目的 观察基于加速康复外科的2种联合麻醉方案对肝肿瘤手术患者应激反应的影响.方法 选取2019年1月至2021年1月于首都医科大学附属北京安贞医院实施开腹早期肝肿瘤手术的128例患者纳入研究,按照随机数字表法将患者分为对照组和观察组,各64例.对照组实施气管插管全身麻醉联合腹横筋膜阻滞;观察组实施气管插管全身麻醉联合硬膜外麻醉.比较2组的手术参数、生命体征指标、麻醉优良率、应激反应指标、不良反应发生率、术后麻醉苏醒情况和手术前后认知功能评分.结果 观察组与对照组手术时间、出血量及插管前和拔管后收缩压、舒张压、心率及麻醉优良率比较,差异均无统计学意义(均P＞0.05).2组拔管后肾上腺素、去甲肾上腺素、多巴胺水平均较插管前升高,但观察组均低于对照组[(203±5)pmol/L比(211±6)pmol/L、(653±7)pmol/L比(663±8)pmol/L、(543±8)nmol/L比(554±9)nmol/L],差异均有统计学意义(均P＜0.05).2组寒战、恶心呕吐、躁动发生率差异均无统计学意义(均P ＞0.05).术后观察组自主呼吸恢复时间、睁眼时间、指令恢复时间均短于对照组,差异均有统计学意义(均P＜0.05).2组术后简易精神状态检查量表、蒙特利尔认知评估量表评分均低于术前,但观察组均高于对照组,差异均有统计学意义(均P ＜0.05).结论 基于加速康复外科的联合麻醉方案在肝肿瘤手术中具有良好的麻醉效果,其中联合硬膜外麻醉的方案相比神经阻滞更佳,可减轻应激反应,减少儿茶酚胺分泌,患者术后恢复更快.

目的:分析冠状动脉旁路移植术(CABG)后重症患者体外膜氧合(ECMO)辅助时间与住院死亡的关系.方法 :回顾性分析148例北京安贞医院心脏外科危重症中心,2010年1月至2017年12月,应用静脉-动脉体外膜氧合(VA-ECMO)的CABG术后重症患者.用Logistic回归分析ECMO辅助时间与患者住院死亡的关系.结果 :148例患者中92例(62.2％)成功脱离ECMO,66例(44.6％)顺利出院.ECMO辅助中位时间为4(3,6)d.与ECMO辅助时间<3 d或≥7 d的患者相比,ECMO辅助时间为3～6 d 的患者住院死亡率最低(40.4％vs.87.5％,P<0.001;40.4％vs.72.7％,P = 0.003).调整女性、左主干病变、SOFA评分及血清乳酸后,以ECMO辅助时间3-6 d为参照,ECMO辅助时间<3 d、≥7 d的OR 值分别为5.72(95％CI:1.62～20.23)、6.98(95％CI:1.46～33.23).结论 :CABG 术后重症患者ECMO辅助时间<3 d或≥7 d是患者住院死亡的风险因素,但ECMO治疗时间的长短还取决于患者潜在疾病的影响.

目的 回顾并总结不停跳冠状动脉旁路移植(OPCABG)联合肺癌根治同期手术的麻醉管理方法.方法 收集2003年5月至2018年1月静脉复合麻醉同期手术46例患者的麻醉管理资料,年龄53～77岁,ASAⅡ或Ⅲ级.记录术中HR、CVP、MAP、CI、PCWP、混合静脉血氧饱和度(SvO2)和动脉血乳酸浓度(Lac),计算肺血管阻力(PVR)、全身血管阻力(SVR)、氧供(DO2)、氧耗(VO2)和氧摄取率(ERO2)并对同期手术麻醉风险进行回顾分析.结果 所有患者顺利完成同期手术,无死亡病例.2例术中发生心肌缺血、低血压,放置主动脉内球囊反搏(IABP),4例出现低心排给与去甲肾上腺素治疗.麻醉诱导后各时点HR、MAP较术前明显下降(P<0.01),术中各时点SVR、PVR、VO2、Lac较诱导后明显下降(P<0.05或P<0.01),CI、DO2与ERO2较诱导后明显增加(P<0.05或P<0.01).结论 麻醉重视术前准备和术中监测,维持术中血流动力学稳定及心肌氧供需平衡,做好心肺功能维护能够保证OPCABG联合同期肺癌根治手术顺利实施.

