舒芬太尼复合七氟烷小剂量丙泊酚麻醉在非体外冠脉搭桥术中的应用

目的探讨舒芬太尼复合七氟烷和小剂量丙泊酚静吸复合全麻在非体外循环冠脉搭桥术（off-pump coronary artery bypass graft,OPCABG）中的应用。方法选择符合条件的非体外循环冠脉搭桥手术患者70例,随机分为两组（n=35）,舒芬太尼组（S组）和芬太尼组（F组）,S组予以舒芬太尼、七氟烷复合小剂量的丙泊酚,F组予以芬太尼、七氟烷复合小剂量的丙泊酚进行静吸复合全麻,观察两组插管前（T0）、插管后（T1）、劈胸骨（T2）、搭回旋支（T3）及穿钢丝（T4）时血流动力学的变化。结果两组平均动脉压（MAP）在T1、T2、T4等强刺激时均升高（P〈0.05）,且F组较S组升高更显著（P〈0.05）;两组心率（HR）在T1～T4各时点均显著升高（P〈0.05）,但组间比较无显著性差异（P〉0.05）;两组混合静脉血氧饱和度（SvO2）在T3时均明显降低（P〈0.05）,但组间比较差异无显著性（P〉0.05）;S组血压反应和心率明显波动的发生率明显低于F组（P〈0.05）。结论舒芬太尼、七氟烷复合小剂量丙泊酚静吸复合全麻具有更稳定的血流动力学效应,对病人的循环干扰小,是OPCABG的一个良好的选择。     

舒芬太尼和芬太尼用于冠脉搭桥手术麻醉诱导的血液动力学变化

舒芬太尼是一种新合成的的强效拟吗啡类镇痛药，镇痛效价是芬太尼的5～10倍，并具有起效快、心血管系统功能稳定、无组胺释放等特点。本研究拟比较舒芬太尼和芬太尼用于非体外循环冠脉搭桥手术麻醉诱导时的血液动力学变化。     

体外循环回路对预充液舒芬太尼浓度的影响

目的 评价体外循环回路对预充液舒芬太尼浓度的影响.方法 实验分为2组(n=6):西京90型大号鼓泡式氧合器体外循环回路组(A组)和玻璃容器组(B组).将预充液(琥珀酰明胶液1000ml和乳酸钠林格氏液1000 ml)预充入大号鼓泡式氧合器体外循环装置或玻璃容器中,从静脉贮血器的静脉端或玻璃容器口快速加入舒芬太尼15μg(浓度为7.5 ng/ml).在加药后3、5、10、20、30、40、50、60、70、80、90 min时,从静脉贮血器的动脉端或玻璃容器中抽取预充液1 ml,采用气相色谱质谱法检测舒芬太尼浓度.结果 与B组比较,A组各时点预充液舒芬太尼浓度明显降低(P＜0.05).结论 体外循环回路对预充液舒芬太尼有明显吸附作用.     

不同体外循环回路对预充液舒芬太尼浓度的影响

目的 评价不同体外循环回路对预充液舒芬太尼浓度的影响.方法 实验分为3组(n=6):西京90型大号鼓泡式氧合器体外循环回路组(Ⅰ组)、Termo Capiox SX18成人膜式氧合器体外循环回路组(Ⅱ组)和玻璃容器组(Ⅲ组).将预充液(琥珀酰明胶液1000 ml和乳酸钠林格氏液1000ml)预充入大号鼓泡式氧合器、膜式氧合器体外循环装置或玻璃容器中,从静脉贮血器的静脉端或玻璃容器口快速加入舒芬太尼15μg(浓度为7.5 ng/ml).于注入舒芬太尼后1、3、5、10、20、30、40、50、60、70、80、90 min时,从静脉贮血器的动脉端或玻璃容器中抽取预充液1 ml,采用气相色谱质谱法检测舒芬太尼的浓度.结果 与Ⅲ组比较,Ⅰ组和Ⅱ组各时点预充液舒芬太尼浓度降低(P＜0.05);与Ⅱ组比较,Ⅰ组各时点预充液舒芬太尼浓度降低(P＜0.05).结论 西京90型大号鼓泡式氧合器和TermoCapiox SX18成人膜式氧合器体外循环回路对舒芬太尼均有吸附作用,且前者吸附作用强于后者.     

