国产舒芬太尼用于术后静脉自控镇痛的疗效和安全性——多中心、随机、双盲、平行对照临床研究

Objective To evaluate efficacy and safety of sulfentanyl (China) for PICA in surgical patients with general anes-thesia in a multiple-center, randomized, double-blind, parallel study. Methods 200 ASA grade Ⅰ -Ⅱ patients aged 18-55 undergo-ing surgery with general aneathesia enrolled from 3 hospitals were randomly and double-blindly divided into 2 groups: sulfentanyl (China, n=100) versus sulfentanyl(German, n=100). Sulfentanyl(China 0.1 μg/kg or German)was given before the end of surgery. VAS scores less than 3 after patient awake and PCA started after extubation(200 μg sulfentanyl was diluted with 50 ml saline solution, background dose 0.5 ml/h,bolus of 0.5 ml with lockout interval 15 min, continuous infusion 48 h). Vital signs including BP, HR, PR, SpO2 and side effects such as nausea, vomiting, urine retention, pruritus, breath depression, etc. And VAS scores with patients in quiet and cough were recorded at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. The total number of PCA, the total effective number of PCA, and the ratio of both and other analgesics as well as the satisfactory degree of patients and the cumulative suffen-tanyl consumption were recorded at 24 h. Results There were no significant difference of BP, HR, PR, SpO2 and the adverse effect and VAS scores in quiet and cough between two groups at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. There were no signifi-cant difference of the total number of PCA, the total effective number of PCA and other analgesics as well as the satisfactory degree of patients and the total dosage of sulfentanyl at 24 h. Conclusion The sulfentanyl (China) had satisfactory effects of postoperative analgesia and had no significant side effects compared with sulfentanyl (German). The efficacy and the side effects of both drugs had no significant difference.     

丙泊酚/异氟醚麻醉对大鼠获取空间记忆能力的损害及c-Fos和EGR-1蛋白的变化

目的 通过研究丙泊酚和异氟醚麻醉对青、老年大鼠Morris水迷宫训练成绩及海马CA1区脑神经元FOS核蛋白(c-Fos)和EGR-1核蛋白表达的变化,探讨麻醉后脑神经元分子水平变化与行为学表现的相关性.方法 雄件SD大鼠3月龄(青年组)和20月龄(老年组)各60只,随机分为对照组(不麻醉)、训练组(不麻醉,行Morris水迷宫训练)、丙泊酚组(丙泊酚100 mg·kg-1·h-1,ip;分别于麻醉2 h/4 h后的2 d/2周行Morris水迷宫训练:P2d,P4d,P2W,P4W)、异氟醚组(异氟醚1.2%;分别于麻醉2 h/4 h后的2 d/2周行Morris水迷宫训练:I2d,I4d,I2W,I4W).Morris水迷宫实验连续进行5 d,每天2次,记录逃避潜伏期变化,用以测试各组大鼠的空间学习记忆能力.行为学实验后立即分离海马组织CA1区,应用免疫组化法和酶标法半定量检测c-Fos和EGR-1核蛋白的阳性表达.结果 4 h异氟醚麻醉后,大鼠的认知功能损害均可持续至麻醉后2周,尤以老年大鼠常见且程度严重,表现为学习速度和记忆质量均有所下降(P<0.05),青年组大鼠学习速度略有下降(P<0.05);4 h丙泊酚麻醉后,老年组大鼠认知功能改变可持续至麻醉后2周,但与异氟醚麻醉相比程度较轻,主要表现为学习速度减慢(P<0.05).免疫组化法和酶标法检测结果:与对照组相比,Morris水迷宫训练后,大鼠海马CA1区c-Fos和EGR-1的表达均明显增加(P<0.05);I4d,I4W组老年大鼠和P4d组青年大鼠c-Fos阳性细胞率与单纯训练组大鼠相比有所下降(P<0.05);I4d组老年大鼠EGR-1阳性细胞率与单纯训练组大鼠相比有所下降(P<0.05).结论 麻醉可能会引起大鼠行为学改变,可持续至麻醉后2 d至2周;随着麻醉时程的延长和年龄的增加,改变更为明显,且异氟醚作用较丙泊酚显著.麻醉对大鼠海马CA1区c-Fos和EGR-1表达的影响可能是导致大鼠行为学改变的机制.     