Purpose: We sought to investigate the relationship between high CVP, AKI, and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass. Materials: All patients aged 18 years or older who underwent cardiac surgery with CPB were prospectively reviewed. Patients were excluded when renal artery were involved before and during surgery. Patients were dichotomized into high CVP group(>10 mmHg) and low CVP group(<10 mmHg). All patients were followed by telephone. Results: A total of 1941 patients were included in observed study. In high CVP group, three hundred forty-seven patients (43.32%) developed AKI, while eighty-six (7.543%) in low CVP group(P <0.0001). Furthermore, in every KDIGO stage, patients of AKI in high CVP group were more than those in low CVP group(P <0.0001). The incidence of AKI increased as CVP increased, especially when CVP was higher than 10cmH2O. In a median followup time of 9.2 months, Crude mortality is 8365% in the high CVP group compared to 1.929% in the low CVP group (p<0.0001). In multivariate analysis, CVP remained the independent predictor of survival. Conclusions: High CVP is associated with AKI, and it is independently related to all-cause mortality in patients underwent cardiovascular surgery with cardiopulmonary bypass. (C) 2018 Elsevier Inc. All rights reserved.

目的 总结外科治疗肥厚型梗阻性心肌病(HOCM)患者的麻醉管理经验.方法 回顾性分析2007年1月至2017年6月首都医科大学附属北京安贞医院150例HOCM行体外循环下左心室流出道疏通术部分联合二尖瓣置换或成形术患者的麻醉管理资料.所有患者均采用静脉复合麻醉,麻醉诱导及维持采用咪达唑仑、丙泊酚、七氟烷、舒芬太尼和顺式阿曲库铵,术中监测并记录不同时段心率、平均动脉压、肺毛细血管楔压、心输出量、心脏排血指数、外周血管阻力、肺血管阻力以及左心室流出道压差.结果 全组患者均顺利完成手术,术中血流动力学平稳,无严重心律失常发生.心脏复跳后,经食管超声心动图示二尖瓣前叶收缩期前向运动现象(SAM征)改善或消失,左心室腔增大.流出道疏通后左心室流出道压差较疏通前明显下降[(22±11)mmHg(1 mmHg=0.133 kPa)比(74 ±31)mmHg] (P ＜0.01),其他监测指标无明显改变(均P＞0.05).结论 对HOCM外科治疗患者的麻醉管理关键在于维持适度的麻醉深度以避免增加心肌收缩力,维持正常的心率、血压及心脏前后负荷,避免使用扩张血管和增强心肌收缩力的药物.

带状疱疹 (herpes zoster, HZ) 是由水痘-带状疱疹病毒 (varicella zoster virus, VZV) 侵犯神经节及皮肤,以沿神经簇集分布疱疹及神经痛为主要临床表现的病毒性疾病.带状疱疹急性期的有效治疗能够减轻带状疱疹后神经痛 (post-herpetic neuralgia, PHN) 的发病程度,提高病人的生活质量.椎旁阻滞已应用于 HZ 疼痛及PHN.臭氧因具有强氧化性,可以阻断痛觉传导,改善微循环,减少局部炎症反应,已逐渐应用于治疗急性带状疱疹及PHN.我中心在治疗带状疱疹的前期临床观察中发现,椎旁神经阻滞的基础上,在皮损区局部进行阻滞,联合臭氧注射,能够对带状疱疹急性期疼痛症状明显的缓解作用,并且能够降低PHN的发病率及疼痛症状.因此我们设计了本研究评价臭氧联合神经阻滞干预带状疱疹急性期的疗效,并对其进行总结分析,以期找到有效的缓解带状疱疹疼痛症状的方法.现报道如下.

