丙泊酚联合瑞芬太尼全静脉麻醉在妇科腹腔镜手术中的应用

目的 研究丙泊酚联合瑞芬太尼全静脉麻醉在妇科腹腔镜手术中的临床应用.方法 选择40例ASA Ⅰ、Ⅱ级择期妇科腹腔镜手术患者,采用丙泊酚联合瑞芬太尼作全静脉麻醉.丙泊酚1.5～2.0mg/kg、瑞芬太尼1 μg/kg、维库溴铵0.1 mg/kg诱导插管,术中维持丙泊酚2～4 mg/(kg·h)、瑞芬太尼0.1～0.3μg/(kg·min),间隔30 min追加维库溴铵2～3 mg.记录围术期血流动力学指标、麻醉药用量及麻醉后患者恢复情况.结果 40例患者麻醉诱导后收缩压(SP)、舒张压(DP)明显降低,心率(HR)减慢,气管插管、切皮气腹时上述指标无明显改变,手术结束后停用麻醉药患者苏醒快,无烦躁不安及再度呼吸抑制现象,术中无知晓.结论 丙泊酚联合瑞芬太尼全静脉麻醉诱导快速,维持麻醉平稳,停药后清醒快,气管导管耐受好,并发症少,适于妇科腹腔镜手术麻醉.     

不同药物用于支撑喉镜手术气管插管时的血流动力学比较

目的比较瑞芬太尼、丙泊酚、艾司洛尔用于支撑喉镜手术气管插管时患者的心血管反应。方法选取2009年13月就诊的60例拟于全身麻醉下行择期支撑喉镜下声带息肉切除术的患者,随机分为丙泊酚组、艾司洛尔组和瑞芬太尼组,每组20例。麻醉诱导采用咪达唑仑、芬太尼和丙泊酚,患者意识消失后给予琥珀胆碱。1min后各组分别给予丙泊酚2mg/kg、艾司洛尔1mg/kg和瑞芬太尼1μg/kg。30s后进行气管插管。记录患者诱导前及插管前、插管后1、3、5min的心率和血压水平。结果各组插管前的收缩压和心率较诱导前明显降低,插管后1、3min的收缩压和心率较插管前升高（P〈0.05）。丙泊酚组和艾司洛尔组插管后的收缩压较瑞芬太尼组升高（P〈0.05）。丙泊酚组插管后心率较瑞芬太尼组增加（P〈0.05）。结论对行支撑喉镜手术的患者,气管插管前30s给予1μg/kg瑞芬太尼较2mg/kg丙泊酚和1mg/kg艾司洛尔能更有效地减轻气管插管时的血流动力学反应。     

小儿七氟醚麻醉喉罩置入时瑞芬太尼最佳剂量的临床研究

目的:研究未用肌松剂5%七氟醚诱导下成功置入喉罩时瑞芬太尼的最佳剂量。方法:30位2～12岁施行整形手术的小儿,5%的七氟醚加100%的氧气吸入麻醉诱导60s后,注入瑞芬太尼速度大于30s。采用改良Dixon序贯法确定喉罩置入时瑞芬太尼的剂量,初始剂量为0.8μg/kg,0.1μg/kg为1个增减单位。喉罩在瑞芬太尼注入结束后90s置入,根据患者的反应("有体动"或"没有体动")调整剂量。结果:在不用肌松剂的情况下,5%的七氟醚加100%的氧气吸入麻醉诱导下,50%小儿喉罩成功置入瑞芬太尼剂量为(0.53±0.08)μg/kg。采用概率检验分析,5%的七氟醚麻醉未使用肌松剂时50%小儿成功置入喉罩瑞芬太尼ED50和ED95分别为0.47μg/kg和0.77μg/kg。结论:小儿5%的七氟醚麻醉未使用肌松剂时,瑞芬太尼成功置入喉罩的ED95为0.77μg/kg。     

