术前焦虑与术后谵妄的研究进展

术后谵妄(POD)是一种常见的手术并发症,表现为术后注意力和意识的急性和波动性认知能力障碍,严重影响患者的康复,是患者不良预后的预测指标之一。目前临床普遍存在的术前焦虑为POD的独立危险因素,在POD的发生、发展过程中发挥着重要作用。针对术前焦虑患者,采取积极、合理的干预措施,或将有效地减少术后谵妄的发生。本文通过探讨术前焦虑对POD的影响,围绕POD的产生原因、作用机制、预防方法等方面进行综述,以期阐明术前焦虑与POD之间的关系,为POD的防治提供新的思路和方法。     

小儿围手术期心理研究进展

背景 患儿和家长由于缺乏麻醉和手术的相关知识,往往会在术前产生焦虑和不安.已证明术前焦虑与术后疼痛、恶心呕吐等相关,并成为影响手术预后的重要因素. 目的 麻醉医师在关爱患儿的同时还应重视其围手术期心理保护.内容 阐述术前焦虑的相关概念、影响因素和危害,介绍应对患儿和家长术前焦虑的处理方法. 趋向 理解小儿围手术期心理学问题,完善情感应激处理方案,将会对患儿和家长产生积极影响.     

加速康复理念下高龄髋部骨折围手术期饮食方案的制定及应用研究

目的探讨在加速康复外科理念下，围手术期高龄髋部骨折患者缩短禁食禁饮时间与术后早期进食进饮的可行性与安全性，制定饮食管理方案并评价其效果。 方法选取2018年12月至2019年12月无锡市第九人民医院收治的150例高龄髋部骨折行人工髋关节置换的患者，入院后2 h内采用营养风险筛查NRS2002评估量表，采用随机数表法进行简单随机分组，将≥3分的130例患者分为干预组和对照组，两组各65例患者。干预组采用本研究制定的围手术期饮食管理方案，对照组采用传统的禁饮食及术后进食方案，比较两组患者术后24 h创伤后应激障碍发生率和谵妄发生率、围手术期口渴饥饿情况、术中误吸及术后恶心、呕吐、腹胀发生率、实际术前禁食禁饮时间及术后进食时间、首次下床时间、平均住院日及患者满意度。 结果与对照组相比，干预组术中误吸及术后恶心、呕吐、腹胀发生率差异无统计学意义。围手术期口渴饥饿情况明显降低、禁食禁饮时间缩短、术后24 h创伤后应激障碍发生率、谵妄发生率、首次下床时间和平均住院日明显缩短，且患者满意度得到提升，差异具有统计学意义（P<0.05)。 结论应用加速康复理念，制定高龄髋部骨折患者围手术期饮食管理方案安全可行，有效降低了老年患者心理障碍发生率，减少术后并发症，促进患者早日康复并提高了满意度。     

芬太尼滴鼻对患儿鼻罩吸入七氟醚麻醉苏醒期谵妄的影响

目的探讨芬太尼滴鼻对患儿鼻罩吸入七氟醚麻醉苏醒期谵妄的影响。方法选择全麻下行舌系带延长术患儿40例,男17例,女23例,ASAⅠ级,年龄2~4岁。随机均分为研究组和对照组。入室后面罩吸入8%七氟醚+氧气进行麻醉诱导,研究组患儿无意识后鼻腔滴入芬太尼2μg/kg,稀释成0.5ml,对照组患儿安静后鼻腔滴入生理盐水0.5ml,两组患儿手术开始前舌系带旁局部浸润注射1%利多卡因2ml。术中鼻罩吸入3%~5%七氟醚+氧气维持麻醉。患儿入手术室前根据改良耶鲁术前焦虑分级表(m-YPAS)评分,诱导期间根据诱导期合作度量表(ICC)对患儿面罩吸入七氟醚诱导期间合作程度评分,术后根据小儿麻醉苏醒期谵妄量表(PAED)及改良加拿大东安大略儿童医院疼痛评分量表(m-CHEOPS),对患儿苏醒期谵妄、疼痛情况进行评分。结果两组患儿术前m-YPAS评分、诱导期ICC评分及术后m-CHEOPS评分差异均无统计学意义。研究组术后PAED评分为(4.8±2.5)分,明显低于对照组的(7.7±4.2)分(P<0.05)。两组患儿围术期生命体征平稳,均未出现严重低血压、低氧血症、心动过缓、呼吸抑制、严重的恶心、呕吐等麻醉相关并发症。两组PACU滞留时间差异无统计学意义。结论芬太尼滴鼻能有效减少患儿鼻罩吸入七氟醚麻醉下行舌系带延长术苏醒期谵妄的发生,且不延长PACU滞留时间。     

针刺辅助麻醉在围手术期中的应用

针刺麻醉是一种减轻疼痛和调节病人生理功能紊乱的方法.具有止痛和镇静的作用.目前作为一种辅助麻醉的方法,用于术前镇静、术中辅助麻醉、术后镇痛、预防手术后恶心呕吐及治疗围手术期并发症.但对其在围手术期的应用仍存在许多矛盾的观点,对其效能及可能的机制仍需将来做进一步的研究.     