Objective To observe the clinical effect of low dosage esmolol applied in general anesthesia induction of hypertrophic obstructive cardiomyopathy.Methods Totally 56 patients undergoing left ventricular septal myectomy for hypertrophic obstructive cardiomyopathy were enrolled from January 2014 to December 2015 in Beijing Anzhen Hospital,Capital Medical University.The patients were randomly divided into observation group and control group,with 28 cases in each group.The observation group had esmolol 50 μg/kg during anesthesia induction;the control group had the same dosage of 0.9％ sodium chloride.Heart rate (HR),mean arterial pressure (MAP),stroke volume (SV) and systemic circulation vascular peripheral resistance (SVR) were recorded at the time of entering operating room (T0) and after anesthesia induction (T1).Usage of phenylephrine was recorded.Results Gender,age,body height,body mass and the grade of American Society of Anesthesiologists had no significant differences between groups at T0 (P ＞ 0.05).HR,MAP,SV and SVR at T1 were significantly lower than those at T0 in both groups[observation group:(66 ±4)times/min vs (78 ±7)times/min,(69 ±8)mmHg vs (80 ± 11) mmHg,(67 ± 6) ml vs (70 ± 6) ml,(902 ± 73) (Dyn · s)/cm5 vs (1 060 ± 98) (Dyn · s)/cm5;control group:(68 ± 5) times/min vs (76 ± 9) times/min,(64 ± 7) mmHg vs (76 ± 13) mmHg,(62 ± 5) ml vs (66 ±8)ml,(869 ±89) (Dyn · s)/cm5 vs (1 008 ± 121) (Dyn · s)/cm5] (P ＜0.05).Use rates of phenylephrine at T1 were significantly higher than those at T0 in both groups [observation group:3.6％ (1/28) vs 0.0％ (0/28);control group:21.4％ (6/28) vs 0.0％ (0/28)] (P ＜ 0.05).At T1,MAP and SV in observation group were significantly higher than those in control group;the use rate of phenylephrine in observation group was significantly lower than that in control group (P ＜ 0.05).Conclusion Giving low doses of esmolol during general anesthesia induction contributes to stable SV and blood pressure in patient with hypertrophic obstructive cardiomyopathy.

Objective:To investigate the effect of autologous plateletpheresis (APP) on perioperative coagulation parameters and clinical effect in patients with vascular surgery.Methods:A total of 44 consecutive patients who received Stanford type A aortic dissection surgery in our hospital were studied,ASA grade from Ⅱ to Ⅲ,aged from 36 to 69 years old.The patients were randomIy divided into two groups:experimental group and control group,the experimental group using autologous plateletpheresis technology,the control group only use other conventional blood protection measures.Blood samples were collected at 3 time points:After induction (T1),protamine antagonized heparin (T2),24 hours after surgery (T3).Samples were analyzed for platelet count (PLT) 、hemoglobin content (HB) 、prothrombin time (PT) 、activated partial thromboplastin time (APTT) 、international standard ratio (INR) 、D-dimer (D-D)、plasma fibrinogen (FIB) 、coagulation parameters of thrombelastogram (TEG)(R、K、Ma、α-angle、EPL).Results:Compared with the C group,Pit and MA value of A group were significantly greater at T2 and T3 (P ＜ 0.05).While the K value of A group were decreased (P ＜ 0.05) at T2 and T3.At T2 the FIB of A group was siguificandy increased (P ＜ 0.05) than C group,the A group K value was significantly less than the control group (P ＜ 0.05).In the A group,the amount of allogeneic RBC and allogeneic plasma infusion,the drainage volume of perioperative were decreased.The time of mechanical ventilation and time of hospitalization were shortened (P ＜ 0.05).Conclusion:Utilization of APP technique can significantly improve the coagulation function of patients with vascular surgery,and reduce the amount of perioperative bleeding and allogeneicblood transfusion.