全身麻醉应用瑞芬太尼与舒芬太尼的效果对比分析

目的:探讨全身麻醉应用瑞芬太尼与舒芬太尼的效果对比,方法:回顾性分析2010年1月至2011年在我院行腹腔镜胆量切除手术患者42例应用瑞芬太尼与舒芬太尼的的临床资料.结果:HR:与TO相比,瑞芬太尼组降低,(P<0.05).MAP:与TO相比,两组Tl和T3,均昱著下降(P<0.05).与T1比较,瑞芬太尼组T2升高(P<0.05).CI:与To相比,舒芬太尼组T1和T3均下降(P<0.05),瑞芬太尼组T1、T2和T3下降(P<0.05).SVRI:与T1比较,瑞芬太尼组T2和T3升高(P<0.05).结论:全身麻醉应用舒芬太尼在心血管稳定性方面效果比瑞芬太尼好.     

舒芬太尼在心脏瓣膜置换术麻醉中的应用

舒芬太尼(sufentanil)是苯基哌啶类药物,现将我们观察其用于心脏瓣膜置换术麻醉的效果及术后恢复情况报道如下。资料与方法一般资料随机选择同一术者的择期手术患者26例,诊断为二尖瓣和/或主动脉瓣狭窄和/或关闭不全,心功能Ⅲ~Ⅳ级。所有患者均为首次接受心脏手术,心胸比例小于     

舒芬太尼复合异丙酚麻醉下体外循环冠脉搭桥术患者双频谱指数与熵指数的关系

目的评价非肌松、深麻醉状态下,双频谱指数(BIS)反映麻醉深度的准确性。方法选择ASAⅢ级的冠脉搭桥术患者59例,麻醉诱导:静脉注射异丙酚2 mg／kg、舒芬太尼1μg／kg、罗库溴铵0．6 mg／kg,术中麻醉维持采用静脉持续输注异丙酚3-4 mg·kg-1·h-1、舒芬太尼1μg·kg-1·h-1。于麻醉诱导前、麻醉诱导开始后1、2、3、4 min、气管插管后即刻、气管插管后1 min、切皮后即刻和劈胸骨后即刻记录BIS、状态熵(SE)和反映熵(RE)。结果与麻醉诱导前相比,麻醉诱导开始后1、2、3、4 min和气管插管后即刻、气管插管后1 min、切皮后即刻及劈胸骨后即刻BIS、SE和RE均下降(P<0．05)。与SE相比,RE在各观察点均升高(P<0．01)。麻醉诱导期间BIS与SE和RE各时间点观察值之间呈明显正相关,r分别为0．898、0．908(P<0．01)。结论在非肌松、深麻醉状态下,BIS对舒芬太尼复合异丙酚静脉麻醉深度的监测不受肌电活动的影响。     

舒芬太尼与芬太尼在小儿心脏手术全麻诱导的观察

我们分别使用舒芬太尼及芬太尼在40例小儿先天性心脏病心脏直视手术全麻诱导进行观察比较,现将结果报告如下。 资料与方法 择期手术的40例小儿先天性心脏病均为非发绀型的房或室间隔缺损。心功能Ⅰ～Ⅱ级,随机分为两组,全麻诱导应用舒芬太尼者(舒组)20例,年龄6.84±3.67岁,体重17.40±6.91kg;应用芬太尼者(芬组)20例,年龄5.51±1.23岁,体重15.90±3.65kg。 麻醉方法 术前药两组均为哌替啶1mg/kg+东莨菪碱0.01mg/kg。 入室后开放静脉,连续监测血压、心电图及SpO_2,     

瑞芬太尼和舒芬太尼用于全身麻醉对患者苏醒的影响对比

目的比较瑞芬太尼和舒芬太尼用于全身麻醉对患者苏醒期的影响。方法将64例择期手术行全身麻醉患者随机分为瑞芬太尼组和舒芬太尼组,每组32例。分别予瑞芬太尼和舒芬太尼麻醉,比较两组患者术毕呼吸恢复时间、呼之睁眼时间、气管导管拔出时间及术后的疼痛语言(VRS)分级评分、镇静(SS)评分及苏醒期内不良反应、。结果两组间术毕呼吸恢复时间、呼之睁眼时间、气管导管拔出时间差异无统计学意义(P0.05),舒芬太尼组患者术后疼痛程度和镇静程度评分优于瑞芬太尼组且苏醒期内恶心呕吐等不良反应发生率明显低于瑞芬太尼组,两组差异有统计学意义(P0.05)。结论瑞芬太尼和舒芬太尼麻醉效果相当,但舒芬太尼麻醉苏醒期更加平稳。     

