对麻醉学科教育改革的思考

目前,麻醉学本科教育设立的大环境已经不再存在,其专业面狭窄的副作用日益显现,取消麻醉学本科专业势在必行。麻醉学科教育必须进行改革,但是改革的方向并不明确。“麻醉长学制教育”和“麻醉和围术期医学教育”是两个可能的方向,各具优点和缺点。比较而言,“麻醉和围术期医学教育”是麻醉学教育改革的一个较优方向。     

地佐辛与芬太尼用于硬膜外阻滞下阑尾切除术中抑制牵拉反应的临床观察

目的:观察地佐辛与芬太尼在硬膜外阻滞下阑尾切除术中,抑制牵拉反应的临床效果和安全性。方法:选择硬膜外下拟行阑尾切除术患者60例,随机分为观察组和对照组,每组各30例。硬膜外阻滞效果确切后开始手术前,观察组缓慢静推地佐辛0.1 mg/kg+托烷司琼2 mg,然后持续泵注地佐辛1.5～2μg/(kg.min)至关腹。对照组缓慢静推芬太尼1μg/kg+托烷司琼2 mg,然后持续泵注芬太尼0.2～0.3μg/(kg.min)至关腹。分别于手术前、切皮时、切开腹膜时、牵拉阑尾时、手术结束时监测患者SBP、DBP、HR、SpO2的变化,并对内脏牵拉反应状况进行评估。结果:切开腹膜时、牵拉阑尾时,观察组与对照组比较差异无统计学意义(P>0.05)。结论:地佐辛与芬太尼在硬膜外阻滞下阑尾切除术中,都具有良好的抑制牵拉反应作用,地佐辛安全性更高。     

The Role of Anesthetic Drugs in Liver Apoptosis

Context

The modern practice of anesthesia is highly dependent ona group of anesthetic drugs which many of them are metabolized in the liver.

Evidence Acquisition

The liver, of course, usually tolerates this burden. However, this is not always an unbroken rule. Anesthetic induced apoptosis has gained great concern during the last years; especially considering the neurologic system.

Results

However, we have evidence that there is some concern regarding their effects on the liver cells. Fortunately not all the anesthetics are blamed and even some could be used safely, based on the available evidence.

Conclusions

Besides, there are some novel agents, yet under research, which could affect the future of anesthetic agents'' fate regarding their hepatic effects.     

The lack of response to suggestion under controlled surgical anesthesia

Thirty-two ASA I or II women undergoing abdominal hysterectomy were randomly allocated to four groups to determine what type, if any, of recorded intraoperative message they would receive. Groups I and II heard a neutral recording with no verbal content. Group III heard an experimental recording with a positive suggestion for a rapid recovery. Group IV had a self-prepared message. The tapes were played during general anesthesia when anesthetic depth was judged to be stable and adequate by vital signs, end-tidal anesthetic concentration and EEG compressed spectral array. No patient reported any recall of intraoperative messages when interviewed on the day after surgery. Chart review showed no difference in days of hospitalization, dose of analgesics required, time to beginning oral intake, or the amount of wound drainage (P greater than 0.05). We conclude that no awareness can be observed directly by recall or indirectly by response to suggestion given under stable and adequate general anesthesia.     

Metabolism-dependent binding of the chlorinated insecticide DDT and its metabolite, DDD, to microsomal protein and lipids

Dichlorodi[U-14C]phenyltrichloroethane ( [14C]DDT), incubated with rat hepatic microsomes and NADPH, produced reactive intermediates which covalently bound to microsomal protein and lipids. In atmospheric oxygen, DDT bound to microsomal protein; however, binding was increased up to approximately 70% by oxygen depletion. Low levels of [14C]DDT binding to microsomal lipids occurred under atmospheric oxygen but, in contrast to protein binding, DDT-phospholipid binding was increased up to 20-fold by oxygen depletion. Dichlorodiphenyldichloroethane (DDD) was rapidly formed from DDT under anaerobic conditions, although when DDD was utilized as substrate, binding to microsomal protein occurred only in the presence of oxygen. Sodium dithionite, added to microsomes, produced [14C]DDT phospholipid and protein binding, and DDD formation, but failed to support DDD metabolism or binding. The data are consistent with the reductive formation of a DDT free-radical intermediate that led to the formation of DDD and that was bound preferentially to microsomal lipids.     

Standardization of the indirect fluorescent antibody test for malaria.

Methods are described whereby results of malarial immunofluorescence tests can be evaluated objectively. The IFA test was quantitated by standardizing the physical system against a fluorescent standard and preparation of biological standards of malarial antisera and fluorescein labelled conjugates. Using these known standards the reactivity of antigens was characterized. It was found that antigen preparations are best when they include mature schizonts, and keep best when they are stored in a dry condition at or below -20 degree C. However, even under carefully controlled conditions of storage, antigens showed considerable variation of reactivity between individual batches.     

Acute Hemodynamic Alterations after Mitral Valve Replacement with the Glutaraldehyde-Treated Porcine Heterograft Prosthesis

Perioperative hemodynamic changes following mitral valve replacement using the porcine heterograft prosthesis were measured in 21 patients with acquired mitral valve disease. Preoperatively, a state of compensatory cardiac failure was suggested by the following: an increased heart rate (HR) (96 beats per minute); low cardiac and stroke volume (SVI) indices (2.3 ± 0.10 L/min/m² and 25 ± 2 ml/beat/m²); and increased systemic vascular resistance (SVR) (1,626 ± 116 dyne sec cm^?5). Both the mean pulmonary artery (PAP) and pulmonary capillary wedge pressures (PCWP) were elevated as well (32 ± 3 and 22 ± 2 torr). Immediate hemodynamic improvement followed valve replacement. HR, SVR, PAP, and PCWP all decreased significantly. Twenty-four hours after valve replacement, PAP (23 ± 1 torr) and PCWP (13 ± 1 torr) demonstrated marked declines, SVR was reduced by one-third (1,173 ± 87 dyne sec cm^?5), HR had decreased by 10 beats per minute, and SVI had increased to 30 ± 2 ml/beat/m². The prompt circulatory improvement of patients soon after mitral valve replacement using the porcine heterograft compares favorably with studies in which other valve types were employed and in which postoperative cardiovascular depression was encountered frequently.     

Influence of volume loading on intraoperative hemodynamics and perioperative fluid retention in patients with valvular regurgitation undergoing prosthetic replacement

Preload and afterload were controlled intraoperatively in 2 groups of patients with valvular regurgitation and congestive heart failure in order to determine the effect of fluid loading on weight gain and subsequent recovery. As a part of their anesthetic management before cardiopulmonary bypass, 16 patients were given 1 liter of crystalloid with nitroprusside infused at 1 microgram/kg/min and 16 received 4 liters of crystalloid with nitroprusside at 4 micrograms/kg/min. Arterial and filling pressures were kept the same in both groups. Heart rate and vascular resistance became significantly lower and cardiac index and stroke volume significantly higher in the fluid-augmented group. The transition to cardiopulmonary bypass was smoother for the fluid-augmented patients. All patients survived, and 2 in each group were ventilated beyond 24 hours. The mean weight gain at surgery was the same in the 2 groups (3 kg). For the first 2 postoperative days, body weight remained unchanged and thereafter, both groups lost weight at 0.6 kg/day. Preoperative weight was reached on day 7 and discharge occurred on day 15, 2 kg below control. Thus, a modest operative weight gain in these patients is inevitable, benign, and independent of the volume of fluid infused before bypass.