右美托咪啶在心脏手术围术期的应用

背景 右美托咪啶(dexmedetomidine,DEX)作为一种高效的α2受体激动剂,不仅具有镇静、镇痛、抗焦虑作用,还有使心脏高危情形受益的抗交感,心肌自律性阻滞作用,因此被越来越多的用于心脏手术围术期.目的 概述及评价DEX在心脏手术围术期应用的有效性及安全性,为临床用药提供参考.内容 阐述DEX心血管系统药理学...     

Early biological markers of anaphylactoid reactions occurring during anesthesia]

Three markers of in vivo histamine release, i.e. plasma histamine and tryptase, and urinary methylhistamine, were assessed using sensitive radioimmunoassays in 18 patients who had experienced an adverse reaction to an anaesthetic agent. Controls were obtained from 35 patients following a general anaesthetic, which included a muscle relaxant, and who remained free from any adverse reaction. A first blood sample was obtained from all 18 patients a mean 25 +/- 26 min after the reaction, and a second one in thirteen a mean 120 +/- 65 min after the reaction. Ten patients had had a life-threatening reaction. Plasma histamine levels were increased in all these cases, and tryptase concentrations in 9 out of 10. Urinary methylhistamine rarely reached pathological levels (4 out of 10). Skin tests were positive in the four tested patients. Plasma histamine concentration was still high in 8 cases thirty minutes after the reaction, and remained increased for more than 2 h in two patients. Among the other eight patients with a moderate reaction, 3 had high histamine levels, with normal or weakly increased tryptase concentrations, and normal urinary methylhistamine. Two of these patients had positive skin tests. There were no abnormal findings in any of the investigations carried out in the other five patients, except for a slightly positive skin test to atracurium in one patient. Plasma histamine had a higher sensitivity than tryptase levels. Methylhistamine concentrations were only rarely of interest. There were no false positives with the three investigated markers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective epidemiologic study of perioperative anaphylactoid reactions occurring in Catalonia (1996-7)

OBJECTIVES: To determine the incidence, immunological mechanisms, severity and clinical course of perioperative allergic reactions. PATIENTS AND METHODS: Prospective epidemiological study lasting 2 years (1996-97). In 20 hospitals in Catalonia (Spain), we studied patients who suffered allergic reactions equal to or greater than grade Ib according to the classification of Laxenaire. Serum and urine samples were collected during the first and sixth hours after the onset of a reaction. Complement factors, total serum and latex-specific serum IgE antibodies, hemostatic markers, serum tryptase and urinary methylhistamine were assayed. Tests for allergy to the drugs used during the perioperative period were performed on all patients who consented. RESULTS: Anesthetic procedures were performed 328,430 times in the 20 hospitals. Thirty-two allergic reactions were reported (1 case/10,263 anesthesias); the frequency was greater during general anesthesia (1 case/6,978 anesthesias). Women suffered 58.3% of the reactions, and the mean patient age was 47.8 +/- 16.5 years. Fifty-six percent of the reactions were severe (grades III-IV), and 68.7% occurred upon immediate exposure. Induction was the moment of greatest risk (50%). Treatment was required by 90.6% of the patients, but no deaths or serious sequelae occurred. Complete analyses could be carried out immediately for 25 patients. High urinary methylhistamine and/or serum tryptase levels were found for 57% of the patients with grade Ib reactions, for 80% of those with grade II reactions, and for 91.7% of those with grade III reactions (p = 0.05). High serum tryptase levels were the only findings for 53.8% of the grade III reactions (p = 0.007). Skin tests were positive for 62.5% of the patients. CONCLUSIONS: The frequency of allergic reactions in Catalonia is 1 case per 10,263 anesthesias performed, but the rate is higher in general anesthesia. Fifty-six percent of the reactions were severe. Most developed immediately and the moment of induction involved the greatest risk. Early assessment of methylhistamine and tryptase levels has been shown to be useful and positivity is linearly associated with severity of reaction. In 62.5% of the patients, positive results were seen in skin tests performed later.     

吲哚菁绿在肝切除围手术期的临床应用

术后肝功能不全、肝衰竭等并发症是影响肝癌患者手术方式及预后的重要因素。围手术期肝脏储备功能评估可早期识别肝脏潜在损伤,评价剩余肝功能,有助于分析肝切除患者的耐受、预后及恢复情况。吲哚菁绿（indocyanine green,ICG）清除试验可以检测正常肝细胞代谢总和,其测量的肝脏储备功能比血清生化检查更加准确,且具有动态性。近年来ICG在术前评估手术风险、指导术式选择,术中评估手术安全性,术后预测预后等方面的应用逐渐深入。本文就ICG在肝切除围手术期应用的最新进展进行综述。     

Corticosteroids and wound healing: clinical considerations in the perioperative period

Background

Determining whether systemic corticosteroids impair wound healing is a clinically relevant topic that has important management implications.

