静脉麻醉药丙泊酚的临床应用

１引言静脉全身麻醉新概念的提出大大地改变了临床麻醉的实践，发达国家已有６０％的手术可在门诊完成，这首先应归功于新一代静脉麻醉药的出现，使我们多年追求的目标逐渐成为现实。丙泊酚（２，６－二异丙基苯酚），作为一种静脉麻醉药应用于临床已经１２年，以其起效迅速、作用时间短、清醒快、易于控制和不良反应少等特点，被麻醉医师广泛运用。本文就其药代动力学（药代学）、临床应用、不良反应等进行了一系列的探讨。２药代动力学丙泊酚具有分布容积大、清除率高、分布和消除迅速、再分布缓慢等特点。其分布半衰期为２～４分钟，消除…     

全反式维甲酸在小肠缺血再灌注中的炎症抑制效应及机制

目的探讨全反式维甲酸（ATRA）对大鼠小肠缺血再灌注的炎症抑制作用和机制。方法24只雄性SD大鼠,每组8只,随机分为假手术组、阻断组和ATRA组。ATRA组术前以ATRA15mg·kg-1·d。灌胃,阻断组以等体积溶媒二甲基亚砜（DMSO）灌胃,共5d。术中阻断肠系膜上动脉60rain后再灌注120min,收集各组大鼠末端回肠和血清。光学显微镜下观察回肠病理学改变、行肠黏膜Chiu氏评分;比色法测定血清二胺氧化酶（DAO）含量和回肠组织髓过氧化物酶（MPO）活性;ELISA法测定回肠组织肿瘤坏死因子仅（TNF-a）及白介素1B（IL-1β）水平;Westernblot检测回肠组织中胞核NF—KBp65蛋白和胞质NF—KB抑制蛋白d（IKBd）的表达量。结果与阻断组相比,ATRA组回肠黏膜病理损伤减轻,Chiu氏评分下降[（2．54±0．69）US．（3．86±0．83）,P〈0．05],血清DAO含量减少[（18．09±4．21）U／LUS．（24．56±4．92）U／L,P〈0．05],组织TNF-d[（61．37±18．66）pg／g135．（97．21±24．67）Pg／g]、IL—1β水平[（115．24±30．82）pg／gcs．（219．83±54．31）pg／g]和MPO活性[（4．62±1．18）U／gUS．（7．16±1．50）U／g]降低,均P〈0．05;胞核NF—KBp65蛋白表达下调[（3．71±0．83）vs．（6．59±1．05）,P〈0．051,胞质IKB仪蛋白含量增加[（0．56±0．12）vs．（0．26±0．05）,P〈0．05]。结论ATRA预处理可以抑制NF—KB的激活,减轻组织的过度炎症反应,对大鼠小肠缺血再灌注损伤具有保护作用。     

右旋美托咪啶对大鼠脑缺血再灌注损伤的保护作用及机制

【目的】 探讨右旋美托咪啶在脑缺血再灌注损伤中的保护作用和相关机制。【方法】 ４２只雄性ＳＤ大鼠随机分为３组,每组１４只：右旋美托咪啶组（Ｄｅｘ）采用右旋美托咪啶５ μｇ·ｋｇ－１·ｈ－１恒速输注２ ｈ;拮抗剂组（Ｄｅｘ＋Ｙｏｈ）于开启注射泵前１０ ｍｉｎ经尾静脉输注拮抗剂育亨宾１ ｍｇ／ｋｇ,余用法同上组;对照组（Ｃｏｎ）以同等速度输注生理盐水２ｈ。所有大鼠行大脑中动脉栓塞术,缺血９０ ｍｉｎ后再灌注。观察术后２４ ｈ神经功能评分、脑梗死体积、水肿指数以及脑组织白介素（ＩＬ）－１β、肿瘤坏死因子（ＴＮＦ）－α水平、核蛋白ＮＦ－κＢｐ６５表达量。 【结果】再灌注２４ｈ后,脑梗死体积的比较显示Ｄｅｘ组（１７ ± ２．８）％较Ｄｅｘ＋Ｙｏｈ组（３８ ± ４．９）％与Ｃｏｎ组（４２ ± ５．７）％明显减小（Ｐ ＜ ０．０５）,水肿指数比较显示Ｄｅｘ组（１．０２１ ± ０．０９８）较Ｄｅｘ＋Ｙｏｈ组（１．３４２ ± ０．１３７）与Ｃｏｎ组（１．４１７ ± ０．１０５）显著降低,差异有统计学意义（Ｐ ＜ ０．０５）。脑组织ＩＬ－１β、ＴＮＦ－α及ＮＦ－κＢｐ６５蛋白表达量的比较均显示Ｄｅｘ组较Ｄｅｘ＋Ｙｏｈ组与Ｃｏｎ组明显下降（Ｐ ＜ ０．０５）。【结论】 右旋美托咪啶通过抑制ＮＦ－κＢ通路的激活减少促炎因子的产生,对大鼠局灶性脑缺血再灌注损伤具有保护作用。     

