丙泊酚与舒芬太尼相互作用的药效学关系

目的观察临床浓度范围内丙泊酚与舒芬太尼相互作用的药效学变化。方法选择ASAⅠ或Ⅱ级、拟在全身麻醉下择期行腹部手术患者36例,应用靶控输注系统给予逐渐增加的丙泊酚和舒芬太尼浓度,第一阶段随机给予三个浓度梯度丙泊酚或舒芬太尼,第二阶段及第三阶段同时给予随机浓度组合的丙泊酚与舒芬太尼,浓度达稳态后记录脑电双频指数(BIS)及血压。浓度效应数据用于计算相互作用指数(α)。结果 BIS与血压变化的直线方程显示,丙泊酚与舒芬太尼两者相互作用指数α与零比较差异无统计学意义。结论临床浓度范围内丙泊酚与舒芬太尼联合应用药效学指标仅表现为简单的相加作用,因此两药联合应用不必减少各自用量。     

复合异丙酚麻醉时舒芬太尼抑制强直电刺激和切皮诱发胸腹部手术患者体动反应的药效学

目的 探讨复合异丙酚麻醉时舒芬太尼抑制强直电刺激和切皮诱发胸腹部手术患者体动反应的药效学.方法 择期胸腹部手术患者50例,年龄18～57岁,ASA分级Ⅰ或Ⅱ级,体重为标准体重的80%～120%,随机分为5组(n=10):舒芬太尼效应室靶浓度0.07、0.10、0.14、0.20和0.28 ng/ml组.靶控输注异丙酚,血浆靶浓度3.0～3.2 μg/ml,患者意识消失时各组按设定的效应室靶浓度靶控输注舒芬太尼,待效应室和血浆浓度达平衡后,给予强直电刺激(频率50 Hz,强度80 mA,波宽0.25ms),观察患者反应后给肌松药,行气管插管,维持上述异丙酚和舒芬太尼的靶浓度到切皮后4 min,试验观察结束.观察强直电刺激和切皮时患者的体动反应情况.采用通过概率单位回归分析法计算舒芬太尼抑制电刺激和切皮诱发的体动反应的半数有效效应室靶浓度(EC50)和EC95及其95%可信区间.结果 复合异丙酚麻醉时舒芬太尼抑制强直电刺激诱发的体动发应的EC50和EC95及其95%可信区间分别为0.12(0.09～0.14)ng/ml和0.20(0.17～0.31)ng/ml,抑制切皮诱发的体动发应的EC50和EC95分别为0.13(0.11～0.16)ng/ml和0.21(0.17～0.29)ng/ml;复合异丙酚麻醉时舒芬太尼抑制强直电刺激和切皮诱发的体动发应的EC50和EC95的比较差异无统计学意义(P＞0.05).结论 复合异丙酚麻醉时舒芬太尼抑制强直电刺激(频率50 Hz,强度80 mA,波宽0.25 ms)诱发的体动发应的EC50和EC95分别为0.12和0.20 ng/ml,抑制切皮诱发的体动发应的EC50和EC95分别为0.13和0.21 ng/ml,且抑制两组刺激诱发的体动发应的药效学无差异,提示强直电刺激可替代切皮用于评价麻醉药的药效学.     

丙泊酚麻醉下舒芬太尼抑制气管插管反应的半数有效浓度

目的探讨丙泊酚靶控输注(TCI)时舒芬太尼抑制气管插管反应的半数有效浓度(Ce50)。方法择期全麻手术患者29例,以效应室浓度TCI舒芬太尼,3 min后给予血浆靶浓度为3μg/ml丙泊酚,意识消失后给予维库溴铵0.1 mg/kg。舒芬太尼效应室靶浓度按序贯法确定,舒芬太尼靶控浓度从0.4 ng/ml开始,相邻靶浓度之间比率为1.2。结果丙泊酚3μg/ml麻醉下,舒芬太尼抑制气管插管反应的Ce50为0.32 ng/ml,95%可信区间(CI)为0.3～0.36 ng/ml。结论在复合TCI丙泊酚3μg/ml时,舒芬太尼抑制气管插管反应的Ce50为0.32 ng/ml。     

舒芬太尼抑制老年患者McGrath视频喉镜下气管插管反应的半数有效浓度

目的 测定舒芬太尼抑制老年患者McGrath视频喉镜气管插管反应的半数有效浓度(median effectiveconcentration,EC50).方法 选择全身麻醉下气管插管行外科手术的老年患者29例,年龄66岁～75岁.患者入室建立静脉通路后给予咪达唑仑0.02 mg/kg.诱导同时以效应室靶浓度(target effect-site concentration,Ce)靶控输注(target-controlled infusion,TCI)丙泊酚和舒芬太尼,丙泊酚的初始Ce为1.5 mg/L,2 min后调至2.5 mg/L;舒芬太尼的Ce浓度为0.3 μg/L.当镇静/警醒评分≤2时,给予罗库溴铵0.6 mg/kg.待舒芬太尼Ce与血浆浓度(plasma concentration,Cp)平衡后McGrath视频喉镜下气管插管.观察患者的气管插管反应,若插管反应呈阳性,按序贯法依次升高下一例舒芬太尼的Ce,若插管反应呈阴性,则降低下一例舒芬太尼的Ce,各相邻浓度间比例为1.2.结果 舒芬太尼TCI抑制老年患者McGrath视频喉镜下气管插管反应的EC50为0.194 μg/L,95％置信区间(confidence interval,cI)为0.174 μg/L～0.212 μg/L(P＜0.01).麻醉诱导过程中舒芬太尼的平均用量为(0.211±0.039) μg/kg(P＜0.01).结论 丙泊酚Ce为2.5 mg/L时,舒芬太尼抑制50％老年患者McGrath视频喉镜下气管插管反应的Ce为0.194 μg/L.     