非体外循环下冠脉搭桥术的器械配合

冠状动脉搭桥(CABG)是治疗冠心病心肌缺血的主要方法之一。传统的方法是在体外循环下、心脏完全停跳下进行，但体外循环可给人体带来一系列的生理和病理紊乱。近十几年来．微创伤、非体外循环下冠脉搭桥术(M1-OPCAB)开始广泛应用于临床，我院2001年～2002年11月在北京教授的指导下，施行OPCAB9例，效果满意，现将手术护理的器械配合报告如下。     

丙泊酚-舒芬太尼TCI全凭静脉麻醉用于非停跳冠脉搭桥手术的可行性和剂量探讨

靶控输注(TCI)已是一种较为成熟的全凭静脉麻醉(TIVA)技术,但针对冠脉搭桥手术(CABG)这一特殊群体的实际应用方面的观察研究尚不多。效应室靶浓度(Ce)的TCI调控更为快速有效,但血浆药物浓度有短时间的超高,对循环的稳定可能不利。目前用吸盘固定局部心肌行非停跳冠脉搭桥手术的     

Perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Two patients in whom myocardial infarction in the inferior wall occurred after off-pump coronary artery bypass grafing (OPCAB) are described. In both patients, the right coronary artery had no critical lesion and was not grafted. There was no ischemic episode during operation. Coronary artery spasms and/or intracoronary thrombus formation may have been causes of these events. To our knowledge, this is the first report on perioperative myocardial infarction in OPCAB.     

非体外循环冠状动脉旁路移植术后的阿司匹林抵抗

目的 通过检测非体外循环冠状动脉旁路移植术(OPCAB)后患者血小板聚集率以及尿11-脱氢-血栓烷B2(11-DH-TXB2)指标,动态观察术后阿司匹林抵抗(AR)的发生情况,探索术后AR的危险因素。方法 冠心病患者290例,首次行OPCAB患者145例(手术组),接受内科药物治疗患者145例(非手术组)。手术组患者于术前及术后服用阿司匹林后第1、4、10天及6个月,检测血小板聚集率以及尿11-DH-TXB2。非手术组患者于服药前及服药后第1、4、10天检测上述指标。同时记录患者各项临床资料。结果 手术组患者服用阿司匹林后第1天的AR发生46例(32％)(抵抗组),其余为非抵抗组。用药后第4天和第10天AR患者下降至19例(13％)和5例(3％)。半年随访中未发现有AR患者存在。非手术组患者,服药后第1天,血小板聚集率均下降至20％以下,平均(8.8±6.8)％,未见AR现象出现。手术组患者术后血小板计数显著高于术前(P＜0.05)。Logistic回归分析发现,OPCAB患者中,体重大于75 kg(OR =0.38,95％CI:0.18～0.79)和术后引流量超过500 ml(OR=3.12,95％CI:1.29～7.53)为术后出现AR的危险因素。结论 OPCAB术后早期,阿司匹林的抗血小板作用受到不同程度抑制,部分患者出现AR现象,予以更为积极有效的抗血小板治疗有重要临床意义。     

Early results of off-pump coronary artery bypass

Objective: The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not. Methods: OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003. Results: The mean number of bypass grafts was 2.43 ±0.82 in the OPCAB group and 2.70±0.71 in the CCAB group (p=0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p=0.822). Conclusion: Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.     

Haemodynamic effects of a milrinone infusion without a bolus in patients undergoing off-pump coronary artery bypass graft surgery

The haemodynamic effects of a continuous infusion of milrinone without an initial bolus dose were evaluated in patients undergoing off-pump coronary artery bypass graft surgery. After internal mammary artery harvest, milrinone 0.5 microg.min(-1).kg(-1) (29 patients) or a normal saline infusion (33 patients) was started and continued until all graft anastomoses were completed. Haemodynamic variables were recorded before application of the tissue stabiliser, at 1, 3, 5 and 10 min after the application of the stabiliser, and after its removal. The administration of a milrinone infusion was associated with a smaller decrease in cardiac output and mixed venous oxygen saturation during all the coronary artery anastomoses, with no severe complications and a decreased dose of norepinephrine infused to maintain systemic arterial pressure.     