OBJECTIVE:To analyze preoperative risk factors of perioperative pulmonary hypertension crisis (PHC) for pregnant woman with severe pulmonary artery hypertension (PAH), and approach its clinical value.METHODS:A retrospective analysis was conducted. The clinical data from 152 pregnant women with severe PAH underwent cesarean delivery admitted to Beijing Anzhen Hospital from January 1st 2008 to December 31st 2016 was collected. The patients were divided into two groups according to with perioperative PHC or not. Through the case management system, age, height, weight, gestational age, pregnancy time, type of PAH, emergency or selective surgery, New York Heart Association (NYHA) cardiac function classification, and preoperative ultrasound left ventricular ejection fraction (LVEF), left ventricular diastolic final diameter (LVEDD), the pulmonary artery systolic pressure (sPAP) estimated by ultrasonic TI method, radial artery systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), pulse oxygen saturation (SpO2) without oxygen, oral sildenafil ingestion, having Swan-Ganz catheter placement or not, and whether used norepinephrine or not, as well as the occurrence of perioperative PHC and clinical outcomes were collected. Possible preoperative risk factors were compared between the two groups by single factor and multiple factors logistic regression analysis. The receiver-operating characteristic curve (ROC) was plotted to assess the diagnostic value of various risk factors.RESULTS:A total of 152 patients were screened. Ten patients got heart surgery under general anesthesia at the same time, and 4 patients experiencing cesarean section with general anesthesia were excluded. 138 patients were enrolled finally, 27 patients underwent perioperative PHC (19.57%), and 17 patients died with a mortality of 62.96%. Compared with non-PHC group, the patients in PHC group were older (years: 25.07±3.55 vs. 27.64±4.82), had a poor cardiac function (NYHA cardiac function classification: 3.22±0.64 vs. 2.85±0.53), a smaller LVEDD (mm: 38.78±4.76 vs. 43.91±9.67), lower SpO2 without oxygen (0.83±0.12 vs. 0.92±0.06) and oral sildenafil ingestion rate (29.63% vs. 56.76%), and higher sPAP estimated by ultrasonic TI method [mmHg (1 mmHg = 0.133 kPa): 113.41±24.73 vs. 99.35±21.10] and DBP (mmHg: 79.63±13.23 vs. 75.23±12.14), more having Swan-Ganz catheter placement (85.19% vs. 57.66%), more Eisenmenger syndrome (70.37% vs. 37.84%), and more emergency operation (48.15% vs. 23.42%, all P ≤ 0.1). The variables with statistically significant differences showed by single factor analysis were collected, and it was shown by multiple factors logistic regression analysis that LVEDD [odds ratio (OR) = 0.878, 95% confidence interval (95%CI) = 0.796-0.968, P = 0.009], whether oral taken sildenafil (OR = 0.161, 95%CI = 0.051-0.515, P = 0.002) or not, SpO2 at room air (OR = 0.882, 95%CI = 0.829-0.938, P = 0.000), Swan-Ganz catheter placement or not (OR = 6.186, 95%CI = 1.533-24.964, P = 0.010) were independent risk factors of perioperative PHC in pregnant women with severe PAH. It was shown by ROC curve analysis that the area under the ROC curve (AUC) of four factors mentioned above combined diagnosis for PHC was 0.878 (P = 0.000) with the sensitivity of 88.89% and specificity of 76.58%.CONCLUSIONS:PHC is very dangerous for gravida with severe PAH, and the mortality rate is very high. LVEDD, oral sildenafil, SpO2 at room air, Swan-Ganz catheter placement or not were independent risk factors of perioperative PHC for severe PAH maternal. Four preoperative factors of perioperative PHC joint diagnosis accuracy were higher.

目的:探讨由自体血小板分离(APP)技术制备的自体富血小板血浆(aPRP)经历分离、存储以及回输后对主动脉手术患者血小板活化程度的影响.方法:选择择期行主动脉手术患者22例,ASAⅡ～Ⅳ级.收集其麻醉诱导后(T1)、血小板分离后(T2)、体外循环停机时(T3)、鱼精蛋白中和肝素后(T4)、aPRP回输后(T5)全血,以及自体血小板分离后(T1 PRP)、回输前(T3PRP)aPRP.应用流式细胞术,采用CD61/PAC-1/CD62P三色法检测血小板早期活化率(PAC-1+ CD62P-)和晚期活化率(PAC-1+ CD62P+).结果:与T1相比,T2点血小板早、晚期活化率均有所下降,但差异无统计学意义(P=0.406,P=1.000).aPRP回输后(T5)血小板早、晚期活化率较T1有所上调,但差异无统计学意义(P＞0.05);回输前(T3PRP)与刚分离后(T1PRP) aPRP相比,血小板早期活化率有所增加,但差异无统计学意义(P =0.307),晚期活化率明显增加,具有统计学差异(P=0.000);与T1相比,T1PRP中血小板早、晚期活化率均有所增加,血小板早期活化率差异无统计学意义(P =0.060),晚期活化率差异有统计学意义(P =0.000);与停机时全血(T3)相比,T3 PRP中血小板早期活化率低于停机时全血水平,但差异无统计学意义(P=0.199).血小板晚期活化率远高于停机时全血水平,差异有统计学意义(P=0.000).结论:aPRP分离后、回输时并不引起主动脉手术患者体内血小板活化程度增加,但分离与存储时aPRP中血小板活化程度增加,对血小板晚期活化程度的影响高于体外循环.活化的血小板回输对机体产生的影响以及血小板分离存储的优化方法仍需进一步研究.

