乌拉地尔控制围术期高血压的临床观察

择期外科手术患者，分为两组：１．静吸复合全麻组（ｎ＝１１），平均年龄６０．７２岁，术前并发冠心病高血压；２．颈丛麻醉组（ｎ＝１１），平均年龄４１．１８岁，术前无高血压，颈丛阻滞后出现血压剧升及心率增快者。两组病人麻醉期间当ＳＢＰ高于２１．３０ｋＰａ及ＤＢＰ高于１２．００ｋＰａ时，即静注乌拉地尔２５ｍｇ，给药后每５ｍｉｎ测定ＳＢＰ、ＤＢＰ、ＨＲ并计算ＲＰＰ。结果：全麻组高血压患者静注乌拉地尔后５～１０ｍｉｎ，ＳＢＰ、ＤＢＰ、ＲＰＰ均缓和下降至正常范围（Ｐ＜０．００１），而ＨＲ无明显变化（Ｐ＞０．０５）。颈丛组静注乌拉地尔后５～１０ｍｉｎ，ＳＢＰ、ＤＢＰ均可降至正常范围（Ｐ＜０．００１），而ＨＲ、ＲＰＰ虽亦明显下降（Ｐ≤０．００１），但未降至正常范围。本文提示，乌拉地不适用于并发冠心病的高血压病人在围术期中的应用，而对颈丛阻滞后的心血管反应，虽有一定的作用，但并不满意。     

二氧化碳气腹不同压力对呼吸,循环,血气参数的影响

对腹腔镜胆囊切除（ＬＣ）患者１５０例随机分成Ａ组（气腹压力１．３￣１．９ｋＰａ）、Ｂ组（气腹压力２．０￣２．７ｋＰａ），观察不同气腹压力对呼吸、循环、血气各参数的变化。结果Ｂ组气腹后１５分ａｗ、ＰＥＴＣＯ２、ＳｐＯ２、ＭＡＰ、ＨＲ、ｐＨ、ＰａＣＯ２、ＳａＯ２的变化明显，各参数与Ａ组比较相差显著及非常显著（Ｐ〈０．０５￣０．０１）。提示ＬＣ时ＣＯ２气腹压力维持在１．３￣１．９ｋＰａ为宜，气腹压力超２     

肾移植术中受者血压对移植肾的影响

慢性肾功能衰竭移植术者３９例，按手术中移植肾开放血流时受者的平均动脉压分为３组。Ａ组Ｂｐ１６．８－２２．８ｋＰａ；Ｂ组Ｂｐ１０．７－１６．７ｋＰａ；Ｃ组：Ｂｐ７．０－９．８ｋＰａ，观察血流开放后移植肾的情况。     

尼莫地平和异氟醚控制性降压期间血流动力学变化的对比研究

用经气管超声多普勒心排血量监测仪对３０例脑膜瘤或脑动静脉畸形手术患者，随机分组（各１５例）对比观察了尼莫地平（Ｎ）或异氟醚（Ｉ）控制性降压期间血流动力学的变化。结果表明，Ｉ组异氟醚吸入加深麻醉（２．０３￣２．２８ＭＡＣ），降压期间ＭＡＰ、ＴＰＲ分别下降２１．０％￣２５．９％和２２．９％￣２４．１％，ＳＩ无明显变化，ＨＲ和ＣＩ分别增加８．３％￣９．４％和２．５％￣７．３％，停降压后血压迅速回升；Ｎ组     

利多卡因pH及PCO2对硬膜外麻醉效果的影响

３０例下胸段硬膜外麻醉病人随机分为三组，均用１．３３％利多卡因，其ｐＨ和ＰＣＯ２分别为，Ａ组ｐＨ４．７～４．８，ＰＣＯ２０．４～０．５ｋＰａ；Ｂ组ｐＨ７；２～７．４，ＰＣＯ２５３．３～５４．７ｋＰａ；Ｃ组ｐＨ７．２～７．４，ＰＣＯ２８．Ｏ～１０．０ｋＰａ。结果：各组麻醉起效时间无显著差异；各组麻醉持续时间为，Ａ组６５．７±３０．３ｍｉｎ，Ｂ组５１．２±３２．７ｍｉｎ，Ｃ组３１．７±１６．７ｍｉｎ（与Ａ组比，Ｐ＜０．０５）。另外，Ａ组肌松率明显高于Ｃ组，Ｐ＜０．０５。结论：单纯提高利多卡因ｐＨ（Ｃ组），则缩短硬膜外麻醉持续时间，肌松差；碱化利多卡因中的高ＰＣＯ２（Ｂ组）在一定程度上可弥补高ｐＨ的作用。     

