心内直视术后胸骨切口感染的发生率并不高,但皮下感染未得到有效治疗进而发展为胸骨感染和纵隔炎,并可能恶化导致败血症、心脏切口感染甚至心脏血管桥破裂,死亡率高达25.7%~52.0%[1].外科清创加肌瓣转移重建是治疗该类疾病的重要手段.深部胸骨感染常发生在心脏术后14 d左右,病情发展很快,通常需要紧急手术[2].由于大多数患者刚经历心血管大手术打击,或处于严重败血症状态,或合并肾脏及呼吸功能异常,甚至还有脑部合并症,因此对再次手术围术期麻醉管理提出了新的挑战.自2015年6月至2016年12月,我院共完成了119例正中开胸心脏大血管手术后胸骨纵隔感染清创修复手术,现将麻醉管理总结如下.

To assess the efficacy of thoracic epidural anesthesia (TEA) with or without general anesthesia (GA) versus GA in patients who underwent cardiac surgery, PubMed, Embase, the Cochrane online database, and Web of Science were searched with the limit of randomized controlled trials (RCTs) relevant to 'thoracic epidural anesthesia' and 'cardiac surgery'. Studies were identified and data were extracted by two reviewers independently. The quality of included studies was also assessed according to the Cochrane handbook. Outcomes of mortality, cardiac and respiratory functions, and treatment-associated complications were pooled and analyzed. The comprehensive search yielded 2,230 citations, and 25 of them enrolling 3,062 participants were included according to the inclusion criteria. Compared with GA alone, patients received TEA and GA showed reduced risks of death, myocardial infarction, and stroke, though there were no significant differences (P > 0.05). With regard to treatment-related complications, the pooled results for respiratory complications (risk ratio (RR), 0.69; 95% CI: 0.51, 0.91, P < 0.05), supraventricular arrhythmias (RR, 0.61; 95% CI: 0.42, 0.87, P < 0.05), and pain (mean difference (MD), -1.27; 95% CI: -2.20, -0.35, P < 0.05) were 0.69, 0.61, and -1.27, respectively. TEA was also associated with significant reduction of stays in intensive care unit (MD, -2.36; 95% CI: -4.20, -0.52, P < 0.05) and hospital (MD, -1.51; 95% CI: -3.03, 0.02, P > 0.05) and time to tracheal extubation (MD, -2.06; 95% CI:-2.68, -1.45, P < 0.05). TEA could reduce the risk of complications such as supraventricular arrhythmias, stays in hospital or intensive care unit, and time to tracheal extubation in patients who experienced cardiac surgery.

Tissue-type plasminogen activator (t-PA) and matrix metalloproteinase-9 (MMP-9) have been reported to play important roles in increased permeability of blood-brain barrier (BBB) under many pathological circumstances. We have showed that Ulinastatin, a broad-spectrum serine protease inhibitor, could alleviate inflammation in the hippocampus of aged rats following partial hepatectomy. In this study, we investigate the expression and potential roles of t-PA and MMP-9 in the protective effect of Ulinastatin. We found that partial hepatectomy increased Evans blue leakage in hippocampus at day 1 and 3 postoperatively. Furthermore, surgery decreased the protein levels of claudin-5, ZO-1, and NF-kB p65 while upregulating the mRNA and protein levels of t-PA and MMP-9 in brain capillaries. All these effects caused by surgery were partially reversed by administering Ulinastatin. Our study sheds light on the roles of t-PA and MMP-9 of BBB in post-surgical neuroinflammation and postoperative cognitive dysfunction. Besides, it could also help to understand the mechanism of Ulinastatin alleviating neuroinflammation.