目的:观察盐酸戊乙奎醚预防不停跳冠状动脉移植术高龄患者术后肺部并发症的效果.方法:选择符合入选标准高龄患者(年龄＞65岁)90例,根据随机抽样方法决定患者进入盐酸戊乙奎醚试验组(n=45)或0.9％氯化钠液对照组(n=45).试验组:在麻醉诱导气管插管后静脉缓慢注射盐酸戊乙奎醚20μg/kg(用0.9％氯化钠液稀释至10mL);对照组:在麻醉诱导气管插管后静脉缓慢注射0.9％氯化钠液10mL.结果:90例患者中有27例患者术后出现了肺部并发症,发生率为30％,两组患者术后肺部并发症发生率分别为17.8％(试验组)和42.2％(对照组),其差异有统计学意义(P＜0.05).结论:盐酸戊乙奎醚应用后,有利于围术期呼吸道管理,可显著降低不停跳冠状动脉搭桥术高龄患者术后肺部并发症的发生率.

Objective To evaluate the effect of recombinant human erythropoietin (rHuEPO) on brain injury in the patients undergoing cardiac valve replacement with cardiopulmonary bypass (CPB).Methods Forty-five patients with chronic valvular heart disease,aged 36-62 yr,weighing 42-92 kg,of American Society of Anesthesiologists physical status Ⅱ or Ⅲ,with New York Heart Association of Ⅱ or Ⅲ,undergoing cardiac valve replacement with CPB,were randomly divided into 3 groups (n =15 each) using a random number table:control group (group C),and different doses of rHuEPO groups (EPO1 group,EPO2 group).In EPO1 and EPO2 groups,rHuEPO 40 and 80 IU/kg were injected intravenously before anesthesia induction,respectively.Before anesthesia induction (T0,baseline value),immediately after endotracheal intubation (T1),immediately after aortic cannulation (T2),immediately after cannulation of superior and inferior vena cava (T3),immediately after the beginning of CPB (T4),when each index was decreased to the minimal value during CPB (T5),after rewarming to 36.5 ℃ (T6),immediately after termination of CPB (T7),and at 1 h after termination of CPB (T8),regional cerebral oxygen saturation (rSO2),tissue hemoglobin index (THI),and changes in concentrations of oxyhemoglobin (△ O2Hb),deoxyhemoglobin (△ HHb) and total hemoglobin (△ cHb) in bilateral frontal lobes were recorded.The patients whose minimal rSO2 ≤ 50％ and decrease in minimal rSO2 ≥ 20％ of the baseline value (△rSO2) were recorded.At T0,T8 and 2 h after termination of CPB (T9),venous blood samples were taken for determination of serum concentrations of S100 protein and neuron-specific enolase (NSE) by ELISA.At 1 day before surgery and 8 days after surgery,the patient's cognitive function was assessed using Mini-Mental State Examination,the Digit Span subtest of the Wechsler Adult Intelligence Scale-Revised (WAIS-R),the Digit Symbol subtest of the WAIS-R,the Trailing Making Test (Part A)and the Stroop Color Word Interference Test,while depression and anxiety were assessed by Zung Self-Rating Depression Scale and Zung Self-Rating Anxiety Scale,respectively.The occurrence of postoperative cognitive dysfunction was recorded.Results There was no significant difference among the three groups in bilateral rSO2 and △ cHb,incidence of bilateral rSO2 ≤ 50％ and postoperative cognitive dysfunction,Zung Self-Rating Depression Scale score,and Zung Self-Rating anxiety Scale score at each time point (P＞0.05).Compared with group C,the incidence of left △ rSO2 ≥ 20％ was significantly decreased,the right △ O2 Hb was increased at T6,8,the serum NSE concentrations were decreased at T9,the serum S100 protein concentrations were decreased at T8,and the number of the Digit Symbol subtest of the WAIS-R completed was increased in group EPO1,and right THI was significantly decreased at T2,T3,T5,T7 and T8,right △ HHb was increased at T2 and T3,and the completion time of Stroop color word interference test B was shortened at 8 days after surgery in group EPO2 (P＜0.05 or 0.01).Compared with group EPO1,the incidence of left △rSO2 ≥ 20％ was significantly increased,the right THI was decreased at T2-4 and T6-8,and the left △ O2 Hb at T6-7 and right △ O2 Hb at T8 were decreased in group EPO2 (P＜0.05).Conclusion rHuEPO 40 IU/kg injected intravenously before induction of anesthesia can mitigate brain injury in the patients undergoing cardiac valve replacement with CPB.

