地氟醚环路内注药法循环紧有入麻醉的应用研究

目的：探讨地氟醚环路内注药法用于循环紧闭吸入麻醉的可行性，并观察地氟醚药代动力学的变化，方法：５０例ＡＳＡⅠ－Ⅱ级择期手术全麻病人，咪唑安定、芬太尼麻醉诱导插管行ＩＰＰＶ。氧流量４Ｌ／Ｍｉｎ通气５分钟，行最低流量循环紧闭吸入麻醉。根据Ｌｏｗｅ的吸收公式，通过气端注入地氟醚的初始剂量，接用微泵持续输入地氟醚，维持地氟醚的肺泡浓度约３％左右。术中根据地氟醚的ＦＡ调整输注速度。切皮前分太尼０．１ｍｇ，术     

低流量氧异氟醚紧闭吸入麻醉在心脏手术中的应用

本文报告在旁气流气体监测仪监测下，使用持续气流麻醉机和注射泵，在１４例心脏直视手术中施行低流量氧－异氟醚紧闭吸入麻醉的结果。于气管插管后关闭麻醉环路，依Ｌｏｗｅ的ｋｇ３／４法则和时间的平方根法则，按计算的通气量和给药量实施。结果表明：关闭环路后，环路内氧分量（ＦｉＯ２、ＦＥＯ２）逐渐下降，于９ｍｉｎ即与关闭前有非常显著的差异（Ｐ＜０．０１），异氟醚于１６ｍｉｎ达到预期浓度（１．３±０．４ＭＡＣ），ＳｐＯ２均≥９８％，血压、心率维持稳定。根据结果认为，在全面监测的基础上，即使对心功能很差的心脏病人，也可安全实施低流量紧闭吸入麻醉。     

七氟醚中、低流量紧闭麻醉与双频指数监测下低流量紧闭麻醉的比较

目的 比较七氟醚中流量、低流量及双频指数监测下低流量循环紧闭麻醉,以探讨七氟醚的应用方法。方法 96例ASA Ⅰ～Ⅱ级择期全麻手术病人,随机分为三组,A组:中流量循环紧闭麻醉,氧流量1000 ml/min;B组:低流量循环紧闭麻醉,氧流量500 ml/min;C组:双频指数监测下低流量循环紧闭麻醉,氧流量500ml/min。各组均以七氟醚环路内吸入维持麻醉。A、B两组根据临床麻醉体征和手术刺激情况调节七氟醚浓度,C组根据BIS值调节七氟醚浓度。结果 A组、B组和C组呼气末七氟醚维持浓度分别为(1.4±0.2)MAC、(1.1±0.2)MAC和(0.8±0.2)MAC水平;七氟醚总耗量分别为(13.3±1.6)m1/h、(9.6±1.5)ml/h和(7.5±1.8)ml/h,C组七氟醚总耗量最低(P<0.01);苏醒时间分别为(14.3±3.3)min、(10.5±2.8)min和(7.5±2.6)min;意识恢复时间分别为(24.5±6.1)min、(17.4±5.5)min和(12.7±4.8)min,c组苏醒时间和意识恢复时间最快;恶心呕吐发生率分别为14.5％±2.6％、10.1％±2.3％和7.5％±2.1％,c组恶心呕吐发生率最低。结论 双频指数监测下七氟醚低流量循环紧闭麻醉具有节约麻醉药,苏醒时间短和恶心呕吐发生率低的优点,是一种良好的麻醉方法。     

低流量紧闭麻醉的回路内七氟醚注药法

目的：采用回路内直接注入七氟醚为２５例病人行低流量紧闭麻醉。方法：将七氟醚液体分次注入钠石灰罐，首次量２ｍｌ，追加量每次１ｍｌ。七氟醚呼气末浓度维持在１％以上。结果：第１ｈ的七氟醚用量为６．９２±２．１６ｍｌ，第２ｈ为４．５７±０．６６ｍｌ（１４例）。首次注药２ｍｌ产生的最大吸入和呼出浓度分别为０．６％～１．７％和０．４％～１．３％。随着麻醉时间的延长，七氟醚的摄取速率减慢，追加给药产生的吸入浓度上升幅度逐渐增大。而七氟醚的用量与体重的相关性较差。结论：钠石灰罐分次注入七氟醚行低流量紧闭麻醉简便可行。     