瑞芬太尼复合丙泊酚全麻下行神经介入手术27例的体会

目的：观察瑞芬台尼复合丙泊酚全麻下行神经介入手术诱导插管时血压的波动情况及手术结束后麻醉恢复时间。方法：用力月西0．1mg／kg，瑞分太尼1ug／kg，丙泊酚1mg／kg，维库澳胺0.1mg／kg诱导插管，术中用瑞分太尼0.1～1.0ug／kg／min，丙泊酚10～20ml／h静脉泵入维持麻醉，间断静推维库澳胺。结果：诱导时血压波动较小，麻醉恢复时间缩短。结论：瑞芬太尼复合丙泊酚全麻插管行神经介入手术具有安全、可控及手术后恢复快而彻底。     

全麻下喷射通气与间歇正压控制通气应用于声带手术的比较

目的 :比较声带显微外科手术中 ,全麻及肌松条件下行喷射通气与间歇正压控制通气的临床效果。方法 :ASAⅠ～Ⅱ级行声带息肉摘除术的成年患者 40例 ,随机分为两组 :Ⅰ组 (喷射通气组 ) 2 0例 ,Ⅱ组 (间歇正压控制通气组 ) 2 0例。两组均以芬太尼 3 μg/kg ,丙泊酚 2mg/kg ,阿曲库铵 0 5mg/kg静脉诱导后 ,Ⅰ组不作气管插管 ,仅在声门口行喷射通气 ;Ⅱ组则行气管插管间歇正压通气。观察比较两组的通气变化、心率、血压及术毕苏醒时间。结果 :Ⅰ组 (喷射通气组 )中 4例由于屏气导致血氧下降 ,置入支撑喉镜后心率明显增快 (P <0 0 5 ) ,血压值变化不明显 ;Ⅱ组 (间歇正压控制通气组 )心率、血压、血氧变化不明显。两组术毕苏醒时间 ,Ⅱ组 (19 0 0± 3 16)min明显短于Ⅰ组 (2 6 5 0± 3 2 4)min(P <0 0 1)。结论 :全麻及肌松条件下行声带手术 ,采用间歇正压控制通气技术优于喷射通气技术 ,麻醉可控性强     

老年术后患者认知功能恢复与瑞芬太尼及丙泊酚静脉用药的影响

目的:研究瑞芬太尼、丙泊酚全凭静脉麻醉对老年患者开胸手术后认知功能恢复的影响。方法:选择2003-01/2004-12年潍坊市人民医院肿瘤外科和胸外科收治的食管癌患者,随机选择40例择期行食管癌根治术患者,ASAⅠ～Ⅱ级,年龄≤65岁,术前无神经、精神系统疾病史或药物滥用史,受教育程度:小学。其中,20例麻醉诱导与维持为:瑞芬太尼+丙泊酚+卡肌宁(瑞芬太尼组),20例为芬太尼+丙泊酚+卡肌宁(芬太尼组)。分别在麻醉手术前一晚、术后30min,2,6,12,24,48h应用简易精神状态量表评定其认知功能。结果:两组自主呼吸恢复时间相似,睁眼时间(4.1±2.6vs2.2±1.0)、拔管时间(6.0±3.1vs3.3±2.0)、陈述自己姓名、出生日期时间(8.9±5.8vs4.0±2.5),瑞芬太尼组明显比芬太尼组短(P<0.01)。与术前相比,两组患者术后30min,2h简易精神状态量表评分值均明显降低(P<0.01);瑞芬太尼组6h评分与术前比无明显差异,芬太尼组简易精神状态量表评分值在术后12h与术前比无明显差异(P>0.05)。结论:瑞芬太尼、丙泊酚全凭静脉麻醉对老年患者开胸手术后认知功能影响小,恢复快。     