目的观察右美托咪定用于纤支镜清醒气管插管中的镇静效果。方法回顾分析68例需清醒气管插管并全麻下行手术患者。随机分为A、B 2组,每组34例。A组患者给予静脉滴注右美托咪定,B组患者给予静脉滴注咪达唑仑。观察并记录插管前(t_1)、插管中(t_2)和插管后(t_3)患者的平均动脉压(MAP)、血氧饱和度(Sp(O_2))和心率(HR)。同时记录患者插管时间。结果 t_1时刻,2组患者的MAP、Sp(O_2)和HR比较差异不明显。在t_1、t_2和t_3时刻,A组患者的MAP、Sp(O_2)和HR指标比较差异不明显。在t_1、t_2和t_3时刻,B组患者MAP和HR指标比较,t_2和t_3时刻明显高于t_1时刻(P均<0.05);而患者Sp(O_2)指标在t_1、t_2和t_3时刻差异不明显。2组患者MAP和HR指标在t_2和t_3时刻比较,A组患者明显低于B组患者,差异明显。2组患者插管时间和一次插管成功比较,A组患者插管时间明显短于B组(P<0.05);A组患者一次插管成功率明显高于B组(P<0.05);A组患者仅出现3例插管耐受差的情况,而B组出现14例,2组比较有显著性差异(P<0.05);A组术后发生咽喉疼痛6例,B组发生13例,2组比较有显著性差异。结论右美托咪定用于纤支镜清醒气管插管中的镇静效果较好,能较好的稳定患者的MAP、Sp(O_2)和HR指标,降低插管时间,提高插管的成功率,推荐临床使用。

目的 比较不同剂量地佐辛用于腰椎间盘突出症患者术后静脉镇痛临床效果.方法 选择60例腰椎间盘突出症手术患者完全随机分为A、B、C3组,各20例.A组:地佐辛0.4 mg/kg+昂丹司琼8 mg,加0.9％氯化钠注射液至100 ml;B组:地佐辛0.6 mg/kg+昂丹司琼8 mg,加0.9％氯化钠注射液至100 ml;C组:地佐辛0.8 mg/kg+昂丹司琼8 mg,加0.9％氯化钠注射液至100 ml.患者均采用持续静脉泵入给药模式,泵注速率2 ml/h.记录患者接镇痛泵后4、8、12、24、36、48 h的镇痛、镇静评分及不良反应.镇痛评分采用视觉模拟评分(VAS)法；镇静评分采用Rasnsay评分法.结果 术后4～8h,B、C组VAS明显低于A组[术后4 h:(2.3±0.7)、(1.9±0.8)分比(3.9±0.8)分,术后8 h:(2.1±0.9)、(1.8±0.6)分比(3.8±0.7)分](P＜0.05),C组Ramsay评分明显高于A、B组[术后4 h:(3.7±0.8)分比(2.0±0.7)、(2.3±0.6)分,术后8h:(3.6±0.7)分比(2.1±0.5)、(2.5±0.9)分](P＜0.05)；术后12～48 h,3组间VAS与Ramsay评分差异无统计学意义(P＞0.05)；C组的不良反应(恶心呕吐、头晕头痛)发生率明显高于A、B组[20.0％ (4/20)比5.0％ (1/20),5.0％ (1/20)；15.0％ (3/20)比0,0.5％ (1/20)] (P ＜0.05).结论 地佐辛0.60 mg/kg用于腰椎间盘突出症患者术后静脉镇痛效果确切,不良反应发生率低,是安全有效剂量.

Objective To evaluate effect of the i-gel laryngeal mask airway without muscle relaxants on elderly patients with lower limb surgery under general anesthesia.Methods A total of 67 elderly patients,who would undergo lower limb surgery during July 2009 and May 2011 in our hospital,were observed effect and complication by laryngeal mask airway without muscle relaxants under general anesthesia.Results A total of 64 patients were inserted laryngeal masks successfully;among the other 3 patients,a size 5 classic laryngeal mask was successfully used in 2 patients whose failure were due to large pharyngeal leak,and the another was reinserted laryngeal mask due to strong throat reflex.All patients underwent surgeries successfully.After operation 1 patient with sore throat relieved by atomization treatment 24 hours later;there were no severe cerebrovascular events and aspiration events related with laryngeal mask.Conclusion The i-gel laryngeal mask is feasible for airway without muscle relaxants on elderly patients with lower limb surgery under general anesthesia.

Postoperative cognitive dysfunction (POCD) is very common complication of surgery in aged individuals. Accumulated evidence suggests that neuroinflammation may be the underlying cause of POCD. The aim of the present study was to investigate the effects of ulinastatin (UTI) on neuroinflammation and on learning and memory of aged rats after anesthesia and surgery. Our results showed that anesthetic isoflurane increased the hippocampal mRNA level of IL-1β, while surgery of partial hepatectomy increased the hippocampal mRNA levels of IL-1β, TNF-α, and IL-6 as well as impaired rats' spatial memory at day 7 post-surgery. UTI (10,000 U/kg, i.v.) decreased the anesthesia- and surgery-induced increases in mRNA levels of all three cytokines, but did not improve the rats' impaired working memory. In conclusion, moderate and temporary suppression of UTI-induced inflammatory cytokines in hippocampus is not sufficient to alleviate the impairment of working memory.

