全身麻醉插管术后院内获得性肺部感染探讨

全身麻醉气管插管术后下呼吸道感染具有较高发生率。分析５２６例手术时间超过４小时普外科病例，经ｕ检验发现全身麻醉气管插管术后患者肺部感染率明显高于持续性硬膜外麻醉术后患者，影响因素主要与全麻插管用具及麻醉机消毒情况有关，也与术前存在慢性阻塞性肺部疾患和术后保留气管插管有关。降低全麻术后肺部感染应重视无菌操作，尽可能对麻醉机管道进行常规消毒。     

80岁以上老年病人髋关节手术麻醉体会

对 2 45例 80岁以上老年病人髋关节手术的麻醉进行如下处理 :术前全面估计病人的全身情况和心、肺等重要脏器的功能状态 ,使病人的全身状态调整到最佳水平 ;首选连续硬膜外麻醉有其优点 ;小剂量、分次给药 ,避免麻醉阻滞平面过广 ;此手术创伤大 ,失血多 ,以及应用骨黏合剂 ,有可能出现心血管反应 ,应及时补充血容量 ,并纠正不良反应 ;肺组织退行性变 ,血氧分压降低 ,术中、术后常规吸氧 ;加强术后监测、护理 ,预防易发生的并发症     

Middle-ear pressure variations during total intravenous anesthesia with propofol, fentanyl, and ketamine

Purpose As the middle-ear cavity is one of the noncompliant gas-filled cavities, an increase in middle-ear pressure (MEP) instead of volume expansion is observed with inhalation of nitrous oxide (N₂O). Changes in MEP cause many complications, such as ear pain, temporary hearing impairment, and postoperative emesis. Therefore, we investigated changes in MEP during total intravenous anesthesia (TIVA) with propofol, fentanyl, and ketamine (PFK) and inhalation of N₂O. Methods Twelve patients were anesthetized with PFK until 60 min after the induction of anesthesia, and then N₂O (60%) inhalation was started. MEP was measured by impedance audiometry (ranging from −300 daPa to +200 daPa) at 10-min intervals during PFK, and at 2-min intervals after the inhalation of N₂O. Results MEP gradually but significantly increased from the preanesthetic value of 16±8 to 34±12 (SEM) daPa 50 min after the induction of PFK. However, MEP did not exceed the normal limit. The values of MEP in all patients were more than 200 daPa within 36 min after the start of inhalation of N₂O in oxygen. Conclusion PFK had a minimal effect on MEP, whereas addition of N₂O to PFK increased MEP dramatically. Therefore, TIVA, or at least PFK, would be a better choice for patients with middle-ear or upper-airway diseases.     

Prevention of nausea and vomiting with granisetron, droperidol and metoclopramide during and after spinal anaesthesia for caesarean section: A randomized, double-blind, placebo-controlled trial

Background: Nausea and vomiting during and after spinal anaesthesia for caesarean section are distressing to the patient. This study was undertaken to evaluate the efficacy and safety of granisetron, droperidol and metoclopramide for the prevention of nausea and vomiting in parturients undergoing caesarean section under spinal anaesthesia.
Methods: In a randomized, double-blind, placebo-controlled trial, 120 patients received granisetron 3 mg, droperidol 1.25 mg, metoclopramide 10 mg or placebo (saline) ( n =30 of each) i. v. immediately after clamping of the foetal umbilical cord. Nausea, vomiting and safety assessments were performed during and after spinal anaesthesia for caesarean section.
Results: The incidence of intraoperative, post-delivery nausea and vomiting was 13%, 17%, 20% and 63% after administration of granisetron, droperidol, metoclopramide and placebo, respectively; the corresponding incidence during 0–3 h after surgery was 7%, 27%, 27% and 43%; the corresponding incidence during 3–24 h after surgery was 7%, 20%, 23% and 37% ( P <0.05; overall Fisher's exact probability test). No clinically important adverse events were observed in any of the groups.
Conclusion: Granisetron is highly effective for preventing nausea and vomiting during and after spinal anaesthesia for caesarean section. Droperidol and metoclopramide are effective for the prevention of intraoperative, post-delivery emesis, but are ineffective for the reduction of the incidence of postoperative emesis.     

