右美托咪定在产科麻醉中的应用进展

正我国产科手术量大,手术方式多,由于产科手术涉及母子安全,因此产科麻醉围术期的安全性与舒适性显得尤为重要。而在无痛人流、剖宫产术中和无痛分娩以及产后镇痛中,均需不断探索一种安全、舒适、经济的,能满足产科麻醉和镇痛需要的药物。右美托咪定作为一种临床上的新药,已逐渐在产科麻醉中使用,本文就右美托咪定在产科麻醉的应用作一综述如下。1无痛人流人工流产术作为一类有创性终止妊娠的方法,患者常会     

靶控输注系统（TCI）在清醒插管中的应用进展

靶控输注系统(TCI)在清醒插管中的应用越来越多地被麻醉医师所关注。清醒插管是临床上处理困难气道插管的常用措施,其过程要求患者处于可唤醒的镇静状态。临床上应用靶控输注丙泊酚、瑞芬太尼达到镇静作用已较普遍,近年来右美托咪啶的应用日益推广,本文针对三种药物使用靶控输注系统在清醒插管中的应用综述了近几年的研究进展。     

剖宫产术围术期预防性应用抗生素的成本效果分析

目的:探讨剖宫产术围术期预防性应用抗生素的成本效果,为剖宫产手术提供有效、经济的抗生素应用方案。方法:选取我院近3年接诊的80例实施剖宫产产妇纳入本次研究,将其随机分为研究组和对照组,每组产妇40例。研究组在胎儿娩出断脐后立即静脉滴注头孢呋辛,术后不再应用抗生素,而对照组术后静脉滴注头孢呋辛,对比两组产妇的成本效果。结果:两组产妇术后体温(平均体温、最高体温)、体温恢复时间、住院时间和术后感染发生率对比均无统计学差异(P0.05);研究组成本效果明显低于对照组(P0.05)。结论:剖宫产术围术期预防性应用抗生素可达到良好的抗感染效果,选择头孢呋辛作为剖宫产手术围术期预防性抗菌药物,是一种有效、经济的方案,可避免围术期过度使用抗生素。     

右美托咪定对生理功能的影响和在临床中的应用

盐酸右美托咪定(dexmedetomidine hydrochloride,Dex))是一种新型α2肾上腺受体激动剂,该药可明显减少麻醉药和阿片类药用量,减轻气管插管及外科手术刺激的血流动力学反应,抑制交感神经反应,增加麻醉期间的循环稳定性,减少麻醉恢复期激动和恶心,是很有前途的麻醉辅助药。该药对缺血的心肌具有保护作用,对呼吸的影响较小,具有镇静、镇痛及抗焦虑作用,还可以降低危重患者的炎症反应以及抗抽搐等作用。右美托咪定还可以对颅内肿瘤切除术期间语言区定位提供良好的镇静作用,在临床中的应用越来越广泛。     

帕瑞昔布钠在术后镇痛中应用的研究进展

手术方式的不断完善和创新,对术后镇痛提出了更高要求。非甾体抗炎药为我国临床术后镇痛常用的一类药物,近年来应用范围仍在不断扩大,但总结长期术后镇痛用药经验发现,传统的非甾体抗炎药易引起胃肠道毒性反应和血小板抑制,因此迫切需要寻找一种安全、有效的术后镇痛药物。帕瑞昔布钠是一种环氧合酶-2(COX-2)特异性抑制剂,注射使用,可用于术后不同程度疼痛的短期治疗,近年来已被临床实践证实具有良好的疗效和较高的安全性。本文结合已经发表的临床研究报道对该药物在术后镇痛中的应用进展进行综述,旨在对该药物的作用机制、疗效、安全性有一个系统性的认识。     

盐酸右美托咪定抗心律失常的研究进展

心律失常是心血管系统的常见病症之一,其发病率和致死率均极高,是心源性猝死的主要诱因。因此,抗心律失常药物的研究与开发已成为医药领域的研究热点。盐酸右美托咪定是一种高选择性α2肾上腺素受体激动剂,广泛应用于重症监护患者的镇静,镇痛及维持血流动力学稳定等方面。近年来,据临床报道,盐酸右美托咪定对先天性心脏病术中及术后常反复发生的交界逸搏性心动过速、房性异位性心动过速、折返性室上性心动过速、室性及室上性心动过速等快速性心律失常具有良好的治疗作用,还可以减轻围术期心肌损伤,有效地维持血流动力学稳定。本文就应用盐酸右美托咪治疗心律失常的研究进展进行阐述。     