冠心病合并认知障碍老年患者行颈动脉内膜切除术麻醉管理1例

颈动脉内膜切除术患者为脆弱脑功能患者, 围手术期易发生神经系统并发症, 且认知功能障碍增加术后神经认知功能紊乱发生的风险。该患者合并冠状动脉粥样硬化性心脏病、高血压、糖尿病、肾动脉狭窄, 围手术期多模式评估患者脑组织灌注及麻醉对脑功能的影响, 术中关注维持心脑等重要器官灌注和脑功能的维护, 采取抗炎、抗应激、体温保护和抗恶心呕吐等综合处理。患者顺利完成手术, 术后无谵妄等神经系统并发症。     

恶心和呕吐的生理学

呕吐反射由呕吐感受器、整合机制和运动输出系统三部分组成。腹腔内脏传入系统、脑最后区和前庭系统为其主要感受器。根据呕吐的发展过程将其分为呕吐前期和呕吐期。术后恶心呕吐的原因包括术前、围术期和术中因素,此外,还与手术本身有关。     

结肠癌患者的路径化围手术期中西医结合护理干预

目的探讨路径化围手术期中西医结合护理干预对结肠癌患者术后早期生活质量的影响。方法将60例结肠癌患者随机分为观察组和对照组各30例。对照组实施围手术期常规护理,观察组实施路径化围手术期中西医结合护理干预,比较两组患者术后1周生活质量。结果术后1周观察组躯体功能、情绪功能、社会功能、总生活质量及疲乏、恶心呕吐、疼痛等方面评分显著优于对照组(P<0.05,P<0.01)。结论路径化围手术期中西医结合护理干预可有效改善结肠癌患者术后早期生活质量。     

恶心和呕吐的生理学

呕吐反射由呕吐感受器、整合机制和运动输出系统三部分组成，腹腔内脏传入系统、脑最后区和前庭系统为其主要感受器。根据呕吐的发展过程将其分为呕吐前期和呕吐期。术后恶心呕吐的原因包括术前、围术期和术中因素，此外，还与手术本身有关。     

不同手术术后恶心呕吐发生频度及止吐药的临床疗效

据文献报道,镇静药在发生镇静作用的同时,也有轻微的止吐作用。我们在临床工作中观察了不同手术术后恶心呕吐(PONV)发生频度的差异及预防性组合使用镇静止吐药的疗效．以求减少患者疼痛与恶心呕吐的发生,增加患者围术期舒适度的同时减轻患者的经济负担。     

Gabapentin: a multimodal perioperative drug?

Gabapentin is a second generation anticonvulsant that is effective in the treatment of chronic neuropathic pain. It was not, until recently, thought to be useful in acute perioperative conditions. However, a growing body of evidence suggests that perioperative administration is efficacious for postoperative analgesia, preoperative anxiolysis, attenuation of the haemodynamic response to laryngoscopy and intubation, and preventing chronic post-surgical pain, postoperative nausea and vomiting, and delirium. This article reviews the clinical trial data describing the efficacy and safety of gabapentin in the setting of perioperative anaesthetic management.     

Preoperative anxiety and postoperative nausea and vomiting in children: is there an association?

We performed a cross-sectional study to explore a potential association between preoperative anxiety and postoperative nausea and vomiting (PONV). The study enrolled 51 unpremedicated children 5-16 yr old undergoing outpatient surgery and standardized general anesthesia. Anxiety of children was assessed in the preoperative holding area and during the induction of anesthesia. The incidence of nausea and vomiting was documented in the postanesthesia care unit (PACU) and 24 h postoperatively (POD#1). In addition to univariate analysis, we used multivariate logistic regression models, wherein the dependent variable was the presence or absence of PONV and the independent variables included potential confounders such as age, sex, and perioperative opioid consumption. Univariate analysis showed that children who experienced nausea (32 +/- 5 vs 31 +/- 4, P = ns) or vomiting (32 +/- 4 vs 32 +/- 5, P = ns) in the PACU did not differ significantly in their anxiety before surgery. A multivariate model, in which the dependent variable was the presence or absence of vomiting at POD#1 and the independent variables included preoperative anxiety, age, sex, and opioid consumption, indicated that preoperative anxiety does not predict the occurrence of nausea and vomiting (P = ns). We conclude that children's anxiety in the preoperative holding area has no predictive value for the occurrence of PONV in the PACU or POD#1. IMPLICATIONS: This study was performed to explore a possible association between children's anxiety before surgery and postoperative nausea and vomiting. We found that controlling for confounding variables, anxiety in the preoperative holding area has no predictive value for the occurrence of postoperative nausea and vomiting.     

