Da-jvO2、CERO2和Da-jvL降低,N组CERO2和Da-jvL升高(P<0.05).结论 胃癌根治术患者瑞芬太尼控制性降压效果良好,可降低脑组织氧耗.     

瑞芬太尼术毕时不同应用模式对颅脑手术患者苏醒期的影响

目的 评价神经外科手术患者全麻苏醒期应用不同模式瑞芬太尼对患者拔管期呛咳反应的影响.方法 ASAⅠ或Ⅱ级择期行颅脑手术的患者60例,均在快速诱导下进行气管插管,术中以微量泵持续输注丙泊酚、瑞芬太尼维持麻醉,术毕按瑞芬太尼的给药方式采用完全随机法分为3组(每组20例):A组缝皮结束时停止输注瑞芬太尼;B组缝皮结束时停止输注瑞芬太尼,包扎头部时再静脉单次注射瑞芬太尼1 μg/kg,C组缝皮结束后继续微泵输注瑞芬太尼0.05 μg· kg-1· min-1至拔管后.记录拔管前、拔管即刻、拔管后1、3 min的心率(heart rate,HR)、平均动脉压(mean arterial pressure,MAP)、血氧饱和度(oxygen saturation,SpO2),记录手术时间、苏醒时间(丙泊酚停止输注至睁眼时间)、拔管时间(缝皮结束至拔管)、丙泊酚与瑞芬太尼的总用量、呛咳程度、拔管后意识状态等.结果 拔管即刻HR:A组(101±7)次/min,B组(90±8)次min,C组(78±9)次min;拔管后1 min的HR:A组(98±9)次min,B组(83±6)次/min,C组(80±5)次/min;拔管后3min的HR:A组(93±5)次/min,B组(82±7)次/min,C组(82±5)次/min;B组、C组在拔管后3个时点的HR低于A组,差异有统计学意义(P＜0.05).拔管即刻MAP:A组(97±11) mm Hg(1 mm Hg =0.133 kPa),B组(87±9)mm Hg,C组(77±7) mmHg;拔管后1 min的MAP:A组(92±8) mm Hg,B组(84±8) mm Hg,C组(75±6) mm Hg;拔管后3 min的MAP:A组(85±6) mm Hg,B组(80±5) mm Hg,C组(76±6) mm Hg;B组在拔管即刻、拔管后1 min的MAP低于A组,差异有统计学意义(P＜0.05),C组在拔管后3个时点的MAP均低于A组,差异有统计学意义(P＜0.05).C组拔管后3个时点的HR、MAP与拔管前比较差异无统计学意义(P＞0.05).A、B、C3组苏醒时间、拔管时间、拔管后OAA/S评分差异无统计学意义(P＞0.05);拔管期A组均出现呛咳,8例轻度、12例中度,B组13例无呛咳、7例轻度呛咳,C组16例无呛咳、4例轻度呛咳,与A组比较,B组、C组呛咳的发生率及程度均降低(P＜0.05).结论 手术结束时继续持续输注0.05 μg·kg-1·min-1的瑞芬太尼或单次静脉注射瑞芬太尼1μg/kg可提高患者的耐管性,减少呛咳反应,抑制拔管期间HR、MAP的过度变化,且不影响患者苏醒时间.     