胸段硬膜外麻醉的研究进展及应用

硬膜外应用局麻药为手术提供麻醉与镇痛,同时胸段硬膜外麻醉与镇痛也被广泛应用于心脏,大血管,胸部和腹部的手术中.它不仅可以加快病人麻醉后的苏醒,而且可以提供很好的术后镇痛.除了上述优点,许多基础及临床研究发现硬膜外麻醉还有许多其它方面的作用,如:减轻神经内分泌系统的应激反应、减少围术期并发症的发生,以及通过暂时性的阻滞胸交感神经提供心肺及胃肠道的保护作用,改善免疫和凝血功能.本文就近年来胸段硬膜外麻醉应用及研究进展作一综述.     

纳布啡在围手术期镇痛的研究进展

纳布啡是一种新型的菲族镇痛药,属于混合型阿片类受体激动/拮抗剂,可在脊髓水平激动κ受体发挥强效的镇痛效果,其镇痛作用起效迅速、药效持久、疗效确切;同时由于纳布啡独特的部分μ受体拮抗特性,使其与吗啡相比,在发挥镇痛作用的同时呼吸抑制轻、血流动力学平稳以及恶心呕吐、皮肤瘙痒、成瘾性等不良反应发生率更低,因此,纳布啡在围手术期镇痛和临床麻醉等多个领域有着广阔的应用前景。现结合纳布啡独特的药代动力学、药理学特点及作用机制,对纳布啡在围手术期镇痛的研究进展作一综述,以期为临床上合理、有效镇痛提供理论参考和实践依据。     

右美托咪定对腹腔镜手术患者苏醒期血清皮质醇、醛固酮及炎症因子水平的影响

目的:探讨腹腔镜手术(LS)应用右美托咪定(Dex)辅助麻醉对患者苏醒期血清皮质醇(COR)、醛固酮(ALD)及炎症因子水平的影响。方法:选取我院2015年3月~2017年3月收治并择期行LS治疗的138例患者,采取随机数字表法均分为两组。所有患者均采取相同的常规静吸复合麻醉,观察组在此基础上于麻醉诱导前15 min(T_0)静脉滴注负荷剂量为1μg/kg的Dex、而后以0.5μg/(kg·h)速度持续静脉泵注Dex至术毕前10 min,对照组以等剂量生理盐水重复以上操作。记录比较两组T0和拔管后15 min(T_1)应激反应指标、炎症因子水平,麻醉苏醒期镇静-躁动评分(SAS)及术后不良反应的发生情况。结果:与T_0时相比,两组T1时血清COR、ALD、CRP、TNF-α、IL-6水平均显著升高(P0.01),且观察组以上指标均显著低于对照组(P0.01)。观察组麻醉苏醒期SAS评分为(2.96±0.32)分,显著低于对照组【(4.14±0.38)分】(P0.01)。观察组术后不良反应率为4.3%,较对照组(15.9%)明显降低(P0.05)。结论:应用右美托咪定辅助麻醉更能有效降低腹腔镜手术患者苏醒期应激反应,抑制机体炎症反应,提高苏醒质量,且安全性高。     

右美托咪定的临床麻醉应用进展

右美托咪定(dexmedetomidine,Dex)是高选择性α2-肾上腺素受体激动剂,具有镇静、镇痛、抑制交感神经活性、无呼吸抑制等药理性质。多项研究证实:围术期或ICUs住院期间给予患者右美托咪定,可以增加患者机械通气耐受力,减少机械通气时间,改善患者病情恢复,减少呼吸抑制,稳定血流动力学,减少麻醉剂用量及降低麻醉剂不良反应发生率,抑制应激反应,保护肺脏、神经功能、心脏功能,降低谵妄发生率,抗寒颤等作用特点。虽然右美托咪定存在心动过缓及低血压等不良反应,故应控制给药速度、剂量,合理用药在以便循环波动可控范围内。目前,右美托咪定可用于重症监护病房(ICUs)、全身麻醉、区域麻醉、小儿麻醉、日间手术及无痛检查等辅助用药。本文主要对右美托咪定的临床麻醉应用做以下介绍。     

