七氟醚和地氟醚紧闭循环麻醉下神经外科手术后病人肾功能的变化

目的 比较七氟醚、地氟醚紧闭循环麻醉下神经外科手术后病人肾功能的变化，评价七氟醚紧闭循环麻醉应用于临床的安全性。方法 36例拟行神经外科手术病人，随机分为2组：七氟醚组（S组）和地氟醚组（D组），每组18例，新鲜气流量1-5L／min洗入2-3 min，之后降低至0．18～0．30L／min，七氟醚、地氟醚呼气末浓度分别维持在2．7％-4．0％、6．0％～10．0％。监测呼吸环路内氟甲基二氟乙烯醚（Compound A）浓度及吸入氧浓度。测定术前、术毕和术后2、24、72h血清氟离子（F^-）、肌酐（Cr）和尿素氮（BUN）浓度，测定术前、术毕和术后24、48、72h尿中总蛋白（TP）、β2微球蛋白（β2-MG）和β-N-乙酰氨基葡萄糖苷酶（NAG）水平。结果 在整个麻醉过程中病人吸入氧浓度不低于75％。术后两组血清Cr、BUN浓度及尿NAG／Cr与术前比较差异无统计学意义，组间比较差异无统计学意义。术后两组尿TP／Cr、β2-MG／Cr升高（P〈0．05），组间比较差异无统计学意义。TP／Cr、β2-MG／Cr与Compound A暴露量之间的相关系数分别为0．02、0．12（P〉0．05）。结论 七氟醚紧闭循环麻醉对神经外科手术后病人肾功能无影响。     

七氟醚紧闭循环麻醉时二氧化碳吸收剂对环路中compound A浓度的影响

目的比较七氟醚紧闭循环麻醉时二氧化碳吸收剂对环路中compound A浓度的影响。方法 42例神经外科择期手术患者随机分为Sofnolime组(S组)和Sodasorb LF组(LF组),每组21例。采用七氟醚紧闭循环麻醉,呼气末七氟醚的浓度保持在2.7%～3.5%。监测呼吸环路内compound A的浓度;采集术前、术毕、术后24、72h的血样,检测血清丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、肌酐(Cr)和尿素氮(BUN)的水平。留取术前、术毕、术后24、48、72h的尿样,检测总蛋白(TP)、β2微球蛋白(β2-MG)和β-N-乙酰氨基葡萄糖苷酶(NAG)。结果 LF组未检测出compound A,S组compound A平均最高浓度为(37.6±10.2)ppm。两组ALT、AST、TBIL、Cr和BUN水平组间、组内比较差异均无统计学意义。两组尿TP/Cr、β2-MG/Cr在术后增加(P0.05),但各时间点组间比较差异均无统计学意义。两组尿NAG/Cr无变化,组间比较差异无统计学意义。结论七氟醚紧闭循环麻醉时,呼吸环路中compound A的最大浓度低于50ppm,对肝、肾功能无明显影响。     

七氟醚吸入麻醉对低出生体重儿术后肾功能的影响

目的观察七氟醚吸入麻醉对低出生体重儿术后肾功能的影响。方法择期手术低出生体重儿60例,男32例,女28例,按照随机数字表法分为七氟醚组(S组)和静脉麻醉组(T组)。S组术中采用七氟醚(氧流量2L/min)半紧闭吸入维持麻醉,根据生命体征调整七氟醚呼气末浓度(CETSev)2.5%~4.0%;T组术中采用静脉泵注丙泊酚6~8mg·kg-1·h-1、瑞芬太尼0.20~0.25μg·kg-1·min-1维持麻醉。记录七氟醚挥发罐开启即刻、开启后15、30、45、60min、关闭即刻的钠石灰中心温度。于术前24h(T0)、术毕(T1)、术后24h(T2)、48h(T3)、72h(T4)抽取外周静脉血,测定血清肌酐(Cr)、尿素氮(BUN);同时采集尿液,定性分析尿糖和尿蛋白阳性率,并测定尿视黄醇结合蛋白(RBP)和β-N-乙酰氨基葡萄糖苷酶(NAG)浓度。结果两组不同时点钠石灰中心温度差异无统计学意义。与T0时比较,T1~T4时两组血清Cr和BUN浓度有升高趋势,但差异无统计意义;T1时两组尿中NAG浓度和T2时两组RBP浓度明显升高(P0.05)。T0~T4时两组患儿Cr、BUN、RBP、NAG浓度差异均无统计学意义。不同时点两组患者尿糖阳性率和尿蛋白阳性率组内组间比较差异均无统计学意义。结论中流量(氧流量2L/min)七氟醚吸入麻醉对低出生体重儿术后肾功能无明显影响。     

