瑞芬太尼复合右美托咪定在心脏手术中的麻醉效果及对血流动力学的影响

目的:分析瑞芬太尼(REM)复合右美托咪定(DEX)在心脏手术中的麻醉效果及对患者血流动力学的影响。方法:选取我院2013年12月至2015年9月行心脏手术的100例患者,按随机数字表法分为两组麻醉Ⅰ组和麻醉Ⅱ组各50例。麻醉Ⅱ组患者以REM复合DEX进行麻醉;麻醉Ⅰ组患者以REM行麻醉。比较不同麻醉方式的麻醉效果及对血流动力学的影响。结果:麻醉Ⅱ组患者手术不同时间点动脉压、心率、血氧饱和度变化不明显,(P0.05)。麻醉Ⅰ组患者插管即刻动脉压、心率、血氧饱和度下降显著,经t检验对比后有统计学意义(P0.05)。麻醉Ⅱ组Ramsay评分明显高于麻醉Ⅰ组,经t检验对比后有统计学意义(P0.05)。两组患者拔管、苏醒、恢复呼吸时间相近,无显著差异(P0.05)。麻醉Ⅱ组麻醉优良率明显高于麻醉Ⅰ组,经x~2检验对比后有统计学意义(P0.05)。结论:REM复合DEX在心脏手术中的麻醉效果确切,可维持患者血流动力学的平稳,提高镇静效果。同时不影响其拔管、苏醒和呼吸恢复,值得推广。     

Hyperbaric pressure of 51 atmospheres is without effect on the depression of oxygen uptake in kidney tissue culture produced by halothane

Although anesthetized animals are awakened when subjected to increased pressure, compression does not result in antagonism of all phenomena associated with these drugs. It has recently been demonstrated that halothane's inhibition of respiration of isolated rat liver mitochondria is not reversed by hydraulic compression to 51 atmospheres. In order to determine whether this phenomenon can be extrapolated to the whole cell, we have investigated the effect of hydraulic compression of intact renal cells equilibrated with halothane, and conclude that pressure does not overcome the inhibitory effect of this anesthetic.     

Reversal by pressure of seed germination promoted by anesthetics

Germination of Panicum capillare L. caryopses induced by solutions of ethanol and ethyl ether was prevented by application of pressure >1 MPa during the period of exposure to the anesthetic. This effect of pressure indicates that germination is correlated with expansion at a site of anesthetic action in a cell membrane. The effects of several other anesthetics were measured on germination of P. capillare seeds. Ethanol, chloroform, and ethyl ether had the highest activity. Methanol and isopropanol were inactive. The effective compounds are thought to distribute preferentially to lipid-solution interfaces in cell membranes of the seeds.     

全麻药物对神经发育影响的争鸣

每年有大量的婴幼儿在全身麻醉下接受各种检查和治疗,麻醉药物的安全问题也成为人们日益关注的问题,全麻药物作用于发育期大脑是否会产生持续性不可逆损伤这一问题,被学者所担忧。虽然动物研究提示了全麻药物具有神经毒性,但临床研究结论并不一致,需要有更多的研究予以探索,并通过合理的用药手段、保护手段,将麻醉药品的副作用降低到最低。本文从基础研究和临床研究方面,简述了当前全身麻醉药对神经发育影响的研究现状,介绍了现有研究的成果和局限性。分析了全麻药物神经毒性可能存在的时间依赖性和剂量依赖性。目前更多的研究趋向于单次、相对短时间的麻醉下手术对神经发育影响很小,未来期待更多的研究予以探索全麻药物神经毒性作用,特别是大剂量重复麻醉暴露对发育期神经的生长影响,从而更好地指导临床治疗。     

Antagonism between high pressure and anesthetics in the thermal phase-transition of dipalmitoyl phosphatidylcholine bilayer