The medical records of patients underwent thoracic surgery with cardiopulmonary bypass (CPB) from July 1,2013 to May 30,2014 were collected and reviewed,the patients who developed postsurgical acute kidney injury (increase in postsurgical serum creatinine＞26.6 μmol/L) during hospital stay were excluded,and a total of 1 509 cases were enrolled in the study.Age,gender,body weight,presurgical complications,presurgical ejection fraction,serum concentration of creatinine on presurgical day 1,CPB duration during surgery,aortic clamping time,volume of blood transfused,duration of intensive care unit stay,mechanical ventilation time,length of hospital stay,and the highest serum concentration of creatinine were collected.The patients were divided into 2 groups according to the increase in postsurgical serum creatinine concentrations (the difference between the highest serum concentration of creatinine during hospital stay and the serum concentration of creatinine on presurgical day 1):no increase in creatinine group (n =508) and minimal increase in creatinine group (increase in postsurgical serum creatinine concentrations≤26.6 μmol/L,n=1 001).All the patients were followed up by telephone,and the fatality was recorded.Kaplan-Meier and log-rank analyses were used to analyze the survival condition,and the risk factors for fatality were identified by using multivariate Cox regression analysis.Compared with no increase in creatinine group,age was significantly increased,the constituent ratios of coronary heart disease,hypertension,diabetes mellitus,and pulmonary hypertension were significantly increased,CPB duration and length of hospital stay were significantly prolonged (P＜0.05),and no significant change was found in the fatality rate on postsurgical day 30 in minimal increase in creatinine group (P＞0.05).The patients were followed up for (298±104) days,and Kaplan-Meier analysis showed that the long-term fatality rate was significantly higher in minimal increase in creatinine group than in no increase in creatinine group (P＜0.05).Multivariate Cox regression analysis showed that age,presurgical coronary heart disease,CPB duration and minimal increase in postsurgical creatinine were the risk factors for fatality,and among these factors,minimal increase in postsurgical creatinine resulted in a 9％ increase in the fatality rate.In conclusion,minimal increase in postsurgical creatinine can not only prolong the length of hospital stay,but also increase the long-term fatality rate in the patients undergoing cardiac surgery with CPB.

Objective To investigate the effect of stage 1 acute kidney injury (AKI) on the prognosis of patients underwent cardiopulmonary bypass (CPB) cardiac operation. Methods A retrospective analysis was conducted. All patients aged ≥ 18 years who underwent cardiac operation with CPB admitted to Beijing Anzhen Hospital from July 1st, 2013 to December 31st, 2015 were enrolled. According to the standard of serum creatinice (SCr) of Kidney Disease Improving Global Outcomes (KDIGO) criteria, the AKI patients with stage 1 and non-AKI patients were served as the research objects. Perioperative clinical data of two groups were collected, and the prognosis was recorded during follow up to draw the Kaplan-Meier survival curve. Cox regression model was used to analyze the risk factors of prognosis in patients with stage 1 AKI experienced CPB during cardiac operation. Results A total of 5 823 patients were enrolled, of which 1 285 patients with AKI, and those in stage 1 was 998, accounting for 77.67% of total AKI patients; and 4 538 in non-AKI group. The mean follow-up period among survivors was (23.13±12.28) months. Compared with non-AKI patients, 30-day mortality of patients with stage 1 AKI was significantly increased [4.00% (40/998) vs. 0.40% (18/4 538), P < 0.01]. It was showed by Kaplan-Meier survival analysis that the cumulative survival rate of patients with stage 1 AKI was significantly lower than that of non-AKI patients (log-rank = 51.989, P < 0.001). It was showed by further subgroup analysis that the cumulative survival rate of patients with stage 1 AKI without serum creatinine (SCr) recovery was significantly lower than that of patients with SCr recovery from stage 1 AKI (log-rank = 43.580, P = 0.000). It was showed by Cox multivariate analysis that stage 1 AKI [hazard ratio (HR) = 2.725, 95% confidence interval (95%CI) = 1.810-4.230, P = 0.000] and prolonged CPB in patients undergoing cardiac operation (HR = 1.013, 95%CI = 1.001-1.017, P = 0.000), combined with coronary heart disease (HR = 1.046, 95%CI = 1.010-1.063, P = 0.005) and diabetes mellitus (HR = 1.060, 95%CI = 1.010-1.090, P = 0.002) were independent risk factors of death in patients undergoing CPB during cardiac operation. Conclusion Stage 1 AKI is the main stage of AKI and it is independently related to all-cause mortality in patients underwent cardiovascular operation using CPB.