Risk factors for prolonged stay after ambulatory surgery: economic considerations

The risk factors that prolong length of stay of ambulatory patients can be classified as preoperative, intraoperative, and postoperative. Preoperative factors include the type of surgery, ear, nose and throat and strabismus surgery, old age and pre-existing congestive heart failure. Intraoperative factors include increasing length of surgery, and general anesthesia, while postoperative factors include postoperative nausea and vomiting, excessive pain and adverse cardiovascular events. The factors that anesthesiologists can address to reduce length of stay are postoperative nausea and vomiting and excessive pain. Multimodal management of postoperative nausea and vomiting and pain can minimize adverse events and thereby reduce length of stay in the postanesthetic care unit, but will not necessarily lead to a reduction in staffing levels. As personnel costs contribute the majority of postanesthetic care unit costs, more than 95%, direct financial savings may not be possible from eliminating adverse events alone. Optimizing the use of the postanesthetic care unit and reducing total hours in the unit with higher operating room turnover may lead to indirect financial benefits.     

Factors contributing to a prolonged stay after ambulatory surgery

We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%-79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA. IMPLICATIONS: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.     

The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis

BackgroundCorticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.MethodsThe MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids.ResultsCritical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA.ConclusionStrong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.     

Acupuncture and anaesthesia

Acupuncture and related techniques are increasingly practised in anaesthesia. This paper reviews the current evidence and applicability of acupuncture and related techniques for anaesthetic procedures and postoperative nausea and vomiting. Recent evidence suggests that manual acupuncture is effective for reducing preoperative anxiety and for postoperative pain relief. Current available data do not support the use of acupuncture as an adjunct to the general anaesthetic in the intraoperative setting. There are extensive and good quality data to support the use of P6 acupoint stimulation techniques for preventing postoperative nausea and vomiting in combination with or as an alternative to conventional anti-emetics. The use of acupuncture for labour pain management appears promising but requires further research. Patient selection, acupoint selection, needling techniques, and mode of acupuncture need to be considered when applying acupuncture and related techniques in the perioperative setting. There are guidelines for the conduct and reporting of acupuncture research, and these should be followed to improve the quality of studies.     

Recovery and outcome after minor pediatric surgery

Recovery and outcome parameters of children undergoing surgery as outpatient are reported. There are minor differences between different drugs in terms of outcome, speed of recovery and recovery adverse events. There is a trend in increasing adverse events (most of all emergence delirium) during recovery from sevoflurane and nitrous oxide. Most complications (pain, nausea, vomiting, croup) are transient and managed before discharge. The most frequent complications at home are undertreated pain, loss of appetite, and behavioral changes.     

Preoperative intravenous midazolam: benefits beyond anxiolysis.

STUDY OBJECTIVE: To evaluate the effect of midazolam on the global perioperative experience, including patient satisfaction, postoperative nausea and vomiting, postoperative pain, and perioperative anxiety and amnesia. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: Ambulatory surgical center affiliated with a tertiary-care hospital. PATIENTS: 88 ASA physical status I, II, and III patients scheduled for outpatient surgery. INTERVENTIONS: Patients were randomized into two groups to receive either 0.04 mg/kg of midazolam or placebo intravenously (IV) 20 minutes preoperatively. MEASUREMENTS: Perioperative measurements included blood pressure, heart rate, and oxygen saturation and the patient's level of anxiety; type of anesthetic administered; the anesthesiologist's guess at the treatment arm; perioperative dosages of fentanyl, morphine, and ondansetron; recovery room length of stay; frequency of nausea and vomiting, and level of postoperative pain in the 24 hours after surgery; the patient's overall satisfaction with the anesthetic, and whether the patient would recommend the premedication to a friend. MAIN RESULTS: Patient demographics, type of surgery/anesthesia, vital signs, case duration, recovery duration, and postoperative pain were all similar between the midazolam and placebo groups. As expected, IV midazolam was an effective anxiolytic. There was no evidence of retrograde amnesia. Fewer patients in the midazolam group suffered from postoperative nausea than did those in the placebo group (25%vs. 50%;p = 0.03), despite receiving similar perioperative antiemetic and opioid administration. Similarly, fewer patients in the midazolam group experienced postoperative vomiting than placebo group patients (8%vs. 21%), although this difference did not reach statistical significance. Only 42% of patients in the placebo group would recommend their premedication to a friend, compared with 85% of patients in the midazolam group (p < 0.001). CONCLUSIONS: In addition to the known anxiolytic effects of midazolam, midazolam premedication is an effective way to reduce the frequency of postoperative nausea, and perhaps vomiting, and increase patient satisfaction.     

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??Noteworthy issues involving the perioperative sedation and analgesia LI Qing-dong??WAN Xian-yao. Critical Care Medical Research Institute of Dalian Medical University??Department of Critical Care Medicine??the First Affiliated Hospital of Dalian Medical University??Dalian 116011??China
Corresponding??WAN Xian-yao??E-mail??13322210199@163.com
Abstract Interventions of preoperative anxiety??assessment and treatment of agitation and pain in critical patients after major operation??sedation and analgesia for postoperative delirium are issues worthy of attention in perioperative period. Preoperative anxiety should not be treated merely by sedatives. Music listening and psychology interview may have more beneficial effect on it. As for critical patients??evaluation-first therapy and analgesia-first sedation should be applied as a strategy. Analgesics and sedatives should be selected based on individualization. It is worth noting that postoperative delirium is easy to be neglected and treated by wrong way.