全麻腹腔镜胆囊切除术和剖腹胆囊切除术对血流动力学的影响

对全麻下２２例腹腔镜胆囊切除术（ＬＣ）和１０例剖腹胆囊切除术（ＯＣ）的血流动力学作了前瞻性比较观察。两组患者一般状况和麻醉方法相仿。由ＮＣＣＯＭ３型心血管监测仪监测结果表明，ＬＣ组气腹后ＭＡＰ、ＳＶ、ＳＩ、ＥＶＩ和ＣＯ、ＣＩ均较手术开始明显下降（Ｐ＜０．０５和Ｐ＜０．０１）；牵拉胆囊时变化不明显；气腹后有３例需给麻黄碱维持血压平稳，气道峰压和平台压明显增高（Ｐ＜０．０１）。ＯＣ组牵拉胆囊时ＳＶ、ＣＯ和 ＥＶＩ下降明显（Ｐ＜０． ０５），进腹探查和胆囊切除时降低不明显。提示 ＬＣ对循环影响最明显的是ＣＯ２气腹，ＯＣ是牵拉胆囊，且前者比后者对循环影响更明显。     

残余尿在前列腺增生症所致膀胱出口梗阻中的临床意义

作者应用压力－流率测定法确定前列腺增生症（ＢＰＨ）患者有无膀胱出口梗阻（ＢＯＯ），并经导管法测定其残余尿，分析５１例有或无膀胱出口梗阻的前列腺增生症患者的残余尿状况。ＢＯＯ组和无ＢＯＯ组分别为３１例和２０例；残余尿分别为３２．８±３５．９ｍｌ和２５．２±２２．７ｍｌ，范围分别为６～２１０ｍｌ和３～８８ｍｌ。两组间残余尿量无显著性差异（Ｐ＞０．０５）；其余指标均存在显著性差异（Ｐ＜０．０１）。作者认为以残余尿作为选择ＢＰＨ患者手术的重要指标并不可靠，ＢＯＯ不是产生残余尿的唯一原因。ＢＯＯ患者可无明显残余尿，无明显残余尿的ＢＰＨ患者不能除外ＢＯＯ。     

异丙酚对颅内压的影响

目的：评价异丙酚对神经外科病人颅内压的影响。方法：１３例颅内胶质瘤成年病人ＡＳＡⅠ～Ⅱ级，择期行开颅手术。在麻醉诱导时，静注异丙酚２ｍｇ／ｋｇ。分别于注药前、后１、２、３、５、７、１０、１５和２０分钟，观察收缩压（ＳＰ），舒张压（ＤＰ），平均动脉压（ＭＡＰ），心率（ＨＲ），脑灌注压（ＣＰＰ），颅内压（ＩＣＰ）的变化。颅内压监测采用腰蛛网膜下腔置管直接测压。结果：静注异丙酚后ＳＰ，ＭＡＰ，ＣＰＰ显著降低（１５．１８±２．２１ｋＰａ降至１３．４４±１．５６ｋＰａ，１１．３３±２．１４ｋＰａ降至９．５４±１．７０ｋＰａ，９．０５±２．４６ｋＰａ降至７．９７±２．１４ｋＰａ）但是随着时间的延长在２０分钟内恢复至基础水平，ＤＰ、ＨＲ给药前后无明显变化，ＩＣＰ给药后明显下降且在观察期内无回升趋势。结论：异丙酚能降低病人的颅内压，适用于神经外科麻醉，对颅内压增高病人应适当调整用量。     

