丙泊酚镇静下瑞芬太尼抑制喉罩置管和气管插管心血管反应的半数有效浓度比较

目的 测定抑制喉罩通气道LMA-Fastrach、LMA-Proseal置管和气管插管心血管反应的瑞芬太尼半数有效浓度以及比较置管期间相应脑电双频谱指数（BIS）的变化.方法 择期全麻下行胆囊切除术患者63例,美国麻醉医师协会（ASA）I～II级,按置管类型的不同随机均分为T、F、P 3组,每组21例.4 mg/L启动并调整丙泊酚靶控,使得BIS稳定于45～55,之后按Minto药代模式设置并启动瑞芬太尼效应室靶控,5 min后给0.6 mg/kg罗库溴铵,2 min后置管：T组气管插管,F组LMA-Fastrach置管,P组放置LMA-Proseal.比较患者麻醉诱导前、诱导后平均动脉压（MAP）、心率（HR）值及置管前后的BIS变化.记录置管前1、2min及置管后5min内的MAP、HR值以判定患者有无心血管反应.应用Dixon-Mood序贯法计算抑制3种置管心血管反应的瑞芬太尼的半数有效浓度（EC50）.结果 与麻醉诱导前相比,3组麻醉诱导后MAP、HR均明显下降[MAP：T、F、P组麻醉诱导前后分别为（87.9＋10.5）mmHg比（71.6＋9.0）mm Hg,（91.8＋8.8）mm Hg比（73.5±9.9）mm Hg,（87.2±10.2）mm Hg比（70.9＋8.6）am Hg,HR：T、F、P组麻醉诱导前后分别为（78.8±11.6）次/min比（68.7＋8.5）次/min,（74.8±10.3）次/min比（64.1±6.7）次/min,（76.7±8.2）次/min比（67.3±8.3）次/min,1 mm Hg=0.133 kPa,P〈0.05],而置管前后的BIS值则无变化（P〉0.05）.瑞芬太尼抑制3组置管心血管反应的半数有效浓度依次为T组4.47 μg/L、F组4.78 μg/L、P组2.05 μg/L.结论 Minto模式靶控测得瑞芬太尼抑制3种置管心血管反应的EC50 LMA-Fastrach置管略高于气管插管,LMA-Proseal置管则最低.     

舒芬太尼引起老年腰麻患者呼吸抑制的半数血浆靶浓度

目的 测定蛛网膜下腔阻滞后老年患者靶控输注(target controlled infusion,TCI)舒芬太尼引起呼吸抑制的半数血浆靶浓度(EC_50).方法 选择择期行下肢或会阴部手术的老年患者30例,ASA Ⅰ～Ⅱ级.患者在左侧卧位下行L_(2-3)穿刺腰硬联合麻醉,腰穿针25G,腰麻药液为0.5%罗哌卡因2.0 mL(10～15 s内注射完毕),感觉阻滞平面固定T_10后,接PCA-TCI程序控制系统靶控输注舒芬太尼.根据预实验结果,本项研究采用Dixon's上下序贯法,第1例患者舒芬太尼血浆靶浓度设置为0.15μg/L,相邻靶浓度之间对数等差0.025,出现5个阴性和阳性变化拐点后中止.术中采用GE-Dash3000监护,监测平均动脉压(MAP)、心电图、脉搏血氧饱和度,采用Datex Utima监测仪连续动态监测患者呼吸功能的变化.观察记录PCA-TCI启动前(T_0),启动后各时点MAP、心率(HR)和每次呼吸的潮气量、分钟通气量、呼吸频率、呼气末二氧化碳分压及其波形、第1秒呼气率(FEV_1%)、吸入呼出氧浓度差(O_(2I-E))、顺应性环(PV环)、脉搏血氧饱和度(SpO_2).结果 根据设定标准,上下序贯法于第19位患者阴性阳性变化拐点,测出舒芬太尼TCI引起呼吸抑制的半数血浆靶浓度为0.16μg/L,95%可信区间是0.155～0.165μg/L.验证中,10例患者在30～40 min时呼吸频率(RR)与T_0相比降低20.1%～23.4%(P<0.05),在35～40 min时FEV_1%与T_0相比降低最为明显,为12.9%～15.7%(P>0.05),35～40 min时P_ET CO_2与T_0相比升高16.5%～23.9%(P<0.05).其他各时间点各呼吸参数与T_0相比差异无统计学意义(P>0.05).1例因低血压纠正后有咳嗽反应退出研究.结论 行下肢或会阴部手术的老年患者蛛网膜下腔阻滞感觉阻滞平面在T10时,靶控输注舒芬太尼引起呼吸抑制的半数血浆靶浓度为0.16μg/L,95%可信区间为0.155～0.165μg/L.     