地氟醚用于低流量吸入麻醉的可行性

目的 探讨溶解度较低的地氟醚在低流量麻醉中的临床应用价值。方法 ４０例择期手术的胸腹部肿瘤病人，ＡＳＡＩ～Ⅱ级，分为Ａ，Ｂ，Ｃ，Ｄ组，Ａ，Ｂ组氧流量分别为２Ｌ／ｍｉｎ和０．５／ｍｉｎ吸入６％的地氟醚（１ＭＡＣ）观察其肺泡浓度升高速率及差别。Ｃ，Ｄ组分别吸入氧流量为０．５／ｍｉｎ１ＭＡＣ异氟醚和安氟醚作为对照组，结果 Ａ组ＦＡ／ＦＩ和ＦＡ／ＦＤ达１／２时间分别为１分钟和４分钟；在１２分钟时ＦＡ／ＦＩ     

不同麻醉深度下中枢神经系统的功能状态(数量化脑电图和麻醉深度的关系)

目的：探讨数量化脑电图与七氟醚麻醉深度的关系。方法：６２例腹部手术病人，常规麻醉诱导、气管内插管。机械通气，潘库溴铵或阿曲库铵维持肌松。手术探查毕，调整每个病人的七氟醚呼气末浓度依次达２％→１．５％→１％，每种浓度维持至少１５分钟，记录３分钟数量化ＥＥＧ及ＭＡＰ、ＨＲ变化。结果：随七氟醚呼气末浓度降低，原始脑电波逐渐由低频高振幅波转变为高频低振幅波；ＳＥＦ和ＭＦ趋势曲线明显右移；ＳＥＦ、ＭＦ、ＢＩＳ、δＲ明显差异（Ｐ＜０．０１）。血流动力学的变化仅在七氟醚呼气末浓度１％与２％时有明显差异（Ｐ＜０．０１）。结论：数量化脑电图能监测不同七氟醚麻醉深度时大脑皮层电活动变化，而ＭＡＰ和ＨＲ只能区别极深和极浅的麻醉状态。     

氧—笑气—七氟醚循环半紧闭式麻醉用于患儿的观察

报告氧－笑气－七氟醚（ＧＯＳ）循环半紧闭式麻醉用于患儿的体会。本组１２例患儿，ＡＳＡⅠ～Ｒ级，年龄４．５～１４岁，体重１８～３９．５ｋｇ，手术时间５５～９６分钟。麻醉诱导：氧３Ｌ／ｍｉｎ－笑气３Ｌ／ｍｉｎ－七氟醚０．５％～４％；以４０％氧－６０％笑气－１％～２％七氟醚维持。结果诱导至应答反应消失时间２．７１±０．６２分，诱导至气管插管时间７．９６±０．８１分，苏醒时间４．９２±０．８２分。结果表明，七氟醚循环半紧闭式麻醉用于小儿患者有诱导快，苏醒快，富有调节性等优点，是一种安全、有效的吸入全麻药。     

静吸复合全麻中阿芬太尼对血流动力学的影响

观察阿芬太尼用于静脉复合麻醉对于气管插管时及术中、术后循环的影响。选择ＡＳＡ Ⅰ￣Ⅱ级择期手术患４０例：实验组（Ａ组）２０例，有阿芬太尼４０ｕｇ·ｋｇ＾－１诱导，维持量每分钟１ｕｇ·ｋｇ＾－１，对照组２０例，用芬太尼４ｕｇ·ｋｇ＾－１诱导，维持量每分钟０．１ｕｇ·ｋｇ＾－１，维持期均吸入１％￣１．５％安氟醚，酌情追加维库溴铵。分别记录两组入室时，给诱导量后１￣５分钟、插管后０￣２分钟及拔管后０￣     

