静脉注射异丙酚在犬脑的摄取和分布

目的 研究静脉注射异丙酚在犬脑的摄取和分布.方法 健康雄性犬6只,12月龄,体重10～12 kg,经右后肢大隐静脉15 s内静脉注射异丙酚7 mg/kg,眼睑反射消失时断头,取颈内动脉和颈内静脉血各2 ml,取脑额叶、顶叶、颞叶、海马、扣带回、丘脑、中脑、桥脑和小脑组织,采用高效液相色谱法测定脑组织和血浆异丙酚水平.结果 颈内动脉和颈内静脉血浆异丙酚浓度分别为11.8±1.5、(5.5±0.7)μg/ml;脑组织异丙酚含量分别为:丘脑(10.4±1.8)μg/g,额叶(8.2±1.1)μg/g,顶叶(8.3±1.2)μg/g,颞叶(8.3±1.4)μg/g,扣带回(8.4±1.2)μg/g,中脑(9.4±1.2)μg/g,桥脑(9.3±1.4)μg/g,小脑(7.7±1.9)μg/g,海马(5.8±1.1)μg/g.脑组织异丙酚含量以丘脑最高,海马最低,颈内动脉血浆异丙酚浓度高于颈内静脉(P＜0.05).结论 静脉注射异丙酚后当犬眼睑反射消失时,其在脑组织的分布不一致,丘脑含量最高,海马最低.     

The effects of hypertonic saline solution (7.5%) on coagulation and fibrinolysis: an in vitro assessment using thromboelastography

We studied the effects of hypertonic (7.5%) and normal saline on coagulation and fibrinolysis in an in vitro model using thromboelastography of human whole blood. Reaction times increased and alpha angles decreased with hypertonic saline replacement at 7.5% blood volume compared with similar dilution with normal saline. At 10% blood volume replacement with hypertonic saline, reaction and coagulation times were significantly increased and alpha angles were decreased. Clot lysis at 30 min was also significantly reduced. We conclude that 7.5% hypertonic saline solution has anticoagulant effects if it replaces 7.5% or more of blood volume.     

Intravenous fluids warming by mattress is simple and efficient during pediatric surgery

BACKGROUND/AIM: Temperature control is essential during pediatric surgery. The effectiveness of two methods of warming intravenous (i.v.) fluids to preserve normothermia was compared during abdominal surgery. METHODS: Intraoperative core temperature (CT) was measured in 59 children, 8 years of age and younger. Patients were randomly allocated to two study groups according to the method of fluids warming. In Group M (n = 30), fluids were warmed by placing the i.v. tubing under a warming mattress, and in Group T (n = 29), by using an active i.v. fluid tube warming system. Observations of CT, infusion fluid temperature (IFT) at the entry to the patient and other relevant parameters were made at 30-min intervals throughout the surgical procedure. RESULTS: The two groups did not differ significantly by age, gender, body weight or length of surgical procedure. Although baseline IFT was significantly lower in Group M than in Group T (33.8 degrees C vs. 35.1 degrees C), it increased during the procedure by 1.2 degrees C in Group M compared to a 0.2 degrees C increase in Group T. Baseline CT was also lower by 0.5 degrees C in Group M compared to Group T (NS), but CT increased in Group M by 1.0 degrees C compared to 0.2 degrees C in Group T, resulting in similar final CTs. CONCLUSIONS: The increase in CT was more pronounced in patients where fluids were warmed under the warming mattress (Group M) than in those with fluids warmed by a coil warming device (Group T). The elevation in CT seen in Group M is associated with an increase in infusion fluid temperature at the line just before the i.v. cannula. Both methods of fluid warming (by placing the i.v. tubing under warming mattress and by using a fluid warming system) effectively preserved normothermia during abdominal surgery in children.     

不同刺激间隔对全麻患者经颅磁刺激运动诱发电位监测的影响

目的 评价不同刺激间隔对全麻患者经颅磁刺激运动诱发电位（TMS-MEP）监测的影响。方法 择期脊髓手术患者20例，ASAⅠ或Ⅱ级，静脉注射异丙酚2mg／kg、芬太尼2μg，kg、氯化琥珀胆碱2mg／kg麻醉诱导，气管插管后机械通气，持续输注异丙酚5mg·kg^-1·h^-1、芬太尼1μg·kg^-1·h^-1维持麻醉至试验结束。在麻醉前、后分别记录2、5、10ms（分别为500、200、100Hz）刺激间隔下4次刺激引出的复合肌肉动作电位（CMAP）的波幅和潜伏期。结果 麻醉前：与2ms相比，5ms刺激间隔下CMAP波幅差异无统计学意义（P〉0．05），与2In8和5In8相比，10ms刺激间隔下CMAP波幅减小（P〈0．05）；麻醉后：与2ms相比，5、10ms刺激间隔下CMAP波幅减小（P〈0．05），与5ms相比，10ms刺激间隔下CMAP波幅减小（P〈0．05）。麻醉前、后各刺激间隔下CMAP潜伏期差异无统计学意义（P〉0．05）。麻醉后5ms刺激间隔下2例患者未记录到CMAP，10ms刺激间隔下4例患者未记录到CMAP。结论 采用2ms刺激间隔下对全麻患者4次经颅磁刺激可在靶肌肉上记录到最大的CMAP波幅，更适用于全麻患者术中施行经颅磁刺激运动诱发电位监测，可有效对抗异丙酚静脉麻醉对运动诱发电位的抑制作用，增加运动诱发电位监测的准确性。     