A型肉毒毒素治疗梨状肌综合征的临床观察

目的探讨使用A型肉毒毒素治疗梨状肌综合征的临床效果。方法25例保守治疗无效的梨状肌综合征患者随机分为两组。A组患者13例，梨状肌内注射0．25％布比卡因3ml加5mg曲安奈德，B组12例，梨状肌内注射0．25％佰比卡因3ml加5mg曲安奈德和100U的A型肉毒毒素。记录两组患者注射治疗前、治疗后2周、1、2和3月的VAS以及不良反应。结果A组治疗后各时点的VAS明显低于治疗前（P〈0．05），治疗后3月的VAS高于治疗后2周、1和2月（P〈0．05）。B组治疗后各时点的VAS明显低于治疗前（P〈o．05），治疗后1、2和3月的VAS明显低于治疗后2周（P〈0．05）。治疗后1、2和3月的VASB组均显著低于A组（P〈0．05）。B组中有2例患者在注射治疗后1周患侧下肢表现为轻微软弱无力，2周后逐步缓解。结论梨状肌内联合注射A型肉毒毒素、皮质激素和局麻药是较好的治疗梨状肌综合征的疗法，具有疗效佳、维持时间长、不良反应少等优点。     

国产舒芬太尼用于术后静脉自控镇痛的疗效和安全性——多中心、随机、双盲、平行对照临床研究

Objective To evaluate efficacy and safety of sulfentanyl (China) for PICA in surgical patients with general anes-thesia in a multiple-center, randomized, double-blind, parallel study. Methods 200 ASA grade Ⅰ -Ⅱ patients aged 18-55 undergo-ing surgery with general aneathesia enrolled from 3 hospitals were randomly and double-blindly divided into 2 groups: sulfentanyl (China, n=100) versus sulfentanyl(German, n=100). Sulfentanyl(China 0.1 μg/kg or German)was given before the end of surgery. VAS scores less than 3 after patient awake and PCA started after extubation(200 μg sulfentanyl was diluted with 50 ml saline solution, background dose 0.5 ml/h,bolus of 0.5 ml with lockout interval 15 min, continuous infusion 48 h). Vital signs including BP, HR, PR, SpO2 and side effects such as nausea, vomiting, urine retention, pruritus, breath depression, etc. And VAS scores with patients in quiet and cough were recorded at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. The total number of PCA, the total effective number of PCA, and the ratio of both and other analgesics as well as the satisfactory degree of patients and the cumulative suffen-tanyl consumption were recorded at 24 h. Results There were no significant difference of BP, HR, PR, SpO2 and the adverse effect and VAS scores in quiet and cough between two groups at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. There were no signifi-cant difference of the total number of PCA, the total effective number of PCA and other analgesics as well as the satisfactory degree of patients and the total dosage of sulfentanyl at 24 h. Conclusion The sulfentanyl (China) had satisfactory effects of postoperative analgesia and had no significant side effects compared with sulfentanyl (German). The efficacy and the side effects of both drugs had no significant difference.     

肝移植手术后肺部感染的危险因素分析

目的 探讨肝移植手术患者术后肺部感染的危险因素。
方法 回顾性分析2005年6月至2013年6月于三家临床医疗中心首次行原位肝移植手术的1 358例患者的临床资料。根据患者术后30 d内是否发生肺部感染将患者分成两组：感染组和非感染组。收集术前资料、术中资料及术后资料，采用单因素分析及二元Logistic回归分析肝移植术后肺部感染的危险因素。
结果 肝移植手术后有316例（23.3%）发生肺部感染，其中有21例（6.7%）死亡。与非感染组比较，感染组术前诊断为慢性重型肝炎、肝癌、丙型肝炎肝硬化、先天性肝脏疾病及肝衰竭、术前合并肝肾综合征、肝昏迷、糖尿病的比例、术前肌酐浓度明显升高（P<0.05），术前总蛋白、白蛋白浓度明显降低（P<0.05），无肝期时间、术后苏醒时间及术后拔管时间明显延长（P<0.05），术中失血量明显增加（P<0.05），术中尿量明显减少（P<0.05），术中使用去氧肾上腺素、阿托品、利多卡因及呋塞米的比例明显降低（P<0.05），术后死亡率明显升高（P<0.05）。二元Logistic回归分析显示：慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植患者术后肺部感染的危险因素；手术方式（经典非转流原位肝移植）、术中使用利多卡因、术前总蛋白>64.6 g/L、术中尿量>1 800 ml是肝移植手术患者术后肺部感染的保护因素。
结论 术前诊断慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植手术后肺部感染的危险因素。     

