丙泊酚和咪唑安定在麻醉苏醒期气管拔管应用的观察

目的观察丙泊酚、咪唑安定镇静对术后气管拔管病人的影响。方法60例ASAⅠ～Ⅱ级腹部手术病人。均于手术结束停麻药后即予吸除吸呼道分泌物，等待达到拔管条件后随机分为三组：丙泊酚组（P组）静脉注射丙泊酚1-2mg／kg 1min后拔管；咪唑安定组（M组）静注咪唑安定0．02-0．04mg／kg 3min后拔管；对照组（D组）即按传统清醒拔管。比较患者MAP、HR变化、呛咳反应、拔管后清醒时间、拔管知晓率及心理反应。结果P组各时点MAP、HR均无显著变化。呛咳反应轻，M组拔管即刻与拔管后5min MAP、HR均明显增加，呛咳反应明显，但较D组轻微（P〈0．05或P〈0．01）。P组、M组清醒时间延长（P〈0．05）。D组拔管知晓率明显增高，心理反应明显（P〈0．01）。结论气管拔管中予适度镇静能抑制心血管反应及心理伤害反应，丙泊酚较咪唑安定用于气管拔管镇静更优越。     

Pre- and post-intervention study to assess the impact of a sedation protocol in critically ill surgical patients

Introduction

Sedation and pain management for mechanically ventilated critically ill surgical patients pose many challenges for the intensivist. Even though daily interruption of sedatives and opioids is appropriate in medical intensive care unit (ICU) patients, it may not be feasible in the surgical patients with pain from surgical incision or trauma. Therefore we developed an analgesia/sedation based protocol for the surgical ICU population.

Methods

We performed a two-phase prospective observational control study. We evaluated a prescriber driven analgesia/sedation protocol (ASP) in a 12-bed surgical ICU. The pre-ASP group was sedated as usual (n = 100) and the post-ASP group was managed with the new ASP (n = 100). Each phase of the study lasted for 5 mo. Comparisons between the two groups were performed by χ² or Fisher’s exact test for categorical variables and the Mann-Whitney test for nonparametric variables. A P value <0.05 was statistically significant.

Results

We found a significant reduction in the use of fentanyl (P < 0.001) and midazolam (P = 0.001). We achieved sedation goals of 86.8% in the post-ASP group compared to 74.4% in the pre-ASP (P < 0.001). Mean mechanical ventilations days in pre- and post-ASP group were 5.9 versus 3.8 (P = 0.033).

Conclusion

In our cohort of critically ill surgery patients implementation of an ASP resulted in reduced use of continuously infused benzodiazepines and opioids, a decline in cumulative benzodiazepine and analgesic dosages, and a greater percentage of Richmond Agitation Sedation Scale scores at goal. We also showed reduced mechanical ventilation days.     

RP-HPLC测定人血浆中咪唑安定的浓度

目的建立咪唑安定血药浓度的检测方法。方法采用RP-HPLC法,艾司唑仑为内标,色谱柱为Hypersil ODS C18(250 mm×4.0 mm,5μm),流动相为甲醇-乙腈-磷酸盐缓冲液(55∶2∶43),柱温40℃,流速1 m.lm in-1,检测波长220 nm。结果咪唑安定的血药浓度在1μg.L-1~2 m.gL-1范围内线性关系良好(r=0.9998),检出限为1μg.L-1,高、中、低浓度平均加样回收率93.94%~98.55%,日内RSD≤3.87%,日间RSD≤8.51%。结论所用方法选择性好,快速、灵敏、准确,适合临床治疗药物的监测及药物动力学研究。     

