Low-dose sufentanil and lidocaine supplementation of general anaesthesia

This randomized double-blind study compared the effects of: (1) saline infusion (C); (2) sufentanil alone (1.0 micrograms.kg-1) (S); and (3) low-dose sufentanil (0.5 micrograms.kg-1) in combination with lidocaine (1.5 mg.kg-1) (LS): on the cardiovascular responses to tracheal intubation and on postoperative ventilation as monitored by respiratory inductive plethysmography in day-care surgical procedures of approximately 60 min duration. Thirty healthy, unpremedicated patients were studied. Thiopentone requirements were reduced by 40 and 28 per cent in the S and LS groups respectively compared with control (P less than 0.001). Both treatments suppressed HR and BP responses (P less than 0.005) to intubation. Postoperatively, PaCO2 was elevated (P less than 0.05) in group S. Dose-related respiratory depression was observed. The incidence of postoperative apnoea was significantly higher in both S and LS groups than compared with control (P less than 0.05). However, only patients in group S showed higher apnoea index and mean apnoea duration over the initial 10-20 min after surgery compared with control (P less than 0.005). In addition, group S showed slower respiratory frequency and prolonged expiratory time (P less than 0.005). In conclusion, an induction dose of sufentanil (1 microgram.kg-1) used in balanced anaesthesia of less than 70 min duration was associated with significant respiratory depression, particularly during the initial 10-20 min after surgery, whereas low-dose sufentanil (0.5 micrograms.kg-1) with lidocaine (1.5 mg.kg-1) had minimal postoperative respiratory depression and comparable attenuation of pressor responses to intubation.     

全麻诱导前预注芬太尼“先发镇痛”效应临床研究

目的：探讨全麻预注芬太尼的先发镇痛效应。／方法：选择40例择期全麻病人,随机分成试验组与对照组（n=20例）,术前常规用药,试验组诱导前用芬太尼5ug/kg,对照组将芬太尼改切皮后静注,术中麻醉维持相同,手术结束后病人自然清醒。术后有镇痛药使用意愿者均使用哌替啶镇痛。结果：两组病人一般情况及芬太尼总用量无显著性差异（P＞0．05）,试验组初次使用镇痛药时间明显延长（P＜0．01）,用药次数及剂量也显著少于对照组（P＜0．01）,试验组术后仅7（35％）例使用派替啶,而对照组使用哌替啶者达15（75％）例,两组差异性显著（P＜0．05）,结论：全麻前预注芬太尼具有良好的先发镇痛效应。     

连续硬膜外复合全麻下老年人胸腔手术时脑电功率谱的变化

目的 探讨老年人连续硬膜外复合全麻下胞腔手术时数量化脑电图与麻醉深度的关系。方法 ３０例老年人胸腔手术,均为连续硬膜外复合静吸全麻,根据吸入异氟醚浓度不同分为肺泡气最低有效浓度（ＭＡＣ）０．６（Ⅰ组）和ＭＡＣ１．０（Ⅱ组）两组,观察术前、诱导前、插管后、切皮进胸探查、进胞后３０,６０ｍｉｎ以及术毕时循环和脑电图边缘频率（ＳＥＦ）、中位频率（ＭＦ）、比率（δＲ）和双频谱指数（ＢＩＳ）的变化。结果 Ⅰ     