盐酸右美托咪啶对重症颅脑损伤患者围术期内皮素-1的影响

目的 观察盐酸右美托咪啶对重症颅脑损伤患者围术期内皮素-1(endothelin-1,ET-1)的影响. 方法 重症颅脑损伤患者40例按随机数字表法随机分为盐酸右美托咪啶组(D组)和对照组(C组)(每组20例).两组分别于麻醉诱导前(T0)、插管即刻(T1)、术毕(T2)、术后1(T3)、3 d(T4)及5 d(T5)晨抽取静脉血测定血浆ET-1的浓度,同时监测各时点血流动力学指标的变化情况. 结果 与T0点心率(HR)(107±9)次/min,平均动脉压(MAP)(125±6) mm Hg(1 mm Hg=0.133 kPa),血浆ET-1 (237±27) μg/L比较,C组在T1时点HR(119±12)次/min显著升高(P＜0.05),T3-5时点HR(70±5)次/min、MAP(82±6) mm Hg 和血浆ET-1浓度(122±12) μg/L降低(P＜0.05);与T0点HR(110±11)次/min,MAP(123±7) mm Hg,血浆ET-1(233±23) μg/L比较,D组在T1-5时点HR(70±5)次 /min和MAP(81±6)mm Hg均显著降低,T2-5时点血浆ET-1浓度(88±8) μg/L显著降低(P＜0.05).两组HR和MAP在T1-3,血浆ET-1在T2-5时点差异具有统计学意义(P＜0.05).C组患者中1例因并发神经源性肺水肿死亡. 结论 重症颅脑损伤患者围术期持续应用盐酸右美托咪啶能有效维持血液动力学稳定,降低患者血浆ET-1的浓度.     

右美托咪啶和硝酸甘油控制性降压在颅内动脉瘤夹闭术中的比较

目的 比较在颅内动脉瘤夹闭术中右美托咪啶或硝酸甘油控制性降压的效果及对脑氧代谢的影响. 方法 60例行颅内动脉瘤夹闭术患者,采用随机数字表法分为右美托咪啶组(D组)和硝酸甘油组(N组).D组泵注右美托咪啶,首剂量1.0 μg/kg(泵注10 min),0.4 μg·kg-1·h-1～0.8 μg·kg1·h-1维持；N组泵注硝酸甘油,首剂量3μg·kg-1·min-1,10 min后3μg·kg-1· h-1～9μg· kg-1· min-1维持.记录麻醉诱导前(T),控制性降压开始后0(T0)、10(T1)、20(T2)、30 min(T3)和停止降压后30 min(T4)的平均动脉压(MAP)、心率(HR),同时采集桡动脉血和颈内静脉球部血行血气分析,计算脑氧摄取率(cerebral oxygen extraction rate,CERO2). 结果 实施控制性降压后,两组MAP均在30 min内达到目标血压.降压期间,HR:D组T3时(66±10)次/ min低于T0时(76±9)次/min(P＜0.05),N组T3时(86±8)次/min高于T0时(77±8)次/min(P＜0.05)；CERO2:D组T3时(27±6)％低于T0时(35±6)％(P＜0.05)；N组T3时(32±6)％与T0时(34±5)％差异无统计学意义(P＞0.05).D组CERO2与MAP呈正相关(r=0.83).结论 右美托咪啶用于颅内动脉瘤术中控制性降压安全、可靠.与硝酸甘油比较,有减慢HR,降低术中脑氧代谢率的优点.     

尼卡地平控制性降压对颅内压的影响

目的 观察尼卡地平控制性降压对颅内压(ICP)的影响.方法 选择ASA Ⅰ或Ⅱ级神经外科手术患者20例,年龄19～50岁.行腰椎穿刺术直接测得ICP.尼卡地平起始剂量为0.01%～0.02%的溶液静脉滴注,维持SBP在100 mm Hg以下.记录降压前(T0)、降压10 min(T1)、20min(T2)、30 min(T3)和结束降压后10 min(T4)、20 min(T5)的ICP、rSO2、HR、MAP.结果 T1～T3时MAP显著低于T0(P<0.01).T4时MAP明显回升(P<0.05),T5时回到T0水平.降压期间ICP、rSO2、HR无明显改变.结论 尼卡地平降压起效快,降压平稳,对ICP、脑氧饱和度无明显影响.     