残余尿在前列腺增生所致膀胱出口梗阻中的临床意义

作应用压力－流率测定法确定前列腺增生症（ＢＰＨ）患有无膀胱出口梗阻（ＢＯＯ），并经导管法测定其残余尿，分析５１例有或无膀胱出口梗阻的前列腺增生症患的残余尿状况。ＢＯＯ组和无ＢＯＯ组分别为３１例和２０例，残余尿分别为３２．８±３５．９ｍｌ和２５．２±２２．７ｍｌ，范围分别为６～２１０ｍｌ和３～８８ｍｌ，两缚间残余尿量无显性差异（Ｐ〉０．０５）；其余指标均存在显性差异（Ｐ〈０．０１）。作认     

尼卡地平预注对高血压患者气管插管心血管反应的预防作用

高血压患者全身麻醉诱导期间应重视如何预防或减轻气管插管时的心血管反应[1]。据报告尼卡地平能有效预防正常血压患者的气管插管反应[2,3]。本文目的是观察尼卡地平预防高血压患者气管插管心血管反应的效果。资料与方法18例ＡＳＡⅡ～Ⅲ级术前有高血压、行择期手术患者,随机均分为Ａ、Ｂ两组。两组患者的性别、年龄、体重、术前病情无明显差异(Ｐ>005)。高血压的诊断参照ＷＨＯ高血压诊断标准:ＳＢＰ≥213ｋＰａ和/或ＤＢＰ≥127ｋＰａ。10例有原发性高血压2～10年,口服硝苯吡啶、卡托普利、依那普利、复方降压片等治疗。术前血压控制在220…     

髋关节置换术中骨水泥植入后对老年患者血流动力学的影响

目的 探讨骨水泥型髋关节置换术中骨水泥植入后对老年患者血流动力学的影响.方法 2008年1月至2009年4月共对50例老年股骨颈骨折或股骨头坏死患者行骨水泥型髋关节置换术,男22例,女28例;年龄70～92岁,平均83.2岁.关节置换原因:股骨颈骨折46例,股骨头骨折术后股骨头坏死4例.比较患者骨水泥植入前和植入后1、2、3、4、5、6、7、8、9、10 min的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、心率、血氧饱和度(SPO2)等数据.结果 术后所有患者血压均有不同程度下降,骨水泥植入后1 min血压开始下降,2～6 min血压下降最为显著,与骨水泥植入前比较差异均有统计学意义(SBP,DBP:P<0.05),7 min开始回升,10 min基本恢复正常.SPO2下降明显,平均从99.65%±0.35%下降至92.80%±1.08%(P<0.05).心率无明显变化,差异无统计学意义(P>0.05).结论 髋关节置换术中骨水泥植入后对老年患者血流动力学影响显著.     

Pleth variability index predicts hypotension during anesthesia induction

Background: The pleth variability index (PVI) is a new algorithm used for automatic estimation of respiratory variations in pulse oximeter waveform amplitude, which might predict fluid responsiveness. Because anesthesia‐induced hypotension may be partly related to patient volume status, we speculated that pre‐anesthesia PVI would be able to identify high‐risk patients for significant blood pressure decrease during anesthesia induction. Methods: We measured the PVI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in 76 adult healthy patients under light sedation with fentanyl to obtain pre‐anesthesia control values. Anesthesia was induced with bolus administrations of 1.8 mg/kg propofol and 0.6 mg/kg rocuronium. During the 3‐min period from the start of propofol administration, HR, SBP, DBP, and MAP were measured at 30‐s intervals. Results: HR, SBP, DBP, and MAP were significantly decreased after propofol administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre‐anesthesia control values. Linear regression analysis that compared pre‐anesthesia PVI with the decrease in MAP yielded an r value of ?0.73. Decreases in SBP and DBP were moderately correlated with pre‐anesthesia PVI, while HR was not. By classifying PVI >15 as positive, a MAP decrease >25 mmHg could be predicted, with sensitivity, specificity, positive predictive, and negative predictive values of 0.79, 0.71, 0.73, and 0.77, respectively. Conclusion: Pre‐anesthesia PVI can predict a decrease in MAP during anesthesia induction with propofol. Its measurement may be useful to identify high‐risk patients for developing severe hypotension during anesthesia induction.     