Rapid sequence intubation without a neuromuscular blocking agent in a 14-year-old female patient with myasthenia gravis

The anesthesia care of a 14-year-old female patient with an acute exacerbation of myasthenia gravis (MG) and a full stomach who required emergency surgery for placement of a hemodialysis catheter is described. A nonventilated rapid sequence induction was successful with the use of propofol, lidocaine, remifentanil, cricoid pressure and no neuromuscular blocking agent. Although the use of combinations of i.v. anesthetic agents have been suggested for tracheal intubation without the need for neuromuscular blocking agents, none of these techniques has been advocated for rapid sequence intubation. We review existing literature on the topic of tracheal intubation using remifentanil and propofol without a neuromuscular blocking agent and on the topic of tracheal intubation of patients with MG using i.v. anesthesia and no neuromuscular blocking agents.     

不同脂肪乳剂预先给药对罗哌卡因致老龄大鼠心血管毒性的影响

目的 评价不同脂肪乳剂预先给药对罗哌卡因致老龄大鼠心血管毒性的影响.方法 健康雄性SD大鼠24只,月龄18月,体重400～550 g,随机分为3组(n=8):生理盐水组(NS组)、长链脂肪乳剂组(LLE组)和中/长链脂肪乳剂组(MLE组).腹腔注射氯胺酮100 mg/ks麻醉,监测ECG、BP和HR,气管插管后行机械通气,潮气量2 ml/100 g,通气频率60次/min.静脉注射维库溴铵0.5 mg维持肌松.NS组、LLE组和MLE组分别经颈静脉输注0.9%氯化钠注射液、20%长链脂肪乳剂注射液和20%中/长链脂肪乳剂注射液,输注速率均为3 ml·ks~(-1)·min~(-1);5 min后均静脉输注0.75%盐酸罗哌卡因注射液10 mg·ks~(-1)·min~(-1),直至出现心跳停止.记录出现心律失常时、BP较基础值下降20%时和心跳停止时罗哌卡因的用量.结果 与NS组比较,LLE组和MLE组出现心律失常时、血压较基础值下降20%时和心跳停止时罗哌卡因的用量增加(P＜0.05);LLE组和MLE组出现心律失常时、BP较基础值下降20%时和心跳停止时罗哌卡因的用量比较差异无统计学意义(P＞0.05).结论 长链脂肪乳剂和中/长链脂肪乳剂预先给药可减轻罗哌卡因致老龄大鼠心血管毒性.     

乳化异氟烷预处理对兔心肌缺血再灌注损伤的影响

目的 评价乳化异氟烷预处理对兔心肌缺血再灌注损伤的影响.方法 雄性新西兰白兔32只,体重2.5～3.0 kg,随机分为4组(n=8):缺血再灌注组(IR组)、异氟烷预处理组(I组)、乳化异氟烷预处理组(EI组)和脂肪乳组(INT组).采用结扎左冠状动脉前降支30 min、再灌注180 min的方法建立兔心肌缺血再灌注模型.各组稳定30 min后,I组吸入3%异氟烷,维持呼气末浓度2.20%30 min,洗脱15 min;EI组先以1 ml/s的速率静脉注射8%乳化异氟烷8～10 ml,然后静脉输注6～8 ml·kg-1·h-1,维持呼气末浓度1.28%30 min,洗脱15 min;INT组先以1 ml/s的速率静脉注射30%脂肪乳9 ml,然后静脉输注7 ml·kg-1·h-1持续30 min.于稳定30 min(T0)、缺血前(T1)、缺血即刻(T2)、缺血30 min(T3)、再灌注60 min(T4)、120 min(T5)和180 min(T6)时,记录HR、SP和MAP,计算HR和SP的乘积(RPP).于T6时抽取动脉血样3 ml,测定血清肌酸激酶(CK)、乳酸脱氢酶(LDH)的活性和IL-6、IL-10的浓度,并测定心肌梗死范围.结果 与T0时比较,T2-6时各组HR、MAP和RPP呈进行性下降(P<0.05);四组间HR、MAP和RPP比较差异无统计学意义(P>0.05).与IR组比较,I组和EI组心肌梗死范围减小,血清CK、LDH的活性和IL-6浓度降低,L-10浓度升高(P0.05).结论 乳化异氟烷预处理可减轻兔心肌缺血再灌注损伤,机制可能与其抑制炎性反应有关.     