术中不同速率输注右美托咪定在全凭静脉麻醉中的量效关系研究

目的：以脑电双频指数（bispectral index,BIS）作为麻醉镇静程度指标,探讨不同速率输注右美托咪定（dexmedetomidine,DEX）对全凭静脉麻醉中丙泊酚用量,术中重要时点血液动力学及麻醉恢复质量的影响。方法：选择拟于全麻下行妇科腹腔镜手术的患者60例（ASAI～II级）,根据DEX输注速率不同随机分为四组,即D1、D2、D3和D4组,每组15例,麻醉诱导前四组均给予负荷剂量DEX0．5μg·kg-1,10min输注完毕,继而四组分别以0．2、0．4、0．6和0．8μg·kg^-1·h^-1输注速度持续输注至冲洗腹腔。四组麻醉诱导方法相同,术中以BIS作为麻醉深度指标,根据BIS值调节丙泊酚血浆靶浓度维持麻醉。记录入室用药前（T0）、DEX负荷量输注后（T1）、气腹即刻（T2）、气腹后5min（T3）、气腹后30min（T4）、解除气腹后5min（T5）、拔喉罩即刻（T6）、拔喉罩后1min（T7）时收缩压（SBP）、舒张压（DBP）、心率（HR）、丙泊酚平均用量、苏醒时间、拔喉罩时间、拔喉罩后15rainOAA／s评分、术中及术后24小时内不良反应的发生情况。结果：①D2、D3、D4组丙泊酚平均用量较D1组明显减少（P〈0．05）,D3、D4组丙泊酚平均用量较D：组明显减少（P〈0．05）。D3、D4组间差异无统计学意义（P〉0．05）。②与T0比较,Tl～T2时四组SBP、DBP、HR降低（P〈0．05）,T3～T4时D3、D4组SBP、DBP、HR降低（P〈0．05）,D1、D2组SBP、DBP无明显变化（P〉0．05）,T5～T7时四组SBP、DBP、HR降低（P〈0．05）;D3、D4组在T3～T4时SBP、DBP较D1、D2组明显降低（P〈O．05）,D1、D2两组间差异无统计学意义（P〉0．05）,D3、D4两组间差异无统计学意义（P〉0．05）。③D4组苏醒时间、拔喉罩时间、较Dlq组明显延长（P〈0．05）,D4组OAA／s评分较D1-3组明显降低（P〈0．05）。④D4组使用阿托品次数较D1-3组明显增多（P〈0．05）,四组术中使用麻黄碱次数和术后24小时内恶心、呕吐、寒战差异无统计学差异（P〉0．05）。结论：在妇科腹腔镜手术中,DEX作为全身麻醉辅助用药,负荷剂量0．5μg·kg-1,术中持续输注速率0．4μg·kg-1·h-1可以有效降低丙泊酚用量,使围手术期的血流动力学保持平稳,不延长苏醒时间和拔喉罩时间,且不良反应更少,值得临床推广应用。     

Brain protective effect and hemodynamics of dexmedetomidine hydrochloride in patients with intracranial aneurysm

ObjectiveThe purpose of the study was to investigate the effect of dexmedetomidine hydrochloride (Dex) on the recovery of cognitive function, hemodynamics, and postoperative analgesia in patients undergoing intracranial aneurysm craniotomy. Methods: general anesthesia was performed on patients undergoing intracranial aneurysm craniotomy in neurosurgery. Patients were randomly divided into three groups: Dex 1 group (Dex dose: 1 μg/kg), Dex 2 group (Dex dose: 0.5 μg/kg), and blank control group (normal saline). The changes of heart rate, arterial pressure, intraoperative brain function index, and postoperative pain score were recorded and compared. Results: in Dex 1 group and Dex 2 group, the heart rate of T1 and T2 phase was significantly lower than that of T3-T7 phases (P < 0.05); compared with the control group, the heart rate of Dex 1 group and Dex 2 group was significantly lower (P < 0.05). The average arterial pressure of the control group and Dex groups was significantly different (P < 0.05). Compared with the control group, there were significant differences between Dex 1 group and Dex 2 group: S100 β protein in T7-T10, NSE (neuron specific enolase) in T9 and T10, pain score in T8, T9 and T10 after operation. Conclusion: the application of Dex in the resection of intracranial aneurysms can protect the brain of patients, minimize the influence of operation on hemodynamics, and relieve postoperative pain, which is worthy of clinical application.     