Measurement of airway resistance in anesthetized and paralyzed subjects: Proposal for evaluation of K1 values

The effects of lung volume and respiratory airflow on airway resistance were studied in five anesthetized and paralyzed patients. Airway resistance measured during the inspiratory phase with intermittent constant airflow inflatoins decreased in inverse correlationship to increases in lung volume. Airway resistance measured during the expiratory phase with an airway interruption technique, on the other hand, increased with a linear relationship to the expiratory airflow as expressed by a function of Y = K₁ + K₂X. K₁, calculated from the values of airway resistance corresponding to three different airflows, was unaffected by intentional expiratory resistance loading. Thus, simultaneously with the measurement of airway resistance by this method, expiratory gas sampling with a Douglas bag can be done if necessary. Since the K₂ value of the endotracheal tube used in this study (Portex^® I.D. 8mm, length 26cm) was quite high (5.0cmH₂O·1^–2·sec²), depending on the airflow, the presence of the endotracheal tube strongly affected the measurement of airway resistance during general anesthesia. K₁ measured by the above method, however, may be considered as the best way to evaluate the lower airway resistance independent of either lung volume or expiratory airflow.(Sakai T, Yoshida H, Yano H et al.: Measurement of airway resistance in anesthetized and paralyzed subjects: proposal for evaluation of K₁ values. J Anesth 2: 139–145, 1988)     

Comparison of Output Particle Size Distributions from Pressurized Aerosols Formulated as Solutions or Suspensions

The delivery of particles as small as possible (preferably <5 µm) to the respiratory tract should be the aim of those formulating metered dose inhalers (MDIs). This may be facilitated by the formulation of solution, rather than suspension-type, pressurized aerosol units. Two series of MDIs were compared; one contained suspended micronized disodium fluorescein (0.1%, w/v), while the other contained the same concentration of dissolved salicylic acid. Either oleic acid, L--phosphatidylcholine, or sorbitan trioleate was incorporated at 0.15% (w/v) as suspending agent (disodium fluorescein) or solubilizing agent (salicylic acid). The propellant blend was 70% (w/w) Freon 12 and 30% (w/w) Freon 11 in all cases. This exhibited a vapor pressure of 50.6 psig (444.7 kPa) at 21°C. The output particle size distribution of the aerosol reaching the cascade impactor showed a mass median aerodynamic diameter (MMAD) of approximately 4 and 2 µm for the suspension and solution formulations respectively, regardless of the surfactant used. Larger MMADs were observed for solution aerosols formulated with oleic acid (2.32 µm) compared to those containing L--phosphatidylcholine (1.93 µm) or sorbitan trioleate (2.07 µm). Possible reasons for these observations are discussed.     

前锯肌平面阻滞和胸椎旁神经阻滞在胸腔镜手术中的麻醉效果及对疼痛因子的影响

目的 研究前锯肌平面阻滞与胸椎旁神经阻滞对胸腔镜手术患者的麻醉效果及对疼痛因子的影响。方法 选取2020年11月—2021年9月安徽省池州市人民医院60例接受胸腔镜手术治疗的患者作为研究对象,按照随机数字表法分为A组和B组,每组30例。两组患者术中均接受气管插管全身麻醉,麻醉诱导前,A组选择前锯肌平面阻滞,B组选择胸椎旁神经阻滞。比较两组患者的麻醉效果、阻滞操作时间、阻滞起效时间、阻滞持续时间、生命体征、术后镇痛泵按压次数、术后舒芬太尼使用量、疼痛因子、术后疼痛评分及术后不良反应发生率。结果 A组的麻醉优良率为96.67%,B组的麻醉优良率为93.33%,两组比较,差异无统计学意义（P>0.05）。两组患者的麻醉平面、阻滞起效时间比较,差异无统计学意义（P>0.05）;A组较B组阻滞操作时间缩短,阻滞持续时间延长。两组患者切皮前后收缩压、舒张压、心率差值比较,差异无统计学意义（P>0.05）。A组的术后48 h内镇痛泵按压次数、术后舒芬太尼使用量较B组减少（P <0.05）。两组患者手术前后血清PGE2、IL-6差值比较,差异有统计学意义（P <0.05）...     