Methods

We reviewed literature on the effects of corticosteroids on wound healing from animal and human studies searching MEDLINE from 1949 to 2011.

Results

Some animal studies show a 30% reduction in wound tensile strength with perioperative corticosteroids at 15 to 40 mg/kg/day. The preponderance of human literature found that high-dose corticosteroid administration for <10 days has no clinically important effect on wound healing. In patients taking chronic corticosteroids for at least 30 days before surgery, their rates of wound complications may be increased 2 to 5 times compared with those not taking corticosteroids. Complication rates may vary depending on dose and duration of steroid use, comorbidities, and types of surgery.

Conclusions

Acute, high-dose systemic corticosteroid use likely has no clinically significant effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals.     

Hypoalbuminaemia in the perioperative period: clinical significance and management options

Albumin has been the focus of literally thousands of articles since its first use in the clinical setting during World War II. Despite being at the centre of several clinical controversies, many questions still remain regarding the use and abuse of albumin. The major physiologic functions include maintaining colloid osmotic pressure, binding and transport of metabolically active molecules, serving as an antioxidant, use as a surrogate marker of nutritional status and predictor of outcome in elective surgical populations, having an anti-thrombotic influence on platelets, aiding in acid-base balance and having a protective influence on capillary membrane integrity. Albumin will continue to be widely used in clinical medicine despite many of the drawbacks. It now appears the benefits in the use of albumin in most cases outweigh the risks. The clinical implications of hypoalbuminaemia as an indicator of surgical or intensive care unit (ICU) outcome or nutritional status is clearly disease- and organ specific. The use of albumin as a volume expander appears to have limited, if any, benefit over crystalloid. The "secondary" benefits of albumin in specific surgical and intensive-care conditions, such as sepsis and organ dysfunction, are numerous and are well supported in the current literature.     

右美托咪啶在围术期临床应用的研究进展

背景右美托咪啶(dexmedetomidine,DEX)是一种高选择性的α2肾上腺素受体(α2 adrenoreceptor,α2AR)激动剂,于2000年3月在美国首次上市,它与α2、α1肾上腺素受体结合的比例是1 620∶1(比可乐定高8倍).它的半衰期比可乐定短,消除半衰期为2 h,分布半衰期为6 min,其较短...     

Characteristics of anaphylactic reactions to antibiotics administered under anesthesia]

Wide application of active chemical and biological substances in medical practice is inevitably associated with the appearance of adverse side reactions sometimes hazardous for patients' life. Especially grave allergic reactions are observed to antibiotics administered under narcosis. Narcosis would inhibit an anaphylactic response, but with its cessation when the allergen concentration in blood is high enough an extremely rapid anaphylactic reaction would develop that promptly resulted in a terminal patients' condition. Three case reports are described. Reanimation measures proved to be a success only in 2 cases.     

The use of Statins in the perioperative period

3 Hydroxy 3 Methyl Glutaryl Coenzyme A Reductase Inhibitors’ (statins) are increasingly being used in patients with cardiovascular disease. The Scottish Intercollegiate Guidelines Network (SIGN) and National Institute of Health and Clinical Excellence (NICE) recommend their use in primary and secondary prevention of cardiovascular events. Patients on preoperative statins will frequently present for surgical procedures. The increase in adverse cardiovascular outcomes in high risk patients if statins are withheld in the immediate postoperative period should be weighed against the small but serious risk of rhabdomyolysis associated with statins. The potential for drug interactions should be considered when prescribing for patients on statins.     

不同年龄组腹腔镜胆囊切除术围手术期的临床分析

目的:对比不同年龄胆囊结石患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)围手术期指标,探讨高龄患者的特点及手术治疗的安全性。方法:回顾分析为327例胆囊结石患者行LC的临床资料。将患者按年龄分为3组:高龄组(年龄≥75岁)、老年组(50≤年龄<75)、中青年组(年龄<50),对比分析3组患者合并症、术后并发症、住院时间、待手术日、手术时间、术后恢复时间、肠道功能恢复时间、术前白蛋白、术后第1天白蛋白及手术对患者白蛋白的影响。结果:在合并症方面,高龄组与其他两组相比差异有统计学意义(P<0.01),老年组与中青年组差异有统计学意义(P<0.05);3组患者手术并发症、手术时间、手术对患者白蛋白的影响差异无统计学意义(P>0.05)。高龄组住院时间、待手术日、术后恢复时间、肠道功能恢复时间、术后第1天白蛋白与其他两组相比差异有统计学意义(P<0.01),高龄组与老年组的术前白蛋白水平均低于中青年组,差异有统计学意义(P<0.01),高龄组与老年组相比差异亦有统计学意义(P<0.05)。结论:高龄组患者合并症较多,营养状况较差,但加强围手术期处理,高龄患者行LC仍是安全、可行的。     