不同麻醉药物配伍在结肠镜检查中的应用与护理支持

目的:比较芬太尼复合咪唑安定与复合异丙酚两种静脉麻醉方法的用于肠镜检查中的临床麻醉效果和安全性.方法:130例美国麻醉医师协会(ASA)Ⅰ-Ⅱ级患者随机分为2组:FM组(芬太尼 咪唑安定,n=75),FP组(芬太尼 异丙酚,n=55).观察两组镇静镇痛程度、遗忘程度、起效时间、苏醒时间、镜检满意度、呼吸抑制及血压、心率及血氧饱和度的变化.结果:FFM组、FP组均取得了良好的镇静镇痛效果,FP组作用更显著(t=29.33,P<0.01;t=1 5.35,P<0.01);FP组起效时间(t=6.63,P<0.01)、苏醒时间(t=7.83,P<0.01)、遗忘率(X~2=22.70,P<0.01)、镜检满意度(P<0.01或P<0.05)明显优于组FM;对血压和血氧饱和度的影响FM组低于FP组,两组呼吸抑制(SPO2<90%)率FM组(4%)与FP组(3.6%)相比差异无著性(P>0.05).结论:芬太尼复合咪唑安定与复合异丙酚均有良好的镇静镇痛效果,是安全有效的;且护理支持中必须加强呼吸、循环监护及镇静观察.     

咪唑安定在呼吸机应用中的镇静抗焦虑作用

目的:观察咪唑安定在呼吸机应用过程中的镇静、抗焦虑作用。方法:20例在呼吸机应用过程中出现焦虑、恐惧、烦躁不安(Ramsay镇静评分1级)患者,首先静脉注射咪唑安定,负荷量0.03～0.3 mg/Kg,然后给予维持量0.02-0.2 mg/Kg·h-1,用0.9％氯化钠稀释后持续静脉泵人。结果:24小时内16例病人Ramsay镇静评分达到2-4级,有效率为80.00％。结论:咪唑安定对呼吸机应用过程中的焦虑、恐惧、烦躁不安有镇静、抗焦虑作用,并且能改善心率、呼吸频率和SaO2。     

Sedation in the ICU

The effect of midazolam on the induction dose-response curve for alfentanil was studied in non-premedicated ASA physical status I or II patients. The response to the verbal command was used as an end point of anaesthesia. Dose-response curves for midazolam, alfentanil, and their combination were determined with a probit procedure, and compared with algebraic (fractional) analysis of drug interaction. Interaction between midazolam and alfentanil was found to be synergistic (supra-additive). The results suggest that the use of this combination is advantageous not only because it helps to achieve different anaesthetic goals with specific drugs (a benzodiazepine for unconsciousness and an opioid for blockade of the responses to noxious stimulation), but also because its components are complementary for unconsciousness.     

异丙酚联合芬太尼、咪达唑仑在纤维结肠镜检查中的应用

目的：探讨异丙酚联合芬太尼、咪达唑仑在纤维结肠镜检查中的有效性和安全性。方法：我院2008年1月～2010年8月行纤维结肠镜检查的患者82例,ASA分级Ⅰ～Ⅱ级,随机将患者分成两组,各41例。B组为异丙酚联合芬太尼、咪达唑仑组,R组为对照组,单纯应用异丙酚组。结果：两组患者均取得良好的麻醉效果。检查前、检查开始时及检查结束时B组患者血压波动及心率变化明显低于R组,且异丙酚总用量、意识及定向力恢复时间、呼吸抑制发生率B组亦明显低于R组（P〈0.05）。结论：异丙酚联合芬太尼、咪达唑仑用于纤维结肠镜检查的麻醉,可以加强麻醉效果,减少异丙酚对心肌的抑制作用,增强了对应激反应的抑制,具有安全、有效、方便、药物用量小、不良反应少、苏醒时间短等优点,是一种安全有效的麻醉方法。     