尼卡地平控制性降压对局部脑氧饱和度的影响

目的观察颅内动脉瘤夹闭术中控制性降压对局部脑氧饱和度(rScO2)的影响。方法 15例ASAⅠ级的择期颅内动脉瘤夹闭手术患者,丙泊酚-瑞芬太尼全凭静脉麻醉,暴露动脉瘤期间静脉泵注尼卡地平0.5～1μg·kg-1·min-1,逐渐降低术前基础MAP的10%、20%和30%,夹闭动脉瘤后停止降压,观察降压过程中MAP、HR和rScO2的变化趋势。结果尼卡地平控制性降压过程中,随着MAP的逐渐下降,rScO2略有升高,T5时rScO2恢复至T1水平,各时点MAP、HR、PETCO2、BIS和rScO2差异均无统计学意义。结论颅内动脉瘤夹闭术中应用尼卡地平行控制性降压安全可行,不会影响脑氧供需平衡。     

Beating coronary bypass with right-heart bypass

Two patients with bilateral obstructive carotid artery disease underwent beating heart coronary bypass including revascularization of the circumflex branch using right-heart bypass in a stable hemodynamic state. Without this mechanical support, lifting the left ventricle for the exposure of the posterior wall could impair the hemodynamic state of the patient. Right-heart bypass in addition to aortic no-touch technique can be a safer option for complete coronary revascularization in patients at high risk for neurological complications.     

Coronary artery bypass without cardiopulmonary bypass.

The purpose of this article is twofold: to describe our technique for performing coronary artery bypass grafting without cardiopulmonary bypass (off pump) and to demonstrate that this operation is safe, in terms of mortality and certain indices of morbidity. Very little has been published in regard to off-bypass operations. From 1985 through 1990, 220 patients underwent operation off bypass; 220 on-pump controls were retrospectively matched for number of grafts, left ventricular function, and date of operation. Groups were compared in terms of mortality and ten indicators of morbidity. The same analysis was performed for ten subgroups. We found no statistically significant difference between groups in mortality (off pump, 1.4% [3/220]; on pump, 2.4% [5/220]), which held across all subgroups. Patients undergoing operation off pump required blood far less often (not transfused: off pump, 72.7% [160/220]; on pump, 54.6% [116/220]; p = 0.005 by Fisher's exact test), and the low output state occurred statistically less frequently off pump (off pump, 5.5% [12/220]; on-pump, 12.7% [28/220]; p = 0.01 by Fisher's exact test). Further research should be directed to which subgroups can be operated on to advantage off pump and which, if any, groups of patients should be confined to on-bypass operations.     

Multivessel sequential bypass grafting without cardiopulmonary bypass

Background Multivessel sequential coronary artery bypass grafting without cardiopulmonary bypass has become a reality. Initially the revascularization of posterior coronary arteries (obtuse marginal branches of the circumflex artery) was difficult due to access and difficulty in stabilization of the heart as well as compromising the haemodynamic status of the heart. With stabilization of the heart with Octopus II (Medtronic, Inc. Minnesota, USA) we have demonstrated that sequential grafts as well as composite arterial grafts can easily and safely be used in complete arterial revascularization of the myocardium. Methods From January 1, 1996 till December 31, 1999, 832 consecutive patients underwent coronary artery bypass surgery without cardiopulmonary bypass. From July 1998, seventy-nine patients operated had atleast 1 conduit used as a sequential graft and 12 patients had composite ‘Y’ grafts. Before July 1999, 67 patients (61 sequential and 6 ‘Y’ conduits) underwent surgery without mechanical stabilization (Group A) and after July 1999 in 24 patients (18 sequential and 6 ‘Y’ conduits) mechanical stabilization (Octopus II) was used. Results Total number of sequential anastomosis including composite grafts was not significantly different in both groups. But due to Octopus II stabilization, number of anastomosis in composite ‘Y’ graft group significantly increased from 2.96 ±0.2 to 4.02 ±0.3. Also intramyocardial coronary artery revascularization which was only 10.4% in Group A increased to 20.8% in Group B. In Group A only 8.9% composite grafts were performed while in Group B it was 25% which was statistically significant. Conclusions Cardiac stabilization with Octopus II has improved ability for revascularization of remote coronary arteries arising from circumflex. Although overall anastomoses have not increased, the number of patients receiving composite grafts using all arterial conduits have increased significantly. Patency rates of all sequential conduits as well as composite grafts have remained equally good in both groups.     

Coronary artery bypass surgery without cardiopulmonary bypass

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 ± 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 ± 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.