缺血预处理-后处理对大鼠肠缺血再灌注损伤的影响

Objective To evaluate the effects of ischemic preconditioning-postconditioning on the intestinal ischemia-reperfusion (IR) injury in rats. Methods Forty healthy male SD weighing 225-275 g were randomly assigned into 5 groups ( n = 8 each): group I sham operation (group S) ; group II intestinal IR (group IIR); group Ⅲ ischemic preconditioning (group Ipr); group IV ischemic postconditioning (group Ipo); group V Ipr+ Ipo. The rats were anesthetized with intraperitonel 20% urethane 5 ml/kg. Superior mesenteric artery (SMA) was occluded for 60 min followed by 60 min reperfusion. In group S, SMA was isolated but not occluded. In group Ipr, SMA was occluded for 10 min followed by 10 min reperfusion, and the rest procedures were performed using the method described in group IIR. In group Ipo, 60 min ischemia was followed by three 30 s episodes of ischemia at 30 s intervals for reperfusion. In group Ipr+ Ipo, Ipr was performed followed by Ipo and the procedures were performed using the methods described in group Ipr and Ipo. The animals were killed at 60 min of reperfusion. The intestinal tissues were immediately removed for determination of MDA content, SOD and MPO activities and the degree of damage to intestinal mucous membrane was scored according to Chiu score. Arterial blood samples were taken for determination of plasma concentrations of TNF-α and 1L-6. Results Compared with group S, Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly increased, whereas SOD activity decreased in the other 4 groups ( P < 0.05). Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly decreased, whereas SOD activity increased in group Ipr, Ipo and Ipr + Ipo as compared with group IIR ( P < 0.05). Chiu score and MDA content were significantly lower, whereas SOD activity higher in group Ipr + Ipo than in group Ipr and Ipo ( P < 0.05). No significant differences were detected in the indices between group Ipr and group Ipo ( P > 0.05). Conclusion Ischemic preconditioning-postconditioning can attenuate the intestinal IR injury in rats, and the efficacy is better than that of either Ipr or Ipo alone.     

缺血预处理-后处理对大鼠肠缺血再灌注损伤的影响

Objective To evaluate the effects of ischemic preconditioning-postconditioning on the intestinal ischemia-reperfusion (IR) injury in rats. Methods Forty healthy male SD weighing 225-275 g were randomly assigned into 5 groups ( n = 8 each): group I sham operation (group S) ; group II intestinal IR (group IIR); group Ⅲ ischemic preconditioning (group Ipr); group IV ischemic postconditioning (group Ipo); group V Ipr+ Ipo. The rats were anesthetized with intraperitonel 20% urethane 5 ml/kg. Superior mesenteric artery (SMA) was occluded for 60 min followed by 60 min reperfusion. In group S, SMA was isolated but not occluded. In group Ipr, SMA was occluded for 10 min followed by 10 min reperfusion, and the rest procedures were performed using the method described in group IIR. In group Ipo, 60 min ischemia was followed by three 30 s episodes of ischemia at 30 s intervals for reperfusion. In group Ipr+ Ipo, Ipr was performed followed by Ipo and the procedures were performed using the methods described in group Ipr and Ipo. The animals were killed at 60 min of reperfusion. The intestinal tissues were immediately removed for determination of MDA content, SOD and MPO activities and the degree of damage to intestinal mucous membrane was scored according to Chiu score. Arterial blood samples were taken for determination of plasma concentrations of TNF-α and 1L-6. Results Compared with group S, Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly increased, whereas SOD activity decreased in the other 4 groups ( P < 0.05). Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly decreased, whereas SOD activity increased in group Ipr, Ipo and Ipr + Ipo as compared with group IIR ( P < 0.05). Chiu score and MDA content were significantly lower, whereas SOD activity higher in group Ipr + Ipo than in group Ipr and Ipo ( P < 0.05). No significant differences were detected in the indices between group Ipr and group Ipo ( P > 0.05). Conclusion Ischemic preconditioning-postconditioning can attenuate the intestinal IR injury in rats, and the efficacy is better than that of either Ipr or Ipo alone.     