地氟醚与七氟醚麻醉对老年病人术后认知功能的影响

目的 探讨地氟醚及七氟醚复合麻醉对老年病人术后认知功能恢复的影响。方法 70例择期行全膝或全髋关节置换术的病人,年龄均在65岁以上。静注芬太尼、异丙酚、琥珀胆碱快速诱导插管后随机分为地氟醚和异氟醚组。麻醉诱导前及手术后1、3、6及24h应用Mini-Mental State（MMS）测试方法评定其认知功能。结果 与术前相比,两组病人术后1h MMS值均明显降低。地氟醚组由29.5±0.5降至27.8±1.7;七氟醚组由29.2±1.0降至27.4±1.7。其中85％以上病人术后3h MMS恢复至术前水平。两组病人术前及术后1、3、6及24h MMS比较均无显著差异。结论 老年病人应用地氟醚或七氟醚麻醉,其术后认知功能恢复相似,仅有一过性认知障碍。     

七氟醚麻醉血药浓度及血,尿无机氟的改变

测定８例七氟醚麻醉患者药代动力学及血、尿无机氟的浓度变化和排泄速率。麻醉维持采用连续吸入２％七氟醚、５０％Ｎ２Ｏ－Ｏ２共１小时，麻醉开始后血七氟醚浓度迅速上升，其峰值浓度（３９１±１２０。２μｍｏｌ／Ｌ）出现在吸入后１５分。排泄半衰期为２０。５２分，排泄率系统为０。０３３７８。吸入七氟醚后血清无机氟逐渐升高，峰值浓度出现在停止吸入后３０分。血清无机氟的排泄半衰期和排泄率系数分别为２２１１分和０。０     

异氟醚控制性降压对颅内动脉瘤夹闭术血中S100B含量的影响

目的　测定颅内动脉瘤夹闭前后血中S1 0 0B蛋白含量 ,研究异氟醚控制性降压对脑功能的影响。方法　择期颅内动脉瘤夹闭术病人 30例 ,ASAⅠ～Ⅱ级 ,随机分为两组 :异氟醚降压组 (n=1 5 )和异氟醚非降压组 (n =1 5 )。非降压组术中吸入 1MAC异氟醚维持麻醉。降压组行异氟醚控制性降压 ,平均动脉压下降幅度 30 %～ 4 0 % ,夹闭动脉瘤后降低异氟醚吸入浓度 ,终止降压。分别于切皮前、动脉瘤夹闭后即刻、2、4h、术后第 1、2天取血测定S1 0 0B蛋白含量 ,并于术后 1周随访病人 ,记录有无术后神经系统并发症。结果　 (1 )异氟醚降压后 30min平均动脉压由诱导前的 (95 2± 1 2 3)mmHg降至 (5 8 8± 5 4 )mmHg ,停止降压后 30min血压回升至 (75 1± 8 3)mmHg。降压后外周血管阻力及心肌收缩加速度下降 ,但心率及心输出量均无显著性变化 ;(2 )异氟醚降压组与非降压组间同一时间点血中S1 0 0B蛋白浓度无明显差异。降压组术后第 1天及第 2天血中S1 0 0B蛋白浓度均显著升高 (F =2 94 4 ,P =0 0 1 8)。结论　在颅内动脉瘤夹闭术中应用异氟醚控制性降压可能加重了术后脑损伤 ,不利于病人围麻醉期脑功能的保护     

回路内麻醉气体吸附器的临床应用

目的在吸入麻醉术后恢复阶段,观察回路内麻醉气体吸附器是否可缩短吸入麻醉的苏醒时间。方法在固定潮气量、每分通气量和新鲜气体流量的条件下,术毕关闭挥发罐后,比较使用回路内麻醉气体吸附装置对回路内麻醉气体浓度变化的影响。结果使用吸附器后,回路内麻醉气体浓度降至MAC0．3所需时间,异氟醚由20．0±0．3分钟降至3．3±0．5分钟(P＜0．01)。安氟醚由25．0±0．1分钟降至3．5±0．5分钟(P＜0．01)。结论应用回路内麻醉气体吸附器可显著缩短病人苏醒时间,并减少气源浪费和环境污染。     

