鼻内镜手术中控制性降压麻醉后动脉压、心率与术野出血的关系

目的观察鼻内镜手术中，全身麻醉控制性降压后动脉压、心率与术野出血的关系。方法48例病人依据美国麻醉医师协会(ASA)病情分级Ⅰ、Ⅱ级，进行鼻内镜手术的病人被随机分成2组，每组24人。N组只接受硝普钠进行控制性降压麻醉；C组接受硝普钠和艾司络尔进行控制性降压麻醉。常规麻醉诱导，用1～2％异氟醚和50％N2O维持。两组病人术中平均动脉压保持在60～65mmHg之间，C组病人通过调整艾司络尔用量将心率维持在80～90次／分。根据Fromme术野质量评分表在手术开始后5、15、30、45分钟由同一术者进行术野质量评分。结果C组病人术中心率明显低于N组，同样C组的术野质量评分也明显低于N组。结论鼻内镜手术控制性降压后术野质量与心率密切相关。     

鼻内镜手术中瑞芬太尼和硝普钠控制性降压效果比较

目的比较鼻内镜手术中瑞芬太尼和硝普钠控制性降压的效果。方法72例择期鼻内镜手术患者随机分成3组，每组24例。N组硝普钠控制性降压：C组硝普钠控制性降压并用爱络控制心率（heart rate，HR）：R组瑞芬太尼控制性降压。前两组术中平均动脉压（mean arterial blood pressure，MAP）维持在60-65mmHg，C组将HR控制在80～90次／分，R组MAP控制在66-75mmHg。根据Fromme术野质量评分（scores of surgical field quality，SSFQ）由同一术者在手术开始后5，15，30，45分钟进行评定。结果R组MAP明显高于前两组，SSFQ和HR明显低于C组，更明显低于N组。结论鼻内镜手术中瑞芬太尼控制的靶血压明显高于硝普钠，术野质量亦明显优于硝普钠。     

鼻内镜手术中控制性降压麻醉后动脉压、心率与术野出血的关系

目的 观察鼻内镜手术中,全身麻醉控制性降压后动脉压、心率与术野出血的关系。方法 48例病人依据美国麻醉医师协会(ASA)病情分级Ⅰ、Ⅱ级,进行鼻内镜手术的病人被随机分成2组,每组24人。N组只接受硝普钠进行控制性降压麻醉;C组接受硝普钠和艾司络尔进行控制性降压麻醉。常规麻醉诱导,用1～2％异氟醚和50％N_2O维持。两组病人术中平均动脉压保持在60～65mmHg之间,C组病人通过调整艾司络尔用量将心率维持在80～90次/分。根据Fromme术野质量评分表在手术开始后5、15、30、45分钟由同一术者进行术野质量评分。结果 C组病人术中心率明显低于N组,同样C组的术野质量评分也明显低于N组。结论 鼻内镜手术控制性降压后术野质量与心率密切相关。     

内镜鼻窦手术中出血与麻醉方式的关系

目的　探讨有效减少内镜鼻窦手术中出血的麻醉方式。方法　选择临床分型分期为Ⅱ型3期的慢性鼻窦炎鼻息肉病例80例，随机分为4组，每20例1组，分别在局部麻醉、普通全麻、硝普钠(SNP)行控制性降压全麻和SNP复合美托洛尔行控制性降压全麻下手术。术后统计分析各组的出血量、手术时间以及全麻各组的平均动脉压(MAP)、心率(HR)、心率收缩压乘积(RPP)和SNP用量。结果　各组手术的平均出血量和手术时间分别是①局麻组为(91.25±72.55)ml和(57.95±9.70)min；②普通全麻组为(436.5±36.39)ml和(102.5±45.87)min；③SNP降压组为(109.75±59.48)ml和(70.00±20.77)min；④SNP复合美托洛尔组为(104.50±88.70)ml和(69.00±22.51)min。SNP复合美托洛尔行控制性降压全麻，血压下降明显、平稳，且心率也明显下降，SNP用量减少。结论　局麻和控制性降压全麻下手术的出血量明显少于普通全麻，且手术时间较短。控制性降压全麻以SNP复合美托洛尔为优。     