肠缺血后处理对兔缺血再灌注损伤小肠上皮细胞线粒体形态和功能的影响

目的观察缺血后处理对小肠缺血再灌注损伤的保护作用。方法30只大白兔随机分为3组，每组8只：A组，假手术组；B组，肠缺血再灌注损伤模型组；C组，肠缺血再灌注损伤模型肠缺血后处理组，实验结束后取小肠标本进行小肠上皮细胞形态和呼吸功能指标测定。结果A、C两组线粒体的数目、周长均大于B组，A、C两组问比较，A组较大（P〈0．05）。A、C两组线粒体的面积、最大直径、最小直径、等效直径均小于B组（P〈0．05），A、C两组间比较差异无统计学意义（P〉0．05）。B组线粒体的体积密度小于A组，面积密度、比表面和粒子数密度均小于其余两组（P〈0．05）。A、C两组间三维平面形态计量学各参数比较差异无统计学意义（P〉0．05）；B、C组线粒体呼吸控制比率（RCR）低于A组差异有统计学意义（P〈0．05），与C组比较，B组下降更为明显（P〈0．05）。结论小肠缺血后处理对缺血再灌注损伤肠上皮细胞线粒体形态和功能均有保护作用。     

氟比洛芬酯对乳腺癌手术的超前镇痛效果

非甾体类消炎镇痛药（NSAIDs）少有恶心、呕吐、尿潴留、呼吸抑制等麻醉性镇痛药特有的不良反应，被广泛用于各种手术的术后镇痛。氟比洛芬酯（凯芬）注射液是一种非甾体类消炎镇痛药脂微球制剂，其经过脂微球（LM）包裹，具有了靶向性，可以靶向聚集在手术切口及炎症部位，显示出强力且速效的镇痛作用。本研究的方法是以超前镇痛（pre-emptive）概念为基础，在手术前用氟比洛芬酯进行超前镇痛，观察全身麻醉下乳腺癌手术的术后疼痛情况。     

曲马多与芬太尼用于全麻诱导对患者呼吸循环的影响

目的比较曲马多、芬太尼用于全麻诱导对患者呼吸、循环的影响.方法 20例ASA Ⅰ～Ⅱ级在全身麻醉下行择期手术的患者随机分为两组(n=10):曲马多组(T组)和芬太尼组(F组).T组诱导时静注曲马多 3 mg/kg,F组静注芬太尼 3 μg/kg,随后静注咪唑安定及琥珀胆碱后行气管插管控制呼吸.术中监测HR,SBP,DBP,MAP及SpO2,并监测肌松药应用前的呼吸频率(RR)、分钟通气量(VE)及呼气末二氧化碳(PETCO2).结果①与诱导前值相比,曲马多静注后3 min,VE,RR,SpO2和PETCO2变化不显著;芬太尼静注3 min,RR逐渐下降23.6%(P<0.05),VE下降49.9%(P<0.01),SpO2下降,最低降至79%(P<0.05).②曲马多静注3 min内,SBP上升10.4%,DBP上升10.6%,MAP上升10.8%,与注药前相比差异有显著性(P<0.05).芬太尼静注 3 min,血压变化不大(P>0.05),而心率下降(P<0.01).插管后即刻:T组较诱导前SBP上升31%(P<0.01),DBP上升35.2%(P<0.01),MAP上升31%(P<0.01),HR上升14%(P<0.01);F组血压与诱导前值比较差异无显著性(P>0.05).插管前后T组与F组之间血压变化幅度差异有显著性(P<0.01).结论曲马多对呼吸无抑制作用,但不能抑制气管插管时的心血管反应.芬太尼能抑制气管插管时的心血管反应,但有呼吸抑制作用.     