硬膜外阻滞复合全身麻醉用于慢性阻塞性肺病病人的临床效果

目的比较硬膜外阻滞复合全身麻醉或单纯全身麻醉对上腹部和胸腔内手术病人术后肺功能和肺部并发症的影响。方法24名伴有中度术后肺部并发症危险的慢阻肺病人,接受上腹部或胸腔内手术,随机分成单纯全身麻醉(GA组)和硬膜外阻滞复合全身麻醉(Epi-Ga组)两组。术后采用VRS法评定镇痛效果。根据临床症状和体征、X线胸片、血气分析和床旁肺功能测定评估是否发生肺部并发症。术前1d和术后3d内评估和记录上述指标。结果术毕,GA组病人平均(34±16)min苏醒,(67±22)min拔除气管导管;Epi-Ga组苏醒时间和拔管时间分别为(12±4)和(32±12)min。术后第1天和第2天,Epi-Ga组病人术后镇痛效果明显优于GA组(P<0.01)。术后第1天,Epi-Ga组病人的FVC、FEV1/FVC%和FEF25%-75%下降不如GA组显著(P<0.05)。GA组有4例需要纤维支气管镜协助吸痰,而Epi-Ga组则无一例需要。两组病人术后肺炎、肺不张、支气管痉挛和呼吸衰竭的发生率无显著差异。结论局麻药加阿片类药物硬膜外自控镇痛使病人术后更加舒适,且能够改善病人术后肺功能。尽管两组病人术后肺部并发症无明显差异,但硬膜外阻滞复合全身麻醉以及术后硬膜外自控镇痛确实能够方便慢阻肺病人的术后管理。     

Factors Influencing the Growth in Knowledge of Trainees in General Practice

Objectives: The relation between the content of postgraduate training for general practice and the outcome in terms of the growth in knowledge of trainees was investigated. The training variables included were: (1) the number of patients seen per day, (2) the trainer, (3) the practice and (4) the theoretical curriculum.Methods: Subjects were 58 trainee-trainer pairs. Growth in knowledge was assessed by two written tests administered with eight months interval. Training variables were evaluated by means of questionnaires and logbook-registration. The correlation was explored between each of the training variables and the knowledge tests scores. To correct for interactional effects, a step-wise multiple regression analysis was performed with the second test as dependent variable and the first test as well as the training variables as independent variables.Results: Significant growth in knowledge was demonstrated. Non of all training variables investigated explained the variance in scores on the second test equally good or better than the scores on the entry test.Conclusions: The impact of the separate training-components on the growth in knowledge, remains unclear. We may speculate, that the sort of knowledge assessed with the written literature based true/false test is different from the sort of knowledge transferred during every day training: evidence based knowledge versus experience based knowledge. Equally valid is the conclusion that these findings fit into the theory that in adult learning the outcome is more learner than teacher dependent.This revised version was published online in September 2005 with corrections to the Cover Date.     

Anaesthesia and the Sturge-Weber syndrome

We report a series of 13 patients with Sturge-Weber syndrome anaesthetised on 17 occasions. Anaesthesia management varied depending on the clinical manifestations which ranged from localized, superficial skin lesions to extensive systemic involvement. These patients tolerate anaesthesia well but anaesthetic management includes evaluation for associated anomalies. Difficulty with intubation may occur due to angiomas of the mouth and upper airway. Anaesthesia should be planned to avoid trauma to the haemangiomata and increases in intraocular and intracranial pressure. Nous rapportons une série d’observations concernant des porteurs du syndrome de Sturge-Weber anesthésiés à 17 occasions. L’anesthésie a varié selon les manifestations cliniques qui allaient de la lésion superficielle localisée à l’atteinte systémique grave. Ces patients tolèrent bien l’anesthésie mais celle-ci nécessite une recherche des anomalies associées pour fin d’évaluation. La présence d’angiomes de la bouche et des voies respiratoires supérieures peut rendre l’intubation difficile. La planification de l’anesthésie doit inclure la prévention du traumatisme aux hémangiomes et de l’augmentation de la tension intraoculaire et cérébrale.     

The emergency medicine training needs of rural general practitioners

This study aimed to identify the emergency medicine training needs of rural general practitioners (GPs) in the catchment area of the Hunter Rural Division of General Practice. The GPs were surveyed using a questionnaire in which they were asked about their confidence levels in a number of specific emergency medicine skills, and about the areas of emergency medicine that they saw as priorities for upskilling. More than a third of GPs who were responsible for on-call work at the hospital indicated that they had low levels of confidence in a number of their emergency medicine skills, in particular skills relating to paediatric emergencies, cardiovascular emergencies, and respiratory emergencies. These emergency medicine domains were also seen as high priorities for upskilling by the majority of the respondents. The study shows that rural doctors need the opportunity to access emergency medicine training that provides upskilling not only in the management of clinical problems, but also in practical procedures.     