清醒镇静与深度镇静在食管胃底静脉曲张内镜诊疗术的麻醉效果及安全性分析

摘要 目的：研究在清醒镇静与深度镇静下实施食管胃底静脉曲张内镜诊疗术的麻醉效果及安全性分析。方法：选取在我院2020年5月至2022年5月收治的94例食管胃底静脉曲张患者，按照随机数字表法将静脉曲张患者分为对照组和观察组，每组47例。对照组采用清醒镇静（咪达唑仑+芬太尼），观察组采用深度镇静在对照组基础上增加丙泊酚。观察对照组与观察组手术治疗时患者基生命体征变化以及手术治疗后的麻醉效果及安全性。比较两组患者治疗后治疗后的总有效率。结果：观察组总有效率显著高于对照组，差异具有统计学意义（P<0.05）。观察组出院时间、麻醉达标时间及术后拔管时间显著小于对照组，差异具有统计学意义（P<0.05）。各时间点实验组患者HR相比差异无显著性（P＞0.05）。在T2，T3，T4时，实验组患者MAP、HR均较对照组显著降低（P＜0.05）。两组患者手术时Ramsay评分和术后满意度比较，两组患者均无统计学差异。对照组和观察组不良反应发生率分别为12.75%和8.49%，两组比较差异无统计学意义（P>0.05）。结论：深度镇静对于食管胃底静脉曲张行内镜诊疗疗效显著而且安全可靠，疗程短，见效快，恢复快，患者接受程度高,提高治疗成功率，值得进行推广。     

Optimization of conscious sedation in plastic surgery.

The administration of conscious sedation by the plastic surgeon must be safe, efficient, and consistent. In the proper setting, with trained staff and appropriate backup, conscious sedation can allow optimal patient satisfaction with expedient recovery in addition to cost containment. The highly effective local anesthesia afforded by dilute, high-volume ("tumescent") infiltration extends the use of conscious sedation to cases previously performed under general anesthesia or deep sedation. The purpose of this analysis was to identify variables in conscious sedation that affect traditional outcome parameters in ambulatory surgery, particularly the duration of recovery and adverse events such as nausea and emesis. All perioperative and operative records of 300 consecutive patients having plastic surgical procedures under conscious sedation were carefully reviewed. Patients were ASA class I or II by requisite. Conscious sedation followed a standardized administration protocol, using incremental doses of two agents: midazolam (0.25 to 1 mg) and fentanyl (12.5 to 50 mcg). A subset of patients received preoperative oral sedation. Multivariate statistical analysis was conducted using SPSS 8.0 for Windows (SPSS Inc., Chicago, Ill.). Of the 300 patients, same-day discharge was intended for 281. Eight procedure categories were defined. No anesthetic complications occurred. As expected, recovery time was significantly correlated with the duration and type of procedure (p < 0.001) and the total dosage of both intraoperative sedative agents (p < 0.001). Interestingly, a negative correlation with advancing age existed (p < 0.001), likely reflecting the significantly higher intraoperative sedative dosing in younger patients (p < 0.001). When controlled for the effects of procedure duration and intraoperative sedative dosing, two other variables-use of preoperative oral sedation and postoperative nausea/emesis-significantly lengthened recovery time (p = 0.0001 for each). Fifteen unintended admissions occurred secondary to nausea, prolonged drowsiness, or pain control needs. Conscious sedation is an effective anesthetic choice for routine plastic surgical procedures, many of which would commonly be performed under general anesthesia. In our experience with a carefully structured and controlled conscious sedation protocol, the technique has proven to be safe and effective. This analysis of outcome parameters identified two important and potentially avoidable causes of recovery delay following conscious sedation-oral premedication and nausea/emesis. Nausea and emesis were particularly problematic in that they were responsible for 11 of 15 (73 percent) unintended admissions. Preoperative sedation is valuable in certain circumstances, and its use is not discouraged; however, its benefits must be weighed against its unwanted effects, which can include a prolongation of recovery.     