肝移植术患者罗库溴铵不同给药方式肌松效果的比较

目的 比较肝移植术患者间断静脉注射(Ⅳ)、静脉输注(CI)和靶控输注(TCI)罗库溴铵的肌松效果.方法 拟行肝移植术的患者36例,性别不限,年龄21～63岁,体重48～80 kg,Child-Pugh评分7～9分,肝功能Child分级B或C级,随机分为3组(n=12):Ⅳ组、CI组和TCI组.采用TOF模式进行肌松监测,Ⅳ组:麻醉诱导时静脉注射罗库溴铵0.6 mg/kg,无肝前期T1恢复至25%时、无肝期和新肝期T4/T1(TOFR)恢复至25%时追加0.15 mg/kg.TCI组:麻醉诱导时靶控输注罗库溴铵,初始效应室靶浓度3μg/ml,调整靶浓度,维持T1 5%～10%;无肝期和新肝期开始时暂停TCI,随后以效应室靶浓度0.1μg/ml再次输注,调整靶浓度,维持T15%～10%.CI组:麻醉诱导时静脉注射罗库溴铵0.6 mg/kg,无肝前期以30μg·kg-1·min-1的速率开始静脉输注,调节输注速率,维持T1 5%～10%,无肝期和新肝期开始时暂停CI,随后以1μg·kg-1·min-1的速率静脉再次输注,调整输注速率,维持T15%～10%.各组于肌松达最大效应时行气管插管,于缝合腹膜后停止给药.记录麻醉诱导时罗库溴铵肌松起效时间、T1最大抑制程度和气管插管条件满意情况;记录各组无肝期T1 25%恢复时间及TOFR 25%恢复时间,新肝期停药后T125%恢复时间、TOFR 25%恢复时间、TOFR 75%恢复时间、TOFR90%恢复时间及恢复指数;记录罗库溴铵总用量.结果 与Ⅳ组比较,TCI组和CI组气管插管条件满意率、罗库溴铵总用量、麻醉诱导时罗库溴铵起效时间、T1最大抑制程度和各期肌松恢复情况差异均无统计学意义(P＞0.05).肌松效应监测图显示Ⅳ组各期罗库溴铵肌松效应波动较大,TCI组和CI组各期肌松效应较为平稳.结论 采用Ⅳ、CI和TCI给药时,肝移植术患者罗库溴铵肌松起效和恢复情况无差异,而采用TCI或CI给药时,肌松效应较Ⅳ更加平稳.     

20%脂肪乳剂对大鼠血浆和心肌罗哌卡因水平的影响

目的 评价20%脂肪乳剂对大鼠血浆罗哌卡因浓度和心肌罗哌卡因含量的影响.方法 雄性SD大鼠60只,体重220～270 g,随机分为2组(n=30):生理盐水组和脂肪乳剂组.股静脉注射l%罗哌卡因5 mg/kg后,脂肪乳剂组股静脉注射20%脂肪乳剂注射液5 ml/kg;生理盐水组股静脉注射等容量生理盐水.分别于给予罗哌卡因后5、10、20、40、60和120 min时取5只大鼠,心尖取血样后取心肌组织,采用高效液相色谱法测定血浆罗哌卡因浓度和心肌罗哌卡因含量.结果 与生理盐水组比较,脂肪乳剂组给予罗哌卡因后20 min时血浆罗哌卡因浓度升高,给予罗哌卡因后5、10 min时心肌罗哌卡因含量降低(P＜0.01).结论 20%脂肪乳剂可在短时间内与大鼠血液中的罗哌卡因结合,减少在心肌组织中的分布,有助于降低其心脏毒性.     

Effectiveness of different diagnostic tools for upper urinary tract urothelial carcinoma

ObjectiveThe results of urinalysis, radiographic studies, urinary cytology examinations, and ureterorenoscopy (URS) biopsies, as well as the results of histopathology can be used to establish a diagnosis of upper urinary tract urothelial carcinoma (UTUC).Materials and MethodsWe enrolled 99 patients who underwent radical nephroureterectomy (RNU) during the period 2003–2007. A total of 65 random urine and 83 URS washing cytology examinations, 48 intravenous urography (IVU), 59 retrograde pyelography (RP), and 81 URS biopsy results were available prior to RNU and were compared with the pathological grades and stages of these surgical specimens.ResultsNinety-three UTUCs were found among the 99 RNU specimens. Initial presentations and urinalysis results could not predict tumor stages. The patient with preoperative pyuria was significantly associated with high-grade UTUC (75.0% vs 52.6%, p = 0.031). Random urine and URS washing cytology results could not predict tumor grades or stages. The sensitivity of 3-day random urine cytology was significantly better than 2-day and 1-day examinations (p = 0.002 and p = 0.019, respectively). The abnormal findings in IVU and RP accounted for 89.4% and 100%, respectively. Non-enhancement of images was significantly associated with high tumor grading (p = 0.01). URS biopsy (n = 72) was positive for malignancy in 52 patients (69.3%). Biopsy grade had a significant correlation with surgical tumor grade (κ = 0.649) and high-grade biopsy results were significantly associated with invasive tumor stage (pT2–T4) (p = 0.004).ConclusionCombining random urine cytology for 3 nonconsecutive days, upper urinary tract images, and URS biopsies provided an accurate diagnosis of UTUC. This study found that preoperative pyuria in urinalysis, non-enhancement in IVP or RP, and high-grade tumor in URS biopsy could predict high-grade tumor in RNU specimens.