国产舒芬太尼用于术后静脉自控镇痛的疗效和安全性——多中心、随机、双盲、平行对照临床研究

Objective To evaluate efficacy and safety of sulfentanyl (China) for PICA in surgical patients with general anes-thesia in a multiple-center, randomized, double-blind, parallel study. Methods 200 ASA grade Ⅰ -Ⅱ patients aged 18-55 undergo-ing surgery with general aneathesia enrolled from 3 hospitals were randomly and double-blindly divided into 2 groups: sulfentanyl (China, n=100) versus sulfentanyl(German, n=100). Sulfentanyl(China 0.1 μg/kg or German)was given before the end of surgery. VAS scores less than 3 after patient awake and PCA started after extubation(200 μg sulfentanyl was diluted with 50 ml saline solution, background dose 0.5 ml/h,bolus of 0.5 ml with lockout interval 15 min, continuous infusion 48 h). Vital signs including BP, HR, PR, SpO2 and side effects such as nausea, vomiting, urine retention, pruritus, breath depression, etc. And VAS scores with patients in quiet and cough were recorded at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. The total number of PCA, the total effective number of PCA, and the ratio of both and other analgesics as well as the satisfactory degree of patients and the cumulative suffen-tanyl consumption were recorded at 24 h. Results There were no significant difference of BP, HR, PR, SpO2 and the adverse effect and VAS scores in quiet and cough between two groups at the beginning of infusion at 0, 1, 4, 12, 24, 48 h. There were no signifi-cant difference of the total number of PCA, the total effective number of PCA and other analgesics as well as the satisfactory degree of patients and the total dosage of sulfentanyl at 24 h. Conclusion The sulfentanyl (China) had satisfactory effects of postoperative analgesia and had no significant side effects compared with sulfentanyl (German). The efficacy and the side effects of both drugs had no significant difference.     

小剂量氯胺酮-丙泊酚复合静脉麻醉用于无痛胃镜检查的临床研究

目的 观察丙泊酚镇静中辅以小剂量氯胺酮是否有利于改善麻醉和镇痛效能并减少丙泊酚和氯胺酮的相关不良反应.方法 无痛胃镜检查患者100例,年龄28～65岁,ASA Ⅰ ～Ⅱ级.随机分为2组:P组,单纯静脉注射丙泊酚;PK组,给予丙泊酚复合小剂量氯胺酮(1％丙泊酚20 m加入氯胺酮50 mg配成约4:1的丙泊酚-氯胺酮混合液)静脉注射.P组单纯静脉推注丙泊酚,以1.5mg/kg开始,每次增加0.5 mg/kg.PK组首次剂量为氯胺酮0.25 mg/kg,此时丙泊酚量按比例约为1 mg/kg,每次增加氯胺酮0.05 mg/kg合并丙泊酚0.2 mg/kg.所有患者注射至睫毛反射消失、胃镜插入时无明显肢体活动等反应时开始内镜检查,此时的静脉药物使用量记录为有效剂量.检查中如有明显体动或吞咽反射则两组患者均追加丙泊酚0.5 mg/kg,记录丙泊酚总用量.术中观察患者血压、心率、脉搏血氧饱和度(SpO2)、呼吸频率,是否有注射痛;记录丙泊酚及氯胺酮有效剂量和丙泊酚总用量;记录有无托下颌、辅助通气,内镜置人时有无体动,意识恢复时间(最后给药至呼之能应的时间),正常行走时间(意识清醒至能正常行走的时间).记录患者术中做梦、清醒后头晕及主观舒适度情况.结果 两组患者的年龄、体重、性别比例差异均无统计学意义,P组患者麻醉诱导后血压、心率较麻醉诱导前降低,但差异无统计学意义.P组注射痛(80％ vs.30％)、术中托下颌(30％vs.4％)及体动发生率(48％ vs.26％)明显高于PK组(P均＜0.05),PK组有5例患者术后述头晕.P组丙泊酚有效剂量[(2.15±0.37) vs.(1.05±0.01)mg/kg,P＜ 0.01]和总用量[(2.38±0.32) vs.(1.15±0.21)mg/kg,P＜0.05]显著高于PK组,两组患者术后恢复情况差异无统计学意义.所有患者均顺利完成内镜检查,患者满意度为100％.结论 在无痛胃镜检查中,单独应用丙泊酚或丙泊酚合用小剂量氯胺酮均可满足操作需要,但丙泊酚1 mg/kg合用氯胺酮0.25 mg/kg是更为安全可靠的方案.     