控制性降压麻醉在鼻内窥镜手术中的应用

鼻硬性内窥镜直视下进行各类复杂困难手术，出血多，止血困难。选５２例Ⅱ～Ⅳ期鼻窦炎、鼻息肉患者。随机分为降压组和对照组各２６例，在全麻下用硝普钠（０．５～５μｇ／ｋｇ／分钟）进行控制性降压，以减少术中出血。对降压组各项血流动力学和血气分析变化进行观察，结果表明降压组出血量比对照组减少４５％，手术时间缩短４２％，效果显著，无并发症。降压后心率（ＨＲ）增快，每搏量（ＳＶ）、心输出量（ＣＯ）、中心静脉压（ＣＶＰ）降低。表明有相对血容量不足的倾向，应注意充分扩容。     

瑞芬太尼和硝普钠对兔鼻黏膜血流的影响

目的 观察静脉持续泵入瑞芬太尼和硝普钠对兔鼻黏膜血流的影响。方法 将20只新西兰大白兔随机分为瑞芬太尼组（R组）和硝普钠组（S组）,每组10只。建立兔全麻模型后,R组静脉持续泵入瑞芬太尼,S组静脉持续泵入硝普钠,分别记录2组给药前及给药后新西兰大白兔的心率（HR）、平均动脉压（MAP）、颈总动脉血流（CABF）和鼻黏膜血流（NBF）。结果 与给药前比较,R组HR减慢,MAP轻度下降,CABF轻度减少,NBF明显减少,且差异均有统计学意义（P<0.05）; S组HR增快,MAP显著下降,CABF轻度减少,NBF明显增加,差异亦均有统计学意义（P<0.05）。给药后,S组比R组MAP下降幅度大（P<0.05）; S组NBF明显增多,而R组NBF明显减少。S组同步监测的MAP与NBF呈负相关（r=-0.51, P＜0.05）, R组MAP与NBF间无明显相关性(P＞0.05),2组MAP与CABF之间及CABF与NBF之间均无明显相关性(P＞0.05)。结论 与硝普钠相比,瑞芬太尼可显著减少鼻黏膜微循环血流,而对MAP和CABF影响轻微,提示选择瑞芬太尼用于鼻内镜手术的控制性降压更安全、有效。     

几种不同降压药物用于内镜鼻窦手术的临床分析

目的观察硝普钠、硝酸甘油、硝酸甘油 盐酸艾司洛尔及尼卡地平用于内镜鼻窦手术中控制性降压的有效性和安全性及其对血液动力学的影响.方法 80例Ⅱ型3期慢性鼻窦炎鼻息肉患者随机分成四组,即组Ⅰ(硝普钠)、组Ⅱ(硝酸甘油)、组Ⅲ(硝酸甘油 盐酸艾司洛尔)和组Ⅳ(尼卡地平).用美国cardiodyn无创血液动力学监测系统阻抗法连续观察用药期间的血液动力学的变化.结果血压的变化:注药后5分钟平均动脉压(MAP)均较基础值下降(P＜0.05).组Ⅰ舒张压(DBP)的下降幅度明显大于其它三组(P＜0.01);组Ⅲ和组ⅣDBP的影响较小.心率(HR)的影响:组Ⅱ心率(HR)增快较其它三组更明显,而组Ⅲ对HR的影响明显小于其它三组(P＜0.01),其次组ⅣHR增快的幅度略低于组Ⅰ和组Ⅱ.心输出量(CO)的影响:组Ⅰ和组Ⅳ5～10分钟心输出量(CO)较基础值均有不同程度的增加(P＜0.05),而组Ⅱ和组ⅢCO较基础值有所下降(P＜0.05),5分钟分别下降33.3%和27.1%.结论硝酸甘油 盐酸艾司洛尔或尼卡地平用于内镜鼻窦手术中控制性降压对血液动力学影响较小,降压过程平稳,易于调控.     