小儿麻醉诱导期舒芬太尼对丙泊酚镇静作用的影响

目的本研究通过观察小儿麻醉诱导期意识消失(LOC)时脑电双频指数(BIS)以及丙泊酚的效应室浓度(EC)变化,了解不同剂量的舒芬太尼对丙泊酚镇静作用的影响。方法 45例患儿择期接受手术.年龄3～8岁,ASA Ⅰ或Ⅱ级。随机均分为三组:S_1、S_2组分别输注舒芬太尼0.01、0.02 μg·kg~(-1)·min~(-1);C 组,生理盐水持续输注。所有患儿均不使用术前药,入室后开放静脉,稳定5 min 后分别输注舒芬太尼或生理盐水。输注30min 后,开始丙泊酚靶控输注,所有患儿的丙泊酚起始 EC 设定为 1 μg/ml,以后再逐渐递增至2、3、4 μg/ml。分别于基础时点、舒芬太尼输注30 min 后、丙泊酚每次达到预设 EC 稳定1 min 后以及 LOC 即刻记录 BIS、丙泊酚 EC、OAA/S 评分、HR、SBP及 MAP。结果患儿 LOC 时 S_1组丙泊酚 EC_(50)[1.28 μg/ml,95%可信区间(CI):0.99～1.53μg/m1]和 S_2组丙泊酚 EC_(50)(0.98 μg/ml,95%CI:0.52～1.33 μg/ml)均显著低于 C 组(2.02 μg/ml,95%CI:1.70～2.28 μg/ml)(P<0.05),S_2组 BIS_(50)(83,95%CI:78.7～92.9)明显高于 C 组(74,95%CI:70.2～79.8)(P<0.05)。结论舒芬太尼与丙泊酚复合应用可以降低患儿意识消失所需要的丙泊酚效应窒浓度,两者之间存在协同作用,舒芬太尼可以加强丙泊酚的镇静作用。     

胸腹部手术患者靶控输注舒芬太尼复合异丙酚的药效学

目的研究复合靶控输注(TCI)异丙酚致患者意识消失时,胸腹部手术患者对切皮刺激无体动反应所需舒芬太尼效应室靶浓度的EC50和EC95。方法择期胸腹部手术患者50例,ASAⅠ或Ⅱ级,年龄18-57岁,随机分为5组(n=10),舒芬太尼效应室靶浓度分别设定为0．07、0．10、0．14、0．20、0．28 ng／ml。持续监测患者平均动脉压、心率、脉搏血氧饱和度、呼气末二氧化碳分压、心电图。麻醉诱导:起始血浆靶浓度(Cp)为3．0μg／ml,以0．3μg／ml为浓度梯度递增,持续TCI异丙酚致意识消失,并维持该浓度至试验结束,记录此时异丙酚的Cp和效应室靶浓度(Ce)。随后按预设的不同Ce持续TCI舒芬太尼,待效应室和血浆室浓度平衡后,静脉注射琥珀胆碱1．5 mg/kg,行气管插管。观察并记录切皮刺激时的体动反应和心血管反应,计算抑制切皮体动时舒芬太尼Ce的EC50和EC95。结果患者意识消失时各组间异丙酚的血浆和效应室靶浓度及给予琥珀胆碱后插管至切皮的时间比较差异无统计学意义(P>0．05);随着舒芬太尼Ce的增高,每组切皮刺激体动发生率依次降低,对切皮刺激无体动反应的舒芬太尼Ce的EC50为0．12 ng/ml,其95％可信区间为0．09-0．14 ng/ml,EC95为0．20 ng/ml,其95％可信区间为0．17-0．31 ng/ml。结论复合TCI异丙酚[Cp(3．1±0．3)μg/ml]致意识消失时,抑制胸腹部手术患者切皮反应的舒芬太尼Ce的EC50为0．12 ng/ml,EC95为0．20 ng／ml。     

不同效应室浓度舒芬太尼复合丙泊酚全麻诱导对意识消失及血流动力学的影响

丙泊酚复合舒芬太尼靶控输注(TCI)静脉麻醉时,两者的药效呈现协同作用[1].我们通过采用丙泊酚-舒芬太尼效应室TCI静脉麻醉,观察不同舒芬太尼效应室浓度(Ce)对诱导期患者意识消失(LOC)及血流动力学反应的影响.     