BACKGROUND Advances in minimally invasive surgical techniques and neonatal intensive care for neonates have allowed for repair of the neonatal esophageal atresia with tracheoesophageal fistula (EA/TEF) to be approached endoscopically. However, thoracoscopic surgery in children is still performed in only a few centers throughout the world. The aim of this study was to compare the neonatal tolerance to the thoracoscopic repair (TR) and the open repair (OR) and also to discuss anesthetic management in thoracoscopic procedure. METHODS We performed a prospective study enrolling newborns diagnosed with EA with distal TEF (type C) receiving the repair surgery between June 2009 and January 2012 in our institution. Data collected included the newborns' gestational age and weight at the time of the operation, operative time, parameters of intraoperative mechanical ventilation, oxygenation, end-tidal carbon dioxide (ETCO2), and analysis of blood gases. Time to extubation and length of stay were also recorded. RESULTS Intravenous induction with muscle paralysis followed by pressure-control ventilation and tracheal intubation regardless of the position of the fistula can be performed uneventfully in EA/TEF newborns with no additional airway anomalies and large, pericarinal fistulas in our experiences. The thoracoscopic approach appeared to take longer than the open approach. During the procedure of repair, hypercarbia and acidosis developed immediately 1 hour after pneumothorax in both groups. CO2 insufflation did have additional influence on the respiratory function of the newborns in the TR group; values of PaCO2 and ETCO2 were higher in the TR group but the difference did not reach statistical significance. By the end of the procedure, values of PaCO2 and ETCO2 returned to the baseline levels while pH did not, but all parameters made no difference in the two groups. Besides, time to extubation was shorter in the TR group. CONCLUSIONS Thoracoscopic repair of EA/TEF is comparable to the open repair, and is believed to be safe and tolerable in selected patients. A wider range of neonates may be acceptable for thoracoscopic EA/TEF repair with increasing surgical experience.

<正>肝性脑病患者的脑电图大多有不同程度的异常,其程度与临床症状及意识障碍程度相平行。如果患者在意识清醒时脑电图(EEG)出现θ和δ活动,则大多数病例其后会发生昏迷,证实EEG改变早于临床变化。而双频指数(BIS)是脑电双频谱,一种数字量化的脑电,其值为0～100。它综合了

Near-infrared spectroscopy is a new noninvasive method of monitoring oxygen saturation at a tissue level,it has been used to measure regional tissue oxygen saturation in skeletal muscle as an indicator of perfusion in trauma patients.It can help identify patients who have ongoing inadequate tissue oxygenation,despite normal blood pressure,heart rate and pulse oximetry parameters.Here is to make a review on some of the recent advancese of near-infrared spectroscopy monitoring muscle oxygen saturation as guidance for the resuscitation of traumatic shock,massive blood transfusion,and other clinical uses.

患者,男,50岁,农民.因头皮撕裂伤伴上下肢功能障碍2h于2009年8月11日入院,患者2h前因行走不便,失足跌入路边约2米深排水渠造成头皮撕裂伤伴上下肢功能障碍.入院体查:T 36.8℃,R 20次/min,P 104次/min,BP134/76mmHg( 1mmHg =0.133kPa),身高170cm,体重138kg,BMI=47.7kg/m2神智清醒.既往史:自幼体健,智力低下,文盲;26岁结婚,一儿一女,均健康.

Background Hydroxyethylstarch (HES) is a widely used plasma substitute for correcting intravascular volume deficit and improving systemic hemodynamics as well as microcirculation. HES dissolved in isotonic saline may result in acid-base have been available. Purpose To review the chemical properties and the developing process of different generations of HES. The advantages of new balanced solutions over the unbalanced in acid -base status, coagulation and renal function are also discussed.Content Several studies demonstrated that such modern balanced HES preparations appeared to be safer with regard to acid-base balance, hemostasis, kidney function. Besides, the preliminary results in assessing the value of a total balanced volume replacement strategy including plasma-adapted HES solutions are quite promising. Trend The use of this new balanced HES will be widely Accepted in the future,and total balanced volume replacement strategy might be a pronising approach to further improves the safety of HES.