控制性降压麻醉在复发性鼻息肉内镜鼻窦手术中的应用体会

目的：探讨控制性降压麻醉在内镜鼻窦手术中的应用。方法：选择临床分型分期为Ⅲ型的复发性鼻息肉或兼有慢性多发性鼻窦炎或兼有全组鼻窦炎病例90例（165侧）施行内镜鼻窦手术，随机分为控制性降压麻醉治疗组45例（83侧），局麻＋杜冷丁对照组45例（72侧），全部病例随访3个－2年，结果：控制性降压麻醉治疗组术中出血明显减少，与局麻＋杜冷丁对照组相比有显著差异（P＜0．001），治愈57例（63．3％），好转28例（31．1％），无效5例（5．6％），治愈好转率为94．4％，术前90例嗅觉减退或丧失的患者中，术后19例恢复，34例改善，37例无变化，治愈好转率58．9％（53／90），结论：控制性降压麻醉在内镜鼻窦手术中可以明显减少手术出血，提供清晰的手术视野，使病变显露清楚，手术者操作方便，为防止息肉和炎症复发提供了技术上的保证。     

“精控性”低血压麻醉在耳鼻喉科手术的应用

控制性低血压(controlled hypoteosion)是第二次世界大战结束后不久出现的一种麻醉法,它藉降低患者动脉压以减少手术部位的出血,但其并发症并不罕见,文中引用一例用硫喷妥钠、琥珀胆硷、笑气和氟烷作控制性低血压麻醉进行额窦、筛窦手术引起截瘫的病例。作者介绍的“精控性”低血压(deliberate hypotension)中使用的主要药物为硝普钠(SNP),该药通过直接作用于血管壁的平滑肌使血管舒张而降低血压,且因其作用时间短,故使血压迅速恢复正常。作者主张用“精控性”一词以代替“控制性”一词。     

尼卡地平控制性降压在鼻内镜手术中的应用

目的探讨尼卡地平控制性降压在鼻内镜手术中应用的优越性。方法择期全麻下鼻内镜手术80例,随机分为2组：A组安氟醚组和B组尼卡地平组各40例。比较两组的降压效果,降压中监测平均动脉压和心率,记录降压起效时间、维持时间和复压时间,记录两组降压过程中的不良反应。结果①尼卡地平组降压起效时间比安氟醚组快,复压时间比安氟醚组短（P〈0．01）;②安氟醚组心率变化快慢不定,尼卡地平组心率均减慢,但无心动过缓现象,差异有统计学意义（P〈0．05）：③安氟醚组不良反应重,尼卡地平组不良反应轻微（P〈0．01）。结论与安氟醚组相比,鼻内镜手术中应用尼卡地平能较好的控制血压,复压时间短,心血管抑制轻,降压不仅迅速,更重要的是平稳。     

The effect of beta-blocker premedication on the surgical field during endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS: A number of previous studies have tried to assess the effects of hypotension on the surgical field during endoscopic sinus surgery. These studies have been limited by inadequate sample sizes, lack of a control group, and limited data collection. The aim of the present study was to determine whether the routine use of beta-blockers as a pre-medication could improve the operative field in endoscopic sinus surgery. STUDY DESIGN: A prospective, randomized, double-blinded, placebo-controlled trial. METHODS: Eighty patients undergoing endoscopic sinus surgery who fit the inclusion and exclusion criteria were randomly assigned to receive either a beta-blocker, Metoprolol (group 1), or a placebo tablet (group 2) 30 minutes before surgery. A standard anesthetic protocol was followed. At the commencement of surgery and at regular 15-minute intervals the surgical field, blood loss, heart rate, blood pressure, and isoflurane concentration were assessed. RESULTS: There was a significant difference in overall mean heart rate between the placebo and beta-blocker groups (P <.0001). In the entire group, surgical grade correlated with heart rate (r = 0.36, P <.05) but not with mean arterial blood pressure. Mean surgical grade was similar between the placebo and beta-blocker groups, but early in the study a significantly better surgical field was recorded in the beta-blocker group (P <.001). Surgical grade was significantly better in those with a mean heart rate of less than 60 beats per minute (P <.02). CONCLUSION: Although "optimum" conditions were present in the patients receiving beta-blocker, the authors thought that the grading system was not discriminating enough to demonstrate a significant difference between the groups. The crucial finding in the study was the correlation between heart rate and surgical grade in the entire group. During endoscopic sinus surgery surgery, anesthetic manipulations should be directed at maintaining a low heart rate.     