Combined spinal-epidural anesthesia for renal transplantation

INTRODUCTION: A patient undergoing renal transplantation presents unique problems to the anesthetist, as almost every body system is affected. The combined spinal-epidural technique has become popular in lower abdominal surgeries because it offers the advantages of both spinal and epidural techniques. We review our experience of combined spinal-epidural technique in patients undergoing renal transplantation with respect to demographics, intraoperative anesthesia, hemodynamics, postoperative analgesia, and untoward adverse events. MATERIALS AND METHOD: Fifty consecutive patients scheduled for elective renal transplantation over a period of 4 months who consented for combined spinal-epidural anesthesia were enrolled in the study. Combined spinal-epidural anaesthesia was performed using a double-space technique in the right lateral position. Intraoperative monitoring included electrocardiography, pulse oximetry, noninvasive blood pressure, central venous pressure, and urinary output after clamp release. Intravenous fluids, colloids, and blood products were infused so as to keep the central venous pressure between 12 and 15 mm Hg. Postoperative analgesia was provided with buprenorphine via an epidural catheter. We noted intraoperative and postoperative complications. RESULTS: Neuraxial blockade was satisfactory in all but four patients who required supplementation with general anesthesia for unduly prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 64.24 +/- 12.3 mL/kg. During the postoperative period, all patients had good postoperative pain relief with no incidence of epidural hematoma. CONCLUSION: Combined spinal-epidural anesthesia proved to be a useful regional anesthetic technique, combining the reliability of spinal block and versatility of epidural block for renal transplantation.     

Preoperative blood pressure and intraoperative hypothermia during lower abdominal surgery

BACKGROUND: Preoperative factors including age and body habitus affect intraoperative hypothermia during general anesthesia. We hypothesized that preoperative blood pressure also plays a contributory role in the induction of intraoperative hypothermia. METHODS: We evaluated the effect of preoperative systolic blood pressure (SBP) on core temperature during lower abdominal surgery under general anesthesia. In 36 female patients under 65 years of age, patients with a preoperative SBP of 140 mmHg or greater upon arrival in the operating theater were assigned to the high SBP group (n=18), while those with SBP below 140 mmHg were assigned to the normal SBP group (n=18). Anesthesia was maintained with isoflurane and nitrous oxide combined with epidural buprenorphine, and routine thermal care was provided intraoperatively. RESULTS: There were no significant differences in age, height or weight between the two groups. Tympanic membrane temperature in the normal SBP group started to decrease significantly from 15 min after induction of anesthesia compared to that in the high SBP group, and continued to decrease further at two hours after induction. Vasoconstriction threshold, determined to be tympanic membrane temperature at the time when a forearm minus finger skin surface gradient exceeded 0 degrees C, was significantly higher in the high SBP group than in the normal SBP group. CONCLUSION: These results suggest that preoperative SBP has some preventive effect on the decrease in intraoperative core temperature during lower abdominal surgery under general anesthesia.     

Improved Long-Term Outcomes After Renal Transplantation Associated with Blood Pressure Control

Hypertension has a negative impact on long-term outcomes after renal transplantation. We investigated the effect of a recent decline in blood pressure among renal transplant patients in the Collaborative Transplant Study (CTS) database on long-term graft and patient survival. CTS data were used to evaluate transplant outcomes in relation to recipient systolic blood pressure (SBP) for 24,404 first cadaver kidney recipients transplanted between 1987 and 2000. Patients whose SBP was > 140 mmHg at 1 year posttransplantation but controlled to < or = 140 mmHg by 3 years had significantly improved long-term graft outcome compared with patients with sustained high SBP to 3 years (RR 0.79; CI 0.73-0.86; p < 0.001). Additional examination at 5 years showed that SBP lowering after year 3 was associated with improved 10-year graft survival (RR 0.83; CI 0.72-0.96; p = 0.01), whereas even a temporary increase in SBP at 3 years was associated with worse survival (RR 1.37; CI 1.19-1.58; p < 0.001). Changes in SBP were paralleled by changes in the incidence of cardiovascular death among recipients younger than 50 but not in older recipients. Lowering SBP, even after several years of posttransplantation hypertension, is associated with improved graft and patient survival in renal allograft recipients.     