气管表面麻醉或/和硬膜外阻滞降低异氟醚吸入全麻用药量

目的 探讨气管表面麻醉或/和硬膜外阻滞能否降低全身麻醉时异氟醚的使用量.方法 上腹部手术病人60例,随机分为单纯全身麻醉组(G组)、全身麻醉联合气管表面麻醉组(GL组)、全身麻醉联合硬膜外阻滞组(GE组)、全身麻醉联合气管表面麻醉和硬膜外阻滞组(GLE组).各组术前及诱导用药相同,术中异氟醚维持麻醉,维库溴铵维持肌松,根据病人生命体征调整异氟醚吸入浓度.比较各组术中异氟醚的使用量及术后不良反应的发生情况.结果 G、GL、GE、GLE四组呼气末异氟醚MAC维持值分别为(1.01±0.11)、(0.89±0.07)、(0.63±0.06)和(0.51±0.08);异氟醚消耗量分别为(12.9±1.8)、(11.2±1.7)、(6.7±1.2)和(5.3±0.9)ml/h.GLE组术后不良反应最少,无一例病人发生术中知晓.结论 气管表面麻醉或/和硬膜外阻滞明显降低吸入全身麻醉时异氟醚需用量.     

七氟醚对丙泊酚闭环靶控效果的影响

目的 探讨静吸复合麻醉中七氟醚对闭环靶控输注丙泊酚调控麻醉深度效果的影响. 方法 60例ASA分级Ⅰ、Ⅱ级择期行全身麻醉腹部手术患者,采用随机数字表法分为3组(每组20例):单纯丙泊酚组(A组)、丙泊酚复合吸入0.6MAC七氟醚组(B组)和丙泊酚复合吸入0.8 MAC七氟醚组(C组).3组患者丙泊酚输注速率均由BIS介导的闭环靶控系统自动反馈调节.A组患者全程持续使用丙泊酚静脉麻醉;B组和C组应用丙泊酚维持20 min后开始吸入3％七氟醚,并根据各自MAC设定值调整吸入浓度,于吸入40 min后停止七氟醚;给药过程中连续观察靶控输注丙泊酚的血药浓度变化并做统计分析. 结果 B组和C组术中BIS与A组比较,差异无统计学意义(P＞0.05).与A组比较,B组和C组丙泊酚血药浓度在七氟醚吸入后逐渐下降,停药后缓慢上升(P＜0.05);吸入后30 min和40 min时,C组[(1.8±0.6),(1.2±0.4) mg/L]较B组[(1.9±0.6),(1.7±0.6) mg/L]与A组[(2.5±0.6),(2.5±0.6)mg/L]比较,血药浓度下降的更明显(P＜0.05);组间丙泊酚血药浓度变化速度比较,C组比B组下降和上升的速度更快(P＜0.05),均于停止吸入后40 min趋于稳定. 结论 BIS闭环靶控丙泊酚麻醉系统在复合七氟醚0.8 MAC以内的状态下,可以有效地自动反馈调节麻醉深度.     

紧闭循环麻醉时七氟醚对病人肝肾功能的影响

目的 评价紧闭循环麻醉时七氟醚对病人肝肾功能的影响.方法 拟行普外科手术病人40例,ASA Ⅰ或Ⅱ级,年龄20～60岁,随机分为2组(n=20),麻醉诱导后S1.组和S2组分别吸人6%～8%国产或进口七氟醚,新鲜气流量2～4 L/min,2～3 min后调整新鲜气流量至0.18～0.30 L/min,随后维持七氟醚呼气末浓度2.6%～3.5%.于术前、术毕、术后1、2、3和5 d时测定血清丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)活性、总胆红素(TB)、肌酐(Cr)、尿素(BUN)、β2-微球蛋白(β2-MG)浓度和尿液β2-MG浓度.结果 与术前比较,术毕、术后1、2 d时两组尿液β2-MG浓度升高(P<0.05),术后1～5血清ALT、AST活性和TB、Cr、BUN和β2-MG浓度差异无统计学意义(P0.05);各指标组间比较差异无统计学意义(P0.05).结论 紧闭循环麻醉时七氟醚对病人肝肾功能无明显影响.     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020