Objective To summarize our expiences in central venous catheterization at bedside in adults.Methods Data of 556 adult patients undergoing central venous catheterization at bedside from March 2007 to August 2010 in our hospital were retrospectively analysed.Results Central venous catheterizations were achieved in all patients successfully.Eight-six patients were defined as difficult catheterization,of which,41 were accompanied by some elements with regard to difficult cannulation.Among those,12 cannulations were done by using ultrasound,9 by bending the puncture needles like an arch.Jugular haematoma occurred in one patient,which was considered as serious complication.Conclusion In this article,the most often occurred problems and methods to solve them were summarized.Actually,various techniques exist in various circumstances to achieve successful cannulation.Vascular ultrasound technology helps to avoid serious complications,may enhance one-time success rate of puncture.

北京军区总医院于2008年2月成功实施1例腰骶部相连的联体男婴分体手术,现将麻醉处理情况报告如下.

2008年6月18日,我们在利比里亚维和期间,救治埃塞俄比亚籍军人被枪击致胸腹联合伤1例.现分析报告如下.

Objective To summarize our experiences in utilizing new field operation vehicle.Methods Based on the data from normal practice on the field operation vehicle,the advantages and disadvantages of new field operation vehicle were summarized.Results New field operation vehicle had advantages of good mobility,convenient use and easy disassembly.In the meantime,there were disadvantages including nondurable oxygen supply pipe,inconvenient repair of interior oxygen supply pipe,mismatch of the power switch with civil power supply system and lack of water supply device and drainpipe project.Conclusion New field operation vehicle can basically meet the requirements of field battle or stringency medical services.However,there are still some details needing improvement.

Objective To develop a connector between anesthetic machine and oxygen provider for continual oxygen supply to anesthetic machine during field operation.Method According to the principle of three-way block and one-way qas wave,the new connector with two-routes but one-way for the anesthetic machine was made.Result This setting enable the anesthetic machine to connect two oxygen providers at one time.Conclusion With low cost and being easy to install and dissemble,it can be connected to all kinds of anesthetic machine,thus ensuring the persistence work of the anesthetic machine when changing oxygen provider.

近年来,肺栓塞的发病率在心血管疾病中仅次于冠心病和高血压,并逐渐被临床所重视.北京军区总医院于2005年和2007年成功抢救2例术中发生急性肺栓塞病例,现报道如下.

野战麻醉在战伤救治中发挥着重要作用.虽然现代麻醉学无论在技术设备还是药物开发方面都有了根本的改善,临床麻醉设备越来越精良,麻醉药物的种类也越来越多,新药不断出现,临床麻醉用药可选择范围更加广泛,野战医疗手术设备也越来越先进.这一点从伊拉克战争中美国军队的野战医疗船可见一斑[1].然而,受战争或突发事件发生地点的地理环境、伤员伤情等因素影响,有些现代化设备并无用武之地,我们必须根据野战或应急救护特点对设备进行合理的设计,对药品进行有目的地筛选.近几年来,我院野战医疗所从实战出发,在演练中积累了一定的经验,现将野战应急医疗救援时对麻醉的特殊要求作一探讨.

Objective:To observe the effect of L-arginine(L-arg) and aminoguanidine(AG) on endotoxin(ED)-induced lung injury in rats and to explore the mechanism of lung injury relief by L-arg and AG.Methods:35 rats were randomly divided in control group,ED Group 1,ED plus L-arg group(L-arg Group),ED plus AG group(Group AG),ED+L-arg+AG group 1(Group AA 1).240 minutes after injection of ED,lung tissues were collected from the rats in each group with thoracotomy,then NF-κB activity,serum NO~-_2/ NO~-_3 concentration and pulmonary vascular permeability were determined.The other 22 more rats were treated with ED(ED Group 2n=11) and ED plus L-arg and AG(Group AA 2,n=11),and were followed up for 5 days to calculate survival rate and observe pathological changes of lung tissues.Results:NF-kB activity,serum NO~-_2/ NO~-_3 concentration and pulmonary vascular permeability in ED Group 1 rised obviously than those in controls(P<0.05);those three parameters declined significantly in L-arg Group and Group AA 1 than in ED Group 1(P<0.05);NF-κB activity did not change very much in Group AG compared with that in ED Group 1(P>0.05);the mortality was 18.2% in Group AA 2 45.5% in ED Group 2,respectively without a significant difference between these two groups(P>0.05),while the pathological alterations were lighter in Group AA 2.Conclusions:L-arg could greatly inhibit ED-induced NF-κB activity in rat lung tissue and AG could not.Combined administration of L-arg and AG could obviouly relieve ED-induced pathological alterations in lung injury.