Using remifentanil and sufentanil in functional endoscopic sinus surgery to improve surgical conditions

The purpose of the study was to compare three types of general anesthesia for functional endoscopic sinus surgery (ESS) with controlled hypotension measuring the quality of visibility of the surgical field and the blood loss during the operation. Seventy-one patients underwent endoscopic ethmoidectomy bilaterally for nasal polyposis and/or chronic sinusitis. The patients were divided into three groups according to the type of anesthesia they had: group A (sufentanil/sevoflurane), group B (remifentanil/propofol), and group C (fentanyl/isoflurane). The mean estimated blood loss for group A was 117.83 ml, for group B it was 100.5 ml and for group C it was 198.89 ml. The average quality of visibility of the surgical field was 1.57 for group A, 1.3 for group B and 2.79 for group C. The quantity of blood loss (p < 0.01) and the visibility of the surgical field (p < 0.001) demonstrated a difference among the three groups. Remifentanil and sufentanil during functional ESS enable controlled hypotension and a general improvement in surgical conditions.     

静脉全麻对鼻内镜手术中出血量的影响

目的 观察综合措施基础上静脉全身麻醉对鼻内镜手术中出血量的影响。方法 将60例患者随机分为2组, 每组30例。A组为静脉全麻组, B组为吸入全麻组。两组患者诱导气管插管后, A组以丙泊酚及瑞芬太尼持续泵注维持麻醉至手术结束前5 min停药;B组以吸入七氟烷维持麻醉, 手术结束前5 min停药。两组均行桡动脉置管测压和采血, 综合措施包括:手术开始前15 min行急性高容量血液稀释、控制性降压及静脉注射蛇毒类血凝酶1.0单位。观察手术开始前30 min(T₀)、手术开始后30 min(T₁)、90 min(T₂)及手术结束后30 min(T₃)4个时间点的动脉血气、静脉血乳酸浓度、凝血功能变化。记录2组患者手术结束时术中出血量及手术时间。结果 与T₀比较, T₁、T₂、T₃ 3个时间点动脉血气、静脉血乳酸浓度及凝血功能差异无统计学意义(P>0.05)。A组手术出血量明显少于B组(P<0.05)。结论 综合措施基础上采用静脉全身麻醉有助于减少鼻内镜手术中出血量。     

鼻内窥镜手术全麻控制性降压期间肱动脉间接测压与足背动脉直接测压的比较

45例全麻控制性降压下行鼻内窥镜手术患者 ,同期监测肱动脉间接压力和足背动脉直接压力。共收集 110 5对数据。结果显示 ,两种监测方法的相关性较差。正常及高血压状态下 ,足背动脉直接测得收缩压高于肱动脉间接测压数值 ,而舒张压低于肱动脉间接测压数值。低血压状态下 ,是背动脉直接测得的收缩压、舒张压和平均压均低于肱动脉间接测压数值     

The efficacy of esmolol,remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery

IntroductionControlled hypotension is a reversible procedure in which the patient’s baseline mean arterial blood pressure is reduced by 30% and sustained at 60–70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures.ObjectivesThe purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency.MethodsThe research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon’s satisfaction.ResultsBetween May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15–51), 43.0 mL (21–105) and 40.0 mL (26–97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon’s satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001).ConclusionLess volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients’ characteristics and advantages/disadvantages of the drugs.     

Marked hypotension induced by adrenaline contained in local anesthetic

OBJECTIVES: Local anesthetics containing adrenaline, which often cause cardiovascular side effects, are routinely used in functional endoscopic sinus surgery (FESS) for the main purpose of hemostasis. The controversies concerning hemodynamic effects of adrenaline in local infiltration are widely discussed, but there is no definite conclusion. A prospective, randomized, double-blinded study was carried out to discover the hemodynamic effects after local infiltration of 1:200,000 adrenaline contained in 2% lidocaine under general anesthesia. STUDY DESIGN: Seventy-six adult patients undergoing FESS during general anesthesia were allocated randomly into three groups. Group I patients (n = 26) received 2% lidocaine 2 mL with adrenaline (1:200,000), group II patients (n = 25) received saline 2 mL with adrenaline (1:200,000), and group III patients (control group, n = 25) received saline 2 mL without adrenaline for local infiltration. Electrocardiogram (ECG) and heart rate (HR) were monitored simultaneously; systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MAP) were directly measured in radial artery continuously after local infiltration. METHODS: SBP, DBP, MAP, and HR were recorded at 10 time points: before infiltration (baseline), 0.5 minutes, 1 minute, 1.5 minutes, 2 minutes, 2.5 minutes, 3 minutes, 3.5 minutes, 4 minute, and 5 minutes after infiltration. RESULTS: Significant hemodynamic changes, particularly hypotension (P < .01), after local infiltration were observed in group I and group II compared with the baseline, but not in group III. However, there were no significant hemodynamic changes between group I and group II at the same time points (P > .05). The significant hemodynamic changes lasted no longer than 4 minutes. CONCLUSIONS: Lidocaine (2%) or saline with adrenaline (1:200,000) does cause temporary hypotension and other hemodynamic changes during general anesthesia, which last no longer than 4 minutes. The causative mechanism is caused by the effect of adrenaline. This is a preliminary study.     