不同麻醉深度下中枢神经系统的功能状态

探讨数量化脑电图与七氟醚麻醉深度的关系。方法：６２例腹部手术病人，常规麻醉诱导，气管内插管，机械通气，潘库溴铵或阿曲库铵维持肌松。手术探查毕，调查每个病人的七氟醚呼气未浓度依次达２％→１．５％→１％，每种浓度维持至少１５分钟、记录３分钟数量化ＥＥＧ及ＭＡＰ，ＨＲ变化，结果：随七氟醚呼气末浓度降低，原始脑电波逐渐由低频高振幅波转变为高频低振幅波；ＳＥＦ和ＭＦ趋势曲线明显右移；ＳＥＦ，ＭＦ，ＢＩＳ，δ     

小流量吸入麻醉定量给药的探讨

对１６例开胸术全麻患者初步探讨了小流量吸入麻醉的定量给药。初始相载气量是５Ｌ／ｍｉｎ，挥发器刻度由０．５％开启，Ｖｒ８～１０ｍｌ／ｋｇ，呼吸频率为２０次／ｍｉｎ，每５次通气增加半个百分浓度，到４％时做１２次通气，然后进入维持相，将载气量改为１Ｌ／ｍｉｎ，ＶＴ不变，呼吸频率改为１０次／ｍｉｎ，挥发器输出刻度为１％，１小时后再将挥发器调为０．７５％，在以后的２～３小时内不做任何调整。按此法给药，维持期安氟醚ＦＡ０．５５％，异氟醚ＦＡ０．７６％。辅以小剂量芬太尼，麻醉平稳，术后无记忆。     

Coasting: worth the effort?

A new anesthesia machine incorporates a "coasting mode", but the extent to which a coasting technique can maintain anesthesia at the end of a procedure under optimal conditions (closed circuit anesthesia) remains unknown. Sixty-nine patients undergoing peripheral or abdominal surgery were assigned to 1 of 9 groups, depending on when desflurane coasting (in O2/air) was started (after 4, 9, 16, 25, 36, 49, 64, 81, or 100 min). The end-expired desflurane concentration was maintained at 4.5% in O2/air prior to coasting with a conventional anesthesia machine. After initiating coasting (using a closed-circuit technique), we examined when the end-expired desflurane concentration reached 70, 60, 50, and 40% of its value during maintenance (= 30, 40, 50 and 60% decrement times, respectively). Decrement times increased with increasing duration of anesthesia, and varied widely. After 64 min of maintenance anesthesia, the end-expired desflurane concentration remained at or above 70, 60, 50, and 40% of its maintenance value during 10.3 +/- 2.3, 16.0 +/- 3.5, 25.0 +/- 5.9, and 45.4 +/- 19.3 min, respectively (average +/- standard deviation). Coasting can briefly maintain anesthesia towards the end of a procedure. While savings with an automated coasting mode are likely to be modest per patient, they may become substantial when multiplied by the number of procedures per day per operating room with no increase in the clinical workload of the anesthesia provider.     

地氟醚麻醉用于颅内手术的临床观察

目的探讨地氟醚麻醉用于颅内手术时颅内压的改变。方法16例颞叶肿瘤择期手术病人,麻醉诱导气管内插管后,吸入1MAC地氟醚维持,监测并记录麻醉前、诱导中、麻醉后20、30、40、50分钟的脑脊液压力(CSFP)、MAP和的变化。结果在维持28～31mmHg水平的条件下,全麻诱导期CSFP、MAP明显下降(P＜0．01)。吸入1MAC地氟醚后CSFP逐渐上升;但50分钟后仍低于麻醉前水平,MAP明显低于麻醉前(P＜0．01)。结论神经外科手术应用异丙酚诱导,保持在28～30mmHg,吸入1MAC地氟醚维持麻醉不增加颅内压。     

The Magnitude and Time Course of Vecuronium Potentiation by Desflurane Versus Isoflurane

Background: Preliminary studies suggest that desflurane and isoflurane potentiate the action of muscle relaxants equally. However, variability between subjects may confound these comparisons. A crossover study was performed in volunteers on the ability of desflurane and isoflurane to potentiate the neuromuscular effect of vecuronium, to influence its duration of action, and on the magnitude and time course of reversal of potentiation when anesthesia was withdrawn.