目的:评价急性等容血液稀释(ANH)对非体外循环冠状动脉旁路移植术(CABG)患者内环境与氧代谢的影响.方法:选择非体外循环CABG患者60例,年龄40～70岁,体质量50 ～ 100kg,采用随机数字表法,分为两组(每组n=30),对照组(C组)和ANH组.ANH组于麻醉诱导平稳后经中心静脉重力放血,将红细胞压积(Hct)稀释到30％,同时以与采血速率(15 ～ 25 mL/min)相同的速率输注等容量6％羟乙基淀粉130/0.4氯化钠注射液,ANH过程持续时间为15～25min.于ANH前、ANH后5,30,60及120min,自体血输注完毕后10和60min时采集桡动脉和肺动脉血样行血气分析,记录Hb,pH值,乳酸、PaO2和血浆渗透压,同时经肺动脉导管监测数据,记录混合静脉血氧饱和度(SvO2),计算氧供(DO2)、氧耗(VO2),氧摄取率(O2ER)及动,静脉血氧含量差(Ca-vO2).结果:与C组比较,ANH组SvO2、O2 ER及PaO2升高,Hb和血浆渗透压降低(P＜0.05),DO2、VO2、Ca-vO2、pH值和乳酸水平,差异无统计学意义(P＞0.05).结论:6％羟乙基淀粉130/0.4等容血液稀释对非体外循环CABG患者内环境与氧代谢无明显影响.

依托咪酯( etomidate)是咪唑的羟化盐，由于对心血管系统抑制较轻，广泛用于临床麻醉。而依托咪酯对肾上腺皮质的抑制作用一直受到争议，也限制了其在某些领域的应用。本文总结依托咪酯在临床的应用及不良反应，对依托咪酯在心脏麻醉中应用的现状进行综述。

目的:评价注射用兰地洛尔治疗手术期心动过速性心律失常的疗效与安全性.方法:采用随机、双盲、安慰剂平行对照、多中心的临床试验方法,将240例患者随机分为治疗组和对照组(1:1),治疗组采用注射用兰地洛尔治疗,对照组采用安慰剂治疗,治疗后比较疗效.结果:共有239例患者完成试验,其中治疗组120例,对照组119例.治疗组的心动过速控制率为87.5％,对照组的心动过速控制率为4.2％,治疗组优于对照组(P＜0.05).治疗组起效时间中位数为1 min,安慰剂组起效时间中位数为大于2 min,治疗组优于对照组(P＜0.05).治疗组在治疗期及访视期心率收缩压乘积与治疗前相比显著下降,差异有统计学意义(P＜0.05);安慰剂组在治疗2 min时心率收缩压乘积与治疗前相比未见显著下降,差异无统计学意义(P＞0.05).结论:注射用兰地洛尔治疗手术期心动过速性心律失常安全、有效.

Objective To investigate the influence of dexmedetomidine on hemodynamics during off pump coronary artery bypass grafting under sevoflurane anesthesia.Methods Totally 60 patients who underwent off pump coronary artery bypass grafting under sevoflurane anesthesia from April 2014 and April 2015 were randomly divided into dexmedetomidine group and control group.The heart rate,mean arterial pressure (MAP),cardiac output (CO) during operation were monitored after radial artery puncture (T0),after tracheal intubation (T1),when sternum being opened (T2),when grafting with left anterior descending branch (T3),when grafting with posterior descending coronary artery (PDA) (T4) and at the end of operation (T5).The intraoperative blood transfusion volume,blood loss and urine volume and the hypotension at T4 were observed and compared between the two groups.Results Sex,age,height,body mass,anesthesia time,operation time,intraoperative blood transfusion volume,intraoperative blood loss,intraoperative urine output showed no significant difference between the two groups (P ＞ 0.05).At T0 time point,there was no significant difference of MAP and heart rate between the two groups (P ＞ 0.05).At time points of T0 to T5,CO showed no significant difference between the two groups (P ＞ 0.05);at T1,T2,T4,T5,the MAP and heart rate in dexmedetomidine group were significantly lower than those in control group [MAP:(72 ± 11) mmHg vs (78±11) mmHg,(76 ±9) mmHg vs (82 ±12) mmHg,(65±8) mmHg vs (68 ±10) mmHg,(71 ± 12) mmHg vs (76 ± 10) mmHg;heart rate:(68 ± 13) times/min vs (74 ± 14) times/nmin,(72 ± 10) times/min vs (76 ± 11) times/min,(69 ± 12) times/min vs (78 ± 13) times/min,(66 ± 12) times/min vs (73 ± 11) times/min] (P ＜ 0.05).At T4,hypotension occurred in 8 cases (26.7％) in control group and 7 cases (23.3％) in dexmedetomidine group,showing no significant differences between the two groups (P ＞ 0.05).Conclusion Intraoperative continuous infusion of dexmedetomidine can reduce the stress response,moderately reduce mean arterial pressure and slow the heart rate,while not reduce the cardiac output,being applicable in anesthesia during off-pump coronary artery bypass surgery.