咪唑安定硬膜外注射时患者血流动力学及通气功能变化

咪唑安定（ＭＩＤ）硬膜外注射的节段性镇痛效应及其对患者血流动力学（ＭＡＰ、ＨＲ、ＳＩ、ＣＩ、ＴＦＩ、ＶＥＴ、ＥＶＩ、ＳＶＲＩ、ＩＣ、ＰＥＩ、ＬＶＷＩ、ＲＰＰ）与通气功能（ＶＴ、ＲＲ、ＶＥ、ＦＥＶ１、Ｉ－ＥｔＯ２、ＰＥＴＣＯ２、ＳｐＯ２）的影响。４４例患者随机分成四组：Ｅ１组硬外注ＭＩＤ０．０５ｍｇ／ｋｇ，Ｅ２组硬外注ＭＩＤ０．１ｍｇ／ｋｇ，Ｖ１、Ｖ２组为静脉组，剂量与Ｅ１、Ｅ２组相同。结果：（１）     

慢性神经痛大鼠脊髓背角星形胶质细胞缝隙连接蛋白43表达的变化

目的 研究慢性神经痛大鼠脊髓背角星形胶质细胞缝隙连接蛋白43(Cx43)表达的变化。方法 20只SD大鼠随机分为两组,神经痛模型(CCI)组:结扎右侧坐骨神经,假手术(Sham)组:未结扎坐骨神经,每组10只。分别于手术前1 d、术后1、3、5、7、14 d(分别记为T0、T1、T2、T5、T7、T14)观察大鼠疼痛行为学变化,测定右后肢热刺激回缩潜伏期(PWTL)、电刺激回缩阈值(PWET),并于T14取L4-5脊髓,采用免疫组化法分析Cx43和胶质原纤维酸性蛋白(GFAP)表达的变化。结果 与T0比较,CCI组T1-14PWTL缩短、PWET降低(P<0.01),Sham组T1-5PWTL缩短、PWET降低(P<0.01),T7后恢复至术前水平(P>0.05)。CCI组右侧脊髓背角GFAP、Cx43染色均强于Sham组,且主要集中在Ⅰ-Ⅱ层。CCI组右侧脊髓GFAP、Cx43阳性染色面积均大于Sham组(P<0.01),CCI组、Sham组GRAP阳性染色面积分别占(29±7)％、(19±5)％、Cx43阳性染色面积分别占(17±3)％、(4±1)％。两组左侧脊髓GFAP与Cx43染色差异无显著性。结论 慢性神经痛大鼠脊髓背角星形胶质细胞Cx43与GFAP增加,提示星形胶质细胞缝隙连接可能在神经痛的形成和维持中起重要作用。     