The effect of hypotensive anesthesia on renal hemodynamics

Deliberate hypotensive anesthesia (MBP = 36 mm Hg) using Halothane, hyperventilation, and positive pressure respiration (peak inspiratory pressure = 15 cm H₂O) was used in 7 dogs for a 2-hr period. Xenon-133 washout was employed by injection of 800–1500 μCi through a catheter placed under fluoroscopic control in the right renal artery. Washout curves were obtained before hypotensive anesthesia, during and after a return of normal hemodynamics using a collimater placed over the right flank. The curves were analyzed and total renal blood flow plus four components of renal blood flow were developed: I cortex; II juxtamedulla; III inner medulla; and IV hilar fat. Using an indocyanine green indicator dilution curve, cardiac output was measured. Urinary output was collected and blood gases monitored.Total renal blood flow decreased significantly during hypotensive anesthesia only to return toward normal within 30 min of discontinuing deliberate hypotension (328 control → 159 during hypotensive anesthesia → 227 ml/100 g/min after hypotensive anesthesia). This decrease in renal blood flow was associated with a fall in cardiac output which also returned toward normal promptly after discontinuing inhalation anesthesia (3.2 → 1.7 → 3.0 liter/min). The ratio of renal blood flow/cardiac output did not change with hypotensive anesthesia indicating an absence of renal vasoconstriction, and renal vascular resistance actually fell from .427 to .306 mm Hg/ml/100 g/min. During the recovery phase, because the blood pressure and cardiac output returned to the control level before renal blood flow, the ratio of renal blood flow/cardiac output fell from 7.1 to 4.9% and the renal vascular resistance rose from .306 to .611 mm Hg/ ml/100 g/min. It was apparent that during recovery renal vasoconstriction developed.The fall in renal blood flow with hypotensive anesthesia was associated with a significant fall in Component I (cortical) flow (414 → 257 → 330 ml/100 g/min) but no significant change in Component II (outer medullary) flow (72 → 74 → 98 ml/ 100 g/min) or the percent distribution of radioactivity between cortex and medulla. This indicates a selective decrease in cortical flow and an absence of marked intrarenal shunting which is seen with hypovolemic hypotension. Urine output fell during hypotension (65 → 20 → 80 ml/hr) but did not cease entirely in any animal. The explanation for the known renal safety of hypotensive anesthesia rests primarily with the absence on intrarenal shunting and associated vasoconstriction during hypotension.     

Effects of ACE inhibition in normotensive patients with chronic glomerular disease and normal renal function

A double-blind, placebo-controlled study was carried out to assess the effects of a three-month treatment with a new ACE inhibitor, Benazepril (BNZ), on systemic and renal hemodynamics, and urine protein excretion, in 20 patients with chronic glomerulonephritis, normal blood pressure (130/83 +/- 16/10 mm Hg), and normal renal function (creatine clearance 106 +/- 25 ml/min). Treatments with placebo or BNZ were assigned randomly. A wide range of proteinuria lowering effect was observed in overall population (from 1 to 84%, average 34%). Following the arbitrary level of a 30% reduction, two well-matched subgroups (10 patients for each one) were obtained: "good responders" (average decrease 51%), and "poor responders" (average decrease 17%). The main distinctive feature between the two groups was a higher plasma renin activity level in good than in poor responders. A positive correlation between the fall in proteinuria and blood pressure was found. Although the decrease in blood pressure seems to represent the major factor in determining the reduction in proteinuria, a multiple correlation analysis showed that the most prominent role (71%) was attributable to the combined decrease in blood pressure and filtration fraction, and then also to the efferent arteriole dilatation. Our conclusion is that ACE inhibitors are capable of also reducing proteinuria in patients with renal disease with normal blood pressure, the effect being more pronounced in those exhibiting humoral, systemic and renal hemodynamic patterns, indicating a greater activity of circulating and renal renin angiotensin system.     

Blood pressure after cardiac transplantation in childhood.