Hypothermia in a surgical intensive care unit

Background

Inadvertent hypothermia is not uncommon in the immediate postoperative period and it is associated with impairment and abnormalities in various organs and systems that can lead to adverse outcomes. The aim of this study was to estimate the prevalence, the predictive factors and outcome of core hypothermia on admission to a surgical ICU.

Methods

All consecutive 185 adult patients who underwent scheduled or emergency noncardiac surgery admitted to a surgical ICU between April and July 2004 were admitted to the study. Tympanic membrane core temperature (Tc) was measured before surgery, on arrival at ICU and every two hours until 6 hours after admission. The following variables were also recorded: age, sex, body weight and height, ASA physical status, type of surgery, magnitude of surgical procedure, anesthesia technique, amount of intravenous fluids administered during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, ICU length of stay, hospital length of stay and SAPS II score. Patients were classified as either hypothermic (Tc ≤ 35°C) or normothermic (Tc> 35°C). Univariate analysis and multiple regression binary logistic with an odds ratio (OR) and its 95% Confidence Interval (95%CI) were used to compare the two groups of patients and assess the relationship between each clinical predictor and hypothermia. Outcome measured as ICU length of stay and mortality was also assessed.

Results

Prevalence of hypothermia on ICU admission was 57.8%. In univariate analysis temperature monitoring, use of warming techniques and higher previous body temperature were significant protective factors against core hypothermia. In this analysis independent predictors of hypothermia on admission to ICU were: magnitude of surgery, use of general anesthesia or combined epidural and general anesthesia, total intravenous crystalloids administrated and total packed erythrocytes administrated, anesthesia longer than 3 hours and SAPS II scores. In multiple logistic regression analysis significant predictors of hypothermia on admission to the ICU were magnitude of surgery (OR 3.9, 95% CI, 1.4–10.6, p = 0.008 for major surgery; OR 3.6, 95% CI, 1.5–9.0, p = 0.005 for medium surgery), intravenous administration of crystalloids (in litres) (OR 1.4, 95% CI, 1.1–1.7, p = 0.012) and SAPS score (OR 1.0, 95% CI 1.0–1.7, p = 0.014); higher previous temperature in ward was a significant protective factor (OR 0.3, 95% CI 0.1–0.7, p = 0.003). Hypothermia was neither a risk factor for hospital mortality nor a predictive factor for staying longer in ICU.

Conclusion

The prevalence of patient hypothermia on ICU arrival was high. Hypothermia at time of admission to the ICU was not an independent factor for mortality or for staying longer in ICU.     

快通道麻醉在小儿先天性心脏病手术中的应用及对镇静、镇痛效果的影响

目的:探讨快通道麻醉在小儿先天性心脏病手术中的应用及对镇静、镇痛效果的影响。方法:选择2016年6月至2018年5月在桂林医学院附属医院进行手术治疗的小儿先天性心脏病患儿82例,按照随机数字表法分为对照组(41例)和观察组(41例),对照组进行常规麻醉,观察组则采用快通道麻醉。对比两组患儿麻醉药物用量、手术时间、阻断时间、体外循环时间、术后拔管时间、住院时间、住院费用及并发症发生情况,观察两组患儿术后12h镇静、镇痛效果。结果:观察组患儿芬太尼和罗库溴铵用量明显低于对照组(P0.05)。两组患儿的术中各指标比较无统计学差异(P0.05),而与对照组相比,观察组患儿术后住院时间、拔管时间均缩短,且住院费用减少(P0.05)。观察组患儿术后12h的镇静及镇痛效果均优于对照组(P0.05)。观察组患儿术后并发症发生率为17.07%(7/41),低于对照组的39.02%(16/41)(P0.05)。结论:快通道麻醉可减少小儿先天性心脏病手术的芬太尼和罗库溴铵用量,不仅缩短术后拔管时间和住院时间,降低住院费用,而且可改善镇静及镇痛效果,安全有效。     