The antagonizing action of hydrostatic pressure against anesthesia is well known. The present study was undertaken to quantitate the effects of hydrostatic pressure and anesthetics upon the phase-transition temperature of dipalmitoyl phosphatidylcholine vesicles. The drugs used to anesthetize the phospholipid vesicles included an inhalation anesthetic, halothane, a dissociable local anesthetic, lidocaine and an undissociable local anesthetic, benzyl alcohol. All anesthetics decreased the phase-transition temperature dose-dependently. In the case of lidocaine, the depression was pH dependent and only uncharged molecules were effective. The application of hydrostatic pressure increased the phase-transition temperature both in the presence and the absence of anesthetics. The temperature-pressure relationship was linear over the entire pressure range studied up to 340 bars. Through the use of Clapeyron-Clausius equation, the volume change accompanying the phase-transition of the membrane was calculated to be 27.0 cm3/mol. Although the anesthetics decreased the phase-transition temperature, the molar volume change accompanying the phase-transition was not altered. The anesthetics displaced the temperature-pressure lines parallel to each other. The mole fraction of the anesthetics in the liquid crystalline membrane, calculated from the van't Hoff equation, was independent of pressure. This implies that pressure does not displace the anesthetics from the liquid membrane, and the partition of these agents remains constant. The volume change of the anesthetized phospholipid membranes is entirely dependent upon the phase-transition and not on the space occupied by the anesthetics.     

High-pressure infrared study of phosphatidylserine bilayers and their interactions with the local anesthetic tetracaine

High-pressure Fourier-transform infrared (FT-IR) spectroscopy was used to study the barotropic behavior of phosphatidylserine bilayers and their interactions with the local anesthetic tetracaine. The model membrane systems studied were multilamellar aqueous dispersions of 1,2-dimyristoyl-sn-glycero-3-phospho-L-serine (DMPS) and 1,2-dioleoyl-sn-glycero-3-phospho-L-serine (DOPS) in the absence and the presence of tetracaine at pH 5.5 and 9.5. The infrared spectra were measured at 28 degrees C in a diamond anvil cell as a function of pressure up to 25 kbar. The results show that the barotropic behavior of the negatively charged phosphatidylserine bilayers is very similar to that observed for zwitterionic phospholipids, such as phosphatidylcholine and phosphatidylethanolamine, with corresponding acyl chains. The results also indicate that the local anesthetic partitions into phosphatidylserine bilayers in an environment close to the membrane-water interface and interacts electrostatically with the lipid head group. Application of high hydrostatic pressure on the lipid-anesthetic systems results in the pressure-induced expulsion of the anesthetic from a membrane to an aqueous environment. The pressures required for expulsion of anesthetic from bilayers are much higher for the unsaturated lipid (DOPS) than for the saturated lipid (DMPS) (approximately 6 kbar vs approximately 2 kbar, respectively). Whereas incorporation of the anesthetic into DOPS bilayers does not affect significantly the structural and dynamic properties of the disordered acyl chains in the liquid-crystalline phase, it orders the DMPS acyl chains in the gel phase.     

Interfacial adsorption of an inhalation anesthetic onto ionic surfactant micelles and its desorption by high pressure

The effects of pressure and temperature on the critical micelle concentration (CMC) of sodium dodecylsulfate (SDS) were measured in the presence of various concentrations of an inhalation anesthetic, methoxyflurane. The change in the partial molal volume of SDS on micellization, $\text{Δ}\text{V}{}_{\mathrm{<mtext>m</mtext>}}$, increased with the increase in the concentration of methoxyflurane. The CMC-decreasing power, which is defined as the slope of the linear plot between ln(CMC) vs. mole fraction of anesthetic, was determined as a function of pressure and temperature. Since the CMC-decreasing power is correlated to the micelle/water partition coefficient of anesthetic, the volume change of the transfer (ΔV_p^o) of methoxyflurane from water to the micelle can be determined from the pressure dependence of the CMC-decreasing power. The value of ΔV_p^o amounts 6.5±1.8 cm³·mol^?1, which is in reasonable agreement with the volume change determined directly from the density data, 5.5±0.6 cm³ · mol^?1. Under the convention of thermodynamics, this indicates that the application of pressure squeezes out anesthetic molecules from the micelle. The transfer enthalpy of anesthetic from water to the micelle is slightly endothermic. The partial molal volume of methoxyflurane in the micelle (112.0 cm³·mol^?1) is smaller than that in decane (120.5 cm³·mol^?1) and is larger than that in water (108.0 cm³·mol^?1). This indicates that the anesthetic molecules are incorporated into the micellar surface region, i.e., the palisade layer of the micelle in contact with water molecules, rather than into the micelle core.     