吗啡-芬太尼复合麻醉下非体外循环冠状动脉旁路移植术患者的转归

目的 探讨吗啡-芬太尼复合麻醉下非体外循环下冠状动脉旁路移植术患者的转归.方法 拟在非体外循环下行冠状动脉旁路移植术的患者72例,年龄41～64岁,随机分为2组(n=36):芬太尼复合麻醉组(F组)和吗啡-芬太尼复合麻醉组(MF组).静脉注射芬太尼10～20μg/kg、咪达唑仑0.1 mg/kg、依托咪酯0.3 mg/kg和维库溴铵0.1 mg/kg进行麻醉诱导,气管插管后行机械通气.麻醉维持:MF组静脉输注吗啡0.15 mg·kg-1·h-1+芬太尼8μg·kg-1·hZ-1,F组静脉输注芬太尼10μg·kg-1·h-1,2组均吸入0.5%～2.0%异氟烷,间断静脉注射维库溴铵4 rag.2组术后进行静脉镇痛,MF组和F组分别静脉输注吗啡0.75 mg/h吗啡和芬太尼10μg/h.分别于术前(基础状态)、术后1、2、3 d进行恢复质量评分(QoR评分).于拔除气管导管后15 min、4 h、24 h时进行Ramsay镇静评分.记录术后不良反应的发生情况.结果 与F组比较,MF组术后QoR评分升高,术后发热发生率降低(P＜0.05或0.01),Ramsay镇静评分和其他不良反应的发生率差异无统计学意义(P＞0.05).结论与芬太尼复合麻醉比较,吗啡-芬太尼复合麻醉有利于非体外循环下冠状动脉旁路移植术患者预后.     

尼卡地平对非心肺转流冠状动脉旁路移植术患者术中血流动力学和氧代谢的影响

目的 探讨尼卡地平对非心肺转流冠状动脉搭桥术(off-pump coronary artery bypass grafting,OPCABG)患者术中血流动力学和氧代谢的影响.方法 选择拟行OPCABG患者79例,年龄51～68岁,ASAⅢ或Ⅳ级,随机分为两组,近端血管吻合前分别持续泵注尼卡地平0.5 μg·kg-1·h-1组(N组,n=41)或硝酸甘油0.5 μg·kg-1·h-1组(G组,n=38).记录麻醉前(T0)和用药后10min(T1)、30min(T2)、60 min(T3)、90 min(T4)时的氧代谢、血流动力学等指标变化情况,包括SvO2、MAP、PaO2、CO、HR和肺血管阻力(PVR)、体循环血管阻力(SVR)、CI、氧摄取率(ERO2)、乳酸(Lac)等.结果 与T0时比较,T3,T4时两组患者氧耗明显降低,Lac浓度明显升高,且N组均明显低于G组(P＜0.05);T3,T4时G组PaO2、氧供明显降低,ERO2明显升高,N组PaO2、氧供明显高于,ERO2明显低于G组(P＜0.05).与T0时比较,两组T1～T3时PAP、T1～T4时PVR和SVR均明显降低,T3,T4时CI明显升高(P＜0.05),且T1～T4时N组PVR和SVR明显低于G组,T4时CI明显高于G组(P＜0.05).两组患者均顺利完成手术,术后均无严重并发症发生.结论 尼卡地平可有效改善OPCABG患者术中氧代谢并维持血流动力学稳定.     