Anaesthetic experience with paediatric interventional cardiology

Anaesthetic and sedation techniques, complications and outcomes were reviewed in 176 children undergoing 184 interventional cardiologic procedures. Techniques included sedation only, and ketamine, inhalational or narcotic anaesthesia. Ketamine infusion was the technique most frequently used. Ketamine was associated with a higher incidence of respiratory complications (P < 0.05) than the other techniques. The higher incidence of hypercarbia (15.6 per cent), which did not affect outcome, may be attributable to the use of supplemental sedatives. The incidence of upper airway obstruction (7.8 per cent) was similar to that of previous studies. Vascular compromise resulted from the procedure in 33 patients, necessitating surgical correction in 16. Cardiac perforation occurred in four cases, causing one death. Pulmonary valve stenosis was most amenable to balloon dilatation and aortic valve stenosis least amenable. Ketamine was the anaesthetic agent preferred by cardiologists for use in the catheterisation suite when general anaesthesia was required. Vigilant monitoring by anaesthetic staff is necessary during the procedure, and avoidance of concomitant narcotics is recommended if a ketamine technique with spontaneous ventilation is used. Les techniques anesthésiques et de sédation ainsi que les complications et les issues ont été revues chez 176 enfants subissant 184 procedures cardiaques. Les techniques ont inctu soil la sédation seulement, soit l’anesthésie à la kétamine, aux agents d’inhalation ou aux narcotiques. La perfusion de kétamine était la technique la plus fréquemment utilisée. La ketamine était associée à une plus grande incidence de complication respiratoire (P < 0.05) comparativement aux autres techniques. La plus grande incidence d’hypercarbie (15.6 pour cent), n’ayant pas affecté l’issue, pourrait être attribuée à l’utilisation additionnelle de sédatifs. L’incidence d’obstruction des voies aériennes supérieures (7.8 pour cent) était similaire aux études préalables. Un problème vasculaire suite à la procédure fut observé chez 33 patients dont 16 ont requis une correction chirurgicale. Une perforation cardiaque est survenue dans quatre cas provoquant le décès d’un seul patient. La sténose de la valve pulmonaire était la procédure la plus susceptible d’être dilatée et la sténose de la valve aortique la moins susceptible. La kétamine était l’agent anesthésique préféré par les cardiologistes lors des cathétérisations quand une anesthésie générate était requise. Une surveillance vigilante par une équipe anesthésique fut nécessaire durant la procedure. Il faut aussi éviter l’administration de narcotiques si la kétamine est administrée en respiration spontanée.

---

Presented in part at the Canadian Anaesthetists’ Society annual meeting in Halifax, June 1988.     

Relationships between Responsiveness of the Bronchi to Acetylcholine and Cyclic AMP Response of Lymphocytes to Beta1- and Beta2-Adrenergic Receptor Stimulation in Patients with Asthma

Decreased response of beta-adrenergic receptor has been considered to he one of the causes of increased responsiveness of the bronchi in asthma. Since beta-adrenergic receptor has two subtypes, beta₁ and beta₂, and the bronchodilating effect of beta stimulants is mediated by beta₂-receptor, responsiveness of the bronchi is expected to correlate to the cyclic AMP response of lymphocytes to a beta₂-stimulant. Responsiveness of the bronchi was expressed as respiratory threshold to acetylcholine (RT-Ach), which was the minimal concentration of acetylcholine solution to cause an initial decrease of FEV₁ of more than 20% of the baseline value. Beta₁ and heta₂-responses were expressed as the increments of cyclic AMP content of 10⁶ lymphocytes incubated with norepinephrine (beta₁-stimulant) and salbutamol (beta₂-stimulant).
RT-Ach showed a significant correlation with the beta₂-cyclic AMP response of lymphocytes, but not with the beta₁ -response among patients with asthma. Sixteen symptomatic patients on continuous beta-stimulants showed lower RT-Ach value and diminished beta₂-receptor activity of lymphocytes compared with 14 patients in remission. These results suggest that selective beta₂-adrenergic blockade may he one of the causes of bronchial hypersensitivity in asthma, though it should be noted that in this study beta-adrenergic responses were examined in lymphocytes and were compared with the responsiveneness of the bronchi. Possible beta-receptor subsensitivity induced by administration of beta-stimulants is discussed.