The effect of topical instillation of 2.5% phenylephrine and 1.0% tropicamide on the blood pressure of hypertensive patients

Background: Pupillary dilation is necessary to complete a thorough examination of the internal ocular structures and perform threshold visual fields on the automated perimeter. In our clinic, the topical instillation of 2.5% phenylephrine and 1.0% tropicamide following one drop of topical anesthetic is used routinely for pupil dilation. The vasoconstrictive effects of phenylephrine can cause an increase in peripheral resistance resulting in elevation of systolic and diastolic blood pressures. A rise in systemic blood pressure has been shown to occur following topical instillation of phenylephrine (Heath, Arch Ophthalmol, 1936;16:839–846). This study investigates the effect of topical instillation of 2.5% phenylephrine and 1.0% tropicamide on the blood pressure of known hypertensive patients 30 and 70 min after instillation. Methods: 118 hypertensive patients, all of whom were being treated with anti-hypertensive medications, were involved in the study. Fifty-six patients were dilated with two drops 2.5% phenylephrine and two drops 1.0% tropicamide instilled 5 min apart after one drop of local anesthetic (proparacaine 0.5%). The remaining 62 patients were examined but not dilated. Blood pressure was measured using a sphygmomanometer and stethoscope (right arm sitting) prior to dilation and 30 and 70 min following drop instillation. Results: No clinically significant increase in blood pressure at 30 and 70 min after instillation was observed in the hypertensive group that was dilated. In addition, the change in blood pressure of the dilated group and undilated group was not statistically significant. Conclusion: This study shows that pupillary dilation with 2.5% phenylephrine and 1.0% tropicamide did not significantly increase systemic blood pressure in this population of hypertensive patients.     

Effects of small nonpolar molecules on membrane compressibility and permeability: A theoretical study of the effects of anesthetic gases

We explore from a theoretical perspective the effects of small nonpolar molecules, such as anesthetic gases, on membrane compressibility and permeability. As a model system we expand a previously proposed generalization of Nagle's model for biomembrane phase transitions. In this model anesthetic gases alter membrane compressibility, causing profound changes in membrane permeability. Anesthetics either increase or decrease membrane permeability, depending on whether the membrane lipid is originally in the solid or melted state, or in a two-phase region. These changes are reversed by high pressure, in agreement with experimental results. Anesthetic-induced changes in compressibility are predicted to inhibit fusion of phospholipid vesicles to each other and to planar bilayers, and thus might be expected to inhibit the fusion of presynaptic vesicles with the presynaptic nerve membrane. This work provides a detailed molecular theory for many of the effects of anesthetic gases on both synapse and axon, and provides a coherent framework for understanding diverse experimental results.     

Pressure-induced exclusion of a local anesthetic from model and nerve membranes

Because it is well established that the anesthetic state can be reversed by pressure, a number of molecular theories that have been proposed for the mechanism of action of both local and general anesthetics can be tested by varying the pressure. Using Fourier transform infrared spectroscopy, we report here the first direct observation of the expulsion from lipid bilayers of a local anesthetic, tetracaine, by pressure. Moreover, we establish for the first time that this phenomenon is common to both model membranes and to myelinated and unmyelinated nerve membranes, vindicating the utility of model membrane systems. A distinctive feature of this behavior in model systems is that, in saturated phosphatidylcholines at high pH, expulsion only occurs in the presence of cholesterol, whose ordering effect on the acyl chains evidently assists pressure in squeezing the anesthetic out of the bilayer. This pressure-induced phenomenon may provide insight into the molecular mechanisms underlying the antagonistic effect of pressure against anesthesia.     

Asymmetric antagonistic effects of an inhalation anesthetic and high pressure on the phase transition temperature of dipalmitoyl phosphatidic acid bilayers

The phase transition temperature ($\text{T}{}_{\mathrm{<mtext>t</mtext>}}$) of dipalmitoyl phosphatidic acid multilamellar liposomes is depressed 10°C by the inhalation anesthetic methoxyflurane at a concentration of 100 mmol/mol lipid. Application of 100 atm of helium pressure to pure phosphatidic acid liposomes increased $\text{T}{}_{\mathrm{<mtext>t</mtext>}}$ only 1.5°C. However, application of 100 atm helium pressure to dipalmitoyl phosphatidic acid lipsomes containing 100 mmol methoxyflurane/mol lipid almost completely antagonized the effect of the anesthetic. A nonlinear pressure effect is observed. In a previous study, a concentration of 60 mmol methoxyflurane/mol dipalmitoyl phosphatidylcholine depressed $\text{T}{}_{\mathrm{<mtext>t</mtext>}}$ only 1.5°C, exhibiting a linear pressure effect. The completely different behavior in the charged membrane is best explained by extrusion of the anesthetic from the lipid phase.     