慢性鼻窦炎鼻息肉围手术前期处理对术中出血影响的观察

OBJECTIVE: To explore the method of reducing bleeding during endoscopic sinus surgery for chronic sinusitis and nasal polyp. METHODS: Bleeding during surgery and the effective rate of two groups patients with chronic sinusitis and nasal polyp were compared (68 cases in group A with preoperative treatment, 30 cases in group B without preoperative treatment). RESULTS: The effective rate between group A(91.2%) and group B (80%) is of significant difference (F = 8.617, P = 0.026); The volume of bleeding during surgery between group A that is (53.2 +/- 41.8) ml and group B that is (97.2 +/- 59.0) ml is of significant difference (F = 27.946, P = 0.002). CONCLUSIONS: Controlling the inflammatory reaction of chronic sinusitis and nasal polyp by preoperative treatment is the most important factor to reduce bleeding while undergoing endoscopic sinus surgery. However, the followings are also important factors to reduce bleeding in endoscopic sinus surgery, such as adequate use of vasoconstrictor in the middle nasal meatus during surgery, the use of deliberate hypotension during surgery, controlling the high risk factors by preoperative treatment and reducing trauma during surgery, etc.     

Intravenous anesthesia provides optimal surgical conditions during microscopic and endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS: Controlled hypotension is used to improve surgical conditions during microscopic and endoscopic sinus surgery. New short-acting anesthetics such as propofol and remifentanil allow exact control of intraoperative blood pressure and thus might be valuable tools to improve intraoperative conditions for the otorhinolaryngological surgeon. Intravenous anesthesia was compared with traditional balanced anesthesia by subjective assessment of surgical conditions made by two experienced otorhinolaryngological surgeons. STUDY DESIGN: Prospective, randomized, patient- and observer-blinded study. METHODS: Ninety consecutive patients were randomly assigned to receive intravenous anesthesia with propofol 5 to 8 mg.kg-1.h-1 and remifentanil 10 to 30 microg.kg-1.h-1 or with isoflurane (0.4-1.0 vol%) and repetitive doses of 0.5 to 1 mg alfentanil. An injectable vasodilator was used in both groups to keep mean arterial pressure between 60 and 70 mm Hg (8-9.3 hecto-pascal). The attending otorhinolaryngological surgeon was unaware of the type of anesthesia administered. Immediately after the operation the surgeons rated surgical conditions (bleeding from the surgical field) on a visual analogue scale (0-10 cm) and on a verbal rating scale. RESULTS: Blood pressure was not different between the two groups, but heart rate was lower in the intravenous anesthesia group (mean heart rate in the intravenous anesthesia group, 62 beats per min [95% confidence interval, 52-72]; mean heart rate in the balanced anesthesia group, 75 beats per min [95% confidence interval, 67-83]). Surgical conditions were rated to be significantly better (P <.0001) during anesthesia with propofol-remifentanil (median rating: 2.8; 25th/75th percentile: 2.0/3.4) compared with isoflurane-alfentanil (median rating: 4.9; 25th/75th percentile: 3.6/7.6). CONCLUSIONS: Intravenous anesthesia using propofol-remifentanil provides better surgical conditions compared with a traditional balanced anesthesia technique using isoflurane-alfentanil. It is hypothesized that lower cardiac output caused by decreased heart rate during deep general anesthesia is responsible for this result.