Changes in jugular bulb oxygen saturation during off-pump coronary artery bypass graft surgery

BACKGROUND: The effect of haemodynamic derangement during coronary artery anastomosis in off-pump coronary artery bypass surgery on cerebral blood flow has not been elucidated. Jugular bulb oxygen saturation is a useful indicator of cerebral blood flow provided that the cerebral metabolic rate is constant. This study was designed to evaluate the changes in jugular bulb oxygen saturation during off-pump coronary artery bypass surgery. METHODS: With IRB approval, 48 patients were included. After anaesthesia, an 18-G catheter was introduced into the jugular bulb. Haemodynamic variables and oxygen profiles from gas analysis of jugular bulb blood and arterial blood were obtained: after sternotomy (baseline); at 5 min after the beginning of the anastomosis of the left anterior descending artery, obtuse marginal artery, and right coronary artery; and after sternal closure. RESULTS: Cardiac index and mixed venous oxygen saturation decreased significantly during anastomosis of all three arteries compared to the baseline value. Although the changes in jugular bulb oxygen saturation during anastomosis were statistically significant compared to its baseline value, jugular bulb oxygen saturation remained within normal limit throughout the study. CONCLUSIONS: Jugular bulb oxygen saturation, which represents the global cerebral oxygenation, was well maintained during the anastomosis of all coronary arteries despite significant haemodynamic changes during off-pump coronary artery bypass (OPCAB).     

Predictors of atrial fibrillation after off-pump coronary artery bypass graft surgery

OBJECTIVE: Atrial fibrillation is the most common complication after coronary artery bypass graft surgery. This arrhythmia may lead to hemodynamic compromise, prolonged hospitalization, and increased risk for cerebral thromboembolism. Older age is the only variable consistently associated with the development of postoperative atrial fibrillation; however, no strong predictive model exists. The purpose of this study was to identify perioperative characteristics associated with new-onset atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting. DESIGN: Prospective, observational. SETTING: University tertiary care hospital. PARTICIPANTS: One hundred sixty consecutive patients undergoing off-pump coronary artery bypass grafting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Incidence of postoperative atrial fibrillation was the major outcome. Atrial fibrillation occurred in 33 patients (20.6%). Multivariate analysis identified reintervention (odds ratio 26.8), revascularization of the ramus medianus (odds ratio 3.9), and age (odds ratio 1.069 per year) as the only independent predictors of postoperative atrial fibrillation. All patients were in sinus rhythm at hospital discharge. One hospital death was noted. CONCLUSIONS: Despite the less invasive approach, the incidence of postoperative atrial fibrillation is high after off-pump coronary artery bypass grafting. Older age, grafting of the ramus medianus, and a redo operation were predictors of new-onset postoperative atrial fibrillation. It is possible that left atrial stretching with heart dislocation during revascularization of the lateral wall could lead to postoperative atrial fibrillation.     

乌司他丁对非体外循环冠状动脉旁路移植术病人围术期炎性反应的影响

目的观察乌司他丁对非体外循环冠状动脉旁路移植术(OPCABG)病人围术期炎性反应的影响。方法拟行OPCABG的病人24例,采用随机、双盲方法分为对照组(C组)和乌司他丁组(U组),每组12例。静脉注射咪达唑仑0.1mg/kg、芬太尼10～20μg/kg、哌库溴铵0.1mg/kg麻醉诱导后气管插管,机械通气,吸入1%～2%异氟烷、间断静脉注射芬太尼(2～5μg/kg,总量最高为50μg/ kg)、持续静脉输注哌库溴铵0.03～0.05mg·kg~(-1)·h~(-1)维持麻醉。U组麻醉诱导后开始恒速静脉输注乌司他丁6 000U/kg(30min内输完),然后以1 000 U·kg~(-1)·h~(-1)的速率持续静脉输注至手术结束。C组采用的同样方法输注等容量的生理盐水。分别在切皮前即刻(T_1)、冠状动脉全部吻合结束后0.5h (T_2)、术后2h(T_3)、6h(T_4)、18h(T_5)采集静脉血,测定血浆白细胞介素-6(IL-6)、IL-10、终末补体复合物(TCC)的浓度及CD11b/CD18的表达。结果与T_1比较,C组在T_(3,4)时IL-6浓度、T_3时IL-10浓度升高,T_(2-4)时CD11b/CD18表达升高,2组在T_2时TCC浓度均升高(P<0.05或0.01);与C组比较,U组在T_3时IL-6、IL-10浓度降低,在T_(2～4)时CD11b/CD18表达降低(P<0.05或0.01)。结论乌司他丁可在一定程度上抑制OPCABG病人围术期IL-6、IL-10浓度及CD11b/CD18表达的升高,具有减轻炎性反应的作用。