Cardiorespiratory effects of diazepam-ketamine, xylazine-ketamine and thiopentone anesthesia in male Wistar rats--a comparative analysis

Several anesthetics are known to cause respiratory and cardiovascular depression in humans and animals; but, these diverse effects have not been extensively investigated in laboratory rodents. The objective of this study is to choose a suitable anesthetic combination for use in surgical models eg. coronary artery ligation in rats. Male Wistar rats were anesthetized with three different drugs viz. diazepam-ketamine (DK) (2.5 mg/Kg, intraperitoneally (i.p); 50 mg/Kg, i.p), xylazine-ketamine (XK) (5 mg/Kg i.p; 50 mg/Kg i.p) and thiopentone (T) (40 mg/Kg i.p) and the respiratory and cardiovascular functions were assessed after coronary artery ligation. Heart rate (HR), mean arterial pressure (MAP), partial pressure of carbon dioxide (PaCO2), partial pressure of oxygen (PaO2), oxygen saturation percentage (O2 sat (%)), arterial blood pH and rectal body temperature were studied in detail. During the anesthetic regime, HR was lower till 60 min in XK and T ligated group (333 +/- 6; 304 +/- 8 beats/min) and it was near normalcy in the case of DK ligated group (394 +/- 6 beats/min). Significant respiratory depression was particularly reflected in the T ligated group with an increase in PaCO2 at 30 min (40.32 +/- 2.64 mmHg), which decreased to 38.2 +/- 2.23 mmHg at 60 min. Throughout the investigation, DK showed the least overall effects compared to XK and T on respiratory functions. Thus, DK could be considered to be a suitable anesthetic for use in a surgical model such as coronary artery ligation in albino rats.     

Effect of general anesthetics on the properties of lipid membranes of various compositions

Computer simulations of four lipid membranes of different compositions, namely neat DPPC and PSM, and equimolar DPPC-cholesterol and PSM-cholesterol mixtures, are performed in the presence and absence of the general anesthetics diethylether and sevoflurane both at 1 and 600 bar. The results are analyzed in order to identify membrane properties that are potentially related to the molecular mechanism of anesthesia, namely that change in the same way in any membrane with any anesthetics, and change oppositely with increasing pressure. We find that the lateral lipid density satisfies both criteria: it is decreased by anesthetics and increased by pressure. This anesthetic-induced swelling is attributed to only those anesthetic molecules that are located close to the boundary of the apolar phase. This lateral expansion is found to lead to increased lateral mobility of the lipids, an effect often thought to be related to general anesthesia; to an increased fraction of the free volume around the outer preferred position of anesthetics; and to the decrease of the lateral pressure in the nearby range of the ester and amide groups, a region into which anesthetic molecules already cannot penetrate. All these changes are reverted by the increase of pressure. Another important finding of this study is that cholesterol has an opposite effect on the membrane properties than anesthetics, and, correspondingly, these changes are less marked in the presence of cholesterol. Therefore, changes in the membrane that can lead to general anesthesia are expected to occur in the membrane domains of low cholesterol content.     