Methods: Adductor pollicis twitch tension was monitored in 16 volunteers given 1.25 MAC desflurane on one occasion, and 1.25 MAC isoflurane on another. In eight subjects, vecuronium bolus dose potency was determined using a two-dose dose-response technique; the vecuronium infusion dose requirement to achieve 85% twitch depression also was determined. Also in these subjects, the magnitude and time course of spontaneous neuromuscular recovery were determined when the anesthetic was withdrawn while maintaining a constant vecuronium infusion. In the other eight subjects, the time course of action of 100 micro gram/kg vecuronium was determined.

Results: Vecuronium's ED50 and infusion requirement to maintain 85% twitch depression were 20% less during desflurane, compared to isoflurane, anesthesia; vecuronium plasma clearance was similar during the two anesthetics. After 100 micro gram/kg vecuronium, onset was faster and recovery was longer during desflurane anesthesia. When the end-tidal anesthetic concentration was abruptly reduced from 1.25 to 0.75 MAC, twitch tension increased similarly ([nearly equal] 15% of control), and time for the twitch tension to reach 90% of the final change was similar ([nearly equal] 30 min) with both anesthetics. Decreasing anesthetic concentration from 0.75 to 0.25 MAC increased twitch tension by 46 plus/minus 10% and 25 plus/minus 7% of control (mean plus/minus SD, P < 0.001) with desflurane and isoflurane, respectively; 90% response times for these changes were 31 plus/minus 10 min and 18 plus/minus 7 min (P < 0.05), respectively.     

模拟紧闭环路内不同的碱石灰对地氟烷分解反应的比较

目的 研究模拟紧闭环路内三种成分不同的十燥碱石灰与地氟烷发生分解反应生成一氧化碳(CO)的差异。方法 选用钡石灰、国产钠石灰及Sofnolime。在麻醉机的Y-piece端接一贮气囊做为模拟肺。二氧化碳(CO_2)以200ml·min~(-1)的流速通入环路。设定分钟通气量6L·min~(-1),呼吸频率(RR)12次/min,使P_(ET)CO_2在35～45 mm Hg。根据碱石灰的种类不同将实验分为三组,每组实验重复三次。向环路内通入二氧化碳及氧气的同时开启蒸发罐,洗入期开始,当呼气未地氟烷浓度达9％时关闭蒸发罐及新鲜气流,紧闭环路,继续机械通气直至180min。监测 P_(ET)CO_2、重复吸入CO_2分压、地氟烷的吸入、呼出浓度及上下罐反应温度。用气相色谱仪测定CO浓度。结果 三种碱石灰分解地氟烷生成CO的峰浓度及平均浓度由高到低的顺序依次是钡石灰、Sofnolime及国产钠石灰。钡石灰组CO达峰浓度时间明显快于其它两组(P<0.05)。与上罐相比下罐温度上升时间延迟。国产钠石灰组洗入时间较其余两组短。在温度上升期钠石灰组上罐温度上升速度快而钡石灰组下罐温度上升速度快。结论 在模拟紧闭环路内,使用钡石灰发生CO中毒的危险性要高于钠石灰。但仅仅去除钠石灰中的KOH,不能减少吸入全麻药的分解,相反生成CO的量可能增多。     

Spontaneous recovery profile of rapacuronium during desflurane, sevoflurane, or propofol anesthesia for outpatient laparoscopy