舒芬太尼对剖宫产患者罗哌卡因蛛网膜下腔阻滞量效关系的影响

目的 探讨舒芬太尼对剖宫产患者罗哌卡因蛛网膜下腔阻滞效果的影响及罗哌卡因的量效关系.方法 择期行剖宫产的单胎和妊娠足月初产妇60例,ASA Ⅰ～Ⅱ级,随机分为3组(n=20):1%罗哌卡因15 mg复合5 μg舒芬太尼(SR1组);1%罗哌卡因13 mg复合5μg舒芬太尼(SR2组);1%罗哌卡因10 mg复合5μg舒芬太尼(SR3组),均用生理盐水稀释至3 mL.L_(3-4)蛛网膜下腔穿刺成功后,将混合液注入蛛网膜下腔.记录3组的感觉、运动阻滞情况、术中麻醉效果、硬膜外用药量、麻醉后不良反应发生情况、血压和心率的变化、胎心变化情况、新生儿出生后1、5 min时Apgar评分、脐动脉pH值和碱剩余(BE)值、术后不良反应与处理,用概率单位回归方法建立罗哌卡因的量效关系直线方程,计算ED_50(50%可信区间)及ED_(95)(95%可信区间).结果 SR3组麻醉效果分级低于其他两组(P<0.05).3组的最高阻滞平面、达到最高平面的时间及达到Bromage 3级时间差异无显著性(P>0.05),而SB3组麻醉平面消退至T_(12)的时间及Bromage分级恢复至0级的时间均短于SR1、SR2组(P<0.01).SR3有12例(60%)Bromage分级达到3级,低于其他两组(P<0.05).罗哌卡因的量效关系直线方程为:Y=-3.117+8.04610gX,决定系数(r~2)为0.997.ED_(50)和ED_(95)分别为8.3～11.6 mg、14.5～18.3 mg.3组在麻醉后不良反应发生率、麻黄素和阿托品使用率、新生儿出生后1、5 min时Apgar评分及脐动脉pH值和BE值差异无显著性(P>0.05).术后随访未发现有任何神经并发症.结论 罗哌卡因复合舒芬太尼蛛网膜下腔阻滞可以安全用于剖宫产麻醉,罗哌卡因的ED_(50)及ED_(95)分别为8.3～11.6 mg和14.5～18.3 mg.     

子宫切除术后舒芬太尼病人自控-靶控镇痛的安全性和有效性

Objective To investigate the efficacy and safety of patient-controlled analgesia (PCA) with target controlled infusion (TCI) of sufentanil after abdominal total hysterectomy. Methods Sixty ASA I or II patients aged 20-59 yr weighing 45-75 kg undergoing elective abdominal total hysterectomy were randomly allocated into 3 groups of 20 patients each. The initial target plasma concentration (CP ) of sufentanil was set at 0.08 μg/L in group I and II and at 0.1 μg/L in group Ⅲ . The operation was performed under combined spinal-epidural anesthesia with 0.75% bupivacaine (for spinal) and 2% lidocaine (for epidural). The epidural catheter was removed after operation. TCI of sufentanil was started after operation when the patients felt no pain (VAS = 0) in group I and when VAS ≥ 2 in group Ⅱ and Ⅲ . The lockout interval was set at 6 min. If the patients pressed the button once, the target CP increased by 0.005 μg/L. If the button was pressed 3 times successively within 20 s, the target CP increased by 0.008 μg/L. If the button was not pressed for 80 min, the target CP decreased by 0 .005 μg/L automatically. VAS scores, BIS values, MAP, HR, SpO2 and RR were recorded immediately before (T0) and at 1, 2, 4, 8, 16, 24 h (T1-6) after TCI was started. The number of attempts (D1) and successfully delivered doses (D2) was recorded. The total amount of sufentanil administered and side effects were recorded during the 24 h after operation. Results The analgesia was satisfactory in all 3 groups. The VAS scores were < 3 and significantly higher in group Ⅱ and Ⅲ than in group I . The total amount of sufentanil administered during the 24 h after operation was significantly larger in group II and HI than in group I . The D1 and D2 were significantly larger during the 0-2 h after operation in group Ⅱ and Ⅲ than in group I .Tachycardia, bradycardia, respiratory depression, hypotension and over-sedation were not observed. Conclusion PCA with TCI of sufentanil is effective and safe for postoperative analgesia. It is better to start PCA-TCI before the patient feels pain after operation with the initial target CP set at 0.08 μg/L.     