Membrane permeable local anesthetics modulate NaV1.5 mechanosensitivity

Voltage-gated sodium selective ion channel Na_V1.5 is expressed in the heart and the gastrointestinal tract, which are mechanically active organs. Na_V1.5 is mechanosensitive at stimuli that gate other mechanosensitive ion channels. Local anesthetic and antiarrhythmic drugs act upon Na_V1.5 to modulate activity by multiple mechanisms. This study examined whether Na_V1.5 mechanosensitivity is modulated by local anesthetics. Na_V1.5 channels wereexpressed in HEK-293 cells, and mechanosensitivity was tested in cell-attached and excised inside-out configurations. Using a novel protocol with paired voltage ladders and short pressure pulses, negative patch pressure (-30 mmHg) in both configurations produced a hyperpolarizing shift in the half-point of the voltage-dependence of activation (V_1/2a) and inactivation (V_1/2i) by about -10 mV. Lidocaine (50 µM) inhibited the pressure-induced shift of V_1/2a but not V_1/2i. Lidocaine inhibited the tonic increase in pressure-induced peak current in a use-dependence protocol, but it did not otherwise affect use-dependent block. The local anesthetic benzocaine, which does not show use-dependent block, also effectively blocked a pressure-induced shift in V_1/2a. Lidocaine inhibited mechanosensitivity in Na_V1.5 at the local anesthetic binding site mutated (F1760A). However, a membrane impermeable lidocaine analog QX-314 did not affect mechanosensitivity of F1760A Na_V1.5 when applied from either side of the membrane. These data suggest that the mechanism of lidocaine inhibition of the pressure-induced shift in the half-point of voltage-dependence of activation is separate from the mechanisms of use-dependent block. Modulation of Na_V1.5 mechanosensitivity by the membrane permeable local anesthetics may require hydrophobic access and may involve membrane-protein interactions.     

Membrane permeable local anesthetics modulate NaV1.5 mechanosensitivity

Voltage-gated sodium selective ion channel Na_V1.5 is expressed in the heart and the gastrointestinal tract, which are mechanically active organs. Na_V1.5 is mechanosensitive at stimuli that gate other mechanosensitive ion channels. Local anesthetic and antiarrhythmic drugs act upon Na_V1.5 to modulate activity by multiple mechanisms. This study examined whether Na_V1.5 mechanosensitivity is modulated by local anesthetics. Na_V1.5 channels wereexpressed in HEK-293 cells, and mechanosensitivity was tested in cell-attached and excised inside-out configurations. Using a novel protocol with paired voltage ladders and short pressure pulses, negative patch pressure (-30 mmHg) in both configurations produced a hyperpolarizing shift in the half-point of the voltage-dependence of activation (V_1/2a) and inactivation (V_1/2i) by about -10 mV. Lidocaine (50 µM) inhibited the pressure-induced shift of V_1/2a but not V_1/2i. Lidocaine inhibited the tonic increase in pressure-induced peak current in a use-dependence protocol, but it did not otherwise affect use-dependent block. The local anesthetic benzocaine, which does not show use-dependent block, also effectively blocked a pressure-induced shift in V_1/2a. Lidocaine inhibited mechanosensitivity in Na_V1.5 at the local anesthetic binding site mutated (F1760A). However, a membrane impermeable lidocaine analog QX-314 did not affect mechanosensitivity of F1760A Na_V1.5 when applied from either side of the membrane. These data suggest that the mechanism of lidocaine inhibition of the pressure-induced shift in the half-point of voltage-dependence of activation is separate from the mechanisms of use-dependent block. Modulation of Na_V1.5 mechanosensitivity by the membrane permeable local anesthetics may require hydrophobic access and may involve membrane-protein interactions.     

Spinal puncture headache

Headache is the commonest complication of spinal puncture. There is no significant difference in the incidence of headache after lumbar puncture, whether or not the puncture is followed by injection of an anesthetic agent. The sequence of events leading to postlumbar puncture headaches is probably (1) decreased volume of cerebrospinal fluid with lowered pressure; (2) increased differential between the pressure of the cerebrospinal fluid and the intracranial venous pressure; (3) dilation of venous structures with increase in brain volume; and (4) production of tension on the pain sensitive areas in the cranium. Prevention of postlumbar puncture headache consists largely in attempts to avoid the development of the pressure differential between that of the cerebrospinal fluid and intracranial venous pressure. Treatment consists of analgesics, hydration and attempts to restore normal cerebrospinal fluid pressure.     

Anesthetic inhibition of firefly luciferase, a protein model for general anesthesia, does not exhibit pressure reversal.