重症肌无力患者无肌松药下靶控输注丙泊酚时舒芬太尼诱导气管插管的半数有效浓度

目的 研究靶控输注(TCI)丙泊酚时舒芬太尼复合气管内表面麻醉,在无肌松药下诱导重症肌无力(MG)患者气管插管所需的半数有效浓度.方法 拟行经胸骨正中劈开胸腺切除术的MG患者20例,AsA Ⅰ或Ⅱ级.麻醉诱导丙泊酚采用血浆浓度(Cp)TCI,维持3.5μg/ml不变;舒芬太尼采用效应室浓度(Ce)TCI,按序贯法确定浓度,依次为0.15、0.23、0.34、0.50 ng/ml等比递增,相邻效应室靶浓度之间比例为1.5.复合气管内表面麻醉后行气管插管.监测诱导、插管过程中的血压,心率和脑电双频指数(BIS).结果 50%患者完成插管时舒芬太尼的浓度为0.23 ng/ml,95%的可信区间为0.20～0.27 ng/ml.结论 MG患者在不使用肌松药和复合气管内表面麻醉的情况下完成气管插管,丙泊酚血浆靶浓度为3.5 μg/ml,舒芬太尼半数有效效应室靶浓度为0.23 ng/ml.     

靶控输注瑞芬太尼和异丙酚麻醉诱导时镇静催眠效应的相互作用

目的 探讨靶控输注(TCI)瑞芬太尼和异丙酚麻醉诱导时镇静催眠效应的相互作用.方法 择期全麻手术患者32例,ASAⅠ或Ⅱ级,年龄22～63岁,体重指数18～25 kg/m2.采用TCI异丙酚和瑞芬太尼诱导麻醉,随机分为4组(n=8):Ⅰ组单纯TCI异丙酚,Ⅱ组～Ⅳ组TCI瑞芬太尼,血浆靶浓度分别为2、4、6 ng/ml,当瑞芬太尼血浆靶浓度与效应室浓度达平衡时开始TCI异丙酚,异丙酚初始血浆靶浓度均为0.5μg/ml,当异丙酚血浆靶浓度与效应室浓度达平衡时以0.5μg/ml的浓度梯度递增诱导至患者意识消失.每隔3min观察睫毛反射和意识状态,同时抽取桡动脉血样6ml,分别采用反相高效液相色谱法和高效液相色谱-紫外法测定异丙酚和瑞芬太尼血药浓度.采用药效学相互作用模型公式和等辐射法分析两者镇静催眠效应的相互作用.结果 与Ⅰ组比较,Ⅱ组～Ⅳ组睫毛反射消失和意识消失时异丙酚血药浓度降低,而Ⅱ组～Ⅳ组随瑞芬太尼血药浓度升高,异丙酚血药浓度依次降低(P<0.05).睫毛反射消失和意识消失时,异丙酚和瑞芬太尼血药浓度用药效学相互作用模型曲线拟合均优于直线回归(P<0.05).拟合出睫毛反射消失时EC50,prop=2.77μg/ml、EC50,rem=26.67 ng/ml,其等辐射法公式EC prop/2.77+Ecrem/26.67=0.69;意识消失时EC50,prop=3.76μg/ml、EC50,rem=31.56 ng/ml,其等辐射法公式Ecprop/3.76+Ecrem/31.56=0.65.结论 麻醉诱导期间,TCI瑞芬太尼(血浆靶浓度2～6ng/ml)和异丙酚在镇静催眠效应上呈协同作用.     

反应曲面法分析丙泊酚和瑞芬太尼对脑电双频指数影响的相互作用

目的 以脑电双频指数(bispectral index,BIS)为指标,观察不同丙泊酚-瑞芬太尼浓度组合产生的镇静效应,构建丙泊酚和瑞芬太尼相互作用的反应曲面模型,确定量效关系及相互作用类型,并分析这种相互作用对BIS临床监测的提示.方法 采用交叉对照研究;无术前用药、美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级、择期行全麻手术的患者40例,按随机数字表法分为丙泊酚组(22例)和瑞芬太尼组(18例).以靶控输注方式分两个阶段递增和递减药物浓度(丙泊酚,1 mg/L～5 mg/L;瑞芬太尼,1 μg/L～7 μg/L),经洗脱期后,给予第2种药物.每间隔1 min采集BIS指标,采用非线性混合效应模型对研究数据进行分析. 结果 丙泊酚和瑞芬太尼相互作用对BIS影响的药效学模型以Minto反应曲面模型较好拟合;两药对BIS表现为协同作用(相互作用系数β2＞0);年龄不影响两药的50％有效浓度(50％ effective concentration,EC50),但对斜率(γ)有显著影响(P＜0.01).反应曲面模型的参数分别为EC50.Prop=2.96 mg/L,EC50.Reni=38.1 μg/L,γ=1.86+(年龄-50)0.017 2,Eman=8.61,E0=90.8,β2=0.83.结论 丙泊酚联合瑞芬太尼有镇静协同效应;年龄不影响BIS降低的幅度(Emax不变),也不影响两药联合作用的敏感性(EC50不变),但老年人联合用药时BIS的反应性增加(γ随年龄增加而增加).     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020