We evaluated the spontaneous recovery characteristics of rapacuronium during desflurane-, sevoflurane-, or propofol-based anesthesia in 51 consenting women undergoing laparoscopic tubal ligation procedures. After the induction of the anesthesia with standardized doses of propofol and fentanyl, 1.5 mg/kg IV rapacuronium was administered to facilitate tracheal intubation. Patients were randomized to receive either 1 minimum alveolar anesthetic concentration of desflurane, 1 minimum alveolar concentration of sevoflurane, or 100 microg. kg(-1). min(-1) propofol infusion in combination with 66% nitrous oxide in oxygen for maintenance of anesthesia. Neuromuscular blockade was monitored at the wrist by using electromyography. The degree of maximum blockade and the times for first twitch recovery (T(1)) to 5%, 25%, 50%, 75%, and 90%, as well as the recovery index, were similar in all three anesthetic groups. However, recovery times for the train-of-four ratio to achieve 0.7 and 0.8 were significantly longer with desflurane (44.4 +/- 18.9 and 53.5 +/- 22.4 min) and sevoflurane (44.8 +/- 15.1 and 53.2 +/- 15.8 min) compared with propofol (31.8 +/- 5.3 and 36.5 +/- 6.5 min). Eight patients (16%) required a maintenance dose of 0.5 mg/kg rapacuronium and reversal of rapacuronium residual block occurred in three (6%) patients. We conclude that spontaneous recovery after an intubating dose of 1.5 mg/kg rapacuronium was significantly prolonged by both desflurane and sevoflurane compared with propofol-based anesthesia. Routine monitoring of neuromuscular activity is recommended even when a single bolus dose of rapacuronium is administered during ambulatory anesthesia. IMPLICATIONS: When administered for laparoscopic surgery, the duration of action of an intubating dose of rapacuronium was prolonged 40%-50% by desflurane and sevoflurane, respectively, (versus propofol). Monitoring recovery of neuromuscular blockade produced by rapacuronium is particularly important when desflurane or sevoflurane is administered to ensure that an adequate recovery (train-of-four > or = 0.8) is achieved by the end of anesthesia.     

异丙酚、地氟醚或七氟醚复合瑞芬太尼麻醉对脑功能区手术患者术中唤醒试验的影响

目的 探讨异丙酚、地氟醚或七氟醚复合瑞芬太尼麻醉对脑功能区手术患者术中唤醒试验的影响.方法 择期拟行脑功能区肿瘤切除术患者60例,ASA Ⅰ或Ⅱ级,年龄18～60岁,随机分为3组:异丙酚组(P组)、地氟醚组(D组)及七氟醚组(S组),每组20例.静脉注射依托咪酯0.3mg/kg、芬太尼3 μg/kg、维库溴铵0.1 mg/kg行麻醉诱导,采用1%丁卡因喉头及气管粘膜表面麻醉后行气管插管.P组、D组和S组分别靶控输注异丙酚,血浆靶浓度2.0μg/ml,持续吸入地氟醚、七氟醚1.5 MAC维持麻醉.各组均靶控输注瑞芬太尼,血浆靶浓度2.5 ng/ml,唤醒试验前血浆靶浓度降为0.5 ng/ml,静脉注射曲马多100mg,停用麻醉药,行唤醒试验.记录唤醒时间,观察唤醒试验时躁动及寒颤的发生情况.结果 各组患者唤醒时间差异无统计学意义(P>0.05),P组寒颤发生率较D组和S组高(P<0.05).结论 采用异丙酚、地氟醚或七氟醚复合瑞芬太尼麻醉,脑功能区手术患者术中唤醒时间无差别,地氟醚或七氟醚复合瑞芬太尼麻醉时有关并发症发生率低,更适用于术中唤醒试验.     

The effect of heat-moisture exchanger and closed-circuit technique on airway climate during desflurane anesthesia

Purpose We assessed whether closed-circuit anesthesia (CCA) could provide a more favorable airway climate than semiclosed anesthesia (SCA), and we also determined the beneficial effect of heat moisture exchangers (HMEs) on the preservation of airway climate during desflurane anesthesia. Methods Forty patients scheduled for colorectal surgery (n = 10 for each group) were randomized to receive a fresh gas flow of 250 or 3000 ml·min⁻¹ with or without HMEs. Anesthesia was maintained by adjusting the inspired concentration of 6% desflurane. Absolute moisture and temperature of inspired gases were measured as the baseline value first at 5 min after tracheal intubation, and then at 10, 20, 45, 60, 90, and 120 min after the induction of anesthesia. Results At 120 min, the inspiratory humidity and temperature were higher in CCA than in SCA. The HME led to major improvements of the humidity (from 22.1 to 35.7 mg H₂O·l⁻¹) and temperature (from 23.6°C to 31.5°C) of anesthetic gases in the CCA group. Conclusion CCA was much more advantageous than SCA for maintaing the patient’s airway climate during the 2-h study. The beneficial effect of HME on the airway climate should be emphasized, especially in patients undergoing general anesthesia.     

