硬膜外阻滞复合全麻在老年患者上腹部手术的应用

目的: 评价硬膜外阻滞复合全麻应用于老年患者上腹部手术的可行性。方法: 30例择期上腹部手术老年患者,ASAⅠ~Ⅱ级,随机分为观察组(硬膜外阻滞复合全麻组)和对照组(全麻组)。两组全麻诱导和维持方法相同,全麻诱导用咪达唑仑0.05 mg/kg、芬太尼4 μg/kg、丙泊酚1 mg/kg、维库溴铵0.1 mg/kg。观察组于诱导前取T_9~10椎间隙行硬膜外穿刺置管,注入1.0%利多卡因加0.25%布比卡因混合液3~5 ml。测定麻醉平面后给追加量,麻醉平面控制在T₄以下,全麻维持选用丙泊酚2~4 mg·kg-1·h-1静脉持续输注,间断静脉注射芬太尼、维库溴铵,需要时吸入0.5%~1%异氟烷。于麻醉前、插管后、切皮后、手术后1 h、拔管后,采外周静脉血测定血清皮质醇、肾上腺素和血糖浓度;记录循环指标、术中知晓、术后躁动及全麻药用量。结果: 对照组血清皮质醇在手术后1 h和拔管后均明显高于观察组(P<0.01),观察组手术后1 h肾上腺素和血糖浓度均明显低于对照组(P<0.01);观察组切皮后和拔管后平均动脉压、心率上升幅度均明显低于对照组(P<0.01)。观察组全麻药用量和术后躁动发生率均低于对照组(P<0.01~P=0.035)。结论: 硬膜外阻滞复合全麻用于老年患者上腹部手术血流动力学稳定,应激反应小,全麻药用量和术后躁动减少,是一种安全可行的麻醉方法。

Combined epidural and general anesthesia in upper abdominal surgery for the elderly

Objective: This study was designed to characterize the ultrastructure of the coccoid Helicobacter pylori(H. pylori) forms in the tissues of carcinoma.Methods: Transmission electron microscopy(TEM) technique was used to examine the structure of coccoid H. pylori in 4 cases of gastric carcinoma and 2 cases of esophageal carcinoma.Results: It was found that the coccoid H. pylori were scattered in cancer nest and cancer interspace,some of which enterded cancer cells,macrophages and other cells.The coccoid H. pylori appeared to be similar to the L-forms of other bacteria with varying cell shape and size,different cytoplasmic electron densities and defects in cell wall.Two types of coccoid H. pylori could be distinguished in the tissues of carcinoma by TEM.Type A was smaller with higher electron density in the cytoplasma,and flagellation on the cell membrane,suggesting that it could be viable.However,the type B was larger with lower electron density in the cytoplasma,and no flagellation on the cell membrane,suggesting that it could be a degenerative form.Conclusions: The coccoid forms of H.pulori still have certain degree of viability,thus they may play an important role in the transmission of H. pylori,the relapse of H. pylori related disease after treatment and the development of the related carcinoma.