Positive end-expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration

BACKGROUND: General anaesthesia impairs the gas exchange in the lungs, and moderate desaturation (SaO2 86-90%) occurred in 50% of anaesthetised patients in a blinded pulse oximetry study. A high FiO2 might reduce the risk of hypoxaemia, but can also promote atelectasis. We hypothesised that a moderate positive end-expiratory pressure (PEEP) level of 10 cmH2O can prevent atelectasis during ventilation with an FiO2 = 1.0. METHODS: Atelectasis was evaluated by computed tomography (CT) in 13 ASA I-II patients undergoing elective surgery. CT scans were obtained before and 15 min after induction of anaesthesia. Then, recruitment of collapsed lung tissue was performed as a "vital capacity manoeuvre" (VCM, inspiration with Paw = 40 cmH2O for 15 s), and a CT scan was obtained at the end of the VCM. Thereafter, PEEP = 0 cmH2O was applied in group 1, and PEEP = 10 cmH2O in group 2. Additional CT scans were obtained after the VCM. Oxygenation was measured before and after the VCM. RESULTS: Atelectasis (> 1 cm2) was present in 12 of the 13 patients after induction of anaesthesia. At 5 and 10 min after the VCM, atelectasis was significantly smaller in group 2 than group 1 (P < 0.005). A significant inverse correlation was found between PaO2 and atelectasis. CONCLUSIONS: PEEP = 10 cmH2O reduced atelectasis formation after a VCM, when FiO2 = 1.0 was used. Thus, a VCM followed by PEEP = 10 cmH2O should be considered when patients are ventilated with a high FiO2 and gas exchange is impaired.     

Total purchasing, community and continuing care: lessons for future policy developments in the NHS

The introduction of total purchasing pilots (TPPs) into the National Health Service (NHS) gave general practitioners (GPs) significant new opportunities to take responsibility for the development of community and continuing care (CCC) services. Based on five case studies of TPPs involved in developing CCC this paper asks three questions: (1) to what extent were the TPP’s involvement in CCC informed by an awareness of CCC policy?; (2) were TPPs involved in joint commissioning to develop integrated purchasing or provision which was informed by population based needs assessment?; (3) were TPPs seeking to involve users, carers and voluntary agencies in their plans? The findings indicate that TPPs showed little awareness of national or local policy for CCC, although their project initiatives did address some of the policy issues (in particular a recognition of the need for joint working at the practice level). At the time of fieldwork, four of the case study TPPs had begun to investigate the potential for integrated purchasing, and three of them had relatively sophisticated models of both horizontally and vertically integrated provision of care. However, the TPPs developments were not based on systematic population based needs assessment. The paper concludes that there is potential for the primary care led groups proposed in the recent white papers in England, Scotland and Wales to improve integration of care both horizontally and vertically. However, they may need policy guidance and push to: encourage them to put CCC high on their agenda for action; to work with people with expertise in population based, prevention focused, needs assessment; and to find innovative ways to include users, carers and voluntary agencies. Incentives or levers (such as control over budgets) may be needed to promote joint working between staff in different agencies.     

试析大型综合医院在社区医疗服务中的作用

根据国家城市卫生服务体系改革的原则及对基层医院和大医院的功能定位,分析大型综合医院在社区医疗服务中的作用。指出大型综合医院应加强与城市基层医院的联系,建立全科医生培训基地,为社区医疗服务输送适用人才,建立切实可行的转诊制度,成为社区医疗服务的坚强后盾,提高社区医疗服务的质量和水平,促进社区医疗服务的发展。