The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases

The use of conscious sedation is rapidly gaining acceptance and popularity in plastic surgery. At the present time, many procedures are performed using intravenous sedation and local anesthesia. The purpose of this article was to examine the safety and outcome of full abdominoplasties performed under conscious sedation at the authors' institution. Over a 6-year period from 1997 to 2002, 266 abdominoplasties were performed by the two senior authors. One hundred thirteen of these (42 percent) were performed under a general or regional anesthetic because a concurrent procedure was performed that precluded the use of conscious sedation (64 hysterectomies, 18 hernia repairs, six urogynecologic procedures, 10 breast reductions, and one laparoscopic cholecystectomy) or because of patient and surgeon preference (14 cases). One hundred fifty-three abdominoplasties (58 percent) were performed under conscious sedation using intravenous midazolam and fentanyl along with a local anesthetic. No patients had an unplanned conversion to deep sedation or general anesthesia. Eighty percent of these cases were performed with a concurrent procedure (80 liposuctions, 19 breast augmentations, 20 mastopexies, three capsulotomies, and 13 varied facial aesthetic procedures). In addition, 12 patients had concurrent hernia repairs (five ventral and seven umbilical) under conscious sedation. Mean follow-up was 10 months (range, 1 to 56 months). There were no intraoperative complications and no major postoperative complications. The minor complication rate was 11.1 percent (10 seromas requiring needle aspiration in the office, three superficial wound infections, two cases of marginal skin necrosis, one stitch abscess, and one pseudobursa requiring reexcision). Seven revisions were performed for suboptimal scars (5 percent). The results of this study demonstrate that abdominoplasties can be performed under conscious sedation in a safe and cost-effective manner for almost all patients. This type of procedure is well tolerated, has a low complication rate, and has high patient satisfaction. Increasing experience and small modifications in local anesthesia and surgical technique have strengthened the authors' conviction that conscious sedation is the preferred method of anesthesia for most patients undergoing abdominoplasty.     

Perioperative management of cosmetic liposuction

Recent qualms about the safety of aesthetic lipoplasty may be attributable more to support system flaws than to technical process deficiencies. The authors here focus on perfunctory patient monitoring when sedative or analgesic drugs are given, cavalier infiltration of mega-dose lidocaine, cursory intraoperative patient observation by team members with conflicting responsibilities, anesthesia providers unfamiliar with the unique surgical physiology of liposuction, hurried-discharge policies that virtually ignore the residual depressant effects of sedatives and analgesics, and compressive dressings that impair postoperative chest-wall expansion and venous return. Whereas pulmonary embolism remains the leading process cause of morbidity from liposuction, complications from austere resource allocation to dedicated patient monitoring should be largely preventable. Not all lipoplasties require an anesthesia provider but-when heavy sedation, mega-dose lidocaine, or both, are projected-a trained team member dedicated exclusively to patient safety and comfort should be a minimum patient care standard. The potential role of lidocaine cardiotoxicity in tumescent anesthesia is widely underappreciated and that of hypothermia goes mostly unrecognized. These, plus largely preventable or potentially correctable perioperative events such as pulmonary edema, fluid imbalance, or improperly administered sedative and analgesic drugs, demand upgrading and expansion of monitoring, resuscitative, and recuperative facilities in physician offices. In fact, ASPS guidelines urge that anesthesia services be engaged for dedicated patient care whenever "major" liposuction or conscious sedation is projected, because liposuction is neither as benign nor as simple a procedure as heretofore reputed. To assess objectively the operative and anesthetic risk of obesity, document body mass index for the preoperative record; morbid obesity (body mass index >/= 35.0), for instance, is a known risk multiplier for sedatives and analgesics. Other system issues such as the dynamic profile of high-dose lidocaine pharmacokinetics, the deportation of fat globules in the bloodstream, and the incidence of intraoperative hypothermia remain as unresolved topics for interdisciplinary, multi-institutional clinical research.