BACKGROUND: There has been little formal study of blood pressure in children after cardiac transplantation. METHODS: Twenty-four-hour and clinical blood pressure (BP) were measured in 28 children (>6 months after transplantation) and compared with a large amount of normal data. RESULTS: Conventional (clinical) systolic BP (SBP) was elevated in 9 (32.1%) of 28 (95% confidence interval [CI] 15.8 to 52.3), and conventional diastolic BP (DBP) was elevated in 5 (17.8%) of 28 (95% CI 6.0 to 36.8). Mean 24-hour BP was >97.5 percentile in 2 (7.7%) of 26 (95% CI 0.9 to 25.1) for SBP and in 7 (28.0%) of 25 (95% CI 12.1 to 49.4) for DBP. In comparison with the control population, mean nighttime SBP was 8.9 mm Hg higher in the transplanted group (95% CI 4.8 to 13.1), but daytime and mean 24-hour SBP were similar. Mean day, night, and 24-hour DBP was significantly higher in the transplanted patients. The nighttime decrease in BP was significantly less than controls for SBP, but not for DBP. Conventional BP measurement was poorly predictive of 24-hour BP. There was a significant association between mean 24-hour SBP and interventricular septal thickness (r(2)=0.35; p=0.01). DBP was not associated with interventricular septal thickness (r(2)=0.07; p=0.20) but was significantly correlated with the time since transplantation (r=0.42; p=0.03 for conventional DBP and r=0.43; p=0.04 for 24-hour DBP). CONCLUSIONS: The elevation of DBP in children after cardiac transplantation is unexplained. The elevation in nighttime SBP has possible important therapeutic implications and is not predicted by conventional (clinical) BP measurement.     

General anesthesia for a patient on hemodialysis with arteriosclerosis obliterans

A 48-year-old man with arteriosclerosis obliterans was scheduled for axillofemoral bypass. He had chronic renal failure and on hemodialysis (HD) for 22 years. On the morning of the day of surgery he received HD and two hours later anesthesia was induced with fentanyl 300 micrograms and midazolam 6 mg, and maintained with fentanyl, nitrous oxide and intermittent isoflurane. The common carotid artery was cannulated to measure arterial blood pressure because arteries in extremities were not available. Internal jugular vein at the other side of the arterial catheterization was cannulated to measure central venous pressure. Crystalloid and blood transfusion was performed to adjust hemodynamics and central venous pressure. Hemodynamics were stable during surgery and no complication occurred regarding the common carotid arterial line. The common carotid artery was useful for blood pressure monitoring in a patient whose extremities were not available. Midazolam and fentanyl could give stable hemodynamics to a patient with arteriosclerosis obliterans and chronic renal failure.     

创伤休克患者不同麻醉深度下诱导插管的血流动力学变化

目的 比较创伤休克患者在不同麻醉深度下诱导插管时的血流动力学变化. 方法 根据进入手术室的时序,按区段随机分组法将40例非颅脑损伤的创伤休克患者随机分为A、B两组,每组各20例.患者入室后行脑电双频指数(bispectral index,BIS)监测,麻醉诱导以咪达唑仑1.5 mg/min缓慢静注,当BIS达到预定值(A组60±3,B组45±3)时立即给予芬太尼3μg/kg、琥珀胆碱1.5mg/kg,肌肉松弛后气管插管.分别记录两组入室时(T0)、BIS达预定值时(T1)、气管插管即刻(T2)、插管后1 min(T3)、插管后3 min(T4)的BIS值、心率(HR)、收缩压(SBP)和咪达唑仑的用量. 结果 组内比较A组各时点HR、SBP差异无统计学意义,B组T1[(138±15)次/分]、T2[(146±15)次/分]、T3[(147±11)次/分]、T4(146±10)次/分]时点的HR较T0[(127±16)次/分]明显增加,而T2[(72±10)mm Hg(1 mm Hg=0.133 kpa)]、T3[(74±10)mm Hg]、T4[(76±11)mm Hg]时点的SBP较T0[(82±7)mm Hg]明显下降(P<0.05);两组间HR的差异出现在T3(P=0.005)、T4(P<0.001)时点;两组间SBP的差异出现在T4(P=0.005)时点.A组咪达唑仑用量约为0.117 mg/kg,较B组减少约17%(P<0.001). 结论 麻醉诱导插管时采用相对较浅的麻醉深度(BIS=60)更有利于创伤休克患者血流动力学的相对平稳.