成人不同浓度七氟醚诱导无肌松气管插管时瑞芬太尼的半数有效量

目的确定在不同浓度七氟醚复合瑞芬太尼诱导无肌松气管插管时瑞芬太尼的半数有效量（ED50）。方法 2009年7月-2009年11月择期手术患者60例,ASAI～II,年龄20～59岁,按照入室的顺序随机分为Ⅰ组（2%七氟醚组）和Ⅱ组（3%七氟醚组）,预冲8%七氟醚诱导,眼睑反射消失后,调节七氟醚呼气末浓度分别维持在2%或3%,同时按照序贯法注入瑞芬太尼,瑞芬太尼注射90s后气管插管。记录麻醉诱导前、患者意识消失时、插管前1min、插管后1min及插管后3min心率、平均动脉压的变化。结果 2%、3%的七氟醚复合瑞芬太尼诱导气管插管时瑞芬太尼的半数有效量（ED50）及其相对应的95%可信区间分别为0.585μg/kg及0.533～0.626μg/kg和0.492μg/kg及0.451～0.572μg/kg。结论 2%、3%的七氟醚复合瑞芬太尼诱导气管插管时瑞芬太尼的半数有效量及其相对应的95%可信区间分别为0.585μg/kg及0.533～0.626μg/kg和0.492μg/kg及0.451～0.572μg/kg。     

瑞芬太尼联合丙泊酚用于老年开胸患者全凭静脉麻醉的效果分析

目的评价瑞芬太尼联合丙泊酚用于老年开胸患者全凭静脉麻醉的临床效果。方法 60例拟行开胸手术的老年患者,ASA分级为Ⅰ~Ⅱ级,随机分为瑞芬太尼组(R组),和芬太尼组(F组),每组各30例。麻醉诱导:R组采用咪唑安定0.05 mg/kg,丙泊酚2 mg/kg,瑞芬太尼1μg/kg,维库溴铵0.1 mg/kg。F组采用芬太尼3μg/kg,代替瑞芬太尼。气管插管行机械通气。麻醉维持:R组持续泵注瑞芬太尼0.1~0.3μg/(kg.min),丙泊酚3~4 mg/(kg.h)。F组芬太尼0.03~0.05 mg/(kg.min),丙泊酚3~4 mg/(kg.min)持续泵入,两组均间断静脉注射维库溴铵0.03 mg/kg。R组在手术结束前10 min停止泵入丙泊酚,在手术结束时停止泵入瑞芬太尼。F组在手术结束前25 min停止泵入芬太尼,手术结束前10 min停止泵入丙泊酚。结果 R组诱导时血压下降幅度明显小于F组。麻醉维持期间,R组血流动力学变化小于F组。结论瑞芬太尼联合丙泊酚全凭静脉麻醉用于老年开胸患者麻醉效果好,对患者的心率及血压改变不明显,术毕苏醒迅速。     

无创机械通气治疗重症肌无力危象所致急性呼吸衰竭的临床研究

目的评价无创机械通气治疗重症肌无力危象所致急性呼吸衰竭的临床应用价值。方法记录无创机械通气治疗前、治疗2 h、治疗结束时患者的心率(HR)、呼吸频率(RR)、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、无创机械通气时间、ICU住院时间和胆碱酯酶抑制剂应用剂量。结果无创机械通气前患者HR(106.8±25.5)次/m in,RR(26.6±10.0)次/m in,pH(7.34±0.06),PaO2(56.3±19.0)mm Hg,PaCO2(58.8±7.8)mm Hg,无创机械通气2 h后患者HR、R、动脉血pH、PaO2、PaCO2等指标较无创机械通气前明显改善(P<0.05)。胆碱酯酶抑制剂溴化吡啶斯的明平均用量为(456±251)mg。平均无创机械通气时间(6.0±4.6)d。平均ICU住院时间为(11.1±7.7)d。结论无创机械通气能降低重症肌无力危象所致急性呼吸衰竭患者的气管插管率。     

无创正压通气治疗急性Ⅰ型呼吸衰竭的临床意义

目的:探讨无创正压通气治疗急性Ⅰ型呼吸衰竭的疗效。方法:采用无创正压通气治疗33例不同病因引起的急性Ⅰ型呼吸衰竭患者,观察其疗效。结果:20例通气成功,通气1小时后呼吸困难缓解,呼吸频率由(36±6)次/分下降至(24±4)次/分(P<0.05);动脉血氧饱和度由治疗前的0.83±0.07升至0.96±0.04,氧合分数(动脉血氧分压/吸入气氧浓度)由治疗前的112±25上升至236±31,平均通气时间为29小时,均无死亡。13例通气失败,改行气管插管机械通气,其中8例死亡。结论:无创正压通气治疗急性Ⅰ型呼吸衰竭,能有效地改善气体交换,并避免气管插管。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.