麻醉系实习生的教学和培养-PBL教学

临床麻醉学的教学任务,不仅要求学生逐步掌握专业基本操作技能,更需要培养学生的麻醉专业临床思维能力和综合能力。文章阐述了医学生实习阶段要进行各方面基础知识的联系、整合,完成由"知"向"行"的升级的特点。提出"基于问题的教学"(PBL)法强调发扬学生自主学习,在培养临床思维等方面有十分明显的优势,非常契合麻醉实习教学的要求。     

骨科患者术后认知功能障碍相关危险因素的研究进展

术后认知功能障碍(postoperative cognitive dysfunction,POCD)可导致患者手术后并发症增多、康复延迟、住院天数延长和医疗费用增加,并可严重影响患者术后的康复和远期生活质量.有的甚至可能持续数年,最终发展为老年痴呆和阿尔茨海默病[1].发生POCD的骨科手术患者,在早期,躁狂型POCD患者不配合治疗,不恰当的肢体活动会造成骨折移位或关节脱位;而抑郁型POCD患者对外界刺激反应性降低,易并发坠积性肺炎、褥疮、下肢深静脉血栓等并发症;在晚期,POCD则会降低患者的手术疗效,增加术后死亡率.并且骨科手术相对其他非心脏手术具有更多的POCD高危因素,POCD发病率更高.现对骨科POCD相关危险因素综述如下.     

三甘氨酰基赖氨酸加压素对肝移植术病人围术期肾功能的影响

Objective To evaluate the effects of teriipressin on perioperative renal function in patients undergoing liver transplantation. Methods Forty ASA Ⅲ or Ⅳ patients (31 males and 9 females) aged 35-55 yr and weighing 46-81 kg were randomly divided into 2 groups (n=20 each): terlipressin group and control group. The patients were premedicated with intramuscular midazolam 2- 3 mg and atropine 0.5 mg. Swan-ganz catheter was placed via the right internal jugular vein and the radial artery was cannulated. Electrocardiography (ECG), blood pressure (BP), heart rate (HR), central venous pressure (CVP) and pulmonary artery pressure (PAP) were monitored during general anesthesia. General anesthesia was induced with midazolam (0.1-0.2 mg/kg), fentanyl (5-10 μg/kg), propofol(1-2 mg/kg) and vecuronium (0.1 mg/kg) and maintained with 0.5%-1.5% isoflurane, propofol infusion at 2-5 mg·kg-1·h-1 and intermittent i.v. boluses of fentanyl and vecuronium. The patients were mechanically ventilated after tracheal intubation. In the terlipressin group, 2 mg of terlipressin was added to 50 ml of normal saline (NS) and was continuously infused at 10 ml/L from beginning of operation until the end of anhepatic phase, while in the control group, NS was infused only. Blood and urine samples were taken before operation(T0), at the end of anhepatic phase (T1), at the end of operation (T2), and on the 1st and 2nd day after operation (T3, T4)for determination of plasma angiotensin Ⅱ (AT- Ⅱ ), serum β2-microglobulin (MG), blood urea nitrogen (BUN) and creatinine (Cr) concentrations and N-acetyl-βd-glucosaminidase (NAG) concentrations in the urine. Urine output was measured during pre-anhepatic, anhepatic and neo-hepatic phase and on the 1 st and 2nd day after operation. Results The urinary NAG and serum β2-MG concentrations were significantly increased at T1 as compared with the baseline at T0 in both groups. The urinary NAG, plasma AT-Ⅱ, serum β2-MG, BUN and Cr concentrations were significantly lower and the urinary output was significantly higher during T2-4 in the terlipressin group than in the control group. Conclusion Terlipressin has protective effects on renal function in patients undergoing orthotopic liver transplantation.