Holter electrocardiographic findings in surgical patients during the perioperative period]

Eighty patients undergoing abdominal surgery were studied to evaluate ECG changes in perioperative period and also identify the factors influencing the incidence and the severity of postoperative ventricular arrhythmia. Holter ECG was recorded with CM5 and NASA leads from the night before operation to the night of the 2nd postoperative day. Tachycardia (greater than or equal to 100 beats.min-1) was found in 46.3% of the patients preoperatively and in 55% postoperatively. Bradycardia (less than or equal to 50 beats.min-1) was found in 30% of the patients mostly in the night prior to the operation, while only 1 patient (1.3%) demonstrated bradycardia postoperatively. SVPCs were observed in high incidence ranging from 75% preoperatively to 85% postoperatively. Two patients had paroxysmal supraventricular tachycardia postoperatively. VPCs were observed in 42.5% of the patients preoperatively and in 53.8% postoperatively. Warning arrhythmias which were ranked as more dangerous than Lown 2 were observed in 15% of the patients preoperatively, in 11.3% intraoperatively and in 23.8% postoperatively. Serious arrhythmias which needed immediate treatment were found in 6.3% of the patients preoperatively, in 10% intraoperatively and in 11.3% postoperatively. ST depression was recorded in 11 patients at CM5 and 2 patients at NASA leads. Chi-square and Hayashi's multidimensional quantification analyses were applied to determine the relationship between postoperative VPCs and pre- and intra-operative clinical factors. Factors such as age, type of surgery, intraoperative VPCs, ASA classification, ischemic changes in preoperative ECG, intraoperative blood loss, operation time, Goldman score, untreated hypertension as well as ischemic heart disease and abnormal findings of Master ECG were considered to be contributing to the high incidence and the severity of post-operative VPCs. When multidimensional quantification analysis is applied to the data, the occurrences of no VPCs, occasional VPCs, warning VPCs and serious VPCs could be predicted in postoperative patients.     

老年食管癌切除术围手术期临床分析

目的 探讨高龄食管癌患者行食管切除术的危险性及术后并发症与年龄的关系。方法:1996～1999年对247例食管癌切除患者,根据年龄分为两组:Ⅰ组(老年组),年龄≥60岁共54例,Ⅱ组(非老年组),年龄<60岁共193例,比较两组术前危险因素及术后并发症。结果 两组病例术前危险因素Ⅰ组51.8％,Ⅱ组13％。术后并发症Ⅰ组为40.9％,Ⅱ组为11.9％。两组病例术前后危险因素及术后并发症存在着显著差异。结论 积极对老年食管癌患者进行手术危险因素及并发症的防治,可取得满意的手术治疗效果。     

围手术期的心理护理

目的通过对患者进行围手术期的心理护理，可使患者以最佳状态进入手术室，安全的耐受手术，保证手术成功。方法对382例围手术期患者发放责任护士需求表从而进行心理护理，消除患者的陌生感，取得彼此问的了解、信任及良好的人际关系。结果306例围手术患者能平静的接受手术，24例围手术患者因年龄小，惧怕手术但家属能从容接受手术，52例围手术患者充满信心的接受手术。结论围手术期的心理护理，可消除手术带给患者的紧张和恐惧感，保证手术顺利进行和术后迅速康复，对提高护理质量有促进作用。     

Diagnosis of the causes of anaphylactoid anaesthetic reactions

Adverse, anaphylactoid, reactions to the intravenous drugs and other substances used in anaesthesia and surgery pose a major problem in many countries. The scope of the problem is somewhat difficult to judge since agreement can rarely be reached as to what is, or as to what is not, an adverse reaction. While the death of a fit young patient undergoing minor investigative surgery is an obvious candidate for inclusion, many of the very minor incidents of urticaria, mild hypotension and mild bronchospasm are less easy to classify since they may arise from theatre techniques, from underlying pathology, known or unsuspected, as well as from complex psychosomatic and psychosocial stimuli. Minor manifestations may not hinder the immediate procedure, but their incorrect interpretation may lead to a disaster during a general anaesthetic procedure weeks, or even years, later.