咪达唑仑对剖宫产术初产妇情绪和记忆的影响

目的 探讨咪达唑仑对剖宫产手术产妇情绪和记忆的影响.方法 72例择期剖宫产术产妇随机分成4组,Ⅰ、Ⅱ和Ⅲ组麻醉前30 min分别肌注咪达唑仑0.05、0.06和0.07 mg/kg,Ⅳ组肌注生理盐水1.5 ml,同时肌肉注射阿托品0.01 mg/kg.于注药前和注药后30 min进行焦虑视觉类比试验(AVAT)、状态焦虑问卷(SAI)测试及Ramsay镇静水平评估.将麻醉准备到手术结束过程分为5阶段,每项告知产妇,记录剖宫产术后4 h产妇能准确回忆的项目.结果 注药后30 min时,Ⅰ～Ⅲ组AVAT分别下降36.4%、43.2%和43.1%;SAI分别下降20.9%、24.8%和26.9%,均获得Ramsay 2～4级镇静水平.Ⅰ～Ⅲ组和Ⅳ组比较记忆保留组间差异均有统计学意义(P均＜0.01).Ⅰ～Ⅲ组以遗忘静脉穿刺过程的居多,4组产妇对椎管内麻醉穿刺和新生儿娩出后性别识别两过程全部记忆完觋整.结论 剖宫产手术前给予咪达唑仑0.05～0.07 mg/kg,对产妇有良好的镇静和抗焦虑作用,对外显记忆有一定程度的影响,其中对信息量小和关注程度低的信息能产生顺行性遗忘作用,能保留信息量大和关注程度高的信息的完整记忆.     

Effects of midazolam and phenobarbital on brain oxidative reactions induced by pentylenetetrazole in a convulsion model

Context: Brain oxidative reactions are involved in epilepsy as well as neurodegenerative diseases. In animal convulsion models, some anticonvulsants have been found to suppress oxidative reactions associated with convulsions. However, the effect of anticonvulsants on brain oxidative reactions has not fully been clarified.

Objective: Midazolam and phenobarbital are often used as an intravenous anesthetic, and are known to have anticonvulsive effect, but antioxidative effect of these drugs has rarely been studied. Thus, the purpose of this study was to evaluate the effects of these drugs on the degree of convulsions and brain oxidative reactions in an animal convulsion model.

Materials and methods: In order to evaluate brain oxidative reactions, we measured malondialdehyde (MDA) level and heme oxygenase (HO)-1 mRNA expression level in the brain of mice in a convulsion model generated by a single injection of pentylenetetrazole (PTZ). We evaluated the effects of midazolam and phenobarbital on the degree of PTZ-induced convulsions and on the changes in brain MDA level and HO-1 mRNA expression level.

Results: After PTZ injection, severe convulsions were observed in all mice. MDA level was increased in the whole brain, while HO-1 mRNA expression level was increased only in the hippocampus. Both midazolam and phenobarbital prevented the convulsions and suppressed the increase in both MDA level and HO-1 mRNA expression level in the brain.

Conclusion: In this study, both midazolam and phenobarbital suppressed PTZ-induced MDA and HO-1 reactions in the brain, suggesting that these drugs inhibit brain oxidative reactions in a convulsion model.     

咪达唑仑与异丙酚对Ⅱ型糖尿病患者下肢手术循环和心率变异性的影响

目的 观察咪达唑仑、异丙酚在Ⅱ型糖尿病患者下肢手术镇静中循环和心率变异性(HRV)的变化。方法 40例在连续硬膜外麻醉下实施下肢手术，ASAⅡ～Ⅲ级的Ⅱ型糖尿病患者，根据镇静药物的不同，随机分为两组：咪达唑仑组(M组，n=20)，异丙酚组(P组，n=20)，比较镇静前后循环和心率变异性的变化。结果 M组警觉，镇静评分(OAA／S)达3分后，低频(LF)、低频高频比(LF/HF)、总功率(TP)较基础值显著降低(P＜0．01)，且显著低于P组(P＜0．05～0．01)，HF无显著变化。P组LF、HF、TP均较基础值显著降低(P＜0．05～0．01)，LF／HF显著升高(P＜0．01)，HF显著低于M组(P＜0．01)，LF／HF较M组显著升高(P＜0．01)。结论 咪达唑仑主要抑制交感神经活性，有益于改善糖尿病患者迷走/交感神经的均衡性，为Ⅱ型糖尿病患者术中镇静的较安全用药。