一种新型的术后镇痛方法——自控靶控镇痛新技术

自控-靶控镇痛（PCA—TCI）是一种新型的术后镇痛方法，该方法是将患者自控镇痛（PCA）和靶控输注技术（TCI）结合起来的创新技术，PCA—TCI能使患者体内镇痛药物迅速达到设定的血药浓度，患者可通过PCA对血药浓度自如调控，最大限度地符合按需法则和给药个体化规律。本文主要介绍这种新型的术后镇痛技术，并对舒芬太尼PCA-TCI静脉镇痛研究进展进行综述。     

硬膜外注入不同浓度利多卡因对全麻病人异丙酚及异氟醚用量的影响

目的 观察在相同麻醉深度下,硬膜外注入不同浓度利多卡因对全麻病人异丙酚及异氟醚用量的影响。方法 45例择期上腹部手术病人,根据复合硬膜外用药的不同随机分为三组:生理盐水对照组(Ⅰ组)、1％利多卡因组(Ⅱ组)、2％利多卡因组(Ⅲ组),每组15例。硬膜外阻滞平面确定后麻醉诱导以25 mg/min异丙酚连续输注至病人神志消失;麻醉维持吸入异氟醚使脑电双频谱指数(BIS)值维持在50-55,硬膜外以7 ml/h泵注维持。记录异丙酚用量、异氟醚呼气末浓度(ETiso)及BIS、听觉诱发电位指数(AAI)。结果 病人意识消失时异丙酚用量:Ⅰ组(1.7±0.4)mg/kg、Ⅱ组(1.2±O.3)mg/kg和Ⅲ组(1.0±0.3)mg/kg,Ⅲ组和Ⅱ组异丙酚用量比Ⅰ组明显减少(P<0.01)。ETiso分别为Ⅰ组(0.85±0.10)％,Ⅱ组(0.65±0.06)％,Ⅲ组(0.57±0.12)％,Ⅱ组、Ⅲ组比Ⅰ组和Ⅲ组比Ⅱ组明显降低(P<0.01或0.05)。结论 维持相同的麻醉深度下,硬膜外注入1％利多卡因组比2％利多卡因组既能减少全麻药的用量,又能保持循环的相对稳定。     

子宫切除术后舒芬太尼病人自控-靶控镇痛的安全性和有效性

Objective To investigate the efficacy and safety of patient-controlled analgesia (PCA) with target controlled infusion (TCI) of sufentanil after abdominal total hysterectomy. Methods Sixty ASA I or II patients aged 20-59 yr weighing 45-75 kg undergoing elective abdominal total hysterectomy were randomly allocated into 3 groups of 20 patients each. The initial target plasma concentration (CP ) of sufentanil was set at 0.08 μg/L in group I and II and at 0.1 μg/L in group Ⅲ . The operation was performed under combined spinal-epidural anesthesia with 0.75% bupivacaine (for spinal) and 2% lidocaine (for epidural). The epidural catheter was removed after operation. TCI of sufentanil was started after operation when the patients felt no pain (VAS = 0) in group I and when VAS ≥ 2 in group Ⅱ and Ⅲ . The lockout interval was set at 6 min. If the patients pressed the button once, the target CP increased by 0.005 μg/L. If the button was pressed 3 times successively within 20 s, the target CP increased by 0.008 μg/L. If the button was not pressed for 80 min, the target CP decreased by 0 .005 μg/L automatically. VAS scores, BIS values, MAP, HR, SpO2 and RR were recorded immediately before (T0) and at 1, 2, 4, 8, 16, 24 h (T1-6) after TCI was started. The number of attempts (D1) and successfully delivered doses (D2) was recorded. The total amount of sufentanil administered and side effects were recorded during the 24 h after operation. Results The analgesia was satisfactory in all 3 groups. The VAS scores were < 3 and significantly higher in group Ⅱ and Ⅲ than in group I . The total amount of sufentanil administered during the 24 h after operation was significantly larger in group II and HI than in group I . The D1 and D2 were significantly larger during the 0-2 h after operation in group Ⅱ and Ⅲ than in group I .Tachycardia, bradycardia, respiratory depression, hypotension and over-sedation were not observed. Conclusion PCA with TCI of sufentanil is effective and safe for postoperative analgesia. It is better to start PCA-TCI before the patient feels pain after operation with the initial target CP set at 0.08 μg/L.