缺血预处理-后处理对大鼠肠缺血再灌注损伤的影响

Objective To evaluate the effects of ischemic preconditioning-postconditioning on the intestinal ischemia-reperfusion (IR) injury in rats. Methods Forty healthy male SD weighing 225-275 g were randomly assigned into 5 groups ( n = 8 each): group I sham operation (group S) ; group II intestinal IR (group IIR); group Ⅲ ischemic preconditioning (group Ipr); group IV ischemic postconditioning (group Ipo); group V Ipr+ Ipo. The rats were anesthetized with intraperitonel 20% urethane 5 ml/kg. Superior mesenteric artery (SMA) was occluded for 60 min followed by 60 min reperfusion. In group S, SMA was isolated but not occluded. In group Ipr, SMA was occluded for 10 min followed by 10 min reperfusion, and the rest procedures were performed using the method described in group IIR. In group Ipo, 60 min ischemia was followed by three 30 s episodes of ischemia at 30 s intervals for reperfusion. In group Ipr+ Ipo, Ipr was performed followed by Ipo and the procedures were performed using the methods described in group Ipr and Ipo. The animals were killed at 60 min of reperfusion. The intestinal tissues were immediately removed for determination of MDA content, SOD and MPO activities and the degree of damage to intestinal mucous membrane was scored according to Chiu score. Arterial blood samples were taken for determination of plasma concentrations of TNF-α and 1L-6. Results Compared with group S, Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly increased, whereas SOD activity decreased in the other 4 groups ( P < 0.05). Chiu score, MDA content, MPO activity, and plasma concentrations of TNF-α and IL-6 were significantly decreased, whereas SOD activity increased in group Ipr, Ipo and Ipr + Ipo as compared with group IIR ( P < 0.05). Chiu score and MDA content were significantly lower, whereas SOD activity higher in group Ipr + Ipo than in group Ipr and Ipo ( P < 0.05). No significant differences were detected in the indices between group Ipr and group Ipo ( P > 0.05). Conclusion Ischemic preconditioning-postconditioning can attenuate the intestinal IR injury in rats, and the efficacy is better than that of either Ipr or Ipo alone.     

国内麻醉科医师应用二氧化碳吸收剂的现状调查

目的 调查国内麻醉科医师应用二氧化碳（CO₂）吸收剂的现状,为统一CO₂吸收剂更换的指标、限值和流程提供参考。
方法 采用自主设计调查问卷开展网络问卷调查,主要内容包括麻醉科医师的基本情况、对CO₂吸收剂应用理论的理解和CO₂吸收剂临床应用的现状。
结果 本次调查发放并回收有效问卷475份,其中49.9%来自华南地区,其他地区的麻醉科医师占50.1%。在对CO₂吸收剂应用理论的理解方面,被调查者最常使用的CO₂吸收剂种类为钠石灰,6.3%的被调查者尚不清楚所在机构使用的CO₂吸收剂种类;13.5%的被调查者能选出全部影响CO₂吸收剂吸收效率的理论因素;分别有79.8%、66.7%和44.8%的被调查者认为CO₂吸收剂“缺乏统一的更换标准和流程”、“环境污染”和“更换操作复杂”应得到关注。在CO₂吸收剂临床应用的现状方面,更换频率与麻醉科医师所在医院的等级显著相关（P<0.05）;更换标准主要依赖FiCO₂和CO₂吸收剂变色量;96.4%的被调查者选择整罐更换,仍有23.8%的被调查者错误地在手术室内更换CO₂吸收剂,有粉尘吸入经历的被调查者高达73.7%。
结论 目前国内麻醉科医师对CO₂吸收剂的应用理论和安全性认识不足,对CO₂吸收剂的更换缺乏统一标准、更换流程欠规范,建议对各级麻醉科医师开展针对性专题培训,并应进一步探索安全高效的CO₂吸收剂更换标准化流程。