Reduction of the MAC of desflurane with fentanyl.

Opioids are known to affect the MAC of inhalational anesthetics. We have determined the interaction between fentanyl and desflurane, following a bolus injection of fentanyl at induction in 134 adult patients. Five groups of patients were studied. Four groups received desflurane or isoflurane in oxygen with either fentanyl 3 or 6 micrograms/kg and thiopental 2-5 mg/kg given as a bolus injection at the time of induction. An additional group received desflurane in oxygen alone. Groups were stratified by age. MAC determination, in response to the stimulus of skin incision, was made using the "up-down" method and logistic regression. The MAC desflurane in oxygen was 6.3% (5.3-7.6%, 95% confidence interval [CI]). Fentanyl 3 micrograms/kg produced a fentanyl plasma concentration of 0.78 +/- 0.53 ng/ml at skin incision and resulted in a MAC for desflurane of 2.6% (2.0-3.2%, 95% CI) %. Fentanyl 6 micrograms/kg produced a fentanyl plasma concentration of 1.72 +/- 0.76 ng/ml at skin incision and resulted in a MAC for desflurane of 2.1% (1.5-2.6%, 95% CI). To compare recovery times to eye-opening and response to commands, patients were grouped according to the plasma fentanyl concentrations at the time of awaking. Recovery was faster in patients who received desflurane than in those who received isoflurane. The authors conclude that the MAC of desflurane is significantly reduced 25 min following a single dose of 3 micrograms/kg of fentanyl and that increasing the fentanyl dose to 6 micrograms/kg produces little further decrease in MAC. Desflurane is also associated with faster recovery from anesthesia than is isoflurane.     

连续硬膜外腔阻滞对地氟醚麻醉期间交感神经活动的影响

目的 观察连续硬膜外阻滞对地氟醚诱发交感神经兴奋性增强反应的预防作用。方法 ３０例病人随机分为地氟醚组和连续硬膜外阻滞与地氟醚联合醉组,每组１５例。麻醉诱导气管内插管后,地氟醚组以挥罐设定浓度（ＦＤ）２％开始,并以每间隔３０ｓ递增１％的方法吸入地氟醚－氧,直至达到满足手术要求的浓度并维持麻醉;联合麻醉组在全麻诱导前于Ｔ９－１０或Ｔ１０－１１间隙行硬膜外穿刺置管,术中用利多卡因维持硬膜外阻滞,其余步     

Propofol Fails to Attenuate the Cardiovascular Response to Rapid Increases in Desflurane Concentration

Background: A rapid increase in desflurane concentration to greater than 1 MAC transiently increases heart rate, arterial blood pressure, and circulating catecholamine concentration. Because propofol decreases sympathetic outflow, it was hypothesized that propofol would blunt these responses.

Methods: To test this hypothesis, five healthy male volunteers were studied three times. After induction of anesthesia with 2 mg *symbol* kg sup -1 propofol, anesthesia was maintained with 4% end-tidal desflurane in oxygen (0.55 MAC) via an endotracheal tube for 32 min. On separate occasions, in random order, either no propofol or 2 mg *symbol* kg sup -1 propofol was administered either 2 or 5 min before increasing end-tidal desflurane concentration from 4% to 8%.

Results: Without propofol pretreatment, the increase to 8% desflurane transiently increased heart rate (from 63+/-3 beats/min to 108 +/-5 beats/min, mean+/-SEM; P < 0.01), mean arterial pressure (from 73+/-1 mmHg to 118+/-6 mmHg; P < 0.01), and epinephrine concentration (from 14+/-1 pg *symbol* ml sup -1 to 279+/-51 pg *symbol* ml sup -1; P < 0.05). There was no significant change in norepinephrine concentration (from 198+/-37 pg *symbol* ml sup -1 to 277+/-46 pg *symbol* ml sup -1). The peak plasma epinephrine concentration was attenuated by each propofol pretreatment (158+/-35 pg *symbol* ml sup -1, propofol given 2 min before, and 146 + 41 pg *symbol* ml sup -1, propofol given 5 min before; P < 0.05), but neither propofol pretreatment modified the cardiovascular or norepinephrine responses.