Objective To evaluate the value of central venous-arterial carbon dioxide difference [P(cv-a) CO2] combined with stroke volume variation (SVV) in guiding hemodynamic therapy during off-pump coronary artery bypass grafting (OPCABG).Methods One hundred and twenty patients undergoing off-pump coronary artery bypass grafting were randomly assigned into P group (60 cases) given P(cv-a)CO2 combined with SVV-directed therapy,and C group (60 cases) given central venous pressure (CVP)-directed therapy.The heart rate(HR),mean arterial pressure (MAP),CVP,SVV,P(cv-a)CO2 and arterial blood lactate levels were monitored at the time of anesthesia induction (T0),the beginning of grafting (T1),30 min (T2),60 min (T3) and 90 min (T4) after the beginning of OPCABG and the end of the surgery (T5).The PaO2/FiO2 and fluid balance at the end of the surgery were recorded,and the recovery situation was observed.Results The level of arterial lactate was higher in C group than that in P group at T4 and T5 [(2.4 ± 0.5) mmol/L vs (1.3 ± 0.6) mmol/L,(2.9 ± 1.9) mmol/L vs (1.3 ± 0.8) mmol/L] (P ＜ 0.05).The fluid balance was significantly higher and the PaO2/FiO2 was significantly lower in C group than those in P group at the end of the surgery [(964±360) mlvs (413 ±210) ml,(310 ±58) vs (420 ±70)] (P＜0.05).P group showed great advantage in reducing ICU time,mechanical ventilation time,postoperative respiratory failure incidence and renal failure incidence compared with C group [(26±18) h vs (39 ±20) h,(51 ±31) h vs (76±24) h,1.6％ (1/60) vs 13.3 ％ (8/60),5.0％ (3/60) vs 16.7％ (10/60)] (P ＜ 0.05).Scores of the vasoactive-cardiotonic agents in P group was lower than that in C group[(2.0 ±0.8) scores vs (10.1 ±0.8) scores] (P ＜ 0.05).Conclusion P(cv-a) CO2 combined with SVV is superior to CVP in guiding the hemodynamic therapy for patients undergoing OPCABG.

目的 观察全身麻醉诱导前预防性注射小剂量地佐辛在抑制舒芬太尼诱发的咳嗽反射中的作用.方法 择期全身麻醉手术患者100例,随机分为地佐辛组和对照组各50例,面罩吸氧5 min后,地佐辛组静脉注射地佐辛0.1 mg/kg、对照组静脉注射等量生理盐水,10 min后2组均于5 s内静脉注射舒芬太尼0.3μg/kg,2 min后依次静脉注射咪达唑仑、丙泊酚、罗库溴铵进行麻醉诱导.记录2组麻醉诱导前、插管前、插管后即刻、插管后1 min、插管后3 min收缩压、舒张压及心率,比较舒芬太尼注射后2 min内2组咳嗽反射发生情况.结果 2组麻醉诱导前、插管后即刻、插管后1 min、插管后3 min收缩压、舒张压及心率比较差异无统计学意义(P＞0.05);地佐辛组咳嗽反射发生率(2％)明显低于对照组(32％)(P＜0.05).结论 全身麻醉诱导前预防性注射小剂量地佐辛,对舒芬太尼诱发的咳嗽反射有明显抑制作用.