The surprising observation that pressures of the order of 150 atmospheres can restore consciousness to an anesthetized animal has long been central to theories of the molecular mechanisms underlying general anesthesia. We have constructed a high-pressure gas chamber to test for "pressure reversal" of the best available protein model of general anesthetic target sites: the pure enzyme firefly luciferase, which accounts extremely well for animal potencies (over a 100,000-fold range). We found no significant pressure reversal for a variety of anesthetics of differing size and polarity. It thus appears that either firefly luciferase is not an adequate model for general anesthetic target sites or that pressure and anesthetics act at different molecular sites in the central nervous system.     

Effect of cervical sympathetic trunk transection on renal sympathetic nerve activity in rats

Stellate ganglion blockade (SGB) with a local anesthetic increases muscle sympathetic nerve activity in the tibial nerve in humans. However, whether this sympathetic excitation in the tibial nerve is due to a sympathetic blockade in the neck itself, or due to infiltration of a local anesthetic to adjacent nerves including the vagus nerve remains unknown. To rule out one mechanism, we examined the effects of cervical sympathetic trunk transection on renal sympathetic nerve activity (RSNA) in anesthetized rats. Seven rats were anesthetized with intraperitoneal urethane. RSNA together with arterial blood pressure and heart rate were recorded for 15 min before and 30 min after left cervical sympathetic trunk transection. The baroreceptor unloading RSNA obtained by decreasing arterial blood pressure with administration of sodium nitroprusside was also measured. Left cervical sympathetic trunk transection did not have any significant effects on RSNA, baroreceptor unloading RSNA, arterial blood pressure, and heart rate. These data suggest that there was no compensatory increase in RSNA when cervical sympathetic trunk was transected and that the increase in sympathetic nerve activity in the tibial nerve during SGB in humans may result from infiltration of a local anesthetic to adjacent nerves rather than a sympathetic blockade in the neck itself.     

Dose effect of pentobarbital sodium on control of breathing in cats

The dose effect of pentobarbital sodium on integrated ("moving time average") phrenic activity (EPHR), transdiaphragmatic pressure (Pdi), gastric pressure (Pga), changes in lung volume (V), and mechanical properties of the respiratory system was studied in six cats breathing room air. Increased pentobarbital dose from an initial value of 35 mg/kg ip, had no substantial effect on the relationship between EPHR and Pdi during both unoccluded and occluded inspirations, indicating that the diaphragmatic excitation-contraction coupling was not affected. Similarly, increased anesthetic dose had no effect on the relationship between EPHR and delta Pga during both occluded and unoccluded breaths, suggesting that the contribution of the diaphragm to the breathing movements did not change with increasing depth of anesthesia. Although the time course of phrenic activity showed substantial interanimal differences, the shape of the phrenic neurogram did not change substantially with increased pentobarbital dose in any of the cats studied. Increased anesthetic dose depressed, in the same proportion, the rate of rise of EPHR, Pdi, and V, but the mechanical properties of the respiratory system remained unchanged. The depression of ventilation with increased anesthetic dose was not proportional to the drop in central inspiratory activity, as quantified in terms of rate of rise of EPHR.     

High pressure antagonism of alcohol effects on the main phase-transition temperature of phospholipid membranes: biphasic response.

The combined effects of high pressure (up to 300 bar) and a homologous series of 1-alkanols (ethanol C2 to 1-tridecanol C13) were studied on the main phase-transition temperature of dipalmitoylphosphatidylcholine (DPPC) vesicle membranes. It is known that short-chain alkanols depress and long-chain alkanols elevate the main transition temperature. The crossover from depression to elevation occurs at the carbon-chain length about C10-C12 in DPPC vesicle membranes coinciding with the cutoff chain-length where anesthetic potency suddenly disappears. Alkanols shorter than C8 linearly decreased the transition temperature and high pressure antagonized the temperature depression. Alkanols longer than C10 showed biphasic dose-response curves. High pressure enhanced the biphasic response. In addition, alkanols longer than the cutoff length depressed the transition temperature under high pressure at the low concentration range. These non-anesthetic alkanols may manifest anesthetic potency under high pressure. At higher concentrations, the temperature elevatory effect was accentuated by pressure. This biphasic effect of long-chain alkanols is not related to the 'interdigitation' associated with short-chain alkanols. The increment of the transition temperature by pressure was 0.0242 K bar-1 in the absence of alkanols. The volume change of the transition was estimated to be 27.7 cm3 mol-1. This value stayed constant to the limit of the present study of 300 bar.